Every finding on record at Fitchburg Healthcare

Based on observations, interviews, and record review, for one Resident (#43) out of a total sample of 27 residents, the facility failed to provide effective pain management consistent with professional standards of practice, resulting in persistent pain, inability to sleep, and inability to participate in scheduled occupational therapy (OT) sessions for the Resident. Specifically, the facility failed to: -ensure that an order from the Nurse Practitioner (NP) to administer Oxycodone (opioid pain medication) IR (immediate release) to the Resident every six hours as needed (PRN) for pain was implemented and administered when previous scheduled and PRN Oxycodone orders were ended/stopped. -communicate recommendations for pain management received from the Resident's Palliative Care Team on 2/4/26 to the Physician/NP until 2/6/26. -coordinate with the Physician/NP for alternative pain management instructions and medications when the Resident reported persistent pain [at a pain level of six out of 10] after he/she was administered PRN Oxycodone and the scheduled Oxycodone doses were not delivered to the facility from the pharmacy. Findings include: Resident #43 was admitted to the facility for short term rehabilitation and ordered for scheduled Oxycodone HCl Oral Tablet 7.5 mg tablet by mouth two times a day for pain for five days, effective 1/31/26 and Oxycodone HCl Oral Tablet 5 mg, every six hours PRN for pain for five days, effective 1/30/26 for Stage Four cancer. On 2/2/26, the NP assessed Resident #43 and wrote an order to continue (not to end after five days) the Resident's PRN Oxycodone. The NP order to continue the PRN Oxycodone was not entered into the computer until 10:45 A.M. on 2/5/26 (three days after the order was written) resulting in the scheduled and PRN Oxycodone orders ending on 2/4/26. On 2/4/26, Resident #43 received two 5 mg PRN Oxycodone doses (one at 12:03 A.M. and another at 4:54 P.M.), and the 9:00 A.M. scheduled 7.5 mg Oxycodone dose (total of three doses for 2/4/26). Resident #43 did not receive the 7.5 mg scheduled P.M. dose due to the order ending and no further PRN doses were administered after 4:54 P.M on 2/4/26. The Palliative Team Treatment Plan for Oxycodone medication was not addressed timely and when the Oxycodone PRN was resumed and reported by the Resident as not effective, the facility staff failed to contact the Provider for alternative instructions to manage the Resident's persistent pain. Resident #43's pain was not managed from 2/4/26 evening through 2/6/26, resulting in him/her experiencing persistent pain, inability to sleep, and unable to participate in scheduled occupational therapy (OT) sessions. Resident #43 was admitted to the facility in January 2026 with diagnoses including multiple sites of muscle wasting and atrophy, low back pain, malignant neuroendocrine tumors, and jejunal carcinoid tumor. Review of the facility's policy titled Pain Assessment and Management, dated April 2018 and last revised June 2025 indicated the following: -The purpose of the policy was to ensure pain management was provided to residents consistent with professional standards of practice, person centered care plan, and the resident goals and preferences. -Chronic pain refers to pain that typically lasts greater than three months and can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or unknown cause. -Strategies for pain management may include but are not limited to the following: -Assessing the potential for pain, recognizing the onset, presence and duration of pain, and assessing the characteristics of the pain. -Addressing/treating the underlying causes of the pain, to the extent possible. -Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on the resident specific assessment, preferences, and choices. -Monitoring appropriately for effectiveness . including defining how and when to monitor the resident's symptoms and degree of pain relief; and -Modifying the approaches, as necessary. Review of Resident #43's January 2026 Hospital Discharge Summary indicated: -was experiencing new right sided abdominal pain. -chronic pain conditions included spinal stenosis, cancer pain, constant headaches from a pituitary tumor, arthritis, and thoracotomy pain. -The Resident was medically cleared to go to short term rehab. -Start taking: -Oxycodone IR (immediate release) 15 milligram (mg) tablet (replaces Oxycodone 5 mg capsule). Take 0.5 tablet (7.5 mg total) by mouth two times a day for five days. Max daily amount: 15 mg. -Oxycodone IR 5 mg tablet (replaces Oxycodone 5 mg capsule). Take one tablet (5 mg) by mouth every six hours as needed (PRN) for pain for up to five days. Max daily amount: 20 mg. Review of the Minimum Data Set (MDS) Assessment, dated 2/5/26, indicated Resident #43: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. -never needed to have someone help him/her when reading instructions, pamphlets, or other written material from his/her doctor or pharmacy. -prior level of function was independent for self-care, indoor mobility, and cognitive function. -level of function at the time of the MDS Assessment was partial/moderate assistance for self-care and transfers, and supervision/touching assistance for walking ten feet. -received opioid medication. -received PT (physical therapy) and OT services. -had an active diagnosis of Cancer. -demonstrated rejection of care four to six days during the observation period. -reported having pain almost constantly over the five days previous to the Assessment observation period that: -made it hard to sleep. -limited the Resident's ability to participate in day-to-day activities. -reported his/her worst pain level on a zero to 10 scale over the previous five days was nine out of 10. Review of the Pain Care Plan, initiated 1/30/26 and revised 2/2/26, indicated Resident #43: -would not experience a decline in overall function related to pain through the next review (target date 4/30/26). -would be monitored for effectiveness . from routine and PRN pain medication. -would have a referral made to the Resident's Physician to consider pre-medication for pain prior to treatments to optimize participation. -would be observed for pain and Provider updated as warranted. -changes in pain location/type, frequency/intensity would be reported to the Physician. Review of the Initial Interdisciplinary Care Meeting Note, dated 2/4/26, indicated Resident #43: -was present for the meeting. -goal was to work with Physical Therapy (PT) and Occupational Therapy (OT) to gain strength and return home. -had Palliative Care in place for a diagnosis of Stage Four Cancer. -medications were reviewed. Review of Resident #43's January 2026 Physician Orders indicated: -Acetaminophen Oral Tablet 325 milligrams (mg), give three tablets by mouth every six hours related to other low back pain, start 1/31/26. -Acetaminophen Tablet 650 mg, give 650 mg by mouth every six hours as needed for pain ., start 1/30/26. -Lidocaine External Patch 5 percent (%), apply to lower back topically one time a day related to other low back pain ., start 1/31/26. -Oxycodone HCl Oral Tablet 15 mg, give 0.5 tablet (7.5 mg) by mouth two times a day for pain for five days, ordered 1/30/26, start 1/31/26. -Oxycodone HCl Oral Tablet 5 mg, give one tablet by mouth every six hours as needed for pain for five days, start 1/30/26. -Pregabalin (anticonvulsant) Oral Capsule 75 mg, give two capsules by mouth two times a day related to other low back pain, start 1/31/26. Review of Resident #43's Nurse Practitioner (NP) Progress Note, effective 2/2/26, indicated:-chief complaint was neck pain and weakness.-has chronic pain from spinal stenosis and thoracotomy pain.-reports back pain that was worse with movement and relieved with pain medications.-was on Oxycodone 7.5 mg twice a day for five days and Oxycodone 5 mg three times a day. -The NP and Resident discussed evaluating whether the Resident's pain could be managed on 5 mg Oxycodone every six hours as needed (PRN).-The assessment and plan included: -Continue with PT and OT for generalized weakness. -Continue Oxycodone, changed to 5 mg every six hours as needed (PRN), . for chronic pain disorder. -Will evaluate if new pain regimen is working. Review of Resident #43's Physician Progress Note, effective 2/4/26, indicated to continue Oxycodone for chronic pain. Review of the Palliative Care Physician Note, dated 2/4/26 and faxed to the facility on 2/4/26 at 3:35 P.M. indicated Resident #43: -was under the medical care of the Palliative Care Physician. -suffered from chronic pain which was primarily musculoskeletal. -had a carcinoid tumor, experienced an esophageal perforation, and underwent a thoracotomy and chest tube placement which was painful. -now had post-thoracotomy pain. -most recent pain regimen included but was not limited to: -Oxycodone 7.5 mg twice daily. -Oxycodone 5 mg up to three times daily as needed. -Palliative Care Physician recommended continuing the Oxycodone medication. Review of Resident #43's February 2026 Medication Administration Record (MAR) indicated: *Scheduled Oxycodone: -last scheduled dose of 7.5 mg Oxycodone was administered on 2/4/26 at the 9:00 A.M. administration time. -reported pain level at the time of administration was four out of 10. -scheduled 7.5 mg Oxycodone was discontinued on 2/4/26. *PRN Oxycodone: -last PRN dose of 5 mg Oxycodone was administered to the Resident on 2/4/26 at 4:54 P.M. -reported pain level at the time of administration was eight out of 10. -The PRN dose of Oxycodone was assessed as effective for the Resident with a reported pain level of four out of 10. On 2/5/26 at 10:28 A.M., the surveyor observed Resident #43 exit the bathroom in his/her room, using a rolling walker to walk to his/her bed. The surveyor observed that the Resident was bent forward at the waist while walking. During an interview at the time, Resident #43 said he/she was having a problem with pain management while at the facility and that he/she was concerned the facility was not providing the pain medication he/she needed. Resident #43 said that he/she has Stage Four Cancer and had chronic pain for many years due to musculoskeletal problems. Resident #43 said he/she participated in a meeting with facility staff the previous day (2/4/26) and told the staff about his/her pain management regimen prescribed through his/her Palliative Care Team. Resident #43 said he/she contacted his/her Palliative Care Team and requested they fax his/her pain treatment plan to the facility. Resident #43 said he/she did not know if the Palliative Care Team had faxed the pain treatment plan to the facility yet. The Resident said the facility had discontinued his/her scheduled and PRN Oxycodone which he/she had been prescribed for years. Resident #43 said his/her last dose of Oxycodone was on Wednesday (2/4/26) and that he/she was currently in a lot of pain. Resident #43 said he/she was frustrated and had asked staff throughout the previous night if there was any update from the Doctor regarding the Oxycodone. On 2/5/26 at 10:45 A.M., the surveyor observed Nurse #4 entered Resident #43's room and give the Resident a medicine cup containing one pill. Nurse #4 was observed telling the Resident the pill was a 5 mg dose of PRN Oxycodone that she had just clarified with the Doctor to administer to the Resident. Nurse #4 was observed asking the Resident for his/her current pain level and the Resident said eight. Resident #43 accepted the 5 mg dose of PRN Oxycodone, then said that he/she should also be getting a 7.5 mg dose of Oxycodone scheduled twice daily. Nurse #4 said to the Resident that Unit Manager (UM) #2 would work on the Resident's pain medication schedule with the Doctor. Review of Resident #43's clinical record on 2/5/26 indicated: -An order dated 2/5/26, for Oxycodone HCl Oral Tablet 5 mg, give 5 mg by mouth every six hours PRN for pain related to other malignant neuroendocrine tumors. Further review of the clinical record failed to indicate any new orders for the scheduled Oxycodone medication. Review of the OT Progress Notes, dated 2/5/26 and 2/6/26, indicated Resident #43: -declined participation in his/her OT sessions due to reports of pain. -pain was assessed as: *2/5/26: -6 out of 10 at rest; constant, all over, throbbing. -9 out of 10 with movement, constant, all over, throbbing. -pain was communicated to nursing staff and that nursing staff were working on it. *2/6/26: -9 out of 10 at rest and with movement, constant, all over, discomfort, and aching. On 2/6/26 at 9:04 A.M., the surveyor observed from the hallway outside of Resident #43's room that the Resident was positioned in bed, and his/her feet were moving continuously back and forth over the edge of the bed out from under the covers. Nurse #2 was observed entering the room and administered medication to the Resident. During an interview on 2/6/26 at 9:27 A.M., UM #2 said the NP wrote a script to continue Resident #43's PRN Oxycodone when the NP assessed the Resident on 2/2/26, and the NP gave the script to UM #2. UM #2 said she did not enter the order to continue the Resident's PRN Oxycodone into the computer until approximately 10:45 A.M. on 2/5/26 (three days after the script was written). UM #2 said Resident #43 did not have access to PRN Oxycodone any time after 6:00 P.M. on 2/4/26 until 10:45 A.M. on 2/5/26. UM #2 said she had just spoken with the NP this morning (2/6/26) regarding Resident #43's Palliative Care Physician's recommendations for Oxycodone that were faxed to the facility on 2/4/26. UM #2 said the NP approved the Oxycodone recommendations made by the Palliative Care Team and the Resident's scheduled Oxycodone was not expected to be delivered to the facility by the pharmacy until between 2:00 P.M. and 3:00 P.M. on 2/6/26. UM #2 said Resident #43 could request the ordered 5 mg dose of PRN Oxycodone every six hours until the scheduled dose for 7.5 mg Oxycodone was delivered to the facility. During an interview on 2/6/26 at 9:43 A.M., Nurse #2 said Resident #43 did not really talk much about his/her pain at the beginning of the week when he/she had been receiving PRN and scheduled Oxycodone. Nurse #2 said by Wednesday (2/4/26), the Resident was talking about his/her pain more and expressed frustration that his/her Oxycodone prescriptions were not being filled. Nurse #2 said Resident #43 told her that he/she had been under Palliative Care. Nurse #2 said this morning (2/6/26), the Resident reported a pain level of 7 out of 10 and described the pain as cancer pain, and Nurse #2 administered 5 mg of PRN Oxycodone to the Resident. Nurse #2 said Resident #43 told her that he/she was frustrated with the lack of having the scheduled Oxycodone reinstated (two days since the scheduled Oxycodone had been last administered). During an interview on 2/6/26 at 11:30 A.M., Resident #43 said when he/she did not have access to scheduled and PRN Oxycodone from the evening of 2/4/26 through the night and into the morning on 2/5/26, he/she was not able to sleep, experienced a lot of pain and continually asked staff if there was any update on whether he/she could have Oxycodone. Resident #43 said when Oxycodone was administered to him/her at the facility, the Nurses would not always return to ask whether the Oxycodone had been effective. Resident #43 also said he/she had not been pain-free for years and that he/she had been living at a pain level of 4 to 5 out of 10 for a long time. Resident #43 said a pain level of 4 to 5 out of 10 was acceptable for him/her. Resident #43 said he/she did not like to take Acetaminophen because Acetaminophen did nothing for his/her cancer related pain. Resident #43 said all he/she wanted was for the facility to provide Oxycodone the way he/she had been prescribed prior to admission to the facility so that he/she could have an acceptable level of pain. During an interview on 2/6/26 at 12:15 P.M., the Occupational Therapist (OT) said Resident #43 had been doing well with OT at the beginning of the week and around Wednesday (2/4/26), the Resident complained of more pain and was worried about his/her ability to access medication for pain. The OT said Resident #43 was unable to participate in his/her scheduled OT session on 2/5/26 because the Resident was in too much pain when she approached him/her in the morning and the OT session was rescheduled to the afternoon. The OT said Resident #43 did not participate in the rescheduled afternoon OT session on 2/5/26 because the Resident was not receiving scheduled Oxycodone and was in pain. The OT said she had not approached the Resident yet today (2/6/26) for the Resident's OT session. During an interview on 2/6/26 at 1:10 P.M., Nurse #2 said a resident's pain report could change throughout a shift and that when a resident was assessed for every shift pain monitoring, it did not mean the resident's pain stayed at their reported level for the whole shift. Nurse #2 said if a resident reported no pain or an acceptable level of pain for that resident during the required shift pain assessment, she did not typically check on that resident's pain level again during the shift unless the resident notified her that their pain had increased or became unacceptable. Nurse #2 said she reassessed Resident #43's pain after administering 5 mg of PRN Oxycodone to the Resident this morning (2/6/26) to determine whether the PRN Oxycodone had been effective for the Resident. Nurse #2 said the Resident reported his/her pain had decreased to 6 out of 10 from 7 out of 10 and that she was aware the Resident's acceptable level of pain was 4 to 5 out of 10. Nurse #2 said the 5 mg PRN dose of Oxycodone she had administered that morning was not effective for the Resident. Nurse #2 said she could have called the Provider for instructions to see if anything else could be offered to manage the Resident's pain, but she did not. During an interview on 2/10/26 at 12:36 P.M., the NP said she assessed Resident #43 on 2/2/26 and that she was not aware the Resident had been under Palliative Care at the time of the assessment. The NP said she followed the recommendations from the hospital to discontinue the scheduled (7.5 mg) Oxycodone on 2/4/26. The NP said she gave a verbal order and also wrote a script on 2/2/26 to continue 5 mg Oxycodone every six hours PRN for the Resident since the scheduled Oxycodone was going to be discontinued. The NP said she discussed this plan with the Resident and that her plan had been to re-evaluate the Resident on Saturday (2/7/26). The NP said the Resident's other medications prescribed for pain were long-acting medications, and the Oxycodone that was prescribed was a short-acting medication. The NP said the Resident should never have experienced a period of time when PRN Oxycodone was not available. The NP said the facility did not alert her that the Resident had persisting pain and of the recommendations from the Palliative Care Physician until the morning of 2/6/26. The NP said at that time she approved the Palliative Care Physician's recommendations for scheduled (7.5 mg) Oxycodone twice a day for the Resident.

Based on observations, interviews, and record reviews, the facility failed to ensure that one Resident (#12) out of total sample of 27 residents, on one (Three West) of four units observed, was afforded a dignified dining experience.Specifically, for Resident #12, the facility failed to ensure the Resident was positioned per preference and that staff were seated and not standing over the Resident while assisting him/her to eat. Findings include: Review of the facility policy titled Resident Meal Service and Dining, revised 7/2024, included but was not limited to:-Residents are served food and beverages in a manner that provides nourishing and attractive meals, dignity, and social interaction based on the resident preferences to the degree possible. -The facility staff strives to provide a pleasant dining experience and create an environment(s) where residents eat that are homelike and conducive to dining. This may include but not limited to:>Providing positive and encouraging interactions between staff and residents that are polite, respectful and maintain resident confidentiality.>Staff sit down next to the resident while feeding and/or assisting with feeding. >Confirming the residents are properly positioned to maximum eating abilities. Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 11/2024, included but was not limited to: -Residents will be provided with care, treatment and services as appropriate to maintain or improve as able their ability to carry out activities of daily living (ADLs).-Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:>Dining (meals and snacks). Resident #12 was admitted to the facility in January 2018 with diagnoses including Multiple Sclerosis, Dysphagia Oropharyngeal Phase, Spastic Hemiplegia affecting unspecified side, Abnormal posture, Dysphagia, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Review of the Minimum Data Set (MDS) Assessment, dated 12/15/25, indicated Resident #12:-was severely cognitively impaired as evidence by a Brief Interview for Mental Status (BIMS) score of three out of a possible score of 15. -has an impairment on one side of his/her upper extremity.-has impairment on both lower extremities. -was dependent on staff for eating. Review of Resident #12's current Physician orders dated 2/10/26, indicated:-Elevate head of bed (HOB) as tolerated to promote ease of breathing and prevent shortness of breath (SOB) while lying flat every shift, initiated 6/17/24.-Monitor for signs and symptoms (s/s) of aspiration (accidental inhalation of food, liquid, saliva, or vomit into the airway and lungs) every shift, initiated 2/7/19. -Diet: Regular Diet, puree texture, honey thick liquids related to dysphagia oropharyngeal phase (difficulty swallowing foods or liquids, ranging from mild difficulty to complete and painful blockage), initiated 6/7/25. On 2/10/26 at 8:04 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 assisting Resident #12 to eat his/her breakfast meal while the Resident was lying in bed with the head of the bed elevated at a 20-degree angle. Resident #12 was observed lying on his/her right side and slouching down with both of his/her feet touching the foot board. CNA #1 was observed to be standing while assisting Resident #12 to eat while the Resident was lying in bed. During an interview at the time, Resident #12 said that he/she was uncomfortable with the way he/she was positioned in bed for the breakfast meal. CNA #1 said that she typically works the 11:00 P.M. to 7:00 A.M. shift and does not assist residents with meals. During an interview on 2/10/26 at 8:39 A.M., Unit Manager (UM) #1 said that the head of Resident #12's bed is expected to be elevated when the Resident was being assisted with meals if eating in his/her bed. UM #1 also said that the risk for Resident #12 not being properly positioned in bed during his/her breakfast meal was aspiration. UM #1 further said that CNA #1 should have positioned Resident #12 with the head of the up prior to assisting the resident with his/her meal. During an interview on 2/10/26 at 4:45 P.M., the Director of Nursing (DON) said that her expectation was that nursing staff should be seated at an eye level with the residents when assisting them to eat during meals and not stand over the residents. The DON also said Resident #12 should be positioned and the head of the bed elevated while in bed during the meals. Refer to F880

Based on record review, and interview, the facility failed to notify the Provider when test results were outside the parameters ordered, for one Resident (#13), out of a total sample of 27 residents. Specifically, the facility failed to notify the Provider as ordered, when Resident #13's finger stick blood sugar (FSBS) reading was greater than 301 mg/dL (milligrams/ deciliter), putting the Resident at risk of complications related to hyperglycemia. Findings include: Review of the facility policy titled Change in Resident's Condition or Status, last revised 7/2024 included:-The facility professional staff will communicate with physicians, residents and family regarding changes in condition as warranted.-The nurse will notify the resident's provider or on-call provider when there has been a change in resident condition.-Except in medical emergencies, notifications will be made in a reasonable time frame to physicians and family.-The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's policy titled Obtaining a Fingerstick Glucose Level, last revised 11/2020, included:-The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.-Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc.-Report results promptly to the supervisor and the Attending Physician.-Report other information in accordance with facility policy and professional standards of practice. Resident #13 was admitted to the facility in January 2026 with diagnoses including Type II Diabetes Mellitus, End Stage Renal Disease (ESRD), and Dependence on Renal Dialysis. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. Review of Resident #13's February 2026 Physician's orders included:-Insulin Lispro Solution (a short-acting, man-made version of human insulin) 100 units/milliliter (unit/ml) Inject as per sliding scale: if 150 - 200 = 1u (unit); 201 - 250 = 2u (units); 251- 300 = 3u (units); 301-999 = 4u (units); If FSBS (Finger Stick Blood Sugar) above 301 give 4 units and notify MD (Medical Doctor)/NP (Nurse Practitioner), subcutaneously four times a day related to Type II Diabetes Mellitus, with meals and at bedtime. Review of the Resident's Medication Administration Record (MAR) for February 2026 indicated the following FSBS levels recorded at 7:00 A.M., 11:30 A.M., 4:30 P.M., and 9:00 P.M.:*7:00 A.M.:-2/5/26 = 368 mg/dL-2/6/26 = 388 mg/dL*11:30 A.M.:2/7/26 = 305 mg/dL*4:30 P.M.:2/5/26 = 466 mg/dL2/6/26 = 460 mg/dL*9:00 P.M.:2/4/26 = 449 mg/dL2/5/26 = 495 mg/dL2/6/26 = 460 mg/dLReview of Resident #13's progress notes dated 2/1/26 through 2/9/26 failed to indicate any notifications to the Physician/NP as required when FSBS levels were greater than 301. During an interview on 2/9/26 at 12:32 P.M., the surveyor and Unit Manager (UM) #2 reviewed Resident #13's clinical record. UM #2 said that any Physician notification communication should have been documented in the progress note section of the medical record. UM #2 said that each time Resident #13's blood sugar was elevated greater than 301 mg/dL, there should have been a progress note written reflecting that the Physician had been notified of the elevated blood sugars. UM #2 said she could not provide any evidence that the Physician had been notified when Resident #13's blood sugar result was greater than 301 mg/dL as ordered.

Based on observations and interviews, the facility failed to maintain a clean and homelike environment for one Resident (#14) out of a total sample of 27 Residents, on one unit (Two East) out of four units observed. Specifically, the facility staff failed to ensure that Resident#14's enteral tube feeding (nutritional supplement provided through a tube into the stomach) pole (where the feeding pump is attached) and privacy curtain located next to the feeding pump/pole equipment was maintained in a clean and sanitary manner. Findings include: Resident #14 was admitted to the facility November 2022 with diagnoses including cerebral infarction, and gastrostomy (feeding tube, also referred as G-tube) status. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #14:-was severely cognitively impaired as evidenced by a BIMS score of zero out of a total possible score of 15.-was dependent on staff for Activities of Daily Living (ADLs). -has a feeding tube. On 2/9/26 at 9:01 A.M., the surveyor observed multiple areas of dried brown material splattered over the base of Resident #14's feeding tube pole and privacy curtain. On 2/10/26 at 8:12 A.M., the surveyor observed multiple areas of dried brown material remained splattered over the base of Resident #14's feeding tube pole and privacy curtain. On 2/11/26 at 7:42 A.M., the surveyor observed that multiple areas of dried brown material remained splattered over the base of Resident #14's feeding tube pole and privacy curtain. On 2/11/26 at 7:46 A.M., the surveyor and Unit Manager (UM) #3 observed Resident #14's soiled feeding tube pole and privacy curtain. During an interview at the time, UM #3 said that the Resident's equipment should be kept clean and that the nursing staff are responsible for cleaning the tube feeding equipment once they notice that it has been soiled. UM #3 also said that the facility staff should notify the housekeeping staff to clean the privacy curtains when they are visibly soiled and they had not. UM #3 said that Resident #14's room was unsanitary and undignified. During an interview on 2/11/26 at 7:56 A.M., the Staff Development Coordinator (SDC) said that the soiled items in Resident #14's room would be an infection control concern and that the staff should have addressed the Resident's soiled items timely. During an interview on 2/11/26 at 10:50 A.M., the Administrator said the facility did not have a policy on environmental rounds or cleaning of Residents' rooms. The Administrator also said that the management team at the facility performed random rounds of Resident rooms daily during the week and they had not been made aware of Resident #14's room, but if they had been they would have cleaned it immediately. The Administrator said that the facility had a process to perform environmental rounds on all Resident rooms quarterly throughout the year.

Based on observations, interviews, and record review, the facility failed to ensure all residents residing on one Unit (Three West) out of four total resident units observed, including Resident #113, were free from physical restraints implemented for staff convenience pertaining to restricting wandering residents. Specifically, the facility failed to ensure:-that all residents residing on the Three [NAME] unit were assessed for safety and the residents' ability to self-release a Do Not Enter sign [strap] secured across the residents' doorways, when six and ten residents rooms were observed on three different occasions with the Do Not Enter sign secured across the doorways to the individual rooms, and one resident was observed ducking under the strap to exit his/her room, putting the residents at risk of social isolation and non-assessment of the physical restraint use.-for Resident #113, identified with progressive decline in intellectual functioning, that he/she was able to release the Do Not Enter sign [strap] secured across the doorway when facility staff requested he/she demonstrate releasing the device and the Resident was unable to release the device to exit his/her room. Findings include: Review of the facility policy titled Use of Restraints, dated November 2017 and revised January 2024, indicated the following:-Restraints shall only be used to treat the resident's medical symptom(s) . -Physical restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement . -The definition of a restraint is based on the functional status of the resident and not the device. -Prior to placing a resident in restraints, there shall be a pre-restraining evaluation . -If the resident cannot remove a device in the same manner in which the staff applied it given that the resident's physical condition and this restricts his/her typical ability to change position or place, that device may be considered a restraint. Resident #113 was admitted to the facility in April 2020 with diagnoses including unspecified symptoms and signs involving cognitive functions and awareness and Altered Mental Status. Review of Resident #113's Active Care Plan, reviewed 12/8/25, indicated the following: -When not participating in activity program, [Resident] prefers to . walk around the unit and socialize with staff and peers (initiated 8/3/21). -The Resident had chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to brain deterioration, memory loss, and Dementia (initiated 5/5/21) -The Resident walked with continual supervision/one assist as needed (initiated 8/29/20). On 2/5/26 at 11:43 A.M., the surveyor observed the following on the Three [NAME] Unit: -Each resident room doorway was equipped with a Do Not Enter sign that could be secured across the doorway. -Ten resident rooms had the Do Not Enter signs secured across their doorways. -Resident #113 stood in the doorway of his/her room, looking into the hallway and the Do Not Enter sign was observed secured across the doorway in front of the Resident. -Resident #113 said he/she felt dizzy and Certified Nurses Aide (CNA) #3 approached the Resident. -CNA #3 invited the Resident for activities and lunch and the Resident agreed. -CNA #3 released the Do Not Enter sign from the doorway by sliding one side of the sign up and out of a grooved device attached to one side of the door frame. -Resident #113 exited the room. On 2/10/26, between 9:42 A.M. and 9:48 A.M., the surveyor observed the following on the Three [NAME] Unit: -Each resident room doorway was equipped with a Do Not Enter sign that could be secured across the doorway. -Six resident rooms had the Do Not Enter signs secured across the room doorways. -One Resident was observed to exit his/her room by bending forward at the waist and ducking under the Do Not Enter sign. -Resident #113 stood in the doorway of his/her room, with the Do Not Enter sign secured across the doorway in front of the Resident. -At 9:48 A.M., Resident #113 leaned forward, with the front of his/her body touching the Do Not Enter sign and looked to his/her left down the hallway. -Resident #113 then asked aloud why he/she lived there and said he/she wanted to go home. On 2/10/26 at 10:03 A.M., the surveyor observed that ten resident rooms had the Do Not Enter signs secured across the room doorways. During an interview on 2/10/26 at 1:58 P.M., CNA #3 said the Do Not Enter signs engaged across resident doorways had been implemented approximately four to six months earlier. CNA #3 said the Do Not Enter signs were installed to keep residents who wandered out of other resident rooms. CNA #3 said the Do Not Enter signs did not have any kind of breakaway feature and that to release the signs, you would have to lift the side of the sign that was inserted into the grooved device on the doorway. CNA #3 said that a lot of the residents could remove the Do Not Enter signs and that some residents would duck under the signs to get out of their rooms. During an interview on 2/10/26 at 2:13 P.M., Unit Manager (UM) #1 said the Do Not Enter signs were implemented about six months prior. UM #1 said the signs were installed to keep residents out of other residents' space. UM #1 said there were no individual resident assessments completed at the time the Do Not Enter signs were installed to determine whether implementing the signs could result in residents not being able to exit their rooms. UM #1 said that Resident #113 was able to remove the Do Not Enter signs on his/her own. Resident #113 was observed at this time standing in the doorway of his/her room, behind the secured Do Not Enter sign. UM #1 asked Resident #113 if he/she wanted to come out of the room and the Resident said yes. The Resident used two hands to grasp the middle of the Do Not Enter sign and pulled up then slightly toward his/her body, then bent forward. Resident #113 then said, I don't know how. UM #1 was observed to release the Do Not Enter sign for the Resident and the Resident #113 exited his/her room. During an interview on 2/10/26 at 4:48 P.M., the Director of Nursing (DON) said when facility staff added a device for a resident, such as a seatbelt or an alarm, a restraint assessment would be completed to determine whether or not the resident could remove the device and whether the device might be considered a restraint. The DON said if the device was determined not to be a restraint, the resident would be monitored weekly to ensure there was no change resulting in restraint. The DON said restraint assessments were not initiated for any residents when the Do Not Enter signs were installed on the Three [NAME] Unit. The DON said the purpose for the Do Not Enter signs was to keep residents who wandered out of other residents' rooms. The DON said that the facility's interdisciplinary team (IDT) had decided to obtain and install the Do Not Enter signs and that the IDT had not discussed the possibility that the signs could have been restraints.

Based on observations, interviews, and record review, the facility failed to ensure that a person-centered care plan relative to eating assistance and supervision was implemented for one Resident (#110) out of a total sample of 27 residents. Specifically, for Resident #110, the facility failed to implement continual supervision by one (staff) and assist of one staff as needed to set up meals as required, when the Resident experienced a significant weight decline and was care planned for feeding assistance and supervision. Findings include:Review of the facility policy titled Resident Meal Service and Dining, revised 7/2024, included but was not limited to: Residents are served food and beverages in a manner that provides nourishing and attractive meals, dignity, and social interaction based on the resident preferences to the degree possible. -The facility staff strives to provide a pleasant dining experience and create an environment(s) where residents eat that are homelike and conducive to dining. This may include but not limited to:>Staff is available to provide supervision and assistance to residents throughout the meal services as needed. Review of the facility policy titled Nutrition, revised 7/2024, included but was not limited to: *Residents maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. >The nutritional status of the resident is assessed upon admission, quarterly, annually, when a significant change occurs, and/or more frequently as deemed necessary by the interdisciplinary team (IDT). >The Registered Dietician Nutritionist (RDN) collaborates with the IDT and/ or resident/ resident representative to develop a resident-focused, interdisciplinary plan of care to outline nutrition-related goals and individualized interventions to address the specific needs of the resident. >The IDT facilitates communication of the implementation and evaluation of nutrition interventions amongst the team.>Nutrition interventions are evaluated for effectiveness as warranted.>The IDT monitors care planned nutrition interventions ongoing. >The RDN identifies residents needing frequent monitoring/evaluation (i.e. [that is], more frequent than quarterly) by the RDN. Examples of residents that may need frequent monitoring by the RDN may include but are not limited to residents:>Nutritional status is reassessed upon a significant change of condition in (i.e., weight change).>The care plan is updated as needed. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised 1/2024, included but was not limited to: *A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs that are developed for each resident. >The care plan interventions are derived from information gathered as part of the comprehensive assessment.>The resident comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident. >Evaluation of residents is ongoing, and care plans are revised as information about the residents and the residents' conditions changes. >The IDT team reviews and updates the care plan when there has been a significant change in the residents' conditions, when there is a change and at least quarterly, in conjunction with the required quarterly minimum data set (MDS) assessment. Resident #110 was admitted to the facility in November 2020 with diagnoses including Duodenal Ulcer, Moderate Protein Calorie Malnutrition, Type 2 Diabetes Mellitus, Muscle Wasting Atrophy, Gastroesophageal Reflux Disease (GERD), Iron Deficiency Anemia, and Gastritis. Review of Resident #110's Weight Summary from 9/10/25 (weight 104.0 pounds [lbs.]) through 1/21/26 (weight 88.6 lbs.) indicating a significant weight loss. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #110:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15. -has poor appetite. -required set up or clean up assistance with eating. Review of Resident #110's Activity of Daily Living (ADL) Care Plan, revised 11/24/25, indicated:-the Resident has an ADL self-care deficit as evidenced by need assistance with ADLs, Dementia, impaired mobility, unable to initiate, sequence or complete a task. >eating: the Resident requires continual supervision of one (staff)/ assist of one as needed. Review of Resident #110's Care Plan Meeting Notes, dated 11/11/25, indicated:-the Resident's Healthcare Proxy (HCP- person assigned to make medical decisions on behalf of a person if they are unable to communicate or make decisions for themselves) had a concern about the Resident's weight loss and shared that the Resident eats better when his/her meals are cut up, the crust cut off the sandwiches etc. Review of Resident #110's Nutrition Care Plan, revised 1/22/26, indicated:-Significant weight decline.-by mouth (PO) at times 50 percent (%).-Edentulous (lacking teeth) - tolerates regular textured food.-Provide feeding assistance as needed. Review of Resident #110's February 2026 Physician's orders, indicated:-Regular diet regular texture, Thin Liquids consistency, Fortified Hot Cereal, initiated 2/16/22.-Frozen Nutritional Treat (or magic cup) two times a day related to moderate protein - calorie malnutrition 4 oz with lunch and dinner, initiated 11/20/23.-Ensure Plus (or equivalent) two times a day, give 8-ounce (8 oz) twice a day (BID) with lunch and dinner due to (d/t) potential for alteration in nutrition, initiated 1/22/26. Review of Resident #110's Care Card, dated 2/10/26, included but was not limited to:>Continual supervision of one (staff) and/or assist of one as needed.Review of Resident #110's Dietician Progress Note dated 1/22/26, indicated: -Weight 88.6, -7.5% change, has had a significant weight decline in six months from 105 to current 89, (weight) loss of 15%. -NP and family made aware. Review of Resident #110's Medical Nutrition Therapy assessment dated [DATE], indicated the following: *Physical and Functional Data:>Independent>Supervision>Extensive Assist>% of weight change in 90 days: 14%. On 2/5/26 at 9:22 A.M., the surveyor observed Resident #110 reclining in with the head of bed in the upright position and a bedside table with a breakfast tray in front of him/her. The surveyor observed that the breakfast meal was untouched and there was no staff member present in room at the time. On 2/6/26 at 8:10 A.M., the surveyor observed a staff member enter Resident #110's room and placed a breakfast tray on the Resident's bedside table. The staff member was observed setting the Resident's tray up for the meal and then exited the room. The surveyor observed the Resident lying in his/her bed with his/her eyes closed, and the breakfast meal included an English muffin with butter, a cup of cranberry juice and a cup of mandarin oranges. The surveyor did not observe a staff member present in the room with the Resident. On 2/6/26 at 8:31 A.M., the surveyor observed Resident #110 lying in bed with his/her eyes closed, and the breakfast meal remained untouched on the bedside table in front of the Resident. The surveyor did not observe any staff members returning to the room to assist after the meal was set up for the Resident. On 2/6/26 from 12:22 P.M. through 12:45 P.M., the surveyor observed Resident #110 lying in bed and a lunch meal on the bedside table in front of the Resident. The surveyor observed that the lunch meal included fish, mixed vegetables, pasta, a magic cup, a carton of milk, a cup of coffee, cranberry juice and Ensure Plus with a straw. The surveyor observed that Resident #110 was not provided with assistance or supervision by staff during the meal and the lunch tray remained untouched. On 2/6/26 at 12:49 P.M., the surveyor observed Unit Manager (UM) #1 enter Resident #110's room to retrieve the untouched lunch tray and placed the tray in the meal truck located in the hallway. During an interview on 2/6/26 at 1:01 P.M., UM #1 said that Resident #110 required cueing from staff during meals and that usually cues [sic] the Resident to eat his/her meals. During an interview on 2/6/26 at 1:09 P.M., UM #1 said that he had reviewed Resident #110's care plans, and the care plan indicated the Resident required continual supervision of one and/or assist of one as needed (PRN) with meals. UM #1 said he determined that the assistance of one as needed means that staff would check on the Resident and provide cues during meals. UM #1 said that he typically checks on the Resident during meals and cues him/her because UM #1 has a good rapport with the Resident, but he had not checked in on the Resident during the breakfast or lunch meals today to ensure that the Resident was eating but he should have. UM #1 also said that all the Certified Nurse Aide's (CNAs) working on the unit today were not familiar with Resident #110. UM #1 further said that the risk of the Resident not getting continual supervision or assist of a staff member during meals was that the Resident could continue to lose weight, which could lead to decreased immunity, muscle loss and nutritional deficiencies. On 2/10/26 from 8:21 A.M. through 8:37 A.M., the surveyor observed Resident #110 lying in his/her bed with a breakfast tray on the bedside table and no staff member present in the Resident's room to assist or supervise the breakfast meal at the time. During an interview on 2/10/26 at 10:55 A.M., the Registered Dietician (RD) said that Resident #110 has been on her weight loss list for a couple of months. The RD said that she noticed the weight loss in November 2025 and December 2025 as the Resident had lost 12 pounds. The RD said that she placed the Resident on weekly weights and added supplemental Ensure Plus, magic cup, and fortified cereal to the Resident's diet and the Resident had gained two pounds. The RD also said that the Resident could eat his/her meals but sometimes required assistance and at times staff to assist with feeding him/her during meals. The RD further said that the risk of continual weight loss for Resident #110 would be impaired nutrition which can lead to decreased nutritional status such as pressure injury, and loss of muscle mass. During an interview on 2/10/26 at 4:43 P.M., the Director of Nursing (DON) said if Resident #110 was care planned for continual supervision during meals, then nursing staff should provide supervision during the meals. The DON also said that a staff member should always be with the Resident during meals to provide supervision and assistance needed during mealtimes.

Based on observations, interview, and record review, the facility failed to ensure activities of daily living (ADL's- activities related to personal care which includes washing, dressing, and oral hygiene) were provided for one Resident (#136) out of a total sample size of 27 residents. Specifically, for Resident #136, the facility failed to provide assistance with oral hygiene when the Resident required assistance to complete oral hygiene due to weakness and hemiparesis (weakness of one side of the body), placing the Resident at risk for dental complications. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 11/2024, included but was not limited to: Residents will be provided with care, treatment and services as appropriate to maintain or improve as able their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: >Hygiene (bathing .and oral care). Resident #136 was admitted to the facility in July 2025 with diagnoses including muscle wasting and atrophy, hemiparesis, muscle weakness and Anoxic Brain Damage (damage due to loss of oxygen supply to the brain). Review of Resident #136's person-centered ADL care plan revised 1/26/26, indicated: -has an ADL self-care deficit due to weakness with interventions including oral care assist/dependent.-encourage proper hygiene. Review of Resident #136's active Certified Nurse Aide (CNA) Care Kardex (brief overview of a Resident's care needs) indicated: -Mouth care: Assist/Dependent Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #136: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15 points. -had not demonstrated rejection of ADL care. -required partial/moderate assistance for oral hygiene. On 2/5/26 at 9:30 A.M., the surveyor observed Resident #136 awake and lying in his/her bed and wearing sleepwear. During an interview at the time, Resident #136 said that he/she was not offered or provided with routine oral hygiene by the staff, required assistance for care due to his/her weakness and could sometimes do his/her own oral care if the CNA set up the supplies for him/her on the over the bed table. The Resident smiled at the surveyor and a thick white substance was observed on the Resident's upper and lower gum line. Resident #136 said he/she had not received assistance with oral hygiene since being admitted to the facility. On 2/9/26 at 3:22 P.M., the surveyor observed Resident #136 awake and lying in bed. During an interview at the time, Resident #136 said that he/she had already received assistance for washing up that morning, but the CNA had not offered to set up the toothbrush supplies for him/her. Resident #136 also said that he/she was not provided assistance with oral hygiene over the weekend. Resident #136 was able to smile upon the surveyor's request, and a thick white substance was observed covering the upper and lower gumline of the Resident's mouth. On 2/10/26 at 10:10 A.M., the surveyor observed Resident #136 awake and lying in bed. During an interview at the time, Resident #136 said he/she had been washed up for the day but was not provided with oral hygiene supplies to brush his/her teeth. Resident #136 said he/she would like to brush his/her teeth every day, but the staff do not offer to help. During an interview on 2/10/26 at 12:39 P.M., Unit Manager (UM) #4 said that oral hygiene should be offered to all residents twice a day with morning and evening care unless otherwise specified by the resident. UM #4 said she was familiar with Resident #136 and his/her care needs. UM #4 said that Resident #136 has weakness and required a set-up of supplies for oral hygiene care. UM #4 said Resident #136 did not have the ability to set up oral hygiene supplies for himself/herself. During an interview on 2/10/26 at 12:10 P.M., CNA #4 said she was assigned to Resident #136. CNA #4 said that Resident #136 was totally dependent on the CNA to get washed-up because the Resident was weak. CNA #4 said that Resident #136 did not refuse care when care was offered. CNA #4 said that oral hygiene should be done twice a day, in the morning and in the evening for the Resident. CNA #4 said Resident #136 was able to brush his/her teeth as long as the CNA set him/her up with supplies and loaded toothpaste on the toothbrush. CNA #4 said that she did not assist Resident #136 with oral hygiene today because she got too busy. During an interview on 2/10/26 at 12:53 P.M., Social Worker (SW) #2 said that oral care should be provided by the CNA staff during daily care for the residents in the facility. The surveyor and SW #2 observed Resident #136's teeth and SW #2 said that the white plaque build-up on the Resident's teeth was extensive and did not appear to have received oral hygiene. Resident #136 said that he/she had not been provided with oral hygiene assistance since his/her admission to the facility. During an interview on 2/10/26 at 2:29 P.M., Minimum Data Set (MDS) Nurse #1 said that oral hygiene was important for Resident #136 because not being provided with oral hygiene could result in infection or tooth loss. Please Refer to F791

Based on observations, interviews, and record review the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#27) out a total sample of 27 residents. Specifically, the facility failed to: -For Resident #27, obtain a Physician's order for a baseline oxygen flow rate, oxygen titration liter flow range and portable oxygen flow rate when the Resident was diagnosed with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, placing the Resident at risk for respiratory complications related to oxygen use. Findings include: Review of the facility policy titled Oxygen Administration, last revised 1/2024 included: The purpose of this procedure is to provide guidelines for safe oxygen administration. >Verify there is a Physican's order in place for oxygen administration. >Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. >Document the rate of oxygen flow, route. Review of the AARC Clinical Practice Guideline for Oxygen Therapy, dated 8/8/14 at https://www.aarc.org/wp-content/uploads/2014/08/08.071063.pdf indicated the following in part: -Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations.-There is a potential in some spontaneously breathing hypoxemic (low oxygen level) patients with hypercapnia (high carbon dioxide level) and chronic obstructive pulmonary disease (COPD) that oxygen administration may lead to an increase in PaCO2 (carbon dioxide).-Undesirable results or events may result from noncompliance with Physicians' orders or inadequate instruction in home oxygen therapy. Resident #27 was admitted to the facility in September 2025 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia and Obstructive Sleep Apnea (OSA). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #27: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. -received oxygen therapy. Review of Resident #27's active Physician orders indicated: -titrate oxygen via nasal cannula (NC - flexible tube placed in the nose to deliver oxygen) to maintain oxygen saturation above 90% every shift, start date 9/23/25. -portable oxygen while out of the room every shift, start date 9/10/25. -No prescribed baseline oxygen flow rate relative to oxygen titration and portable oxygen use. Review of Resident #27's December 2025, January 2026, and February 2026 Treatment Administration Records (TAR) and Medication Administration Records (MAR) indicated that the Resident was administered oxygen every day.Further Review of the December 2025, January 2026, and February 2026 TARs and MARs failed to indicate documentation of the oxygen flow rate that was being administered to the Resident. On 2/5/26 at 10:00 A.M., the surveyor observed Resident #27 seated in a wheelchair in his/her room with a NC in place and the oxygen flow rate set at 3 liters per minute (LPM) on the oxygen concentrator. During an interview at the time, the Resident said that he/she did not adjust the oxygen flow rate up or down, only the staff did that. On 2/9/26 at 9:05 A.M., the surveyor observed Resident #27 seated in a wheelchair at his/her bedside with a NC in place and oxygen set at 1 LPM on the oxygen concentrator. During an interview on 2/9/26 at 12:37 P.M., the Assistant Director of Nurses (ADON) said he was the Nurse assigned to Resident #27. The ADON said Resident #27 was on continuous oxygen but sometimes could go without the oxygen. The surveyor and the ADON observed the Resident's portable oxygen device which was attached to the Resident's wheelchair and delivering oxygen via NC at 3 LPM. The surveyor and the ADON also observed the Resident's Physician orders for oxygen that did not include a prescribed oxygen flow rate. The ADON said that a prescribed flow rate for oxygen administration was important to have in place for Resident #27 because administering too much oxygen could send the Resident's carbon dioxide levels too high and administering too little oxygen could cause the Resident to become short of breath. During an interview on 2/9/26 at 1:11 P.M., the Director of Nursing (DON) said that an oxygen flow rate in Resident #27's oxygen orders should have been included. The DON further said that the flow rate of oxygen administered should also be documented on the Resident's TAR, that way the staff would know if the Resident's need for oxygen was increasing. The DON said that an increased need in oxygen would indicate a decline in the Resident's condition and the Doctor could then be notified for additional work-up to be done in-house or send the Resident to the hospital.

Based on observations, interview, and record review, the facility failed to administer medications per professional standards of practice resulting in two significant medication errors for one Resident (#136) out of a total sample of 27 residents. Specifically for Resident #136, the facility staff failed to hold (not administer) administration of: -Amlodipine Besylate (used to treat high blood pressure) medication for six days between 1/1/26 - 1/31/26 as ordered, for a Systolic Blood Pressure (SBP) less than 110 millimeters of Mercury (mmHg), placing the Resident at risk for cardiac compromise. -Enalapril Maleate (used to treat high blood pressure) medication for five days between 1/1/26 - 1/31/26 per Physician's order, for a SBP less than 110 mmHg, placing the Resident at risk for cardiac complications. Findings include: Resident #136 was admitted to the facility in July 2025 with diagnoses including Atrial Fibrillation (A-fib), Hypertension (HTN), and sudden cardiac arrest. Review of Resident #136's person-centered Cardiovascular Care Plan, initiated 7/28/25 and revised 1/26/26 indicated: -has an altered cardiovascular status of A-fib, HTN and history of sudden cardiac arrest with interventions including monitoring vital signs (temperature, respiratory rate, heart rate and blood pressure) as ordered. Review of Resident #136's active Physician orders indicated: -Amlodipine Besylate 5 mg tablet by mouth one time a day related to HTN, hold if SBP less than 110 mmHg, start date 8/22/25. -Enalapril Maleate 20 mg tablet by mouth one time a day related to HTN, hold if SBP less than 110 mmHg, start date 11/5/25. Review of Resident #136's January 2026 Medication Administration Record (MAR) indicated: *Amlodipine Besylate 5 mg tablet by mouth was administered to the Resident outside of the Physician ordered parameters on the following days: -1/1/26 at 9:00 A.M.: SBP 107 mmHg-1/21/26 at 9:00 A.M.: SBP 108 mmHg -1/22/26 at 9:00 A.M.: SBP 98 mmHg-1/23/26 at 9:00 A.M.: SBP 99 mmHg-1/24/26 at 9:00 A.M.: SBP 102 mmHg-1/28/26 at 9:00 A.M.: SBP 108 mmHg*Enalapril Maleate 20 mg tablet by mouth was administered to Resident #136 outside of the Physician ordered parameters as follows: -1/1/26 at 9:00 A.M.: SBP 107 mmHg-1/21/26 at 9:00 A.M.: SBP 108 mmHg-1/22/26 at 9:00 A.M.: SBP 98 mmHg-1/23/26 at 9:00 A.M.: SBP 99 mmHg-2/24/26 at 9:00 A.M.: SBP 102 mmHg During an interview on 2/11/26 at 8:38 A.M., Unit Manager (UM) #4 said that Resident #136 had SBP parameters relative to Amlodipine Besylate and Enalapril Maleate medication administration. UM #4 said that both medications should be held if the Resident's SBP was less than 110 mmHg. The surveyor and UM #4 observed Resident #136's January 2026 MAR and UM #4 said that she was unaware that the medications had been administered outside of the Physician ordered parameters, but they should not have been. UM #4 said that Resident #136's blood pressure can run low sometimes and that was probably why the Physician had ordered the parameters. UM #4 said that Resident #136 was at risk for his/her blood pressure bottoming out, which meant that the Resident's blood pressure could drop lower when the Amlodipine Besylate and Enalapril Maleate medications were administered outside the ordered parameters. During an interview on 2/11/26 at 8:49 A.M., the Director of Nursing (DON) said that all Nurses should follow the Physician ordered parameters for medication administration. The DON said that Resident #136 receiving the Enalapril Maleate and Amlodipine Besylate medications outside of the Physician ordered parameters could cause risk for his/her blood pressure to bottom out which means he/she could pass out, get dizzy, fall, or at worse cause death.

Based on observation, interview, and record review, the facility failed to ensure that medication was stored in a safe and sanitary manner in the medication carts on one (2 West) of four medication carts observed.Specifically, the facility failed to ensure that staff was not storing medications in an unsafe and unsanitary manner when:-staff stored one pre-poured medication cup containing resident medications in the top drawer of the 2 [NAME] medication cart.-and a second medication cup containing pre-poured, unlabeled medications was also observed in the top drawer of the 2 [NAME] medication cart. Findings include:Review of the facility policy titled, Storage of Medication, dated September 2018, included but was not limited to:-Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.-The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia. Medications are to remain in these containers and stored in a controlled environment. On 2/5/26 at 8:14 A.M., the surveyor and Nurse #1 observed the two [NAME] medication carts as follows:-Nurse #1 opened the medication cart and there was a medication cup containing an unidentified/unlabeled tablet, five large white tablets inside the medication cart. During an interview at the time, Nurse #1 said the five large white tablets were Tylenol medication that was pre-poured by the previous shift because the facility had large bottles of Tylenol medications and it was easy to just pre-pour some of the Tylenol medications for easy administration.-a second medication cup that contained two large purple capsules, one small white tablet, and one large white tablet. During an interview at the time, Nurse #1 said the medication belonged to a resident. Nurse #1 said she had poured the resident's medications to administer but the resident said he/she would take his/her medication after he/she returned from a smoking break. Nurse #1 said she put the medication back in the top drawer but did not label the medication cup with the resident's name. Nurse #1 further said the medications were the resident's scheduled medications as follows:-Phospha 250 Neutra tablet (phosphorus medication containing potassium phosphate and sodium phosphate).-Loratadine tablet (antihistamine medication used for allergy symptoms).-Potassium Chloride capsules (medication used to prevent or treat low levels of potassium).Nurse #1 said she had pre-poured the medications between 7:30 A.M. to 8:00 A.M. after she had taken report from the 11:00 P.M. to 7:00 A.M. (night) shift nurse. During a follow-up interview on 2/5/26 at 2:15 P.M., Nurse #1 said the resident's medication was not scheduled to be administered until 10:00 A.M. Nurse #1 said she should not have pre-poured the medications. During an interview on 2/5/26 at 2:45 P.M., the Director of Nursing (DON) said it was not the facility practice to pre-pour medications for residents. The DON also said that her expectation was that Nurses were not supposed to pre-pour medications when the medications were not due to be administered.

Based on observation, interviews, and record review, the facility failed to provide assistance for one Resident (#136) out of a total sample of 27 residents, in accessing routine dental services. Specifically, the facility failed to evaluate whether Resident #136 wished to obtain access to routine dental care, placing the Resident at risk for delayed routine dental services and impaired oral health. Findings include: Review of the facility policy titled Ancillary Physician Services, revised 3/2025 included the following: -Routine ., Dental and Audiology services are available to meet the resident's health needs. >Routine ., Dental and Audiology services are provided to our residents through: -A contract agreement . -Referral to the residents personal . -Referral to a community . or -Referral to other health care organizations that provide . >Residents have the right to select .Dental and Audiologist of their choice when services are needed. >Resident insurance will be billed . >Social Services or nursing representatives will assist residents with appointments ., and for reimbursement of services under the state plan, if eligible. Resident #136 was admitted to the facility in July 2025 with diagnoses including Dysphagia (difficulty swallowing) and Diabetes. Review of the Resident's Minimum Data Set (MDS) Assessment, dated 11/7/25, indicated: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 points out of a total possible score of 15 points. -has not demonstrated rejection of care. During an interview on 2/5/26 at 9:30 A.M., the surveyor observed Resident #136 awake and lying in his/her bed. Resident #136 said that he/she was not offered or provided with routine oral hygiene by the staff and required assistance for care due to his/her weakness and could sometimes do his/her own oral care if the CNA set up the supplies for him/her on the over the bed table. The Resident was observed with a thick white substance on the upper and lower gum line when he/she smiled at the surveyor. Resident #136 said he/she would love to see a Dentist but was not sure how to book a routine cleaning at the facility. Review of Resident #136's medical record failed to indicate that the Resident was offered dental services to meet his/her needs and had accepted or declined routine dental services. During an interview on 2/10/26 at 12:53 P.M., Social Worker (SW) #1 said a Dental Provider is contracted with the facility and comes into the facility to provide routine dental care for the residents. SW #1 said that a Dental Provider consent form should be completed by a facility SW together with all long-term care residents or their representative. SW #1 said that Resident #136 has been covered by a Medicaid Health Insurance Plan since his/her admission and did not have a completed Dental Provider form in his/her medical record. During an interview on 2/10/26 at 1:25 P.M., the Director of Nursing (DON) said that the Dental Provider form to select dental services should be part of the admission packet and reviewed by the facility Social Worker(s). During an interview on 2/10/26 at 2:29 P.M., MDS Nurse #1 said the Dental Provider form should have been reviewed by a SW with Resident #136 as soon as the facility knew that the Resident was here for long-term care on 11/2/25. MDS Nurse #1 said that the facility reviewed the Dental Provider forms during each MDS review, but the Resident's form had accidently been missed. MDS Nurse #1 said that a delay in routine dental services placed Resident #136 at risk for infection and loss of teeth.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#12) out of a total sample of 27 residents. Specifically, for Resident #12, the facility staff failed to appropriately follow Enhanced Barrier Precautions (EBP's - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of organism transmission to the Resident, staff, and other residents within the facility. Findings include:Review of the facility policy titled Infection Control Guidelines for Nursing Procedures, revised 7/2024, included but was not limited to: *To provide guidelines for general infection control while caring for residents.-Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing resident's infections which may include:>Prevention of the transmission of multi-drug-resistant organisms (MDROs). Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). -EBP is indicated for nursing home residents with any of the following:>Infection or colonization with an MDRO when contact precautions do not otherwise apply. >Use of gown and gloves during high-contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing.>Examples of high contact resident activities: dressing, transferring, changing linens. Resident #12 was admitted to the facility in January 2018 with diagnoses including retention of urine and History of Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. Review of the Minimum Data Set (MDS) Assessment, dated 12/15/25, indicated Resident #12:-was severely cognitively impaired as evidence by a Brief Interview for Mental Status (BIMS) score of three out of total possible score of 15. -has an impairment on one side of his/her upper extremity.-has impairment of both lower extremities.-was dependent on staff for eating. Review of Resident #12's Physician Orders dated 2/10/26, indicated:-Enhanced Barrier Precaution (long-term) due to history of MRSA, initiated 6/16/25. Review of Resident #12's Comprehensive Person-Centered Care Plan initiated 6/16/25, indicated:-Enhanced Barrier Precautions (long-term) due to history of MRSA. On 1/10/26 at 7:55 A.M., the surveyor observed a sign posted outside of Resident #12's door that indicated: *STOP ENHANCED BARRIER PRECAUTIONS >EVERYONE MUST: -clean their hands including before entering and when leaving the room. >providers and staff must also: -wear gloves and a gown for the following high contact resident care activities: -transferring. -changing linens. On 2/10/26 at 8:04 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 assisting Resident #12 with his/her breakfast meal while the Resident was lying flat on the right side of the bed and slouched down facing CNA #1. During an interview at the time, the Resident said that the position he/she was lying in was uncomfortable. CNA #1 was observed leaving the Resident's room and alerted CNA #2 to assist in repositioning the Resident. CNA #1 and CNA #2 entered Resident #12's room without either CNA performing hand hygiene and donning PPE prior to repositioning Resident #12 in bed. During an interview on 2/10/26 at 8:11 A.M., CNA #2 said that Resident #12 was not on any form of precautions and she did not wear a gown or gloves when she assisted in repositioning the Resident in bed. During an interview on 2/10/26 at 8:14 A.M., CNA #1 said that she typically works the night (11:00 P.M. - 7:00 A.M.) shift on a different unit, on a per diem basis and did not use PPE to provide care for the Resident unless the Resident had a bowel movement. During an interview on 2/10/26 at 8:19 A.M., Unit Manager (UM) #1 said that Resident #12 was on EBP for MRSA in the urine. UM #1 said that staff were expected to wear gown and gloves when care was provided to the Resident including handling bed linens. UM #1 said the risk of staff not wearing PPE was transmission of infections to other residents. On 2/10/26 at 8:27 A.M., the surveyor and UM #1 observed CNA #1's left hand resting on the bed while she fed Resident #12. During an interview at the time, UM #1 said that any contact with the Resident and or his/her bedding required staff to wear gloves and gown, but CNA #1 and #2 did not. During an interview on 2/10/26 at 4:45 P.M., the Director of Nursing (DON) said that Resident #12 had a history of MRSA in his/her urine and CNA #1 and CNA #2 should have donned a gown and gloves when touching Resident #12's skin and bed linens to reposition the Resident in bed.

Based on observation, interviews and records reviewed, for one of three sampled residents (Resident #1), who resides on a secured Dementia unit, has a known behavior that includes physical aggression and has been involved in multiple resident to resident physical and verbal altercations, the Facility failed to ensure that they provided him/her with an adequate level of staff supervision on the unit to maintain residents safety in an effort to prevent resident to resident altercations, therefore placing him/her and other residents on the unit at risk for injury. Findings include: Review of the Facility policy titled, Care Plan, comprehensive Person-centered, revised 01/2024, indicated a comprehensive, person-centered care plan will be developed for each resident. The policy indicated a care plan will include objectives that meet the residents' physical, psychosocial and functional needs. The policy indicated that the resident comprehensive care plan will identify problem areas and their causes as warranted and develop interventions that are targeted and meaningful to each resident. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 02/26/25, indicated there was a resident-to-resident altercation involving Resident #1 and Resident #3, when Resident #1 put his/her hand on Resident #3's neck, resulting in a skin tear (laceration) to Resident #1. Review of the report submitted by the Facility via the HCFRS, dated 06/16/25, indicated a resident-to-resident altercation involving Resident #1 and Resident #2 had occurred when Resident #1 went into Resident #2's room and stood over him/her resulting in scratches to Resident #1. Review of the report submitted by the Facility via the HCFRS, dated 08/13/25, indicated a resident-to resident altercation was witnessed by staff in which Resident #1 was observed to have pinched another Resident. Review of the report submitted by the Facility via the HCFRS, dated 09/15/25, indicated a resident-to-resident altercation involving Resident #1 and Resident #2 had occurred while Resident #1 was standing in Resident #2's room doorway. Review of the report submitted by the HCFRS, dated 12/12/25, indicated a resident-to-resident altercation involving Resident #1 and Resident #2 had occurred, on when Resident #1 removed the STOP sign and entered Resident #2's room resulting in a laceration to Resident #1. Review of the report submitted by the Facility via the HCFRS, dated 12/20/25, indicated a resident-to-resident altercation involving Resident #1 and Resident #2 had occurred when Resident #1 removed the STOP sign and approached Resident #2 while he/she was in bed resulting in a bruise to Resident #1. Resident #1 was admitted to the Facility October 2023, diagnoses included Alzheimer's dementia, dementia with unspecified severity with other behavioral disturbance, generalized anxiety disorder and insomnia. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 10/06/25, indicated he/she was severely cognitively impaired and wandered, placing the resident at significant risk of getting into a potentially dangerous place, was dependent for activities of daily living (eating, toileting, hygiene, dressing) and required supervision for ambulation. Review of Resident #1's Behavior Care Plan, dated as initiated 04/12/2024 and reviewed/revised on 12/26/25, indicated Resident #1 wanders on the unit, refuses/resists care, rummages, paces and throws/smears food, finds furnishings and will attempt and be successful at taking them apart or destroying items, enters other residents' rooms and is difficult to redirect at times, takes his/her personal belongings such as blankets, clothes, activity items, decorations etc. and throw/places them into trash receptacles, is aggressive towards [Spouse] at times and puts non-food items in his/her mouth and will refuse to allow staff to remove. Resident #1's Behavior Care Plan Interventions included; encourage [spouse]/health care proxy to not try and force resident to do things that he/she is showing signs of not wanting to do, invite and encourage activity programs consistent with established interests, offer snacks or drinks as a redirection tactic, provide non-confrontational environment for care, when agitated reapproach at a later time when resident is less agitated. Resident #2 was admitted to the Facility in July 2022, diagnoses included unspecified dementia with other behavior disturbance, cerebral infarction (stroke), diabetes mellitus and Schizophrenia (brain disorder that disrupts how a person thinks, feels and behaves). Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 12/08/25, indicated he/she was cognitively intact, exhibited physical, verbal, and other behavior symptoms, rejected care, was dependent on staff for toileting, hygiene, dressing and required supervision for ambulation. Review of Resident #2's Behavior Care Plan, dated as initiated 04/29/25 and reviewed/revised 12/26/25, indicated he/she rejected/refused care, was sexually inappropriate, had angry outburst, and had a history of assaultive behaviors. Resident #2's Behavior Care Plan intervention included; encourage to call for assistance if someone enters his/her room, encourage to keep the STOP sign on his/her door at all times, when agitated reapproach at a later time when he/she is less agitated. During an interview on 12/30/25 at 9:15 A.M., Resident #2 said that Resident #1 came into his/her room all of the time and went into all of his/her drawers. Resident #2 said that he/she would wake up and be startled by Resident #1 standing at the foot of his/her bed. Resident #2 said that he/she had made staff aware that Resident #1 was bothering him/her and was told by staff to ring the call bell if Resident #1 entered his/her room. Resident #2 said that he/she would ring the bell, and yell for staff but that Resident #1 would continue to enter his/her room and approach him/her before staff would get there. Resident #3 was admitted to the Facility in September 2018, diagnoses included unspecified dementia with other behavioral disturbance, Schizophrenia, major depressive disorder, and anxiety disorder. Review of Resident #3's Minimum Data Set (MDS) Assessment, dated 12/08/25, indicated he/she was severely cognitively impaired, rejected care, wandered, was dependent on staff assistance for activities of daily living (eating, toileting, hygiene, dressing) and required supervision for ambulation. Review of Resident #3's Behavior Care Plan, dated as initiated on 04/16/25, and reviewed/revised on 10/08/25, indicated he/she exhibited repetitive actions/questions, exit seeking, crying pacing, wandering, placing self under the bed, physical aggression towards others, confronting other residents that rummage through his/her closet, and making attempts to grab males by the face.Resident #3's Behavior Care Plan interventions included STOP sign Velcro banner will be placed across resident door to deter other residents from entering his/her room, reassure resident to avoid placing self under bed, when agitated reapproach at a later time when resident is less agitated.During a telephone interview on 12/26/25 at 10:45 A.M., Visitor #1 said that Resident #1 had physical altercations with other residents at the Facility at least six or eight times, but that there were never any witnesses. Visitor #1 said that the Police had been to the facility at least twice to investigate theses altercations. Visitor #1 said that Resident #1 wanders throughout the day into all rooms, pushes chairs and other furniture, and is unable to participate in activities because he/she cannot focus. Visitor #1 said the facility staff do not provide enough supervision for Resident #1.On 12/30/25 from 9:30 A.M, until 9:38 A.M., while on Resident #1, #2 and #3's unit (3 West), the surveyor made the following observations: -Resident #1 was in the unit dining/day room located at the end of the hallway. -The dining/day room is not located in an area where staff walk by the dining/day room to get to other rooms. - The dining/day room is not visible from the Nurses station. -There are areas within the interior of the dining/day room that staff would only be able to visualize when standing in the doorway to the room. -There were four residents sitting at tables in the dining/day room, and Resident #1 was observed to be standing over a table where two residents were sitting. -Resident #1 took a dining/day room chair and pushed it across the room into a wall, then walked over to another chair and pushed that chair into a different wall. -Resident #1 was observed to be mumbling while walking up to the other residents seated at tables and removing the tablecloths.-Resident #1 exited the dining/day room and proceeded to walk down the hallway. -During the entire time of the observation, from 9:30 A.M. to 9:38 A.M., there were no staff member present to provide supervision in the dining/day room during the observation and no staff members entered to check on the residents while the surveyor was there. During a telephone interview on 01/02/26 at 3:00 P.M., the Psychiatric Nurse Practitioner (NP) said that Resident #1 should not be in the dining/day room without staff supervision. The NP said that Resident #1 would benefit from one-to-one supervision.Review of Resident #1's Psychiatric Evaluation and Consultation, dated 12/17/25, indicated he/she had more behaviors lately and was sometimes noncompliant with medications and care. The Note indicated that Staff should continue to redirect him/her and monitor for any signs or behaviors that would indicate harm to self or others and send to ER (emergency room). During an interview on 12/30/25 at 2:00 P.M., Certified Nurse Aide (CNA) #1 (who worked the 7:00 A.M. to 3:00 P.M. shift, four days a week and had provided care to Resident #1) said that Resident #1 wanders into other residents' rooms and takes their personal items and that he/she had mastered taking the STOP sign banners off of the doorways. CNA #1 said Resident #1 requires two care-givers to provide care because he/she hits and pushes staff. During an interview on 12/30/25 at 3:40 P.M., Certified Nurse Aide (CNA) #2, (who was assigned to provide care to Resident #1 on the 3:00P.M. through 11:00P.M. shift, five days a week) said that Resident #1 will remove the STOP signs that are across the doorways and go into other resident's rooms and try to take their blankets. CNA #2 said that one time she witnessed Resident #1 pick up an air mattress pump machine, that had been attached to the end of a bed and attempt to hit the resident lying in bed with the machine, but she had been able to stop him/her.CNA #2 said that Resident #1 gets aggressive and will raise his/her fists. CNA #2 said that she had seen Resident #1 remove the STOP sign, open the door, and enter Resident #2's room on multiple occasions. CNA #2 said that she had told Resident #2 to ring the call bell when Resident #1 was in his/her room because she cannot supervise Resident #1 while she is in other rooms providing care. CNA #2 said she was not aware of any specific person that supervised Resident #1 when she busy with other residents.During an interview on 12/30/25 at 2:30 P.M., the Unit Manager said that Resident #1 goes into other residents' rooms every day. The Unit Manager said the STOP sign banners work about 80% of the time but on other days Resident #1 will take all the STOP sign banners down. The Unit Manager said although Resident #2 had agreed to a room change (in an effort to deter Resident #1 from going into his/her room) it had not altered Resident #1's behavior and Resident #1 continued to go into Resident #2's room. The Unit Manager said he was aware that Resident #2 became upset when Resident #1 had entered his/her room and that there had been physical altercations between them. During an interview on 12/30/25 at 3:00 P.M., the Director of Social Services (DSS) said Resident #1 is into everything, wanders and is intrusive. The DSS said that Resident #1 and Resident #2 do not get along and that for the past several months staff have been trying to deter (keep) Resident #1 away from Resident #2, but that Resident #1 is fixated on going into Resident #2's room. The DSS said Resident #2 should have been moved to another unit prior to the incident on 12/20/25 and that she questions if the Facility is an appropriate setting for Resident #1, because he/she is hard to redirect and will fixate on other residents. During an interview on 12/30/25 at 4:05 P.M., the Assistant Director of Nurses (ADON) said Resident #1 wanders daily, can be aggressive and can be difficult to redirect. The ADON said the facility has tried two types of STOP sign banners on the doors, but that Resident #1 has figured them out and continues to enter other residents' rooms. The ADON said prior to the altercation involving Resident #1 and Resident #2 on 12/20/25, staff had redirected Resident #1 away from Resident #2's room three times, had closed the door, and replaced the STOP sign each time. The ADON said he was aware that resident-to-resident altercations had occurred involving Resident #1, Resident #2 and Resident #3. The ADON said staff watch Resident #1 as much and as close as they can, but that sometimes they don't get to him/her in time. The ADON said Resident #1 should not have been in the day/dining room with other residents unsupervised.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner, when during the provision of care, two staff members overheard Certified Nurse Aide (CNA) #1 interacting with Resident #1, during which CNA #1 used profanities and spoke to him/her in a raised, very loud tone of voice.Findings include:Review of the Facility's Policy titled, Abuse Investigation and Reporting, dated as last revised February 2024, indicated that every resident in the facility will be treated with respect and dignity. Review of the Facility's Policy titled, Resident Rights, dated as last revised January 2024, indicated all residents have a right to a dignified existence and employees shall treat all residents with kindness, respect, and dignity.Resident #1 was admitted to the Facility in May 2025, diagnoses included Lewy Body Dementia (a type of brain disease characterized by the accumulation of abnormal protein deposits called Lewy bodies in the brain) and Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event).Review of Resident #1's admission Minimum Data Set Assessment, dated 05/26/25, indicated he/she had severe cognitive impairment as evidenced by a score of 01 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).Further review of the MDS Assessment indicated Resident #1 usually understood others (missed some part/intent of message but comprehended most conversation), experienced hallucinations, physical and verbal behavioral symptoms directed toward others, and a history of rejection of care. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 07/14/25, indicated that on 07/14/25, the Shift Supervisor notified the Director of Nursing (DON) that a Unit Nurse requested the Shift Supervisor's assistance because the Unit Nurse said she heard yelling and cursing coming from the hallway bathroom, which was occupied by a Certified Nurse Aide (later identified as CNA #1) and a resident (later identified as Resident #1). Review of the Facility's Incident Summary indicated the Administrator interviewed CNA #1 who said she told Resident #1, I am sick of this [NAME] and [NAME] shit (Resident's name), come on! The Report also indicated the Administrator asked CNA #1 if she made any additional unprofessional, vulgar, or inappropriate comments and that CNA #1 told him she could not recall exactly what she said but acknowledged she may have used the word dumbass.During an interview on 09/17/25 at 12:07 P.M. (which also included a review of her written witness statement, dated 07/14/25), Nurse #1 said on 07/14/25, just after dinner time (exact time unknown), she was behind the nursing station when she heard yelling coming from the hallway bathroom which was located diagonally across from where she was standing. Nurse #1 said she heard CNA #1 shouting, stop, stop, stop, you fucking dumb ass, coming from behind the closed bathroom door. Nurse #1 said she immediately responded to the shouting by banging on the bathroom door, telling CNA #1 to immediately stop what she was doing and to exit the bathroom. Nurse #1 said CNA #1 told her (through the closed door) she was unable to open the door because Resident #1 was not in a safe position for her to leave his/her side. Nurse #1 said she then summoned two other unit CNAs to stand at the door while she went to the adjacent unit to elicit help from the Shift Supervisor.Nurse #1 said that CNA #1 finally opened the bathroom door, and she and the Shift Supervisor told CNA #1 to leave the Unit, and the two other unit CNAs assumed completion of care for Resident #1.During a telephone interview on 09/17/25 at 1:44 P.M. (which also included a review of her written witness statement, dated 07/14/25), CNA #2 said she was working during the 3:00 P.M. to 11:00 P.M. shift on 07/14/25 and just after dinnertime (exact time unknown) she heard CNA #1 yelling and cursing from behind the bathroom door (near the nursing station). CNA #2 said she heard CNA #1 yell, you fucking stand up and said she also heard CNA #1 use the word dumbass and that CNA #1 was being very loud towards Resident #1.CNA #2 said that Nurse #1 requested that she and another CNA stand at the bathroom door, and said after CNA #1 finally opened the door, she and the other CNA went into the bathroom to assist Resident #1.During a telephone interview on 09/17/25 at 2:04 P.M. (which also included a review of her written witness statement, dated 07/14/25), the Shift Supervisor said Nurse #1 came to request her assistance regarding an incident involving CNA #1 and Resident #1 in the bathroom. The Shift Supervisor said Nurse #1 told her that CNA #1 was yelling profanities at Resident #1, that she tried to get CNA #1 to exit the bathroom, and that CNA #1 was not removing herself from the situation, despite Nurse #1's insistence. The Shift Supervisor said when she arrived on the Unit with Nurse #1, CNA #1 was still in the bathroom with Resident #1, however at that time, she did not hear any yelling or cursing. The Shift Supervisor said she called the Director of Nurses (DON), who advised her to tell CNA #1 to leave the unit immediately upon exiting the bathroom. The Shift Supervisor said CNA #1 left the unit at her request and went downstairs to wait for further instruction. During a telephone interview on 9/23/25 at 9:45 A.M., (which included review of her Written Witness Statement, dated 06/14/25) CNA #1 said the incident with Resident #1 occurred on 7/14/25 and that the date on her statement (6/14/25) was incorrect. CNA #1 said she was asked to change Resident #1 after he/she experienced an incontinent episode, and she brought him/her to the bathroom. CNA #1 said that Resident #1 was exhibiting his/her usual signs of agitation, she had him/her stand with her assistance, removed his/her brief, and then he/she grabbed her instead of the wheelchair, then he/she began to walk around as his/her brief were falling around his/her ankles. CNA #1 said Resident #1 was mostly non-verbal and often would not follow verbal cues or directions and could be resistant to care. CNA #1 said she asked the nurse to have somebody come help her as soon as they could because Resident #1 was known to be difficult with care, but nobody came to her help her. CNA #1 said Resident #1 started to move about the bathroom after his/her pants and brief were around his/her ankles, and that she became frustrated while trying everything she could to try to keep him/her safe. CNA #1 said that her voice carries even if she is not yelling and she said she remembers saying to Resident #1 that she was sick of this [NAME] and [NAME] shit and that she may have used the word dumbass but could not remember the exact context. CNA #1 she said she could not remember exactly what else she said but acknowledged that she did not speak to Resident #1 in an appropriate or respectful manner.During a telephone interview on 09/18/25 at 1:50 P.M., the Director of Nurses (DON) said the Shift Supervisor called her on 07/14/25 to report that Nurse #1 heard CNA #1 yelling at Resident #1 in the hallway bathroom. The DON said she told the Shift Supervisor to tell CNA #1 to leave the unit and requested the Shift Supervisor put Nurse #1 on the phone so she could obtain a statement from her. The DON said Nurse #1 told her she was standing at the far end of the nursing station, which was behind plexiglass two to three rooms away from the bathroom, and she said she heard CNA #1 yelling at Resident #1 in the hallway bathroom. The DON said Nurse #1 told her she heard CNA #1 yell, Stop fucking doing that! Stop, stop, stop! and she said Nurse #1 told her said she heard CNA #1 use the word dumbass. The DON said she then called the Administrator who was still in the Facility and requested he respond to the incident.During an interview on 09/17/25 at 4:45 P.M., the Administrator said the DON called him on 07/14/25 sometime between 6:30 P.M. and 7:00 P.M. and reported that CNA#1 was heard yelling and swearing at Resident #1 and he initiated an investigation immediately.The Administrator said when he interviewed CNA #1, she admitted telling Resident #1 she was sick of this [NAME] and [NAME] shit and he said when he asked CNA #1 if she called Resident #1 anything derogatory, such as dumbass, said CNA #1 admitted to saying something along those lines, but had said she could not remember exactly the manner in which that word was used. The Administrator said CNA #1 was immediately placed on leave pending further investigation and was subsequently terminated from her position.

Based on record review, policy review and interview, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for one Resident (#111) out of a total sample of 24 residents. Specifically, for Resident #111 the facility failed to have the Resident evaluated for the capacity to make medical decisions following a decline/change in their cognitive status. Findings include: Review of the facility policy titled Advanced Directives, last revised January 2024, indicated the following: -the interdisciplinary team (IDT) will conduct ongoing review of the resident's decision-making capacity and communicate significant changes as appropriate. -determine the decision-making capacity of the resident and invoke (activate) the decisions of the legal representative as appropriate. 1. Resident #111 was admitted to the facility in December 2023, with diagnoses including vascular Dementia (decline in reasoning, planning, memory, judgement, and other thought processes caused by brain damage from impaired blood flow to the brain), Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and Aphasia (language disorder that makes it difficult to understand, speak, read or write resulting from damage to the language center of the brain). Review Resident #111's of the Minimum Data Set (MDS) Assessments indicated the following Brief Interview for Mental Status (BIMS) exam scores on the following dates: -1/24/24:11 out of 15 points, moderate cognitive impairment -3/11/24: 9 out of 15 points, moderate cognitive impairment -6/10/24: 5 out of 15 points, severe cognitive impairment -9/9/24: 4 out of 15 points, severe cognitive impairment Review of Resident #111's Psychological Services Progress Note, dated 7/18/24, indicated that the Resident: -has functional and behavioral challenges related to memory -cognition and decision-making difficulty -has poor recall Review of the Physician's Progress note, dated 8/23/24, indicated that the Resident: -is a poor historian due to Dementia -is unable to provide a review of symptoms as the patient was unable cooperate Review of Resident #111's Care Plan for Impaired Cognition, last revised 9/4/24, indicated: -the Resident has a deficit in memory, judgement and short-term memory loss -observe and report changes in cognitive status During an interview on 9/25/24 at 10:16 A.M., Resident #111 said that they were confused and had difficulty answering the surveyors' questions. During an interview on 9/30/24 at 10:37 A.M., the MDS Nurse said that she was the person responsible in the facility to complete the BIMS with the residents and notifies the residents Unit Manager (UM) of any changes in their cognitive status. The MDS Nurse also said that the UM then will notify the Physician to address the Resident decision-making capacity. During an interview on 9/30/24 at 10:53 A.M., the MDS Nurse said that she was unable to provide evidence that the Physician had been informed of Resident #111's change in cognitive status. During an interview on 9/30/24 at 3:23 P.M., UM #2 said that Resident #111 should have had a capacity evaluation completed once the BIMS score started to decline but did not.

Based on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP/ Nurse Practitioner [NP]) of a significant change in condition for two Residents (#23 and #111) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician/NPP: 1. For Resident #23, when the blood sugar reading was greater than 400 mg/dL (milligrams per deciliter). 2. For Resident #111, when the blood sugar reading was less than 70 mg/dL and greater than 401 mg/dL. Findings include: Review of the facility policy for Diabetes- Clinical Protocol, last revised December 2020 indicated: -the Physician will follow-up any acute episodes associated with a change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. -the Physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. -the staff will identify and report complications such as .hypoglycemia (low blood sugar). The Physician will help staff clarify and respond to these episodes. Review of the facility policy for Change in Resident's Condition or Status, last revised July 2024 indicated: -the nurse will notify the resident's provider or on call provider when there has been a change in resident condition - .notifications will be made in a reasonable time frame to physician and family. -the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Resident #23 was admitted to the facility in September 2023, with a diagnosis of Diabetes Mellitus Type 2 (DM II- a chronic medical condition where the body cannot effectively use insulin [hormone that regulates blood glucose/sugar] or produce enough insulin and has trouble controlling blood sugar levels). Review of Resident #23's Care Plan for Diabetes last revised 9/4/24, indicated: -administer medications as ordered. See Medication Administration Record (MAR). Monitor effectiveness and side effects. -check blood glucose levels per Physician's order. -monitor for signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Review of the Resident's September 2024 Physician's orders included: >Lantus (long-acting insulin) - Subcutaneous Solution- (injection between the skin and muscle for treatment of Diabetes) 100 UNIT/ML (units/milliliter); Inject 15 units subcutaneously at bedtime for Diabetes, start date 6/4/24 >Humalog (fast-acting insulin injection) Subcutaneous Cartridge -100 UNIT/ML; Inject subcutaneously before meals related to Type 2 Diabetes, start date 2/8/24, as per sliding scale: -if blood sugar is 150 - 199 mg/dL = give 2 units (u). -200 - 249 mg/dL = give 4u. -250 - 299 mg/dL = give 6u. -300 - 249 mg/dL = give 8u. -350 - 399 mg/dL = give 10u. -400 - 999 mg/dL = give 12u, and then call MD (Doctor of Medicine/ Physician) for further orders. Review of the Resident #23's July 2024 to September 2024 Medication Administration Record (MAR) indicated the following blood sugar levels recorded on the following days: -7/31/24 at 11:30 - 450 mg/dL -8/11/24 at 16:30 - 411 mg/dL -8/13/24 at 16:30 - 434 mg/dL -8/24/24 at 11:30 - 408 mg/dL -9/20/24 at 16:30 - 400 mg/dL Review of the Resident's Nursing Progress Notes from 7/31/24 through 9/20/24 did not indicate any Physician notification as required when the Resident's blood sugar levels were greater than 400 mg/dL. During an interview on 10/1/24 at 11:04 A.M., the Nursing Regional Director of Operations said that the facility was unable to provide evidence that the Physician had been notified of the elevated blood sugars. The Nursing Regional Director of Operations also said that the Physician should have been notified when the blood sugars were that elevated, and they had not been. 2. Resident #111 was admitted to the facility in December 2023 with a diagnosis of DM II. Review of Resident #111's Care Plan for Diabetes last revised 9/4/24, indicated: -administer medications as ordered. See MAR. Monitor effectiveness and side effects. -check blood glucose levels per Physician's order. -monitor for signs and symptoms of hyperglycemia and hypoglycemia. Review of the Resident's September 2024 Physician's orders included: >Insulin Glargine (long-acting insulin) - Subcutaneous Solution- 100 UNIT/ML; Inject 15 units subcutaneously at bedtime for Diabetes, with a start date of 9/24/24 >Humalog (fast acting insulin injection) Subcutaneous Cartridge -100 UNIT/ML; Inject subcutaneously before meals related to Type 2 Diabetes, start date 12/31/23, as per sliding scale: -if blood sugar is 0 - 60 mg/dL, administer no insulin and follow hypoglycemic protocol and notify MD. -60 - 200 mg/dL = give 0u. -201 - 250 mg/dL = give 4u. -251 - 300 mg/dL = give 6u. -301 - 350 mg/dL = give 8u. -351 - 400 mg/dL = give 10u. -400+ mg/dL = give 12u, and then call MD for further orders. >GlucaGen Hypokit (glucagon- a natural substance that raises blood sugar) Solution Reconstituted inject 1 mg (milligram) intramuscularly as need for blood sugar of less than 70 if resident is not responsive or able to swallow. Activate emergency medical services (EMS) and notify Provider, start date 1/22/24 Review of the Resident #111's August 2024 to September 2024 MAR indicated the following blood sugar levels recorded on the following days: -8/5/24 at 11:30 - 418 mg/dL -8/13/24 at 11:30 - 471 mg/dL -8/22/24 at 16:30 - 423mg/dL -9/22/24 at 6:30 - 55 mg/dL -9/22/24 at 16:30 - 56 mg/dL Review of the Resident's Nursing Progress Notes from 8/5/24 through 9/22/24 did not indicate any Physician notification as required when the Resident's blood sugar levels were greater than 400 mg/dL and below 70 mg/dL. During an interview on 10/1/24 at 11:04 A.M., the Nursing Regional Director of Operations said that the facility was unable to provide evidence that the Physician had been notified of the high and low blood sugars. The Nursing Regional Director of Operations also said that the Physician should have been notified when the blood sugars were outside of the acceptable range, and the Physician had not been notified.

Based on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for five Residents (#59, #90, #113, #56, and #111) out of a total sample of 24 residents. Findings include: 1. Resident #59 was admitted to the facility in August 2024, with diagnoses including Unspecified Dementia with behavioral disturbance (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis, usually associated with adverse behaviors). Review of the Resident #59's PASRR Level I, dated 9/3/24, indicated the Level I screen was completed after the Resident's admission to the facility. 2. Resident #90 was admitted to the facility in May 2023, with diagnoses including Unspecified Dementia with behavioral disturbance, Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy), and adjustment disorder (a disorder characterized by a group of symptoms such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after a stressful life event). Review of Resident #90's PASRR Level I, dated 5/15/23, indicated the Level I screen was completed after the Resident's admission to the facility. 3. Resident #113 was admitted to the facility in October 2023, with diagnoses including Unspecified Dementia with behavioral disturbance, generalized Anxiety Disorder, and a history of alcohol abuse. Review of Resident #113's PASRR Level I, dated 10/19/23, indicated the Level I screen was completed after the Resident's admission to the facility. During an interview on 9/26/24 at 12:14 A.M., the Social Worker (SW) said every resident being admitted to the facility should have a PASRR Level I completed prior to their admission to the facility. The SW said for Residents #59, #90, and #113, their PASRR Level I's had been completed after the Residents were already admitted to the facility. 45429 4. Resident #56 was admitted to the facility in January 2024, with diagnoses including Major Depressive Disorder and Schizoaffective Disorder (mental health condition marked by a mix of schizophrenia symptoms like hallucinations [seeing things or hearing voices] and delusions [believing things that are not real or not true], and mood disorder symptoms such as depression, mania and hypomania), Seizure Disorder (also known as Epilepsy, a brain condition that causes recurring seizures [sudden, uncontrolled burst of electrical activity in the brain that causes changes in behavior, movements, feelings and level of consciousness]). Review of Resident #56's medical record failed to indicate a Level I PASRR had been completed prior to admission to the facility. Further review of the medical record indicated that the PASRR Level I, dated 2/1/24, was completed after the Resident's admission to the facility. During an interview on 9/26/24 at 10:51 A.M., Social Worker (SW) #1 said the facility completed the PASRR late. The SW said that the PASRR should have been completed prior to admission and it was not. 5. Resident #111 was admitted to the facility in December 2023, with diagnoses including Major Depressive Disorder and Adjustment Disorder. Review of Resident #111's medical record failed to indicate a Level I PASRR had been completed prior to admission to the facility. Further review of the medical record indicated that the PASRR Level I, dated 2/29/24, was completed after the Resident's admission to the facility. During an interview on 9/26/24 at 10:51 A.M., Social Worker (SW) #1 said the facility completed the PASRR late. The SW said that the PASRR should have been completed prior to admission and it was not.

Based on interview, and record review, the facility failed to the facility failed to provide care and services consistent with professional standards of practice for two Residents (#113 and #91) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #113, ensure that Physician orders were obtained for a recommended Hemoglobin A1C (HbA1c - test used to identify Diabetes [disease that affects how the body uses blood sugar]) lab to be drawn as recommended by the Behavioral Health Nurse Practitioner (NP) for the Resident on medications for mental health conditions. 2. For Resident #91, maintain and document fluid restrictions and administer dietary supplements as ordered by the Physician for treatment of End Stage Renal Disease (the final stage of kidney disease where the kidneys can no longer function on their own leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and fluid from the body when the kidneys stop working] or a kidney transplant to maintain life) requiring Hemodialysis (a procedure where a machine with a special filter called a dialyzer is used to remove waste from the blood). Findings include: 1. Review of the National Alliance on Mental Illness (NAMI) website article titled, Why Screening for Diabetes is Important (Especially if You Take Psychiatric Medications), dated 3/25/14, at https://www.nami.org/blog-post/why-screening-for-diabetes-is-important-especially-if-you-take-psychiatric-medications-2/ indicated: -the American Diabetes Association (ADA) suggests screening regularly for Diabetes for those who use medications to treat mental health conditions. -as medications used to treat mental health conditions pose an additional risk for the increase in Diabetes. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, last revised 2/2020, indicated the following: -The Physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. Resident #113 was admitted to the facility in October 2023, with diagnoses including Unspecified Dementia with behavioral disturbance (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis, usually associated with adverse behaviors), generalized Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), and a history of alcohol abuse. Review of the Psychiatric Evaluation and Consultation Notes dated: 6/13/24, 7/18/24, 8/1/24, and 9/11/24, indicated the Psychiatric Nurse Practitioner recommended Resident #113 have a HbA1c lab drawn as he/she was prescribed an antipsychotic medication. Review of Resident #113's September 2024 Physician's orders indicated Resident #113 had an active order for Haloperidol (Haldol - an antipsychotic medication), with a start date of 5/28/24. Review of the August 2024 and September 2024 Medication Administration Records (MARs) indicated Resident #113 was administered Haloperidol daily as prescribed when he/she was in the facility. Further review of Resident #113's medical record indicated no documentation that the recommended HbA1c lab had been drawn. During an interview on 9/26/24 at 3:34 P.M., the Minimum Data Set (MDS) Nurse said the recommended HbA1c lab was never drawn for Resident #113. The MDS Nurse said Behavioral Health notes should be reviewed regularly by the attending Physician and orders should have been put into place for Resident #113 to have the HbA1c lab drawn within a week of the Behavioral Health Nurse Practitioner recommending the lab work. 50320 2. Review of a 2016 National Institute of Diabetes and Digestive and Kidney Disease Article titled Eating and Nutrition for Hemodialysis at https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis/eating-nutrition indicates: -Your choices about what to eat and drink while on hemodialysis can make a difference in how you feel and can make your treatments work better. Between dialysis treatment sessions, wastes can build up in your blood and make you sick. -You can reduce waste buildup by controlling what you eat and drink. -You can match what you eat and drink with what your kidney treatments remove. Some foods cause wastes to build up quickly between your dialysis sessions. If your blood contains too much waste, your kidney treatment session may not remove them all. - .Hemodialysis removes extra fluid from your body. However, hemodialysis can remove only so much fluid at a time safely. -If you come to your hemodialysis with too much fluid in your body, your treatment may make you feel ill. You may get muscle cramps or have a sudden drop in blood pressure that causes you to feel dizzy or sick to your stomach. Review of a 2017 National Kidney Foundation Journal of Renal Nutrition titled Tips for Dialysis Patients with Fluid Restrictions at https://www.jrnjournal.org/article/S1051-2276(17)30143-7/fulltext indicates: -There are many components to the renal diet that are important when educating end-stage renal disease (ESRD) patients requiring hemodialysis. -Intake of the correct amount of fluids on a daily basis is crucial to stabilizing your kidney patient and reducing potential symptoms associated with fluid overload including shortness of breath, headaches, abdominal bloating, hypertension, heart failure, and edema. -Limiting fluid consumption is a complex part of the renal diet as there are many factors that play into patient acceptance of this restriction. -Recommended weight gain between dialysis sessions is individualized and fluctuations above ideal are often indicators of noncompliance with fluid and diet nutritional goals. -Long-term research has demonstrated that greater and undesired fluid gain between dialysis sessions with ESRD patients increases risk of all-cause and cardiovascular death. Resident #91 was admitted to the facility in August 2024, with diagnoses including End Stage Renal Disease (ESRD), Dependance on Renal Dialysis and Atherosclerotic Heart Disease (a condition in which fatty material collects along the walls of arteries and causes narrowing. The fatty material thickens, hardens, and may eventually block the arteries). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #91 was cognitively intact as evidenced by a Brief interview for Mental Status (BIMS) score of 13 out of 15. Review of Resident #91's medical record indicated that the Resident had dialysis and nutrition care plans with interventions to monitor/provide intake of diet and fluids as ordered. Review of Resident 91's Physician's orders indicated: -8/9/24: on a renal diet, regular texture with thin liquids consistency, for diet 1200 milliliter (ml) fluid restriction, double proteins with all meals. -8/10/24: has Dialysis every Tuesday, Thursday and Saturday at 11:00 A.M. Review of the Nurse Practitioner NP) Progress Note, dated 8/13/24 under assessment and plan indicated: -Diastolic Heart Failure (condition in which the left ventricle [the heart's main pumping chamber] becomes stiff and unable to relax between heartbeats to fill properly with blood) EF (ejection fraction - measurement of the percentage of blood leaving the heart each time it contracts) 50%. -Continue to monitor fluid status and compliance with Dialysis. -End Stage Renal Disease on Hemodialysis. Continue dialysis, monitor I's and O's (intake and output). Review of the Physician's order dated 8/16/24, indicated: -Nepro shake with carb steady (a nutritionally complete liquid formula with a vitamin and mineral profile specifically designed for people with chronic or acute kidney failure requiring dialysis) in the afternoon give 8 oz (ounces) daily at 2 P.M. Review of the August 2024 Medication Administration Record (MAR) indicated that the Nepro shake was not administered due to the Resident being out of the facility on the following days: -8/17 -8/22 -8/24 -8/27 -8/29 Review of the September 2024 MAR indicated the Nepro shake was not administered due to the Resident being out of the facility on the following days: -9/3 -9/5 -9/7 -9/10 -9/12 -9/14 -9/19 -9/24 -9/26 Further review of Resident #91's clinical record indicated on 9/2/24 the Physician ordered the following: -Maintain Fluid Restriction as ordered: >Nursing 480 ml (milliliters) total: 150 ml (5oz) fluid per shift for medication passes, additional 30 ml (fluid) if needed. >Meals 720 ml total: Breakfast 240 ml, Lunch 120 ml, 2 P.M.- Nepro shake 240 ml, Dinner 120 ml. Review of the September 2024 MAR indicated that the Resident was over his/her 1200 ml fluid restriction amount on the following dates: -9/4 intake of 1347 ml -9/6 intake 1320 ml -9/7 intake 1260 ml -9/8 intake 1800 ml -9/9 intake 1560 ml -9/16 intake 1500 ml -9/20 intake 1440 ml -9/21 intake 1440 ml -9/24 intake 1240 ml -9/25 intake 1300 ml During an interview on 9/26/24 at 2:41 P.M., the Dietitian said there is no policy on fluid restriction, that the Dietitian puts individual Residents' fluid restrictions on the unit in the Certified Nurses Aides (CNA) room and in the chart. The Dietitian said she puts the fluid restriction orders in to the kitchen to go on the meal ticket and enters the fluid restriction orders in the care plan. The Dietitian said the Nurses are educated on the fluid restriction and the Dietitian brings the fluid restriction to the Resident and educates them if they are able to understand. The Dietitian said she thought that Resident #91 was offered the Nepro shakes at dialysis which would account for the days on the MAR the Resident was not receiving the shakes due to being out of the building. The Dietitian said if the dialysis center does not communicate with the facility about whether Resident #91 drank the shake or not, the facility does not know if the Resident was given the shake and how much the Resident drank, so the facility would be unable to add that to the fluid intake for the day. During an interview on 9/30/24 at 8:43 A.M., Nurse #5 said every shift he monitors fluid restriction and document how much fluid he had given the Resident over his shift. If the Resident is over his/her fluid restriction, the Nurse should let the Provider (Physician) and the Dietitian know. Nurse #5 said if a Resident is on a fluid restriction and on dialysis the dialysis Provider should be informed of the fluid restriction. Nurse #5 said the fluid restriction should be written on the dialysis communication sheet that goes with the Resident to dialysis and the Nurse on duty is responsible for filling out the dialysis communication sheet. During an interview on 9/30/24 at 9:14 A.M., the Director of Nursing (DON) said she thought the Nepro shake was given to the Resident at dialysis. The DON said if the shake was not written on the dialysis communication sheet there was no way to know if the Resident had been given the shake or know how much fluid the Resident had taken in. During an interview on 9/30/24 at 11:45 A.M., Resident #91 said he/she does not drink or eat anything at dialysis. Resident #91 said that sometimes at the end (of dialysis) the dialysis staff give him/her something called a vitamin drink. The Resident was unable to say how often he/she was given the vitamin drink or the specific name of the drink.

Based on observation, interview, and record review, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#11) out of a total sample of 24 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #11. Findings include: Resident #11 was admitted to the facility in May 2021, with diagnoses including Unspecified Schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior), Unspecified Dementia (a mental disorder that occurs when someone has Dementia but does not have a specific diagnosis), Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest or pleasure in activities that a person used to enjoy), and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated that it was very important to the Resident to: -have books, newspapers, and magazines to read -listen to music you like -do favorite activities -participate in religious activities -to go outside to get fresh air when the weather is good Review of the Resident's Activity Care Plan, last revised 8/3/24, listed interventions including but not limited to: -prefers to attend all rosary groups and weekly catholic mass, receives weekly communion -staff is to provide materials as needed for independent leisure time, staff will assess the need regularly -prefers to spend time in (their) room watching TV (television) and socializing with staff and peers No evidence was found in the Activity Care Plan to include interventions for musical activities, or to go outside when the weather was good. Review of the most recent MDS dated [DATE], included a Brief Interview of Mental Status (BIMS) score of 3 out of 15 possible points indicating the Resident was severely cognitively impaired. Review of the Resident's Activity Participation Log indicated the following: >August 2024: -19 days of a 1:1 interaction with the Resident Active in a Greeting Time visit -11 days of a 1:1 interaction where the Resident Verbalized in a Greeting Time visit -1 day independent active TV activity >September 2024: -17 days of a 1:1 interaction with the Resident Active in a Greeting Time visit -11 days of a 1:1 interaction where the Resident Verbalized in a Greeting Time visit -3 days of independent active TV activity -4 days of a 1:1 interaction with a Brief Verbalization in a Greeting Time visit -3 days of a 1:1 interaction with active reminiscing -2 days with no activity recorded -2 days of the Resident refusing offer to join the book/drama club or exercise Further review of the August 2024 and September 2024 Activity Participation Logs showed no evidence that the Resident had been offered or refused any religious activities, reading materials, musical activities, going outside, or more than 4 days of independent active TV activity. On 9/25/24 at 11:33 A.M., the surveyor observed Resident #11 sitting in a chair facing the middle of the bed and the wall beyond the bed. The surveyor observed that there was nothing on the walls and no personal items. The surveyor further observed the bedside table was out of the Resident's reach at the foot of the bed and the television (TV) was turned off. The surveyor observed the Resident had no activity in place and was rocking back and forth in the chair. On 9/25/24 at 3:54 P.M., the surveyor observed Resident #11 sitting in a chair facing the middle of the bed and the wall beyond the bed. The surveyor observed that the Resident was not participating in any activity. During an interview at the time, the Resident said he/she would like to watch TV. The surveyor observed a staff member responded to the request and tried to turn the TV on with the remote control. The staff member told the surveyor that the TV does not turn on. The Activity Director (AD) arrived in the Resident's room and said that the cord from the TV was partially out of the electrical outlet. The staff worked on getting the TV turned on, but were not successful when the surveyor exited the room. On 9/26/24 at 1:07 P.M., and 9/30/24 at 1:09 P.M., the surveyor observed Resident #11 lying in bed with eyes open. The surveyor observed the TV was located on the bedside table and was not turned on. The surveyor observed the Resident was not participating in any activity. On 10/1/24 at 10:00 A.M., the surveyor observed Resident #11 sitting in the chair beside the bed facing across the bed towards the wall. The surveyor observed the overbed table had 2 TV remotes on it and was located at the bottom of the bed, out of the reach of the Resident. The surveyor observed there was a daily chronical paper which listed the activities for the day on the foot of the bed, out of the reach of the Resident. The surveyor observed there were no pictures, or personal items visible in the Resident's space, no reading materials available, the TV was not turned on, and the Resident was not participating in any activity. On 10/1/24 at 10:10 A.M., during an observation and interview with the AD, Resident #11 was observed sitting in the chair beside the bed facing the wall. The surveyor observed the TV was off and there were no activity materials available for the Resident. The surveyor observed that the overbed table was located at the bottom of the bed and there were 2 TV remotes on the overbed table that was out of the reach of the Resident. When the surveyor asked the AD what activities were provided for the Resident, the AD said that someone would come around later and visit. When the surveyor asked if the TV should be on, the AD said it probably should have been and she turned on the TV and put the remote back on the overbed table out of the reach of the Resident. When the surveyor asked if there were any individual activities for the Resident to do independently in the room per the plan of care, the AD said that there should have been. The surveyor observed the AD go through the Resident's bedside table to look for activity materials but was not able to locate any. The AD said there used to be reading materials here. The AD said that the Resident did attend a religious program on Saturdays and liked to go outside. The AD said that the Resident also liked to join some programs in the activity room. During an interview on 10/1/24 at 11:44 A.M., the surveyor and the AD reviewed the Resident's Activity Care Plan and Activity Participation Logs for August 2024 and September 2024. The AD said that there were religious programs on Wednesdays and Sundays and she thought the Resident was attending some but maybe the Resident had not come in a while. The AD also said that staff do invite the Resident to musical programs but maybe the Resident did not want to come. The AD said that maybe the activity staff carry a radio with them, and the Resident could listen to music while they visited the Resident. The AD was not sure why the Resident did not have any reading materials but maybe the Resident did not ask for reading materials. The AD said that refusals of activities should be recorded on the Activity Participation Log, but was unable to provide any evidence that the Resident had been offered or refused any religious programs, musical activities, going outside, or reading materials during August 2024 and September 2024. When the surveyor said that over the last 4 days of survey the Resident was not observed participating in any activities, the AD did not respond to the surveyor.

Based on observation, record and policy review, and interview, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#23) out of a total sample of 24 residents. Specifically, for Resident #23, the facility staff failed to: 1. verify the correct size indwelling urinary catheter as ordered by the Physician and ensure the verified size urinary catheter was in place. 2. to obtain an appointment with a Urologist as requested by the Nurse Practitioner (NP) to prevent catheter related complications. Findings include: Review of the facility policy for Indwelling Foley Catheter Insertion, last revised December 2020, indicated: -to verify that there is a Physician's order for this procedure. -review the resident's care plan to assess for any special needs of the resident. -the following information should be recorded in the resident's medical record: the size of the Foley catheter and the amount of fluid used to inflate the balloon. Resident #23 was admitted to the facility in September 2023, with diagnoses including benign prostatic hyperplasia (BPH- enlarged prostate gland, which blocks the flow of urine) and urinary retention (inability to completely empty the bladder of urine). Review of Resident #23's clinical record indicated a NP Progress Note dated 1/6/24, that indicated: -the Assessment and Plan was to have the Resident be seen by Urology secondary to the diagnosis of obstructive uropathy (blockage of urinary flow). -the administration of Flomax (medication that relaxes the muscles in the prostate gland and bladder). Review of Resident #23's Care Plan for indwelling urinary catheter, last revised 9/4/24, indicated: -the Resident will not develop any complications associated with catheter usage. -an intervention to change the catheter per policy and MD (Doctor of Medicine/Physician) orders. -an intervention to review for possible removal of catheter as indicated. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #23 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated that the Resident had an indwelling urinary catheter and was dependent for activities of daily living (ADL's- basic skills such as bathing, dressing, eating, etc.). Review of Resident #23's September 2024 Physician's orders indicated: -Change Foley catheter as needed for blockage/leakage, start date 5/27/24 -Change Foley catheter every day shift starting on the 2nd and ending on the 2nd of every month, start date 6/2/24 -Foley catheter 16 Fr (French scale or system used to size catheters), 10 ml (milliliter) balloon (retention balloon- a tiny balloon at the end of the indwelling urinary catheter that is inflated with water to prevent the indwelling urinary catheter from sliding out of the body), start date 9/15/23. Review of Resident #23's Treatment Administration Record (TAR) for September 2024 indicated that the Foley catheter had been changed on 9/13/24 as needed for blockage or leakage. Review of the clinical record indicated a progress note dated 9/13/24, that indicated Resident #23 received Tramadol (opiate analgesic medication) 50 mg as needed (PRN) for moderate to severe pain. On 9/26/24 at 9:01 A.M., the surveyor observed Resident #23's Foley catheter which was a size 18 Fr Foley catheter. During an interview on 9/26/24 at 9:02 A.M., Unit Manager (UM) #2 said that Resident #23 should have a size 16 Fr Foley catheter in place according to the Physician's orders. UM #2 declined to observe the Resident's urinary catheter with the surveyor and said that she believed the information conveyed to her by the surveyor was true. UM #2 also said that increasing the urinary catheter size can cause trauma to the Resident and that he/she have not been seen by a Urologist. During an interview on 9/26/24 at 10:11 A.M., the Director of Nursing (DON) said that the Physician's orders related to Resident #23's urinary catheter size were not being followed. The DON also said that the Resident had not been seen by Urology but should have been seen after the NP had requested it (the Urology visit).

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose plan of care indicated he/she required extensive assistance of two staff members with the use of a mechanical lift for all transfers, the Facility failed to ensure staff implemented and followed interventions from Resident #1's Plan of Care related to transfers and staff assistance. On 11/07/22, although Certified Nurse Aide (CNA) #3 asked the Unit Manager for assistance with transferring Resident #1 from a shower chair into bed with the mechanical lift, CNA #3 had already begun to transfer him/her, and Resident #1 was suspended up and over the shower chair, before the Unit Manager was fully in the room and in close enough proximity to provide hands on assistance. When CNA #3 raised Resident #1, his/her body shifted in the lift pad, which then caused his/her left leg to move and twist in an upward position. Resident #1 complained of left leg pain, x-rays were obtained, and revealed he/she had a left intertrochanteric fracture (type of hip fracture). Resident #1 was transferred to the Hospital Emergency Department, was admitted , and required surgical intervention to repair of the fracture. Findings Include: Review of the Facility Policy titled, Care Plans, Comprehensive Person-Centered, dated as revised 11/2017, indicated that a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The Policy indicated that the care plan would aid in preventing or reducing decline in the resident's functional status and/or functional levels. The Policy indicated that Care Plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Resident #1 was admitted to the Facility in August 2019, diagnoses included muscular dystrophy (group of genetic diseases that cause progressive weakness and loss of muscle mass), muscle weakness, and rheumatoid arthritis (autoimmune disease causing chronic inflammation effecting joints). Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, he/she was non-ambulatory, had bilateral lower extremity impairments, and was dependent with two staff members to assist for transfers. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated as reviewed on 08/29/22, indicated that Resident #1 required the use of a mechanical lift with the assistance of two staff members for all transfers. Review of Resident #1's Nurse Progress Note, dated 11/07/22, indicated that during a transfer with a mechanical lift, when lifted above the shower chair, Resident #1 shifted out of proper alignment, vocalized discomfort, and the operator (identified as CNA #3) then transferred him/her into bed. The Note indicated Resident #1 stated that it hurt when he/she was lifted out of the shower chair, his/her Physician's Assistant was notified, and new orders were obtained for a left hip x-ray. Review of Resident #1's Imaging Report, dated 11/07/22, indicated that he/she had a moderately displaced intertrochanteric left hip fracture. A subsequent Nurse Progress Note, dated 11/07/22, indicated Resident #1's Nurse Practitioner was updated regarding his/her hip fracture and that he/she was transferred to the Hospital Emergency Department (ED). Review of Resident #1's Hospital Orthopedic Consult Note, dated 11/08/22, indicated that he/she was transferred to the Hospital ED and admitted to the Hospital from the Facility on 11/07/22 after sudden onset of left upper thigh pain during a transfer from a shower chair to his/her bed in a mechanical lift. The Note indicated that Resident #1 denied any popping sound or fall but said his/her left leg was suddenly raised up during the transfer. The Note indicated that Resident #1 was a good historian and indicated that surgical intervention was planned for Resident #1. During an interview on 1/11/23 at 08:35 A.M., Resident #1 said only one staff member (identified as CNA #3) had transferred him/her with the mechanical lift that day (11/07/22), and he/she had left leg pain right afterwards. Resident #1 said he/she fractured his/her hip because the mechanical lift was not hooked up right when he/she was being transferred and said that his/her left leg went up in a funny position. Resident #1 said when the nurse (identified as the Unit Manager) came into the room, both he/she and CNA #3 told the nurse what happened. Resident #1 said the Facility obtained x-rays, he/she found out he/she had a fracture, and was transferred to the hospital where he/she had surgery. During an interview on 01/11/23 at 12:15 P.M., the Unit Manager said that on 11/07/22 Certified Nurse Aide (CNA) #3 told her she needed help transferring Resident #1 and said she told CNA #3 to get Resident #1 all hooked up to the mechanical lift and to call her when she was ready to transfer him/her. The Unit Manager said when CNA #3 called her into Resident #1's room, as she walked in the doorway, CNA #3 had already started to raise Resident #1 up (with the mechanical lift) out of the shower chair. The Unit Manager said there were three beds in Resident #1's room at the time and his/her bed was the furthest bed away from the doorway. The Unit Manager said she walked past the end of first bed closest to the doorway, and as she approached the second bed, CNA #3 had already raised Resident #1 up out of the shower chair. The Unit Manager said she observed Resident #1's body start to shift to the right. The Unit Manager said she observed Resident #1's left leg go upwards as she reached them. The Unit Manager said it appeared that Resident #1's left hip had twisted. The Unit Manager said she assisted with the remainder of the transfer and when they got Resident #1 into bed, he/she complained that his/her left leg hurt. The Unit Manager said two people were required to be present during the mechanical lift transfer, that one person was needed to operate the mechanical lift and the second person needed to guide the resident to ensure proper body alignment while in the lift pad. The Unit Manager said CNA #3 should have waited for her and should not have started to lift Resident #1 with the mechanical lift until she was right there beside them to provide hands on assistance. During an interview on 01/11/23 at 1:28 P.M., CNA #3 said on 11/07/22 after she helped shower Resident #1, that she used the mechanical lift to transfer him/her from the shower chair back into bed, and said as soon as she raised him/her up and out the shower chair with the mechanical lift, his/her left hip started to twist. CNA #3 said when she started to lift Resident #3 with the mechanical lift, the Unit Manager was in the doorway to the room and said she should have waited until the Unit Manager was beside them before she started to move Resident #1. CNA #3 said two staff members were required to assist during a mechanical lift transfer, one to operate the mechanical lift and the other to touch (hands on) and guide the resident. During an interview on 01/11/23 at 1:00 P.M., the Staff Development Coordinator (SDC) said it was Facility Policy for two staff members to be present during any mechanical lift transfer and said that meant both staff member's are hands on, and did not mean someone was watching. The SDC said one staff member needed to maneuver (operate)the lift while the other staff member maneuvered (hands on) the resident. During an interview on 01/11/23 at 3:02 P.M. and 3:40 P.M., the Director of Nursing (DON) said mechanical lifts required the assistance of two staff members. The DON said this should be done to ensure all around resident safety.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the required level of staff assistance and that assistive equipment (lift pad) was positioned correctly by staff, in an effort to maintain Resident #1's safety during a mechanical lift transfer to prevent incidents/accidents resulting in an injury. On 11/07/22, Certified Nurse Aide (CNA) #3 placed the mechanical lift pad under Resident #1 (per facility investigation the pad was not positioned properly) and began to transfer Resident #1 from a shower chair into bed, with the mechanical lift before the second staff member (identified as the Unit Manager) was fully in the room beside the resident, and in close enough proximity to provide hands on assistance. As CNA #3 raised Resident #1 up out of the shower chair, his/her body shifted, and his/her left leg moved and twisted in an upward position. Resident #1 complained of left leg pain, x-rays were obtained, and revealed he/she had a left intertrochanteric fracture (type of hip fracture). Resident #1 was transferred to the Hospital Emergency Department, was admitted , and required surgical intervention to repair of the fracture. Findings Include: Review of the Facility Policy titled Lifting Machine, Using a Mechanical Lift, dated as revised 04/2018, indicated at least two nursing staff members were needed to safely move a resident with a mechanical lift. The Policy indicated to make sure the sling (pad) is securely attached to the clips and that it is properly balanced. Resident #1 was admitted to the Facility in August 2019, diagnoses included muscular dystrophy (group of genetic diseases that cause progressive weakness and loss of muscle mass), muscle weakness, and rheumatoid arthritis (autoimmune disease causing chronic inflammation effecting joints). Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, he/she was non-ambulatory, had bilateral lower extremity impairments, was dependent and required assistance of two staff members for transfers. Review of Resident #1's Activity of Daily Living (ADL) Care Plan, dated as reviewed on 08/29/22, indicated that Resident #1 required the use of a mechanical lift with the assistance of two staff members for transfers. Review of Resident #1's Nurse Progress Note, dated 11/07/22, indicated that during a transfer with a mechanical lift when lifted above the shower chair, he/she shifted out of proper alignment, vocalized discomfort, and the operator (identified as CNA #3) then transferred him/her into bed. The Note indicated Resident #1 stated that it hurt when he/she was lifted out of the shower chair, his/her Physician's Assistant was notified, and new orders were obtained for a left hip x-ray. Review of Resident #1's Imaging Report, dated 11/07/22, indicated that he/she had a moderately displaced intertrochanteric left hip fracture. A subsequent Nurse Progress Note, dated 11/07/22, indicated Resident #1's Nurse Practitioner was updated regarding his/her hip fracture and that he/she was transferred to the Hospital Emergency Department (ED). Review of Resident #1's Hospital Orthopedic Consult Note, dated 11/08/22, indicated that he/she was transferred to the Hospital ED and admitted to the Hospital from the Facility on 11/07/22 after sudden onset of left upper thigh pain during a transfer from a shower chair to his/her bed in a mechanical lift. The Note indicated that Resident #1 denied any popping sound or fall but said his/her left leg was suddenly raised up during the transfer. The Note indicated that Resident #1 was a good historian and indicated that surgical intervention was planned for Resident #1. During an interview on 1/11/23 at 08:35 A.M., Resident #1 said only one staff member (identified as CNA #3) had transferred him/her with the mechanical lift that day (11/07/22), and he/she had left leg pain after right afterwards. Resident #1 said he/she fractured his/her hip because the mechanical lift was not hooked up right when he/she was being transferred and that his/her left leg went up in a funny position. Resident #1 said when the nurse (identified as the Unit Manager) came into the room, both he/she and CNA #3 told the nurse what happened. Resident #1 said the Facility obtained x-rays, he/she found out he/she had a fracture, and was transferred to the hospital where he/she had surgery. During an interview on 01/11/23 at 12:15 P.M., the Unit Manager said that on 11/07/22 Certified Nurse Aide (CNA) #3 told her she needed help transferring Resident #1 and said she told CNA #3 to get Resident #1 all hooked up to the mechanical lift and to call her when she was ready to transfer him/her. The Unit Manager said when CNA #3 called her into Resident #1's room, as she walked in the doorway, CNA #3 had already started to raise Resident #1 up out of the shower chair with the mechanical lift. The Unit Manager said there were three beds in Resident #1's room at the time and his/her bed was the furthest bed away from the doorway. The Unit Manager said she walked past the end of first bed closest to the doorway, and as she approached the second bed, CNA #3 was already raising Resident #1 up from the shower chair. The Unit Manager said she observed Resident #1's body start to shift to the right in the lift pad. The Unit Manager said she observed Resident #1's left leg go upwards as she reached them. The Unit Manager said it appeared that Resident #1's left hip had twisted. The Unit Manager said she assisted with the remainder of the transfer and when they got Resident #1 into bed, he/she complained that his/her left leg hurt. The Unit Manager said two people were required to be present during the transfer, one person to operate the mechanical lift and the second person to guide the resident to ensure proper body alignment while in the lift pad. The Unit Manager said CNA #3 should have waited for her and should not have started to lift Resident #1 with the mechanical lift until she was right there beside them to provide hands on assistance. The Unit Manager said that after the incident, that same day, she, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and CNA #3 re-created the transfer to try to see what could have happened. The Unit Manager said the DON sat in the shower chair, and they used the same lift pad and mechanical lift that had been used for Resident #1, to lift and transfer the DON. The Unit Manager said when CNA #3 lifted the DON up out of the shower chair, the DON's body shifted while being transferred in the same manner that Resident #1's had shifted. The Unit Manager said they determined that the pad to the mechanical lift had not been placed correctly under Resident #1, that there was a small fold in the lift pad, and the lift pad needed to be more taut (stretched or pulled tight) under the resident. During an interview on 01/11/23 at 1:28 P.M., CNA #3 said on 11/07/22 after she helped shower Resident #1, she used the mechanical lift to transfer him/her from the shower chair back into bed, and said as soon as she raised him/her up from the shower chair with the mechanical lift, his/her left hip started to twist. CNA #3 said when she started to raise Resident #3 with the mechanical lift, the Unit Manager was in the doorway to the room and said she should have waited until the Unit Manager was beside them before she started to move Resident #1. CNA #3 said two staff members were required to assist during a mechanical lift transfer, and said one staff member needed to operate the lift and the staff member needed to touch (hands on) and guide the resident. CNA #3 said after the incident, she, the DON, ADON, and Unit Manager re-created the transfer to see what happened and said she transferred the DON in the same manner as she had transferred Resident #1. CNA #3 said that as she lifted the DON from the shower chair with the mechanical lift, the DON started to twist like Resident #1 had twisted. CNA #3 said that during the demonstration she learned that the pad to the mechanical lift was incorrectly placed under Resident #1 when he/she was transferred. CNA #3 said the lift pad was not placed under Resident #1's thighs properly. During an interview on 01/11/23 at 1:00 P.M., the Staff Development Coordinator (SDC) said she was notified by the DON that Resident #1 sustained a hip fracture because of how he/she had been positioned in the pad for the mechanical lift. The SDC said it was determined that the pad had been up bunched in the back and had not been pulled forward enough under Resident #1 at the time of the transfer. The SDC said that it was also Facility Policy for two staff members to be present during any mechanical lift transfer and said that meant both staff members are hands on, and did not mean someone watching. The SDC said one staff member needed to maneuver (operate) the lift while the other staff member maneuvered (with hands on) the resident. During an interview on 01/11/23 at 3:02 P.M. and 3:40 P.M., the Director of Nursing (DON) said after she heard about the incident with Resident #1's transfer on 11/07/22, she asked the staff members involved to demonstrate what happened by having them attempt to transfer her with the mechanical lift. The DON said while she was in the mechanical lift, as she was lifted from the shower chair, her body also started to shift when she was lifted. The DON said they determined that it was because the pad was not in the proper position and that said the seam to the pad rested higher over the hip than it should have. The DON said that mechanical lifts required the assistance of two staff members. The DON said this should be done to ensure all around safety.

Based on record review and interview, for 1 of 3 sampled Residents (Resident #1), the Facility failed to provide the necessary treatment and services to prevent worsening of pressure sores. Resident #1 had stage 1 pressure sores on each heel on admission, no changes were made to off-load pressure on the heels. The right heel pressure sore progressed to deep tissue trauma. Findings include: The Facility's Skin Integrity Guideline, undated, stated that, under Documentation of Weekly Skin Evaluation/Observations: The Licensed Nurse was to document weekly on identified wounds using the Wound Evaluation Flow Sheet (one per wound identified). The interim skin care plan intervention, dated 8/24/15 indicated to apply barrier cream to the feet, a house protocol. The skin integrity guideline (pressure ulcer protocol), undated indicated that for stage 1 pressure sores; evaluate current pressure relieving interventions - bed, chair, foot wear, and other bony prominence areas. If non-blachable reddened area is present over a boney prominence, may apply thin [MEDICATION NAME] or Foam and change as needed. Cleanse after each incontinence episode. Apply moisture barrier product. The Wound protocol was not followed for the heels (a barrier cream (instead of a [MEDICATION NAME] or Foam) was added to the nursing care plan). The Clinical Health Status Sheet (Nursing Admission Sheet), dated 8/24/15, Nurse #2 found stage one pressure sores on each of Resident #1's heels. Resident #1 had bilateral dark pink heels which were non-blanchable with slightly swollen lower extremities. The Wound Evaluation Flow Sheet indicated the stage one pressure sores observed and documented on admission 8/24/15, there were no measurements (a baseline for comparison for monitoring the pressure sores). The Surveyor interviewed Nurse #2 at 4:39 P.M. on 12/14/15. Nurse #2 said that she found stage 1 pressure sores on both of Resident #1's heels. Nurse #2 said she did not measure the stage 1 pressure sores on the heels (as a baseline for monitoring them). Nurse #2 said that she should have applied a barrier treatment to the heels and did not on 8/24/15. Nurse #2 said that she did not call the Physician to inform the Physician regarding the stage 1 pressure sores. The Nurse Practitioner #1's note dated 8/25/15, indicated under conditions addressed today, that there was no documentation to indicate Resident #1 had stage1 pressure sores on each heel. The Nurse's Notes dated 8/24/15 through 8/27/15 indicated that there is no evidence that this Resident's bilaterally heel pressure sores were assessed or monitored. The Physical Therapy notes dated from 8/25/15 through 9/3/15 indicated that there was no documentation to indicate that Physical Therapy was informed of Resident #1's heel pressure sores. The Surveyor interviewed Physical Therapist (PT) #1 at 10:50 A.M. on 12/17/15, PT #1 (the primary Physical Therapist providing rehabilitation for ambulation 4 times a week since 8/25/15). PT #1 was not aware Resident #1 had bilateral pressure sores on admission 8/24/15, and did not know about the pressure sores until 9/4/15 (for 11 days) when off-loading boots were obtained for this Resident by another supplier. PT #1 said that if she knew about the bilateral pressure sores found on admission, then she would have elevated Resident #1's legs to off-load the heels with foot rests when he/she was out of bed. She stated that Resident #1 did not have foot rests for elevating the feet until later in his/her stay at the facility. The Nurse's Note of 8/28/15 at 4:22 P.M., indicated that Resident #1 had a change in the left heel pressure sore (5 days after admission); there was now a dark round gray spot area noted on the left heel. No measurements were documented. The Wound Evaluation Flow Sheet indicated that measurements were documented for the 1st time 8/28/15, and the pressure sore had progressed (worsened) and was 5 centimeters (cm) by 5 cm. The Nurses Note of 9/1/15 at 3:01 P.M. indicated that the right heel had a dark fragile area with intact edges and was fragile. Physician #1 was updated and evaluated Resident #1. This was an unstagable pressure sore with an eschar (black) in the wound bed. The Wound Evaluation Flow Sheet indicated that no measurement was documented on 9/1/15 when the pressure sore worsened. Nurse's Notes on 9/1/15 at 10:44 A.M., indicated that both feet had 2+ [MEDICAL CONDITION] (0 - no fluid to 4- significant fluid) and the right heel had a dark fragile area. The physician's orders [REDACTED]. The pressure sore care plan was updated on 9/2/15 and posey boots (to relieve the pressure on the heels, after the right heel pressure sore had worsened) were added to the care plan. The Wound Evaluation Flow Sheet indicated measurements were taken for the second time on 9/2/15 and the documentation of the wound was inaccurately staged as a stage 2 (According to the National Pressure Ulcer Advisory Panel until an eschar is removed to expose the base of the wound the true depth of the wound cannot be determined, it is unstagable). The pressure ulcer measured 3.5 centimeters by 3.5 centimeters with no depth and black grayish exudate (a new finding with pressure sore drainage). Nurses Notes on 9/7/15 at 12:42 P.M. indicated that the right heel was dark purple color (deep tissue trauma) with soft intact skin. Nurse Practitioner #1's note dated 9/4/15 indicated this Resident had an unstagable pressure ulcer on the right heel. There was 2+ to 3+ swelling in the right foot. Nurse Practitioner #1 note read, Once again asked that pt (patient) have the foot elevated on a foot rest in the wheelchair. There is no foot rest in (his/her) room. Could not reach Physical Therapy/Rehabilitation. The Surveyor interviewed NP #1 at 2:42 P.M. on 12/23/15, NP #1 said she was not informed regarding this Resident's pressure sore on 8/25/15 when she first visited Resident #1. NP #1 said that there was a delay in Resident #1 receiving the footrests on his/her wheelchair to relieve pressure on the heels and decrease the [MEDICAL CONDITION] in the feet. NP #1 said that the elevation of the feet with the footrest would decrease the pressure on the heels and [MEDICAL CONDITION]. NP #1 said the offloading boots (later ordered when the heel pressure sore was worse) was not consistently on Resident #1's foot even after it was ordered. The Surveyor interviewed Family Member #1 at 12:55 P.M. on 12/10/15. Family Member #1 indicated the Facility did not have foot rests to elevate (to decrease the lower extremity [MEDICAL CONDITION]) Resident #1's feet until 9/5/15. Family Member #1 said that on 9/7/15, she found Resident #1's boots (too relieve pressure) were put on so tight with the Velcro straps that it left imprints in Resident #1's foot. The Surveyor interviewed the Assistant Director of Nursing (ADON)/Staff Development (SD) at 1:31 P.M., on 12/14/15, the ADON/SD said that Resident #1's stage 1 pressure sore should have been measured on admission. The Surveyor interviewed Physician #1 at 3:30 P.M. on 12/11/15, Physician #1 said that Resident #1 came in with stage one pressure sores and then ended up with a right purple heel (deep tissue trauma due to unrelieved pressure). The Surveyor interviewed Unit Manager (UM) #1 at 5:00 P.M. on 12/14/15, UM #1 said that Resident #1's heels were off-loaded when he/she was in the wheelchair by elevating them with the wheelchair footrests and a pillow. UM #1 said that Resident #1 always had the footrests on his/her wheelchair although this was not documented or care planned. The Surveyor interviewed Family Member (FM) #1 at 1:10 P.M. on 12/17/15, FM #1 said the footrests were not on Resident #1's wheelchair until 9/5/15 (12 days after admission, for offloading the heels and decreasing the lower extremity [MEDICAL CONDITION]). FM #1 said Resident #1 was peddling his/her wheelchair in slipper socks against the hard floors and she had ankle swelling ([MEDICAL CONDITION]), and she had to make a fuss or words to that effect to finally get the footrests. The Surveyor interviewed FM #2 at 2:45 P.M. on 12/22/15, FM #2 said that foot rests were not on Resident #1's wheelchair until 9/5/15 after the pressure sore had already worsened.

Based on record review, observation and interview, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 11 residents with falls (#11) in a total sample of 24. Findings included: For Resident #11, the facility failed to provide adequate supervision and assistance devices to prevent 7 falls and/or accidents in 11 months, 1 fall resulting in a right hip fracture. Resident #11 was admitted to the facility in 4/08 with [DIAGNOSES REDACTED]. The Fall Investigation of 10/9/10 at 3:00 P.M. indicated that the resident was ambulating without assistance in the Resident Lounge and was found on the floor. There was no injury. Resident refuses alarms, throws them away, and hides them. New interventions included: Educate and ensure that resident wears proper footwear. Monitor for patterns and trends. Review of Progress Notes and the Fall Investigation indicated that on 12/12/10 at 9:30 A.M., the resident was observed sitting on the side of the bed. The resident reached down for shoes and slid out of bed to the floor. There was no injury. New interventions included: Non-skid strips to window side of bed on floor. Bilateral bed rails as enablers. Resident refused alarms. Reacher encouraged. Monitor for patterns and trends. The annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/13/11, indicated that the score from the Brief Interview for Mental Status (BIMS) was 12 out of 15 (moderate cognitive impairment). The resident was independent with transfers and ambulation, required limited assist with bathing, dressing and toilet use, was occasionally incontinent of bladder, and had 2 falls since the prior assessment. The At Risk For Falls Care Plan, initiated on 1/21/11, included: *Assess for pain every shift. *Bed in low position. *Call light or personal items available and in easy reach, provide reacher at bedside. *Footwear to prevent slipping-encourage when refuses. *Monitor for bleeding, bruising, falls, skin tears. *1/2 side rails in bed to enable bed mobility and define bed parameter. Review of Progress Notes and the Fall Investigation indicated that on 4/6/11 at 8:45 P.M., the resident was found sitting on the floor next to bed. The resident was wearing non-skid socks and had been ambulating back from the bathroom using a walker. There was no injury. Interventions included: Frequent checks for safety. Commode at bedside. Non-skid floor strips extended to window side of bed. Again refused alarms. The quarterly MDS assessment, with an ARD date of 4/15/11, indicated a BIMS score of 10 (moderate cognitive impairment). The resident declined and now required supervision with transfers and ambulation in the hallway, limited assist with ambulation in bedroom, extensive assist with toilet use, and had 1 fall since the prior assessment. Review of Progress Notes and the Fall Investigation indicated that on 5/1/11 at 9:30 P.M., the resident was found sitting on the floor next to bed. There was no injury. The resident stated, "I was walking and tripped on the floor strips." Interventions included: Physical Therapy screen. Floor strips were found to be secure. Obtain urinalysis and Culture and Sensitivity. Three day tracking for bowel and bladder. Psychiatric evaluation of medications. The Psychiatric Diagnostic/Treatment Evaluation of 5/12/11 indicated that the resident lacked the capacity to make informed decisions due to impaired memory and judgement. The Physical Therapist Progress Note and Discharge Summary of 5/26/11 indicated that the resident had limited cognition and required supervision for all mobility. Review of Progress Notes and the Fall Investigation indicated that on 6/18/11 at 5:00 A.M., the staff heard a loud bang, and the resident was found on the floor at bedside. The resident indicated that the resident was fixing the bed sheets. There was no apparent injury at the time of the fall. At 12:00 P.M., the resident complained of increased right upper thigh pain. The resident was transferred to the hospital and was found to have sustained an impacted right hip fracture. New interventions included: Place alarm box in a privacy bag. Alarmed floor mat next to bed, on door side. The care plan was updated to include the new interventions on 7/12/11. The Fall Risk Assessment of 6/27/11 indicated a score of 16 (a score of 10 or greater indicated a fall risk). The significant change MDS assessment, with an ARD of 7/17/11, indicated that the resident was unable to complete the BIMS exam and had short and long term memory loss. The resident required assist with transfers, ambulation, bathing, dressing and toilet use, was frequently incontinent of bowel and bladder, and had a new [DIAGNOSES REDACTED]. Review of Progress Notes, the Hospital Discharge Summary and the Fall Investigation indicated that on 8/13/11 at 11:15 A.M., the alarm sounded and the resident was found sitting on the bathroom floor. The resident had attempted to self toilet (The resident required assist with toilet use). The resident sustained [REDACTED]. The resident was sent to the hospital. The CAT-Scan of the neck and head were negative. The resident refused a hip X-ray, but was able to ambulate without difficulty. The resident returned to the facility at 4:00 P.M. with [DIAGNOSES REDACTED]. New interventions included: Obtain urinalysis and culture and sensitivity. Three day bladder diary. Obtain a urinalysis. Review bed Management. Review of Progress Notes and the Fall Investigation indicated that on 9/9/11 at 5:00 P.M., the resident was found sitting in a wheelchair in the bedroom. The resident sustained [REDACTED]. Resident #11 indicated that they wanted to walk to the hallway bubbler. As both residents were confused and the incident was not witnessed, it was unclear if the resident actually fell or how the skin tear was sustained. Nurse's Note Intervention: Alarms in place, proper footwear in place, call bell within reach, and encouraged resident not to ambulate without assist (resident had short term memory loss). The resident was transferred to the hospital on [DATE] because the right arm skin tear would not stop bleeding. The resident returned with an Aquacel Dressing. New interventions included: Fifteen minute checks. Rehabilitation screen. Velcro seatbelt trial. Geriatric sleeves (Geri-sleeves). On 9/13/11, between 8:30 A.M. and 10 A.M., the resident was observed lying in bed. The alarm and floor pad were in place. The bed was in the high position instead of in the low position. Interview with the Director of Nurses at 2:00 P.M. indicated that the resident used the bed remote control at times and might have raised the bed. The Director of Nurses indicated that the control should be kept in a privacy bag out of reach. On 9/14/11 at 9:05 A.M., the resident was observed lying in bed in the low position. The bed remote control was clipped to the bed rail within the resident's reach. The control was not in a privacy bag out of reach. On 9/14/11 at 3:00 P.M., the Director of Nurses acknowledged that Resident #11 sustained 7 falls and/or accidents in 11 months, one fall resulting in a hip fracture. Additional documentation of 9/19/11, provided by the Director of Nurses, indicated that further facility investigation of the (9/9/11) incident indicated that the resident may have sustained the skin tear on the door latch.