Every finding on record at Ellis Nursing Home (The)

Based on observation, record review and interviews the facility failed to identify and assess the use of an abdominal binder (wide compression belt that encircles the abdomen and is secured into place) as a potential physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) for one Resident (#8) of 26 sampled residents. Findings include:Review of the facility policy titled Use of Restraints, dated as revised 8/1/23, indicated but was not limited to:-Restraints shall only be used for the safety and well-being of the resident's and only after other alternatives have been tried unsuccessfully,-Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience,-When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented; and-Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. Resident #8 was admitted to the facility April 2026 with diagnoses which included dementia, and gastrostomy status (stomach feeding tube/G-tube, a medical device inserted directly through the abdomen into the stomach used to deliver food, liquids, and/or medications). Review of the Minimum Data Set (MDS) Assessment, dated 4/24/26, indicated he/she had a short- and long-term memory problem per staff interview. Further review of the MDS failed to indicate the use of physical restraints. Review of Resident #8's physician orders indicated but was not limited to:-Keep G-tube under abdominal binder every shift, dated 4/18/26 Review of Resident #8's care plans failed to indicate he/she had been care planned for the use of a physical restraint. Review of Resident #8's medical record failed to indicate he/she had been assessed for the use of a physical restraint. Review of Resident #8's April and May 2026 (4/18/26 through 5/13/26) Treatment Administration Record (TAR) indicated the abdominal binder was signed off every shift as ordered. Review of Resident #8's progress notes, on the following dates, indicated his/her abdominal binder was in place:-4/17/26-4/19/26, -4/20/26,-4/21/26,-5/4/26, and-5/13/26 On 5/14/26 at 9:52 A.M., the surveyor observed Resident #8 in bed wearing an abdominal binder. During an interview on 5/14/26 at 9:54 A.M., Certified Nursing Assistant (CNA) #1 said Resident #8 wore an abdominal binder to prevent him her/her from pulling his/her G-tube. CNA #1 said Resident #8 was unable to remove the abdominal binder on their own. During an interview on 5/14/26 at 9:59 A.M., Nurse #1 said Resident #8 wears an abdominal binder because he/she grabs at the G-tube and tries to remove it. Nurse #1 said Resident #8 could not undo the abdominal binder independently. During subsequent interview on 5/14/26 at 12:47 P.M., Nurse #1 said Resident #8 had not been able to physically remove his/her abdominal binder in the past since his/her admission to the facility. Nurse #1 said Resident #8 came from another facility with the abdominal binder. Nurse #1 said she did not know if the abdominal binder had been assessed as a restraint because he/she came to the facility with it in place. Nurse #1 said she was not aware of an assessment or care plan that speaks to the abdominal binder but nurses sign off on the TAR that it was in place every shift. During an interview on 5/14/26 at 12:53 P.M., Unit Manager #1 said Resident #8's abdominal binder was in place to prevent him/her from pulling out their G-tube. Unit Manager #1 said she had seen the Resident attempt to remove the binder as a behavior because it may have been uncomfortable and because it was preventing him/her from pulling out the G-tube. Unit Manager #1 said she did not think Resident #8 could remove the abdominal binder but he/she could try to adjust it because it was uncomfortable and worn at all times except for with care in order to protect the G-tube. Unit Manager #1 said Resident #8 was admitted to facility with the abdominal binder in place and the facility did not assess the binder as a restraint or as the least restrictive device. Unit Manager #1 reviewed the medical record and said there was no assessment or care plan to address the use of the abdominal binder. On 5/14/26 at 1:23 P.M., the surveyor observed Unit Manager #1 ask Resident #8 to release the abdominal binder. Resident #8 was unable to release or remove his/her abdominal binder upon request. During an interview on 5/14/26 at 1:30 P.M., the covering Director of Nurses (DON) said when a resident was unable to easily release an abdominal binder on command it becomes a restraint. The covering DON said Resident #8 should have been assessed and care planned for a restraint.

Based on document review and interview the facility failed to ensure medical records were complete and accurate, containing evidence of completed pharmacy recommendations for review by the Pharmacy consultant monthly to verify recommendation completion for one Resident (#1) out of a total sample of 26 residents. Findings include: Review of the facility policy titled: Medical records and chart handling, last updated 8/1/23, indicated but was not limited to the following: -All resident records shall be maintained in an organized, legible, accurate and timely manner Review of the facility policy titled: Medication therapy, last updated 8/1/23, indicated but was not limited to the following: -the consultant pharmacist will review each resident's medication regimen monthly -all decisions related to medications shall include appropriate elements of the care process, such as: regular pharmacist's review and physician review Review of the facility policy titled: Consultant pharmacist reports, Medication regimen review, dated: 1/2024, indicated but was not limited to the following: -the consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records and other applicable documents. The facility shall make available to the pharmacist all appropriate records. Review of the Pharmacy service agreement, provided by the facility, dated 2/21/23 indicated but was not limited to the following: the facility shall: - provide the consultant pharmacist with access to the resident charts (and/or access to electronic medical record portal)-respond to issues reported by the consultant pharmacist through corrective actions that resolve such issues as warranted Resident #1 was admitted to the facility in December of 2023 and had the following diagnosis: Adjustment disorder with mixed anxiety and depressed mood, type 2 diabetes mellitus with polyneuropathy, and chronic kidney disease stage 4 (severe). Review of the current physician orders, on 5/14/26, indicated the Resident was on Amitriptyline HCl (antidepressant) 10 milligrams (MG) for anxiety at bedtime. Review of the monthly pharmacy reviews in the medical record, conducted by the pharmacy, indicated the following:8/27/25: MD Rec: risk versus (vs.) benefit of Amitriptyline9/23/25: MD Rec: risk vs. benefit of Amitriptyline10/22/25: MD Rec: risk vs. benefit of Amitriptyline11/17/25: MD Rec: risk vs. benefit of Amitriptyline12/15/25: MD Rec: risk vs. benefit of Amitriptyline1/16/26: MD Rec: risk vs. benefit of Amitriptyline2/19/26: MD Rec: risk vs. benefit of Amitriptyline3/18/26: MD Rec: risk vs. benefit of Amitriptyline4/20/26: MD Rec: risk vs. benefit of Amitriptyline Review of the Physician and Nurse Practitioner notes from August 2025 to April 2026 failed to indicate the physician documented the risks vs. benefits of the Amitriptyline use. Review of the electronic and paper portions of the medical record failed to indicate the recommendation left by the pharmacist was addressed by the physician During an interview on 5/14/26 at 1:12 A.M., Unit manager #3 said the pharmacist comes in and reviews the medical record and then sends the recommendations (recs) to the Director of Nurses (DON) and they are handed out to the units for completion. She said once she receives the recs she reviews them with the Physician or Nurse Practitioner (NP) and places them in their folder and then once they are signed and complete sends them back to the DON who keeps them in her office. She said the recs are not part of the medical record and are not available on the unit. She said she's surprised this rec is incomplete for so long since she addresses them so quickly, but she would have to go request the information from the DON to find out what the situation is. She reviewed the medical record for Resident #1 and said there was no information for this rec available in the record, she also checked the Physician folder and said no information was available there as well. On 5/14/26 at approximately 11:30 A.M., the covering DON provided the survey team with a signed MD rec from the pharmacy regarding the risk vs. benefit of Amitriptyline dated 10/7/25. During an interview on 5/14/26 at 11:44 A.M. the covering DON said the process for pharmacy recs is that they are emailed to the DON and then distributed to the unit managers for completion and then returned to the DON and filed, and in this case in the DON office. He said the recs are not part of the medical record and unavailable for the consultant pharmacist to review each month. He said the Pharmacist not having access to the completed recs and them not being part of the medical record is clearly a process issue that needs correction. He said the expectation is the medical record should be complete and accurate and that is a necessity for the Pharmacy consultant to be able to complete their job correctly. During an interview on 5/14/26 at 12:19 P.M., the Lead pharmacy consultant said the facility's consultant completes the monthly medication regimen reviews onsite each month, so they have access to the full medical record. She said the consultants review all orders, progress notes, medication administration records, labs, psych, Physician & NP notes and previous pharmacy recs. She said while onsite the consultant sends the report to facility designated person. She said this Resident having the same MD recommendation for the risk vs. benefit of Amitriptyline from August 2025 to April 2026 would indicate either the recommendation had not been addressed or is not part of the medical record. She said the pharmacy contract indicated that the consultant must have access to the medical record to complete their responsibilities and that completed recommendations are supposed to be part of the medical record in the same way the pharmacy consultant documents directly into the medical record that they completed the review and have left recs or not. She said without accurate and complete medical records there is no guarantee the consultant pharmacist could identify issues or provide guidance in accordance with long term care and pharmacy professional guidelines. She said the expectation by the pharmacy is that the facility maintains complete and accurate medical records, including the completed and signed recommendations previously made so the consultants can complete reviews correctly each month. During an interview on 5/14/26 at 1:26 P.M., the medical records staff said part of her role is to ensure the medical records are complete and accurate. She said she files things left on the unit into the record and anything else she is asked to put in there and will check with different departments if they have any pieces of the medical record they need filed, such as rehab. She said she does not ask the DON if they have any pieces of the medical record that should be filed, because she figures there is no reason for the DON to maintain any part of a residents' medical record in their office since that would make the record incomplete. During an interview on 5/14/26 at 1:40 P.M., the Administrator said he was not fully aware that the completed pharmacy recs were not part of the medical record and being stored in the DON's office. He said every part of the medical record, including the completed recommendations, should be in the record and available for the Pharmacy consultants to review. He said his expectation is for the medical record to be complete and without those documents being available for review by the Pharmacy consultant it is not.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure the call bell system was functioning properly in his/her room, when on 12/06/25 after family members complained his/her call light was not working, it was determined that the reset button had been taped down disabling the ability for the call light to function properly. Findings include: The Facility Policy, titled Call System, dated 08/01/23, indicated the following:-residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.-each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.-call system communication may be audible or visual.-the resident call system remains functional at all times.-if audible communication is used, the volume is maintained at an audible level that can be easily heard.-if visual communication is used, the lights remain functional. Resident #1 was admitted to the Facility in December 2025, diagnoses included fracture of right pubis (break in the pubic bone; part of the pelvis), repeated falls, Parkinson's disease, and paraplegia. During a telephone interview on 01/14/26 at 2:25 P.M., Family Member #1 said on 12/06/25 Resident #1 told her that he/she had been calling for help, and no one answered his/her call light. Family Member #1 said she informed Nurse #2 that Resident #1's call light was not working and when Nurse #2 went to Resident #1's room she (Nurse #2) witnessed that his/her call light was not working. Family Member #1 said Nurse #2 informed her that a call was being placed to maintenance about Resident #1's call light not working, that Nurse #2 offered a Resident #1 handheld bell to use to call for staff, but said handheld the bell was never brought to Resident #1 to test out. Family Member #1 said she returned to the Facility later that afternoon, found out that maintenance had not been to Resident #1's room and that his/her call light was still not working properly. Family Member #1 said when Family Member #2 arrived she pushed Resident #1's call light several times and the light was not going off. Family Member #1 said Family Member #2 went to push the call light reset button and noticed it had been taped down with several pieces of clear tape. Family Member #1 said Family Member #2 informed Nurse #2 that Resident #1's call light was not working because someone had taped the reset button down. Family Member #1 said Nurse #2 came to Resident #1's room and removed the tape. During an in-person interview on 01/15/26 at 3:02 P.M., (which included review of her written statements) Nurse #2 said on 12/06/25 Family Member #1 called her to Resident #1's room because his/her call light was not working. Nurse #2 said she pulled both call light cords from the wall, plugged them back in and both call lights in the room were working. Nurse #2 said she told Family Member #1 that Resident #1's call light seemed to be working and if it was not working then she would call maintenance. Nurse #2 said she offered Resident #1 a handheld bell just in case and Family Member #1 adamantly refused the bell. Nurse #2 said later that afternoon, Family Member #2 showed her a video on her cell phone, and she (Family Member #2) said look at this someone taped the reset button. Nurse #2 said she went to Resident #1's room and observed that there was clear tape over the call light reset button and said she immediately removed the tape. Nurse #2 said she never called maintenance because when she checked it, Resident #1's call light system was working properly. Nurse #2 said she had no clue who or when the tape was placed over the reset button. During a telephone interview on 01/20/26 at 11:14 A.M., (which included review of her written statement) Nursing Supervisor #2 said Nurse #2 informed her that Resident #1's call light was not working, that there was something wrong with it and said she told Nurse #2 to call maintenance. Nursing Supervisor #2 said later that day (exact time unknown) Nurse #2 called her and said Resident #1's family was having an issue with his/her call light. Nursing Supervisor #2 said she went to Resident #1's room to speak to his/her family and they told her that the call light reset button had been covered with tape. The Supervisor said the tape had already been removed before she went to meet with Resident #1's family. Nursing Supervisor #2 said she tested the call lights in Resident #1's room and they were both working. Nursing Supervisor #2 said she notified the Director of Nursing (DON) that tape had been found over Resident #1's call light reset button. During an in-person interview on 01/15/26 at 1:58 P.M. and a follow-up telephone interview on 01/26/26 at 1:05 P.M., the Maintenance Director said on 12/08/25 he was informed there had been a problem with Resident #1's call light over the weekend because Resident #1's family said there was tape over the call light reset button. The Maintenance Director said that if tape or any pressure is placed over a call light reset button the call light would not work or light up, to call staff for assistance. During an in-person interview on 01/15/26 at 4:12 P.M. and a follow-up telephone interview on 01/26/26 at 2:18 P.M., the Director of Nurses (DON) said on 12/06/25 Nursing Supervisor #2 informed her that Resident #1's family was upset about his/her call light reset button being taped down. The DON said she called Nursing Supervisor #1 and asked him to do a call light audit on Resident #1's unit that day. The DON said she interviewed the Nurses and Certified Nurse Aides (CNAs) that worked on the unit on 12/06/25 and said that she and the Administrator watched the surveillance camera footage on the unit to see who entered and exited Resident #1's room. The DON said they could not determine how the tape got placed over Resident #1's call light reset button. The DON said it is her expectation that all staff notify maintenance if a resident's call light is not functioning properly. On 01/15/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction with an effective date of 12/10/25, which addressed the area(s) of concern as evidenced by:A. Resident #1 is no longer in the Facility.B. On 12/06/25, the Nursing Supervisor completed an audit on all residents' call lights on the unit that Resident #1 resided on.C. On 12/08/25, the Maintenance Director completed a full house audit on all residents' call lights, no issues were identified.D. On 12/08/25 through 12/15/25, The Maintenance Director and/or designee conducted daily call light monitoring audits on the unit Resident #1 had resided on.E. On 12/10/25, the Staff Development Coordinator provided education to all staff on call lights.F. The Maintenance Director and/or designee will conduct call light monitoring audits weekly for one month, and random audits will be on-going or until overall compliance is achieved. G. The results of the audits will be presented and reviewed at the monthly QAPI Committee meeting until compliance is achieved.H. The Director of Nursing and/or designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents, (Resident #1) who was re-admitted with multiple pressure injuries, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice related to timely follow-up on provider recommendations for wound care and accurate transcription of treatment orders.Findings include:Review of the Facility Policy titled Consults: Health Drive, Wound MD, and other outside Consultants, dated as last updated 08/01/25, indicated that residents who have consultants will have recommendations reviewed by attending MD/NP/PA/LIP.The Policy further indicated the staff RN/LPN will review consultation reports and recommendations with the prescriber, prescriber will decide on if recommendations are followed and orders obtained, nursing will document new orders and order supplies if necessary, and nursing will document per house protocol.Review of the Facility Policy titled Verbal Orders, dated as last updated 08/01/23, indicated that the individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed.Resident #1 was admitted to the Facility in March 2025, diagnoses include diabetes mellitus with neuropathy (weakness and numbness due to nerve damage), peripheral vascular disease, and hemiparesis (weakness on one side of the body).Resident #1 had an acute 10-day Hospital stay and was re-admitted to the facility on [DATE].Review of Resident #1's Wound Evaluation and Management Summary, dated 05/29/25 (written by Wound Physician), indicated he/she had 4 separate pressure injuries with 4 recommended treatments as follows;1) Unstageable due to necrosis (dead tissue) sacrum full thickness pressure injury with recommended treatment nursing to apply Calcium Alginate (promotes wound healing forming a gel and absorbs wound fluids) once daily and as needed and Santyl (removes dead tissue from wounds so they can heal) apply one daily and as needed (PRN).However, review of Resident #1's Treatment Administration Record (TAR) dated 05/28/25 through 07/02/25, indicated that nursing was providing a treatment to his/her sacrum according to the original physician's order from 05/13/25, indicating that nursing apply NSW followed by Calcium Alginate and cover with boarder gauze daily and PRN.Further review of Resident #1's Medical Record, including but not limited to the TAR, Medication Administration Record (MAR), Physician's Orders, and Care Plans, indicated that there was no documentation to support a new order had been obtained for Resident #1's Stage 4 sacral pressure injury upon readmission, even after the Wound Physician made new recommendations, and nursing continued to follow an old and incomplete Physician's Order, dated 05/13/25. Review of Resident #1's Physician's Orders, dated 06/03/25, indicated nursing to treat area with normal saline wash (NSW) followed by (F/B) Calcium Alginate and cover with border gauze daily and PRN to sacrum wound.Review of Resident #1's Physician's Orders, dated 07/03/25, indicated nursing to apply Santyl Ointment 250 units per gram (gm) to sacrum topically one time a day for wound care.Further review of Resident #1's Medical Record indicated that there was no documentation to support that the treatment that had been recommended on 05/29/25, had been accurately transcribed until 07/03/25.2) Stage 3 (deep wound that extends through the layers of skin and subcutaneous tissue) pressure injury to the right heel full thickness with recommended treatment for nursing to apply Xeroform (allows hydration in the wound to promote healing) gauze applied once daily and as needed with gauze island border applied once daily and as needed.Review of Resident #1's Physician's Orders, dated 07/03/25, indicated nursing to treat area with a NSW, pat dry, apply Xeroform (cut to fit wound bed) and cover with boarded gauze once daily and as needed to his/her right heel.Review of Resident 1's Medial Record, including but not limited to the MAR, TAR, Physician's Orders, and Care Plans, indicated that there was no documentation to support the dressing that had been recommended by the Wound Physician on 05/29/25, had been obtained until 07/03/25.3) Stage 3 pressure injury to the right buttocks full thickness with recommended treatment for nursing to apply Silver Sulfadiazine (used to prevent wound infections) once daily and as needed, peri (surrounding edges) wound treated with house barrier cream apply once daily and as needed; and4) Stage 3 pressure injury to the left buttocks full thickness with recommended treatment for nursing to apply Silver Sulfadiazine once daily and as needed, peri wound treated with house barrier cream apply once daily and as needed.Review of Resident #1's Physician's Orders, dated 05/29/25, indicated nursing to treat area with Silver Sulfadiazine Cream 1 percent (%) to buttocks topically, on the day shift for wound care and mix with House Barrier Cream.Review of Resident #1's Physician's Orders, dated 06/05/25, indicated nursing to treat area with Silver Sulfadiazine Cream 1 percent (%) to Left buttocks topically, on the day shift for wound care and mix with House Barrier Cream.Review of Resident #1's Medical Record, including but not limited to the TAR, MAR, Physician's Orders, and Care Plans, indicated that there was no documentation to support that each pressure injury, left buttocks and right buttocks, had a specific treatment that had been recommended on 05/29/25 by the Wound Physician and had not been transcribed accurately.Further review of the Wound Summary indicated additional recommendations to include off-load wounds, reposition per Facility Protocol, and Float Heels in bed.Review of Resident #1's Medical Record, including but not limited to the TAR, MAR, Physician's Orders, and Care Plans, that other than one Nurse Entry on 07/13/25, that there was no documentation to support that Resident #1's heels were ever elevated. Review of Resident #1's Wound Evaluation Management Summary, dated 07/10/25, 07/17/25, and 07/24/25 indicated it included a new recommendation, to apply a Pressure Off-Loading Boot to his/her right heel.Review of Resident #1's Medical Record indicated that there was no documentation to support, and pressure off-loading boot was ever applied to help with the healing of Resident #1's right heel pressure injury. During a telephone interview on 09/08/25, Nurse #1 said that on 05/28/25, she had completed the re-admission skin assessment for Resident #1 and said she does not recall obtaining any new orders for his/her wounds. Nurse #1 said that she did remember that Resident #1 had an existing pressure injury to his/her bottom and had a treatment in place before he/she went to the hospital and Nurse #1 said that she thinks the Unit Manager is responsible for obtaining the physician's orders upon a resident's readmission and that nursing should have obtained 4 new Physician's Orders upon admission for his/her wounds. During an interview on 09/02/25 at 2:29 P.M., Nurse #2 said that she remembered Resident #1 had multiple pressure injuries upon his/her return from the hospital, however said she does not recall ever getting recommendations from the Wound Physician for Resident #1.Nurse #2 said that the Wound Physician does not write orders and said he rounds with the Unit Manager weekly and the Unit Manager is responsible for reporting the recommendations to his/her physician and obtaining any treatment orders for the resident. During a telephone interview on 09/08/25 at 12:09 P.M., the Former Unit Manager said that it was her responsibility to round with the Wound Physician weekly and once the Wound Physician uploaded his progress notes (before he leaves the Facility), she would review any recommendations and bring them to the Providers' attention and obtain any new Physician's Orders.The Former Unit Manager said that there should have been separate and accurate physician's orders for each of Resident #1's pressure injuries and does not know what happened.During an interview on 09/02/25 at 4:02 P.M., the Interim Director of Nurses (DON) said that he was not aware that recommendations made by the Wound Physician had not been followed through with or that Resident #1's Physician's orders were not all transcribed accurately.The Interim DON said that it is the Facility's expectation that any recommendation received by a third-party provider, including a Wound Physician, must be reviewed timely with the resident's provider and new and accurate orders are to be obtained.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who, on 05/06/25, had been restrained in his/her wheelchair by Certified Nurse Aide #1, the Facility failed to ensure Administration reported the alleged incident to the Department of Public Health (DPH) within two hours as required, when although the Director of Nurses was aware on 05/06/25, the Facility did not report the use of the restraint to DPH until 05/12/25, (almost a week later). Findings include: Review of the Facility's Policy titled, Abuse Reporting and Investigation, dated as updated 08/01/23, indicated that: - if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, and -the administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible to surveying/licensing the facility. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted, 05/12/25, indicated that Resident #1 was observed sitting in his/her room in his/her wheelchair with sheet wrapped around his/her waist. The Report indicated that the Facility questioned if it was an inappropriate use of restraint, and that Resident #1 had no injuries. Review of the Facility's Investigation Report, undated, indicated that on 05/06/25 around 7:00 A.M., staff were completing walking rounds and noticed Resident #1 in his/her room, in his/her wheelchair with a restraint across his/her waist. The Report indicated that the restraint was removed immediately, Resident #1 was assessed, no injuries were noted, and he/she was not in any distress. Resident #1 was admitted to the Facility in December 2021, diagnoses included dementia and generalized anxiety disorder. Review of Resident #1's Quarterly Minimum Date Set (MDS) assessment, dated 03/22/25, indicated he/she had severe cognitive impairment and was dependent on staff for care and mobility. During an interview on 05/22/25 at 10:26 A.M., CNA #1 said on 05/06/25, he placed a fitted sheet across Resident #1's waist, wrapped the sheet around the armrests of the wheelchair, then tied the sheet behind the wheelchair to keep him/her from falling and that it was a bad decision. During an interview on 05/20/25 at 12:20 P.M., (which included a review of her written witness statement, dated 05/06/25), CNA #2 said she walked into Resident #1's room on 05/06/25 in the morning and saw Resident #1 wheeling him/herself around in his/her wheelchair, when she noticed a sheet around Resident #'1's waist, wrapped around the wheelchair armrests, and tied behind his/her wheelchair. CNA #2 said she notified the Assistant Director of Nurses (ADON) immediately. During an interview on 05/23/25 at 9:56 A.M., the Assistant Director of Nurses (ADON) said that on 05/06/25 between 7:00-7:30 A.M., CNA #2 told her that there was a sheet tied around Resident #1's waist and wheelchair, so she (ADON) went into Resident #1's room. The ADON said she saw Resident #1 sitting in his/her wheelchair with a sheet across his/her waist and tied behind the wheelchair. The ADON said she told CNA #2 to remove the sheet, and she (ADON) immediately reported the restraint to the Director of Nurses (DON). During an interview on 05/20/25 at 2:54 P.M., the Director of Nurses (DON) said that on 05/06/25, the ADON told her that she (ADON) and CNA #2 saw a sheet around Resident #1's waist and tied behind Resident #1's wheelchair. The DON said she determined that the sheet wrapped around Resident #1 and tied behind his/her wheelchair was a restraint. The DON said she did not report the restraint incident to DPH immediately, as required. During an interview on 05/20/25 at 3:17 P.M. the Regional Clinical Coordinator said he offered guidance to Facility staff during investigations. The Regional Clinical Coordinator said he did not know why the restraint allegation had not been reported to DPH in a timely manner.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had severe cognitive impairment, the Facility failed to ensure Resident #1 was free from the use of a physical restraint, when on 05/06/25, Certified Nurse Aide (CNA) #1 used a sheet to restrain Resident #1 in his/her wheelchair to prevent him/her from falling. Findings include: Review of the Facility's Policy, titled, dated as revised 08/01/23, indicated the following: -physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body, and -restraints shall only be used to treat the resident's medical symptoms and never for discipline, staff convenience, or for the prevention of falls. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted, 05/12/25, indicated that on 05/06/25, Resident #1 was observed sitting in his/her room in his/her wheelchair with sheet wrapped around his/her waist. The Report indicated that the Facility questioned the inappropriate use of a restraint, and that Resident #1 had no injuries. Review of the Facility's Investigation Report, undated, indicated that on 05/06/25 around 7:00 A.M., staff were completing walking rounds and noticed Resident #1 in his/her room in his/her wheelchair with a restraint (bed sheet) across his/her waist. The Report indicated that the restraint was removed immediately, Resident #1 was assessed, no injuries were noted and he/she was not in distress. Resident #1 was admitted to the Facility in December 2021, diagnoses included dementia and generalized anxiety disorder. Review of Resident #1's Quarterly Minimum Date Set (MDS) assessment, dated 03/22/25, indicated he/she had severe cognitive impairment and was dependent on staff for care and mobility. Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her Quarterly MDS on 03/22/25, indicated Resident #1 required assistance with ambulation to prevent falls. During an interview on 05/22/25 at 10:26 A.M., CNA #1 said during his overnight shift that started on 05/05/25 at 11:00 P.M., and ended on 05/06/25 at 7:00 A.M., Resident #1 did not sleep and made repeated attempts to stand up and walk by him/herself. CNA #1 said Resident #1 was unsteady on his/her feet, and he was afraid he/she would fall, so he stayed with Resident #1 throughout his shift. CNA #1 said that around 6:50 A.M., after he dressed Resident #1, he left him/her in his/her wheelchair while he provided care to Resident #1's roommate. CNA #1 said he was in the room with Resident #1 while he/she had the sheet tied around him/her and only left the room for a brief period of time. CNA #1 said he then returned to Resident #1's room to remove the sheet from around him/her at the end of his shift (7:00 A.M.), when a staff member (CNA #2) noticed the restraint and reported it to the Assistant Director of Nurses (ADON). CNA #1 said he placed the sheet around Resident #1 for his/her safety because he had to provide care to other residents. CNA #1 said he made a bad decision. CNA #1 said he had three residents on his assignment that night that were trying to get up and walk on their own, and he was just trying to keep them safe. During an interview on 05/20/25 at 12:20 P.M., (which included a review of her written witness statement, dated 05/06/25), CNA #2 said she walked into Resident #1's room on 05/06/25 in the morning and saw Resident #1 wheeling him/herself around in his/her wheelchair, when she noticed a sheet around Resident #1's waist, wrapped around the wheelchair armrests, and tied behind his/her wheelchair. CNA #2 said Resident #1 was not in distress, and that she called the ADON (who was on Resident #1's unit at the time), into Resident #1's room so she (ADON) could see the restraint. CNA #2 said the ADON told her to remove the restraint immediately. CNA #1 said he made a bad decision. During an interview on 05/23/25 at 9:56 A.M., the ADON said that on 05/06/25, she was on Resident #1's unit in the early morning (exact time unknown), but said she starts her shift at 7:00 A.M., and begins rounding on the units immediately. The ADON said CNA #2 told her that she saw a sheet tied around Resident #1's waist and wheelchair. The ADON said she went into Resident #1's room and saw him/her (Resident #1) sitting in his/her wheelchair with a sheet in front of his/her waist and tied behind the wheelchair. The ADON said she told CNA #2 to remove the restraint immediately. The ADON said when observed and assessed Resident #1, he/she was not in distress, he/she had not been attempting to stand while the restraint was on, that he/she had no marks on his/her skin and was at his/her baseline. The ADON said she reported the restraint to the Director of Nurses immediately. During an interview on 05/20/25 at 2:54 P.M., the Director of Nurses (DON) said that on 05/06/25, the ADON told her that she and CNA #2 saw a sheet around Resident #1's waist and tied behind his/her wheelchair. The DON said she determined that the sheet was a restraint, and she suspended CNA #1. The DON said Resident #1 had been trying to stand frequently throughout the night and that CNA #1 should have asked other staff for help, but instead he made a bad decision when he used a sheet to restrain Resident #1 in his/her wheelchair to keep him/her from falling. On 05/20/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 05/06/25, Resident #1 was assessed by nursing, he/she had no visible injuries, was not found to be in any distress, and was at his/her baseline. B) Social Services and Nursing staff continue to monitor Resident #1 for the potential of an adverse reaction to the use of a restraint and will provide emotional support, as needed. C) 05/06/25, CNA #1 was suspended pending a Facility Investigation and subsequently terminated from the Facility. D) 05/06/25, The Assistant Director of Nurses began daily restraint audits on all residents, which continued for two weeks, then transitioned to weekly and will continue for two months. E) 05/06/25 through 05/09/25,The Staff Development Coordinator educated all clinical staff on the use of restraints and the facility's abuse policy's. F) 05/20/25, Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team to review the incident and their plan of correction. G) Effectiveness of the corrective action plan will be reviewed during Monthly QAPI meetings until further notice. H) Director of Nursing and Executive Director are responsible for overall compliance.

Based on observations and interviews, the facility failed to follow infection control prevention practices. Specifically, the facility failed to: 1. Ensure effective hand hygiene practices and appropriate PPE (personal protective equipment) were utilized when entering in and exiting out of resident rooms, including residents on transmission-based precautions; and 2. Ensure resident hand hygiene was implemented during meal service. Findings include: 1. Review of the facility's policy titled Isolation - Initiating Transmission-Based Precautions, dated 8/1/23, indicated, but was not limited to, the following: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. -Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. -When transmission-based precautions are implemented, the infection preventionist (or designee): a. clearly identifies the type of precautions, anticipated duration, and the personal protective equipment (PPE) that must be used; b. explains to the resident (or representative) the reason(s) for the precautions; c. provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE; d. determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions: (1) The signage informs the staff of the type of CDC (Centers for Disease Control and Prevention) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. (2) Signs and notifications comply with the resident's right to confidentiality or privacy. e. ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; f. ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and g. ensures that an appropriate linen barrel/hamper and waste container; with appropriate liner, are placed in or near the resident's room. -Transmission-based precautions remain in effect until the attending physician or infection preventionist discontinues them, which occurs after criteria for discontinuation are met. Review of the CDC Contact Precautions sign indicated the following: -Everyone must: Clean their hands, including before entering and when leaving the room. -Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A. Resident #383 was admitted to the facility in April 2025 with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA, a type of bacteria that is resistant to many antibiotics). Review of Resident #383's active Physician's Orders indicated, but was not limited to, the following: -Contact Precautions every shift for MRSA in nares (nostrils) + Klebsiella pneumoniae (a type of bacteria that can cause infection and is often resistant to multiple antibiotics) [order date 4/15/25] Review of Resident #383's Care Plans indicated, but was not limited to, the following: -Focus: PRECAUTIONS: [Resident #383] is on contact precautions R/T (related to) MRSA in nares + Klebsiella pneumoniae -Interventions: Institute appropriate precautions as warranted (Contact precautions) Review of Resident #383's MRSA PCR (a laboratory test used to detect the presence of MRSA bacteria) results from a specimen obtained from the Resident's nares on 4/18/25 indicated Resident #383 tested positive for MRSA. Review of the Nurse Practitioner's Progress Note, dated 4/25/25, indicated Resident #383 had tested positive for MRSA of the nares while in the hospital, but it was unclear whether he/she was treated. The Resident was retested at the facility and was again positive for MRSA and was started on Bactroban (a topical antibiotic treatment). On 4/24/25 at approximately 10:17 A.M., the surveyor observed Unit Manager #2 and Nurse #2 assessing Resident #383 after he/she had sustained a fall. A yellow CDC Contact Precautions sign was posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. On 4/24/25 at 10:21 A.M., the surveyor observed Unit Manager #2 and Nurse #2 leave the Resident's room. A housekeeper then entered Resident #383's room without appropriate PPE on. On 4/24/25 at 10:29 A.M., the surveyor observed Unit Manager #2 and the Director of Nursing entered Resident #383's room without donning (putting on) PPE. On 4/28/25 at 11:59 A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed a student volunteer enter the Resident's room with a lunch tray. The student volunteer did not don any PPE before entering the room. On 4/29/25 at 12:24 P.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed Certified Nursing Assistant (CNA) #1 enter Resident #383's room without donning PPE. During an interview on 4/24/25 at 10:21 A.M., Nurse #2 reviewed Resident #383's electronic health record and said that Resident #383 was not on precautions for an active infection, but because he/she had a Foley catheter. During an interview on 4/29/25 at 9:55 A.M., Nurse #1 said that Resident #383 was on Contact Precautions and that staff should don a gown and gloves when entering the Resident's room, even if care was not being provided. During an interview on 4/29/25 at 12:24 P.M., CNA #1 said that a gown and gloves should be worn when going into Resident #383's room. B. Resident #122 was admitted to the facility in February 2025 with diagnoses including urinary tract infection (UTI) and dementia. Review of Resident #122's active Physician's Orders indicated, but was not limited to, the following: -Contact Precautions every shift for VRE (Vancomycin-resistant Enterococcus, a type of bacteria that is resistant to the antibiotic Vancomycin) in urine [order date 3/27/25] Review of Resident #122's Care Plans indicated, but was not limited to, the following: -Focus: PRECAUTIONS: [Resident #122] is on contact precautions r/t (related to) VRE in his/her urine. 4-3-25 Continues with contact precautions r/t VRE/urine Interventions: Institute appropriate precautions as warranted (Contact precautions) -Focus: INFECTION: Resident has infection and is at risk for complication due to UTI, VRE evidenced by >100,000 vancomycin resistant enterococcus Interventions: Keep resident on isolation precaution as ordered Review of Resident #122's urine culture results from a urine sample obtained on 4/17/25 indicated the Resident tested positive for Vancomycin-resistant enterococcus. On 4/24/25 at 10:53 A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed the Director of Nursing standing in the Resident's room. The Director of Nursing stated she was waiting for another staff member to come and assist her to transfer the Resident into bed. The Director of Nursing had no PPE on. C. Resident #390 was admitted to the facility in April 2025 with diagnoses including repeated falls and dementia. On 4/28/25 at 11:59 A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. A CNA entered the Resident's room without donning PPE and exited without performing hand hygiene. The same CNA reentered the Resident's room on 4/28/25 at 12:02 P.M. without donning PPE and exited the Resident's room without performing hand hygiene. During an interview on 4/28/25 at 1:11 P.M., Nurse #1 said Resident #390 was transferred to the Elmwood Unit from another unit in the facility. Nurse #1 said that Contact Precautions had been implemented for Resident #390 while awaiting the results of his/her urine culture. Nurse #1 said that Resident #390 may have been exposed to a multi-drug resistant organism from his/her former roommate. Review of Resident #390's active Physician's Orders indicated an order was obtained for a UA C&S (urinalysis and urine culture and sensitivity) on 4/28/25. Further review indicated an order for Contact Precautions was entered on 4/29/25. Review of Resident #390's Progress Notes indicated, but was not limited to, the following: -4/28/25 at 11:17 A.M.: Resident #390 was moved to a room on the Elmwood Unit to reduce the risk of house acquired infection and a urine culture would be obtained to rule out UTI. -4/28/25 at 10:08 P.M.: Contact precautions maintained. During an interview on 4/29/25 at 12:29 P.M., the Infection Prevention Nurse said that for residents requiring Contact Precautions, all staff should be wearing at least a gown and gloves upon entry to the resident's room. The Infection Prevention Nurse confirmed that Resident #390 had been moved to another unit and Contact Precautions were initiated while the results of the Resident's urine culture were pending as he/she was possibly exposed to a multi-drug resistant organism. 49428 2. Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, updated 8/1/23, included but was not limited to the following: -All employees who handle, prepare, or serve food are trained in the practices of safe food handling and preventing foodborne illness; -Employees must wash their hands after engaging in other activities that contaminate the hands. On 4/23/25 at 8:48 A.M., the surveyor observed, on the Cherrywood Unit, staff serving meals to residents in resident rooms and in the Unit dining room with no hand hygiene performed between residents. The surveyor observed that staff did not offer hand hygiene to the residents prior to the meal. On 4/23/25 at 12:21 P.M., the surveyor observed the following on the Cherrywood Unit: -One staff member checking trays prior to distribution, no hand hygiene performed prior to this task; -Unit staff members not performing hand hygiene prior to passing trays to residents or between passing trays to residents; -clothing protectors delivered with trays to resident rooms. On 4/24/25 at 8:15 A.M., the surveyor observed six residents seated in the Driftwood Unit dining room waiting for breakfast. There was no observation of resident hand hygiene being performed. On 4/24/25 at 8:23 A.M., the surveyor observed staff serving meals to the residents in the Driftwood Unit dining room, still with no hand hygiene offered to or performed on the residents. The surveyor observed three of six residents eating food items with their bare hands. One resident in the dining room said he/she was not offered for his/her hands to be cleaned prior to the meal but that would be nice. During an interview on 4/24/25 at 8:34 A.M., the surveyor observed one Resident eating breakfast in his/her room. The Resident said he/she eats meals in his/her room and in the Driftwood Unit dining room. The Resident said staff does not offer to clean the Resident's hands and he/she usually takes his/her own wipes to the dining room to clean his/her hands prior to meals. The Resident said it would be a good idea if staff offered to clean residents' hands prior to meals. On 4/24/25 at 12:23 P.M., the surveyor observed 13 residents seated in the Cherrywood dining room with no observation of hand hygiene being offered to or performed on residents. On 4/24/25 at 12:31 P.M., the surveyor observed staff serving meals to the residents in the Cherrywood dining room. The surveyor observed staff removing food items from trays, cutting food, and donning clothing protectors on the residents. There was no observation of staff performing hand hygiene between these tasks. On 4/24/25 at 11:55 A.M., the surveyor observed, on the Applewood Unit, CNAs serving meals to residents with no observation of the CNAs practicing hand cleaning or sanitizing between residents. On 4/24/25 at 12:13 P.M., the surveyor observed, on the Cherrywood Unit, staff and CNAs serving meals to Residents in the unit dining room and to resident rooms with no observations of staff cleaning or sanitizing their hands between residents. On 4/24/25 at 12:24 P.M., the surveyor observed 14 residents in the Cherrywood Unit dining room. No hand hygiene had been offered to or performed on residents. On 4/24/25 at 12:33 P.M., the surveyor observed 14 residents in the Cherrywood Unit dining room had received their meals with no observation of staff offering or cleaning the residents' hands. During an interview on 4/24/25 at 12:40 P.M., the Director of Nursing (DON) said staff must sanitize their hands and the Residents' hands prior to meals.

Based on record review and interview, the facility failed to ensure for one Resident (#31), out of a total sample of 25 residents, recommended specialist appointments were scheduled. Specifically, the facility failed to ensure specialty eye appointments were scheduled. Findings include: Review of the facility's policy titled Ancillary Services, updated 8/1/23, indicated but was not limited to the following: -Services provided to our residents are performed in accordance with current acceptable standards of clinical practice; -Residents will be offered ancillary services including but not limited to, ophthalmology, audiology, podiatry, and psych services. If resident chooses services outside of ancillary services provided at the facility all efforts will be made to ensure they are seen; -Schedule of services will be provided with as much information as possible, in a timely fashion as possible; -Nursing staff will be responsible for reviewing any and all recommendations from the ancillary services and communicate that to the attending physician/nurse practitioner/physician's assistant for approval or refusal of the recommendation; -Nursing staff will be responsible to ensure that documentation is completed including but not limited to, documentation in nursing note of service provided, recommendations, notification of family and any feedback by the physician regarding orders, changes to plan of care, etc. Resident #31 was admitted to the facility in May 2023, status post corneal transplant surgery, with diagnoses that included major depressive disorder, anxiety disorder, chronic angle-closure glaucoma, corneal edema, corneal transplant status, and encounter for surgical aftercare following surgery on the sense organs. Review of the Minimum Data Set (MDS) assessment, dated 1/18/25, indicated Resident #31 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview on 4/28/25 at 9:52 A.M., Resident #31 said he/she would like to know what happened to his/her eye appointments. During an interview on 4/29/25 at 8:21 A.M., Unit Manager (UM) #3 said she was unaware of the Resident wanting to see a specialty eye doctor. On 4/29/25 at 8:27 A.M., Resident #31 told UM #3 and the Clinical Coordinator he/she would like to follow up with his/her eye specialist. During an interview on 4/29/25 at 8:50 A.M., Resident #31 said he/she was blind in the right eye and very impaired in the left eye. He/she was interested in continuing his/her care with the eye specialist because vision is important and that is where he/she had their eye surgery in May 2023. The Resident said his/her vision had worsened over time since the surgery. The Resident said CNA #2 escorted him/her to their last eye appointment, which was sometime in 2023, and he/she missed their last known scheduled appointment in 2023 because he/she was told there was no staff available to escort him/her off campus to the appointment. He/she said they kept asking nursing about scheduling the specialty eye appointments but either there was no one to escort the Resident or the Resident never received follow-up, so the Resident said he/she stopped asking about eye appointments. On 4/29/25 at 9:22 A.M., the surveyor telephoned the eye specialist's office and spoke with a member of the office staff. She said Resident #31 was last seen by the eye specialist in September 2023 and indicated there were several missed and canceled appointments after September 2023. She said he/she was supposed to have repeat surgery which was not scheduled. Review of the Eye specialist records, dated 9/29/23, indicated but were not limited to the following: 5/10/23 - Resident #31 had corneal transplant surgery on 5/10/23. The Resident remained in the hospital several days due to feeling unsafe for discharge. The Resident missed eye appointments on 5/17/23 and 5/18/23. 5/19/23 - Resident stated his/her vision had been improving but became blurry. 5/30/23 - Still at rehab. Reports vision has decreased significantly. 6/28/23 - Resident stated his/her eye was not doing any better, vision still not good. 8/16/23 - Resident stated his/her vision had been wavering with some days better than others. 9/29/23 - Resident stated his/her vision is much worse in the left eye, and he/she had not been getting Latanoprost (an ophthalmic solution used to reduce pressure inside the eye) and he/she ran out of Combigan (a prescription eye drop that lowers pressure inside the eye) the day prior and needs a refill. Review of Resident #31's medical record indicated, but was not limited to, the following: Nurse Practitioner note, dated 9/30/24, stated the Resident's vision remained poor and he/she thought it was getting worse. Assessment and Plan: corneal edema - stable, followed by ancillary eye specialist. He/she has virtually no vision in his/her right eye. He/she is upset that his/her vision seems to be getting worse. Follow up with eye specialist. During an interview on 4/29/25 at 11:39 A.M., Unit Manager (UM) #3 said Resident #31 was admitted to the facility in May 2023 from the eye clinic status post eye surgery. UM #3 reviewed the Resident's medical records and said the last nursing note associated with an eye appointment was on 11/20/23 and stated Resident #31 was scheduled for a specialist eye appointment on 11/21/23 and the ride was booked, but there was no further documentation of the appointment or future appointments. UM #3 said she was unsure of what the plan was for ancillary specialty eye services for Resident #31. During an interview on 4/29/25 at 12:45 P.M., Certified Nursing Assistant (CNA) #2 said she had escorted the Resident to multiple eye appointments and could not recall the date of the last appointment as it was likely over a year ago. Further review of the Resident's medical record indicated, but was not limited to, the following: Nurse Practitioner note, dated 1/3/25, stated Assessment and Plan: Glaucoma stable, followed by eye specialist. Patient with decreased vision in left eye. He/she has virtually no vision in right eye. Continues on multiple eye drops for left eye. Follow up with eye specialist. During an interview on 4/29/25 at 2:45 P.M., the Clinical Coordinator said Resident #31 missed some his/her initial follow-up eye appointments due to emotional struggles regarding his/her vision. The Clinical Coordinator said, other than that, he was unaware of any issues with scheduling or transporting the Resident to ancillary specialty eye care services. During an interview on 4/29/25 at 2:45 P.M., the Director of Nursing (DON) said she expected staff to track residents' ancillary service recommendations, needs, and preferences. She said the UM was responsible for scheduling ancillary appointments and the facility would honor a resident's preference for an escort to assist them to their appointment. The DON said she would expect staff to notify her of any issues scheduling or getting a Resident to ancillary appointments. The DON said Resident #31 should have had a continuation of specialty eye services per recommendation, request, or as needed.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen was maintained in a sanitary and safe condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, updated 8/1/23, included but was not limited to the following: Cleaning and Sanitation of Kitchen Surface: -all surfaces in kitchen are to be maintained with cleanliness and sanitation; -all vents shall be clean and free from debris. On 4/23/25 at 7:33 A.M., the surveyor observed, in the main kitchen, a build up of dust on the air handler above clean trays. On 4/28/25 at 11:50 A.M., the surveyor observed the following in the main kitchen: -Large dust clumps throughout the vent grate located in the main kitchen area; -Splotches of dust attached to numerous ceiling tiles located in the main kitchen area; -Yellow/white, raised powdery substance and dust throughout shelving in the walk-in refrigerator; -Black, raised buildup and dust throughout the condenser fan covers in the walk-in refrigerator. During an interview on 4/28/25 at 11:55 A.M., the Food Service Director (FSD) said maintenance would need to remove the walk-in refrigerator condenser fan covers in order to clean them, and she was unsure whether the covers were on the maintenance department's cleaning schedule. The FSD said the fan covers should be free of buildup and debris. During an interview on 4/29/25 at 3:00 P.M., the Director of Maintenance said he did not perform any cleaning or maintenance tasks in the main kitchen other than maintenance requests to fix broken items. During an interview on 4/29/25 at 3:05 P.M., the Director of Housekeeping said his department does not perform any cleaning tasks in the main kitchen. The floor technician, who sometimes performs cleaning tasks, said he has never cleaned in the main kitchen. Review of Weekly Cleaning Assignments for January, February, and March indicated, but was not limited to, the following task: Walk-in refrigerator - Fan and Shelving, Remove fan cover; thoroughly wipe all shelving. All weeks were initialed by staff indicating the task was completed for all weeks in January, February, and March. During an interview on 4/29/25 at 2:15 P.M., the surveyor and FSD observed the buildup and dust in the ceiling vents, on the ceiling tile, and on the walk-in refrigerator shelving. The FSD said vents, ceiling tiles, and shelving should be clean and free of buildup and debris. During an interview on 4/29/25 at 2:50 P.M., the Clinical Coordinator said he expected the main kitchen to be clean and surfaces free of buildup.

Based on document review, observation, and interview, the facility failed to develop, implement, and individualize comprehensive plans of care for two Residents (#126, #109), out of a total sample of 25 residents. Specifically, the facility failed: 1. For Resident #126, to develop and implement a care plan for the Resident's biliary drains (tubes inserted in the bile ducts to treat a blockage) and portacath (a type of central venous line that is surgically inserted beneath the skin and leads into the heart that is used to administer intravenous (IV) fluids and medications and to take blood samples); and 2. For Resident #109, to ensure the Resident's skin care plan addressed the Resident's current skin condition of a heel pressure ulcer. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 8/1/23, indicated but was not limited to the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. -The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that wound otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR (Preadmission Screening and Resident Review) recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Resident #126 was admitted to the facility in March 2025 with diagnoses including gallbladder cancer with metastasis to the liver, duodenum, and peritoneum; protein-calorie malnutrition; bile duct obstruction; and bacteremia (bacterial infection of the bloodstream). Review of Resident #126's hospital Discharge Summary, dated 3/7/25, indicated the Resident underwent portacath placement in February 2025 and left and right biliary drain placements in January 2025. Review of Resident #126's medical record indicated that the Resident's biliary drains were exchanged on 4/9/25. Review of the active Physician's Orders for Resident #126 included but was not limited to: -Flush biliary drain twice daily with 0.9 NaCl (Sodium Chloride) 10ml (milliliters) [order date 3/7/25] -Chlorhexidine Gluconate Cloth External Pad 2% Apply to L and R nephrostomy site topically every evening shift every Fri for Dressing change Biliary tube sites [order date 3/24/25] -Sodium Chloride Solution 0.9% Use 10ml via irrigation every date and evening shift [order date 3/7/25] Review of the current care plans for Resident #126 failed to indicate a care plan was developed reflecting the presence and/or care of the Resident's portacath and biliary drains. Review of the manufacturer's guide indicated it was recommended the portacath be flushed with 5ml of heparinized saline every four weeks when not in use. During an interview on 4/23/25 at 9:09 A.M., Resident #126 said he/she has two drains in his/her abdomen that the nurses at the facility were managing. Resident #126 said he/she had received intravenous fluids through an IV in his/her arm for a few days, but the IV had since been removed. During an interview on 4/29/25 at 8:42 A.M., Unit Manager #2 said she did not know if there were any physician's orders and/or a care plan in place reflecting the presence of and/or maintenance of the portacath that Resident #126 had placed in February 2025. The surveyor showed Unit Manager #2 the portacath information included in the Resident's hospital Discharge Summary. Unit Manager #2 said she would get more information from the Director of Nursing and report back to the surveyor. During a subsequent interview on 4/29/25 at 9:08 A.M., Unit Manager #2 said that Resident #126's chemotherapy was on hold while he/she was at the facility and that the nurses at the facility were not accessing the Resident's portacath to administer medications or maintenance flushes. Unit Manager #2 said that the Resident's portacath and biliary drains should have been included in the Resident's care plan. During an interview on 4/29/25 at 9:29 A.M., Resident #126 showed the surveyor where his/her portacath was located. The Resident said that when he/she was in the hospital in March, the nurses there were administering antibiotics and fluids through the portacath access. The Resident said at the facility, the nurses did not access the Resident's portacath but an additional IV was placed in his/her arm. During an interview on 4/29/25 at 10:24 A.M., the Director of Nursing said that it is her expectation that devices such as biliary drains, IVs, etc. be care planned for all residents. The Director of Nursing said that the facility staff were capable of accessing and caring for Resident #126's portacath, but currently were not performing maintenance to maintain patency. 49428 2. Resident #109 was admitted to the facility in January 2024 with diagnoses including dementia and history of falling. Review of the Minimum Data Set (MDS) assessment, dated 4/5/25, indicated Resident #109 had one unhealed, unstageable pressure ulcer and was receiving pressure ulcer care. During an interview on 4/24/25 at 8:44 A.M., the wound doctor said Resident #109 had a heel pressure ulcer that he was following. Review of current care plans for Resident #109 failed to indicate the presence of the Resident's heel pressure ulcer, but did indicate the Resident had a pressure ulcer on his/her elbow and buttock. During an interview on 4/29/25 at 12:34 P.M., Unit Manager (UM) #3 reviewed Resident #109's care plan. UM #3 said the care plan indicated the Resident had pressure ulcers on his/her elbow and buttock. UM #3 said the elbow and buttock pressure ulcers had resolved and the Resident only had the heel pressure ulcer which was not indicated in the care plan. UM #3 said Resident #109's care plan should have been updated to reflect the resolved pressure ulcer and the care plan should indicate the current heel pressure ulcer. During an interview on 4/29/25 at 2:37 P.M., the Director of Nursing (DON) said Resident #109's skin care plan should have been updated to reflect the Resident's current skin condition of a heel pressure ulcer.

Based on interviews and record review, the facility failed to ensure two Residents (#23, #110), in a sample of 25 residents, were seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated. Specifically, the facility failed: 1. For Resident #23, to ensure the Resident was seen by the Physician at least every 120 days after the first 90 days after admission; and 2. For Resident #110, to ensure the Resident was seen by the Physician at least every 120 days after the first 90 days after admission. Findings include: 1. Resident #23 was admitted to the facility in December 2023 with diagnoses including dementia and chronic kidney disease. Review of the Physician's Progress Notes indicated Resident #23 was seen by the Physician for an initial visit in December 2023. The Physician's Progress Notes indicated that the Resident was not seen by the Physician again until 2/25/25. All interval visits between December 2023 and February 2025 were conducted by the NP. During an interview on 4/29/25 at 1:57 P.M., Unit Manager #3 said the NP who works with the Resident's Attending Physician is typically in the facility on Mondays, Wednesdays, and Fridays and sees the residents more routinely. Unit Manager #3 said that she does not track Physician visits or know when each resident must be seen by the Physician. Unit Manager #3 said she was aware of the regulatory requirement for Physician visits. During an interview on 4/29/25 at 2:45 P.M., the Director of Nursing (DON) said she expected the Physician visits to occur once every 30 days for the first 90 days after a resident is admitted , and then the frequency is once every 60 days with visits alternating between the Physician and NP. The DON said Resident #23 should have had alternating visits by the Physician and NP. 49428 2. Resident #110 was admitted to the facility in August 2024 with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), and hypertension. Review of the Physician's Progress Notes indicated Resident #110 was last seen by the Physician on 8/27/24. Further review of the medical record indicated all subsequent visits were completed by the Nurse Practitioner (NP), indicating Resident #110 had not been seen by a Physician in 245 days. Further review of Resident #110's medical record indicated there were 74 days between the NP's visits on 10/14/24 and 12/27/24. During an interview on 4/29/25 at 2:45 P.M., the DON said she expected the Physician visits to occur once every 30 days for the first 90 days after a resident is admitted , and then the frequency is once every 60 days with visits alternating between the Physician and NP. The DON said Resident #110 should have had timely and alternating visits by the Physician and NP.

Based on observation, record review, and interview, the facility failed to prevent a decline in range of motion causing the development of bilateral hand contractures (shortening and hardening of tissues leading to rigidity of joints) for one Resident (#52), out of a total sample of 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion (ROM), dated 8/1/23, indicated but was not limited to the following: -As part of the resident's comprehensive assessment, the nurse will identify the resident's: current range of motion of his/her joints; limitations in movement or mobility; opportunities for improvement; and previous treatment and services for mobility. -As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility. -The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. -The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. -Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. -The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. -Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. Resident #52 was admitted to the facility in August 2020 with a diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement). On 4/16/24 at 11:09 A.M., the surveyor observed Resident #52 lying in bed with their arms crossed on their chest, the left and right hand were observed to have fingers closed to the palm (no hand positioning devices were observed). Review of the Minimum Data Set (MDS) assessment, dated 2/24/24, section GG Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion indicated Resident #52 had no impairments in the upper extremities. Review of the Patient Screening from the Rehabilitation (Rehab) Department, dated 8/7/2020, indicated Resident #52's ROM (range of motion) is WFL (within functional limits) throughout and the Resident was able to ambulate 200 feet with a rolling walker. Review of the Physical Therapy Evaluation and Plan of Treatment, dated 6/30/22, indicated Resident #52 demonstrated flexion contractures of bilateral shoulders, elbows, and hands. Review of the Physician's Progress Note, dated 3/1/24, indicated Resident #52 had bilateral upper extremity contractures. Review of the care plans indicated Resident #52 had Parkinson's disease with progression of symptoms including rigid muscles (any part of the body-may even be painful and limit my range of motion), with a goal of not experiencing further progression of current symptoms through next review, with an intervention of utilizing Baclofen (a medication used to help relax muscles) to help with stiffness. Review of the medical record, including care plans, failed to indicate the upper extremity contractures and the goal and interventions associated with the limited range of motion. On 4/17/24 at 2:32 P.M., the surveyor observed Resident #52 lying in bed with their arms crossed on their chest, the left and right hand were observed to have fingers closed to the palm, no positioning devices were observed. During an interview with observation on 4/18/24 at 12:07 P.M., the surveyor observed Resident #52 lying in bed with his/her arms crossed on their chest with bilateral fingers closed to the palm. Nurse #5 said she was unable to fully extend fingers on either hand of Resident #52 and she would have to contact Occupational Therapy to determine if the Resident needed any positioning devices for their hands. She said she had been working on this unit for several months and the Resident had presented this way for that amount of time. During an interview on 4/18/24 at 1:00 P.M., the Certified Occupational Therapy Assistant (COTA) said Resident #52 had not previously received Occupational Therapy (since Admission over three years prior). She said the process was that if a Resident presented with a decrease in range of motion, then the nurses would refer a resident to the Rehab Department to determine if assistive devices should be used. During an interview on 4/18/24 at 3:21 P.M., Unit Manager #4 said she observed Resident #52 to have contractures and reviewed the medical record and was unable to find any interventions or plan for the contracted hands. During an interview on 4/18/24 at 3:32 P.M., the Director of Rehab said she had screened Resident #52 following the surveyor's inquiry and would be conducting an evaluation based on Resident #52 having bilateral hand contractures. She said she reviewed the admission screening from 2020 which did not indicate Resident #52 had hand contractures or needed assistive/positioning devices. She said Resident #52 would benefit from passive range of motion to decrease the risk of further contracture. She said she was unable to tell what the Resident's previous baseline was or when the hand contractures developed. During an interview on 4/19/24 at 9:50 A.M., Certified Nursing Assistant (CNA) #6 said she cleans the inside of the hands of Resident #52 daily. She said it is difficult to open the Resident's hands or move the arms, so she leaves the fingers in the down position (closer to the palm) to clean the inside of the hands. She said she did not know how long the Resident's hands had been unable to open fully. During an interview on 4/19/24 at 1:15 P.M., the MDS coordinator said during the MDS assessment a Resident should be physically assessed for limited range of motion and she was unable to determine when Resident #52 developed bilateral upper extremity contractures based on the MDSs. During an interview on 4/19/24 at 1:23 P.M., the Assistant Director of Nurses said the process for when a resident had a decline in range of motion was for the CNAs to notify the nurses and the nurses would notify the physicians to determine the interventions and plan. She reviewed the care plans for Resident #52 and was unable to determine when the hand contractures developed and what the plan or interventions were for the contractures. Review of the Occupational Therapy Evaluation and Plan of Treatment, dated 4/19/24, indicated Resident #52 had flexor hand/finger contractures at the metacarpophalangeal joint (knuckle) of digits 2 through 5 on both hands. The assessment indicated it was recommended to wear left and right hand rolls for two hours on and two hours off maximum in the beginning to improve passive range of motion for adequate hygiene, reduce pain caused by joint deformity, inhibit abnormal reflex patterns, inhibit abnormal positions, develop/establish wearing schedule, manage tone and maintain joint integrity.

Based on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to: 1. Ensure monitoring of antibiotic use that did not meet criteria for antibiotic treatment was completed for three Residents #291, #61, and #78, out of a total sample of 26 residents; and 2. Ensure a stop date or clinical rationale was provided for continued use of an antibiotic for one Resident #20, out of a total sample of 26 residents. Findings include: 1. Review of the facility's policy titled Antibiotic Stewardship, dated as updated 8/1/23, indicated but was not limited to the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program -The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents -Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: drug name, dose, frequency of administration, duration of treatment, start and stop date, number of days of therapy, route of administration and indications for use -When a nurse calls a physician/prescriber to communicate a suspected infection, he/she will have the following information available: Signs and symptoms, when symptoms were first observed, resident's hydration status, current medication list, allergy information, infection type, and time of the last antibiotic dose. -When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order. -When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the facility's policy titled Antibiotic Stewardship - Orders for Antibiotics, dated as updated 8/1/23, indicated but was not limited to the following: -Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis; and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy began while culture was pending). -Empirical use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the clinical record. Review of the facility's policy titled Surveillance for Infections, dated as updated 8/1/23, indicated, but was not limited to the following: -The infection preventionist (IP) or designated infection control personnel is responsible for gathering and interpreting data. -The surveillance should include a review of any or all of the information to help identify possible indicators of infections: antibiotic review Review of the facility's policy titled Infections - Clinical Protocol, dated as updated 8/1/23, indicated, but was not limited to the following: -Based on review of the clinical situation, the physician or provider and staff will identify whether antibiotics are warranted or whether those that have already been started should continue or change. During an interview with the Director of Nursing (DON) and Staff Development Coordinator (SDC) on 4/22/24 at 9:16 A.M., the DON said she is working as the facility's Infection Preventionist (IP) and the SDC is assisting her. The DON said the facility uses McGeer criteria sheets to determine if an infection meets criteria for antibiotic use. The SDC said she is responsible for tracking, monitoring and reviewing antibiotic use in the facility, and she completes and maintains the tracking documents titled Line Listings, for all antibiotic use in the facility. Review of the facility provided tracking documents titled Line Listings, indicated but were not limited to the following: February 2024 - Resident #291 documented as having a urinary tract infection (UTI) with McGeer criteria not being met but was treated with Cipro (an antibiotic). Review of the medical records for Resident #291 failed to indicate a review of the antibiotic use had been completed by the IP or designee and communicated to the physician or nurse practitioner. March 2024 -Resident #61 documented as having a UTI with McGeer Criteria not being met but was treated with Levaquin (an antibiotic). -Resident #78 documented as having a UTI with McGeer Criteria not being met but was treated with Amoxicillin (an antibiotic). Review of the medical records for Resident #61 and #78 failed to indicate a review of the antibiotic use had been completed by the IP or designee and communicated to the physician or nurse practitioner. During an interview on 4/22/24 at 9:37 A.M., both the DON and SDC reviewed the identified issues with Residents #291, #61, and #78 and said they could not locate any additional information or documentation that would indicate any antibiotic reviews had occurred by the IP or designee. The SDC said she sometimes completes reviews with the MD/NP verbally, but does not recall completing an antibiotic review, and there is no documentation in the medical record. The DON said her expectation is for resident use of antibiotics to be reviewed with the MD/NP shortly after initiation, and the outcome of the review to be documented in the medical record. During an interview on 4/22/24 at 9:51 A.M., the DON said the antibiotic stewardship program is not being followed properly as it should be per the facility's policies. 48084 2. Resident #20 was admitted to the facility in December 2023 with diagnoses which included urinary tract infection (UTI), chronic kidney disease, weakness, dehydration, and failure to thrive. Review of the discharge summary from the acute care hospital, dated 12/22/23 indicated but was not limited to the following: -Urine culture was positive for a UTI and was treated with five-day course of antibiotics. -Resident's outpatient Urologist office was contacted and there is NO PLAN for prophylactic antibiotics at this time. -Discharge Medication list did not include an antibiotic. Review of the Physician's Progress Note, dated 12/27/23, indicated Resident was admitted after being treated for a UTI and the current medication list did not include an antibiotic. Review of the Physician's Progress Note, dated 12/29/23, indicated the Nurse Practitioner (NP) spoke to the daughter, who spoke to the Urologist; Urologist sent over a prescription, and apparently, they do want him/her on Bactrim (antibiotic) daily, prophylactically to prevent UTIs. Review of the Physician's Progress Note/Admission History and Physical for Long Term Placement, dated 2/6/24, indicated the Resident was recently diagnosed and treated for a UTI and was status post antibiotics. Further review of the note failed to indicate the Resident was on prophylactic antibiotics. Review of the Physician's Progress Note, dated 3/15/24, indicated Resident #20 per their Urologist was on prophylactic Bactrim daily. Further review of the note failed to indicate a clinical rationale for the prophylactic antibiotic. Further review of the medical record failed to indicate a clinical rationale from any provider (Physician, NP, or Urologist) for the continued use of the Bactrim. Unit Manager #3 was unable to locate any documentation since admission from the Urologist indicating the need for prophylactic antibiotics. Review of the Physician's Orders indicated the following: -Bactrim 400-80mg once daily for UTI for 7 days (order written and was discontinued on 12/27/23) -Bactrim 400-80mg once daily for UTI (started 12/30/23 and ended 1/31/24) -Bactrim 400-80mg once daily for UTI (started 1/31/24) Review of the Medication Administration Record (MAR) indicated Resident #20 had received Bactrim once daily as ordered since December 2023. Further review of the progress notes failed to indicate the need for prophylactic antibiotics or why the stop date was removed from the order. Additionally, the Resident had no documented symptoms of a UTI. Review of the Comprehensive Care Plan failed to indicate Resident #20 was on prophylactic antibiotics. During an interview on 4/18/24 at 1:25 P.M., Nurse #6 said she was not sure why Resident #20 was on the Bactrim but assumed it was because he/she had a history of UTIs. During an interview on 4/18/24 at 10:37 A.M., Unit Manager (UM) #3 said she was unable to get any documentation from the Urologist's office indicating he wanted the Resident on prophylactic antibiotics, if so why, and for how long. UM #3 said she had not spoken to the Urologist's office until today and there was no indication any staff had spoken to the office regarding the prophylactic treatment. UM #3 said there should be documentation in the medical record indicating facility staff and Urology discussed the plan regarding the continued use of the Bactrim, how long he/she should be on it and what the indication for long term use was and there was not. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nurses (ADON) said she thinks the Bactrim order came from the Urologist's office and the physician here just kept it. Additionally, she said she tracks it on the line list but there is no documented clinical indication for use in the record that she could find. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said her expectation for prophylactic antibiotics is that the rationale for long term continued use of antibiotics be documented in the medical record and that there be a trial dose reduction to ensure the medication is needed. The DON said the order should be clear, what they are on, for how long, and the reason they need to be on it and this order is not in line with the Antibiotic Stewardship policy with no rationale for prophylactic treatment.

Based on observation, interview, and policy review, the facility failed: 1. To ensure transmission-based precautions (TBP), specifically contact precautions, were implemented according to Centers for Disease Control and Prevention (CDC) guidance, for one Resident (#44), out of three sampled residents; and 2. To ensure staff implemented infection control practices and performed hand hygiene when performing wound care. Findings include: 1. Review of the facility's policy titled Standard Precautions, dated as last revised 8/1/23, indicated but was not limited to the following: -Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected, or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. -Hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water before and after resident contact and after contact with items in the resident's room. -Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact (refer to CDC isolation precaution guidelines). -Gowns (clean, non-sterile) are worn to protect skin and prevent soiling of clothing during procedures and resident care activities. Review of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised 8/1/23, indicated but was not limited to the following: -Hand hygiene is the primary means to prevent the spread of infection. -Use an ABHR or soap and water for the following situations: before and after direct contact with residents, before preparing or handling medications, after contact with objects in the immediate vicinity of the resident, before and after entering isolation precaution setting. -Single use disposable gloves should be used when in contact with a resident, or the equipment, or environment of a resident, who is on contact precautions. Review of the facility's policy titled Isolation-Notices of TBP, dated as last revised 8/1/23, indicated but was not limited to the following: -Notices will be used to alert personnel and visitors of TBP, while protecting the privacy of the resident. -When TBP are implemented, notification is placed on the room entrance, so personnel or visitors are aware of the need for and type of precautions. -Contact Precautions: A sign indicating Contact Precautions on the door to the resident's room. Review of the CDC Contact Precautions Sign being used by the facility, undated, indicated but was not limited to the following: STOP: CONTACT PRECAUTION: EVERYONE MUST: -Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: -Put on gloves before room entry. -Discard gloves before room exit. -Put gown on before room entry. -Discard gown before room exit. Resident #44 was admitted to the facility in August 2023 with diagnoses which included open wound left lower leg, open wound right lower leg, and methicillin resistant staphylococcus aureus (MRSA) infection. The surveyor made the following observations of Resident #44: -4/16/24 at 12:14 P.M., Contact Precautions sign posted at the entrance to Resident #44's room, he/she was walking around the room. -4/17/24 at 12:29 P.M., Contact Precautions sign posted at the entrance to Resident #44's room, he/she was sitting on bed eating lunch; Resident #44's lower extremities from sock to knee were visible with dressings on both. -4/17/24 at 1:11 P.M., CNA #1 entered the room with no gloves or gown on, picked up lunch tray and exited the room. CNA #1 placed the lunch tray in the meal cart and did not perform hand hygiene after. -4/17/24 at 1:12 P.M., Nurse #2 entered the room with no gloves or gown on, stood at bedside talking to Resident #44, he then exited the room, did not perform hand hygiene, walked to the medication cart in the hallway, poured mediations for Resident #44, walked back to room, entered the room, again with no hand hygiene, no gloves, no gown, and administered the medications. Nurse #2 then exited the room with no hand hygiene. Review of Resident #44's medical record including physician orders, treatment administration record (TAR), progress notes, and care plans indicated but were not limited to the following: -Contact Precautions related to MRSA every shift for MRSA to wounds (1/19/24). -Doxycycline 100 milligrams (mg) twice daily for wound infection (4/13/24). -TAR indicated Contact Precautions had been signed off as administered daily as ordered. -Progress note dated 4/5/24 indicated wound culture remains positive for MRSA. -Comprehensive Care Plan indicated that Resident was on Contact Precautions for MRSA to wound. During an interview on 4/17/24 at 1:18 P.M., CNA #1 said Resident #44 is on contact precautions for MRSA and we only need personal protective equipment (PPE) (gloves and gowns) when washing the Resident or doing wound care. During an interview on 4/17/24 at 1:16 P.M., Nurse #2 said the Resident did not have an active infection and he/she was on Enhanced Barrier Precautions (EBP) and did not know why the Contact Precaution sign was there. Additionally, he said the EBP doesn't really mean anything, just that we need PPE for dressing changes, they are not real precautions, and you don't need PPE to enter the room. During an interview on 4/17/24 at 1:20 P.M., Unit Manager #3 said Resident #44 is on Contact Precautions for MRSA in the wounds on both legs. She said the wounds were recently re-cultured and are still positive for infection and he/she is on a course on antibiotics to treat the infection. Additionally, she said there may be some confusion with EBP versus Contact Precautions and who needs what PPE and when, but Resident #44 has an active infection, is on Contact Precautions, and staff should be following the sign which indicates the need for hand hygiene, gloves, and gowns to enter the room. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nurses (ADON) said staff should be following the signs posted on the door and with Contact Precautions they should have full PPE (gloves and gown) per the sign, and they should be performing hand hygiene before entering and after exiting the room. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said with Contact Precautions staff should have full PPE (gloves and gown) per the sign. Additionally, they should be doing hand hygiene before entering and after exiting the room, including picking up a tray and before and after med administration. 36542 2. Review of the facility's policy titled Wound Care, dated as revised 8/1/23, indicated but was not limited to: -Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. -Wash and dry your hands thoroughly. -Put on exam glove. Loosen tape and remove dressing. -Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Put on gloves. -Apply treatment as indicated. -Remove disposable gloves and discard. Wash and dry your hands thoroughly. Resident #28 was admitted to the facility in December 2023. Review of the medical record indicated Resident #28 had a wound to the third toe on the left foot. On 4/18/24 at 2:11 P.M., the surveyor observed Nurse #4 perform wound care for Resident #28 as follows: -Enter the Resident's room and place treatment supplies on the Resident's overbed table (failed to clean the table) -Remove (with bare hands) the left sock of Resident #28, exposing the wound, which was not covered -Put on gloves (failed to perform hand hygiene prior to putting on gloves) -Provide treatment and remove the gloves Unit Manager #4 entered during the treatment to observe the foot of Resident #28. Unit Manager #4 was observed to put on a pair of gloves and directly touch the foot of Resident #28. Unit Manager #4 then walked to the nightstand and picked up a pair of eyeglasses and attempted to put a lens in the glasses (with the same gloves that had been touching the Resident's foot). During an interview on 4/18/24 at 2:40 P.M., Nurse #4 said she did not clean the overbed table prior to putting the supplies down and she did not perform hand hygiene after removing the sock. During an interview on 4/18/24 at 4:35 P.M., the Director of Nurses said hand hygiene should be performed prior to putting on gloves and gloves should be removed, and hand hygiene performed prior to touching eyeglasses.

Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products and maintain safe and clean equipment in four of four nourishment kitchenettes. Findings include: Review of the facility's policy titled Food Safety for Your Loved One, undated, indicated but was not limited to: - If you plan to bring food and/or beverages into the facility for your loved one, please make sure that the food is handled safely to prevent the risk of food-borne illness. - Food and beverages should be labeled and dated to monitor food safety. - Food and beverages in unmarked or unlabeled containers should be marked with the name of the resident and date that the food item was prepared. - Food and beverages with a hand-written label should be thrown away three days after the date marked. The date being Day 1. - Food and beverages that have gone beyond the manufacturer's expiration date should be thrown away. - Microwave ovens and food thermometers or similar device will be available on the unit. On 4/16/24 at 2:56 P.M., the surveyor observed the following on the Applewood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top, bottom, and sides. - The inside of the microwave had paper towels covering the rotating glass plate. - The refrigerator had an opened package of marshmallow candy without resident identification or opened date. On 4/16/24 at 3:11 P.M., the surveyor observed the following on the Elmwood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top, bottom, and sides. - A bottle of nectar thick lemon water in the refrigerator was opened with an open date of 3/29/24. The manufacturer label on the bottle indicated the product should be discarded 10 days after opening. On 4/16/24 at 3:23 P.M., the surveyor observed the following on the Driftwood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The glass plate on the inside of the microwave had food residue. - A 12-ounce bottle of Celsius energy drink and a 16-ounce bottle of unsweetened iced tea were located on the top shelf of the refrigerator without a date or resident identification label. - A carton of orange juice was opened in the refrigerator and was not labeled with an open date. On 4/16/24 at 3:31 P.M., the surveyor observed the following on the Cherrywood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The top plastic portion of the inside of the microwave had bubbling and was breaking apart. - An opened two-liter Coca Cola Zero bottle was on the top shelf of the refrigerator without date or resident identification. - One carton of orange juice, one carton of apple juice, and one carton of cranberry juice were opened and undated in the refrigerator. - Two pieces of pizza were wrapped in aluminum foil in the freezer without a date or resident identification. On 4/17/24 at 12:31 P.M., the surveyor observed the following on the Applewood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top, bottom, and sides. On 4/17/24 at 1:09 P.M., the surveyor observed the following on the Driftwood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The glass plate on the inside of the microwave had food residue. - A 12-ounce bottle of Celsius energy drink and a 16-ounce bottle of unsweetened iced tea were located on the top shelf of the refrigerator without a date or resident identification label. - A carton of orange juice and a carton of apple juice were open in the refrigerator and were not labeled with an open date. On 4/17/24 at 1:15 P.M., the surveyor observed the following on the Cherrywood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The top plastic portion of the inside of the microwave had bubbling and was breaking apart. - Two pieces of pizza were wrapped in aluminum foil in the freezer without a date or resident identification. During an interview on 4/17/24 at 1:45 P.M., the Food Service Director (FSD) said nourishment kitchenettes on each unit are cleaned and stocked daily. The FSD said a dietary aide stocks the nourishment kitchenettes each morning and cleans the inside of the refrigerator. The FSD said a dietary staff member does a deeper cleaning of the unit refrigerators and freezers on Mondays and Wednesdays each week. The FSD said the housekeeping department is responsible for cleaning and maintaining the rest of the nourishment kitchenettes. The FSD said the dietary aides stocking the nourishment kitchenettes would discard any items in the refrigerators or freezers that were not properly labeled. The FSD said when stock items are opened by staff on the units, they are to be labeled with the open date and a use by date that is three days after opening. The FSD said items specifically for a resident should be labeled with their name and the date the item entered the facility. The FSD and the surveyor reviewed the findings of the nourishment kitchenettes. The FSD said all items in the unit refrigerators should be properly labeled based on the facility's policy. During an interview on 4/17/24 at 3:21 P.M., the Housekeeping Manager and the surveyor reviewed the findings of the nourishment kitchenettes, specifically the unit microwaves. The Housekeeping Manager said his department is responsible for maintaining and cleaning the unit microwaves daily. The Housekeeping Manager said there should be no food residue left on the inside of the microwaves. The Housekeeping Manager said it was not safe for the microwave of the Cherrywood Unit Kitchenette to have inside plastic bubbling or broken.

Based on record review, interview, observation, and policy review, the facility failed for five Residents (#109, #37, #106, #52, and #70), out of 26 sampled residents, to develop and implement individualized resident-centered care plans to meet the residents' needs. Specifically, the facility failed: 1. For Resident #109, to implement the care plan for the use of cushioned floor mats at the bedside as a fall intervention; 2. For Resident #37, to consistently implement the care plan for the use of a right-hand Carrot (orthotic device in the shape of a carrot used to prevent worsening hand contracture); 3. For Resident #106, to develop a care plan for the use of long term antibiotics/urinary tract infection (UTI) prophylaxis; 4. For Resident #52, to develop a care plan to include goals and interventions for a Resident with limited range of motion; and 5. For Resident #70, to ensure staff implemented the care plan and placed the Resident's meal in their visual field and provided assistance with feeding during meals. Findings include: Review of the facility's policy titled: Care plans, comprehensive person-centered, updated 8/1/23, indicated but was not limited to the following: -a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident -the comprehensive care plan includes: measurable objectives, describes services that are to be furnished, includes resident's goals, builds on resident's strengths, reflects current recognized standards -care plan interventions are chosen only after data gathering and proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making -interventions address the underlying source of the problem, when possible, not just symptoms or triggers -assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change 1. Resident #109 was admitted to the facility August 2023 with the following diagnoses: unspecified dementia with other behavioral disturbance, restlessness and agitation, and adjustment disorder with mixed disturbance of emotions and conduct. Review of Resident #109's care plan, as of 4/18/24, indicated but was not limited to the following: Focus: I have the potential for falling due to but not limited to alteration in perception and or cognition with decreased safety awareness and/or impulsivity, cardiac dysfunctions, dementia, diabetes, incontinent, potential medication side effects. Resident had a fall on 10/16/23. Goal: I will not have any fall related injury though my next review. Interventions: mats placed beside bedside to prevent injury (date initiated 9/11/2023) The surveyor made the following observations of Resident #109: -4/16/24 at 3:16 P.M., Resident was in bed with no mats placed at the bedside. -4/17/24 at 8:04 A.M., Resident was in bed with no mats placed at the bedside. -4/18/24 at 10:37 A.M., Resident was in bed with no mats placed at the bedside. -4/22/24 at 7:50 A.M., Resident was in bed with no mats placed at the bedside. During an interview on 4/18/24 at 10:37 A.M., Unit Manager #4 said Resident #109 used to have floor mats because he/she would exhibit a behavior of putting himself on the floor and he/she has a history of falls. She said Resident #109 has a scoop mattress now, but the care plan should have been updated if floor mats are not part of the plan of care. She said she wasn't sure when the maintenance director took the floor mats out of the Resident's room. 2. Review of the facility's policy titled Resident Mobility and Range of Motion, dated 8/01/2023, indicated but was not limited to the following: -Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. -Interventions may include therapies, the provision of necessary equipment and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Resident #37 was admitted to the facility in May 2018 with diagnoses including but not limited to personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of the most recent Brief Interview for Mental Status (BIMS) assessment indicated Resident #7 scored a 3 out of 15 indicating severe cognitive impairment. Review of the current Physician's Orders for Resident #37 as of 4/18/24 indicated but were not limited to the following: -Remove Carot (sic) for right hand during am care. Every day shift for poor skin integrity. Remove Carot (sic) to right hand with A.M. care. -To preserve skin integrity, apply Carot (sic) to right hand with P.M. care. Monitor skin integrity related to contracture. Every evening shift for poor skin integrity on with P.M. care and off with A.M. care. Review of the care plans for Resident #37, as of 4/18/24, indicated but were not limited to the following: Focus: - Skin Breakdown Potential: I have a potential for skin breakdown related to but not limited to right hand contracture Goal: -I will remain without any pressure related areas of skin breakdown through my next review (date initiated 5/27/2020, revised on 12/12/2023, target date 4/19/2024) Interventions: -Please insure (sic) that my Right-hand roll is properly placed as ordered by my MD. Inspect my skin and notify my MD for anything abnormal. Review of the Occupational Therapy Discharge Summary dated 5/5/23, indicated but was not limited to the following: -It is recommended that the patient wear a hand roll to R hand at nighttime daily. Don (apply) with P.M. care, Doff (remove) with A.M. care. Nursing staff is aware and agreeable to splinting schedule currently. In-service completed for splinting schedule to continue following discharge from treatment. On 4/17/24 at 7:55 A.M., the surveyor observed Resident #37 in bed; he/she had not yet received morning care and did not have a carrot in their right hand. The right hand was observed in a clenched fist. On 4/18/24 at 7:08 A.M., the surveyor observed Resident #37 in bed with no carrot in their hand. The surveyor detected a strong, foul sweat-like odor when standing next to the Resident on the right side. During an interview on 4/18/24 at 7:29 A.M., Unit Manager #4 met with the Resident with the surveyor. Unit Manager #4 confirmed there was no orthotic in place, and the Resident had not received morning care. Unit Manager #4 said there shouldn't be an odor coming from the Resident's hand and it is likely a result of moisture collecting from the Resident's tight fist. During an interview on 4/16/24 at 1:42 P.M., the Resident's legal guardian said the facility used to have a roll that would be placed in the Resident's hand to prevent their fingers from digging into the palm and to stretch the fingers, but she had not seen the roll in the room in sometime. During an interview on 4/18/24 at 8:01 A.M., the Director of Nursing (DON) said if the staff couldn't find the Carrot that her expectation would be something is placed in the Resident's hand to prevent further decline in range of motion and maintain skin integrity. She said if a physician's order is on the Treatment Administration Record (TAR) the nurse is responsible for ensuring its completion. Review of the TAR indicated that Nurse #4 signed off on the Carrot being in the Resident's hand and removed 12 out of 17 opportunities in April. During an interview on 4/18/24 at 3:38 P.M., Nurse # 4 said she doesn't personally check to see if the carrot is on or off because the unit gets busy. She said she is aware it is on the TAR but the aides should do it. She was unaware that the carrot was not placed in the Resident's hand during the previous observations. She said she depends on the aides to communicate if a resident refuses or an orthotic is missing. 43935 3. Resident #106 was admitted to the facility in November 2022 and has diagnoses including: Acute on chronic congestive heart failure, benign prostatic hyperplasia, dysuria (discomfort with urination) and urinary frequency. Review of the most recent MDS assessment, dated 1/20/24, indicated a BIMS score of 6 out of 15 indicating severe cognitive impairment and the Resident's healthcare proxy (HCP) was activated. Review of the Physician's Orders for Resident #106, dated 4/17/24, indicated but were not limited to the following: -Bactrim (an antibiotic) oral tablet 400-80 milligrams (mg) one tablet one time a day for urinary tract infection (UTI) prophylaxis (11/17/23) Review of the physician's notes from April 2023 to current indicated but were not limited to the following: -Resident was seen by a urologist on 4/11/23 and placed on suppressive antibiotic therapy with Bactrim following a cystoscopy (a procedure used to examine the urethra and bladder lining). -Attending physician examined Resident on 4/14/23 and provided diagnosis of dysuria and indicated per urology recommendations the Resident would be on Bactrim for UTI prophylaxis -4/20/23, MD note indicated use of Bactrim for UTI prophylaxis would be indefinite Review of the current care plans for Resident #106, on 4/18/24, failed to indicate a care plan for long term antibiotic suppressive therapy had been developed or implemented. During an interview on 4/17/24 at 1:13 P.M., Unit Manager #1 reviewed the care plans for Resident #106 and said there should be a care plan in place for long term antibiotic use related to the Resident's urinary issues and was not. During an interview on 4/18/24 at 1:21 P.M., the DON said that the Resident is on a long term antibiotic for suppressive therapy and has a known urinary history and should have a care plan in place, but did not. She said the policy for comprehensive care plans was not followed in this circumstance. 36542 4. Review of the facility's policy titled Resident Mobility and Range of Motion (ROM), dated 8/1/23, indicated but was not limited to the following: -As part of the resident's comprehensive assessment, the nurse will identify the resident's: current range of motion of his/her joints; limitations in movement or mobility; opportunities for improvement; and previous treatment and services for mobility. -The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. -The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. -The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Resident #52 was admitted to the facility in August 2020 with a diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement). On 4/16/24 at 11:09 A.M., the surveyor observed Resident #52 lying in bed with their arms crossed on their chest, the left and right hand were observed to have fingers closed to the palm. On 4/17/24 at 2:32 P.M., the surveyor observed Resident #52 lying in bed with their arms crossed on their chest, the left and right hand were observed to have fingers closed to the palm. During an interview with observation on 4/18/24 at 12:07 P.M., the surveyor observed Resident #52 lying in bed with his/her arms crossed on their chest with bilateral fingers closed to the palm. Nurse #5 said she was unable to fully extend fingers on either hand of Resident #52. Review of a Physician's Progress Note, dated 6/22/23, indicated Resident #52 continued to have rigidity likely due to Parkinson's disease and contractures (shortening and hardening of tissues leading to rigidity of joints). Review of the Physician Progress Note dated 3/1/24 indicated Resident #52 had bilateral upper extremity contractures. Review of the care plans indicated Resident #52 had Parkinson's disease with progression of symptoms including rigid muscles (any part of the body-may even be painful and limit my range of motion) with a goal of not experiencing further progression of current symptoms through next review, with an intervention of utilizing Baclofen (a medication used to help relax muscles) to help with stiffness. Review of the medical record, including care plans, failed to indicate the upper extremity limited range of motion and the goal and interventions associated with the limited range of motion. During an interview on 4/18/24 at 3:21 P.M., Unit Manager #4 said she observed Resident #52 and then reviewed the medical record and was unable to find any interventions for the contracted hands. During an interview on 4/19/24 at 1:23 P.M., the Assistant Director of Nurses (ADON) said the process was for the nurses to develop care plans for any newly identified concerns and there were no current care plans for the bilateral upper extremity contractures. Refer to F688 48084 5. Review of the facility's policy titled Assistance with Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. -Facility staff will serve trays and will help residents who require assistance with eating. -Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example not standing over residents while assisting them with meals. -Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils. Review of the facility's policy titled Assisting the Resident with In-Room Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Review the resident's care plan and provide for any special care needs of the resident. -The resident should be positioned so his or her head and upper body are as upright as possible with head tipped slightly forward. -Place tray on serving area. Be sure it is adjusted to comfortable position and height for the resident. -Arrange dishes and silverware so that they can be easily reached by the resident. -If the resident refused the meal or to eat, document the reason why and intervention taken. -Notify the supervisor if the resident refuses the meal or to eat. Resident #70 was admitted to the facility in November 2017 with diagnoses which included cerebral infarction (stroke) with hemiparesis and hemiplegia (weakness and paralysis) affecting right dominant side, visuospatial deficit and spatial neglect following intracerebral hemorrhage (brain bleed), and failure to thrive. Review of the MDS assessment, dated 2/3/24, indicated Resident #70 was rarely or never understood and was unable to complete the BIMS. Additionally, the Resident's cognitive skills for daily decision making was severely impaired and he/she had impairment on one side and required supervision/touching for eating. Review of the Comprehensive Care Plans for Resident #70 indicated but were not limited to the following: -FOCUS: VISION: Visual Impairment related to CVA (stroke) with right side visual neglect. -INTERVENTIONS: Please place objects in my field of vision-towards my left side. -FOCUS: ACTIVITIES OF DAILY LIVING (ADL): Assist -INTERVENTIONS: Dependent during meals. The surveyor made the following observations of Resident #70: -4/16/24 at 12:30 P.M., the Resident was sitting in a reclining Broda chair (specialty wheelchair for positioning) in the corner of the day room alone, slumped over in chair; their lunch meal was placed on an overbed tray table and staff walked away. The Resident then picked up the adaptive lip plate (plate with high edge to contain food) and spilt the entire plate of food on their chest and lap, down legs, and on the floor. The Resident was observed playing with the food on his/her lap and staff did not call the kitchen for another meal or provide the Resident with assistance to eat anything else. -4/17/24 at 8:05 A.M., the Resident was sitting in a reclining Broda chair in the corner of the day room alone. At 8:23 A.M., the nurse cut up breakfast, placed the meal on the overbed tray table and walked away. The Resident was observed self-feeding dry cereal from an adaptive blue bowl which was on the left side. The plate with the main meal was on the right side. No staff offered assistance with feeding or cues to eat anything on the plate. -4/17/24 at 12:42 P.M., the Resident was sitting slouched over in a reclining Broda chair in the corner of the day room alone. One staff member sat down next to the Resident, however provided no assistance or verbal cues. The Resident was self-feeding ice cream which was on the left side. The plate with the main meal was on the right side and untouched. The Resident was observed to be leaning forward to the table to gather food as the table was not positioned so the food was within easy reach. A Certified Nursing Assistant (CNA) was observed standing next to the Resident, offered one bite of food from the main plate (which Resident accepted), and walked away. No further assistance was provided. -4/18/24 at 8:35 A.M., the Resident was sitting slouched over in a reclining Broda chair in the corner of the day room alone. The meal was placed on the overbed tray table and the staff walked away. Dry cereal in a blue adaptive bowl was on the left side and a plate with the main meal was on the right side. Resident fed self the dry cereal. Staff did not provide assistance or cues with eating. At 8:55 A.M., CNA #10 cleaned up the breakfast trays from the other residents in the day room and removed table linens. She looked at Resident #70 sitting in the reclining Broda chair not eating or being fed and left the room. Resident #70 was left in the day room with their meal still on the overbed tray table and no one to assist him/her with eating. At 9:53 A.M., Resident #70 pushed the overbed tray table away. Resident #70 remained in the day room unsupervised, unassisted until 10:01 A.M. when CNA #10 removed the plate and cups. Review of Resident #70's medical record including physician's orders, progress notes, flow sheets, and meal documentation record indicated but were not limited to the following: -HCC (diabetic) Diet lipped plate with all meals (8/26/20). -Dietitian's note, dated 2/7/24, indicated Resident was dependent on nursing staff for eating. Suction bowl and lip plate provided at meals to help with self-feeding. -CNA flow sheet indicated Resident was provided with moderate assistance for eating. -Review of the meal percentage sheet indicated Resident #70 had consumed 25-50% of meals during the observation period. Further review of the medical record failed to indicate Resident #70 had been offered and refused meals. During an interview on 4/18/24 at 8:55 A.M., CNA #10 said sometimes they help Resident #70 eat, but it depends on his/her mood. She said the Resident is not always a feed and doesn't eat much. During an interview on 4/18/24 at 10:15 A.M., Unit Manager #3 said Resident #70 is a mix of supervision, assist, and feed and it depends on the day. She said staff should be providing assistance and allowing him/her to do what they can, but still helping as needed. She said he/she has right-side visual impairment so leaving the plate on the right side is not good and they were not following the care plan. During an interview on 4/18/24 at 10:25 A.M., Nurse #6 said Resident #70 likes cereal and tries to eat that independently, but the staff should be offering the other food. During an interview on 4/18/24 at 1:30 P.M., the ADON said Resident #70 has right-sided vision concerns so they should be moving plate to the left and helping with meals per the care plan. During an interview on 4/18/24 at 2:40 P.M., the DON said the staff should be offering assistance and have the food item on his/her left side per the care plan.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#10), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #10. Findings include: Review of the facility's policy titled Fingernails/Toenails, Care of, dated 8/1/23, indicated the following: Purpose: to keep nails trimmed; Guidelines: nail care includes daily cleaning and regular trimming; Documentation: the date and time the nail care was given, the condition of resident's nails, any difficulty in cutting the resident's nails, if the resident refused Resident #10 was admitted to the facility in July 2020. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/2/24, indicated the Resident was dependent on one staff person for personal hygiene. On 4/16/24 at 8:45 A.M., the surveyor observed Resident #10 to have long fingernails. The fingernail lengths ranged from 0.1 cm to approximately 1 cm (the width of a standard pen) with the right thumb being the longest. On 4/17/24 at 11:00 A.M., the surveyor observed Resident #10 to continue to have long nails. During an interview on 4/17/24 at 2:39 P.M., the spouse of Resident #10 said the Resident's fingernails were too long. The spouse said the nurse had previously reported that Resident #10 would pull his/her hands away while staff were cutting their nails and now required two staff members to cut their nails. Review of the medical record indicated Resident #10 had their fingernails cut on 2/21/24 (eight weeks prior). During an interview on 4/18/24 at 10:40 A.M., Certified Nursing Assistant (CNA) #2 said she normally cares for Resident #10 and there was no set schedule to cut the Resident's nails. During an interview on 4/18/24 at 10:47 A.M., Unit Manager #4 said the Resident's nails were too long and should be cut periodically. During an interview on 4/18/24 at 10:57 A.M., CNA #3 said she cut the nails of Resident #10 this morning and the nails were too long and needed to be cut. During an interview on 4/18/24 at 11:00 A.M., Unit Manager #4 said she was not sure how the CNAs knew when to cut a resident's nails and after reviewing the Resident's Flow Sheets was unable to see where nail cutting would be documented.

Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for three Residents (#106, #107, and #52), out of 26 sampled residents. Specifically, the facility failed: 1. For Resident #106, to ensure the use of bed and chair alarms were coded on the MDS; 2. For Resident #107, to accurately document the use of chair and bed alarms on the MDS; and 3. For Resident #52, to identify bilateral hand contractures (shortening and hardening of tissues leading to rigidity of joints) on the MDS. Findings include: 1. Resident #106 was admitted to the facility in November 2022 with the following diagnoses: Acute on chronic congestive heart failure, benign prostatic hyperplasia, and frequent falls. Review of the current Physician's Orders for Resident #106, dated 4/17/24, indicated but were not limited to: -Bed alarm: check placement and functioning of alarm every shift (2/17/2023) -Chair alarm: check placement and function of alarm every shift (4/17/2023) During the survey, the surveyor made the following observation of Resident #106: 4/16/24 at 9:28 A.M., Resident alert and awake, lying in bed with head of bed elevated, bed alarm in place. 4/16/24 at 12:20 P.M., Resident alert, lying in bed, with bed alarm in place. 4/17/24 at 8:09 A.M., Resident in bed, bed alarm in place. 4/17/24 at 11:33 A.M., Resident alert, lying in bed, bed alarm in place. Review of the Treatment Administration Record (TAR) for Resident #106 from January 2024 through April 17, 2024, indicated that a licensed nurse verified the placement and function of a bed alarm and chair alarm for the Resident each day. Review of the most recent MDS assessment, dated 1/20/24, failed to indicate under section P, Restraints and Alarms that Resident #106 used a bed or chair alarm. During an interview on 4/17/24 at 3:11 P.M., the MDS Nurse reviewed the medical record and MDS for Resident #106 and said an error was made on the MDS; the Resident does use alarms and a modification of the MDS was required for it to be accurate. 2. Resident #107 was admitted to the facility in October 2022 with the following diagnoses: dementia, difficulty walking, and muscle weakness. Review of the Physician's Orders for Resident #107, dated 4/17/24, indicated but were not limited to the following: -Chair alarm: check placement and function of alarm every shift (4/24/23) -Bed alarm: check placement and function of alarm every shift (4/24/23) During the survey, the surveyor made the following observations of Resident #107: 4/16/24 at 8:12 A.M., Resident alert and awake, sitting in the hallway in his/her wheelchair with chair alarm in place. 4/16/24 at 3:42 P.M., Resident alert, sitting in his/her wheelchair in their room, visiting with family, chair alarm in place. 4/17/24 at 9:04 A.M., Resident alert and awake, sitting in the hallway in his/her wheelchair with chair alarm in place. Review of the TAR for Resident #107 from January 2024 through April 17, 2024, indicated that a licensed nurse verified the placement and function of a chair alarm and bed alarm for the Resident each day. Review of the most recent MDS assessment, dated 3/2/24, failed to indicate under section P, Restraints and Alarms that Resident #107 used a chair or bed alarm. During an interview on 4/17/24 at 3:11 P.M., the MDS Nurse reviewed the medical record and MDS for Resident #107 and said an error was made on the MDS; the Resident does use both a chair and bed alarm daily and modification of the MDS was required for it to be accurate. 36542 3. Resident #52 was admitted to the facility in August 2020 with a diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement). During an interview with observation on 4/18/24 at 12:07 P.M., the surveyor observed Resident #52 lying in bed with his/her arms crossed on their chest with bilateral fingers closed to the palm. Nurse #5 said she was unable to fully extend fingers on either hand of Resident #52. Review of a Physician's Progress Note2, dated 6/22/23, indicated Resident #52 continued to have rigidity likely due to Parkinson's disease and contractures. Review of the Physician's Progress Note, dated 8/14/23, indicated Resident #52 had bilateral hand contractures. Review of the MDS assessment, dated 2/24/24, section GG Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion indicated Resident #52 had no impairments in the upper extremities. During an interview on 4/19/24 at 1:15 P.M., the MDS Coordinator said she reviewed the medical record and observed Resident #52 and said the MDS was incorrect and should have reflected the Resident's upper extremity limited range of motion.

Based on interviews, review of grievance documentation, and policy review, the facility failed to formulate a grievance timely for concerns brought forward by Resident #6 regarding missing hearing aids. Findings include: Review of the facility's policy titled Loss or Damage to Resident's Dentures, Hearing Aids and/or Eyeglasses, undated, indicated but was not limited to the following: -The Social Worker (SW) for the unit the resident resides in needs to immediately be informed by the resident, responsible party, unit manager (UM) or nurse. -The Social Worker will immediately inform the Administrator and a formal grievance will be written followed by an immediate investigation. Review of the facility's policy titled Lost and Found, dated as last revised 8/1/23, indicated but was not limited to the following: -Facility shall assist all residents in safe-guarding their personal property. -Resident or family complaints of missing items must be reported to the Director of Nursing (DON). Review of the facility's policy titled Grievance/Concern, dated as last revised 10/30/20, indicated but was not limited to the following: -The Grievance Policy refers to documenting and acting on specific complaints or concerns voiced by residents, staff, and families. Listening to concrete needs, addressing them with appropriate team member(s), and resolving them are the principal components and nature of the policy. -All grievances generated in the past 24 hours will be discussed at morning meeting and assigned to the responsible person to do the interview/search and recovery. -The Administrator reviews the grievance and refers appropriate staff members for investigation and timely action is taken. -The Director of Social Services maintains a Grievance Log in the Social Service Director's office. Review of the facility's Grievance Report, dated as last revised 8/22/18, indicated but was not limited to the following: -This form shall be utilized to provide written documentation of any concerns expressed by residents, resident representative or staff member and record the follow up action taken and results thereof. -Documentation of Concern: Type includes but was not limited to: Hearing Aids. -Staff members need to be interviewed starting the shift prior of grievances up to 72 hours prior, both nurses assigned / certified nursing assistant depending on the nature of the grievance. -Grievance should be reported to the Supervisor, DON, and Administrator. -Investigation/Actions of Grievance included but were not limited to interview staff involved, interview resident, Resident property protected from further occurrence. Resident #6 was admitted to the facility in February 2021 with diagnoses which included cerebral infarction (stroke) with hemiparesis and hemiplegia affecting left side (weakness and paralysis). Review of the Minimum Data Set (MDS) assessment, dated 2/10/24, indicated Resident #6 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and wore hearing aids. Review of the Resident's Comprehensive Care Plan indicated he/she had a communication deficit, was hard of hearing and wore hearing aids. Additionally, the care plan indicated staff should ensure hearing aids were clean and batteries were functioning. During an interview on 4/16/24 at 1:33 P.M., Resident #6 said both of his/her hearing aids were missing. He/she said they were on the table over the weekend and then they were gone. Resident #6 said Nurse #3 was notified yesterday (4/15/24). Review of the grievance book failed to indicate a grievance for the missing hearing aids had been completed. Review of the nursing progress notes failed to indicate the Resident was missing his/her hearing aids. During an interview on 4/17/24 at 3:29 P.M., Nurse #3 said the missing hearing aids were reported to her yesterday, but she had not searched the room yet. Additionally, she said she had not completed a missing item report because she had not looked for them yet. She said usually if they don't find something by the next day or so, they will report it. She said she did not report the missing hearing aids to anyone including the UM, SW, DON, or Administrator yet. During an interview on 4/18/24 at 10:57 A.M., Resident #6 said Nurse #3 found them a few minutes ago (Three days after the Resident said they were reported missing). During an interview on 4/18/24 at 10:57 A.M., UM #2 said she was not notified the hearing aids were missing until yesterday afternoon. She said immediately after a Resident reports a missing item, especially hearing aids, glasses, or dentures, all departments should be notified, including kitchen, laundry, and housekeeping so they can look on trays, laundry and in the trash for them. She said the room should be searched immediately, the UM, SW, DON, and Administrator should be notified, a progress note written, the family should be notified, and the grievance form filled out. She said the grievance was not filed for the missing hearing aids and it should have been done when the nurse was notified by the Resident that the hearing aids were missing. During an interview on 4/18/24 at 2:16 P.M., the Assistant Director of Nurses (ADON) said she was not aware of the missing hearing aids. She said the grievance should be initiated immediately by whomever is notified. She said the room should be immediately searched and all departments should be notified right away. Additionally, she said the investigation should include all staff that took care of the Resident for the 72 hours prior. She said the process should be done right away and not the next day or the day after. During an interview on 4/18/24 at 2:30 P.M, the DON said she was not aware of the missing hearing aids. The DON said the grievance for missing items should be done right away and that would include searching the room, investigating, and notifying all departments. She said it should not wait until the next day or so; people don't understand how important hearing and vision are until they suddenly have it taken away and that is very detrimental to a resident's care. She said the Resident should not have had to wait days before anyone looked for the hearing aids. She said luckily, they found them today, but they could have ended up in the trash or gotten broken going through the laundry because no one was notified to search for them the other day when they should have been.

Based on observation and interview, the facility failed to ensure Resident #70 was provided with a dignified dining experience. Findings include: Review of the facility's policy titled Dignity, dated as last revised 8/1/23, indicated but was not limited to the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are provided with a dignified dining experience. -Demeaning practices and standards of care that compromise dignity are prohibited. -Staff are expected to promote dignity and assist residents. -Staff are expected to treat cognitively impaired residents with dignity and sensitivity. Review of the facility's policy titled Assistance with Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Review of the facility's policy titled Assisting the Resident with In-Room Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Review the resident's care plan and provide for any special care needs of the resident. -Arrange dishes and silverware so that they can be easily reached by the resident. Resident #70 was admitted to the facility in November 2017 with diagnoses which included cerebral infarction (stroke) with hemiparesis and hemiplegia (weakness and paralysis) affecting right dominant side, visuospatial deficit and spatial neglect following intracerebral hemorrhage (brain bleed), and failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 2/3/24, indicated Resident #70 was rarely or never understood and was unable to complete the Brief Interview for Mental Status (BIMS). Additionally, the Resident's cognitive skills for daily decision making was severely impaired and he/she had impairment on one side and required supervision/touching for eating. The surveyor made the following dining observations: -4/16/24 at 12:30 P.M., Resident #70 was sitting in a reclining Broda chair (specialty wheelchair for positioning) in the corner of the day room alone, slumped over in the chair; their lunch meal was placed on an overbed tray table and staff walked away. Resident then picked up the adaptive lip plate (plate with high edge to contain food) and spilt the entire plate of food on his/her chest and lap, down their legs, and on the floor. Resident was observed to be playing with the food on his/her lap and staff did not intervene to clean up the spilt food, did not call the kitchen for another meal or provide the Resident with assistance to eat anything else. -4/17/24 at 8:05 A.M., Resident #70 was sitting in a reclining Broda chair in the corner of the day room alone. At 8:23 A.M., the nurse cut up the Resident's breakfast, placed the meal on the overbed tray table, and walked away. The Resident was observed self-feeding dry cereal from an adaptive blue bowl which was on the left side. The plate with the main meal was on the right side. Dry cereal was spilt on their clothing protector. No staff offered assistance with feeding or cues to eat anything on the plate. -4/17/24 at 12:42 P.M., Resident #70 was sitting slouched over in a reclining Broda chair in the corner of the day room alone. The Resident's right shoe was off and on the floor in front of the chair. No staff attempted to put the shoe back on. One staff member sat down next to the Resident, however, provided no assistance or verbal cues. The Resident was self-feeding ice cream which was on the left side. The plate with the main meal was on the right side and untouched. The Resident was observed to be leaning forward to reach the table to gather food as the table was not positioned so food was within easy reach. A Certified Nursing Assistant (CNA) was observed standing next to the Resident, offered one bite of food from the main plate (which Resident accepted), and walked away. No further assistance was provided. -4/18/24 at 8:35 A.M., Resident #70 was sitting slouched over in a reclining Broda chair in the corner of the day room alone. The meal was placed on the overbed tray table and the staff walked away. Dry cereal in blue adaptive bowl was on the left side and plate with the main meal was on the right side. Resident fed self the dry cereal; clothing protector had spilt food on it. Staff did not provide assistance or cues with eating. At 8:55 A.M. CNA #10 cleaned up the breakfast trays from the other residents in the day room and removed table linens. She looked at Resident #70 sitting in the reclining Broda chair not eating or being fed and left the room. Resident #70 was left in the day room with their meal still on the overbed tray table, food spilt on the clothing protector and no one to assist him/her with eating. At 9:53 A.M., Resident #70 pushed the overbed tray table away. Resident #70 remained in the day room unsupervised, unassisted, with clothing protector on with food on it until 10:01 A.M. when CNA#10 removed the plate, cups, and clothing protector. The Resident was left in the corner of the day room alone. Review of Resident #70's medical record including physician's orders, progress notes, and flow sheets indicated but were not limited to the following: -HCC (diabetic) Diet lipped plate with all meals (8/26/20). -Dietitian note dated 2/7/24 indicated resident was dependent on nursing staff for eating. Suction bowl and lip plate provided at meals to help with self-feeding. -CNA flow sheet indicated Resident was provided with moderate assistance for eating. Review of the Comprehensive Care Plans for Resident #70 indicated but were not limited to the following: -FOCUS: VISION: Visual Impairment related to CVA (stroke) with right side visual neglect. -INTERVENTIONS: Please place objects in my field of vision-towards my left side. -FOCUS: ACTIVITIES OF DAILY LIVING (ADL): Assist -INTERVENTIONS: Dependent during meals. During an interview on 4/18/24 at 8:55 A.M., CNA #10 said sometimes they help Resident #70 eat, but it depends on his/her mood. She said he/she is not always a feed and doesn't eat much. During an interview on 4/18/24 at 10:15 A.M., Unit Manager #3 said Resident #70 is a mix of supervision, assist, and feed; it depends on the day. She said staff should be providing assistance and allowing him/her to do what they can but still helping as needed. She said he/she has right-sided visual impairment so leaving the plate on the right side is not good. Additionally, she said staff should be promptly cleaning up spills and food as it is not very dignified to sit with food all over one's lap, he/she should not always be left in the corner alone and someone should have fixed his/her sneaker when it was on the floor. She said that is an unacceptable dining experience. During an interview on 4/18/24 at 10:25 A.M., Nurse #6 said Resident #70 likes cereal and tries to eat that independently, but the staff should be offering the other food. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nursing (ADON) said Resident #70 should not be sitting alone with food on their lap during or after meals and should be provided with assistance to eat. Additionally, he/she has right-sided vision concerns so they should be moving plate to the left and helping with meals. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said it is not very dignified to have food on his/her lap and floor surrounding a resident and staff should have provided assistance for a better dining experience.

Based on observations, interviews, and record review the facility failed to maintain an environment free of accident hazards for three Residents (#100, #20, and #214), out of a sample of 22 residents. Specifically, the facility failed to ensure: 1. For Resident #100, that effective care plan interventions were developed and implemented to prevent nine falls, one of which resulted in major injury; 2. For Resident #20, staff reduced the risk of future falls by properly implementing fall risk interventions per facility policy; and 3. For Resident #214, staff properly disposed of a used syringe (sharp). Findings include: Review of the facility's policy titled Falls Prevention Policy, dated October 2020, indicated but was not limited to the following: Tools to be used: -CNA Kardex/Care Plan -New interventions will be reviewed and updated as needed -Nurse Managers will be responsible to educate all pertinent staff regarding new interventions generated -Residents will be part of a walking program. The walking program will be for residents who need assistance with ambulating or just want to ambulate with a staff person. These residents will be ambulated throughout the day. They will be ambulated in hallways, to dining rooms, in their own rooms, etc. Review of the facility's policy titled Falling Stars, dated October 2020, indicated but was not limited to the following: -Falling Star is to aid in falls prevention for residents who trigger as a fall risk. If the resident is admitted with multiple falls or a resident has had 3 falls within the past 3 months, they will trigger for the falling star program. -Unit Managers will ensure that a star is placed outside the resident's room on their name plate. 1. Resident #100 was admitted to the facility in February 2022 after an acute hospitalization for a subdural hematoma following a fall at home. Review of the Minimum Data Set (MDS) assessment, dated 2/13/22, indicated that Resident #100 required extensive assistance of one staff for all activities of daily living, utilized a walker and wheelchair and was unsteady and only able to stabilize with assistance when moving from a seated position to standing. The Resident had a Brief Interview for Mental Status score of 9 out of 15 which indicated moderate cognitive impairment. Review of Resident #100's Interdisciplinary Care Plans included but was not limited to: -Focus: Fall Potential: I have the potential for falling due to: dementia, impulsiveness, weakness, cardiac dysfunctions, history of falls, visual deficits, communication deficits, incontinence and potential medication side effects (2/6/22) -Interventions: I use two upper side rails to assist with positioning and/or transfers as well as to keep me safe while I am in bed (2/6/22); Please come see what I might need when you hear my alarms sound (2/6/22); Physical/Occupational Therapy evaluation and treat when indicated by my Physician (2/20/22). Review of the medical record indicated Resident #100 had nine falls from February 2022 to October 2022. Review of the falls indicated: -2/27/22 at 3:00 P.M., Resident was found on the floor by a Certified Nursing Assistant (CNA) as she was walking by his/her room. Review of the fall investigation indicated the Resident said that he/she was trying to get shoes on when he/she slid out of the chair. The investigation failed to indicate if the alarms were in place and functioning or if any other interventions were in place at the time of the fall. Occupational therapy (OT) conducted a screen on 3/1/22 and indicated the Resident was already on skilled services. The OT indicated the Resident was reminded to use the call light for help as needed until he/she demonstrates independence. -3/6/22 at 8:00 P.M., Resident was found on the floor in his/her room. The Resident told the Nurse that he/she was going home with his/her roommate. The investigation failed to indicate if the alarm was in place and functioning and if any other interventions were in place at the time of the fall. There were no new interventions implemented to reduce the risk of future falls. -3/10/22 at 7:59 P.M., Resident was found sitting on the floor next to the bed in his/her room. A 2 centimeter (cm) skin tear was noted on the Resident's hand. The documentation indicated the Resident's bed was in the lowest position and call bell was within reach. The investigation failed to indicate if the alarm was in place and functioning at the time of the fall. A new order for floor mats at the bedside was obtained and the Resident was re-educated on the importance of using the call light. -3/24/22 at 8:55 P.M., Resident was found on the floor in another Resident's room. The Resident said he/she was trying to go to his/her bathroom, but was in another resident's room. The investigation failed to indicate if the alarm was in place and functioning and if any other interventions were in place at the time of the fall. OT conducted a screen on 3/25/22 and indicated the Resident was already on skilled services, requires contact guard for transfers and should be assisted for toileting. Interventions identified on the care plan to prevent future falls was: placed on falling star program, encourage and assist resident to the toilet at least every 2 hours while awake, and when anxious. -3/27/22 at 7:00 A.M., Resident was found sitting on the floor next to the bed. The Resident said his/she was going for a ride. CNA statements indicated the Resident always gets out of bed unassisted. OT conducted a screen on 3/28/22 and comments included but was not limited to: Status post falls on 3/24 and 3/27. Patient has low bed with mats and nursing is adding chair and bed alarms. Poor safety awareness, frequently attempts to ambulate independently despite ongoing reminders/education to ask for assist. Patient continues on Physical Therapy (PT) and OT. Patient remains in supervised areas throughout the day. Intervention identified on the care plan to prevent future falls was: I have an alarm on my bed and chair to remind me to wait for assistance and not try to get up by myself (3/28/22). This intervention was already in place (2/6/22) and was not a new intervention to prevent further falls. -4/19/22 at 1:31 P.M., Resident was seated in a wheelchair at the nurses' station, stood up, tripped over his/her feet and fell on to his/her buttocks. An intervention identified on the care plan to prevent future falls was: Please walk with me at least every shift while I'm awake, and more often if agitated (4/19/22). -4/27/22 at 5:20 P.M., Resident had an unwitnessed fall in his/her room. A nurse was seated at the nursing station, heard a loud thump and saw the Resident on the floor in front of the chair and bedside table. The investigation noted that the chair alarm was in place and functioning. An intervention identified on the care plan to prevent future falls was: Please have psych services review my medications for effectiveness (4/28/22). On 5/25/22, the care plan for falls was updated to include: Please check on me frequently and make sure my call light and/or hand bell are within my reach. -7/27/22 at 4:10 P.M., Resident was found on the floor in front of his/her wheelchair in his/her room. The Resident was bleeding from the left side of his/her head and lost consciousness. The investigation failed to indicate what interventions were in place at the time of the fall. Further review of the investigation indicated that the Resident's significant other was visiting just prior to the fall. An intervention identified on the care plan to prevent future falls was: Remind my significant other to make nursing aware when he/she gets ready to leave, so that nursing will monitor me (7/27/22). Review of the medical record and hospital documentation indicated that Resident #100 was transferred to the hospital and evaluated in the emergency department following an unwitnessed fall with headstrike. The Resident was found to have a contusion and laceration (requiring 3 staples), extensive intracranial hemorrhage with subdural hematoma as well as intracranial air suggestive of a possible occult skull fracture. The Resident returned to the facility on [DATE] on Hospice services. -10/9/22 at 10:00 A.M., Resident had an unwitnessed fall in the unit dining room. Housekeeping staff alerted a nurse that was at the nursing station that Resident #100 was on the floor. The investigation failed to indicate if the alarm was in place and functioning and if any other interventions were in place at the time of the fall. Interventions identified on the care plan to prevent future falls were: Alarm to be changed as needed for malfunction (10/10/22); Please do not leave me alone when I am in the dining room (10/10/22); I am forgetful and impulsive at times and don't think of my safety at those moments, please sit 1:1 with me if I need it at those times; please check on me frequently as I often forget to ask for assistance with my transfers and/or mobility or I may not remember to take my walker with me; If I appear restless or anxious, please help me find and address the reason (10/12/22). Review of a Nursing Progress Note, dated 10/9/22, indicated that Resident #100's private duty caregiver arrived on the unit at 10:15 A.M. and not 10:00 A.M. as scheduled because she was waiting for COVID testing results. The Nurse reminded facility staff that the Resident needs to be monitored and not left alone without supervision. During an interview on 12/15/22 at 9:54 A.M., the surveyor and Unit Manager #2 reviewed Resident #100's falls and medical record. The Unit Manager said most of the fall investigations were not complete and it is impossible to determine what interventions, if any, were in place at the time of the falls. She said most of the interventions identified on the care plan were ineffective. Unit Manager #2 said the Resident has private duty care daily from 10:00 A.M. to 6:00 P.M., and facility staff are hands off and do not provide supervision or safety checks for the Resident while they are in the facility. She said the Resident must be supervised at all times due to his/her impaired cognitive status and poor safety awareness to ensure his/her safety and prevent further falls. 42742 2. Resident #20 was admitted to the facility with diagnoses including muscle weakness, age related osteoporosis with current pathological fracture, mild cognitive impairment, orthostatic hypotension, syncope (fainting or sudden temporary loss of consciousness), abnormalities of gait and mobility, and glaucoma. Review of the Minimum Data Set (MDS) assessment, dated 11/9/22, indicated Resident #20 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The MDS also indicated Resident #20's balance was not steady during transitions and walking, used a walker, and had had a fall since admission or prior assessment resulting in major injury. Review of the Falls Incident Reports indicated the following: Fall #1 (2/5/22) - unwitnessed, major injury (right pelvic fracture) Fall #2 (7/28/22) - unwitnessed, major injury (rib fractures) Fall #3 (10/23/22) - unwitnessed, major injury (fracture left 5th metacarpal (pinky)) Review of current Physician's Orders for Resident #20 indicated the following: -Clear to ambulate (walk) independently with rolling walker in bedroom, bathroom, and unit. Weight bearing as tolerated on right upper extremity. (3/24/20) Review of the interdisciplinary care plans indicated Resident #20 was at risk for falls, initiated 6/16/20, and required limited assistance from one staff member for ambulation with his/her rolling walker and appropriate footwear, initiated 7/13/21. During an observation with interview on 12/8/22 at 2:23 P.M., the surveyor observed Resident #20 sitting in a wheelchair in his/her room located at the far end of the hall from the nurses' station. A yellow star was observed affixed to the Resident's roommate's nameplate outside the door. The Resident said he/she had fallen three times in a row and walked with a walker. Resident #20 said, My back got wrenched a bit and that he/she had a cut on his/her left knee and had broken his/her pinky. On 12/13/22 at 2:23 P.M., the surveyor observed Resident #20 sitting in a wheelchair in front of the nurses' station. The Resident stood up to use the telephone located on the nurses' station desk sounding off the wheelchair alarm. Staff was nearby and lowered the Resident back into his/her wheelchair. During an interview on 12/15/22 at 10:51 A.M, the Rehabilitation Director and Rehabilitation Services Staff #1 said Resident #20's fall risk factors included impulsiveness, unsteady balance without an assistive device, cognitive decline, and a long history of falls. The Rehabilitation Director said Resident #20 was currently on a functional maintenance program to continue with ambulation (walking) on the unit. Rehabilitation Services Staff #1 said Resident #20 required supervision due to his/her impulsivity. Review of the December 2022 Certified Nursing Assistant (CNA) Kardex (summary of resident's care and preferences) for Resident #20 failed to indicate any safety precautions. During an interview on 12/15/22 at 11:31 A.M., CNA #5 said she was not familiar with the Resident and would refer to the CNA Kardex to see what staff were supposed to do for the Resident. She said the Kardex would tell her if there were any safety precautions in place. During an interview on 12/15/22 at 11:36 A.M., CNA #4 said she was familiar with Resident #20 saying the Resident was confused, especially in the morning, but was not at risk for falls and had not had any falls. She said if she needed information about a Resident, she would ask the nurse or refer to the CNA Kardex. The surveyor reviewed the Kardex with CNA #4 who said there were no safety precautions listed. CNA #4 said safety interventions should have been listed on the Kardex if the Resident was at risk for falls but they were not. She said the Resident tried to get up on his/her own sometimes. During an interview on 12/15/22 at 2:14 P.M., Unit Manager (UM) #4 said the aides followed the Kardex and safety precautions for Resident #20 should have been there but were not. She said Resident #20 was on a functional maintenance plan because he/she was a frequent faller and had completed rehabilitation services. UM #4 said a therapy aide comes to the unit to walk with residents on the program for 30-60 days but, because of the recent outbreak of COVID-19 on the unit (12/2/22), the therapy aide was not coming. She said staff was not doing that right now and had not seen anyone walking with Resident #20. During an observation with interview on 12/15/22 at 2:46 P.M., the surveyor and UM #4 observed the falling star sticker placed over Resident #20's roommate's name. UM #4 said it should have been placed over Resident #20's name to alert staff the Resident was a high risk for falls. She said the falling star program kind of went away. During an interview on 12/15/22 at 3:07 P.M., the Director of Nursing (DON) and Administrator said the functional maintenance program should not stop due to COVID-19 on the unit. The DON said the falling star should have been placed next to Resident #20's name to alert staff he/she was a high risk for falls. The DON further said the CNA Kardex should reflect the most up to date safety interventions in place. 28450 3. Resident #214 was admitted to the facility in December 2022 with diagnoses including atrial fibrillation, type 2 diabetes with right foot ulcer, other acute osteomyelitis right ankle and foot, and legally blind. On 12/9/22 at 10:30 A.M., the surveyor observed the following at the bedside table in the Resident's room: -Enoxaparin (used to prevent blood clot) retractable syringe (hazardous) Review of the medical record indicated Physician's Order for the following: -Enoxaparin Sodium Solution Prefilled Syringe 40 MG/0.4ML. Inject 40 MG subcutaneously one time a day related to paroxysmal atrial fibrillation During an interview on 12/9/22 at 10:42 A.M., Nurse #5 said that she administered the medication to the Resident this morning. Nurse #5 said she made a mistake because she forgot to discard the retractable syringe in the sharps container after administering the injection. During an interview on 12/9/22 at 3:30 P.M., the Director of Nursing said the Nurse should not have left the syringe at the bedside.

Based on observations, interviews, and record review, the facility failed to ensure two Residents (#98 and #88), out of a total sample of 22 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #98, to implement a treatment as ordered and failed to implement effective pressure reduction strategies, resulting in the worsening of a pressure injury; and 2. For Resident #88, to ensure pressure related interventions were consistently implemented to promote wound healing. Findings include: 1. Resident #98 was admitted to the facility in August 2022 with a diagnosis of failure to thrive. Review of the care plans for Resident #98 indicated a potential for skin breakdown related to bony prominence and malnutrition with interventions of administering treatments as ordered and using pressure relieving devices. Review of the medical record indicated on 11/23/22 Resident #98 weighed 64 pounds. Review of the Weekly Skin Assessment, dated 11/29/22, indicated Resident #98 had a change in skin and now had a red coccyx (bone at the end of the spine). Review of the Wound Evaluation and Management Summary from the wound consultant, dated 12/1/22, indicated Resident #98 had a Stage 3 pressure wound on the coccyx measuring 0.6 centimeters (cm) length by 0.3 cm wide by 0.1 cm depth. The wound consultant recommended the following treatment: Silver Sulfadiazine cream and house barrier cream once daily with pressure relieving interventions of a low air loss mattress and a gel cushion to the wheelchair. Review of the Medication Administration Record (MAR) for December 2022 indicated an order to apply Silver Sulfadiazine cream to the coccyx every 24 hours as needed and was not signed off as administered. There was no treatment order on the MAR or Treatment Administration Record (TAR) to reflect the daily treatment of applying Silver Sulfadiazine. On 12/8/22 at 9:30 A.M., the surveyor observed Resident #98 lying in bed. The mattress was noted to be a regular mattress and not an air mattress. During an interview on 12/8/22 at 2:20 P.M., the spouse of Resident #98 said the Resident was tired on this day and had not been out of bed yet. The surveyor observed the Resident in bed, on a regular mattress, not an air mattress. During an interview on 12/8/22 at 2:15 P.M., Nurse #14 said Resident #98 had recently gone out to the hospital and had returned the previous evening. She said the Resident had not returned to his/her previous room as a precaution for infection and was placed in a private room. On 12/9/22 at 8:53 A.M., the surveyor observed Resident #98 lying in bed on a regular mattress, not an air mattress. On 12/13/22 at 1:09 P.M., the surveyor observed Resident #98 lying in bed on a regular mattress. On 12/14/22 at 3:40 P.M., the surveyor observed Resident #98 in his/her previous room lying in bed on an air mattress. The air mattress was observed to be set at 150 (firmness based on weight) and set at normal pressure, with the other option being low pressure. On 12/15/22 at 9:30 A.M., Resident #98 was placed in bed to be seen by the wound consultant. The surveyor observed the air mattress to be set at 150, with normal pressure. During an interview on 12/15/22 at 9:30 A.M., the wound consultant said the air mattress should be set at the minimal setting based on the weight of the Resident, which was 65 pounds. The wound consultant said the air mattress should be set at low pressure. He said he had seen Resident #98 on 12/8/22 in the temporary room and informed staff that Resident #98 needed to be placed on an air mattress that day. He was not aware that Resident #98 was not moved to the air mattress in their permanent room until 12/13/22, 5 days after he requested the change in mattress. On 12/15/22 at 9:35 A.M., the surveyor observed Unit Manager #2 prepare Resident #98 to be seen by the wound consultant. The surveyor observed the Resident to be wearing two briefs and observed a thick cloth pad between the Resident and the air mattress, creating multiple layers between the Resident's wound and the pressure relieving device. During an interview on 12/15/22 at 9:35 A.M., Unit Manager #2 said the double briefs and the thick pad would make the air mattress ineffective and could cause more deterioration of the wound. On 12/15/22 at 9:40 A.M., the surveyor, the Unit Manager and the wound consultant observed the coccyx wound of Resident #98. During an interview on 12/15/22 at 9:41 A.M., the wound consultant said the current treatment was for Silver Sulfadiazine, followed by barrier cream, daily. He said the wound had increased in size and had worsened. The wound consultant said he would be changing the treatment based on the change in the wound. He said the Resident should have been receiving the daily silver sulfadiazine and should have been on an air mattress and the lack of both the treatment and the pressure relief could have contributed to the wound worsening. During an interview on 12/15/22 at 9:45 A.M., Unit Manager #2 said the treatment order for Silver Sulfadiazine should have been entered as a daily treatment and not as an as needed treatment. 42742 2. Resident #88 was admitted to the facility with diagnoses including pressure ulcer of the right buttock stage 3 (full-thickness skin loss) , pressure ulcer of left heel stage 4 (full thickness loss of skin and tissue), non-pressure chronic ulcer of skin of other sites, non-pressure chronic ulcer of right and left lower leg, and non-pressure chronic ulcer of other part of left foot. Review of the Wound Evaluation and Management Summary, dated 12/8/22, indicated the following: -Stage 4 pressure wound of the left heel full thickness Recommendations: Float heels in bed -Arterial wound of the left, first toe partial thickness Recommendations: Bed cradle (frame installed at foot of bed, placed over the body to keep sheets/blankets off legs/feet) -Unstageable (due to necrosis) sacrum full thickness Review of current Physician's Orders indicated the following: -Bed cradle at all times while in bed (9/20/22) -Heel lift booties at all times while in bed every shift for bilateral heels (10/21/21) Review of the Skin Breakdown Care Plan, initiated 8/12/20, indicated Resident #88 had a potential for skin breakdown related to, but not limited to a bony prominence (ankle/heel/hip/scapula/elbow/ear/etc.), declined cognition, decreased mobility, incontinence, and history of healed skin breakdown. Interventions included to keep heel booties on while lying down in bed. Review of the Skin Breakdown, Actual, Care Plan, initiated 7/27/22, indicated Resident #88 had a shear wound to his/her left distal first toe. Interventions included a bed cradle at all times while in bed. Review of the Pressure Ulcer Care Plan, initiated 11/23/22, indicated Resident #88 had an unstageable pressure ulcer to his/her coccyx due to decreased mobility related to chronic kidney disease, dementia, and generalized weakness. Interventions included to turn and reposition the Resident every two hours (no pads under resident) with draw sheet only. On 12/13/22 at 11:07 A.M., the surveyor observed Resident #88 lying in bed. The bed cradle frame was observed resting in the direction of the floor between the foot of the bed and footboard. It was not placed over the body. Resident #88's bed linens were resting on top of his/her lower extremities. Unit Manager (UM) #4 and Nurse #11 removed the bed linens to change the Resident's dressings. Resident #88 did not have heel lift booties on. A cloth pad was observed underneath the Resident's sacrum/buttock area. On 12/13/22 at 2:19 P.M., the surveyor observed Resident #88 lying in bed. The bed cradle frame was observed resting in the direction of the floor between the foot of the bed and footboard. It was not placed over the body at the foot of the bed. Resident #88's bed linens were resting on top of his/her lower extremities. During an interview on 12/13/22 at 2:36 P.M., Nurse #11 said she took the Resident's heel lift booties off that morning to have them washed. She said she did not know anything about a cradle. Nurse #11 and UM #4 entered the Resident's room with the surveyor. UM #4 said there was a cradle, but it was directed downward towards the floor at the foot of the bed. UM #4 said the bed cradle was supposed to be properly installed and in use at all times. On 12/14/22 at 8:11 A.M., the surveyor observed Resident #88 lying in bed. The bed cradle was not placed over the body at the foot of the bed. Resident #88's bed linens were resting on top of his/her lower extremities. During an interview on 12/15/22 at 8:17 A.M., the Wound Physician said Resident #88 had had a significant decline and the sacral wound was a new issue and was a mess. He said the left heel was being treated aggressively and the left distal toe was not fully healed so the Resident should have had a bed cradle in place. During an interview on 12/15/22 at 8:35 A.M., UM #4 said maintenance had to replace the bed cradle because the other one kept falling down and was ineffective. UM #4 said the Resident should not have pads underneath him/her for repositioning, only a draw sheet, but the night shift staff kept putting them on there. Review of the Wound Evaluation and Management Summary, dated 12/15/22, indicated the following: -Stage 4 pressure wound of the left heel full thickness, deteriorated Recommendations: Float heels in bed -Arterial wound of the left, first toe partial thickness, no change Recommendations: Bed cradle -Stage 4 pressure wound sacrum full thickness, deteriorated During an interview on 12/15/22 at 3:05 P.M., the Director of Nursing (DON) and Administrator said staff should have followed physician's orders and recommendations made by the wound care doctor when agreed upon by the attending physician.

Based on observation, record review and staff interview the Facility failed to ensure that the plan of care was followed during transfer from bed to wheelchair to prevent an injury for one Resident (#138) from a total sample of 33 residents. Findings include: Review of the Face Sheet indicated that Resident #138 was admitted to the facility in 10/2013. Resident #138 medical [DIAGNOSES REDACTED]. On 8/16/18 at 08:10 A.M., during the initial tour the Surveyor noticed a brace on the left leg of the Resident. The Surveyor asked the Resident about the brace in place. He/She said I have a broken bone on the left leg Resident #138 continued and said a Certified Nursing Assistant inappropriately transferred him/her from the bed to the wheelchair. Throughout the day Resident #138 remained in bed and displayed lack of mobility. On 8/16/18 at 2:50 P.M., during an interview with the Resident he/she said I remained in bed and cannot sit on the wheelchair. Review of the Annual minimum data set (MDS) assessment dated as completed (MONTH) (YEAR) indicated Resident #138 required two persons assist for transfer. Review of the CNA Care Plan dated 5/17/18 indicated Resident #138 was totally dependent, required assist of two or more physical assist for transfer and positioning. Review of the Resident Fall Potential Care Plan dated as implemented on 5/30/18 included a plan approach/intervention indicating Resident #138 required extensive assist of two for transfer. Review of the Nurse's note dated 6/27/18 indicated Certified Nursing Assistant (CNA) # 7 reported to Unit Manager #1 that the Resident had requested to see the Nurse. The Nurse's note indicated CNA #7 said to the Nurse (Unit Manager #1) during transfer from bed to the wheelchair Resident 138 foot was crossed over each other and the CNA demonstrated to the Nurse how one was crossed over the other. Review of the Facility Investigation indicated Resident #138 complained of pain of the left lower leg after he/she was assisted with transfer from his/her bed to the wheelchair on 6/27/18 in the morning. The Physician, the Nurse Practitioner and the Resident's daughter were notified. Further review of the investigation report indicated at approximately 10:00 A.M. Resident #138 voiced discomfort of the left knee and lower leg to the Nurse on duty. Resident was assessed by the Nurse and was noted to have soft tissue swelling of the left knee area. The investigation report indicated that ice was applied to the affected area. The physician was notified and an order was obtained to perform and X-ray of the left knee and ankle for the Resident. Review of the X-ray reveals a subtle acute lateral tibial plateau fracture (a break of the upper part of the tibia (shinbone) that involves the knee joint. Symptoms include pain, swelling, and a decreased ability to move the knee). Resident was transferred to the hospital for further evaluation and was admitted . Review of the Hospital discharge instructions dated 6/28/18 indicated Resident was to be a non-weight bearing on the left lower extremity plus a brace in place to left lower extremity/knee area. Review of the Re-admission Assessment indicated Resident #138 returned to the facility on [DATE] at 5:00 P.M. via stretcher and had a leg splint to the left left leg located from above the knee to the ankle. He/She was non weight bearing on to left lower extremity. On 08/21/18 at 02:28 P.M., during an interview with CNA #7 said she was a per diem CNA at the facility, left for lack hours and came back full-time approximately six months ago. CNA #7 said on the morning of 6/27/18 at approximately 9:30 A.M., she provided care to the Resident. CNA #7 said as she was provided care the Resident he/she asked her to take him/her downstairs to the mass catholic service. CNA #7 said because there was no one around at the time to help her, she took it upon herself and transferred the Resident from bed to chair alone on the morning of 6/27/18. CNA #7 said the Resident complained of having pain on the left leg after she transferred him/her from the bed to the wheelchair. CNA #7 said since after the incident she had not been providing care to the Resident because his/her daughter does not want CNA #7 to be near his/her mother CNA #7 confirmed Resident # 138 Care Plan indicated two persons assist for transfer. CNA #7 said when she was in training she was told that to follow the CNA care card and to ensure that if someone required two assist to have another person to help. On 08/21/18 03:16 P.M., during an interview with the Director of Nurses (DON) and Unit Manager #1, the DON said the CNA was re-educated because she did not ask for help when in doubt you should ask. The DON confirmed that the CNA did not follow the plan of care.

Based on observations, interviews and record review the Facility staff failed to ensure that for 2 Residents (#1 and #16), of a total sample of 24 Residents, that care and services were provided to prevent the development of deep tissue pressure injuries. Findings included: A review of the Facility policy for Pressure Ulcers/ Skin Breakdown- Clinical Protocol was conducted. The assessment and recognition section indicated the nurse shall describe and document a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue and the physician will help the staff review and modify the care plan as appropriate. 1. For Resident #1 the Facility staff failed to ensure a pressure relieving device was in place to prevent the development of a deep tissue pressure injury on the coccyx per the facility policy. Resident #1 was admitted in 08/2011 with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), signed as being completed 01/09/17, the Resident was severely cognitively impaired. The MDS indicated that the Resident required assistance with bed mobility, transfers, ambulation, and dressing. The MDS also indicated that the Resident was at risk for pressure ulcers. During a tour of the unit on 03/29/17 at 9:30 A.M. the Unit Manager (#2) said Resident #1 had a healed pressure area on the coccyx and was unsure if the Resident had any open areas on their heels. The Resident was observed to have an air mattress on the bed. Review of the medical record was conducted on 03/29/17. A nursing note dated 03/28/17 at 12:30 P.M. indicated Resident #1 had a new open area to the left buttocks, with no drainage and a new order was implemented for normal saline wash, pat dry and apply calcium alginate and cover with a foam dressing. The Norton Plus Pressure Ulcer Risk assessment dated [DATE] was reviewed. The Norton Assessment coded the Resident as a 9 and at High Risk for pressure injury. Risk factors listed on the Norton Assessment included the following: - Physical Condition-poor - Mental State- confused - Mobility-very limited -Incontinence-double incontinence The Care Plan for Skin Breakdown (Potential) initiated on 01/11/17 indicated a potential for skin breakdown related to impaired mobility and incontinence of bowel and bladder with a goal of reducing the potential for skin breakdown for 90 days. The approaches listed to obtain the goal included: -weekly skin check -norton assessments quarterly and as needed -barrier cream -pressure relieving mattress and /or cushion for wheelchair daily A review of the nutritional status for Resident #1 included a quarterly review from the Registered Dietitian written on 03/28/17. The Dietician noted that the Resident had weight loss over three months and his/her weight had stabilized for the previous two weeks. Review of the interim notes from the Dietician indicated the Resident had a weight of 112 lbs (pounds) during the week of 02/25/17 and a weight of 111 lbs the week of 03/28/17, indicating a stable weight for one month. On 03/29/17 at 12:40 P.M. Resident #1 was observed in the unit dining room to be sitting in a maroon wheelchair with foot rests and he/she was not sitting on a pressure relieving device (cushion). The Resident was observed again at 4:30 P.M. to be in the unit dining room, sitting in the wheelchair without a cushion. An interview with Unit Manager #2 was conducted on 03/29/17 at 4:10 P.M. The Unit Manager said the open area was found on 03/28/17 and would be assessed by the wound physician from Vohra the following day. She said the new open area was not an area that had recently healed. The Unit Manager said there were currently no measurements available for the wound as the nurse did not complete them per facility policy. The Nurse (#1) on the unit, who had written the note identifying the wound, was interviewed on 03/30/17 at 3:00 P.M. She said she was alerted by a Certified Nursing Assistant (CNA) of the wound. She said she had not taken measurements of the wound as the Unit Manager usually measures the wound and that she had notified Unit Manager #2 of the wound when it was identified on 03/28/17. The wound physician was interviewed on 03/30/17 at 8:00 A.M. He said he had seen Resident #1 that morning and the wound, located on the coccyx, was unstagable prior to his treatment and would be a stage III following his debridement. He said the open area was slightly to the right of the previous open area, which healed a couple of weeks prior. The wound physician said the he was surprised the Resident had another breakdown in skin so fast. The Surveyor inquired about a pressure relieving device in the wheelchair and the wound physician said if a cushion had been used in the wheelchair it absolutely would have helped to prevent the pressure area. A review of the evaluation from the wound physician, dated 03/30/17 indicated there was an unstageable (due to necrosis) area on the coccyx of at least 4 days duration with light serous exudate. The wound measured 2.5 x 1.5 x 0.2 cm (centimeters). Unit Manager #2 was interviewed on 03/31/17 at 10:30 A.M. The Unit Manager stated the Resident previously had a cushion for her wheelchair and it was part of the plan of care for Resident #1. The Unit Manager stated the CNAs were concerned about the roommate of Resident #1 and had provided the cushion for Resident #1 to the roommate. 2. For Resident #16 the Facility staff failed to ensure a pressure relieving device was utilized to promote the healing of pressure ulcers to the left and right heels. Resident #16 was admitted in 03/2010 with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), signed as being completed 02/06/17, the Resident was severely cognitively impaired. The MDS indicated that the Resident required assistance with bed mobility, transfers, ambulation, and dressing. The MDS also indicated that the Resident was at risk for pressure ulcers. During a tour of the unit on 03/29/17 at 9:30 A.M. the Unit Manager (#2) said Resident #16 had pressure areas to the bilateral heels. Resident #16 was observed to be in bed, a pump for the air mattress was observed to be on the mattress at the foot of the bed and the left foot of Resident #16 was up against the pump. It was observed that both of the Resident's heels were resting on the mattress. Review of the medical record was conducted on 03/31/17. A nursing note dated 03/13/17 indicated the left and right heels for Resident #16 were breaking down. The note indicated the left heel area was measuring 1.3 x 2.4 cm. The Norton Plus Pressure Ulcer Risk assessment dated [DATE] was reviewed. The Norton Assessment coded the Resident as an 8 and at High Risk for pressure injury. Risk factors listed on the Norton Assessment included the following: - Physical Condition-poor - Mental State- confused - Activity- chair bound - Mobility-very limited -Incontinence-double incontinence A review of the physician progress notes [REDACTED].#16 indicated the Resident was in a vegetative state, continuously bed bound and appeared fairly hydrated and nourished. A review of the evaluation from the wound physician, dated 03/16/17 indicated there was a stage III pressure wound to the left heel (3 x 2 x 0.2 cm) of at least 5 days duration with light serous exudate. The recommendation was to off-load the wound, reposition per facility protocol and float heels in bed. On 03/31/17 at 11:30 A.M. Resident #16 was observed in bed, a pump for the air mattress was observed to be on the mattress at the foot of the bed, an off loading device was observed under the Resident's knees and both heels were observed to be on the mattress. The Resident was observed again at 2:00 P.M. with Unit Manager #2. The Resident was in bed, with the mattress pump on the mattress and the off loading device was placed under the Resident's knees, which placed the Resident's heels on the mattress. Unit Manager #2 said that the off loading device should not be that high up under the legs and that the device was used to float the heels of Resident #16 off of the mattress.

Based on record review and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was provided two staff for all transfers per plan of care, when on 11/20/13, Certified Nurse Aide (CNA) #1 transferred Resident #1 alone from the bed to the wheelchair without a gait belt or staff assistance, and Resident #1 sustained a lower left leg laceration that required 7 sutures to close. Findings include: Resident #1 was admitted to the Facility March of 2012 and [DIAGNOSES REDACTED]. The plan of care, dated 3/25/13, indicated that Resident #1 had weakness, fatigue and decreased activity tolerance. Plan of care interventions included assistance of two staff for transfers. The quarterly Minimum Data Set (MDS) assessment, dated 9/3/13, indicated that Resident #1 required two staff for transfers. The CNA care card and CNA flow sheet, dated 11/1/13 to 11/20/13, indicated that Resident #1 required assistance of two staff for transfers. The nurse's note, dated 11/20/13, indicated that Resident #1 sustained a left lower leg laceration, the Physician was notified, and Resident #1 was transferred to the Hospital at 11:45 A.M. for evaluation of a leg laceration. The Surveyor interviewed the Assistant Director of Nurses (ADON) on 12/12/13 at 8:30 A.M. The ADON said on 11/20/13, she was called to Resident #1's room after the CNA #1 transferred Resident #1 unassisted. The ADON said she assessed Resident #1's left leg laceration and told the staff to notify the Physician because Resident #1 probably required sutures to close the laceration. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 12/12/13 at 11:30 A.M. CNA #1 said on 11/20/13, she provided care to Resident #1 and transferred Resident #1 out of bed to the wheelchair. CNA #1 said that she was Resident #1's consistent caregiver, and always had another CNA assist her with the transfers. CNA #1 said Resident #1 was in a hurry and wanted to get out of bed. CNA #1 said Resident #1 offered to help with the transfer on 11/20/13. CNA #1 said she transferred Resident #1 alone, and without a gait belt, from the bed to the wheelchair. CNA #1 said she noticed blood on the floor. CNA #1 said she notified the nurse on duty. The nurse's note, dated 11/20/13, indicated that Resident #1 returned from the Hospital at 3:00 P.M., with 7 sutures in the left leg laceration. The nurse's note indicated that the laceration was covered with a dressing to be left in place for 24 hours, and Resident #1 was provided the pain medication Tylenol 650 milligrams (mg) at 3:10 P.M. for pain. The Surveyor interviewed the Director of Nurses (DON) on 12/12/13 at 8:30 A.M. The DON said she was not sure why CNA #1 transferred Resident #1 alone on 11/20/13. The Surveyor interviewed the Unit Manager on 12/12/13 at 11:15 A.M. The Unit Manager said she was not sure how CNA #1 transferred Resident #1 alone because he/she was heavy and did not assist with the transfers. The ADON said it appeared that Resident #1 may have hit the rounded edges of the wheelchair that the leg rests were attached to, so the wheelchair was padded to prevent any further injuries.

Based on record review and interviews, for one of four sampled residents (Resident #1, the Facility failed to ensure that Certified Nurse Aide (CNA) #1 followed the plan of care for Resident #1, who required two staff for all transfers, when on 11/20/2013, she transferred Resident #1 alone from the bed to the wheelchair without a gait belt or staff assistance, and Resident #1 sustained a lower left leg laceration that required 7 sutures to close. Findings include: The care plan, dated 3/25/13, indicated that Resident #1 had weakness, fatigue and decreased activity tolerance. Care plan interventions included assistance of two staff for transfers. The quarterly Minimum Data Set (MDS) assessment, dated 9/3/13, indicated that Resident #1 required two staff for transfers. The CNA care card and CNA flow sheet, dated 11/1/13 to 11/20/13, indicated that Resident #1 required assistance of two staff for transfers. The Surveyor interviewed the Assistant Director of Nurses (ADON) on 12/12/13 at 8:30 A.M. The ADON said on 11/20/13, she was called to Resident #1's room after CNA #1 transferred Resident #1, unassisted. The ADON said she assessed Resident #1's left leg laceration, and told the staff to notify the Physician because Resident #1 probably required sutures to close the laceration. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 12/12/13 at 11:30 A.M. CNA #1 said on 11/20/13, she provided care to Resident #1 and transferred Resident #1 out of bed to the wheelchair. CNA #1 said that she was Resident #1's consistent caregiver, and always had another CNA assist her with the transfers. CNA #1 said Resident #1 was in a hurry and wanted to get out of bed. CNA #1 said Resident #1 offered to help with the transfer on 11/20/13. CNA #1 said she transferred Resident #1 alone, from the bed to the wheelchair, without a gait belt. CNA #1 said she noticed blood on the floor. CNA #1 said she notified the nurse on duty. The nurse's note, dated 11/20/13, indicated Resident #1 sustained a left lower leg laceration, the Physician was notified, and Resident #1 was transferred to the Hospital at 11:45 A.M. for evaluation of a leg laceration. Refer to F 323 for details.

Based on observation, record review and staff interview, the facility failed to ensure that a resident with a limited range of motion receives the appropriate treatment and services to increase range of motion and prevent contractures for one resident (Resident # 10) in a total sample of 27 residents. For resident #10, the facility failed to implement timely interventions when a decline in range of motion was identified by the physical therapist who treated the resident from mid November until 12/18/11 when services stopped. During the following 2 months, the facility failed to provide range of motion exercises or implement any preventative interventions when the resident's functional mobility continued to decline. During the period of delay, the resident, who on admission in 11/2011 had limitations of range of motion on one side but no contractures, developed "significant contractures of the hip and knee" when evaluated by a physical therapist on 2/16/12. Findings include: Resident #10 was admitted to the facility for rehabilitation following hospitalization for dehydration, acute [MEDICAL CONDITIONS] with left sided [MEDICAL CONDITION], and failure to thrive. Review of the initial minimum data set (MDS) assessment with a reference date of 11/21/11 indicated that the resident had a short term memory deficit, but was able to make his/her needs known. The resident was also coded with mood indicators including trouble sleeping and having little energy. The resident was dependent on staff for most activities of daily living, including bed mobility and transfers due to a limitation in functional range of motion of the upper and lower extremities on one side. Per record review, the admission nursing assessment completed on 11/14/11 documented that the resident's skin was assessed as clear, dry and intact, and the resident's left heel was documented as fragile. The resident had no contractures. Review of a physical therapy evaluation completed 11/16/11, documented that the resident's left lower extremity had increased tone in the left knee. The assessment section documented that the resident had decreased functional mobility and recommended the need to increase the resident's strength and complete assisted range of motion to the left upper and lower extremities. The resident's prior level of functioning was described as independent ambulation. The resident's rehabilitation potential was described as good. The therapist planned to work with the resident 6 times per week for six weeks. Review of the 11/18/11 nurse notes revealed that the resident was a 1 person assist with activities of daily living and transfers. The resident had new complaints of left lower extremity pain and requested [MEDICATION NAME] (narcotic [MEDICATION NAME] medication) for pain relief. On 11/23/11 and 11/24/11, nursing documented that the resident continued to request [MEDICATION NAME] for left leg pain with good effect. However, the Further 11/24/11 nurses notes revealed that the resident required a 2 person assist with transfers. On 12/6/11, Resident #10 was sent to the emergency room for increased confusion, persistent complaints of left leg pain and [MEDICAL CONDITION] of the left foot. Diagnostic testing for [MEDICAL CONDITION] and [MEDICAL CONDITION] were negative. The resident was diagnosed with [REDACTED].M. On 12/7/11, the physical therapist documented that the resident postures with the left lower extremity flexed at the hip and knee with the left hip adducted and internally rotated. The resident complained of knee pain. The resident was issued a pummel cushion for wheelchair positioning. The therapist recommended a Hoyer lift for transfers. The therapist also documented that splints were being considered for the left knee while in bed. Review of the physical therapist visit dated 12/12/11, revealed that the resident had a further decline with increased lean to the left, increased tone and tightness in the left knee. The resident, who was still being treated with antibiotics for a urinary tract infection, did not want to put weight on the left lower extremity. The physical therapist did not address the issue of lower extremity splints that were noted on the 12/7/11 progress note. There was no further documentation available in the clinical record from the physical therapist. The Director of Rehabilitation Services was interviewed on 4/5/12 at approximately 1:30 P.M., said that no Physical Therapy discharge summary was available for review. Review of the 12/12/11 Nurse's Note indicated that the nurse spoke with the health care proxy regarding "the lack of progress with rehab that (resident) is a max 2/Hoyer lift and is physically unable to make gains toward goals ... (resident) is dependant in ADL's and is even assisted with meals .....I explained that in the future if (resident) shows a decline rehab may be able to assess." On 12/15/11, Resident #10 was transferred to the Driftwood unit for long term care. Review of the clinical record revealed no plan to address the decline in the resident's range of motion and no interventions to prevent further decline in the resident's range of motion and functional status. On 1/5/12, a rehabilitation screen sent by the nursing staff identified that changes were noted in the resident's positioning. The request stated that the family was concerned about the resident's left leg contracture - wants leg to be straight. Please evaluate. The need for splint therapy was questioned. Review of the clinical record with Unit Manager #2 on 4/5/12 at 9:15 A.M., revealed no interventions by nursing staff to address the residents decline in range of motion since 12/15/11. The rehab screen requested by the family dated 1/5/12 was not responded to until 2/16/12. . On 2/16/12, the 3:00 P.M. nurses note documented that the resident was seen by the physical therapist for splinting of the left lower extremity. Review of the 2/16/12 physical therapist evaluation revealed that the resident had developed marked contractures of the left hip and a left knee flexion contracture of negative 60 degrees. The resident was referred for splinting. The goal of treatment was to reduce the flexion contracture of the knee by 30 degrees via a progressive application of a dynasplint to be applied by the therapist 3 times per week for 4 weeks. Review of the physical therapist progress notes' revealed that by 3/20/12, improvement in the status of the left knee flexion contracture was noted. The resident was able to extend the knee from negative 60 degrees to negative 40 degrees. Nursing and Certified Nurse Aide staff were educated in application of the dynasplint in order to provide carry over of services beginning 3/20/11. Review of the nurses' notes reflected that staff applied the dynasplint at approximately 11:00 A.M. daily for a 3 hours period as recommended by the physical therapist. During the initial tour of the facility on 4/3/12, resident #10 was observed 9:30 A.M. The resident was lying on his/her back with the head of the bed elevated. The resident's left knee was pulled up and to chest level and the left foot was pulled into the groin. Leg splints were observed on the windowsill. Unit Manager #2 said that the splints were to be applied at 11:00 A.M. Unit Manager #2 said the physical therapist had visited the resident the previous day to reassess the splint application process. The Physical Therapist interviewed on 4/4/12 at 2:30 P.M., said that she assessed the resident on 2/16/12 with significant contractures of the hip and knee. The physical therapist said that the resident was actively followed from 2/16/12 through 3/20/12 for application of dynasplint, three times per week as planned. The physical therapist said the resident's knee and hip contractures had improved and the resident was able to better extend her leg and improve her positioning. The Physical Therapist reported that nursing staff had recent difficulty with the splint application due to problems with the splint straps. The physical therapist reported that the service representative was contacted on 4/3/12, adjusted the splint straps and reeducated staff regarding appropriate application. The Physical Therapist said that she was unaware of why there was a delay in obtaining a rehabilitation screen requested on 1/5/12 in order to ensure timely splinting interventions.

Based on staff interview and the record review of 1 (#25) of 27 sampled residents, the facility failed to ensure that Resident #25 received the cardiac medication as ordered by the physician. The findings include: Resident #25 was readmitted to the nursing facility on 12/13/11 following a hospitalization for the treatment of [REDACTED]. Record review indicated that on 12/14/11 the physician ordered the antiarrhythmic cardiac medication, [MEDICATION NAME] 0.125 milligrams every day. A laboratory test, dated 12/21/11, indicated that the resident's [MEDICATION NAME] level was 1.6, within normal limits of the range of 0.5 to 2.0 ng/ml. Another laboratory test, dated 12/26/11, indicated that the resident's [MEDICATION NAME] level was high with a reading of 2.4. The results were reported to the physician. The physician ordered a decrease in the [MEDICATION NAME] to 0.125 milligrams every other day. Review of the nurses' notes indicated that on 1/1/12 the resident's medications were held secondary to lethargy. On 1/4/12 nursing documented that the resident was observed to be lethargic and had [MEDICAL CONDITION] with an apical pulse range of 38 - 44. The note indicated that the nurse practitioner assessed the resident, spoke to the primary care physician, called "911" and sent the resident to the emergency room for evaluation. A subsequent nurse's note, dated 1/4/12, indicated that the resident was sent to the hospital for a heart rate of 38-40. The note also indicated that the resident had received 2 extra doses of [MEDICATION NAME] since the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication record indicated that the resident received [MEDICATION NAME] on 12/30/11, 1/1/12, 1/2/12, 1/3/12 and 1/4/12. The medication record for January 2012 listed the medication order as [MEDICATION NAME] 125 micrograms (0.125 milligrams) every day. The change in the order from daily to every other day was not carried over correctly from the December 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was hospitalized from [DATE] to 1/6/12 with the [DIAGNOSES REDACTED]. On interview on 4/6/12 at 12:50 PM, the Director of Nurses reported that the error was investigated and found to be caused by a transcription error.