Every finding on record at Fairview Commons Nursing & Rehabilitation Center

Based on records reviewed, interviews, and observations, for two of three sampled residents (Resident #1 and Resident #2) who had lower extremity wounds and were being followed by a Wound Specialist, the facility failed to ensure the residents received quality of care that met professional standards of practice when recommendations made by the Consultant Wound Care Specialist were not implemented as directed. Findings include:Review of the Facility's policy titled, Consultant - Recommendations and Physician's Orders, dated as last revised 02/28/24, indicated the Policy is to ensure a standardized process is maintained whereby consultant's recommendations are reviewed by nursing and communicated to the attending physician for further orders. Further review of the Policy indicated (in part) that:- The attending physician, if in agreement, will order the specific treatments or medications as outlined by the consultant, and the nurse will transcribe the orders, update the care plan as indicated, and communicate changes in nursing report and nursing note. 1. Resident #1 was admitted to the facility in December 2025 with diagnoses including Diabetes, Peripheral Neuropathy (nerve damage often caused by Diabetes) and deep-vein thrombosis (blood clot in a deep vein that can slow normal blood flow).Review of Resident #1's Medical Record included a Nursing Progress Note, dated 06/30/26, that indicated he/she developed a new right heel blister and that he/she was referred to the Wound Care Specialist for consultation. Review of the Wound Care Specialist's Consultation Note, dated 07/02/26, indicated that Resident #1 was referred due to developing a new heel wound which started as a blister believed to have been caused by friction from his/her shoe.The Wound Care Specialist classified the wound as a Diabetic [NAME] Grade 1 wound (superficial open sore that involves the outer layers of skin or subcutaneous tissue but does not yet extend into deeper structures like tendons, joints or bones). Further review of the Consultation Note indicated the following treatment recommendation:- cleanse the wound- apply calcium alginate (a specialized absorbent pad to aid in wound healing)- secure with bordered gauze (an adherent dressing used to cover a wound)- change dressing daily, and as neededReview of Resident #1's July 2026 Physician's Orders indicated the following right heel treatment order:- cleanse the wound with normal saline (NS, a sterile mixture of salt and water used to cleanse wounds)- cover the wound with calcium alginate- cover with bordered gauze- change dressing on Tuesday, Thursday, Saturday, and as neededReview of Resident #1's July 2026 Treatment Administration Record indicated Nursing administered the treatment to his/her heel wound three times a week (on Tuesday, Thursday, and Saturday), and had not changed the dressing daily as recommended by the Wound Care Specialist. During an interview on 08/04/26 at 2:00 P.M., Unit Manager #1 said she is the designated nurse that accompanies the Wound Care Specialist during her weekly wound rounds. Unit Manager #1 said during these rounds, the Wound Care Specialist documents her assessment findings and any treatment recommendations for each consultation and then provides an informal log of all the consultations to her (Unit Manager #1). Unit Manager #1 said she reviews the results of the wound rounds, including any recommendations or treatment changes with the Facility Provider after the wound rounds have been completed and once the Provider approves the recommendations, she (Unit Manager #1) will enter the orders into the EMR the same day as wound rounds. Unit Manager #1 further said that when she presents the recommendations to the Facility Provider, they usually approve the Wound Care Specialist's recommendations. Unit Manager #1 reviewed the Wound Care Specialist's visit notes and recommendations and the Physician's Orders for Resident #1 and said for Resident #1, based on the Wound Care Specialist's recommendations on 07/02/26, he/she should have had his/her right heel treatment completed daily, not three times per week. Unit Manager #1 said the Physician's Orders for Resident #1's wound treatments were never updated to reflect the Wound Care Specialist's recommendations.2. Resident #2 was admitted to the facility in December 2023 with a diagnosis of Dementia. Review of Resident #2's Medical Record included a Nursing Progress Note, dated 07/15/26, that indicated Resident #1 developed a new area to his/her right heel that appeared to be a blister that had opened, and he/she was referred to the Wound Care Specialist for a consultation.Review of the Wound Care Specialist's Consultation Note, dated 07/23/26, indicated that Resident #2 was referred due to developing a new right heel wound and classified the wound as an unstageable pressure injury (localized damage to the skin and/or underlying soft tissue that usually occurs over a bony prominence due to intense or prolonged pressure covered by dead tissue blocking the true depth of the wound). Further review of the Consultation Note indicated the following treatment recommendation:- cleanse the wound with 0.125 percent (%) Dakin's solution (mild diluted bleach solution used as an antiseptic to clean chronic wounds to prevent or treat infection) -apply calcium alginate with silver to base of the wound- cover with 6cm x 6cm bordered gauze- change dressing on Tuesday, Thursday, Saturday, and as neededHowever, review of the Wound Care Specialist's Consultation Note, dated 07/30/26, indicated it included updated treatment recommendations as follows: - cleanse the wound with 0.125% Dakin's solution- apply calcium alginate with silver to base of the wound- secure with superabsorbent pad- change dressing daily and as neededReview of Resident #2's July and August 2026 Physician's Orders indicated the following right heel treatment orders:07/23/26-07/27/26- cleanse the wound with normal saline (NS)- apply calcium alginate with silver- cover with bordered gauze- change dressing on Tuesday, Thursday, Saturday, and as needed07/27/26-08/04/26 (date of survey)- cleanse the wound with NS- apply calcium alginate with silver- cover with superabsorbent dressing- change dressing on Tuesday, Thursday, Saturday, and as neededReview of Resident #2's July and August Treatment Administration Record indicated Nursing administered treatment to his/her heel wound as ordered, however they did not cleanse the wound with Dakin's solution or change his/her treatment frequency to daily on 07/30/26, as recommended by the Wound Care Specialist. During an interview on 08/04/26 at 12:40 P.M., Nurse #1 reviewed Resident #2's treatment orders in the electronic medical record (EMR) and said his/her dressing to his/her right heel is scheduled to be completed during the day shift every Tuesday, Thursday and Saturday, and that the Unit Manager #1 will be administering Resident #2's treatment after she (Nurse #1) medicated Resident #2 for pain.During an interview and observation of Resident #2's wound treatment on 08/04/26 at 1:20 P.M., the surveyor observed Unit Manager #1 cleanse his/her wound with normal saline prior to applying his/her dressings. After the treatment was completed, Unit Manager #1 said Resident #2's heel wound treatments are scheduled for every Tuesday, Thursday, and Saturday.Unit Manager #1 reviewed the Wound Care Specialist's visit notes and recommendations and the Physician's Orders for Resident #2.Unit Manager #1 said for Resident #2, based on the Wound Care Specialist's recommendations on 07/23/26 and on 07/30/26, his/her right heel wound should have been cleansed with Dakin's solution, not normal saline, and that after 07/30/26, he/she should have had his/her right heel treatment completed daily, not three times per week. Unit Manager #1 further said Resident #2's Physician's Orders were never updated to reflect the Wound Care Specialist's recommendations.During a telephone interview on 08/06/26 at 8:20 A.M., the Wound Care Specialist said she visits the facility every week and conducts wound rounds with Unit Manager #1 (or with a designee). The Wound Care Specialist said after she completes rounding, she provides a document to Unit Manager #1 that contains information about each resident's visit information including any changed or new treatment recommendations so that she (Unit Manager #1) can initiate the process of obtaining approval from the Facility Provider to enter the recommendations into the EMR as orders. The Wound Care Specialist said she will then complete a formal visit note with more detail and enter this directly into the facility's EMR by the next day. The Wound Care Specialist said the Facility Provider will almost always approve her recommendations, and she expected that those recommendations would be implemented by Nursing. During an interview on 08/04/26 at 4:15 P.M., the Director of Nurses (DON) said the Facility generally refers any resident with skin integrity issues to the Wound Care Specialist, who visits the facility weekly.The DON said Unit Manager #1 is the designated staff person who completes wound rounds alongside the Wound Care Specialist, and said that after the visits have been completed, the Wound Care Specialist provides a synopsis of each resident visit, including any recommendations, new treatments, or changes in treatments to Unit Manager #1 (or her designee if she is off).The DON said that either Unit Manager #1 or another Unit Manager will utilize this synopsis and obtain any treatment orders needed from the Facility Provider and will then enter the orders into the computer. The DON further said that the Facility Provider generally approves all recommendations made by the Wound Care Specialist.After reviewing both Resident #1 and Resident #2's Wound Care Specialist's recommendations and Physician's Orders, the DON said that Resident #1 and Resident #2 had not received the recommended treatments because their Physician's Orders were never updated to reflect the Wound Care Specialist's recommendations.

Based on observations, interviews, and record reviews, the facility failed to maintain an environment that was free of accident hazards and risks for three Residents (#7, #63, and #67), out of a total sample of 26 residents. Specifically, For Resident #7, the facility failed to conduct a thorough investigation and provide effective interventions and adequate supervision to prevent falls when the Resident was identified as high falls risk due to cognitive impairment, had multiple previous falls including one fall with sustained fractures, and was left unattended in the Activity Room with other residents and sustained a hip fracture requiring hospitalization and surgical intervention.For Resident #63, the facility failed to implement assistive devices and appropriate interventions/notifications during dining to reduce the risks of aspiration (inhalation of foreign materials into the lungs) for the Resident. For Resident #67, who had a history of falls, the facility failed to analyze the reason for the Resident's most recent fall on 6/22/25 and ensure modified interventions to prevent further falls were implemented. Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, revised 12/29/11, indicated the following: -all accidents or incidents involving residents . occurring on the premises must be investigated and reported to the Administrator. -the purpose of the policy was to ensure accurate reporting, timely investigation, and subsequent follow up is completed with each accident/incident in order to identify PI (Process Improvement) opportunities. -regardless of how minor an accident or incident may be . report the accident/incident to the department supervisor as soon as possible. -complete an Incident Report for all reported accidents or incidents. -the nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident. -an Incident and Accident form must be completed prior to the end of the shift and submitted to the Director of Nurses (DON) promptly. -if Incident/Accident Report is completed for a fall, corresponding post fall investigation shall also be completed. Review of the facility policy titled Falls Management: Post Fall, revised and approved on 11/2/23, indicated all residents experiencing a fall will receive appropriate care and investigation of the cause. The policy also included the following: -review of investigation and intervention will be conducted by the centers identified Interdisciplinary Falls Team. -the purpose was to address any injury, provide care for recovery from fall, and reduce the risk for future falls. -review the resident's medical record and assessments to identify any causes that may have contributed to the fall. -complete an Incident Report/Post fall investigation/ 5 Whys Analysis after the fall. -remove any causes of fall and implement preventative measures to prevent reoccurrence. -update care plan/Kardex to reflect new interventions. -conduct Interdisciplinary Falls Team meeting at the subsequent clinical A.M. meeting. >review the 5 Whys analysis. >determine need for additional actions/interventions based on team evaluation of root cause. >communicate information to staff. -review the resident weekly for four weeks at Interdisciplinary meeting to determine effectiveness of interventions. Revise the care plan accordingly. 1.Resident #7 fell in the Activity Room on 6/11/25 and sustained a hip fracture that required surgical intervention. Medical record documentation indicated that staff were not present in the Activity Room at the time of the fall to provide supervision and touch assistance to the Resident if needed. Resident #7 previously sustained a fall on 5/22/25 in the Activity Room and the facility failed to complete a thorough investigation of that fall and implement effective interventions to prevent recurrences of the Resident sustaining any further falls. -Nursing Progress Notes on 5/22/25: Resident #7 was in the Activity Room, was standing in front of his/her rolling walker, attempted to sit in a stationary chair, missed and fell. The Resident's fall was witnessed by other residents who were in the Activity room. An incomplete Falls investigation failed to indicate staff presence at the time of the fall. Nurse #4 said the Resident was educated after the fall, to feel for the arms of the chair prior to sitting. -Nursing Progress Notes on 6/11/25: Resident #7 was observed lying on his/her left side on the floor in the Activity Room. The Resident was found unable to bear weight on his/her left leg, unable to do internal/external rotation (of the left leg), complained of increased pain, transferred out of the facility for evaluation on 6/11/25 and re-admitted to the facility on [DATE] after left hip surgery for partial hip replacement (hemiarthroplasty: surgical repair of the hip after a fracture). Resident #7 was admitted to the facility in April 2023 with diagnoses including Dementia, generalized muscle weakness, unsteadiness on feet and repeated falls. Review of the Minimum Data Set (MDS) Assessments for Resident #7 indicated: -severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of four out of a possible 15 points, dated 3/19/25. -moderate cognitive impairment as evidenced by a BIMS score of 12 out of a possible 15 points, dated 6/4/25. -Chair to bed and bed to chair transfers: required partial to moderate assist -ambulation: required supervision to touch assist Review of the clinical record indicated: -Falls Care Plan, initiated 5/19/23, indicated Resident #7 was at risk for falls due to confusion and forgetfulness. -Nursing Progress Notes and Accident/ Incident Reports on 3/8/25, 3/12/25 and 3/13/25: Resident #7 was found seated on his/her bathroom floor with bruising and swelling observed on the Resident's left [sic] foot. An ordered X-ray determined the Resident had fractures of his/her 3rd and 4th toes. Interventions added to the plan of care subsequent to the fall included: non-skid socks when in bed, staff to make frequent checks every two hours and as needed especially on the evening shift, assistance of staff with activities of daily living (ADLs) and ambulation. -Nursing Progress Notes and Accident/ Incident Reports on 4/14/25: a Certified Nurse Aide (CNA) found Resident #7 lying on the floor in the hallway on his/her right side. The Resident was observed with a hematoma on the back of his/her head. Interventions added to the plan of care subsequent to the fall included: offer for Resident to go to bed after dinner meal, remind Resident to ask for assistance with ADLs, and provide assistance of one staff. -Physical Therapy Discharge summary, dated [DATE], indicated Resident #7 required assistance of staff prior to and following activity for transfers (chair to bed, chair to chair) and contact guard assistance of staff (light touching, tactile cueing), supervision/touching assist with use of rollator device for ambulation. -Nursing Progress Notes and Accident/ Incident Reports on 5/6/25, Resident #7 was self-propelling his/her wheelchair back to the room, stood up, folded up his/her wheelchair to put it aside, stepped back and fell onto the floor. The fall was witnessed by two other residents and a CNA. Intervention added to the plan of care subsequent to the fall included: Resident will have reminder signs in the room to ask for help with tasks. During an interview on 7/31/25 at 9:33 A.M., Rehabilitation Staff #2 said he was very familiar with Resident #7 and had worked on/off with the Resident for over a year. Rehabilitation Staff #2 said Resident #7 had fallen numerous times, and due to his/her cognitive impairment and forgetfulness, required verbal cues to contact guard/assist of one staff with transfers and ambulation using a walker. Rehabilitation Staff #2 said Resident #7 had not been independent with mobility for the past year due to his/her cognition and decreased safety awareness Review of the Accident/Incident Reports indicated: -5/22/25: the fall in the Activity Room was not witnessed by facility staff. The immediate intervention added after the fall indicated for staff to assist in activities. -6/10/25 [sic], indicated Resident #7's fall in the Activity Room (on 6/11/25) was unwitnessed by facility staff. Rehabilitation Staff #3 observed Resident #7 ambulating in the hallway, unassisted by staff towards the Activity Room for the 2:00 P.M. activity. Rehabilitation Staff #3 indicated that she walked with Resident #7 and waited until the Resident sat down in one of the chairs before leaving the Activity Room. Review of CNA #8's statement indicated she was assisting another resident to the activity when she heard screaming, rushed to the door of the Activity Room and observed Resident #7 lying on the floor on his/her left side and after one of the Activity Staff entered the room, CNA #8 went to get assistance. During an interview on 7/31/25 at 9:09 A.M., the Activity Director (AD) said: -Resident #7 attended activities often. -if a resident required assistance of staff for mobility/ambulation due to his/her physical ability, then the CNAs or Nurses would have to assist the resident to activities. -the AD said the Activities Staff usually tried to observe the residents in the Activity Room to determine if it was safe to leave the room unattended when gathering other residents for the scheduled activity. -relative to Resident #7, he/she was previously able to walk independently, but currently he/she utilized a wheelchair and required supervision. -Resident #7 had a fall in the Activity Room in June 2025 which was unwitnessed by staff. At the time of the fall, Activities Staff were gathering residents for the scheduled activity and the Activities Staff had not assisted Resident #7 to the Activity Room. -prior to 6/11/25, Resident #7 was not identified as someone who needed to be supervised for safety while in activities. The AD said after the 6/11/25 fall, Resident #7 was not to be left alone (without facility staff) in the Activity Room. -she was unaware Resident #7 had a fall on 5/22/25 which also occurred in the Activity Room. During an interview on 7/31/25 at 9:26 A.M., Activity Staff #1 said: -when the fall occurred on 5/22/25, Resident #7 was independent with ambulation and could be assisted by Activities Staff to the activities. -Activity Staff #1 said at that time, the Resident would often be brought to the Activity Room and left unattended. -when the Resident fell on 6/11/25, there were no staff in the Activity Room. During an interview on 7/31/25 at 10:03 A.M., the Director of Rehabilitation (DOR) said: -Resident #7 was noncompliant with the use of the assistive device (walker) and has had numerous falls. -since March 2025, the Resident required assistance of one staff with transfers and ambulation using a walker and should be assisted by certified staff (Nurses/CNAs). -non-trained staff (i.e. Activities Staff) should not be providing assistance with the Resident's ambulation/transfers. -when activities occur, there were staff in/out of the room but there were not always staff in the room when residents were present, and residents were left unattended. -she could not recall what interventions were added after Resident #7's fall in the Activity Room on 5/22/25 to prevent recurrence. During an interview on 7/31/25 at 10:38 A.M., Unit Manager (UM) #1 said: -Resident #7 had some falls, was previously ambulatory with a walker, now required assistance from staff and utilized a wheelchair. -the Resident was forgetful and could be non-compliant due to his/her memory impairment. -when a resident falls, a fall investigation would be completed, and an intervention would be put into place and added to the resident's plan of care. -once the initial fall investigation was completed, the fall investigation would be reviewed by the Charge Nurse and/or the UM for completeness and then it was given to the DON for review. -relative to the Resident's fall on 5/22/25, the Accident/Incident Report was incomplete and missing required information. On 7/31/25, the surveyor and the DON reviewed Resident #7's clinical record. During interviews on 7/31/25 at 12:21 P.M. and 12:33 P.M., the DON said: -according to the fall investigation dated 5/22/25, the new intervention indicated for staff to assist in activities, and that the meaning of this intervention was unclear. -the Nurse's Progress Note dated 5/22/25, indicating the immediate intervention was to remind the Resident to feel for the arms for the chair prior to sitting was not an appropriate intervention because the Resident was cognitively impaired. -there was no intervention put into place after the Resident's 5/22/25 fall to prevent additional falls based on the circumstances in the Activity Room. -a more thorough review of the fall investigation should have been completed for completeness and appropriateness of the interventions, and had the facility reviewed the Resident's fall from 5/22/25 more thoroughly, they would have put a plan into place to include supervision when the Resident was in activities. 2. Resident #63 was observed drinking coffee from a non-specialty cup during the breakfast meal when the Resident was recommended to use an assistive device Provale Cup to encourage pacing with drinking. The facility staff allowed the Resident to drink from a regular coffee mug during a breakfast meal observation on two separate occasions: 7/24/25 from 8:31 A.M. to 8:47 A.M. and 7/25/25 from 8:36 A.M to 8:44 A.M., and resulted with Resident #63 coughing and choking, when he/she was supposed to be utilizing a Provale cup. During the 7/24/25 observation, the Resident asked CNA #2 who was present to help him/her with breathing as he/she was coughing and choking. 1 Resident #63 was admitted to the facility in March 2024 with diagnoses including Protein - Calorie Malnutrition, Dementia, Parkinsonism, Gastro-Esophageal Reflux (GERD), Dysphagia, Pneumonia, and Acute Respiratory Failure. Review of Resident #63's MDS assessment dated [DATE], indicated the following: -Moderately impaired cognition as evidenced by a BIMS score of 12 out of 15 -Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time -Usually understands - misses some part/intent of message but comprehends most conversation. Review of Resident #63's Speech Therapy Evaluation dated 4/25/25, indicated: -Assessment Summary in part: >Resident presents with baseline mild oropharyngeal dysphasia (disorder or impairment in initiating a swallow) as he/she demonstrated tolerance of current least restrictive device (LRD) of mechanical soft solids/ground with added moisture (cut into bite size pieces) and thin liquids in Provale cup (cup designed for people with dysphagia to deliver small sips of thin liquids). >Resident benefits from continued supervision and cueing for use of slow rate, small/single sips/bites, upright for at least 30 minutes status post meals. >Skilled Speech Therapy interventions not indicated as Resident was tolerating baseline diet with minimal to no overt signs and symptoms of aspiration and Resident enjoys current diet textures. Review of the Dietician Progress Note dated 7/9/25, indicated Resident #63: -remained a nutritional risk -mechanical soft diet with thin liquids >Intervention (in part): -Provale cup to encourage pacing. Review of Resident #63's meal ticket dated 7/28/25, indicated the following: -Beverage thickened to: Thin -Food in bowls, Provale Cup, small spoons. On 7/24/25 from 8:31 A.M. to 8:47 A.M., in the Unit One Dining Room, the surveyor observed the following: -8:31 A.M.: Resident #63 sat in the Dining Room, eating breakfast independently. Two staff were in the DR, passing breakfast trays and assisting other residents with breakfast set up. Resident #63 was observed to cough consistently from 8:31 A.M. to 8:46 A.M. -8:36 A.M.: Resident #63 coughed hard while drinking and mucus came out his/her nose. -8:44 A.M.: Resident #63 told CNA #2 he/she was all done with breakfast and wanted to leave the DR. CNA #2 cleaned the thick, clear, mucus from his/her upper lip and the Resident remained at the table. -8:47 A.M.: Resident #63 drank from a regular coffee mug (no lid or specialized mug was available on the table for the Resident to utilize), making a loud sucking noise and proceeded to cough repeatedly. Resident #63 told CNA #2 that he/she needed help because he/she was old and needed help breathing. CNA #2 removed Resident #63 from the DR. On 7/25/25 from 8:36 A.M. to 8:44 A.M. the surveyor observed the following in the Unit One Dining Room: -8:36 A.M.: Resident #63 was seated at the DR table, and served his/her meal tray that included a cup of coffee that was thin consistency. Resident #63 picked up his/her cup of coffee, took a sip and began to cough and continued to cough. -8:44 A.M.: Resident #63 placed his/her coffee cup down on the table and exited the DR. A staff member entered the DR and placed a specialized cup on the table when the Resident was exiting the room. During an interview on 7/25/25 at 8:50 A.M., CNA #7 said the Resident required a specialized cup for fluids, but the Resident had already exited the room and did not use the cup when he/she drank the coffee. During an interview on 7/29/25 at 9:59 A.M., the Registered Dietician (RD) said: -Resident #63 currently had a Provale cup in place. -Occupation Therapy (OT) made the recommendation to use the Provable cup on 1/15/25 to help maintain independence while eating, however was unable to locate the documentation. -When a resident was noted to continuously cough during meals staff should stop the resident from drinking right away and let nursing know that he/she needed to be assessed. -RD had not been made aware that Resident #63 had experienced coughing episodes recently until 7/29/25. -The RD expected the Provale cup to be used every meal as it was on the Resident's meal ticket and a part of his/her care plan. During an interview on 7/29/25 at 10:30 A.M., CNA #2 said that the Resident normally coughed during meals. CNA #2 said the staff had notified the Nurses on 7/24/25 when Resident #63 coughed during breakfast and also coughed so hard that mucus came out of his/her nose. CNA #2 said she could not recall which Nurse she notified. CNA #2 further said the Resident typically used the Provale cup for liquids but she could not recall if the Resident utilized the Provale cup on 7/24/25. During an interview on 7/29/25 at 10:46 A.M., UM #2 said she had not been made aware that Resident #63 was experiencing coughing during food intake until today (7/29/25). UM #2 said Resident #63 had problems in the past with choking and was at risk for aspiration. UM #2 said when the Resident experienced coughing episodes during meals, the CNA's should have had the Nurse come in to observe the Resident immediately and downgrade the Resident's diet for safety and then notify the UM as well as the Provider. UM #2 additionally said aspiration pneumonia (pneumonia caused by inhalation of foreign materials into the lungs) was a possible negative outcome in this situation. During an interview on 7/29/25 at 1:27 P.M., the Director of Nursing (DON) said when it was noted that the Resident was coughing repeatedly while eating breakfast, the CNA's should have gotten the Nurse to do an assessment. The DON said the Provider should have been notified because of the coughing accompanied with the mucus/phlegm. The DON said vitals should have been obtained, and a chest x-ray would have been ordered had the Provider been notified. The DON also said had this chain of events occurred the team would have also learned that the Provale cup was not in use as required. 3. Resident #67 was admitted to the facility in July 2025 with diagnoses including Unspecified Dementia, Major Depressive Disorder, Legally Blind, and a history of auditory and visual hallucinations. Review of Resident #67's MDS assessment dated [DATE], indicated Resident #67: -had highly impaired hearing and eyesight. -was severely cognitive impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of 15. -was partial to moderate assist for sitting to standing and transfers. -used a wheelchair to move around. Review of Resident #67's Activities of Daily Living care plan, effective date 12/19/24, indicated the following: -was an assist of one with a gait belt for transfers. Review of Resident #67's Falls Care Plan, updated 5/28/25, indicated: -was at risk for falls and had a history of falls. Review of the late entry Nursing Progress Note dated 6/23/25 and time stamped 12:03 A.M., indicated Resident #67 was found in his/her room on the floor. Further review of the Nursing Progress Note failed to indicate the date and time the incident occurred. Review of the Accident/Incident Report dated 6/22/25, indicated Resident #67 fell on 6/22/25 at 2:05 P.M. -Included in the Accident/Incident Report Packet was the Accident/Incident Report Form completed by nursing, one witness statement from a Certified Nurses Aide (CNA), and a pain assessment. -the Accident/Incident Report Form completed by nursing indicated areas for the Director of Nursing, Administrator, and Medical Director to sign that they had reviewed the report, all areas were blank without the required signatures. Further review of the additional documentation contained in the fall report failed to indicate a 5 Whys Flow chart, documentation that the CNA Kardex had been updated post fall, or documentation that Fall Care Plan interventions were reviewed and modified according to the findings of the 5 Whys Flow chart. During an interview on 7/30/25 at 12:39 P.M., the DON said a full fall investigation was not completed for Resident #67's fall on 6/22/25. The DON said witness statements should have been gathered from all staff on the unit but only one CNA and one Nurse completed documentation. The DON said the 5 Whys flow chart should have been completed and then the Kardex and Fall Care Plan should have been updated with new interventions that were put into place and this was not done. The DON further said nursing should have documented every shift that the Resident was monitored for any changes, for 72-hours post fall and this was not done. The DON said the facility should have been doing regular risk meetings to review falls weekly for four weeks post fall and the facility had not implemented risk meetings. During a follow-up interview on 7/30/25 at 1:34 P.M., the DON said not completing a full fall investigation including analyzing the fall and implementing new appropriate fall interventions puts Resident #67 at risk for further falls and a chance for a fall with injury to occur.

Based on observations, and interviews, the facility failed to ensure that beverages served during meals were palatable and at appropriate temperatures on three (Unit One, Unit Two and Unit Three) out of three units observed. Specifically, the facility failed to ensure the temperature of coffee served during meals were palatable when numerous residents had expressed concerns to the Food Service Director (FSD). Findings include: On 7/28/25 from 2:00 P.M. to 3:00 P.M., the surveyor met with residents during a Resident Council Meeting, and the following was discussed: -the coffee/hot beverages were lukewarm during resident meals. On 7/29/25 at 11:22 A.M., the surveyor requested test trays for the lunch meal for Unit One, Unit Two and Unit Three from the FSD. During an interview on 7/29/25 at 11:44 A.M., the FSD said there have been complaints from residents about the temperatures of the coffee/hot water served not being hot enough. The FSD said she has explained to residents that because of safety, and by the instruction of management, they have been unable to serve the hot beverages over 140 degrees. The FSD said there had been an issue with residents sustaining burns and had received directive from management that this was what needed to occur. The FSD said other food items may be over 140 degrees but the coffee/hot water was unable to be. On 7/29/25 at 11:48 A.M., a test tray was conducted on Unit Three with the Corporate Infection Control Nurse, and the following temperature was obtained:-coffee was 119 degrees Fahrenheit (F), was lukewarm to taste, was not hot or at an appetizing temperature. On 7/29/25 at 12:38 P.M., a test tray was conducted on Unit One with the FSD, and the following temperature was obtained: -coffee was 111.0 degrees F, was lukewarm to taste, was not hot or at an appetizing temperature. On 7/29/25 at 12:48 P.M., test tray temperatures were obtained on Unit Two with Nurse #4, and the following temperatures were obtained: -coffee was 101.9 degrees F, was lukewarm to taste, was not hot or at an appetizing temperature.During an interview at the time, Nurse #4 said the coffee was lukewarm, not hot, and would request to have it heated up if served at this temperature. During an interview on 7/29/25 at 2:45 P.M., the FSD said the resident concerns about the coffee has been an ongoing issue since March 2024, when she was instructed by the previous management to lower the temperature of the coffee/hot water to 140 degrees F prior to sending to the units. The FSD said she knew there was resident concerns about the coffee/hot beverage temperatures since last year, had brought these concerns to the previous administration and was told to inform the residents that the hot beverage temperatures had been lowered for safety reasons. The FSD said she had not relayed these concerns to the new Administrator, who has been at the facility for about one year. The FSD said there was no longer a Quality Assurance Process Improvement (QAPI) plan in place relative to food/beverage temperatures that was active but that she completed test trays to monitor food temperatures. The FSD said the temperature goal for the hot beverages when received by the residents should be close to 140 degrees F.

Based on observations, and interviews, the facility failed to adhere to infection control standards of practice while serving meals to residents on one Unit (Unit One), out of three Units observed, and maintain a hygienically clean environment to prevent contamination and the spread of infection in the facility laundry room.Specifically, the facility failed to:1. Ensure that staff passing breakfast meal trays in resident rooms on Unit One removed personal protective equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) after providing care for one Resident on Enhanced Barrier Precautions (EBP), prior to exiting the resident's room, and did not place a previously delivered resident breakfast meal tray in the unit food truck with undelivered resident meals trays to prevent contamination and the potential spread of infections.2. Ensure that the facility laundry room was maintained in a hygienically clean environment when stagnant water, dust laden fans, and windowsills laden with dead bugs and paint chips were observed in the proximity of clean laundry, to prevent the spread of infection to the extent possible. Findings include: 1.Review of a printout provided by the facility titled, Sequence for Putting on Personal Protective Equipment (PPE). How to safely remove personal protective equipment example1 and 2, undated, retrieved from https://www.cdc.gov/infection-control/media/pdfs/Toolkits-PPE-Sequence-P.pdf indicated: -Remove all PPE before exiting the patient room. On 7/25/25 at 7:50 A.M., the surveyor observed the following during the breakfast meal pass on Unit One: -The meal truck was brought to the unit by the kitchen staff. -three staff members served meal trays to residents in their rooms including Certified Nurse Aide (CNA) #1. On 7/25/25 at 7:53 A.M., the surveyor observed CNA #1: -exit a resident room with a PPE precaution sign at his/her door. CNA #1 was observed wearing a PPE gown and holding a resident breakfast tray in her hands. -CNA #1 walked out into the hallway and approached the breakfast truck that was parked in the hallway and contained undelivered meals for other residents while still wearing the PPE gown from the Precautions resident room. - CNA #1 then turned around, walked to the resident door and placed the breakfast tray that was in her hands on top of the container that contained PPE supplies, while still wearing the PPE gown. - CNA #1 re-entered the same resident's room that had the PPE sign at the door leaving the breakfast tray on the PPE supplies container. - CNA #1 was observed to exit the resident room without the PPE gown. - CNA #1 was observed to pick up the breakfast tray that she previously placed on top of the PPE supplies container and then replaced the contaminated breakfast tray back into the breakfast truck that contained undelivered resident meals. During an interview on 7/25/25 at 7:56 A.M., CNA #1 said that it was the first time she had to wear a gown. CNA #1 said she was informed by other CNAs in the hallway after she came out of the room that she was not supposed to come out of the resident's room wearing a gown. CNA #1 said that the resident had a bag on his/her body, but she was not sure what the bag was. CNA #1 said she knew she had to wear a gown when she entered the Resident's room but was unsure when to remove the gown. CNA #1 said the resident refused his/her breakfast tray, and she was unsure what to do with the breakfast tray. During an interview on 7/25/25 at 8:05 A.M., Unit Manager (UM) #2 said that the Resident was on EBP related to the resident having a colostomy (surgical procedure that creates an opening in the colon to allow stool to be collected in a bag outside the body). UM #2 said CNA #1 should not have worn a gown to deliver a meal to residents if staff was not providing care to the residents. UM #2 said that CNA #1 should not have placed the breakfast tray on the PPE container outside of the resident's room. UM #2 further said that placing the (contaminated) breakfast tray in the meal truck with other undelivered meals was an infection control issue and the breakfast tray should have been returned to the kitchen, not in the meal truck with other residents' breakfast trays, to prevent the spread of infection. During an interview on 7/25/25 at 3:14 P.M., the Infection Control Preventionist Nurse (ICP) said that staff should not return the breakfast tray to the truck with other resident meals. The ICP further said CNA #1 should have removed the PPE gown prior to exiting the Resident's room but she had not. 2. On 7/29/25 from 2:30 P.M. to 2:44 P.M., the following was observed in the facility laundry room: -The trough behind the washing machines had a layer of stagnant water with debris scattered throughout the trough. -The windowsill near the washing machines where slippers were drying had chips that had cracked off the wall and fallen onto the windowsill, and a layer of dead bugs. -Three fans in the dryer/clean linen area that had thick layers of dust on them, were in use, and blowing towards multiple carts of clean laundry. During an interview following the observations in the laundry room, Housekeeper #1 said there was no current cleaning schedule or cleaning check list for the laundry staff to ensure the laundry room remained clean. Housekeeper #1 said it was the responsibility of all the housekeeping staff to tidy up. Housekeeper #1 said the fans should not have a thick layer of dust on them and they should be wiped down regularly especially since they blow towards clean linen and clothing. Housekeeper #1 said the standing water at the back of the washing machines had been there since he started in May 2025 and he was unsure whose job it was to make sure the trough was cleaned regularly. Housekeeper #1 further said the windowsills near the washing machines were dirty and should have been cleaned. During an interview on 7/29/25 at 3:35 P.M., the Director of Maintenance said it was his departments responsibility to make sure the drains were working behind the washing machines, so no standing water built up. The Director of Maintenance said no one had made him aware that there was standing water behind the washing machines. During an interview on 7/29/25 at 3:30 P.M., the Housekeeping Director said surface cleaning in the laundry room was done once weekly. The Housekeeping Director further said there was no log use to show when the laundry room was last cleaned so she was unable to tell when the fans and windowsills were last wiped down.

Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice of fluid management for one Resident (#15), out of one applicable resident receiving dialysis (process that filters waste, salt, and fluid from the blood when the kidneys are unable to work adequately) services, out of a total sample of 26 residents. Specifically, for Resident #15, the facility failed to: -Accurately monitor daily fluid intake as ordered by the Physician, when the Resident was dependent on renal dialysis, placing the Resident at risk for medical complications related to fluid overload. Findings Include: Review of the facility policy titled Dialysis Residents, Coordination of Care Of, dated May 2005, and last revised November 2018, indicated: -The nursing facility is responsible for the overall quality of care and services the resident receives and provides the services, consistent with professional standards of practices, to residents receiving dialysis as outlined by their comprehensive person-centered plan of care. -Care plan will include: monitoring of vital signs, weights, nutritional approaches, fluid needs/restriction, labs. -The nursing facility will be responsible for the overall quality of care the resident receives including the customary standards of care provided by the facility and the following: -Monitoring fluid balance through recording and assessment of intake and output, as indicated. Review of the facility policy titled Intake and Output (I&O), Monitoring Of, dated May 2005 and last revised October 2018, indicated: -Intake and output measurement is instituted based on clinician judgement or physician order. -To monitor for fluid deficit/imbalance. -Resident receiving dialysis. -Resident on physician ordered fluid restriction. Total shift and daily intake and output records. -Notify physician if clinical assessment of resident indicates. Resident #15 was admitted to the facility in December 2023 with diagnoses including End Stage Renal Disease (ESRD), Chronic Kidney Disease (CKD), Hypertension and Urinary Tract Infection (UTI). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #15: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total of 15. -was receiving dialysis. -was on a Therapeutic diet. Review of the Comprehensive Person-Centered Care Plan, initiated 1/15/24, indicated Resident #15:-was at risk for potential for fluid overload related to End Stage Renal Disease with need for Hemodialysis (HD). -Care Plan interventions included: >monitor signs and symptoms of fluid overload and report to notify Medical Doctor/Nurse Practitioner (MD/NP) of significant changes as needed (PRN).>Educate and reinforce information on fluid needs and restrictions and diet recommendations. Review of Resident #15's July 2025 Physician orders indicated: -Dialysis weekly on Monday, Wednesday, and Friday, initiated 4/3/25. -Eve (evening) Fluid Restriction 1500 ML (Milliliters [ml]), initiated 4/9/25 >Dietary: Dinner = 240 ml>Nursing: Eve = 300 ml -Add meal intake to total shift intake -Noc (night) Fluid Restriction 1500 ml, initiated 4/9/25: >Nursing: NOC = 180 ml-Day Fluid Restriction 1500 ml, initiated 4/9/25: >Dietary: Bkfast (breakfast) = 240 ml>Lunch = 240 ml >Nursing: Day = 300 ml-Add meal intake to total shift intake >May not omit diet restrictions on special occasions ., initiated 4/4/25 Review of Resident #15's May 2025, June 2025, and July 2025 Medication Administration Records (MARs) Documentation of Fluids Intake indicated that Resident #15 exceeded the daily fluid intake restriction amount.MAR documentation indicated the following fluid intake amounts on the following dates: May 2025: 5/2/25: 1660 ml, 5/3/25: 1710 ml, 5/4/25: 1895 ml, 5/5/25: 1690 ml, 5/15/25: 1675 ml, 5/16/25: 3700 ml, 5/20/25: 2290 ml, 5/21/25: 1700 ml, 5/22/25: 2425 ml, 5/23/25: 2960 ml, 5/24/25: 1720 ml, 5/25/25: 2870 ml, 5/29/25: 1515 ml and 5/31/25: 1600ml June 2025: 6/1/25: 1955 ml, 6/4/25: 1840 ml, 6/6/25: 1960 ml, 6/8/25: 1790 ml, 6/10/25: 1940 ml, 6/11/25: 1790 ml, 6/15/25: 1850 ml, 6/16/25: 1880 ml, 6/19/25: 2160 ml, 6/20/25: 1660 ml, 6/23/25: 1960 ml, 6/27/25: 2300 ml, 6/28/25: 1900 ml, 6/29/25: 2100 ml and 6/30/25: 1730 ml. July 2025: 7/6/25: 3070 ml, 7/7/25: 1725 ml, 7/10/25: 2260 ml, 7/11/25: 1520 ml, 7/12/25: 2040 ml, 7/13/25: 2140 ml, 7/14/25: 2325 ml, 7/15/25: 2460 ml, 7/16/25: 2200 ml, 7/17/25: 2300 ml, 7/19/25: 2150 ml, 7/20/25: 2320 ml, 7/21/25: 1890 ml, 7/22/25: 1710 ml, 7/24/25: 1820 ml, 7/27/25: 2560 ml, 7/28/25: 1600 ml, 7/29/25: 2220 ml and 7/30/25: 1790 ml. Review of Resident #15's Physician Progress Notes indicated: -3/29/25: stop 1200 ml fluids/24 hours fluid restriction.-5/27/25: Physician exam indicate concerning edema only on lower extremities. Review of Resident #15's Interdisciplinary Progress Notes indicated: -3/20/25: 1200 ml fluid restriction (600 ml dietary/600 ml nursing) -4/10/25: Dialysis recommendation increase fluid restriction to 1500 ml q (every) day. Resident and Dietary aware. -7/31/25: w/o (without) consistency modification and a 1500ml fluid restriction (720 ml dietary/780 nursing). On 7/31/25 at 8:32 A.M., the surveyor observed Resident #15 sitting on his/her bed with a bedside table positioned in front of the Resident and a breakfast tray on the table with an empty coffee cup. During an interview at the time, Resident #15 said that he/she typically gets a full cup of coffee and a small cup of cranberry juice with his/her meals. The surveyor further observed a water bottle on the bedside table that was half filled with water. Resident #15 said that he/she does not like the water from the facility and have his/her family provide 24 packs of bottled water that he/she keeps in his/her room for use. The surveyor observed 16 full plastic water bottles on a second bedside table next to the Resident's bed. During an interview on 7/31/25 at 8:48 A.M., Nurse #5 said that Resident #15 was not compliant with the Physician ordered fluid restrictions. Nurse #5 also said that Resident #15 was allotted 1500 ml of fluids per day and the Resident does not drink water from staff and had his/her own water bottles in his/her room, that was provided by family. Nurse #5 said that the Physician was not aware that Resident #15 was not compliant with the 1500 ml of fluid allowed as Nurse #5 had not brought it to the Physician's attention. During an interview on 7/31/25 at 8:50 A.M., the Charge Nurse/Nurse #4 said that Resident #15 was not compliant with the 1500 ml of fluid restriction. Nurse #4 also said that she had not updated the Physician that the Resident had not been compliant with the 1500 ml fluid restriction as the Resident was his/her own person. During an interview on 7/31/25 at 10:45 A.M., Nurse Practitioner (NP) #1 said that Resident #15 was on 1500 ml fluid restriction and she had not reviewed the Resident's medical records. NP #1 said that she does not know the reason why the Resident was on fluid restriction when the Resident was going to dialysis, and dialysis treatments would be pulling the fluids out. NP #1 also said that monitoring Resident #15's fluid restrictions were nursing responsibilities. NP #1 said the risk for Resident #15 going over his/her allotted fluid restriction order depends on the Resident's medical diagnosis such as Congestive Heart Failure (CHF) and other medical issues that would affect the Resident, including difficulty breathing and fluid overload. NP #1 said that when the dialysis center reinstated the 1500 ml fluid restriction, she initiated the order for the Resident. NP #1 further said that when a recommendation was made, she discussed it with nursing staff and would refer to the dialysis center orders for fluid restrictions. During an interview on 7/31/25 at 11:05 A.M., the Director of Nursing (DON) said that Resident #15's 1500 ml fluid restriction should have been monitored by nursing staff as ordered. The DON also said that nursing staff should have notified the Physician and the dialysis center that Resident #15 was going over the allotted fluid restriction order and follow the dialysis center recommendations. During an interview on 7/31/25 at 12:13 P.M., Additional Staff Member (Dialysis Nurse - DN) #3 said that the dialysis center noticed that Resident #15 was coming in on his/her dialysis days heavier than his/her usual weight and was fluid overloaded when they assessed the Resident's weight prior to starting dialysis treatment. DN #3 said that the facility had not notified the dialysis center that the Resident was consuming more fluids than ordered. DN #3 also said that the dialysis center was removing 2.5 - 2.9 Liters of fluid from Resident #15 when he/she comes in for dialysis treatment. DN #3 said that the dialysis center reinstated the fluid restriction order back to 1500 ml per day. DN #3 also said that the risk of Resident #15 going over the fluid restriction order included fluid overload with the risk of shortness of breath, and edema. DN #3 said at times the Resident might say that he/she do not feel good but was unable to describe the problem. DN #3 said that they monitor the Resident weight trends and typically they remove 1 - 1.5 liters of fluids when the Resident comes for dialysis. DN #3 further that the dialysis center will notify the facility when the dialysis center was removing more than the typical amount of fluids for Resident #15. DN #3 said that the facility staff had not communicated with the dialysis center that the Resident was going over the allotted fluid restriction. During a follow-up interview on 7/31/25 at 1:55 P.M., the DON said Resident #15's fluid restriction order had to be monitored, and nursing staff should notify the Physician and the dialysis center if the Resident was going over the allotted fluid restriction orders. The DON also said that although the Resident is allowed 1500 ml per day fluid restriction by the Physician, nursing staff should notify the Physician and dialysis center if the Resident was consuming more fluid and/or less fluid. The DON said that the risk for less fluid consumption has the potential for altered mental status and dehydration and the risk for more fluid consumption is fluid overload which is not safe for a Resident receiving dialysis care and having a diagnosis of ESRD. During an interview on 7/31/25 at 2:10 P.M., the Registered Dietician (RD) said she reached out to the dialysis center, and she was told that typically they remove 2.5 - 2.9 liters of fluid from Resident #15 when he/she had dialysis treatments. The RD said that nursing has not informed her about the Resident going over his fluid restriction and the expectation was that nursing will notify the RD, and she will in turn reach out to dialysis which she did today. The RD also said that she does not know the reason behind the discontinuation of the fluid restriction in March (3/29/25) by the NP. The RD said that she followed up with dialysis and the Resident was sent to see the Nephrologist and confirmed that the fluid restriction should be reinstated as the Resident was fluid overloaded on the days that Resident #15 had dialysis treatment. The RD said that she would have updated the resident care plan, provided an education to nursing staff, the Resident, and the Resident's family if she was made aware of the Resident being fluid non-complaint. The RD also said that she saw the Resident today and observed several water bottles in the Resident's room and educated the Resident on his/her fluid restriction. The RD said the risk of fluid overload depends on the Resident.

Based on observations, interviews, and record reviews, the facility failed to provide a dignified dining experience for one Resident (#140) out of a total sample of 26 residents.Specifically, for Resident #140, the facility failed to provide a dignified dining experience during breakfast and lunch meal service when the Resident was dependent on staff for assistance with meals and:-was not served his/her meal at the same time as other residents seated at the same table.-had clothing protectors applied instead of napkins before his/her meal was served. Findings include: Review of the facility's policy titled Nutrition and Meal; Meal Tray Delivery Outside of Dining Room, dated 5/2/05, indicated:-Nursing personnel will monitor residents throughout meals to ensure resident assistance is provided promptly, per individual need. Review of the facility's policy titled Residents' Rights, revised dated 10/4/23, indicated:-A facility must treat each resident with respect and dignity and care in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality. The facility must protect and promote the rights of the resident.-The resident has the right to a safe, clean, comfortable and home environment, including but not limited to receiving treatment and support for daily living safely. Resident #140 was admitted to the facility in December 2021 with diagnoses including Pneumonitis due to inhalation of food and vomit, Dysphagia Oropharyngeal Phase, Protein Calorie Malnutrition, and Acute on Chronic Respiratory Failure with Hypoxia. Review of the Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident #140:-was moderately cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15.-required supervision during meals. Review of Person-Centered Care Plan, initiated 12/6/23 and revised 1/9/25, indicated Resident #140:-has impaired swallowing: Dysphagia (difficulty swallowing food or liquids).-has mechanical soft diet with nectar thickened fluids consistency on 1/2/25, liquids changed to honey thickened.>goal - the Resident will not have episodes of choking x 90 days.>intervention - supervision with meals. Review of the Dietician's Nutritional History/Assessment (quarterly) completed on 6/11/25 indicated Resident #140:>Eating Ability - independent, continual supervision 1:8 and set-up with limited assist. On 7/28/25 at 8:54 A.M., the surveyor observed eleven residents and one CNA in the dining room on Unit 1. The surveyor observed that ten residents had breakfast meals and Resident #140 was without a breakfast meal. Resident #140 was observed asking CNA #8 for his/her breakfast meal and CNA #8 said she would look into it. During an interview at the time, CNA #8 said that Resident #140 needed 1:1 supervision so he/she had to wait.On 7/28/25 at 8:58 A.M., the surveyor observed that Resident #140 continued to ask for his/her breakfast meal and CNA #8 said that the Residents' breakfast was on its way. At this time, the surveyor observed CNA #4 remove Resident #140's breakfast meal tray from the food truck and bring it to him/her. On 7/29/25 at 12:28 P.M., the surveyor observed Resident #140, four residents and two staff members in the dining room. The surveyor observed a staff member approach Resident #140 and place a clothing protector on him/her. The surveyor observed a second staff member approach Resident #140's tablemate and served him/her their lunch meal. Resident #140 was observed to look at his/her tablemate and then looked over to the entry way where staff were standing.On 7/29/25 at 12:36 P.M., the surveyor observed Resident #140 waiting to be served his/her lunch meal. At this time, a staff member was observed to set up the Resident's meal, pulled up a chair and sat next to Resident #140. During an interview on 7/29/25 at 12:54 P.M., CNA #2 said that Resident #140 needed staff supervision during meals, and someone should have sat with the Resident when staff were serving meals. CNA #2 further said that she did not know why Resident #140 had to wait and watch other residents receive their meals as he/she waited to be served last. During an interview on 7/29/25 at 1:38 P.M., the Registered Dietician (RD) said that residents were served their meals based on table numbers and how the meals were arranged on the meal truck. The RD gave the surveyor a handwritten resident seated arrangement in the dining room and Resident #140 was listed last on the list. The RD also said that Resident #140 needed supervision during meals and could have received his/her meal at the same time with other residents while he/she remained supervised. During an interview on 7/29/25 at 1:45 P.M., the Clinical Nurse Consultant (CNC) #2 said that staff typically served Resident #140 his/her meal last as Resident #140 grabbed food from his/her tablemate's plate. During an interview on 7/29/25 at 1:48 P.M., the Director of Nursing (DON), said that Resident #140 should have received his/her breakfast and lunch meal at the same time with other residents. The DON further said Resident #140 should have received his/her meals at the same time to provide dignified experience, but they had not.

Based on observations, interviews, and record review, the facility failed to ensure that necessary treatment and services, consistent with professional standards of practice, were provided to promote the healing of pressure ulcers for one Resident (#49) out of a total sample of 26 residents.Specifically, for Resident #49, the facility failed to:-adhere to the Physician ordered wound treatment during wound treatment provided on 7/25/25, putting the Resident at risk for potential worsening of the pressure ulcer.-review the Wound Consultant treatment recommendations made on 7/24/25 to discontinue a medicated cream, with the Resident's Primary Medical Practitioner and update wound treatment orders timely, resulting in a delay in updated wound treatment per the Wound Consultant's recommendations. Findings include: Review of the facility policy titled Skin Integrity Management effective 3/1/2011 and revised 11/15/23, indicated but was not limited to:-Policy: .It is also the policy of this facility, consistent with CMS regulations that any resident with pressure ulcer or injury receives necessary treatment and services, consistent with professional standard of practice, to promote healing, prevent infection and prevent new ulcers from developing.-Purpose:<To maintain the integrity of our resident's skin.<To minimize the risks and prevent the occurrence of skin breakdown.<To develop and implement a comprehensive, person-centered plan of care aimed at maintaining skin integrity, prompt identification, intervention and management of any skin breakdown.-Parameters of a comprehensive skin assessment:.Moisture- skin can be dry or damaged from too much wetness (maceration).-Procedures:<Obtain referral to Wound Consultant who will partner with facility nurse in conducting weekly wound assessment and treatment review.Every treatment recommendation will be reviewed, timely with the resident's primary Medical Practitioner and an order will be entered in the resident's electronic medical record. Review of the facility policy titled Aseptic Dressing Change and Wound Measurement effective June 2010, indicated but was not limited to the following:-Policy: .to provide a safe, hygienic environment for residents who are in need of dressing application by adhering to the guidelines set forth by the Nursing Standard of Practice, CDC and Infection Control Standards.-Procedure:<Apply ointments, etc. as ordered. On 7/25/25 at 11:48 A.M., during a treatment and wound dressing change observation of Resident #49's right ischium pressure ulcer area, the surveyor observed that Nurse #1 failed to apply Skin Prep as ordered by the Physician to the right ischium pressure ulcer periwound. During an interview on 7/25/25 at 3:04 P.M., Nurse #1 said she did not apply Skin Prep to Resident #49's right ischium pressure ulcer periwound during the treatment and wound dressing change performed in the morning on 7/25/25 and that she should have. Resident #49 re-admitted to the facility in August 2024, with diagnoses including pressure ulcer of left buttock, pressure ulcer of right buttock, Diabetes Mellitus with diabetic neuropathy, paraplegia, and peripheral vascular disease. Review of Resident #49's July 2025 Physician's orders indicated:-Right ischium pressure ulcer treatment, initiated 7/3/25<Remove tape slowly to avoid tearing the skin.<Cleanse wound with normal saline or one-quarter strength Dakins (wound cleansing solution). Pat dry.<Skin Prep (a liquid or wipe that forms a protective barrier on the skin) periwound (tissue surrounding the wound).<Apply Calcium Alginate (wound dressing that forms a moist gel) to wound bed.<Tuck one- four by four folded in half to keep periwound from touching.<Secure with gauze and superabsorbent pad.<Wound treatment to be performed twice daily and as needed (PRN). Review of Resident #49's current Plan of Care relative to pressure ulcers, initiated 11/16/24 and revised 5/18/25, indicated:-was at high risk for pressure ulcer development and high risk for delayed or even inability to heal existing wounds.-admitted with multiple pressure ulcers.-will not develop additional areas of breakdown, and existing wounds will progress towards healing.-Resident with Stage four pressure areas located on right and left ischia.-Interventions: Treatment to area per Physician's orders, and follow skin and wound care protocols. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #49:-was cognitively intact as evidenced by a score of 15 out of a possible 15 on a Brief Interview for Mental Status (BIMS) exam.-had two Stage four pressure ulcers, which were present upon admission. Review of Resident #49's Wound Consultant Progress Note with date of service 7/24/25 indicated:-Stage four pressure ulcer of right ischium.-Periwound moist and macerated (softened/impaired skin integrity resulting from prolonged exposure to moisture).-Treatment recommendations are the same as Physician's orders initiated on 7/3/25-Stage four pressure ulcer of left ischium:-Periwound denuded (upper layer of skin [epidermis] and parts of the dermis are stripped away) with non-blanchable ecchymosis (discoloration/type of bruising).-Treatment recommendations:1. Cleanse wound.2. Apply one-quarter strength Dakin's moist gauze to base of the wound.3. Secure with abdominal (ABD) pad, Superabsorbent pad.4. Change twice a day, PRN.-no recommendation pertaining to Lotrisone cream. Review of Resident #49's July 2025 Treatment Administration Record (TAR) indicated:-Clotrimazole-Betamethasone Dipropionate 1% - 0.05% (Lotrisone) cream had been applied to Resident's left ischium pressure ulcer periwound three times daily from 7/25/25 through the 6:00 A.M. administration on 7/29/25. -The wound treatment for Resident's left ischium pressure ulcer, which included application of Lotrisone cream to the periwound, was completed twice daily from 7/25/25 through the 10:00 A.M. treatment on 7/29/25. During an interview on 7/30/25 at 12:49 P.M., the Director of Nursing (DON) said the expectation was that the Physician's orders were followed when wound care treatment was provided. During an interview on 7/31/25 at 1:50 P.M., Physician #1 said the expectation was that Physician's orders were followed when wound care treatment was provided. Physician #1 said that when Skin Prep was not applied to a periwound as ordered, it could result in a potential for pressure injury. During an interview on 7/29/25 at 11:15 A.M., Unit Manager (UM) #1 said Resident #49's wound treatment recommendations made by the Wound Consultant on 7/24/25 had not yet been reviewed by Resident's Provider. UM #1 said that the Wound Consultant recommended [sic] on 7/24/25 that Lotrisone cream no longer be applied to the Resident's left ischial pressure ulcer periwound, and that the recommendation needed to be reviewed with the Provider and the Physician's order needed to be updated. UM #1 said that this was a delay in treatment. During an interview on 7/30/25 at 12:19 P.M., the Wound Consultant said the expectation was that wound treatment recommendations were reviewed by the Residents' Provider and Physician's orders were updated when recommendations were made by the Wound Consultant. During an interview on 7/30/25 at 12:49 P.M., the Director of Nursing (DON) said the expectation was that any recommendations made by the Wound Consultant during weekly wound rounds on Thursdays would be reviewed with the Residents' Provider and the Physician's orders would be updated the same day. During an interview on 7/31/25 at 11:50 A.M., Nurse #2 said the Wound Consultant recommended [sic] discontinuing the Lotrisone cream for Resident #49's left ischium pressure ulcer periwound, noting the rash to the periwound had resolved. Nurse #2 said she did not review the recommendations made by the Wound Consultant on 7/24/25 with the Resident's Provider on 7/24/25, nor did she review the recommendations with the Resident's Provider on 7/25/25. During an interview on 7/31/25 at 1:50 P.M., the Physician said the expectation was that recommendations made by the Wound Consultant would be reviewed with the Provider within 24 hours of the recommendations being made.

Based on interview, and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurate for three Residents (#4, #7 and #67), out of a total sample of 26 Residents. Specifically, For Resident #4, the facility failed to ensure the MDS assessment dated [DATE] accurately indicated the daily use of hypoglycemic (medication to lower blood sugar) and antipsychotic (medication to treat mood and behaviors) medications and did not include the use of anticoagulant (medication to thin the blood and prevent blood clotting) medication. For Resident #7, the facility failed to ensure the MDS assessment dated [DATE] accurately indicated three falls that occurred since the last MDS Assessment. For Resident #67, the facility failed to ensure the MDS assessment dated [DATE] accurately indicated falls that occurred since the last MDS Assessment.Findings include: 1. Resident #4 was admitted to the facility in April 2021 with diagnoses including Diabetes Mellitus Type 1, Cerebral Infarction (stroke) and psychotic disorder with delusions. Review of the January 2025 Physician's orders included the following medications: -Aripiprazole (Abilify - antipsychotic medication), 15 milligrams (mg), daily, initiated 5/13/24. -Novolog Insulin 100 Unit (U)/1 milliliter (ml) solution, 6 units subcutaneous before meals, initiated 7/12/23 -Lantus Solostar Pen 100 U/1 ml solution, 32 units subcutaneous at 8:00 P.M., initiated 12/18/24 -there was no order for the Resident to receive anticoagulant medication. Review of the MDS Assessment, dated 1/29/25, indicated the following under Section N: -received Insulin injections for 7 days of the reference period -was on an antipsychotic medication during the reference period -was on an anticoagulant medication during the reference period -did not receive hypoglycemic agents (including Insulin) during the reference period -Antipsychotic medications were not received Review of the January 2025 Medication Administration Record (MAR), indicated the following were administered during the reference of period of the MDS assessment dated [DATE]: -Aripiprazole 15 mg daily -Novolog Insulin 100 U/1 ml solution 6 units before meals -Lantus Solostar Pen 100 U/1ml solution, 32 units daily at 8:00 P.M.-no anticoagulant medication was administered During an interview on 7/30/25 at 10:00 A.M., MDS Nurse #1 said the 1/29/25 MDS Assessment for Resident #4 was inaccurate and needed to be modified. MDS Nurse #1 said the Resident should have been coded under Section N as receiving hypoglycemic medications and that antipsychotic medication was administered on a routine basis and should not have indicated the Resident received an anticoagulant medication. 2. Resident #7 was admitted to the facility in April 2023 with diagnoses including Hypertension, Diabetes, Dementia, Muscle Weakness, unsteadiness on feet and repeated falls. Review of the Resident's clinical record indicated he/she experienced falls on the following dates: -4/14/25 -5/6/25 -5/22/25 Review of the MDS assessment dated [DATE], indicated the following under Section J: -no falls occurred since the last MDS assessment (dated 3/19/25). During an interview on 7/31/25 at 2:25 P.M., MDS Nurse #3 said the 6/4/25 MDS Assessment for Resident #7 was inaccurate and would need to be modified under Section J. MDS Nurse #3 said Section J should have indicated the Resident had two falls with no injury and had one fall with minor injury since the previous MDS Assessment on 3/19/25. 3. Resident #67 was admitted to the facility in July 2024 with diagnoses including Unspecified Dementia and Major Depressive Disorder. Review of the most recent MDS assessment dated [DATE], indicated Resident #67 had no falls between the last MDS Assessment on 2/26/25 and the current MDS Assessment on 5/21/25. Review of Resident #67's Nursing Progress Note dated 3/22/25, indicated Resident #67 sustained a fall on 3/22/25. Review of Resident #67's Nursing Progress Note, dated 4/5/25, indicated Resident #67 sustained a fall on 4/5/25. During an interview on 7/30/25 at 10:05 A.M., MDS Nurse #1 said Resident #67 had falls on 3/22/25 and 4/5/25 and those falls should have been coded as YES on the most recent MDS assessment dated [DATE] because they happened between the current MDS Assessment and the 2/26/25 MDS Assessment. MDS Nurse #1 further said a modification would need to be done. Please Refer to F689

Based on interview, and record review, the facility failed to ensure an effective discharge plan was implemented for post-discharge care for one Resident (#130) out of a total sample of three residents reviewed for closed records. Specifically, for Resident #130, the facility failed to ensure services such as visiting nurse and therapy, were in place when he/she was discharged from the facility when Resident #130 expressed interest in having the services in place for a safe facility discharge and reduce the risk of re-hospitalization. Findings include: Review of the facility policy titled Discharge Planning, revised 1/24/25, indicated the following: -The purpose of this policy is to establish an effective Discharge planning process that focuses on the resident's discharge goals, the preparation of resident to be active participants and effectively transition to post-discharge care, and the reduction of factors leading to preventable readmissions. >The social services staff, in concert with the interdisciplinary team, will discuss the resident's discharge needs based on the setting he or she is returning to. -Post discharge >The Social Worker or designee will call the resident/responsible party to follow-up after discharge. The purpose of this call is to ask the resident/responsible party if the discharge went according to plan. >Documentation of the calls will be written as an addendum to the closed record in the social service progress notes. Resident #130 was admitted to the facility in May 2025 with a diagnoses including Sepsis and Urinary Tract Infection (UTI). Review of the Social Service Evaluation and assessment dated [DATE], indicated Resident #130 planned to return to the community with support from Visiting Nurses Services (VNA - community provider that has nursing, physical therapy, occupational therapy, and home health aide service that come directly to a persons' home) and Resident Representative (RR) #1. Review of Resident #130's Community - Return to Community Care Plan, effective 5/16/25, indicated Resident #130's goal was to return to his/her home in the community. Review of the Nursing Progress Note dated 5/20/25, indicated the following: -.Patient states.I'm going home after this appointment.Nurse Practitioner (NP) saw patient and gave orders for patient to discharge home with medications and services. Review of the Social Services progress note dated 5/20/25 indicated the following: -Resident states he/she would be going home today.Order for discharge obtained by nursing.Resident booked his/her own primary care (PCP) appointment. RR #1 came and picked up Resident. Review of Resident #130's May 2025 Physician's orders indicated the following: -Discharge home with home health, Physical Therapy, Occupational Therapy, and Nursing evaluation.order date 5/20/25. Review of the Post-Acute Discharge Transition Summary dated 5/20/25, indicated no information under Section B: Discharge Information which contained a line to identify the Home Health Agency and phone number of the Home Health Agency that would provide in-home services. During an interview on 7/28/25 at 1:55 P.M., the Social Work Assistant (SWA) said Resident #130 requested VNA services when he/she returned to the community. The SWA said this information is documented on the Post-Acute Discharge Transition Summary in Section B. The SWA said she could find no documentation VNA services were put into place for Resident #130 at the time of his/her discharge. The SWA further said she was unable to find any documentation a post discharge call was made to check in on Resident #130. During a phone interview on 7/28/25 at 1:55 P.M., Resident #130 said at the time he/she discharged from the facility no one set up VNA services for him/her. Resident #130 said he/she could have really benefited from in-home nursing and therapy services as he/she was deconditioned. Resident #130 said that RR #1 had to set up all the in-home services him/herself once Resident #130 was at home as the facility did not assist in implementing services or provide information about services at the time of discharge. During a phone interview on 7/28/25 at 4:10 P.M., RR #1 said Resident #130 really needed to have nursing, physical therapy, and occupational therapy when he/she discharged to the community but no referrals had been made by the facility. RR #1 said no staff at the facility provided him/her with any information on community services at the time of discharge. RR #1 said he/she had to work in coordination with Resident #130's community Physician to get the services in place and Resident #130 went without services for about two weeks which really set Resident #130's progress back as Resident #130 was deconditioned. During a follow-up interview on 7/30/25 at 9:11 A.M., the SWA said she could not be sure why no staff in the Social Services Department had made a referral for VNA services for Resident #130. The SWA said since the Physician's orders indicated VNA services were to be put into place a referral should have been made for VNA services and this was not done.

Based on observation, interview, and record review, the facility failed to implement abuse policies and procedures when two Certified Nurse Aides (CNA #8 and CNA #2) documented a potential allegation of abuse pertaining to one Resident (#7), out of a total sample of 26 residents. Specifically, the facility failed to ensure the allegations of abuse were identified, reported within the required timeframe, and protection was provided to residents pending the outcome of the investigation, when CNA #8 and CNA #2 documented in witness statements that Nurse #4 responded inappropriately to Resident #7 after the Resident sustained a fall.Findings include: Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, revised 12/29/11, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises must be investigated and reported to the Administrator.The policy also included the following:-to ensure accurate reporting, timely investigation, and subsequent follow up is completed with each accident/incident in order to identify process improvement (PI) opportunities. -regardless of how minor an accident or incident may be . report the accident/incident to the department supervisor as soon as possible.-complete an Incident Report for all reported accidents/incidents.-an employee witnessing an accident or incident involving a resident . must report such occurrence to his/her immediate supervisor as soon as practical.-procedures governing the reporting and investigation of abuse, neglect and/or misappropriation of resident property are located in the facility's Abuse policy.-the nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident.-an incident and accident form must be completed prior to the end of the shift and submitted to the Director of Nurses promptly. Review of the facility policy titled Resident Abuse Prevention, Investigation and Reporting Policy, revised 10/17/22, indicated it was the responsibility of all covered individuals (anyone who is the owner, operator, employee, manager, agent or contractor of the facility) to ensure an environment free of abuse, mistreatment, misappropriation of resident property, and exploitation.The policy indicated:a. purpose of the policy included:-to define abuse, neglect, mistreatment, misappropriation of property, and exploitation.-to outline the process to be followed for internal identification and reporting of suspected abuse.-to describe the investigative process to be used in instances of reported abuse.-to assure the protection of residents during and following an allegation/investigation of abuse.-to outline the procedure for reporting allegations of abuse and investigative findings to the Department of Public Health (DPH) .b. Identification:-all covered individuals are responsible for identifying and reporting immediately to their supervisor to ensure immediate investigation any witnessed or allegation of abuse they are told about by residents, families, visitors, or other staff.c. Protection and Notification:-upon receiving an allegation of abuse, covered individuals will take steps necessary to protect all residents and then immediately notify the Administrator. d. Preliminary Investigation:-because all suspected cases of abuse must be promptly and accurately reported to the DPH within mandated timelines, immediate action is necessary in order to determine whether a reported incident likely constitutes a suspected case of abuse requiring a report.-when a covered individual believes that he or she has reasonable cause to believe that a resident has been abused, neglected or mistreated, exploited or has had property misappropriated, the covered individual has the responsibility to report to his/her supervisor as well as the right to report to DPH. -the Administrator/designee will report to DPH within the required time frames.-determination of whether a suspected case of abuse exists, shall be given the highest priority at the facility. -the Administrator or specific designees shall, as promptly as possible after report of the incident: >remove the accused in order to prevent further potential harm to the resident(s)>examine and speak with the resident, if possible>identify and preliminary interview key witnesses, and>identify and preliminary review key documents and any involved instrumentality in order to determine with reasonable certainty what occurred and whether the incident constitutes a suspected case of abuse. e. Reporting to DPH:-in cases where there is reasonable cause to believe that abuse, neglect, exploitation or mistreatment has occurred, federal regulation requires reporting to the Department by covered individuals, and ultimately the Administrator/designee .>within two (2) hours .allegation of abuse Resident #7 was admitted to the facility in April 2023 with diagnoses including Dementia, muscle weakness, unsteadiness on feet, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following relative to Resident #7:-was moderately cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 12 out of 15-had no behaviors or rejections of care-required partial/moderate assistance of staff with transfers-required supervision or touching assistance of staff with ambulation Review of a Nursing Progress Note dated 6/11/25 at 2:41 P.M., and written by Nurse #4 indicated the following:-he/she was summoned to the Activity Room-Resident #7 was found lying on his/her left side (on the floor) Review of the facility's internal investigation for the fall (on 6/11/25), dated 6/10/25 [sic], indicated the following staff statements:-CNA #8 indicated in a written statement that she heard screaming and observed Resident #7 lying on the floor in the activity room and ran to get someone. Nurse #4 responded, walked slowly to the Resident, did not ask if he/she was okay and instructed staff to get Resident #7 off the floor without completing an assessment. CNA #8 said Nurse #4 looked at the Resident, told him/her to look at her face and the look on Nurse #4's face to the Resident was not nice and Nurse #4 told the Resident this is becoming a every week thing. CNA #8 indicated that she (CNA #8) went back to the unit. -CNA #2 indicated in a written statement that she was called to the activity room for assistance and observed Resident #7 lying on the floor on his/her left side. When the Nurse (#4) arrived, she told CNA #2 to pick the Resident up without performing any assessment. CNA #2 indicated once the Resident was seated in the chair, Nurse #4 said look at my face, this is becoming a every week thing. CNA #2 indicated that once she knew the Resident was safe in the chair, she returned to her unit. Further review of the facility's internal investigation surrounding the fall incident on 6/11/25 indicated the person who prepared the report was Nurse #4. On 7/30/25 at 4:50 P.M., the surveyor and the Director of Nursing (DON) reviewed the facility fall investigation dated 6/11/25. During an interview at the time, the DON said the Unit Managers (UMs) were responsible for reviewing the incident reports, but the ultimate responsibility was on the DON to review them. The surveyor requested the DON review the written witness statements from the 6/11/25 and the DON said she was aware of the witness statement made by CNA #8, who was an agency staff and no longer worked at the facility. The DON said she did follow up with CNA #8 about her statement relative to Nurse #4, and that prior to the 6/11/25 incident, CNA #8 had expressed she had issues with Nurse #4. The DON further said she instructed CNA #8 to not put personal feelings into a statement about a resident incident, and that the purpose of the witness statement was to report what occurred during the incident. The DON said she did not document the conversation with CNA #8. When the surveyor asked the DON to review the written statement dated 6/11/25 from CNA #2, the DON said she did not recall reading the written statement from CNA #2. After reviewing the written witness statements from CNA #8 and CNA #2, the DON said that according to the statements, there would be a potential verbal abuse allegation concern. The DON said Nurse #4 should have been suspended, and the incident should have been reported within two hours to DPH, and these steps did not occur. The DON said it was important to investigate potential abuse allegations in order to protect the resident and other residents from potential further abuse, and to conduct an internal investigation in order to determine if the allegation was substantiated or unsubstantiated, and that this process was not followed. On 7/31/25 at 8:48 A.M., the surveyor observed Nurse #4 was working in the facility on the unit where Resident #7 resided. On 7/31/25 at 11:27 A.M., the surveyor and Unit Manager (UM) #1 reviewed the fall incident from 6/11/25. UM #1 said after the surveyor and the DON spoke about the 6/11/25 incident, she obtained an interview from Resident #7 about the circumstances of the fall on 6/11/25 and also spoke with the Resident's Representative about the incident. UM #1 said she had not seen the initial investigation from 6/11/25 and had she reviewed it, she would have immediately brought the concern to the attention of the DON due to the fact that the CNA witness statements were alarming. UM #1 said there was a dynamic with staff involving Nurse #4 around the date of this incident, but regardless of the dynamics, had she been aware of the staff statements about what occurred with Nurse #4, she would have immediately notified the DON. On 7/31/25 at 11:47 A.M., the DON said after speaking with the surveyors on 7/30/25, she spoke with the Administrator and the Corporate Consultant, and they reviewed the information from the witness statements on 6/11/25. The DON said upon reviewing the witness statements from CNA #8 and CNA #2, it was determined that the incident should be reported to DPH as an allegation of verbal abuse. The DON said at that point Nurse #4 who was working, was brought to and remained in the administration office and interviewed about the incident. The DON said typically, for any allegation of abuse/neglect, the facility would suspend the employee until the internal investigation has been completed. The DON said upon talking with the Corporate Consultant, it was decided that Nurse #4 did not need to be suspended. The DON said the staff involved in the 6/11/25 incident were not interviewed and that typically this would have been done. During an interview on 7/31/25 at 1:01 P.M., the Corporate Consultant said she reviewed the information relative to the 6/11/25 incident offsite as she had left the facility at the time the incident was reported to her. The Corporate Consultant said Nurse #4 was interviewed on 7/30/25 and a written statement was obtained by Nurse #4 on this day (7/31/25), and the investigation would be concluded today. The Corporate Consultant said the protocol for investigating an allegation of abuse indicated for the staff to be suspended pending the outcome of the investigation. The Corporate Consultant said currently, the investigation into the allegation of verbal abuse was not concluded and that it was ongoing. The Corporate Consultant said Nurse #4 returned to the facility on this date (7/31/25) to work. The Corporate Consultant said the abuse policy and procedures were not followed and should have been. Please Refer to F689

Based on interview, and record review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services, the resident has not used all his/her Medicare benefit days, and plans to remain in the facility after coverage has ended) for two Residents (#19 and #141) out of a total sample of 26 residents. Specifically, for Residents #19 and #141, the facility failed to issue a SNF ABN to the Resident and/or Resident Representative for notification that their skilled services may not be paid for by Medicare and what financial responsibility would need to be assumed when the effective date of Medicare Part A coverage for skilled services ended and both Residents remained in the facility. Findings include: 1. Resident #19 was admitted to the facility in May 2025 with diagnoses including Metabolic Encephalopathy, Pneumonia, and Emphysema. Review of Resident #19's Medicare Notice of Non-Coverage (NOMNC) letter indicated Resident #19's Medicare Part A benefit ended at the facility on 7/7/25. Review of Resident #19's Nursing Progress Notes indicated Resident #19 remained in the facility after his/her Medicare Part A benefit ended. Review of the medical record failed to indicate that a SNF ABN letter was provided by the facility for Resident #19. 2. Resident #141 was admitted to the facility in April 2025 with diagnoses including Sepsis, Alzheimer's Disease, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #141's Medicare Notice of Non-Coverage (NOMNC) letter indicated Resident #141's Medicare Part A benefit ended at the facility on 5/22/25. Review of Resident #141's Nursing Progress Notes indicated Resident #141 remained in the facility after his/her Medicare Part A benefit ended. Review of the medical record failed to indicate that a SNF ABN letter was provided by the facility for Resident #141. During an interview on 7/28/25 at 1:09 P.M., Minimum Data Set (MDS) Nurse #1 said Resident #19 remained in the facility after his/her Medicare Part A benefit ended and he/she should have received a SNF ABN letter and did not. During a follow-up interview on 7/28/25 at 1:49 P.M., MDS Nurse #1 said Resident #141 remained in the facility after his/her Medicare Part A benefit ended and he/she should have received a SNF ABN letter and did not.

Based on record review, and interview, the facility failed to ensure that a Level II (comprehensive evaluation that identifies the specialized services required) Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I (initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#60), out of a total sample of 26 residents.Specifically, for Resident #60, the facility failed to request a Level II PASARR evaluation when the Resident screened positive for ID (intellectual Disability)/DD (Developmental Disability) during a Level I PASRR Evaluation. Findings include: Review of facility policy titled Preadmission Screening and Resident Review (PASRR), last revised dated 9/22/23, indicated the following:-Make referrals to the Department of Developmental Services (DDS) and/or the Department of Mental Health (DMH)/Designee in a timely manner, when required.-DDS: individuals who have or may have ID or DD/RC (related condition). Resident #60 was admitted to the facility in November 2024 with diagnoses including Major Depressive Disorder, Disorder of Psychosocial Development and Intellectual Disabilities. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #60:-was severely cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of three out of a possible score of 15. -was prescribed antipsychotic and antidepressant medications. Review of Resident #60's Level I PASRR evaluation completed on 11/19/24, indicated:-was positive for Intellectual and/or Developmental Disability (ID/DD) Further review of Resident #60's clinical record failed to indicate any evidence that a Level II PASRR evaluation had been initiated and/or completed. During an interview on 7/30/25 at 11:00 A.M., the Clinical Reimbursement Coordinator (CRC)/MDS Nurse #2 said that Resident #60's Level I PASRR was submitted to the portal dated 11/22/24 which indicated Resident #60 had a positive screen for ID/DD. The CRC/MDS Nurse #2 said that a Level II PASRR should have been completed for Resident #60, and it was not done. CRC/MDS Nurse #2 said that a Level I assessment should have been faxed and/or called into the DDS office, and it was not faxed or called into the DDS office. CRC/MDS Nurse #2 also said a request for a Level II PASRR should have been submitted to DDS office, but this was not done.

Based on interviews, and record review, the facility failed to ensure that medical records were complete and accurate for one Resident (#76), out of a total sample of 26 residents.Specifically, for Resident #76, the facility failed to:1. ensure the Physician's Orders accurately reflected the Resident's Representative from [DATE] through [DATE], resulting in the potential risk for the Resident's confidential information to be provided to an unauthorized party and the risk for an unauthorized party to make medical decisions for the Resident.2. obtain and document in the Resident's medical record evidence of the Resident's court-appointed Guardian from [DATE] through [DATE]. Findings include: Review of the facility policy titled Medical Records Policy effective [DATE], indicated but was not limited to the following:-Guidelines: Each resident will have an active medical record. This record shall be kept current, complete and available at all times to authorized personnel. Resident #76 was admitted to the facility in February 2025, with diagnoses including encounter for palliative care and history of transient ischemic attack and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #76:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of a possible 15. Review of Resident #76's Order Appointing Temporary Guardian for an Incapacitated Person signed by the Justice of the Probate and Family Court on [DATE], indicated:-Resident was appointed a Temporary Guardian on [DATE].-The powers of the Temporary Guardian included authorization to revoke the Resident's Health Care Proxy.-A review hearing would be held on [DATE].-Appointment of the Temporary Guardian would expire 90 days from [DATE]. Review of Resident #76's Letters of Guardianship for an Incapacitated Person signed by the Register of Probate on [DATE] indicated the following:-Resident was appointed a Temporary Guardian on [DATE].-The Temporary Guardian appointment would expire on [DATE]. 1. Review of Resident #76's [DATE] Physician's orders indicated:-Health Care Proxy (HCP) invoked on [DATE]. Start date [DATE].-No documentation regarding Guardianship. Review of Resident #75's clinical record indicated the Resident's Health Care Proxy to be someone other than the emergency contact provided in the Resident's medical record. During an interview on [DATE] at 9:30 A.M., with Social Worker (SW) #1 and #2, SW #2 said Resident #76's active Physician's orders indicated the Resident's HCP was invoked. SW's #1 and #2 said the current Physician's order was not accurate. SW #2 said an HCP was not the same as the Guardian. SW #1 said the Physician's order should indicate the Resident's HCP was invoked with a legal Guardian. SW #2 said the Physician's order should be updated to accurately indicate Resident #76's Representative so that the facility contacted the Resident's authorized Representative as appropriate. 2. Review of Resident #76's Progress Notes from February 2025 through [DATE] indicated:-Social Services Progress Note, dated [DATE], which indicated the Resident had a Temporary Guardian who attended a Guardianship review hearing on [DATE], and no updated documentation regarding the Resident's authorized Representative had been received by the facility.-No documentation that the facility made attempts to determine the status of the Resident's Guardianship following the Guardianship review hearing on [DATE]. During an interview on [DATE] at 1:40 P.M., SW #2 said Resident #76's Temporary Guardianship appointment expired on [DATE], and the facility did not have evidence of the Resident's current authorized Representative. SW #2 said the facility did not have evidence that the Resident's previously appointed Temporary Guardian had been appointed the Resident's Permanent Guardian. During an interview on [DATE] at 9:30 A.M., SW #2 said the facility should have attempted to obtain documentation regarding the status of Resident #76's Guardianship within two weeks following a Guardianship review hearing. SW #2 said there had not been any attempts made by the facility to determine Resident #76's current Representative until the surveyor inquired about the Resident's Guardianship status on [DATE] (four months after Resident #76's Temporary Guardianship appointment had expired).

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of bilateral nephrostomy tubes (a catheter inserted directly into the kidney that drains urine into a collecting bag outside the body), the facility failed to ensure nursing developed and implemented a baseline care plan related to his/her immediate care and treatment needs related to his/her nephrostomy tubes. Findings include:Review of the Facility Policy titled, Care Planning, revised 02/15/25, included but was not limited to the following:The Facility will develop and implement a Baseline admission Care Plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission and will remain in place until the initial Interdisciplinary Team (IDT) Care Plan Meeting. All Physician orders inclusive of medications, diagnoses, dietary, and therapy services are considered part of the plan of care. Resident #1 was admitted to the Facility in January 2025, diagnoses included Urothelial Carcinoma (a type of cancer that develops in the urothelial cells lining the urinary tract which are found in the bladder, renal pelvis, ureters, and urethra), status post Cystectomy (removal of the bladder), status post hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine over time, often caused by a blockage or obstruction in the urinary tract), and had both an ileal conduit/urostomy (a surgical opening where a portion of the small intestine is used to create a pathway for urine to exit the body after the bladder has been removed) and bilateral nephrostomy tubes. Review of Resident #1's admission Baseline Care Plan, dated 01/08/25, indicated there was no documentation to support that nursing developed a baseline care plan related to his/her nephrostomy tubes, which included goals and interventions, related care, treatment, and maintenance of the nephrostomy tubes. During an interview on 07/16/25 at 12:15 P.M., Unit Manager #1 said their policy is to develop a baseline care plan within 48 hours of admission. After reviewing Resident #1's Baseline Care Plan with the surveyor, Unit Manager #1 said there was no documentation to support that nursing developed a baseline care plan for his/her nephrostomy tubes, and there should have been one completed. During an interview on 07/16/25 at 2:30 P.M., the Director of Nursing (DON) said she reviewed Resident #1's Medical Record and said there was no documentation to support that nursing developed a Baseline Care Plan relative to his/her nephrostomy tubes within 48 hours of his/her admission, as required.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of bilateral nephrostomy tubes (a catheter inserted directly into the kidney that drains urine into a collecting bag outside the body) the facility failed to ensure he/she received adequate nursing care in accordance with professional standards of practice when there were no Physician's orders related to the care and treatment for his/her nephrostomy tubes. Findings include:Review of [NAME] R. [NAME] H (2019) Nursing care and management of patients with a nephrostomy, Nursing Times [online]; 115:11, 40-43) indicated (but was not limited to) the following:- Nurses need to understand how to care for and manage patients with a nephrostomy. - Nurses need to understand issues around fluid management, infection control and management of the tube and bags. - Patients with nephrostomy tubes are at risk of pyelonephritis (inflammation of the kidney, usually due to infection). They should be monitored for signs and symptoms of infection.- Fluid management: If the kidney has become obstructed after initial insertion of the tube insertion, the patient may enter a phase of diuresis, characterized by high-volume outputs from the tube (polyuria). This requires close monitoring of the patient's fluid balances and vital signs. Each drainage route should be monitored separately and an overall total fluid output calculated (usually left/right/urethral and total). The patient's intake (intravenous or oral) should closely match the output. A closely monitored and adjusted fluid balance will prevent patient deterioration associated with rapid fluid loss. - Check drainage tubing is patent (open) and not kinked or twisted. - Ensure nephrostomy is secured at all times with drain fixation dressing (and secondary film dressing if required). - Dressings need to support the nephrostomy tube to prevent accidental tugging and secure it to the patient's skin. - Apply and change body-worn belt as required.- Good wound site care is essential to avoid exit-site infection and should include keeping the drain site clean and dry. - Check insertion site daily for bleeding, infection signs (pain, redness, swelling, leakage). - Drainage bags should be changed every 5-7 days.- Nephrostomy tubes should be changed every three months as recommended by the manufacturer.- The nephrostomy bag should be kept below the level of the kidney to ensure dependent drainage and emptied when it becomes three-quarters full.Resident #1 was admitted to the Facility in January 2025, diagnoses included Urothelial Carcinoma (a type of cancer that develops in the urothelial cells lining the urinary tract which are found in the bladder, renal pelvis, ureters, and urethra), status post Cystectomy (removal of the bladder), status post hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine over time, often caused by a blockage or obstruction in the urinary tract), and had both an ileal conduit/urostomy (a surgical opening where a portion of the small intestine is used to create a pathway for urine to exit the body after the bladder has been removed) and bilateral nephrostomy tubes. Review of Resident #1's Hospital Patient Care Referral Form, dated 01/07/25, under the section, Active Lines, Drains, Airways and Wounds, indicated he/she was being discharged to the Facility with bilateral nephrostomy tubes and a urostomy/ileal conduit. Review of Resident #1's Nursing admission Assessment, dated 01/07/25, completed by Nurse #4, indicated it did not include information about his/her nephrostomy tubes.Review of Resident #1's Nursing admission Summary Progress Note, dated 01/07/25, indicated Resident #1 was admitted with a diagnosis of Colovaginal Fistula, had a right-lower abdominal quadrant urostomy with minimal output, bilateral pcns (percutaneous nephrostomy tubes), pressure sores to bilateral lower extremities, and the Attending Physician approved/confirmed all medications. However review of Resident #1's January 2025 Physician's Orders indicated there were no treatment orders obtained by nursing for the care of his/her nephrostomy tubes. Review of Resident #1's Medical Record which included the Medication Administration Record (MAR), the Treatment Administration Record (TAR), and the Nursing Progress notes indicated there was no documentation to support Nursing staff attempted to obtain Physician's orders for the care and treatment of his/her nephrostomy tubes. There were no Physician's orders related to dressing changes, type and frequency, monitoring of intake and output from each nephrostomy tube, what to do if the nephrostomy tubes were to become obstructed, nephrostomy bag collection change frequency, and flushing instructions, as appropriate. Further review of Resident #1's Medical Record indicated there was no documentation to support Nursing staff routinely assessed and maintained his/her nephrostomy tubes, and no documentation to support Nursing staff were monitoring his/her fluid intake and output from each of his/her nephrostomy tubes or his/her ileal conduit/urostomy.Review of Resident #1's Nursing Progress Notes indicated the following:01/08/25 - Bilateral nephrostomy tubes patent and draining clear yellow urine, dressing to nephrostomy sites changed.01/12/25 - Nephrostomy patent, dressing done with moderate amount of redness around site. Washed, dried and dressing applied.However neither of these Nursing Progress Notes indicated Resident #1's fluid intake and output amounts. During an interview on 07/16/25 at 8:40 A.M., Nurse #4 said Resident #1 had a urostomy and bilateral nephrostomy tubes. After reviewing the Nursing admission Assessment in the electronic health record (EHR) with the surveyor, Nurse #4 said there was no box to check off to reflect if a resident had either a urostomy or nephrostomy on the Assessment. Upon further review of the Assessment Form in the EHR, Nurse #4 said she could have clicked on the field that indicated other which allows the user to type a short note and said she could have entered the information there. Nurse #4 also said that the location of the urostomy and nephrostomy tubes should have been documented on the Skin Assessment portion of the Assessment, and neither were.Nurse #4 said that nephrostomy care and treatment orders should have been obtained from the physician upon admission and that she did not know why they were missed. During an interview on 07/16/25 at 12:15 P.M., Unit Manager #1 said when a resident is admitted from the hospital, it was the responsibility of the admitting nurse to review the Hospital Discharge Summary to determine the resident's needs. Unit Manager #1 said after reviewing Hospital Discharge Summary, the admitting nurse would then review that information with the Attending Physician or their designee, confirm the orders, and then enter them into the EHR. Unit Manager #1 said there should have been Physician's orders in place for the care and treatment of Resident #1's nephrostomy tubes. Unit Manager #1 reviewed Resident #1's Nursing admission Assessment, Physician's Orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) and said there were no Physician's Orders for the care and treatment of his/her nephrostomy tubes, and that Nurse #4 failed to document Resident #1 had nephrostomy tubes on the admission Assessment.Unit Manager #1 reviewed Resident #1's Nursing Progress Notes, dated 01/08/25 and 01/12/25, and said the nurses should not have been providing nephrostomy care without physician's orders, should have realized there were no orders, and nurses should have contacted the Physician to obtain them. Unit Manager #1 said that residents with nephrostomy tubes (and urostomy) should have their fluid intake monitored and documented as well as the fluid output from each source documented, and said there was no documentation to support nursing monitored Resident #1's fluid intake and output, as required. During an interview on 07/16/25 at 2:30 P.M., the Director of Nursing (DON) said prior to or upon admission, the admitting nurse should review the hospital discharge paperwork, then review and obtain necessary orders from the Attending Physician or the on-call provider. The DON said an example of the orders required for the care and treatment for nephrostomy tubes should include orders for how frequently to change the nephrostomy bag, flushing the nephrostomy tubes if appropriate, dressing changes, and fluid monitoring. The DON said she reviewed Resident #1's Medical Record and said there were no orders for nephrostomy care and no documentation to support that nursing staff were monitoring Resident #1s fluid intake or output from each nephrostomy tube or urostomy.After reviewing the Nursing Progress Notes during the interview with the surveyor, the DON said the nursing staff should not have been providing nephrostomy care without physician's orders because the orders are what dictate the specific care a resident should be receiving.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), the Facility failed to ensure they maintained complete and accurate medical records when the Certified Nurse Aide (CNA) Assignment Sheets (document that includes the residents' names, room numbers and a brief synopsis of resident care needs that CNAs use daily as a reference tool) and Kardex (a readily accessible computerized document used by CNAs to quickly reference key information about a patient's care plan, allowing them to efficiently provide appropriate care during their shift), were updated to accurately reflect his/her change in ability to transfer in and out of bed. Findings include: Resident #3 was admitted to the Facility in August 2024, diagnoses included Hemiplegia (paralysis on one side of the body), Osteomyelitis (infection in the bone) of the left ankle and foot, and reduced mobility. Review of Resident #3's Significant Change Minimum Data Set (MDS) Assessment, dated 01/22/25 indicated Resident #3 was moderately cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). The Assessment also indicated Resident #3 was dependent on staff for bed to chair to bed transfers. Review of Resident #3's CNA Kardex indicated he/she required partial to moderate assistance from staff for transfers. Review of the CNA Assignment Sheet master copies (for Resident #3's unit located at the Nurses' Station) indicated that Resident #3 was able to transfer with the assistance of one staff member, and some assignment sheets indicated a different resident's name with the same room number assignment as Resident #3, which also indicated that the resident required the assistance of one staff member. During an interview on 02/05/25 at 12:05 P.M., the Director of Rehabilitation said Resident #3 had experienced a decline in condition and the MDS Assessment on 01/22/25 that indicated he/she was dependent for transfers meant that he/she required the use of a Hoyer lift (a mechanical device that helps move people with limited mobility from one place to another) for safety with transfers which require two staff members. During an interview on 02/04/25 at 10:40 A.M., CNA #1 said she uses the information on the CNA Assignment Sheet and Kardex for information as to what kind of assistance her assigned residents required. CNA #1 said she keeps the Assignment Sheet in her pocket and uses it as a reference throughout her shift. During an interview on 02/04/25 at 12:54 P.M., CNA #2 said she uses the CNA Report [Assignment] sheets to obtain the information she needs in order to take care of the residents assigned to her. During an interview on 02/04/25 at 2:02 P.M., CNA #3 said ideally CNAs should verbally report off to each other at the change of every shift to discuss each resident and what their care needs were, but said that does not always happen. CNA #3 said she thinks there are two or three different master copies of the Unit's (Resident #3's unit) CNA Assignment Sheets, because CNA staffing numbers vary each shift, so the resident caseload needs to be split up differently depending on the number of CNAs working. CNA #3 said that the Assignment Sheets were rarely updated timely and that CNAs should not rely on them for current information as to how to care for their residents. In addition, CNA #3 said that the Kardex information in the computer was also not kept up to date, and that she relied on herself to know what needed to be done for her residents. CNA #3 said she left a note for the Unit Manager two to three weeks ago (exact date unknown) requesting updated CNA Assignment Sheets, but said she was not sure if the Unit Manager ever updated them. During an interview on 02/04/25 at 2:40 P.M., CNA #4 said she gets the information she needs to care for the residents assigned to her from other CNAs, the CNA Kardex and the CNA Assignment Sheet. During an interview on 02/04/25 at 2:50 P.M., CNA #5 said that she gets information about the residents in her care from the CNA that reports off to her at the change of shift, the CNA Kardex, and the CNA Assignment Sheets. During an interview on 02/04/25 at 4:10 P.M., CNA #6 said CNAs should find updated resident care information by looking at the Kardex and the CNA Assignment Sheets. CNA #6 said that Resident #3 used to be able to transfer in and out of bed with one staff member assisting him/her but now he/she required a Hoyer lift with two staff members for transfers, but said he could not recall when this change occurred. During the interview, CNA #6 reviewed the CNA Assignment Sheet that indicated Resident #3 was able to transfer with the assistance of one staff member, with the surveyor. CNA #6 said that the information was incorrect and if a staff member did not know Resident #3 and used the CNA Assignment Sheet for guidance indicating Resident #3 only needed one person for assistance, that would be dangerous for Resident #3. During an interview on 02/05/25 at 2:35 P.M., the Unit Manager said the CNA Assignment Sheets, the Kardex and as well as the Care Plan, should reflect whatever the residents' current care needs were and that she expected the CNAs to utilize the CNA Assignment Sheets as their primary source for resident care information. The Unit Manager said she was responsible for ensuring the CNA Assignment Sheets and the care Kardex were up to date and said she was aware they were not. The Unit Manager said that she would try to hand-write any resident care changes on the CNA Assignment sheets as they occurred because she did not have access to the computerized template, and that until recently she did not know how to update the Kardex in the computer system. During an interview on 02/04/25 at 4:45 P.M., the Director of Nursing (DON) said the CNA Assignment Sheets should not be the only resource for staff to obtain information as to what a resident's care needs were and that CNAs should be reviewing the Kardex prior to caring for any resident. The DON said if a resident had a change in condition, the Kardex should be updated within one week. After reviewing Resident #3's Kardex and CNA Assignment Sheets with the surveyor, the DON said if Resident #3 required a Hoyer lift, the CNA Assignment Sheets and Kardex should have been updated to reflect this change, and had not.

Based on record and policy review, and review of the facility assessment, the facility failed to ensure that annual performance appraisals were completed every 12 months and regular in-service education was provided based on the outcome of the performance appraisals for four Certified Nurses Aides (CNAs) out of a sample of five CNAs. Specifically, the facility failed to ensure that expectations, individual performance, and training requirements were communicated to CNA #3, CNA #4, CNA #5 and CNA #6 through the annual performance appraisal process as required. Findings include: Review of the Facility assessment dated [DATE] indicated: -The facility uses competency-based job descriptions, -a competency-based assessment process for the nursing department and annual performance appraisals to identify the training the staff needs to receive and accompanying plan. Review of the facility policy titled Performance Review indicated: -The facility will attempt to maintain a performance appraisal system that is administered at the completion of one's introductory period and at least once a year to every employee. -The performance appraisal will be used as a tool to assess one's performance and for such things as determining changes that may be appropriate to one's job, setting goals/expectations for the coming year, providing for an opportunity to receive feedback from employees about their job, and determining one's fitness for continued employment. Review of the facility personnel files for CNA #3, #4, #5, and #6 indicated the following: -CNA #3: date of hire 9/3/10, last performance appraisal was completed on 10/18/19. -CNA #4: date of hire 5/13/20, indicated no evidence that an annual performance appraisal had ever been completed. -CNA #5: date of hire 5/28/18, indicated no evidence that an annual performance appraisal had ever been completed. -CNA #6: date of hire 10/7/21, indicated no evidence that an annual performance appraisal had ever been completed. During an interview on 5/14/24 at 8:33 A.M., the Staff Development Coordinator (SDC) said she was not responsible for the staff's annual performance reviews and said she thought the Unit Managers (UMs) completed the annual performance reviews. During an interview on 5/14/24 at 9:05 A.M., the Director of Nurses (DON) said annual performance appraisals/ reviews were not completed consistently. The DON further said the process was for the Human Resource (HR) department to notify the UMs which employees were due for their annual performance appraisal, and it was the UMs responsibility to complete the performance appraisal and review with the employee annually. During an interview on 5/14/24 at 4:37 P.M., CNA #7 said she started working at the facility in 2018 and could not remember if she had ever received an annual performance appraisal. During an interview on 5/14/24 at 5:05 P.M., CNA #8 said she has worked at the facility for more than nine years, and used to have yearly performance appraisals with the UM, however it has been more than two years since she last had a performance appraisal. During an interview on 5/14/24 at 5:16 P.M., CNA #9 said the UMs used to do performance appraisals with the staff, but he could not recall the last time he had a performance appraisal. During an interview on 5/15/24 at 8:30 A.M., CNA #4 said she did not recall ever having had an annual performance appraisal. During an interview on 5/15/24 at 8:37 A.M., CNA #6 said she did not recall the last time she had received an annual performance appraisal. During an interview on 5/15/24 at 8:48 A.M., Nurse #4, who had previously worked as a UM at the facility said UMs, or the employee's direct supervisor were supposed to be notified by HR as to which employees were due to have performance appraisals completed. Nurse #4 said this should be done annually on the employee's anniversary date and the performance appraisals were to be reviewed by the manager with the employee. During an interview on 5/15/24 at 9:10 A.M., UM #2 said the annual performance appraisal process begins with HR providing a list of staff members that were due to be completed to the UMs. UM #2 said the UMs then complete the performance appraisal forms and review the data with the employee at which point the UM and the employee discuss the results, questions, and concerns. UM #2 said this process should be completed annually and the performance appraisals were to be retained in the employee's permanent personnel file. UM #2 further said the last performance appraisal she completed was for a Nurse over a year ago, she had never completed a performance evaluation for a CNA, and had not been notified by HR of any employees due for their annual performance appraisals in over a year. During an interview on 5/15/24 at 11:21 A.M., the DON said the facility did not have a consistent HR person in the building, therefore the annual performance appraisals had not been completed annually as required. During a follow-up interview on 5/15/24 at 1:56 A.M., the SDC said that while she ensured CNAs completed their required annual 12 hours of education, the education provided was not directly related to the results of the annual performance appraisals as she did not have access to that information.

Based on observation, interview and policy review, the facility failed to ensure that medications were labeled in accordance with professional standards to include an expiration date on two (#2 and #4) out of three observed medication carts, and on two units (Unit 1 and Unit 2) out of three observed units. Specifically, the facility failed to ensure that an ophthalmic (relating to the eye and its diseases) medication was appropriately labeled to indicate the bottle open date and/or discard date according to manufacturer's guidelines and prevent the administration of outdated medications that could result in contamination and infections for facility residents. Findings include: According to the National Library of Medicine (2022): https://www.ncbi.nlm.nih.gov/books/NBK540978/#:~:text=Latanoprost%20is%20a%20colorless%2C%20isotonic,46%20%C2%B0F)%20for%20storage, once Xalatan Ophthalmic Drops (generic name Latanoprost: eye drops used to treat high pressure in the eye) is opened, it may be stored at room temperature for 6 weeks. Review of the facility policy titled Medication Storage Information, undated, indicated: -opened Xalatan Ophthalmic Drops should be stored at room temperature and have an expiration date of 6 weeks after opening. On 5/14/24 at 11:54 A.M., the surveyor observed and Nurse #8 observed medication cart #2 on Unit 1. The surveyor and Nurse #8 observed one bottle of Xalatan Ophthalmic Drops in the medication cart drawer that was undated and did not indicate when the medication bottle was opened or when to discard the medication. During an interview at the time, Nurse #8 said the bottle of Xalatan Ophthalmic Drops should be dated when opened. Nurse #8 further said that he would discard the medication bottle when the bottle was empty, or when the Physician's order for the administration of the medication was completed. On 5/15/24 at 1:01 P.M., the surveyor and Nurse #9 observed medication cart #4 on Unit 2. The surveyor and Nurse #9 observed one bottle of Xalatan Ophthalmic Drops in the medication cart drawer without a date that indicated when the bottle was opened or when to discard the medication. During an interview at the time, Nurse #9 said that she was unsure how to know when to discard the medication bottle and would find out. Nurse #9 left and returned and said that the DON said eye drops did not have to be dated when opened. During an interview on 5/15/24 at 1:38 P.M., the surveyor and Director of Nurses (DON) reviewed the undated facility policy titled Medication Storage Information. The DON said the policy indicates that Xalatan Ophthalmic Drops should be discarded 6 weeks after opened. The DON said she could not provide an answer as to how Nurses would know when to discard the two undated bottles of Xalatan Ophthalmic Drops. The DON said the bottles of Xalatan Ophthalmic Drops should labeled when opened to indicate either the date opened or the discard date.

Based on observation, interview, and policy review the facility failed to maintain a clean and homelike environment for one Resident (#11) on one Unit (#1) out of three units observed. Specifically, for Resident #11 who resided on Unit #1 the facility failed to ensure that the Resident's window covering was maintained in a clean manner. Findings include: Review of the facility policy titled Environmental Services Guidelines, dated September 2011, indicated the following: -Cleaning of walls, curtains, blinds, etc. will be completed when dust/soil is visible. On 5/9/24 at 10:20 A.M., the surveyor observed multiple areas of dried dark brown material and a large stain on Resident #11's window covering. During an interview at the time, Resident #11 said his/her window covering was dirty and he/she would like to have it cleaned or replaced. Resident #11 further said that he/she had not seen anyone clean the window covering recently and he/she was unsure what the spots and large stain were from. On 5/13/24 at 8:31 A.M., the surveyor observed that Resident 11's window covering remained with multiple areas of dried dark brown material and a large stain. During an observation and interview on 5/14/24 at 3:36 P.M., the surveyor and the Housekeeping Director observed Resident #11's window covering that remained with multiple spots of dried dark brown material and a large stain. The Housekeeping Director said the Resident's window covering should be wiped down regularly and if it could not be cleaned, housekeeping should have asked to have the window covering removed and replaced. The Housekeeping Director further said no one had informed him of the large stain on the window covering and he had window coverings readily available in the facility, that once staff noticed the window covering was visibly dirty a new window covering should have been requested.

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessments for two Residents (#60 and #21), out of a total sample of 25 residents. Specifically, the facility failed to ensure the MDS Assessment was accurately coded relative to: 1. For Resident #60, the use of hypoglycemic medications (medications that reduce blood sugar [glucose]), antianxiety medication (used to treat feelings of fear, dread, uneasiness that may occur as a reaction to stress) and that the Resident was on dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). 2. For Resident #21, the administration of antipsychotic (used to treat symptoms of psychosis which include hallucinations, delusions and Dementia), antibiotic (used to treat bacterial infections), antianxiety and hypoglycemic medications. Findings include: 1. Resident #60 was admitted to the facility in October 2022, with diagnoses including End Stage Renal Disease (ESRD: medical condition in which the kidneys cease to function on a permanent basis), Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), Anxiety (reaction to stress that can cause fear, dread, and uneasiness), Type 2 Diabetes (inability for the body to regulate blood glucose levels in the blood) and dependence of renal dialysis. a. Review of the December 2023 Physician's orders indicated: -Insulin Lispro Kwikpen 100 Units(U)/1 milliliter (ml), 5 units with meals and 5 units at 6:00 A.M., and 5 units with lunch and dinner, initiated 2/13/23 -Insulin Glargine Pen 100 IU/1 ml solution, 16 units at 6:00 A.M., 16 units at 8:00 A.M. and 16 units at 8:00 P.M. -Clonazepam (antianxiety medication) 0.5 milligrams (mg) daily, initiated 12/28/23 -Dialysis on Mondays, Wednesdays, and Fridays, initiated 11/14/22 -Monitor the Dialysis shunt (surgically created connection between an artery and vein that provides access to the bloodstream for dialysis) every shift, bruit and thrill (sounds that can be heard or felt near a dialysis site and indicates that the site is working), initiated 11/14/22 Review of the December 2023 Medication Administration Record (MAR) indicated the Clonazepam, and the Insulin was administered as ordered and that the dialysis site and bruit and thrill were monitored as ordered. Review of the MDS assessment dated [DATE], indicated Resident #60 received Insulin (type of hypoglycemic medication) for 7 days. Further review of the MDS Assessment did not indicate that the Resident was on hypoglycemic and antianxiety medications or received dialysis during the assessment period. b. Review of the March 2024 Physician's orders indicated: -Dialysis on Mondays, Wednesdays, and Fridays, initiated 11/14/22 -Monitor the Dialysis shunt every shift, bruit and thrill, initiated 11/14/22 Review of the March 2024 MAR indicated the dialysis site, and the bruit and thrill were monitored as ordered. Review of the MDS assessment dated [DATE], indicated Resident #60 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 and was not receiving dialysis during the assessment period. On 5/9/24 at 9:00 A.M., the surveyor observed the Resident seated at the edge of the bed eating breakfast. During an interview, Resident #60 said that he/she had been receiving dialysis three times weekly on Mondays, Wednesdays and Fridays, had been on dialysis for a long time and has had no issues with the treatments. During an interview on 5/14/24 at 2:32 P.M., MDS Nurse #1 said that Resident #60's MDS Assessments dated 12/30/23 and 3/31/24 were reviewed and were inaccurate. Nurse #1 said the identified miscoded areas relative to the use of hypoglycemic medications, antianxiety medication, and that the Resident was not receiving dialysis were an oversight and modifications were made to the assessments. 2. Resident #21 was admitted to the facility in April 2021 with diagnoses including Adjustment Disorder with mixed Anxiety and Depressed Mood, Psychotic Disorder with delusions, Type 1 Diabetes (condition in which the body is unable to regulate blood sugar levels) and Schizophrenia (a serious mental disorder that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others). a. Review of the December 2023 Physician's orders indicated: -Augmentin (antibiotic) 500 mg-125 mg orally twice daily for a urinary tract infection (UTI), initiated 12/8/23 and discontinued 12/22/23 -Aripiprazole (antipsychotic) 15 mg daily, initiated 7/20/21 -Novolog Insulin 100 U/1 ml solution, per sliding scale (varies the dose of Insulin based on blood glucose [sugar] levels) before meals , initiated 7/12/23 -Novolog Insulin 100 U/1 ml solution, 6 units before meals, initiated 7/12/23 -Levemir Insulin 100 U/1 ml solution, 24 units at 8:00 P.M., initiated 6/1/22 Review of the December 2023 MAR indicated the Augmentin, Aripiprazole, and scheduled Insulin medications were administered as ordered. Further review of the December 2023 MAR indicated no documented evidence that an antianxiety medication was administered. Review of the MDS assessment dated [DATE], indicated Resident #21 received 7 days of Insulin and an antianxiety medication, and did not indicate that he/she received an antipsychotic, antibiotic or was on a hypoglycemic medication during the assessment period. b. Review of the March 2024 Physician's orders indicated Valium (antianxiety medication) 2 mg every 8 hours was initiated on 3/15/24. Review of the MDS assessment dated [DATE], indicated Resident #21 received antianxiety medication during the assessment period. Review of the March 2024 MAR indicated the Valium was not administered (was held) until 3/16/24. During an interview on 5/14/24 at 5:21 P.M., MDS Nurse #1 said he reviewed Resident #21's MDS Assessments dated 12/14/23 and 3/15/24, and the MDS Assessments were miscoded relative to the administration of an antipsychotic, antibiotic, antianxiety and hypoglycemic medications.

During observation, interview, and record review, the facility failed to ensure its staff provided repositioning as required to prevent the development of a facility acquired pressure injury for one Resident (#50), out of a sample of 24 residents. Findings include: Resident #50 was admitted to the facility in April 2022 with diagnoses including unspecified Dementia and protein calorie malnutrition (under-nutrition resulting from inadequate intake, digestion or absorption of protein or calories). The Resident was also diagnosed with Covid-19 in January 2023. According to a white paper, copyright November 2022, by Wound Source and HMP Global, Inc., the following pertain to pressure injury: - One of the most critical risk factors for pressure injury (also called a bedsore - an area of injured skin and underlying tissue resulting from prolonged pressure on the skin - people most at risk are those with a condition that limits their ability to change positions), is limited mobility since it exacerbates challenges in shifting weight away from at-risk areas. - Other risk factors include moisture (particularly as related to incontinence), body temperature, age . - Unless contraindicated, all individuals at risk of, or who have pressure injuries should be repositioned on an individualized schedule. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was at risk for pressure injuries with no current unhealed pressure injuries. Further review of the MDS assessment indicated: -the Resident required extensive assistance of two people for bed mobility -was totally dependent on two people for transfers in and out of bed -was non-ambulatory (did not walk). Review of the Physician's Orders for January 2023 indicated: - Weekly skin screening for new areas of concern, weekly on the evening shift, initiated 8/3/22. Review of the Treatment Administration Records (TARs) for November 2022, December 2022 and January 2023 indicated the Resident had no open areas. Review of the Certified Nursing Assistant (CNA) positioning documentation indicated the Resident required assistance of two people for bed mobility. Further review of the CNA positioning documentation for January 2023 indicated no documented evidence the Resident had been repositioned at all during: -1/1/23 -1/9/23 on both the overnight (11:00 P.M.-7:00 A.M.) and the evening (3:00 P.M.-11:00 P.M.) shifts. -and 1/1/23 and 1/7/23 during the day (7:00 A.M.-3:00 P.M.) shift. Review of the medical record included a nursing progress note dated 1/9/23, that documented the following: -The CNA noticed an open area during a brief change. The open area was described as an excoriation (a raw, irritated lesion) measuring 4 centimeters (cm) by 3 cm on the Resident's coccyx (small triangular bone at the base of the spinal column) -with peri-wound (area surrounding the wound) non-blanchable (discoloration of the skin that does not turn white when pressed, a clinically important skin abnormality) ecchymosis (discoloration of the skin resulting from bleeding underneath) -Resident is status-post Covid . During an observation and interview on 1/10/23 at 7:44 A.M., the surveyor observed the certified wound and ostomy care Nurse Practitioner consultant (CWOCN-NP) and the facility Infection Preventionist (IP) nurse provide wound care for Resident #50. The surveyor observed the Resident lying on an air mattress and as the IP and the CWOCN-NP rolled the Resident to his/her side, the surveyor observed the Resident to be lying on a soaker pad (an absorbent pad placed underneath a person to absorb urine) and a bunched up sheet. The surveyor then observed an open area, the coccyx area covered with slough (yellow/white material in the wound bed that consists of protein, fiber and dead skin cells that inhibit wound healing), surrounded by a darkened area of skin. The CWOCN-NP said a dressing would be difficult to maintain due to the location of the wound combined with the Resident's incontinence, and applied Triad paste (a zinc-oxide based paste that absorbs moderate levels of wound drainage). The CWOCN-NP said the wounds were due to pressure and she was treating them as two separate areas: one area a deep tissue injury (DTI- an injury to a person's underlying tissue below the skin's surface that results from prolonged pressure, causing the tissue to die) on the left buttock and the other area considered to be a Stage 3 pressure injury (the third of four stages where the wound penetrates past the top layers of skin but not yet reached the muscle and bone) in the coccyx area. In addition, the CWOCN-NP requested the IP lower the head of the Resident's bed to 30 degrees, and remove one of the two base layers underneath the Resident, either the soaker pad or the sheet. Review of the consultant wound nurse progress note dated 1/10/22 indicated the following: - Coccyx: Pressure ulcer measuring 2.5 cm x 1.7 cm x 0.1 cm (length x width x depth), Stage 3 pressure injury. Less than 50 percent slough to wound base that is consistent with a Stage 3 pressure injury. - Left buttock: DTI measuring 3 cm x 2.0 cm. Raised purple non-blanching tissue consistent with DTI in setting of pressure and shear (a wound occurring when forces moving in opposite directions are applied to tissues in the body such as the skin on the back sticking to a surface such as elevation of the head of a bed while gravity forces the body downward). During an interview on 1/10/23 at 9:30 A.M., CNA #5 said the CNAs were required to document the turning and repositioning of the residents on the positioning sheets kept in a binder at the nurse's station. Upon review of the January 2023 positioning sheet with the surveyor, CNA #5 said there was no documented evidence the CNAs repositioned the Resident during the evening and overnight shifts at all in January and on 1/1/23 and 1/7/23 during the day shift, as required. He further said the Resident was bedbound the week of 1/1/23 due to Covid infection and required turning and positioning every two hours. During an interview on 1/10/23 at 2:28 P.M., Unit Manager (UM) #2 said the only place CNAs documented positioning were the positioning sheets located in the binder at the nurse's station. Upon review of the Resident's January 2023 positioning sheet, UM #2 said it was expected and understood that all residents who required assistance with bed mobility should be turned and positioned every two hours. She further said Resident #50 was bedbound the week of 1/1/23 due to having Covid and there was no evidence the CNAs repositioned the Resident, as required. During a follow up telephone interview on 1/13/23, the CWOCN-NP said the head of the Resident's bed should have been lowered because if too high, would cause a shear injury to the skin. She further said that the air mattress manufacturer recommend no more than one layer between the mattress and the body because the air mattress would be less effective with multiple layers. In addition, she said multiple layers (sheets, soaker pads) underneath a person also puts a person at increased risk of pressure injuries due to warmth and moisture changing the pH of the skin, and increasing its fragility.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -On [DATE] Resident #1 who required continual supervision while eating, was seated in the Unit's Lounge (designated supervised eating area) where a Certified Nurse Aide (CNA) delivered and set-up Resident #1's meal for him/her. The CNA then exited the Unit Lounge, however there were no other staff members in the Unit Lounge at that time to supervise him/her, leaving Resident #1 alone and unsupervised while eating his/her dinner. -Approximately 45 minutes later another CNA walked by the Unit Lounge while collecting dirty dinner trays, saw Resident #1 in obvious distress with his/her head up against the wall and his/her mouth hanging open, it was determined that he/she was choking on his/her food, the [MEDICATION(S)] Maneuver (abdominal thrusts performed on a person to remove food when choking) was performed, 911 was initiated, Resident #1 was transferred to the Hospital, and subsequently died . Findings Include: Review of Facility's Policy titled Nutrition and Meals, dated [DATE], indicated that nursing would monitor residents through meals to ensure assistance is provided promptly according to a Resident's individualized need. Review of the Facility's Policy tilted Documentation- CNA Point of Care, dated as revised ,d+[DATE], defines Continual Supervision as oversight, encouragement, or cueing through the entire activity. For eating one staff member to eight or less residents (1:8 ratio) required. Review of Facility's Policy titled Care Planning, dated as revised [DATE], indicated the facility would develop and implement an individualized care plan based on the comprehensive assessment. The Policy indicated that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the Facility in [DATE], diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Dysphagia Consult, dated [DATE], indicated he/she had severe oropharyngeal dysphagia (disruption or delay in swallowing) affecting his/her safety during swallowing. The Consult indicated that Resident #1 should not eat dry bread, that he/she required extra time during meals, effortful swallowing, monitoring of his/her oral intake rate, and he/she should be positioned upright. The Consult indicated that Resident #1 required supervised eating and these strategies are dependent on staff assistance. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 required staff supervision with eating and he/she experienced coughing or choking during meals. Review of the Speech Therapy Discharge Summary, dated [DATE], indicated that Resident #1 required supervised eating. During an interview on [DATE] at 1:00 P.M., the Speech Language Pathologist said that Resident #1 required staff supervision with all meals. Review of Resident #1's Plan of Care Related to Activities of Daily Living, dated as reviewed [DATE], indicated he/she required Continual Supervision (1:8 ratio) with eating. Review of Resident #1's Licensed Nursing Summary for [DATE], dated [DATE], indicated that Resident #1 required Continual Supervision (1:8 ratio or less) for eating because he/she became easily fatigued, had decreased activity tolerance, weakness, and had decreased strength and endurance. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, indicated that (on [DATE]) she brought Resident #1 a sandwich and French toast. The Statement indicated that she (CNA #1) told Resident #1 to take small bites and chew because she knew he/she would eat fast and would take big bites. The Statement indicated she left the room. During an interview on [DATE] at 3:33 P.M., Certified Nurse Aide (CNA) #1 said on [DATE] between 5:45 P.M. and 6:00 P.M. she served Resident #1 his/her dinner tray in the Unit Lounge. CNA #1 said Resident #1 requested a meal brought in from his/her family member (identified by CNA #1 as diced-up bologna mixed with mayonnaise served on two slices of white bread that was cut in half and some French toast that was cut up into various sizes). CNA #1 said that she told Resident #1 to take small bites, because she knew he/she would take big bites, and was at risk for choking. CNA #1 said after she finished setting up Resident #1 to eat, she left the Unit Lounge, and said there were no other staff members in there to provide supervision to him/her while he/she eat. CNA #1 said she was aware that Resident #1 required supervision with his/her meals but said she did not provide Resident #1 with supervision during his/her evening meal. Review of Certified Nurse Aide (CNA) #2's Typed Witness Statement, dated [DATE], indicated that on [DATE], she observed Resident #1 in the Unit Lounge seated in his/her wheelchair with his/her head up against the wall and his/her mouth was hanging open. The Statement indicated she (CNA #2) called Nurse #1 for assistance, and she (CNA #2) assisted Nurse #1 with removing bread from Resident #1's mouth. During an interview on [DATE] at 10:36 A.M., Certified Nurse Aide (CNA) #2 said on [DATE] around 6:45 P.M., she was walking down the hallway on the unit and was placing a dirty dinner tray onto the food truck outside of the Unit Lounge. CNA #2 said she looked into the Unit Lounge, and observed Resident #1 in his/her wheelchair, with his/her head tilted up, eyes open, mouth open, and she immediately ran into the Unit Lounge where she observed a piece of food in Resident #1's mouth. CNA #2 said she grabbed a piece of food (identified as bread by CNA #2) from Resident #1's mouth and called for Nurse #1. CNA #2 said there were no staff members present when she found Resident #1 unsupervised in the Unit Lounge. CNA #2 said she was aware that Resident #1 required staff supervision during his/her meals and did not know why he/she was left unsupervised. Review of the Change in Condition Note, dated [DATE], indicated that Resident #1 was unresponsive and a Code Blue was called. The Note indicated that there was food in Resident #1's mouth, he/she was gasping for air, nursing performed the [MEDICATION(S)] Maneuver, and more food was removed from Resident 1's mouth. Resident #1 was assessed, did not have a palpable pulse, he/she was lowered to the floor, and staff began to perform Cardiopulmonary Resuscitation (CPR). The Note indicated Resident #1 was transferred to the Hospital. Review of Nurse #1's Typed Witness Statement, dated [DATE], indicated on [DATE] Resident #1 was found unresponsive in his/her wheelchair with his/her head tilted back (in the Unit Lounge). The Statement indicated Nurse #1 performed the [MEDICATION(S)] Maneuver and food came out of Resident #1's mouth. The Statement Resident #1 no longer had a pulse and nursing began CPR. The Statement indicated Emergency Medical Services arrived and transported Resident #1 to the Hospital for further evaluation. During an interview on [DATE] at 2:04 P.M., Nurse #1, who was assigned to and care for Resident #1 on [DATE], said she was not aware that Resident #1 required staff supervision during meals. Nurse #1 said on [DATE] she did not provide Resident #1 with supervision during his/her evening meal. However, review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 signed off on Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 required staff supervision with meals. During an interview on [DATE] at 3:57 P.M., Nurse #2, who was also working on Resident #1's unit in the evening on [DATE], said he was aware that Resident #1 required staff supervision for meals. Nurse #2 said on [DATE] he did not provide supervision to Resident #1 with his/her dinner meal. During an interview on [DATE] at 4:33 P.M., Certified Nurse Aide (CNA) #3 said, who worked the 3:00 P.M. to 11:00 P.M. shift on Resident #1's Unit on [DATE], said she did not provide supervision to Resident #1 while he/she was eating dinner. Review of the Hospital Discharge Summary, dated [DATE], indicated that Resident #1 was transferred to the Hospital after an episode unresponsiveness and cardio-respiratory arrest following an episode of choking on food requiring CPR and intubation. The Summary indicated he/she was admitted to the Hospital with [CONDITION(S)], acute respiratory failure, cardiac arrest, liver shock, and possible aspiration pneumonia. The Summary indicated he/she required mechanical ventilation, was transitioned to Comfort Care Measures only and died on [DATE]. During an interview on [DATE] at 8:51 A.M., the Unit Manager said that on [DATE] staff should have provided Resident #1 with supervision during his/her evening meal. The Unit Manager said that staff should have been in the Unit Lounge supervising Resident #1 the entire time he/she was eating. During an interview on [DATE] at 5:17 P.M., the Director of Nursing (DON) said that nursing should have followed Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A) [DATE] and [DATE], Facility wide audit was completed by the Director of Nursing on All Residents to identify those: - Residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Residents who had a Plan of Care that indicated resident required staff supervision with meals. - Residents who had a Care Kardex (Profile) that indicated resident required staff supervision with meals. B) [DATE], A Quality Assurance Performance Improvement (QAPI) meeting was conducted with facility staff which included the discussion of the choking incident and the results of the Audit completed by the Director of Nursing. C) [DATE], The Interdisciplinary Team identified locations where Residents who required supervision would receive each meal. Nursing staff created a seating plan for each dining area that included those residents who required staff supervision during meals. D) [DATE], The Director of Nursing provided a list of those Residents who required staff supervision with meals to each Unit. E) [DATE], [DATE], and [DATE], Unit Managers, the Staff Development Coordinator, and the Director of Nursing conducted Educational In-services for the nursing department staff on following a Resident's Plan of Care including providing Residents who require staff supervision with meals, following a Resident's Plan of Care, and following a Resident Kardex. F) [DATE], The Food Service Director arranged meal trucks to facilitate the delivery of meals trays to allow those Residents who require staff assistant and/or staff supervision during meal to be the last to arrive to the Unit. G) Unit Managers are completing weekly audits to ensure staff are implementing Plans of Care of those Residents who require staff supervision with meals. H) The Director of Nursing is responsible to ensure the audits are being completed weekly for three months. The audits will be brought to the QAPI meeting for 3 months. I) 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 had a known history of choking and had a Physician's order indicating he/she required staff supervision during all meals, the Facility failed to ensure he/she was provided with the required level of staff supervision to maintain his/her safety while eating. -On [DATE] Resident #1 who required continual supervision from staff while eating, was seated in the Unit's Lounge (designated supervised eating area) where a Certified Nurse Aide (CNA) delivered and set-up Resident #1's meal for him/her. The CNA then exited the Unit Lounge, however there were no other staff members in the Unit Lounge at that time to supervise him/her, leaving Resident #1 alone and unsupervised while eating his/her dinner. -Approximately 45 minutes later another CNA walked by the Unit Lounge while collecting dirty dinner trays, saw Resident #1 in obvious distress with his/her head up against the wall and his/her mouth hanging open, and it was determined that he/she was choking on his/her food, the [MEDICATION(S)] Maneuver (abdominal thrusts performed on a person choking on food) was performed, 911 was initiated, Resident #1 was transferred to the Hospital, and subsequently died . Findings Include: Review of Facility's Policy titled Nutrition and Meals, dated [DATE], indicated that nursing would monitor residents through meals to ensure assistance is provided promptly according to a resident's individualized need. Review of the Facility's Policy tilted Documentation- CNA Point of Care, dated as revised ,d+[DATE], defined Continual Supervision as oversight, encouragement, or cueing through the entire activity. For eating on staff member to eight or less residents (1:8 ratio) is required. Resident #1 was admitted to the Facility in [DATE], diagnosis included [CONDITION(S)] (disabling progressive disease of the brain) and Dysphagia (difficulty swallowing). Review of an Incident Accident Report, dated [DATE], indicated on [DATE] Resident #1 had a choking episode during dinner. The Report indicated the [MEDICATION(S)] Maneuver was performed and a large amount of food was expelled. Review of Resident #1's Dysphagia Consult, dated [DATE], and indicated he/she had severe oropharyngeal dysphagia (disruption or delay in swallowing) affecting his/her safety during swallowing. The Consult indicated that Resident #1 should not eat dry bread and he/she required extra time during meals, effortful swallowing, monitoring of his/her oral intake rate, and he/she should be positioned upright. The Consult indicated that Resident #1 required supervised eating and these strategies are dependent on staff assistance. Review of Resident #1's Physician's Order, dated [DATE], indicated he/she required a mechanical soft diet with nectar (easily pourable, comparable to heavy syrup found in canned fruit) thickened liquids and staff supervision with meals. During an interview on [DATE] at 4:20 P.M., the Nurse Practitioner, who electronically signed Resident #1's Physician's Order for supervised meals, said her expectation was that a staff member would to be present and supervise Resident #1 the entire time during meals. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident #1 required supervised eating and he/she experienced coughing or choking during meals. Review of the Speech Therapy Discharge Summary, dated [DATE], indicated that Resident #1 required supervised eating. During an interview on [DATE] at 1:00 P.M., the Speech Language Pathologist said that Resident #1 required staff supervision when eating his/her meals. Review of Resident #1's Plan of Care Related to Activities of Daily Living, dated as reviewed [DATE], indicated he/she required continual supervision (1:8 ratio) with eating. Review of the Licensed Nursing Summary [DATE], dated [DATE], indicated that Resident #1 required Continual Supervision (1:8 ratio) for eating because he/she became easily fatigued, had decreased activity tolerance, weakness, and decreased strength and endurance. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, undated, indicated that (on [DATE]) she brought Resident #1 a sandwich and French toast. The Statement indicated that CNA #1 told Resident #1 to take small bites and chew because she knew he/she would eat fast and would take big bites. The Statement indicated she left the room. During an interview on [DATE] at 3:33 P.M., Certified Nurse Aide (CNA) #1 said on [DATE] between 5:45 P.M. and 6:00 P.M. she served Resident #1 his/her dinner tray in the Unit Lounge. CNA #1 said Resident #1 requested a meal brought in from his/her family member (identified by CNA #1 as diced-up bologna mixed with mayonnaise served on two slices of white bread that was cut in half and some French toast that cut into various sizes). CNA #1 said that she told Resident #1 to take small bites, because she knew he/she would take big bites and was at risk for choking. CNA #1 said after setting up Resident #1 for dinner, she left the Unit Lounge. CNA #1 said there were no other staff members in the Unit Lounge at the time, CNA #1 there was no one there to supervise Resident #1 while he/she ate. CNA #1 said she was aware that Resident #1 required staff supervision with meals but said she did not provide Resident #1 with supervision during his/her evening meal. Review of Certified Nurse Aide (CNA) #2's Typed Witness Statement, dated [DATE], indicated that on [DATE], she observed Resident #1 in the Unit Lounge seated in his/her wheelchair with his/her head up against the wall and his/her mouth was hanging open. The Statement indicated CNA #2 called Nurse #1 for assistance and she assisted Nurse #1 in removing bread from Resident #1's mouth. During an interview on [DATE] at 10:36 A.M., Certified Nurse Aide (CNA) #2 said on [DATE] around 6:45 P.M., she was walking down the hallway on the unit and was placing a dirty dinner tray onto the food truck outside of the Unit Lounge. CNA #2 said she looked into the Unit Lounge and observed Resident #1 in his/her wheelchair, with his/her head tilted up, eyes open, mouth open, and she immediately ran into the Unit Lounge where she observed a piece of food in Resident #1's mouth. CNA #2 said she grabbed the piece of food (identified as bread) from Resident #1's mouth and called for Nurse #1. CNA #2 said there were no staff members present when she found Resident #1 unsupervised in the Unit Lounge. CNA #2 said she was aware that Resident #1 required staff supervision during his/her meals and did not know why he/she was left unsupervised. Review of the Code Blue Flow Sheet, dated [DATE], indicated Resident #1 choked on a piece of toast. The Sheet indicated that nursing performed abdominal thrusts and Resident #1 spit out watery toast. The Sheet indicated Resident #1 lost his/her pulse, staff initiated Cardiopulmonary Resuscitation (CPR) and Resident #1 was transferred to the Hospital for further evaluation. Review of Change in Condition Note, dated [DATE], indicated that Resident #1 was unresponsive and a Code Blue was called. The Note indicated that there was food in Resident #1's mouth, Resident #1 was gasping for air, nursing performed the [MEDICATION(S)] Maneuver and more food was removed from Resident 1's mouth. Resident #1 then did not have a palpable pulse, he/she was lowered to the floor, and staff began to perform CPR. The Note indicated Resident #1 was transferred to the Hospital. Review of Nurse #1's Typed Witness Statement, dated [DATE], indicated on [DATE] Resident #1 was found unresponsive in his/her wheelchair with his/her head tilted back. Nurse #1 performed the [MEDICATION(S)] Maneuver and food came out of Resident #1's mouth. Resident #1 no longer had a pulse and nursing began Cardiopulmonary Resuscitation. The Note indicated Emergency Medical Services arrived and transported resident #1 to the Hospital for further evaluation. During an interview on [DATE] at 2:04 P.M., Nurse #1 said she was the Nurse Assigned to Resident #1 on [DATE]. Nurse #1 said she was not aware that Resident #1 required staff supervision during meals. Nurse #1 said on [DATE], she did not provide supervision for Resident #1 during dinner. However, review of Resident #1's Medication Administration Record (MAR) for May and June of 2022, indicated that Nurse #1 signed off on Resident #1's Physician's orders (on [DATE], [DATE], [DATE], [DATE], and [DATE]) acknowledging that Resident #1 required staff supervision with meals. During an interview on [DATE] at 3:57 P.M., Nurse #2, who also worked on Resident #1's unit on the evening of [DATE], said he was aware that Resident #1 required staff supervision for meals. Nurse #2 said on [DATE], he did not provide supervision for Resident #1 during his/her dinner meal. During an interview on [DATE] at 4:33 P.M., Certified Nurse Aide (CNA) #3 said, who was working on Resident #1's Unit during the evening shift on [DATE], said she did not provide supervision for Resident #1 with his/her evening meal. Review of the Hospital Discharge Summary, dated [DATE], indicated that Resident #1 was transferred to the Hospital after an episode unresponsiveness and cardio-respiratory arrest following an episode of choking on food requiring CPR and intubation. The Summary indicated he/she was admitted to the Hospital with [CONDITION(S)], acute respiratory failure, cardiac arrest, liver shock, and possible aspiration pneumonia. The Summary indicated he/she required mechanical ventilation, was transitioned to Comfort Care Measures only and died on [DATE]. During an interview on [DATE] at 8:51 A.M., the Unit Manager said that on [DATE] staff should have provided Resident #1 with supervision during his/her evening meal. The Unit Manager said that staff should have been in the Unit Lounge supervising Resident #1 the entire time he/she was eating. During an interview on [DATE] at 5:17 P.M., the Director of Nursing (DON) said that nursing should have followed Resident #1's Physician's Order and implemented interventions from his/her Plan of Care, that a staff member should have been in the Unit Lounge to supervise Resident #1 during his/her evening meal. On [DATE], the Facility presented the Surveyor with a Plan of Correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A) [DATE] and [DATE], Facility wide audit was completed by the Director of Nursing on All Residents to identify those: - Residents who had a Physician's Order that indicated a Resident was supervised for meals. - Residents who had a Plan of Care that indicated resident required staff supervision with meals. - Residents who had a Care Kardex (Profile) that indicated resident required staff supervision with meals. B) [DATE], A Quality Assurance Performance Improvement (QAPI) meeting was conducted with facility staff which included the discussion of the choking incident and the results of the Audit completed by the Director of Nursing. C) [DATE], The Interdisciplinary Team identified locations where Residents who required supervision would receive each meal. Nursing staff created a seating plan for each dining area that included those residents who required staff supervision during meals. D) [DATE], The Director of Nursing provided a list of those Residents who required staff supervision with meals to each Unit. E) [DATE], [DATE], and [DATE], Unit Managers, the Staff Development Coordinator, and the Director of Nursing conducted Educational In-services for the nursing department staff on following a Resident's Plan of Care including providing Residents who require staff supervision with meals, following a Resident's Plan of Care, and following a Resident Kardex. F) [DATE], The Food Service Director arranged meal trucks to facilitate the delivery of meals trays to allow those Residents who require staff assistant and/or staff supervision during meal to be the last to arrive to the Unit. G) Unit Managers are completing weekly audits to ensure staff are implementing Plans of Care of those Residents who require staff supervision with meals. H) The Director of Nursing is responsible to ensure the audits are being completed weekly for three months. The audits will be brought to the QAPI meeting for 3 months. I) The Director of Nursing and/or Designee are responsible for overall compliance

Based on interviews and records reviewed, for one of three sampled residents (Resident #2), the Facility failed to prevent an incident of verbal and physical abuse when on 3/18/20 Nurse #1 referred to Resident #2 as a witch with residents and staff members present, and was then witnessed by staff to pinch Resident #2's cheeks and nostrils in an attempt to administer medications, and then dump water on his/her face after he/she refused to take them. Findings include: Resident #2's most recent Minimum Data Set (MDS) Assessment Form completed 3/4/20 indicated that his/her short and long term memory skills were impaired and his/her decision-making skills were severely impaired. The Surveyor did not interview Resident #2 about the alleged incident due to his/her impaired mental status. During an interview on 6/09/20 at 12:30 P.M., Certified Nurse Aide (CNA) #2 said that on 3/18/20 there were multiple residents gathered at the nurses station, as well as several staff members, and that Nurse #1 gestured toward Resident #2 and said words to the effect, can someone help me with this little witch. CNA #2 said another staff member, CNA #4 went over to help Nurse #1. CNA #2 said she then saw Nurse #1 pinch Resident #2's nostrils closed. CNA #2 said Resident #2 screamed out, and said Nurse #1 dumped water over Resident #2's mouth, which was closed. CNA #2 said she stepped in to stop Nurse #1 and reported the incident to the Director of Nurses During an interview on 6/12/20 at 12:30 P.M., Certified Nurse Aide (CNA) #4 said he went to help Nurse #1, and went to where Resident #2 was seated. CNA #4 said that Nurse #1 attempted to administer pills to Resident #2's by putting them in his/her mouth, that Resident #2 said no, and closed his/her lips real tight. CNA #4 said Nurse #1 then squeezed Resident #2's cheeks. CNA #4 said that, a millisecond later, Nurse #1 moved his hand from Resident #2's cheeks and squeezed Resident #2's nostrils closed. CNA #4 said that he immediately reported Nurse #2's actions to the Scheduler who directed him to the Director of Nurses. During an interview on 6/09/20 at 12:45 P.M., the Speech Therapist said that on 3/18/20 she saw Nurse #1, near the nurses' station, that there were other residents seated near there as well, and that she heard Nurse #1 mutter words to the effect of, these [***] ing residents won't take their pills. The Speech Therapist said that she reported Nurse #1's statement to the Director of Nurses. On 6/9/20, the Facility was found to be in past non-compliance. The Facility provided the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Immediately following the incident on 3-18-20, Nurse #1, who worked for a staffing Agency and worked seven shifts at the Facility during March 2020, was escorted from the Facility. B) On 3/18/20, the Director of Nurses notified the Agency of the allegation and asked that Nurse #1 no longer be assigned to the Facility. C) The Social Worker met with Resident #2 on 3/18/20 and 3/23/20 and assessed that, due to dementia, Resident #2 did not recall the incident and was not displaying any behavioral indicators of increased distress. D) The Staff Development Coordinator said that on 3/18/20 she reviewed that all Agency nurses, including Nurse #1, had received abuse training prior to working any shifts at the Facility. E) The Director of Nurses said that on 3/18/20, she interviewed 5 residents who had received care from Nurse #1 during his seven shifts at the Facility and the Director of Nurses' interviews did not reveal any other concerns about medication administration, abuse or Nurse #1. F) The Director of Nurses provided targeted re-training to CNA #4 on 3-18-20 regarding strategies for intervening during incidents, even when a supervisory staff member is involved. G) The Staff Development Coordinator said that the Facility provided annual abuse training to all staff in January of 2020, in addition to training of all new hires at their orientation. H) The Staff Development Coordinator said that, in response to the alleged incident, on 3/18/20 she began conducting weekly interviews of at least one staff member from every shift to assess their ability to define, recognize and respond to incidents of abuse in accordance with the Facility Abuse Policy and Procedure and provided on the spot education to any staff member's identified knowledge gaps. I) The Director of Nurses and Staff Development Coordinator are responsible for overall compliance.

Based on observation, record review and interview, the facility staff failed to implement adequate supervision and effective interventions to prevent falls for 1 resident (#70) out of a total sample of 24 residents. Findings include: For Resident #70 the facility staff failed to provide adequate supervision and interventions to prevent falls. The resident sustained [REDACTED]. Resident #70 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. Review of the Falls care plan, dated 10/2017, indicated the following interventions: - Provide well lit, uncluttered environment. - Place items resident uses frequently within reach to prevent bending or reaching. - Gait belt for all transfers. - Slipper socks on as resident allows when in bed. - Offer toileting on rounds. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 1/10/18, indicated that the resident was cognitively intact, as evidenced by a score of 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance with transfers, supervision with ambulation and had no falls since the last MDS assessment. Review of the nurse's note, dated 3/6/18, indicated that at 3:30 P.M., the resident was found on the floor. The nurse's note further indicated that the resident was ambulating to the bathroom when the walker fell out from under him/her and they fell . The resident did not sustain an apparent injury. Review of the facility's internal investigation for the fall of 3/6/18, indicated that the facility initiated that the facility was going to put a stop sign to remind the resident to call for assistance. Review of the significant change MDS Assessment, dated 4/4/18, indicated that the resident was moderately cognitively impaired as evidenced by a score of 11 out of a possible 15 on the BIMS, required supervision with transfers and ambulation, and sustained 2 falls with no injury since the last MDS Assessment. Review of the nurse's note, dated 4/20/18, indicated that the resident was found on the floor with his/her back leaning against the bed with the walker in front of him/her. Further review of the nurse's note indicated that the resident stood up from the bed and his/her feet slid out from under him/her. The nurse's note indicated that the resident sustained [REDACTED]. Review of the facility's internal investigation for the fall of 4/20/18, indicated that the resident was again on her way to the bathroom when she fell and activated the call bell after he/she fell . Review of the facility investigation, dated 4/25/18, indicated that the resident was found on the floor, and said that he/she was reaching for shoes and slid off of the bed. Further review of the investigation indicated that resident was found with a skin tear. Review of the nurse's note, dated 5/19/18, indicated that the resident sustained [REDACTED]. Review of the facility's internal investigation for the fall of 5/19/18, indicated that at 1:15 A.M. the resident fell on his/her way to the bathroom. Review of the quarterly MDS Assessment, dated 6/20/18, indicated that the resident was cognitively intact, as evidenced by a score of 15 out of a possible 15 on the BIMS, required supervision for transfers and ambulation, and sustained 2 or more falls with no injury and 2 or more falls with injury, (except major) since the last MDS Assessment. Review of the investigation, dated 7/11/18 that at 6:15 P.M. the resident attempted to pick up a washcloth and fell to the floor. Further review of the facility's internal investigation indicated that the resident would require supervision in the hallway. Review of the nurse's note, dated 8/6/18, indicated that at 4:00 P.M. the resident slid out of the recliner. Further review of the nurse's note indicated that the resident did not sustain an injury. Review of the facility's internal investigation for the fall of 8/6/18, indicated that the resident was wearing white socks. Review of the nurse's note, dated 8/10/18, indicated that at 9:10 P.M., the resident was found on the floor next to the bed, with his/her legs, straight out. The resident stated that he/she slipped. Review of the facility's internal investigation indicated that the resident was alert but forgetful and was ambulating to the bathroom. The call bell was not activated. The investigation further indicated that on 8/13/18, the resident complained of pain in the groin and x-ray results indicated an acute right pubic rim fracture. Review of the falls care plan, dated 8/23/18, indicated the following interventions: - Place items resident uses frequently in reach to prevent bending or reaching. Shoes in basket of walker to prevent him/her from bending down. - Encourage participation in diversional activities. - Keep call bell within reach, slipper socks on as the resident allows. Review of the nurse's note, dated 8/23/18, indicated that at 8:00 P.M., the resident fell in the bathroom. Review of the facility's internal investigation for the fall of 8/23/18, indicated that the resident was alert and oriented but forgetful, did not call for assistance and the call light was not activated, even though a reminder sign was in place. The facility's internal investigation further indicated that an x-ray revealed a new [MEDICAL CONDITION] superior pubic ramus. Review of the falls care plan indicated that on 8/28/2018, the care plan was updated to include the following interventions: - Pad alarms in bed and chair. - Frequent checks, especially through the night. - Offer toileting on all rounds. Review of the significant change MDS Assessment, dated 9/5/18, indicated that the resident was cognitively intact, as evidenced by a score of 14 out of a possible 15 on the BIMS, required extensive with transfers, limited assistance with ambulation, and sustained 2 falls with no injury and 1 fall with injury (except major) since the last MDS. Review of the falls care plan indicated that on 9/20/18, the care plan was updated to include the following interventions: - Gait belt for transfers as she allows. - Non slip socks or proper shoes. Review of the nurse's note, dated 10/8/18, indicated that on 10/7/18, the resident was found on the floor next to the roommate's bed. Further review of the nurse's note indicated that the resident was sent out to the hospital and returned with a left/arm wrist splint in place. Review of the facility's internal investigation for the fall of 10/7/18, indicated that at 10:15 P.M., the resident was alert and oriented but forgetful and did not activate the call light. The x-ray revealed a subacute appearing [MEDICAL CONDITION] sacral area. The x-ray of the left humerus indicated no fracture but gave the resident a left hand splint due to tenderness. Review of the falls care plan indicated that on 10/10/18, the care plan was updated to include the following interventions: - Provide well lit, uncluttered environment. - Encourage call light use. - Offer items to drink with interactions. - Stop sign to remind to use call light located in room. Review of the quarterly MDS Assessment, dated 11/21/18, indicated that the resident was moderately cognitively impaired as evidenced by a score of 10 out of a possible 15 on the BIMS, required extensive assistance with transfers, limited assistance with ambulation, and sustained 1 fall with injury (except major) since the last MDS Assessment. Review of the nurse's note, dated 12/25/18, indicated that the resident was found on the floor. Further review of the nurse's note indicated that the resident did not use the call light. Review of the facility's internal investigation for the fall of 12/25/18, indicated that the resident did not call for assistance. The surveyor observed Resident 01/24/19 at 10:09 A.M. Resident #70 was seated in a recliner chair in his/her room and he/she told the surveyor that they fell and broke an arm. The surveyor interviewed Certified Nursing Assistant (CNA) #3 on 1/29/19 at 1:10 P.M. CNA #3 said that the resident has progressively gotten worse. CNA #3 further said that the resident has to have somebody with him/her in the bathroom. He/she was usually steady but the last week or so has been worse. He/she usually rings the call bell but sometimes goes to the bathroom by himself/herself. There are days when the resident's memory is good and some days when is not as good. The resident has alarms, which usually sound. The surveyor interviewed Unit Manager (UM) #1 on 1/29/19 at 1:25 P.M. UM #1 said that the facility staff have been trying to get ahead of the falls. We've tried stop signs with the resident. He/she takes alarms apart. UM #1 said that the resident requires assistance in the bathroom and the CNAs try to give the resident enough time to completely empty his/her bladder. The resident's impulsiveness. is usually when he/she is going to the bathroom. The resident is forgetful and the staff cannot rely on the resident to use the call bell which is why we we check on him/her her so often. The surveyor observed Resident #70 on 1/29/19 at 2:06 P.M. In his/her room, sitting in a reclining chair, with his/her glasses on the face. The resident wore slippers on with bare feet under the slippers, and did not wear non skid socks.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure that acceptable standards of practice were followed when on 12/3/16, Nurse #2, who was not assigned to the care of Resident #1, incorrectly appled an instant hot pack, and without a physician's orders [REDACTED]. Resident #1 sustained a burn to his/her right axilla and right breast. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. The Facility Policy, titled Compress - Heat pack/Warm Compress, Use of revision date 11/1/11, indicated to apply instant heat packs as ordered by the physician, to wrap pack in towel, and to monitor the resident during and after treatment for [REDACTED]. The Record of Admission, dated 2/6/15, indicated Resident #1's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 11/02/16, indicated that on a Brief Interview of Mental Status (BIMS) Resident #1 scored 8 (score 1-15), which indicated he/she was cognitively impaired. An Accident/Incident Report, and Investigation Summary, dated 12/3/16, indicated Resident #1 had a subnormal temperature, hot packs were placed under Resident #1's bilateral arms in an attempt to raise his/her temperature, approximately 15 minutes later staff went to check on Resident #1 and he/she was discovered to [MEDICAL CONDITION] his/her right upper arm and right breast. The Physician was notified and treatment orders were given. There was no documentation to indicate Resident #1 had a physician's orders [REDACTED]. Instant Hot Compress instructions, printed directly on the instant hot pack, indicated to wrap the hot compress bag in a soft cloth or towel and cautioned that peak temperature may reach 160 degrees Fahrenheit once activated, to avoid contact to skin, and to use a cloth or towel for protection. A Pain Assessment, dated 12/3/16, indicated Resident #1 had a pain score of 2 (score 0-10), indicated mild pain to his/her right upper inner arm. The Skin Condition Record, dated 12/3/16, indicated Resident #1 had a 12 centimeters (cm) by 4cm intact blistered area on his/her right upper inner arm. The Skin Condition Report dated 12/4/16, indicated a 2cm by 1cm intact blister on Resident #1's right breast. A Progress Note, dated 12/6/16, indicated Resident #1 had a burn to the right axilla/breast area after a hot pack treatment and the area was being treated with [MEDICATION NAME] cream. The Surveyor interviewed Nurse #1 at 1:16 P.M. on 1/20/17. Nurse #1 said she was Resident #1's primary nurse on 1/23/17. Nurse #1 said Resident #1 became lethargic, shaking, and was noted to have a rectal temperature of 94.7 degrees Fahrenheit (normal temperature is 97.1 to 99.2 degrees Fahrenheit). Nurse #1 said these were typically signs and symptoms which Resident #1 displayed whenever he/she was feeling unwell. Nurse #1 said she covered Resident #1 with blankets, adjusted the heat thermometer in his/her room, and placed a call to the Physician. Nurse #1 said Nurse #2 overheard her conversation regarding Resident #1's low temperature, and said that Nurse #2 told her that in the past she (Nurse #2) had placed hot packs under residents arms to raise a temperature, and this worked, or words to that effect. Nurse #1 said she told Nurse #2 no and that she would wait for the Physician to call back. Nurse #1 said when the Physician called back she obtained orders for a chest x-ray and to monitor Resident #1's temperatures every shift. Nurse #1 said she then went to pass a few supper trays, and when she went back to check on Resident #1 she noticed the bed sheets had been moved and saw a hot pack, with no covering, under each of Resident #1's arms. Nurse #1 said Resident #1 was sleeping, and she carefully tried to remove the hot packs. Nurse #1 said the hot pack under Resident #1's right arm was directly on the skin and was difficult to remove, and Resident #1 began to moan and said ouch or words to the effect. Nurse #1 said she immediately applied cool compresses under Resident #1's arm, administered Resident #1 his/her prn (as needed) Tylenol and notified the Physician. Nurse #1 said she did not know Nurse #2 had put the hot packs on Resident #1 and did not know how long the hot packs were in place. The Surveyor interviewed Certified Nursing Assistant (CNA) #1 at 1:41 P.M. on 1/23/17. CNA #1 said she heard the conversation between Nurse #1 and Nurse #2 regarding Resident #1's low temperature. CNA #1 said she heard Nurse #2 tell Nurse #1 that she had placed hot packs in residents armpits before to raise their temperature. CNA #1 said she heard Nurse #1 tell Nurse #2 that Resident #1 had run low temperatures in the past and that should wait for the Physician to call her back. CNA #1 said a little while later Nurse #1 called her down to Resident #1's room and asked if she knew who had placed hot packs under Resident #1's arms. CNA #1 said she told Nurse #1 that she had no idea who put the hot packs under Resident #1's arms. The Surveyor interviewed Nurse #2 at 12:17 P.M. on 1/23/17. Nurse #2 said she was not Resident #1's primary nurse on 1/23/17. Nurse #2 said she applied the instant hot packs to Resident #1's bilateral axilla areas in the attempt to raise Resident #1's temperature, or words to that effect. Nurse #2 said she did not read the instructions that were printed on the instant hot packs, did not wrap the instant hot packs in a cloth or towel before placing them under Resident #1's arms, she did not have an order from the physician to apply the instant hot packs, and she did not check Resident #1 after applying the instant hot packs.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure an instant hot pack was applied correctly to Resident #1's bilateral axilla (armpit) areas, and Resident #1 sustained a burn to his/her right axilla and breast area. Findings include: Findings include: The Facility Policy, titled Compress - Heat pack/Warm Compress, Use of revision date 11/1/11, indicated to apply instant heat packs as ordered by the physician, to wrap pack in towel, and to monitor the resident during and after treatment for [REDACTED]. The Record of Admission, dated 2/6/15, indicated Resident #1's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 11/02/16, indicated that on a Brief Interview of Mental Status (BIMS) Resident #1 scored 8 (score 1-15), which indicated he/she was cognitively impaired. An Accident/Incident Report, and Investigation Summary, dated 12/3/16, indicated Resident #1 had a subnormal temperature, hot packs were placed under Resident #1's bilateral arms in an attempt to raise his/her temperature, approximately 15 minutes later staff went to check on Resident #1 and he/she was discovered to have burns on his/her right upper arm and right breast. The Physician was notified and treatment orders were given. Instant Hot Compress instructions, printed directly on the instant hot pack, indicated to wrap the hot compress bag in a soft cloth or towel and cautioned that peak temperature may reach 160 degrees Fahrenheit once activated, to avoid contact to skin, and to use a cloth or towel for protection. The Skin Condition Record, dated 12/3/16, indicated Resident #1 had a 12cm (centimeter) by 4cm intact blistered area on his/her right upper inner arm. The Skin Condition Report dated 12/4/16, indicated a 2cm by 1cm intact blister on Resident #1's right breast. A Progress Note, dated 12/6/16, indicated Resident #1 had a burn to the right axilla/breast area after a hot pack treatment and the area was being treated with Silvadene cream. The Surveyor interviewed Nurse #1 at 1:16 P.M. on 1/20/17. Nurse #1 said she was Resident #1's primary nurse on 1/23/17. Nurse #1 said Resident #1 became lethargic, shaking, and was noted to have a rectal temperature of 94.7 degrees Fahrenheit (normal temperature is 97.1 to 99.2 degrees Fahrenheit). Nurse #1 said these were typically signs and symptoms which Resident #1 displayed whenever he/she was feeling unwell. Nurse #1 said Nurse #2 told her that in the past she (Nurse #2) had placed hot packs under residents arms to raise a temperature, and this worked, or words to that effect. Nurse #1 said she told Nurse #2 no, and called the Physician and obtained orders for a chest x-ray and to monitor Resident #1's temperatures every shift. Nurse #1 said when she later went back to check on Resident #1 she noticed the bed sheets had been moved and saw a hot pack, with no covering, under each of Resident #1's arms. Nurse #1 said Resident #1 was sleeping, and she carefully tried to remove the hot packs. Nurse #1 said the hot pack under Resident #1's right arm was directly on the skin and was difficult to remove, and Resident #1 began to moan and said ouch or words to the effect. Nurse #1 said she immediately applied cool compresses under Resident #1's arm, administered Resident #1 his/her prn (as needed) Tylenol and notified the Physician. Nurse #1 said she did not know Nurse #2 had put the hot packs on Resident #1 and did not know how long the hot packs were in place. The Surveyor interviewed Nurse #2 at 12:17 P.M. on 1/23/17. Nurse #2 said she was not Resident #1's primary nurse on 1/23/17. Nurse #2 said she applied the instant hot packs to Resident #1's bilateral axilla areas in the attempt to raise Resident #1's temperature, or words to that effect. Nurse #2 said she did not read the instructions that were printed on the instant hot packs, did not wrap the instant hot packs in a cloth or towel before placing them under Resident #1's arms, she did not have an order from the physician to apply the instant hot packs, and she did not check Resident #1 after applying the instant hot packs.

Based on observation, interview and record review the facility failed to follow the written care plan and/or Physician's order for 3 of 24 sampled residents (#5, #6 and #15). Findings include: 1. For Resident #5, the facility failed to follow the resident's care plan for supervision at all meals which resulted in a fall with injury. Resident #5 was admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. Review of the care plan in effect (2/21/15 after the unwitnessed fall), indicated the resident was a high fall risk related to a history of falls, poor safety awareness, weakness and psych medication. The goal was to have no fall-related injuries. The interventions included: -Be aware of resident's fall risk, -Provide verbal cues for safety and sequencing when needed, -Assist resident in transfers as needed sit to stand while encouraging resident to do as much as possible, Additionally, a Nutrition Care Plan, dated 2/23/15, related to weight loss and a history of dysphagia (impaired swallowing), had the goal to maintain the resident's weight and have no signs or symptoms of aspiration. The intervention stressed the resident was to have supervision with meals/eating. The resident's current Care Card also indicated the resident was to be supervised for all meals. Review of the Progress Note, Accident Report and Post Fall Investigation of 5/2/15 indicated the resident was complaining of hip pain, was given pain medication at 12:00 P.M., brought back to room and placed in bed. Staff brought the resident a lunch tray (time unknown) and left the resident alone without the required meal supervision. At 12:30 P.M., staff heard the resident's roommate yell for help. Staff observed the resident on the floor face down. The resident was observed to have a hematoma on the forehead with a small contusion on the nose and bleeding from the nostrils. The resident's lunch tray and bedside table were pushed forward when the resident fell off the side of the bed. The resident was sent to the local hospital and found to have a fractured nose. Observation of the resident on 6/1/15 at 3:25 P.M. and 10:12 A.M. found the resident seated in a wheelchair at the nursing station with right facial bruising. At 4:00 P.M., the resident was observed seated in the wheelchair asleep at the end of the unit corridor. On 6/2/15 at 10:00 A.M., the resident was observed at the end of the unit corridor asleep in the wheelchair. At 12:15 P.M., the resident was observed in the main dining room being supervised by staff for the lunch meal. During interview on 6/3/15 at 3:35 P.M., the Director of Nursing said that the care plan intervention of staff supervision during meals was not followed which contributed to the resident's unwitnessed and injurious bedroom fall of 5/2/15. Please refer to F 323. 2 a. For Resident #6, the facility failed to follow the Nutrition and Hydration care plan for an assistive drinking device (a sippy lid for drinking fluids). Resident #6 was admitted to the facility in 3/2014 with the following pertinent diagnoses; Dementia, left [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the Nutrition and Hydration Care Plan, revised 5/26/15, indicated this Resident has cognitive impairment and has a history of significant weight loss. One of the interventions was to have a sippy lid on his/her fluids for meals. Observations on 6/1/15 at 12:45 P.M., found this Resident eating lunch in the Unit 1 Dining Room. There was no sippy lid on the milk or cranberry juice. Observation on 6/2/15 at 8:35 A.M. and at 9:00 A.M., found this Resident eating breakfast. There was no sippy lid on the milk. Observation on 6/3/15 at 8:22 A.M., found this Resident set up by a Certified Nursing Assistant for breakfast with no sippy lid on the coffee or juice. During an interview at this time Unit Manager #1 said, (This Resident) should have a sippy lid (for drinking fluids). b. For Resident #6, the facility omitted 5 doses of this Resident's [MEDICATION NAME] (antibiotic) eye drops. Review of the Physician's order of 3/9/15 indicated [MEDICATION NAME] Ophthalmic ointment was to be applied to this Resident's right eye daily ([MEDICATION NAME] for chronic [MEDICAL CONDITION]). Review of the Medication Administration Record [REDACTED] - On 3/14/15 - On 4/17/15 and 4/29/15 - On 6/1/15 and 6/2/15 During an interview with Unit Manager #1 on 6/3/15 at 2:40 P.M., she said that the antibiotic eye drops were not documented as being given, and she would fill out medication error reports. 3. For Resident #15, the facility failed to follow the Physician's order to have air boots on at all times. Resident #15 was admitted to the facility in 4/2014 with the following pertinent diagnoses; Dementia, cerebro-vascular accident with left [MEDICAL CONDITION]. Review of the Physician's order of 3/15/15 indicated that this Resident was to have air boots on at all times. On 6/4/15 from 8:00 A.M. to 8:25 A.M., the Surveyor observed this Resident in the Dining Room on Unit 1 in a recliner chair with only non-skid socks on. This Resident's heels were pressing into the padded foot rest. There were no air boots on to off load the heels. On 6/4/15 at 8:36 A.M., the Surveyor observed Resident #15 in the Whirlpool Room with Nurse #2. No air boots were on and this Resident's heels were pressing into the foot rests. On 6/4/15 at 8:40 A.M., Resident #15's air boots were on. The Surveyor asked Certified Nursing Assistant #3, Did you just put this Resident's air boots on? She said, Yes I did. The Surveyor said, (Resident #15) did not have the air boots on previously, and she said, They weren't on. The Surveyor said, Are they supposed to be on while (he/she) is out of bed in that chair? She said, Yes. The Surveyor asked, Did (he/she) refuse to have them on? She said, No, the night shift got (him/her) up at 7:00 A.M. without the boots on. During an interview on 6/4/15 at 8:50 A.M. with Nurse #2, the Surveyor asked., Is this the current physician's order for what should be on the Resident's feet? She reviewed the physician's order with the Surveyor and said, (He/she) should have the air boots on while out of bed.

Based on record review, staff interview and observations, the facility failed to ensure that 2 sampled resident out of 9 with falls (#5 and #18) out of a total sample of 24 residents received adequate supervision to prevent accidents. Findings include: 1. For Resident #5, the facility failed to ensure that the resident received necessary supervision during a meal to prevent an unwitnessed fall with a fractured nose. Resident # 5 was admitted to the facility in 9/2011 with [DIAGNOSES REDACTED]. Clinical Record documentation indicated the resident had three unwitnessed falls in the resident's bedroom on 6/8/14, 6/13/14, and 2/21/15 without injury, when trying to transfer from either the bed or wheelchair without assistance. Review of the Quarterly MDS Assessment, dated 8/28/14, indicated the resident was inaccurately coded as having no falls. Review of the care plan of 2/21/15 indicated the resident was a high fall risk related to a history of falls, poor safety awareness, weakness and psych medication. The goal was to have no fall-related injuries. The interventions included: -Be aware of resident's fall risk, -Provide resident education on safe techniques, -Provide call light in reach at all times, -Insure proper footwear is in use before rising, -Remind resident to use call bell when attempting to ambulate or transfer, -Answer call bells promptly, -Maintain a clutter-free environment, -Keep personal items within reach, -Abide by resident's lighting needs (was unspecified), -Provide verbal cues for safety and sequencing when needed, -Assist resident in transfers as needed sit to stand while encouraging resident to do as much as possible, -Assist resident in ambulation, as necessary, -Follow toileting schedule, -Encourage resident to attend all activities, -Bed to low position, -Bed in highest position when resident not in bed, -and Resident education. Additionally, a Nutrition Care Plan, dated 2/23/15, related to weight loss and a history of dysphagia (impaired swallowing), had the goal to maintain the resident's weight and have no signs or symptoms of aspiration. The intervention stressed the resident was to have supervision with meals/eating. The resident's current Care Card also indicated the resident was to be supervised for all meals. Review of the quarterly Minimum Data Set (MDS) review of 2/25/15 indicated the resident was cognitively intact (Brief Interview for Mental Status (BIMS) of 15), had disorganized thinking, was dependent for transfers, dressing, hygiene, bathing, required extensive assist for ambulation (wheelchair), required supervision for eating, had no balance, except for surface to surface transfers and then was unsteady, was incontinent of bladder, inaccurately coded no falls since the prior assessment, and was administered antipsychotic medication daily. Review of the Progress Note, Accident Report and Post Fall Investigation of 5/2/15 indicated the resident was complaining of hip pain, was given pain medication at 12:00 P.M., brought back to room and placed in bed. Staff brought the resident a lunch tray (time unknown) and left the resident alone without the required meal supervision. At 12:30 P.M., staff heard the resident's roommate yell for help. Staff observed the resident on the floor face down. The resident was observed to have a hematoma on the forehead with a small contusion on the nose and bleeding from the nostrils. The resident's lunch tray and bedside table were pushed forward when the resident fell off the side of the bed. The resident was sent to the local hospital and found to have a fractured nose. The facility's investigation was unable to determine who and at what time the resident's lunch tray was brought to the resident's room when the resident experienced a 4th unwitnessed fall in the bedroom. The falls care plan was updated on 5/21/15 with the intervention of staff education, and that, if the resident eats in the bedroom, whoever brings the tray must stay with the resident (for meal supervision) Observation of the resident on 6/1/15 at 3:25 P.M. and 10:12 A.M. revealed the resident seated in a wheelchair at the nursing station with right facial bruising. At 4:00 P.M., the resident was observed seated in the wheelchair asleep at the end of the unit corridor. On 6/2/15 at 10:00 A.M., the resident was observed at the end of the unit corridor asleep in the wheelchair. At 12:15 P.M., the resident was observed in the main dining room being supervised by staff for the lunch meal. During interview on 6/3/15 at 3:35 P.M., the Director of Nursing said that the care plan intervention of staff supervision during meals was not followed which contributed to the resident's unwitnessed and injurious bedroom fall of 5/2/15. 2. For Resident #18, the Facility failed to provide adequate supervision and assistive devices to prevent 8 falls including 6 unwitnessed falls. For 4 of the unwitnessed falls, the resident attempted to sit in a chair and missed the chair. Resident #18 was admitted to the Facility in 8/2014 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) Assessment, dated 9/1/14, indicated that the resident was severely cognitively impaired as evidenced by a score of 3 out of a 15 on the Brief Interview for Mental Status (BIMS), required supervision for transfers and ambulation, and had no falls since admission. Review of the falls care plan, dated 9/17/14, included the following interventions: - Call light within reach at all times. - Assist in transfers as needed, while allowing him/her to do as much as possible. - Assist in ambulation as needed, while allowing him/her to do as much as possible. Review of the nurse's note and fall investigation, dated 10/27/14, indicated that the resident was found sitting on the floor in front of a reclining chair, in the hallway. The resident indicated that he/she tried to sit in the chair but missed the chair and lowered himself/herself to the floor. The resident did not sustain an injury and the fall was unwitnessed. The recliner chair was moved out of the hallway. Review of the falls care plan indicated that the care plan was updated on 10/27/14 to include the following intervention: - Redirect the resident to activities after breakfast. Review of the nurse's note and the facility's investigation, dated 11/14/14, indicated that at 11:30 P.M., the resident was found on the floor next to his/her bed. The side rail was not in place. The fall was unwitnessed and the resident did not sustain an injury. Review of the falls care plan indicated that the care plan was updated on 11/14/14 to include the following intervention: - Side Rail in place. Review of the quarterly MDS Assessment, dated 11/19/14, indicated that the resident was severely cognitively impaired as evidenced by a score of 3 out of a 15 on the BIMS, required extensive assistance for transfers, supervision for ambulation, and 2 or more falls with no injury since the last assessment. Review of the nurse's note and fall investigation, dated 11/22/14, indicated that at 10:30 A.M., the resident was found sitting on the on the foot pedal of a wheelchair, in the hallway. The resident appeared to have attempted to sit in the chair but missed the chair. The resident did not sustain an injury and the fall was unwitnessed. Review of the falls care plan indicated that the care plan was updated on 11/22/14 to include the following intervention: - Move clutter from hallway. Review of the quarterly MDS Assessment, dated 2/16/15, indicated that the resident was severely cognitively impaired as evidenced by a score of 2 out of 15 on the BIMS, required extensive assistance for transfers, required supervision for ambulation in his/her room, was independent with ambulation in the hallway, and had 2 or more falls with no injury since the last assessment. Review of the nurse's note and the facility's investigation, dated 3/5/15, indicated that at 7:15 P.M., during the medication pass, the nurse heard a crash. The resident was found on the floor behind the nurse's station. The resident appeared to have attempted to sit on a stool and slipped. The fall was unwitnessed, and the resident did not sustain an injury. Review of the falls care plan indicated that the care plan was updated on 3/5/14 to include the following intervention: - Staff education. Review of the nurse's note and the facility's investigation, dated 3/18/15, indicated that at 6:10 P.M., the resident was found on the floor in the hallway. The resident appeared to have attempted to sit in in a wheelchair and missed the chair. The fall was unwitnessed and the resident did not sustain an injury. Review of the falls care plan indicated that the care plan was updated on 3/18/14 to include the following intervention: - Lay down after lunch as the resident will allow. Review of the nurse's note and the facility's investigation, dated 4/13/15, indicated that at 5:00 A.M., the resident was found with his/her upper body on the floor and lower body on the bed. The resident sustained [REDACTED]. The fall was unwitnessed. Review of the falls care plan indicated that the care plan was updated on 4/13/14 to include the following intervention: - Scoop mattress (a mattresses with the sides slightly raised to prevent falling out of a bed). Review of the nurse's note and the facility's investigation, dated 4/29/15, indicated that at 7:10 P.M., the resident was witnessed bending down to touch an object on the floor and falling to his/her knees. The resident did not sustain an injury. Review of the nurse's note and the facility's investigation, dated 5/5/15, indicated that at 6:30 A.M., a Certified Nurse Aide (CNA) brushed the resident's hair while the resident was in a standing position. The resident lost his/her balance and fell to the floor. Review of the falls care plan indicated that the care plan was updated on 5/5/15 to include the following intervention: - Staff education. The Surveyor observed Resident #18 on 6/4/15 at 1:20 P.M. Resident #18 was walking in the hallway from the main dining room. A staff member was walking with the resident. During an interview with Unit Manager #1 and Nurse #3 on 6/4/15 at 2:25 P.M., Nurse #3 said that the resident falls when he/she is tired and 4 of the falls occurred when the resident appeared to have attempted to sit on a chair and missed the chair. Unit Manager #1 also said that the resident may fall when he/she is tired.

Based on record review and interview, for one of five sampled Residents (Resident #1) the Facility failed to ensure a safe transfer by mechanical lift when Certified Nurse Aide (CNA) #1 and CNA #2 used an extra large sling instead of the medium sling required for Resident #1.CNA #1 and CNA #2 also incorrectly attached the sling and as a result, Resident #1 fell out of the sling and sustained a small subarachnoid and subdural bleed in the right temporal region of the head. Findings included: Resident #1 was admitted to the Facility in April 2004, with [DIAGNOSES REDACTED]. A review of a CNA care card, dated 11/29/10, indicated Resident #1 was totally dependent on staff for transfers using a mechanical lift. The CNA care card did not indicate what type of lift sling or what size lift sling should be used for Resident #1. A review of an ADL (activities of daily living) care plan, last updated on 3/16/11, indicated Resident #1 was totally dependent on staff for all ADLs related to a cerebrovascular accident with left [DIAGNOSES REDACTED]. Care plan interventions included using a mechanical lift for transfers. The care plan did not indicate what type of lift sling or what size lift sling should be used for Resident #1. A quarterly Minimum Data Set (MDS) assessment, dated 6/7/11, indicated Resident #1 only sometimes understood others and was only sometimes understood by others. The MDS indicated Resident #1 had impaired long term memory and impaired short term memory. The MDS indicated Resident #1 was totally dependent on staff for bed mobility, transfers, dressing, locomotion, toilet use, and personal hygiene. The MDS indicated Resident #1 weighed 120 pounds. An undated SBAR (situation, background, assessment, and request) nurse's note indicated Resident #1 fell on to the floor during a transfer with a mechanical lift and was unresponsive for one minute after the fall. The nurse's note indicated Resident #1 then complained of back pain and a physician's orders [REDACTED]. The nurse's note indicated Resident #1 was kept on the floor until the ambulance arrived. A review of an incident report (for clarification), dated 8/27/11, indicated at 9:20 P.M. Resident #1 was being transferred from wheelchair to bed with a mechanical lift and slid out of the sling onto the floor. The incident report indicated Resident #1 was in the sling approximately four feet above the floor when Resident #1 fell out of the sling and onto the floor. CNA #1 was interviewed at 3:05 P.M. on 9/30/11. CNA #1 said CNA #1 and CNA #2 brought the mechanical lift into Resident #1's room and placed the lift next to Resident #1's wheelchair. CNA #1 said Resident #1 was seated in the wheelchair and there was a split leg sling already under Resident #1. CNA #1 said CNA #1 had never been trained to use the split leg sling, they used the sling because it was already under Resident #1. CNA #1 said the sling was also too big for Resident #1. CNA #1 said they crossed the leg straps under Resident #1's legs (which was incorrect) and attached the sling to the mechanical lift the way they believed it should be attached. CNA #1 said CNA #2 worked the mechanical lift and CNA #1 moved around to hold Resident #1, but before CNA #1 could get around, Resident #1 fell out of the sling. CNA #1 said CNA #2 tried to catch Resident #1, but it happened so fast CNA #2 did not have time to catch Resident #1. CNA #1 said CNA #1 did not observe the fall. because CNA #1 was in the process of moving around the lift. CNA #1 said Resident #1 just fell out of the sling onto the floor. CNA #1 said CNA #1 did not know how Resident #1 hit the floor and could not recall how Resident #1 was lying on the floor. CNA #2 was interviewed at 3:40 P.M. on 9/30/11. CNA #2 said Resident #1 was on CNA #2's assignment during the 3:00 P.M. to 11:00 P.M. shift on 8/27/11. CNA #2 said Resident #1 had been up in the wheelchair since the beginning of the shift and needed to be transferred into bed. CNA #2 said a split leg sling was already under Resident #1 in the wheelchair and the sling was very large for Resident #1, but they used the sling anyway. CNA #2 said CNA #2 had never been inserviced on the split leg sling. CNA #2 said CNA #2 was not sure how to attach the sling, but it never occurred to CNA #2 to ask someone to help with the sling. CNA #2 said CNA #2 and CNA #1 crossed the ends of the sling under Resident #1's legs, not over the legs as it was supposed to be attached. CNA #2 said CNA #2 operated the mechanical lift. CNA #2 said CNA #2 raised the lift, then pulled the lift back, and pushed the lift towards Resident #1's bed. CNA #2 said when they got the lift near the bed, CNA #2 looked down to maneuver the legs of the lift under the bed, and out of the corner of CNA #2's eye, CNA #2 observed Resident #1 fall out of the sling. CNA #2 said CNA #2 did not observe how Resident #1 fell out of the sling and did not know if Resident #1 fell head first or feet first onto the floor. CNA #2 said CNA #2 believed Resident #1 was either on Resident #1's back on the floor of in kind of a C position on the side. CNA #2 said CNA #2 did not observe Resident #1's impact on the floor and was not sure if CNA #2 heard a thud when Resident #1 hit the floor. CNA #2 said when CNA #2 spoke to Resident #1, Resident #1 was not responsive for about 20 to 30 seconds, but then Resident #1 started to talk. CNA #2 said CNA #2 told CNA #1 to go get the nurse. CNA #2 said while speaking to the nurse, Resident #1, said Resident #1's neck and back hurt. Nurse #1 was interviewed at 2:50 P.M. on 9/30/11. Nurse #1 said Nurse #1 was doing a medication pass when CNA #1 came and told Nurse #1 about the fall. Nurse #1 said Nurse #1 went to the room and Resident #1 was on the floor on Resident #1's back. Nurse #1 said Resident #1 was conscious when Nurse #1 got to the room. Nurse #1 said Resident #1 complained about being cold and complained of back pain. Nurse #1 said Resident #1 wanted to get up off the floor, but was kept on the floor until the ambulance arrived, because of the possibility of back injury. Nurse #1 said Nurse #1 asked CNA #1 and CNA #2 how they hooked the sling to the mechanical lift, but all they said was that Resident #1 was secure in the lift. Nurse #1 said Nurse #1 asked the two CNA's several times how they attached the sling and never got a straight answer from them. Nurse #1 said after Resident #1 left by ambulance, Nurse #1 looked at the sling, which was still on the mechanical lift and the sling was attached to the lift incorrectly. The Unit Manager was interviewed at 12:20 P.M. on 9/30/11. The Unit Manager said the correct size for mechanical lift slings was determined based on the manufacturer's recommendation. The Facility provided the Surveyor with the Manufacturer's literature for the type of mechanical lift used to transfer Resident #1. According to the Manufacturer's literature, a medium sling should be used on a resident that weighed from 100 to 175 pounds (Resident #1 weighed 120 pounds per the MDS). The Director of Nursing (DON) was interviewed at 1:20 P.M. on 9/30/11. The DON said after the incident, the mechanical lift complete with the sling in place was brought into the DON's office. The DON said the sling was incorrectly attached to the lift and the sling was an extra large sling. A review of the Hospital medical record, dated 8/28/11, indicated Resident #1 arrived at the emergency department after falling from a mechanical lift while approximately 3 to 4 feet above the floor. The Hospital Medical Record indicated Resident #1 had a brief loss of consciousness. The Hospital medical record indicated Resident #1 had some baseline dementia and had no memory of the fall. The Hospital medical record indicated Resident #1 had a posterior scalp hematoma. The Hospital medical record indicated two computed tomography (CT) scans of Resident #1's brain were obtained. A CT scan, dated 8/27/11, indicated suggestion of a small subarachnoid and subdural bleed at the right temporal convexity and right cephalhematoma. A CT scan, dated 8/28/11, indicated a slight increase in prominence of petechial hemorrhage and subdural blood in the right temporal region. The CT scan on 8/28/11 indicated the findings were more prominent than on the previous day. A nurse's note, dated 8/28/11 at 10:00 A.M. indicated Resident #1 returned to the Facility via ambulance. The Surveyor attempted to interview Resident #1 at 1:10 P.M. on 9/30/11; however, Resident #1 was unable to answer questions appropriately and was unable to participate in the interview. Refer to F 498.

Based on record review and interview, for one of five sampled Residents (Resident #1) the Facility failed to ensure that staff were properly trained to use the split leg type sling for the mechanical lift. Specifically, Certified Nurses Aide (CNA) #1 and CNA #2 failed to use the correct size sling and failed to correctly attach the sling to the mechanical lift and as a result, Resident #1 fell out of the sling and sustained a small subarachnoid and subdural bleed in the right temporal region. Findings included: Resident #1 was admitted to the Facility in April 2004, with [DIAGNOSES REDACTED]. A CNA care card, dated 11/29/10, indicated Resident #1 was totally dependent on staff for transfers using a mechanical lift and an ADL (activities of daily living) care plan, last updated on 3/16/11, also indicated Resident #1 required a mechanical lift for transfers; however, neither the care plan nor the CNA care card indicated what type of lift sling or what size lift sling should be used for Resident #1. A quarterly Minimum Data Set (MDS) assessment, dated 6/7/11, indicated Resident #1 only sometimes understood others and was only sometimes understood by others. The MDS indicated Resident #1 had impaired long term memory and impaired short term memory. The MDS indicated Resident #1 was totally dependent on staff for bed mobility, transfers, dressing, locomotion, toilet use, and personal hygiene. The MDS indicated Resident #1 weighed 120 pounds. An undated SBAR nurse's note indicated Resident #1 fell on to the floor during a transfer with a mechanical lift and was unresponsive for one minute after the fall. An incident report (for clarification), dated 8/27/11, indicated at 9:20 P.M. Resident #1 was being transferred from wheelchair to bed with a mechanical lift and slid out of the sling onto the floor. The incident report indicated Resident #1 was in the sling approximately four feet above the floor when Resident #1 fell out of the sling and onto the floor. CNA #1 was interviewed at 3:05 P.M. on 9/30/11. CNA #1 said Resident #1 was seated in the wheelchair and there was a split leg sling already under Resident #1. CNA #1 said CNA #1 had never been trained to use the split leg sling, but they used the sling because it was already under Resident #1. CNA #1 said the sling was also too big for Resident #1. CNA #1 said they crossed the leg straps under Resident #1's legs (which was incorrect) and attached the sling to the mechanical lift the way they believed it should be attached. CNA #1 said Resident #1 fell out of the sling. CNA #1 said this was CNA #1's first job as a CNA and CNA #1 had been trained how to operate the mechanical lift with a full body sling and a shower sling, but CNA #1 had never been trained to use the split leg sling. CNA #1 said after the incident, CNA #1 received education on how to use the split leg sling. CNA #2 was interviewed at 3:40 P.M. on 9/30/11. CNA #2 said a split leg sling was already under Resident #1 in the wheelchair and the sling was very large for Resident #1, but they used the sling anyway. CNA #2 said CNA #2 had never been inserviced on the split leg sling. CNA #2 said CNA #2 was not sure how to attach the sling and it never occurred to CNA #2 to ask someone to help with the sling. CNA #2 said CNA #2 and CNA #1 crossed the ends of the sling under Resident #1's legs, not over the legs as it was supposed to be attached (which CNA #2 learned later). CNA #2 said Resident #1 fell out of the sling. CNA #2 said CNA #2 was used to working with the full body sling, and was not familiar with the split leg sling. CNA #2 said CNA #2 had worked at the Facility for several years, but had never been inserviced on the split leg sling. The Director of Nursing was interviewed at 1:20 P.M. on 9/30/11. The Director of Nursing said the sling was incorrectly attached to the lift and the sling was an extra large sling, not the medium size sling required for Resident #1. The Staff Development Coordinator (SDC) was interviewed at 12:35 P.M. on 9/30/11. The SDC said during orientation the SDC discussed the operation of the mechanical lift, but did not go over slings, because a preceptor went over the actual operation of the lift with orientees. The SDC said they mostly used a full body sling not the split leg sling, so staff were only oriented on the full body sling. The SDC said the Facility completed competency on the mechanical lift yearly, but that did not include the split leg sling. A review of the Hospital medical record, dated 8/28/11, indicated Resident #1 arrived at the emergency department after falling from a mechanical lift while approximately 3 to 4 feet above the floor. The Hospital medical record indicated Resident #1 had a posterior scalp hematoma and CT scans completed on 8/27/11 and 8/28/11, showed a small subarachnoid and subdural bleed at the right temporal convexity and a right cephalhematoma. Refer to F 323.