Every finding on record at Gardner Heights Health Care Center, Inc

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure the radiators did not have sharp areas exposed, were free of rust, were secured to the wall, and missing molding repaired to maintain a homelike environment. The findings include: Observations on the Laurel unit on 4/20/26 from 10:46 AM to 11:17 AM, identified the following: room [ROOM NUMBER]: The end cap on the right side of the radiator located along the wall under the window was located on the floor by the radiator, leaving multiple sharp surfaces exposed. room [ROOM NUMBER]: The radiator had a bulging area in the center, and the left side of the radiator was missing the louver that tilts to adjust the heat intensity, the floor under the radiator contained dirt and debris and the windowsill paint above the radiator had scuffed areas where the paint was missing. room [ROOM NUMBER]: The radiator cover along the bottom of the radiator was not in place and resting on the floor, several sharp edges were exposed, and the top of the radiator appeared to have brown rust stains. Observation on 4/27/26 at 9:30AM identified room [ROOM NUMBER] was missing wall molding behind the door to the room and the door was difficult to close because the bottom of the door dragged the floor. Further, the radiators in rooms [ROOM NUMBERS] were in disrepair. Observation on 4/27/26 at 9:35 AM identified that a radiator in the Maple dining room located on the wall under the window had an area that was unattached to the wall.Observation on 4/27/26 at 9:40 AM identified the radiator in the cedar dining room located on the far-right wall had an area that bulged, and several areas of molding were missing and/or damaged. Observation on 4/27/26 at 9:45 AM identified a radiator located on the Laurel Hallway had a sharp edge protruding into the hallway from the bottom left corner. Interview and observations of the Laurel unit with the Maintenance Director on 4/27/26 at 9:50 AM identified all of the identified concerns had not been previously identified. The concerns had not been placed in the maintenance book by the nursing staff to be addressed. The Maintenance Director further identified that rounds had been completed on the Cedar unit at the beginning of the month, last month on the Laurel unit and two months ago on the Maple unit. Additionally, the Maintenance Director identified that the sharp areas exposed on the radiator could pose a safety risk for the residents, and the radiators in disrepair did not contribute to a homelike environment for the residents. Interview with the Administrator on 4/27/26 at 2:00 PM identified she was unaware of concerns with the radiators. She further noted that there had been some radiators that were repainted in the past. She further noted that the exposed sharp edges could potentially be an issue for the residents. She noted that environmental rounds are completed throughout the facility to identify issues. Environmental rounds dated 11/25/25, and 2/16/26 did not identify concerns with the radiators. The rounds were signed off by maintenance, the DNS, the Administrator and were completed by the IP. Review of the Environmental surveillance policy directed it is the policy of the facility that the Infection Preventionist and supporting department heads will complete environmental rounds quarterly. Environmental rounds will be an integral part of the daily routine and will be performed regularly throughout the facility. Areas identified will be shared with the appropriate department head.

Based on observations, clinical record reviews, review of facility documentation, review of facility policy and interviews for two of six sampled residents (Resident #3 and Resident #56) reviewed for foot care, the facility failed to ensure the resident received podiatry services for trimming of toenails. The findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, polyneuropathy, and atrophic disorder of the skin. The admission MDS assessment dated [DATE] identified Resident #3 was cognitively intact, had no behaviors, required substantial/maximal assistance with bed mobility, and personal hygiene, and independent for dressing. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 1/13/26 identified Resident #3 needed staff assistance related to ADL's with interventions that included full mechanical lift assist x2 to standard wheelchair, ambulate only with therapy, may use a wheelchair for positioning/transport, keep commonly used articles within reach. Hospital discharge paperwork dated 1/9/26 identified a referral placed to ensure follow up with primary care physician, podiatrist and wound care center. Under follow up appointment the paperwork directed to follow up with the primary care physician within 1-2 weeks, podiatry specialist within 1-2 weeks of discharge, and follow up with wound care center. Physician's order dated 1/9/26 placed by the admitting nurse signed by the medical director directed wound, vision, dental, podiatry, audiology and psychiatric services as needed. This order was discontinued on 3/5/26. Physician's order dated 3/5/25 directed to obtain a routine vision, dental, podiatry, and audiology consult. This order was discontinued on 3/7/26.\ Interview with Resident #3 on 4/20/26 at 10:00AM identified he/she had been requesting from the facility to be seen by podiatry as he/she needed his/her nails trimmed and was diabetic. Resident #3 identified he/she was offered the service when admitted and was told that the facility would set it up for him/her. Review of the clinical chart identified no podiatry visits had been scheduled, canceled, refused, or completed. No notes regarding podiatry care were in the clinical chart nor were there any podiatry consents received or services declined. Interview with the ADNS on 4/22/26 at 12:00PM identified when a patient is admitted from the hospital the admitting nurse reviews the paperwork and gives the information to the supervisor or ADNS regarding any upcoming appointments. The ADNS is responsible for making the follow up appointments and either scheduling with the podiatric provider routine services or would make an appointment with an outside provider if needed. The ADNS identified that no appointment was made for Resident #3 following admission and there should have been one made for him/her. The ADNS further identified that Resident #3 was never signed onto Health drive services during his/her time in the facility as well, no was there evidence of decline of services. Observation and measurement of the resident's toenails with the DNS and Infection Preventionist (wound nurse) on 4/23/26 at 1:30PM identified on the left foot the great toenail measured 0cm, 2nd toenail measured 4cm, 3rd toenail measured 2cm, 4th toenail measured 3cm, and 5th toenail measured 1cm. On the right foot the great toenail measured 1cm, the 2nd toenail measured 2cm, the 3rd toenail measured 1cm, the 4th toenail measured 2cm, and the 5th toenail measured 0cm. Interview with the DNS on 4/23/26 at 1:45PM identified Resident #3 should have been seen by podiatry and would be followed approximately every 60 days by the podiatrist for toenail care due to the diabetic status. Therefore, the resident should have been on the second visit from podiatry from admission. Review of the Ancillary Services policy directed ancillary services include, but are not limited to podiatry, dentistry, optometry, audiology, and other specialized care as required by resident's condition. Resident's ancillary needs will be determined during admission and as part of ongoing assessments by the interdisciplinary team. Ancillary services will be provided by the facility or through coordination with qualified external providers. Residents and or their legal representatives will be informed of available services and assisted in scheduled appointments as needed. Resident #56 was admitted to the facility in August of 2024 and had diagnoses that included cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #56 had severely impaired cognition, dependent on staff for dressing, personal hygiene, putting on and/taking off footwear, transfers, bed mobility and was non-ambulatory. The care plan dated 2/2/26 identified Resident #56 had diabetes with interventions that directed to watch for increased pain and/or numbness and vascular changes in extremities and report to MD/APRN. The care plan further identified Resident #56 was at risk for skin breakdown due to decreased mobility, incontinence with interventions that directed to inspect skin when providing care for sign/symptom of breakdown. The monthly physician's order directed consults with vision, dental, podiatry, audiology and psychiatric services as needed and body audit on admission and weekly by the licensed nurse on Tuesday on shower days with an origination order date 8/24/24. The physician's order for February/2025 through April/2026 directed weekly body audit on every Tuesday on the evening shift on shower day. Observation and interview on 4/21/26 at 1:58 PM with NA #1 identified Resident #56 lying in bed when NA #1 asked the resident permission prior to removing his/her socks and noted the resident's toenails on feet needed to be trimmed. NA #1 identified that she had noted the resident's toenail length and reported it to the nurse about a month ago, which the nurse told her then, the resident would be placed on the podiatry list. NA #1 indicated that she was unable to recall the name of the nurse who she told about the resident's toenails. Review of Resident #56 clinical records failed to identify the resident had been seen by the podiatrist since his/her admission. Review of the Nursing admission assessment dated [DATE] failed to identify Resident #56 had toenails that need trimming nor did it reflect any concerns or issues with his/her toenails. Review of the Treatment Administration Record (TAR) for the period of August/2025, and from November 2025 through April 21, 2026, identified weekly body audits were completed on Resident #56 assigned shower day. Further, review of the clinical records for the period of January/2025 through April 21, 2026, failed to identify a note reflecting any issues or concerns with Resident #56's toenails nor did the records identified Resident #56 and/or his/her conservator had refused/offered podiatry services. Interview with the ADNS on 4/21/26 at 2:30 PM identified an email was sent to the company that provides podiatry services to the facility on 3/13/26 to add Resident #56 to the podiatry list and the resident was then scheduled to be seen on May 11, 2026. She further identified Resident #56's conservator did not want to sign the consent form even though he/she wanted the resident to receive podiatry services. The ADNS identified Resident #56 needed to be seen by podiatry and the conservator was hesitant in signing the consent, so they completed a physician order form provided by the company on 4/1/26 for the resident to be seen. The ADNS further identified for a resident to be seen by the podiatrist or received other services from the contracted provider, she would need to send over the resident's demographic sheet (face sheet) and consent form them to be enrolled in the various services offered. The DNS then joined the interview when they were asked why the resident wasn't placed on the podiatry list sooner and the DNS responded that she was not aware that the resident needed podiatry services prior. Observation on 4/22/26 at 9:47AM with LPN #2 and RN #1 identified Resident #56 was seated in the wheelchair and LPN #2 let the resident know what she was about to do prior to removing the resident socks and the following was noted: on the left foot: the great toenail extending over the tip of the toe measuring 2.0 centimeters (cm) with a nail thickness of 1.0 cm; the 2nd toenail extending over the tip of the toe measuring 2.0 cm with a nail thickness of 0.5cm; the 3rd toenail extending over the tip of the toe towards under the 2nd toenail measuring 1.5 cm; the 4th toenail curved and extending over the tip of the toe measuring 1.8 cm and the 5th toenail curved towards the sole of feet with a dark line midway across the nail which extended over the of the toe measuring 2.8 cm. On the right foot noted: the great toenail extending over the tip of the toe measuring 3.5 cm with a nail thickness of 1.0 cm curving towards the 2nd toenail, and dark discoloration to the right side of the great toe; the 2nd toenail extending over the tip of the toe measuring 2.4 cm; the 3rd toenail extending over the tip of the toe measuring 2.0 cm which is curved under the 2nd toenail; the 4th toenail extending over the tip of the toe measuring 2.8 cm; and the 5th toenail extending over the tip of the toe measuring 2.7cm which curved towards the 4th toenail. According to the article title Nails in Older Adults by Albucker SJ, Conway J, [NAME] SR. identified on average toenails grow 1.0 mm/month and fingernails grow 3.0mm/month. A review of the Podiatrist's service dates at the facility for the period of October 1, 2025, through April 24, 2026, identified that the Podiatrist visited the facility a total of 6 times to provide podiatry services. Interview with LPN #1 in the presence of the DNS and RN #1 on 4/22/26 at 12:06 PM identified Resident #56's conservator had mentioned the need for podiatry services at least once in the last 6 months and each time it was mentioned she would report it to the front office which is the DNS and ADNS. Interview with the ADNS and DNS in the presence of RN #1 on 4/22/26 at 12:05 PM identified the resident had not received podiatry services since admission. The ADNS identified she became aware of the toenails when the resident's conservator had removed the resident's sock, and she came in to assess the area. The DNS and the ADNS identified that they would expect the toenails to have been identified sooner than 3/13/26, given that skin checks are completed weekly and care is provided to the resident daily. Interview on 4/22/26 at 2:30 PM with NA #2 identified she had seen the toenails and thought the resident was on the podiatry list. She further identified the toenails has been like that for more than a month and did not notify the nurse as the podiatrist does come to the facility. She further indicated that she should have let the nurse know when she had noticed the length of the toenails. Interview with APRN #1 (Wound care Specialist) on 4/22/26 at 2:46PM identified a resident with diabetes should automatically have an order for daily diabetic foot checks. When asked what are the complications that could occur if toenails are not trimmed and she responded it could lead to skin break down, infections and ingrown nails. Interview with the Charge Nurse LPN #5 on 4/23/26 at 3:20 PM identified she completes weekly skin check on the resident's shower days which includes checking the resident's nails, and when an issue is identified with the skin, she would then write a progress note. She further identified that they knew about Resident #56's toenail. LPN #5 further identified she could not recall seeing the length of his/her toenail, nor could she recall if any of the nurse aide told her about the resident's toenail. She indicated that if she was told about a resident toenail needing to be trimmed, she would report it to the nursing supervisor and could not recall if she did. Interview with Person #1 (Senior Account Manager for the contracted service provider that is used by the facility for ancillary services) on 4/23/26 at 11:29 AM identified for a resident to be enrolled in podiatry services the facility would only need to send over the resident's face sheet and the completed physician order form provided by their company by indicating the services in which the resident need. After these documents are received the resident will automatically be added to the list to be seen by the provider on their next visit to the facility. She further identified Resident #56 was enrolled in podiatry on 3/13/26 and was not added to the list of residents to be seen on 3/18/26 as the podiatrist list was full at the time, hence the resident was placed on the May 11, 2026, list. She further identified if a resident had a greater need to be seen by the podiatrist the facility would need to let the podiatrist know before the visit or at the time of the visit, so they could be seen. Interview with the ADNS, LPN #2, in the presence of the DNS and RN #1 on 4/24/26 at 11:53 AM identified Resident #56 toenails would be a priority to be seen by the podiatrist immediately. However, they failed to identify that the podiatrist was made aware of the resident urgent need on 3/13/26, and at the time of the podiatrist visit on 3/18/26 and after. The ADNS identified she contacted the contracted company again on 4/1/25 when the resident was noted to have a darkened area with a small opening to the side of the right great toe and sent over the company's physician order form. Review of the Ancillary Services policy identified ancillary services include, but are not limited to, podiatry, dentistry, optometry, audiology, and other specialized care as required by the resident's condition. The policy further identifies the resident's ancillary service needs will be evaluated during admission and as part of ongoing assessments by the interdisciplinary care team and primary physician.

Based on observations, review of facility documentation and staff interviews, the facility failed to ensure the secured unit was addressed in the facility assessment. The findings include:Observations on all days of the survey 4/20, 4/21, 4/22, 4/23, 4/24 and 4/27/26 identified a secured unit located on the right side of the building after entering through the front door. The unit consisted of two entrance doors accessible from the inside of the facility that required a numeric code to be entered to enter or exit the unit. Inside the unit, there were four additional doors to exit the unit. One door required a numeric code to exit and exited into an internal courtyard. One door required a numeric code to exit and exited outside the rear of the building. Two doors, which were one door into a vestibule containing another door, required a numeric code to exit or enter. To come back into the building the interior door had an entrance button, not a numeric code to come back in. The exterior doors were confirmed to have a delayed, alarmed egress in the event of an emergency. The unit consisted of three hallways with cameras that fed to a monitor at the secured unit nurses' station. The unit capacity was 35 residents.Observations on all days of the survey 4/20, 4/21, 4/22, 4/23, 4/24 and 4/27/26 identified sensors on the walls in the hallways and near exit doors throughout the entire building identified as sensors to support the wanderguard system for wandering residents. The system was confirmed to be working.Review of facility documentation identified criteria for admission to a secured dementia unit that included a diagnosis of dementia and behaviors, elopement or wandering, that required closer supervision for safety.Review of the facility assessment dated [DATE] identified the number of licensed beds was 130 and served residents with common diagnoses that included Alzheimer's disease, non-Alzheimer's dementia, impaired cognition and other behaviors that require intervention. The assessment indicated that acuity of residents with behavioral symptoms and cognitive performance had an average number of residents identified as 36 and indicated special treatments for behavioral health needs an average number of 36. Section 2 of the assessment identified resident support/care needs that included care of someone with cognitive impairment and indicated all staff on hire and annually receive competency training on caring for people with dementia, Alzheimer's and cognitive impairments. The physical environment and building/plant needs failed to identify a wander guard system and failed to identify the facility had a secure unit.Interview with the Administrator on 4/22/26 at 10:39 AM identified a secured unit policy that was implemented [DATE] and indicated the unit was called the secured dementia unit. Further interview with the Administrator on 4/22/26 at 11:16 AM indicated that she was unable to locate the secured unit in the facility assessment and that it must have been an oversight. Additionally, the Administrator confirmed capacity of the facility was 120 beds.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure, and interviews for one of two sampled residents (Resident #116) reviewed for advanced directives, the facility failed to ensure consent was obtained and a physician's order was in place for the resident's wishes regarding advanced directives and decisions related to cardiopulmonary code status from the resident/responsible party. The findings include: Resident #116 was admitted to the facility in April/2026 with diagnoses that included pneumonia, acute respiratory failure with hypoxia and malignant neoplasm of head, face and neck. The nursing admission assessment dated [DATE] identified Resident #116 was cognitively impaired and required the assistance of two people for transfers, and positioning. A review of Resident #116's clinical record from [DATE], through [DATE], failed to reflect a physician's order directing a code status/advance directive elected by the resident or his/her representative nor did the clinical records identify a Medical Interventions Consent form completed by the resident or by his/her representative. Resident #116 identified that he/she was not asked on admission about his/her code status until [DATE] when he/she elected full code (CPR) (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Interview with the Charge Nurse (LPN #3) on [DATE] at 1:39 PM identified that if Resident #116 had a life-threatening emergency where it would be necessary to provide CPR or withhold CPR, she would first look on the banner section of the electronic records for the resident's code status and if it is not there she would look in the physical chart under the advance directive tab. LPN #3 reviewed the electronic record and noted that Resident #116 did not have an elected code status. She then looked in the physical chart under the advanced directive tab and noted there was no Medical Interventions Consent form. LPN #3 identified that the Medical Interventions Consent form is completed on admission by the resident/resident representative. LPN #3 further identified that Resident #116 was responsible for him/herself and was able to complete and sign the Medical Interventions Consent form. Interview with the DNS in the presence of RN #1 on [DATE] at 1:53 PM identified that she would have expected the form to be completed and the physician's order put in place prior to [DATE]. Interview with the Nursing Supervisor (RN #2) on [DATE] at 9:57 AM identified she was the nurse who completed Resident #116 admission paperwork and at the time of the resident's admission he/she was confused, so she let the oncoming shift know about what areas of the admission that were not complete. When asked if the resident is responsible for themselves and is unable to sign what would be the resident code status in a life-threatening emergency where it would be necessary to provide CPR or withhold CPR, RN #2 responded that the code status from the hospital discharge paperwork would be implemented. She further identified the physician order would be written based on the hospital paperwork and if there were no code status on the paperwork the resident would be a full code. RN #2 further indicated there was no code status indicated on Resident #116 hospital discharge paperwork. Upon reviewing the records with the surveyor, she identified the resident did have a code status of full code. RN #2 then identified she should have placed an order directing full code until the resident was able to decide as sometimes residents change their code status upon admission. She further identified that each resident should have a physician's order directing his/her code status. Subsequent to surveyor's inquiry, a Medical Interventions Consent form for Resident #116 was completed and signed by the resident on [DATE] indicating a code status of full code.Review of the Advance Directives policy identified that upon admission to the facility advance directives will be reviewed with the resident and/or the resident's substitute decision maker (s) by the licensed nursing staff or the attending physician. The policy further identified the advance directive consent form will be kept in the resident's medical record, a physician order will be obtained regarding advance directives. The policy further identified if no decision is made related to advanced directives the resident will remain a full code until a decision is made by the resident or substitute decision maker (s).

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of five sampled residents (Resident #15) reviewed a resident-to-resident altercation, the facility failed to ensure the resident was free from abuse. The findings include: Resident #15's diagnoses included bipolar disorder, anxiety disorder, and dementia. The annual MDS assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, required supervision with transfers and was ambulatory. The care plan dated 10/11/24 identified Resident #15 was involved in a resident-to-resident altercation with interventions that directed to notify MD/APRN, offer psychiatric support services, and social work follow up and support. Resident #104's diagnoses included dementia, unspecified psychosis, and mood disorder.The annual MDS assessment dated [DATE] identified Resident #104 was moderately cognitively impaired, required partial/moderate assistance with bed mobility, transfers, dressing, and substantial/maximal assistance with personal hygiene. The assessment further identified that the resident utilized a walker and wheelchair for mobility. The care plan dated 10/11/24 identified Resident #104 was involved in a resident-to-resident altercation with interventions that directed to notify MD/APRN, offer psychiatric support service, and social work follow up and support. The nurse's note dated 10/10/24 at 6:49PM identified the charge nurse reported that Resident #104 slapped Resident #15 on the left side of the face in the theater room. Resident #15 complained of severe pain in the jaw, ear, and left side of the neck and reported it felt like his/her jaw was broken. The APRN's progress note dated 10/10/24 at 11:26PM identified Resident #15 was evaluated for a contusion to the left jaw following being slapped by another resident. Resident #15 complained of pain being a level 10 on a scale of 1 to 10 with 10 being the most severe and was worried his/her jaw was broken. The note further identified the resident was sent to the hospital emergency department for evaluation. Review of the Reportable Event report dated 10/10/24 at 4:30PM identified LPN #7 witnessed Resident #104 place a chair in front of Resident #15 blocking his/her path to exit the dining room. Resident #15 attempted to grab the handles of Resident #104's wheelchair and asked why Resident #104 was blocking the path. Resident #104 slapped Resident #15 on the left side of the face. Resident #15 described the slap as hard as hell and noted that it made him/her see stars and lose his/her balance briefly. Resident #15 identified his/her pain level was a 10 out of 10. The nursing supervisor was informed and police were called. Resident #15 was sent to the hospital for evaluation. The report further identified that Resident #104 had no prior incidents of this type of behavior. Review of the hospital emergency department report dated 10/10/24 identified Resident #15's complained that he/she was assaulted and had jaw pain. Resident #15 was treated for a closed head injury and ordered Tylenol as needed for pain control. The nursing note dated 10/10/24 identified Resident #104 was sent to the hospital emergency department for a psychiatric evaluation following the altercation with another resident and was cleared to return to the facility. Review of Social Work notes dated 10/11/24, 10/14/24, and 10/15/24 identified Resident #15 felt a little sore and had no signs or symptoms of emotional distress and no concerns voiced. Interview on 4/27/26 at 1:00 PM with the DNS identified she was the ADNS at the time of the incident and did not specifically recall the incident however she was aware of it. The DNS further identified that all residents should be free from abuse in the facility. Review of the Abuse Policy directed all residents are treated with kindness, compassion, and dignity, and that any allegations of abuse are thoroughly investigated and addressed in accordance with all applicable laws and regulations. Defining abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #56) with an alteration in skin integrity, the facility failed to ensure the wound was assessed per the standard of practice, and failed to ensure a physician's order was in place to address the alteration in skin integrity and failed to ensure weekly monitoring of the alteration in skin integrity. The findings include:Resident #56 was admitted to the facility in August of 2024 with diagnoses that included cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit and muscle weakness.The quarterly MDS assessment dated [DATE] identified Resident #56 had severely impaired cognition, was dependent on staff for dressing, personal hygiene, putting on and/taking off footwear, transfers, bed mobility and was non-ambulatory.The care plan dated 2/2/26 identified Resident #56 had diabetes with interventions that directed to watch for increased pain and/or numbness and vascular changes in extremities and report to MD/APRN. The care plan further identified Resident #56 was at risk for skin breakdown due to decreased mobility, and incontinence. Care plan interventions directed to inspect skin when providing care for signs/symptoms of breakdown. The nurse's note dated 4/1/26 at 12:54 PM written by the ADNS identified Resident #56 was noted to have a darkened area with a small open area measuring 0.3 by 0.1 by 0.1 centimeters (cm) to the right great toe. The APRN was notified with new orders to cleanse with normal saline followed by bacitracin ointment and dry protective dressing daily and to follow-up with podiatryThe physician order dated 4/1/26 directed to cleanse right great toe with normal saline followed by bacitracin ointment and dry clean dressing, and to change every day and as needed for 10 days.Review of the clinical record failed to identify that the darkened area on the right great toe was measured, only the small open area was measured when first identified on 4/1/26.Observation and interview on 4/22/26 at 9:47AM with LPN #2 and RN #1 identified Resident #56 was seated in the wheelchair and LPN #2 let the resident know what she was going to do prior to removing the resident's socks, once the socks were removed, a discolored area to the side of the right great toe with a scabbed area towards the center of the discolored area. Both LPN #2 and RN #1 identified this was a new area, and noted the resident had a skin impairment on the left 2nd toe that resolved on 4/21/26.Interview on 4/24/26 at 11:53 AM with the ADNS in the presence of LPN #2 (Wound Nurse), the DNS, and RN #1 identified she was notified by the charge nurse to assess the area to the right toe. The ADNS further identified that at the time of her initial assessment she had not classified the wound, she left the classification to the APRN to determine. Review of the clinical record failed to identify that the Wound Care APRN or the wound nurse evaluated the area identified on 4/1/26 on the right great toe and failed to identify that the area had been assessed since the initial documentation. Observation and interview with the ADNS, LPN #2 (wound nurse) and RN #1 on 4/24/26 at 2:05 PM identified Resident #56 lying in bed. LPN #2 removed the resident's socks and noted the area to the right side of the great toe which measured 2.0 cm in length by 1.0 cm in width by 0.0 depth, within the discolored area towards the top noted some areas appeared darker measuring 0.5cm in length by 1.0cm with width; in the middle of the discolored areas noted a peeled back scab measuring 0.3 length by 0.3 cm in width; on the lower area of the discoloration measured 1.2 cm in length by 1.1 cm in width. The ADNS identified the area seen currently as what she had identified on 4/1/26, which now appeared lighter and improved from her first observation of the area, wherein the area was much darker. The ADNS further identified she should have measured the open area and the darkened area that was identified. The Wound Care APRN (APRN #1) initial evaluation progress note dated 4/7/26 at 7:13 AM identified Resident #56 was seen for an evaluation and management of a wound on the left second toe, a diabetic foot ulcer, partial thickness. The note failed to identify that an evaluation of the right great toe was completed.Interview on 4/24/26 at 11:53 AM with LPN #2 (Wound Nurse), the DNS, the ADNS and RN #1 identified that they run a 24-hour nurse's progress report to review and discuss concerns at morning report. LPN #2 further identified that any wound issues that were identified would be discussed in the meeting as well. LPN #2 further identified Resident #56 had an area to the left 2nd toe and was unaware of the area to the right great toe. LPN #2 further identified that when APRN #1 came on 4/7/26 for the initial assessment of the wound, she showed the APRN the left foot 2nd toe which had discoloration because that is where she thought the resident had the wound, therefore the right foot was not seen by the APRN. Interview with the ADNS, LPN #2 and RN #1 on 4/24/26 at 2:05 PM identified that the ADNS co-signs LPN #2's notes indicating she agrees with LPN #2's documentation. The ADNS was then asked when she reviewed LPN #2's note why she didn't see it was the left foot instead of the right, when she responded that it did not dawn on her at the time.Review of the weekly wound report documentation failed to identify Resident #56's right great toe was thoroughly assessed/monitored and documented on weekly from the date it was discovered, 4/1/26 through 4/22/26.Interview on 4/24/26 at 11:53 AM with LPN #2 in the presence of the DNS, the ADNS and RN #1 identified wounds including skin discoloration are seen weekly by the wound care APRN and the wound nurse and is documented on until the area is resolved. LPN #2 identified she was unaware of the area to the right great toe so there was no weekly documentation or monitoring completed.Review of the Wound and Skin Care Protocol policy identified skin areas will have weekly documentation until healed, and wounds will be reviewed at the weekly at risk meeting utilizing the skin and pressure ulcer tracking sheet.Review of the physician order for the period of April 7, 2026, through April 22, 2026, failed to identify a treatment directing care of the wound to the right great toe.Interview on 4/24/26 at 11:53 AM with LPN #2 in the presence of the DNS, the ADNS and RN #1 identified she had deleted the current treatment for the right great toe on 4/7/26 when the resident was first seen by APRN #1 and the new order for the left second toe was entered into the electronic medical record. LPN #2 identified she had made a mistake as the order had stated right great toe when she discontinued the order. Review of the Wound and Skin Care Protocol policy identified residents are assessed by the nurse for risk of skin breakdown. Weekly body audits will be completed on bath/shower day by a licensed nurse. The policy further identified skin areas will have weekly documentation until healed.

Based on a review of facility staffing, review of facility documentation and staff interviews for 4 of 4 days reviewed, the facility failed to ensure that staffing met the State of Connecticut, Public Health Code minimum staffing requirements of 3.0 Per Patient Day (PPD) hours and failed to meet ratios as outlined in the facility assessment. The findings include:The facility triggered for low weekend staffing Oct through [DATE] and triggered for one star staffing.Facility staffing on Saturday, 11/15/25, identified a census of 112 residents.The facility schedule dated 11/15/25 (Saturday) identified that for Nurse Aide (NA) staff, there were 174 PPD hours worked during the 7:00 AM to 9:00 PM time frame. The facility schedule dated 11/15/25 (Saturday) identified that for Licensed staff, there were 64 PPD hours worked during the 7:00 AM to 9:00 PM time frame. The combination of the Nurse Aide and Licensed staff PPD hours was 238 PPD hours. According to the Public Health Code 3.0 Staffing Grid, the facility was required to have 243.04 PPD hours of combined Licensed and NA staff (a shortage of 5.04 hours) for a census of 112 residents.Review of the facility accident and incident tracking form dated November 2025, there were 10 unwitnessed falls or injuries during the month of November. There was one unwitnessed fall that occurred on 11/15/25 on the 3 PM to 11 PM shift on the secured unit.Review of the facility assessment dated [DATE] identified 1 RN supervisor each shift and staffing ratios of Licensed nurses to residents as 1:30-35 on days and evenings and 1:40 on nights. The assessment identified ratio of direct care staff (NA) to residents 1:8-10 on days, 1:10-15 on evenings and 1:20-25 on nights.Review of the facility staffing compliance guidelines dated 4/26/26 identified that for an actual census of 110-114 the facility required 5 RN/LPN and 14 NAs on the 7 AM - 3 PM shift (a shortage of 2 NAs) and 5 RN/LPNs and 11 NAs on the 3 PM - 11 PM shift (a shortage of 1 RN/LPN) b. Facility staffing on Sunday, 1/4/26, identified a census of 112 residents.The facility schedule dated 1/4/26 (Sunday) identified that for Nurse Aide (NA) staff, there were 170 PPD hours worked during the 7:00 AM to 9:00 PM time frame. The facility schedule dated 1/4/26 (Sunday) identified that for Licensed staff, there were 62 PPD hours worked during the 7:00 AM to 9:00 PM time frame. The combination of the Nurse Aide and Licensed staff PPD hours was 232 PPD hours. According to the Public Health Code 3.0 Staffing Grid, the facility was required to have 63.84 PPD hours of Licensed staff (a shortage of 1.84 hours) and 243.04 PPD hours of combined Licensed and NA staff (a shortage of 11.04 hours) for a census of 112 residents.Review of the facility accident and incident tracking form dated January 2026 identified 20 unwitnessed accident/injuries during the month of January 2026. The tracking indicated 3 unwitnessed incidents on 1/4/26 before 9 PM. This unwitnessed incident occurred on the secured unit.Review of the facility staffing compliance guidelines dated 4/26/26 identified that for an actual census of 110-114 the facility required 5 RN/LPN and 14 NAs on the 7 AM - 3 PM shift (a shortage of 1 RN/LPN and 1 NA) and 5 RN/LPNs and 11 NAs on the 3 PM - 11 PM shift. There was not a shortage based on facility staffing grid. c. Facility staffing on Monday, 4/13/26, identified a census of 108 residents.The facility schedule dated 4/13/26 (Monday) identified that for Nurse Aide (NA) staff, there were 160 PPD hours worked during the 7:00 AM to 9:00 PM time frame. The facility schedule dated 4/13/26 (Monday) identified that for Licensed staff, there were 56 PPD hours worked during the 7:00 AM to 9:00 PM time frame. The combination of the Nurse Aide and Licensed staff PPD hours was 216 PPD hours. According to the Public Health Code 3.0 staffing Grid, the facility was required to have 61.56 PPD hours of Licensed staff (a shortage of 5.56 hours) and 234.36 PPD hours of combined Licensed and NA staff (a shortage of 18.36 hours) for a census of 108 residents.Review of the facility accident/incident tracking form dated April 2026 identified 14 unwitnessed incidents for the month of April 2026 with 1 unwitnessed incident on 4/13/26.Review of the facility staffing compliance guidelines dated 4/26/23 identified that for an actual census of 100-104 residents, the facility required 5 RN/LPN and 14 NAs on the 7 AM -3 PM shift (a shortage of 1 RN/LPN and 1 NA) and 5 RN/LPN and 11 NAs on the 3 PM - 11PM shift (a shortage of 1 RN/LPN and 1 NA)Observation of the facility secured unit all dates of the survey 4/20, 4/21, 4/22, 4/23, 4/24 and 4/27/26 identified a secured unit, requiring a numeric code to enter and exit at the two entrances inside of the facility and three doors that exited the facility to outside space. Resident capacity on this unit was 35 with a daily census of 34 and 3 NAs assigned to the unit. A census of 34 would indicate the need for 4 NAs according to the facility assessment, indicating a shortage of 1 NA on the secured unit.Review of the facility assessment dated [DATE] identified staffing was based on census and acuity and identified ratios of Licensed nurses to residents 1:30-25 on days and evenings and 1:40 on nights and ratio of direct care staff (NAs) of 1:8-10 on days, 1:10-15 on evenings and 1:20-25 on nights.Review of the facility schedule dated 4/13/26 (Monday) identified that the ADNS and the DNS were pulled from their positions to staff units in the facility. However, review of the DNS time sheet for the week identified hours worked on 4/13/26 (Monday) indicated the time worked 7:30 AM to 5:00 PM was identified as DNS hours and not RN supervisor hours.Interview with the DNS on 4/27/26 at 12:32 PM identified that she denotes on her time card what position she held for the designated day of work. The DNS indicated that if she worked something other than as the DNS, it would be written in on the time sheet. The DNS could not recall her main duties on 4/13/26. Interview with the Human Resources Dir (HR) and the Administrator on 4/24/26 at 10:58 AM identified HR was responsible for submitting the PBJ staffing (which indicated the facility had low weekend staffing October through December 2025. HR indicated she had a staffing form that she used to confirm adequate staffing. The Administrator identified the form as an old form and left the office to get an updated form. HR put the form away and did not provide a copy for me.Interview with the scheduler on 4/24/26 at 11:10 AM identified she fills the schedule according to direction from the administrator. The scheduler indicated she did not figure out staffing based on hourly requirements according to census but followed direction from the Administrator. The scheduler was not aware of how many hours per resident were needed to staff Licensed staff nor NA staff. Interview with the Administrator on 11/19/24 at 1:48 PM identified he is aware of the 3.0 staffing requirements. He indicated that the high staffing turnover in the facility was the cause of the facility not being able to meet the staffing requirements. The Administrator further identified that the facility's policy was the 3.0 staffing requirements were provided by corporate but could not identify if the corporate guidance reflected requirements, and indicated staffing assignments were based on acuity.Interview with the Administrator on 4/27/26 at 12:44 PM identified that both SW#1 and SW#2 had BS in Human Services. The Administrator indicated she was aware of the 3.0 staffing and was looking for the direction for staffing received from corporate and was not familiar with the hours per resident required for staffing. Interview with HR on 4/27/26 at 12:35 PM identified she was responsible for submitting the PBJ staffing but could not identify if the facility was short on staffing. The HR indicated if they are short, the ADM might get an email.Interview with NA#3, NA#4, NA#5 and NA#6 on 4/27/26 between 2:07 PM and 2:20 PM identified that, at times, NA assignments included more than 10 residents per NA. All of the NA's identified that the assignments kept them busy throughout the day, they could use additional NAs, they identified good teamwork and the ability to manage the resident load.Interview with ADM on 4/27/26 at 2:25 PM identified she did not know what the facility staffing compliance grid was based on and indicated that was what the facility followed for staffing and was directed from corporate and would need to be reviewed.

Based on observation, staff interview, and facility policy, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include: An observation on 4/24/26 at 9:26AM identified the maple medication cart unattended and unlocked in the hallway on the maple unit outside of the resident's room against the wall to the left side of the resident's door. The nurse was in the resident's room with her back to the doorway. An interview with LPN #8 on 4/24/26 at 9:28 AM identified that she did not lock the medication cart before entering a resident room and had positioned the cart outside of the resident's door to left hand side out of sight. She did not lock it due to being nearby, however, identified that she had worked at the facility for about a year and knew that the medications should be locked as well as controls being under two locks. LPN#8 further identified it could be a safety issue to leave a cart unattended in the hallway. Interview on 4/24/26 at 10:20AM with the DNS identified that medication carts should be locked when out of sight of the nurse. Review of the facilities Medication Administration policy directed all medications to be stored in a secure, locked area accessible only to authorized personnel. Narcotics and controlled substances must be double-locked and counted per facility protocol.

Based on a review of the clinical record and staff interviews for one sample resident (Resident #83) reviewed for pressure injury, the facility failed to ensure that the resident's pressure injury was accurately coded on the Minimum Data Set (MDS). The findings include: Resident #83's diagnoses included dementia, type 2 diabetes mellitus with diabetic neuropathy, and cerebral infarction.The nurse's note dated 2/25/26 at 4:49 PM identified Resident #83 was readmitted to the facility following an episode of unresponsiveness. A skin assessment completed upon readmission and identified multiple bruises to the upper extremities and an intact blood blister on the left heel. The left heel blood blister measured 5 cm in length and 5.5 cm in width.APRN #2's initial wound progress note dated 2/26/26 documented Resident #83 was evaluated for wound management. The wound note indicated the resident had a right lateral ankle diabetic foot ulcer and a new onset Deep Tissue Injury (DTI) to the left heel related to pressure. The left heel DTI measured 5 cm in length and 6 cm in width with no measurable depth. The wound base was described as purple in color with epithelial tissue present. The treatment plan was to apply skin prep to the wound base every shift.APRN #2's weekly wound progress note dated 3/2/26 documented that the left heel DTI measured 6 cm in length and 6 cm in width with no measurable depth. The wound base remained purple in color, with slight erythema noted in the peri-wound area and no exudate present.APRN #2's weekly wound progress note dated 3/9/26 documented that the left heel DTI measured 6 cm in length and 7 cm in width with no measurable depth. The wound base remained purple with erythema present and no exudate.The quarterly MDS assessment dated [DATE] identified Resident #83 had severe cognitive impairment and required total assistance for bed mobility, personal hygiene, toileting, transfers, and use of a wheelchair for mobility. The assessment further identified the resident was at risk for pressure ulcers but documented no pressure ulcers present. Although multiple clinical entries documented the presence of an unhealed pressure injury, Section M of the 3/9/26 MDS did not code any pressure ulcer. The facility failed to code yes for the presence of an unhealed pressure ulcer and failed to code the unstageable DTI as required.Interview with RN #1 (MDS Coordinator) on 4/22/26 at 11:30 AM identified that LPN #1 was responsible for completing the MDS coding. RN #1 identified that when a resident had a pressure ulcer during the seven day look back period, Section M must be coded to reflect the presence of the unhealed pressure ulcer. After reviewing Resident #83's clinical record, RN #1 confirmed that the resident did have an unhealed pressure ulcer during the look back period.Interview with LPN #1 on 4/22/26 at 12:30 AM identified that she was responsible for completing the MDS coding. LPN #1 identified that any resident with an unhealed pressure ulcer must be coded in Section M to indicate its presence. After reviewing Resident #83's clinical record, LPN #1 acknowledged that the resident had an unhealed DTI during the MDS seven day look back period and confirmed that she miscoded Section M by failing to include the pressure injury.Subsequent to surveyor inquiry, the facility corrected and resubmitted Resident #83's MDS to accurately reflect the presence of the pressure injury.The Resident Assessment Instrument (RAI) 3.0 Manual requires facilities to mark yes when an unhealed pressure ulcer is present and to code the correct stage of the pressure ulcer in Section M.

Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews, for one sampled resident (Resident #114) reviewed for death, , the facility failed to ensure the resident had a physician order for a Registered Nurse (RN) to pronounce death. The findings include: Resident #114's diagnoses included hemiplegia, type 2 diabetes mellitus, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #114 had moderately impaired cognition. The nurse's progress note dated [DATE] at 2:59 AM written by RN #3 identified Resident #114 was unresponsive, no spontaneous breathing observed and pupils were fixed and dilated. The note further identified resident was DNR/DNI (do not resuscitate and do not intubate) an order confirmed in chart and resident was pronounced at 1:17AM. Interview and review of the physical chart and electronic record with the DNS and RN #1 on [DATE] at 12:37 PM failed to identify a physician order directing a Registered Nurse may pronouncement (RNP) death in both active and discontinued physician orders. The DNS identified that there should have been a physician order directing that a RN may pronounce death and if there was no order in place the nurse should have notified the MD/APRN. Interview with RN #3 on [DATE] at 1:12 PM identified prior to pronouncing death on a resident, that he would check the physician's order for their code status for a DNR/DNI and for RN pronouncement. He further identified that he could not recall if he had seen an order for RNP and if it were not there, he would notify the MD/APRN and hospice. Interview with MD #2 on [DATE] at 12:24 PM identified there should be a physician order in place for a RN to pronounce death and this is ordered when death is expected, and this is determined by the MD/APRN. She further identified there should be a RN pronouncement order in place prior to the pronouncement of death and if there is no order then the MD/APRN should be contacted and they would then have to come into the facility to do the death pronouncement. Review of the Death of Resident Pronouncement by a Registered Nurse policy identified RNs may pronounce a resident's death if MD's order and progress notes are present. The policy further identified the physician will write an order stating RN may pronounce death and a progress note explaining that death is anticipated.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) sampled resident (Resident #1) who require staff assistance of one (1) and an adaptive device during transfers, the facility failed to ensure Resident #1 was transferred from the chair to the bed according to the physician's order. The findings include: Resident #1's diagnoses included. dementia, osteopenia (when the bone loses density), osteoarthritis, anxiety and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE], identified Resident #1 had a Brief Interview for Mental Status score of 2 out 15 indicating poor memory recall, required a walker and wheelchair with mobility and moderate assistance with transfers. The Resident Care Plan dated 2/24/25 identified Resident #1 required assistance with activities of daily living, was a fall risk and had diagnoses of osteoarthritis and osteopenia. Interventions directed to transfer Resident #1 with caution according to physician orders. A current monthly April physician's order, originally initiated on 10/1/24, directed to provide assistance of one (1) staff member with a rolling walker for all transfers. The nurse's note dated 4/5/25 at 10:09 AM identified Resident #1 was found to have swelling and pain in the left lower leg with bruising present. The note indicated Resident #1's skin was intact and upon palpation (touch), Resident #1 demonstrated a guarding behavior with decreased range of motion to the left leg. The note identified the Advanced Practice Registered Nurse, APRN #1, was notified, and an order was obtained for a stat (immediate) x-ray of the left lower extremity to be performed. The nurse's note dated 4/5/25 at 9:27 PM identified the x-ray report indicated a fracture of the left tibia and fibula shaft (the bones in the lower leg), APRN #1 was notified, and an order was obtained to send Resident #1 to the Emergency Department. Review of a statement made by the 3-11PM nurse aide, Nurse Aide (NA) #2, identified she reported she had not utilized Resident #1's rolling walker for transfers in quite some time. Interview and clinical record review with the acting Director of Nursing (DON) on 4/29/25 at 2:18 PM identified Resident #1 had an order in place for transfers that directed the use of a rolling walker. The acting DON identified NA #2's statement states NA #2 did not use the rolling walker for transfer on 4/4/25. The acting DON identified NA #2 should have used the rolling walker for the transfer of Resident #1. Interview with NA #2 on 4/29/25 at 3:02 PM identified on 4/4/25, she was assigned to Resident #1. NA #2 explained she did transfer Resident #1 from the chair to the bed at approximately 4:00 PM without the benefit of the rolling walker and just did a stand and pivot transfer, with no additional staff present. NA #2 identified Resident #1's rolling walker had not been in the room for quite some time. Although attempted, an interview with MD #3 (Orthopedic Surgeon) was unable to be obtained.

Based on observations, staff interviews, facility documentation and facility policy related to the dishwasher temperatures in the Dietary Department, the facility failed to identify when dishwasher temperatures were below the manufacturers guidelines. The findings include: On 8/16/24 at 9:45 observation of the dishwashing room in the Dietary Department with the Dietary Manager identified Dietary Aide (DA) #3 approximately half way through scraping and putting dirty dishes from breakfast through the dishwasher. The Dietary Manager identified the dishwashing machine was a high temperature machine. The wash cycle temperature was observed to reach 141 degrees Fahrenheit, (should be above 150 degrees Fahrenheit, per manufactures guidelines and posting on the front of the dish machine). On 8/16/24 at 9:56 AM, dishwasher temperature logs were reviewed with the Dietary Manager and identified on 8/1/24, 8/2/24, 8/3/24, 8/4/24, 8/5/24, 8/6/24, 8/7/24, 8/8/24, 8/9/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/15/24, and 8/16/24 the wash temperatures were recorded at 140 degrees Fahrenheit, (should be above 150 degrees Fahrenheit, per manufactures guidelines). The temperature logs failed to reflect any follow up regarding the low temperatures. Interview with the Dietary Manager at that time identified that the temperature log sheet noted wash temperatures should be 140 degrees or above (a discrepancy from the dishwasher machine indicating the wash temperature should be above 150 degrees) and that was the reason there low temperatures were not identified. Subsequent to surveyor inquiry on 8/16/24, the facility used paper services for lunch, the vendor of the dishwashing machine was contacted, arrived at the facility and serviced the dishwasher. Interview with the vendor on 8/16/24 at 3:23 PM identified he assessed the dishwasher machine and stated everything was working normal on heat but did increase setpoint for heat from 153 degrees Fahrenheit to 163 degrees Fahrenheit to maintain a reading of above 150 degrees. While the vendor was on site, the wash cycle was reading at 160 degrees Fahrenheit. After surveyor inquiry of low dishwashing temperatures, Dietary staff were in-serviced on 8/16/24 that before putting dirty dishes through the dishwasher, it needed to be cycled about 4 times and the wash temp on the machine needed to be 150 degrees Fahrenheit or greater. The rinse temperature should be 180 degrees Fahrenheit or greater. If the dishwasher machine fails to meet these requirements during a cycle, dishwashing is to stop, and Dietary Manager or [NAME] Supervisor are to be notified. Interview on 8/16/24 at 1:35 PM with DA #3 identified that he documented dishwashing temperatures on 8/3/24, 8/5/24, and 8/15/24 and did not recognize the temperatures were low because on the Dish Machine Temperature Log stated a minimum temperature of 140 degrees Fahrenheit was acceptable. He did not notice the label on the dishwasher machine with manufactures guidelines instructing dishwashing wash cycle to be 150 degrees or greater. Interview on 8/19/24 at 9:10 AM with the Dietary Manager identified that she did not notice the sticker on the dishwashing machine with manufacturer guidelines of wash temperatures of 150 degrees or more. The temperature log stated the minimum temperature required was 140 degrees Fahrenheit. The Dietary Manager stated she assumed the paper log was correct as it was the way the log had been since she began her employment at the facility.

Based on observations, interviews, review of the clinical record, and facility policy in 1 of 3 dining rooms (Laurel dining room) observed for Residents (Resident #31, #42, #44, #45, #52, #93 and Resident #99) who were dining, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #31's diagnoses included Alzheimer's disease, dysphasia, ventricular tachycardia and anxiety disorder. The Resident Care Plan dated 6/24/24 identified Resident #31 was at an increased risk for decreased nutritional status. Interventions included adaptive equipment per physician's order, diet as ordered, and different foods/fluids to be offered and encouraged. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #31 was severely cognitively impaired and was dependent on staff for eating, toileting and transfers. The Resident Care Card (Individualized Resident Assignment) identified Resident #31 was to be fed in his/her room or in the dining room. Observation on 8/16/24 at 12:34 PM identified NA #7 feeding Resident #31 in the dining room not at eye level with the resident and standing over him/her. Observation on 8/16/24 at 12:40 PM identified Licensed Practical Nurse (LPN #8) feeding Resident #31 in the dining room, not at eye level with the residents and standing over him/her. At 12:45 PM LPN #8 was offered a chair by another staff member and refused stating I am ok. 2. Resident #42's diagnoses included Alzheimer's disease, feeding difficulties, and dysphagia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 was severely cognitively impaired and was totally dependent on staff for eating. The Resident Care Plan dated 7/27/24 identified that Resident #42 required assistance with activities of daily living (ADL) due to diagnosis of Alzheimer's disease but failed to identify the assistance required with dining. A physician's order dated 8/15/24 directed to assist Resident #42 to eat all meals. Observation on 8/19/24 at 12:55 PM identified RN #2 standing over Resident #42 above eye level and assisting the resident to eat his/her lunch. There were nine (9) empty chairs noted to be available in the dining room. 3. Resident #44's diagnoses include unspecified dementia, dysphasia, muscle contracture, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #44 was moderately cognitively impaired, required set up for eating, and needed partial/moderate assistance for toileting and transfers. The Resident Care Plan dated 8/14/24 identified Resident #44 had the potential for a nutritional decline. Interventions included encouraging foods/fluids and offering different foods/fluids. The Resident Care Card (Individualized Resident Assignment) identified Resident #44 feeds him/herself in the dining room. Observation on 8/16/24 at 12:40 PM identified a Licensed Practical Nurse (LPN #8) feeding Resident #44 in the dining room, not at eye level with the residents and standing over Resident #44. 4. Resident #45's diagnoses included dementia, dysphasia, hypertension and glaucoma. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was severely cognitively impaired and required substantial/maximal assistance for eating and toileting and partial/moderate assistance for transfers. The Resident Care Plan dated 7/3/24 identified Resident #45 was at risk for decreased nutritional status. Interventions included offering different foods/fluids. The Resident Care Card (Individualized Resident Assignment) identified Resident #45 feeds him/herself with setup assistance in the dining room. Observation on 8/14/24 at 12:38 PM identified Nursing Assistant (NA) #4 feeding Resident #45 in the dining room not at eye level and standing over the resident. 5. Resident #52's diagnosis included multiple sclerosis, Alzheimer's disease, and feeding difficulties. A physician's order dated 7/16/24 directed to assist Resident #52 for eating. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #52 was moderately cognitively impaired and required partial to moderate assistance for feeding. The Resident Care Plan dated 7/25/24 identified that Resident #52 required assistance with Activities of Daily Living (ADLs). Interventions included assistance with meals as needed. Observations on 8/13/24 at 12:30 PM, 8/14/24 at 12:45 PM, 8/15/24 at 12:30 PM, 8/16/24 at 12:50 PM and 8/19/24 at 1:00 PM identified Resident #52 in the dining room, seated alone, against a wall, while other residents were seated together at tables. Resident #52 had an overbed table that held his/her lunch which had been set up by staff and he/she was feeding him/herself. Empty space at other tables was available. Interview with the ADNS on 8/19/24 at 12:29 PM identified that Resident #52's wheelchair did not fit under any of the dining tables. Interview with NA #13 on 8/19/24 at 1:30 PM identified that Resident #52 had been sitting by his/herself for several months, the Resident Care Card did not indicate that the resident needed to be seated alone, and NA #13 did not know of any reason why Resident #52 could not be seated with other residents. 6. Resident #93's diagnoses included Alzheimer's disease, dysphagia, and cognitive communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #93 was severely impaired and was dependent for feeding. The Resident Care Plan dated 7/25/24 identified that Resident #52 required assistance with Activities of Daily Living (ADL). Interventions included assisting with mouth care, encouraging the resident to independently eat, and assist Resident #93 to complete the meal as needed. Observation on 8/19/24 at 12:20 PM identified Resident #93 in the dining room, seated alone, against a wall, while other residents were seated together at tables. Resident #93 had an overbed tray table in front of him/her. RN #2 was noted to be standing over the resident above eye level and assisting him/her to eat. There were nine (9) empty chairs noted to be available in the dining room as well as empty space available at other tables. 7. Resident #99's diagnoses included generalized muscle weakness, unspecified feeding difficulties, dementia, and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #99 was moderately cognitively impaired, required set up for eating, and was dependent on staff for toileting and transfers. The Resident Care Plan in effect on 8/14/24 identified Resident #99 had the potential for a nutritional decline. Interventions included encouraging fluids and encouraging the resident to eat their meal independently and that assistance was needed to complete the meal. The Resident Care Card (Individualized Resident Assignment) identified Resident #99 feeds him/herself with setup and assistance. Observation on 8/14/24 at 12:38 PM identified Nursing Assistant (NA #4) feeding Resident #99 in the dining room not at eye level and standing over the resident. An interview with Nurse Aid (NA) #4 on 8/14/24 at 12:48 PM identified that she stood to feed a couple residents because that was her preference when assisting residents at mealtime. An interview with the Director of Nurses (DNS) on 8/16/24 at 1:00 PM identified it was the facility policy for staff to sit while feeding residents at mealtime. An interview with NA #7 on 8/16/24 at 2:25 PM identified that it was the facility policy to sit while feeding a resident but could not find a chair. Observation of the dining room at the time of the observation identified four empty chairs available. An interview with the MDS Coordinator (LPN #8) on 8/19/24 at 11:41 AM identified that she was unaware of the facility policy on feeding residents, but it was not unusual for her to help with feeding. LPN #8 identified she prefers standing to feed in the dining room and resident rooms because she felt like there was better leverage and it was her personal preference because it was more comfortable. Interview with the ADNS on 8/19/24 at 12:29 PM identified that Resident #42, 52 and # 93 should have been assisted to eat by a staff member who was in a seated position and not standing over the residents. Additionally, the ADNS indicated that residents should be seated together at a table and not isolated by themselves. She indicated that there was one table that was higher than the others and that she would see if Resident #52 and Resident #93's wheelchairs would fit under that table. If their wheelchairs were unable to be placed at the higher table, she would notify maintenance staff to see what could be done to accommodate both residents to dine at a table with others. Review of the Feeding Policy dated 12/7/23 directed that assistance during feeding was provided in a dignified and respectful manner, and staff should not stand while feeding the resident. Review of the Feeding policy dated 12/7/23 directed, in part, do not stand when feeding resident. Although requested. A facility policy regarding placing residents at dining tables for meals was not provided. 51102 51183 51313

Based on interviews, review of clinical records, and facility policy for 2 of 3 residents, (Resident #23 and Resident #29) reviewed for abuse, the facility failed to report incidents of unknown origin to the State Agency. within the 24-hour time requirement. The findings include: 1. Resident #23's diagnoses included dementia, abnormal posture, muscle weakness, and congestive heart failure. The annual Minimum Data Set assessment dated [DATE] identified Resident #23 had severely impaired cognition and was dependent with eating, oral hygiene, toilet use, showering, personal hygiene, and chair/bed to chair transfers. a. A facility Reportable Event form dated 2/2/24 at 6:00 PM identified Resident #23's family reported a 1.0 centimeter (cm) by 1.0 cm bruise on Resident #23's left shoulder. Although the facility conducted investigations, they were not able to determine a root cause for the bruise. The facility did not report the injury of unknown origin to the State Agency. b. A facility Reportable Event form dated 8/6/24 at 7:00 PM identified that Registered Nurse (RN) #2 reported an incident of discoloration on Resident #23's third and fourth fingers on his/her right hand and his/her left leg. Although the facility conducted investigations, they were not able to determine a root cause for the bruise. The facility did not report the injury of unknown origin to the State Agency. 2. Resident #29's diagnoses include dementia, chronic obstructive pulmonary disease, and cerebral infarction. The annual Minimum Data Set assessment dated [DATE] identified that Resident #29 had moderately impaired cognition, required substantial/maximal assistance with eating, and was dependent with oral hygiene, toilet use, showering, personal hygiene, and chair/bed to chair transfers. a. A facility Reportable Event form dated 5/28/24 at 1:30 PM identified that Nurse Aide (NA) #5 reported a discolored area on Resident #29's fourth finger of the left hand. Although the facility conducted investigations, they were not able to determine a root cause for the bruise. The facility did not report the injury of unknown origin to the State Agency. b. A facility Reportable Event form dated 6/26/24 at 12:30 PM identified Resident #29's family reported 2 bruises measuring 1.0 centimeter (cm) by 2.0 cm and 0.3 cm by 0.7 cm on the Resident #29's left inner forearm. Although the facility conducted investigations, they were not able to determine a root cause for the bruises. The facility did not report the injury of unknown origin to the State Agency. An interview with the DNS on 8/19/24 at 12:26 PM (in the presence of two Corporate RNs), identified that the DNS did not report the incidents of Resident #23 and Resident #29 injuries of unknown origin to the State Agency because he only reported fractures and big origins and was not aware of the need to report injuries of unknown origin to the State Agency. Review of the facility's Reportable Events Policy identified that any injuries of unknown origin should be reported to the Department of Public Health (State Agency) no later than 2 hours after the allegation is made if the event includes abuse or serious bodily injury or not later than 24 hours after the allegation if the events do not involve abuse or cause serious bodily injury.

Based on observations, record reviews, facility documentation, facility policy and interviews for 3 of 6 residents (Resident #30, Resident #53 and Resident #105), reviewed for Nutrition, the facility failed to provide a nutritional supplement for a resident with known weight loss. The findings include: 1. Resident #30's diagnoses included type 2 diabetes mellitus, dysphagia and chronic kidney disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #30 was significantly cognitively impaired, required set-up or clean-up assistance with eating and extensive assistance of 2 staff for transfers and toileting. The Resident Care Plan dated 5/2/24 identified significant weight loss with fortified cereal added. Interventions included to provide supplements as ordered and encourage Resident #30 to eat as much of his/her meal independently and assist with completing his/her meal as needed. A Nutritional assessment dated [DATE] identified Resident #30's weight on 5/1/24 was 94.4 pounds and that he/she, over the last 6 months, had a significant weight loss of 38.6 pounds (29% loss) and had chronic severe malnutrition. A physician's dietary supplement order dated 7/30/24, directed to provide fortified cereal, 180 milliliters (ml) in the morning. A Dietician's note dated 7/30/24 at 12:41 PM identified Resident #30 at a weight of 88.4 pounds a decrease of 8.6 pounds in 1 month (8.9% loss) with Resident #30 receptive to hot cereal in the morning. Observation and interview with Resident #30 on 8/16/24 at 8:20 AM identified the resident was seated in his/her room in a wheelchair with a plate of scrambled eggs and a banana on the overbed table in front of him/her. Fortified cereal was not observed. Resident #30 indicated he/she would like to have fortified hot cereal, but cereal had not been served for breakfast. Interview and record review with Dietary Aide (DA) #1 on 8/16/24 at 8:25 AM identified that she had served Resident #30 his/her breakfast but failed to include fortified cereal. DA #1 reviewed the Dietary Roster (form directing staff what to serve) kept on the steam table and verified that fortified cereal was listed for Resident #30 to receive for breakfast. Dietary Aide #1 further identified that she had made a mistake and should have reviewed the Dietary Roster when serving Resident #30 his/her breakfast. Interview and observation with the Administrator on 8/16/24 at 8:28 AM identified that Resident #30 did not have fortified cereal on his/her tray table. The Administrator indicated that if the fortified cereal was listed on the Dietary Roster, it should have been served to Resident #30 with his/her breakfast. Subsequent to surveyor inquiry, the Administrator obtained a bowl of fortified cereal for Resident #30 from Dietary Aide #1, and Resident #30 was served at 8:32 AM. Observation with the Administrator on 8/16/24 at 8:40 AM identified that Resident #30 had consumed 100% of the fortified cereal and Resident #30 stated It was good!. Interview and record review on 8/16/24 at 11:15 AM with Dietician #1 identified that Resident #30 had significant weight loss and had a physician's orders for fortified cereal in the morning, 180 ml. Dietician #1 indicated, based on the Fortified Cereal Recipe she provided, that a 6 oz. (180 ml.) serving of Fortified Cereal contained 487 kilocalories (kcal.). Dietician #1 further identified that there was no area for percentage of intake documentation included with the current nutritional supplement order on Resident #30's medication administration record (MAR) and that she tracked that information to determine ongoing nutritional recommendations. Dietician #1 identified that she would need to get the current order for the nutritional supplement corrected by the nurse. 2. Resident # 53's diagnoses included Alzheimer's disease and adult failure to thrive. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 53 was severely cognitively impaired and required supervision or touching assistance with eating, substantial/maximal assistance with oral hygiene, and was dependent for personal hygiene. The Resident Care Plan (RCP) in effect from 2/20/24 through 2/29/24 identified Resident #53 was at risk for a nutritional decline and had weight loss. Interventions included providing the diet as ordered, offering to set up meals, and to offer and encourage different foods/fluids (supplements were not included in the RCP). A Dietician's note dated 4/9/24 at 2:37 PM identified the resident had a weight loss of 5.6 pounds (lbs.) over 1 month (3.5%) and 10.6 lbs. over 6 months (6.4%) not a significant weight loss, that his/her food intake was good, eating 75-100% of meals, and that it is recommended Resident #53 receive 180 ml fortified cereal every morning for additional calories, and to continue the diet as ordered. A physician's order dated 4/9/24 directed to provide 180 ml of fortified cereal every morning and the amount consumed was to be documented. The physician order section identified a diet slip dated 4/9/24 with all copies, white, pink and yellow still attached. The slip directed that the Dietary Department provide fortified cereal 180 ml. The slip lacked a nurse signature or date the Dietary Department was sent notification. A nurse's note dated 4/10/24 at 5:12 PM identified that the Resident Representative for Resident #53 and the facility Advanced Practice Registered Nurse (APRN) were updated on the resident's weight loss and recommendation from the Dietician. A physician's order dated 8/6/24 directed to discontinue administration of 120 ml of house supplement in the afternoon, and to start a new order to administer 120 ml of house supplement two times a day. A Nutritional Assessment by the Dietician dated 8/13/24 identified, Resident #53 had continued weight loss, which was now significant, and that the house supplement had been increased to twice a day. Observation of Resident #53 on 8/19/24 at 8:45 AM, identified that Resident # 53's breakfast had been delivered and consisted of French toast, bacon, a small cup of sliced strawberries, and a glass of juice. Fortified cereal had not been provided. Interview with the Director of Dietary on 8/19/24 at 9:25 AM, identified that the Dietary Roster did not include an entry for Resident #53 to receive fortified cereal. It was further identified that when a diet slip is received in the kitchen, the Director of Dietary updates the diet roster with the necessary information and fortified cereal is entered into the far right column and highlighted in green. Observation and interview with Licensed Practical Nurse (LPN) #4 and LPN #8 on 8/19/24 at 9:35 AM identified the Director of Dietary approached LPN #4 requesting a copy of the fortified cereal dietary request form. LPN #8 indicated that the facility process was to verify the order in the computer, sign the slip, bring the white copy to the kitchen, and then file the other copies of the slip in the chart, but that the white slip had not been sent, and remained in the clinical record. Subsequent to surveyor inquiry, the unsigned dietary slip dated 4/9/24 was signed by LPN #4 and brought to the kitchen by LPN #8. Interview with NA #3 on 8/19/24 at 10:00 AM, identified that Resident #53 had eaten his/her full breakfast, and that there was no fortified cereal served with his/her meal. NA #3 further identified that when documenting the meal intake in the clinical record, it does not specify food items that are to be provided. Although Resident #53 had not received fortified cereal for breakfast, a review of the Medication Administration Record on 8/19/24 at 11:35 AM, identified in the LPN #4 had documented that Resident #53 had consumed 180 ml of fortified cereal (100%) that morning. Interview with the Director of Nursing Services (DNS) on 8/19/24 at 1:00 PM, identified that the facility process to notify the Dietary Department of changes in supplementation was to fill out the dietary slip, the nurse would sign and bring the white section to the kitchen to add to the Dietary Roster and file the other copies in the clinical record. The DNS identified that NA would know to provide fortified cereal to the residents because the nurse would see the order and that they did not update the NA Resident Care Card (Individualized Resident Assignment) to include fortified cereal. 3. Resident #105's diagnoses included severe protein calorie malnutrition, anxiety, and chronic obstructive pulmonary disease. The Resident Care Plan dated 6/3/24 identified a problem with malnutrition and dietary intake. Interventions included to provide the diet as ordered, refer to the Dietician as needed, assist with eating if needed, and fortified foods as ordered. The admission Minimum Data Set assessment dated [DATE] identified Resident #105 was cognitively intact, required partial to moderate assistance with transfers, and was completely independent with eating. A physician's order dated 7/27/24 directed to provide Resident #105 with 180 milliliters (ml) of fortified cereal in the morning. Review of facility weight documentation identified that Resident #105 weighed 150 pounds on 7/3/2024. On 7/31/2024 Resident #105 was noted to weigh 137 pounds, a 13 pound weight loss in 1 month (8.67% loss) had occurred. An observation and review of the Medication Administration Record (MAR) on 8/16/24 at 8:48 AM identified Resident #105 in bed, asleep with his/her breakfast on the tray table. Resident #105 was without the benefit of fortified cereal (or any cereal). A Review of the Medication Administrations Record (MAR) identified a directive that Resident #105 should be provided with fortified cereal. Although the notation indicated that Resident #105 had consumed 100% of his/her fortified cereal, the nutritional supplement had not been provided. Interview with the Dietary Director on 8/16/24 at 8:50 AM identified that meals were provided per the Dietary Roster, located on the steam table. The Dietary Director indicated that the Dietary Roster failed to identify that Resident #105 was to receive fortified cereal and if the cereal was required, the directive would have been prepopulated on the Dietary Roster. Review of physician's order dated 7/27/24 with the Dietary Director directed facility staff to provide fortified cereal to Resident #105. Observation of the steam table with the Dietary Director failed to identify the availability of any fortified cereal. Subsequent to surveyor inquiry the Dietary Director indicated that Resident #105 would be provided with fortified cereal. Review of the undated Nutritional Supplementation Program policy directed, in part, that high calorie supplements should be documented in the administration record and that the Dietician's progress notes should address parameters for identification of nutritional risk, goal and approach, and that all disciplines should continue to monitor for progress towards the goal, adjusting the care plan as necessary. Additionally, the Dietician should assure that the resident is identified on the nourishment roster as to the supplement order and proper amount, and that a supplementation program should strive to increase overall intake and thereby improve the nutritional support offered to the resident with goals of supplementation consumption and weight gain. Review of the Resident Profile/Care Cards policy directed, in part, that care cards will be updated as needed with changes to guide caregivers in providing resident with assistance with care in order to achieve and maintain their highest practical level of well-being. 51101 51183

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #75) reviewed for dental services, during the clinical record review, it was noted that the facility failed to ensure blood pressures were taken prior to the administration of an antihypertensive (blood pressure reduction) medication . The findings include: Resident #75 was admitted to the facility on [DATE] with a diagnosis that included dementia and hypertension. The Social Services admission assessment dated [DATE] identified Resident #75 had vascular dementia and was confused and forgetful at times. The Resident Care Plan (RCP) in effect on 8/2/22 identified Resident #75 with cardiovascular disease. Interventions included administering medications as ordered, obtaining weights and vital signs as ordered. A physician's order dated 8/3/22 directed facility staff to take Resident #75's blood pressure prior to the administration of lisinopril 20 milligrams (mg) by mouth and to hold (not administer) the medication for a systolic blood pressure (SBP) that was less than 110 millimeter of mercury (mmHg). Review of the Medication Administration Records from 8/3/22 to 8/14/24 failed to identify that facility staff had regularly taken Resident #75's blood pressure prior to each administration of lisinopril over the last 24 months. An interview and record review with LPN #3 on 8/14/24 at 12:35 PM identified that he did not obtain Resident #75's blood pressure prior to administering lisinopril in the morning. LPN #3 stated that he did not obtain vitals because the order did not direct to take a blood pressure prior to administering the lisinopril. LPN #3 indicated that the blood pressure breakdown attachment (directive) may have been inadvertently omitted when the order was initially placed, however, LPN #3 stated that physicians' order should have been followed for the administration of lisinopril for Resident #75. Subsequent to surveyor's inquiry on 8/14/24, the blood pressure breakdown was added to the lisinopril 20 mg physician order, the APRN and Resident #75 representative were updated, and a normal blood pressure reading was obtained. Interview and record review with the DNS on 8/16/24 at 9:50 AM identified that the floor nurse was responsible for obtaining blood pressures for residents who have an order to obtain a blood pressure prior to administering the medication. The DNS could not explain why the blood pressure breakdown was not added to the medication order but identified that the physician's order should have been followed. Interview with APRN #1 on 8/16/24 at 10:00 AM identified that Resident #75 was stable and did not present with any acute issues since he/she was admitted to the facility. APRN #1 further indicated that Resident #75 could have experienced a further drop in blood pressure resulting in dizziness or a syncope attack if the lisinopril had been administered with a systolic blood pressure of less than 110. Physician's order policy provided did not specify that physician's orders should be followed. 50250

Based on review of the clinical record, facility policy, and interviews for 3 of 4 sampled residents (Resident #44, #56, and #85) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure residents were free of facial hair. The findings include: 1. Resident #44's diagnoses included dementia, contracture of right-hand muscle, and generalized muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and required moderate assistance with personal hygiene, set up assistance with eating, and supervision with oral hygiene. The RCP in effect on 8/10/24 identified Resident #44 required assistance with ADL's. Interventions included assistance with personal hygiene, set up assistance with eating and supervision with oral hygiene. Intermittent observations throughout the day on 8/13/24, 8/14/24 and 8/15/24, identified Resident #44 with visibly long, black facial hair noted below the lower lip. Physicians order in effect from 7/1/24 through 8/15/24 directed a body audit to be performed every week by a licensed nurse on their shower day (Friday) and document results on the Body Audit Form. Review of Resident #44's clinical record from 7/3/24 to 8/15/24 identified that Resident #44's body audit audits were performed on 7/3/24, 7/10/24, 7/17/24, 7/24/24, 7/31/24, and 8/7/24 with no new concerns or refusals noted on the Body Audit Forms. 2. Resident #56's diagnoses included dementia, generalized muscle weakness and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 was severely cognitively impaired, required moderate assistance with personal hygiene, set up assistance with eating, and supervision with oral hygiene. The Resident Care plan (RCP) in effect on 8/1/24 identified Resident #44 required assistance with ADL's due to the resident's cognitive status. Interventions included assistance as needed to meet toileting needs, feeding as needed, and keeping commonly used items within reach. Intermittent observations throughout the day on 8/13/24, 8/14/24 and 8/15/24, identified Resident #56 with visibly long, white facial hair noted below the lower lip. Physicians order in effect from 6/15/24 through 8/15/24 directed a body audit to be performed every week by a licensed nurse on their shower day (Friday) and document results on the Body Audit Form. Review of Resident #56's clinical record from 6/26/24 to 8/15/24 identified that Resident #56's body audits were performed on 6/29/24, 7/6/24, 7/13/24, 7/20/24, 7/27/24 and 8/3/24 without any issues or refusals being identified. 3. Resident #85's diagnoses included dementia, muscle weakness and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #85 was cognitively intact and required set up assistance with eating and moderate assistance with personal hygiene. The RCP in effect on 8/1/24 identified Resident #85 needed staff assistance with ADL's. Interventions included assisting as needed to meet toileting needs, mouth/dental care, feeding, and keeping commonly needed items within reach. Intermittent observations throughout the day on 8/13/24 and 8/14/24, identified Resident #85 with visibly long, white facial hair noted below the lower lip. Physicians order in effect from 7/1/24 through 8/15/24 directed a body audit to be performed every week by a licensed nurse on their shower day (Friday) and document results on the Body Audit Form. Review of Resident #85's clinical record from 7/2/24 to 8/12/24 identified that Resident #44's body audits were performed on, 7/2/24, 7/6/24, 7/8/24, 7/13/24, 7/20/24, 8/10/24 and 8/12/24 with no new concerns or refusals noted on the Body Audit Forms. Interview and observation with NA #6 on 8/15/24 at 2:40 PM indicated that she was taking care of Resident #44, Resident #56 and Resident #85. NA #6 identified that she normally assists residents with shaving and grooming on their shower days and as needed. NA #6 further stated that some residents are combative and resistant to care resulting in difficulty to provide needed care appropriately. NA #6 identified that she normally reports care refusal to a licensed nurse and re-approaches the resident at a different time to provide the needed care. Interview and record review with LPN #5 on 8/15/24 at 2:50 PM identified that all nursing staff provide resident care including shaving of residents. LPN #5 indicated that sometimes residents refuse and are combative with care. LPN #5 was not sure when Resident #44, Resident #56 and Resident #85 had last been shaved, and was unable to provide any documentation that Resident #44, Resident #56 and Resident #85 had refused to be shaved. Subsequent to the surveyor's inquiry, Resident #44's, Resident #56's and Resident #85's facial hair was shaved. Interview with DNS on 8/16/24 at 9:50 AM identified that the nurse aides are expected to help all residents that require assistance with ADLs, and he has seen residents refuse or become combative with care. The DNS identified that refusal of care should be documented in resident's clinical record. Further, the DNS identified that body audits are done on a weekly basis and any areas of concern should be noted on the Body Audit Form. Review of the facility's AM care/ADLs policy identified in part, that individualized assistance is provided to residents in preparation for daily activities according to their wishes and plan of care. Nursing staff will assist with care for each resident daily as needed and resident's individual preferences and choices will be honored and included in the morning routine. The procedure includes shaving residents if needed unless otherwise indicated.

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #17) reviewed for accidents, the facility failed to complete a safe transfer with the mechanical lift. The findings include: Resident #17's diagnoses included left sided hemiplegia and hemiparesis (muscle weakness) following a cerebral infarction (stroke), abnormalities of gait and mobility, and need for assistance with personal care. A physician's order dated 2/8/23 directed to transfer Resident #17 via total mechanical lift, that Resident #17 was non-ambulatory, and that Resident #17 was independent with adaptive wheelchair with left leg rest (use both leg rests for transport). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was moderately cognitively impaired, in a wheelchair, and required total dependance with toileting hygiene, bathing, and chair to bed transfers. Additionally, the MDS did not identify any previous falls. The Resident Care Plan dated 4/26/24 identified Resident #17 was a fall risk due to multiple risk factors. Interventions included to transfer per physician orders, encourage Resident #17 to ask and wait for staff assistance for transfers, and to use a wheelchair for mobility. Review of the Reportable Event Form dated 5/27/24 at 2:30 PM identified that Resident #17 was assisted to the floor from the mechanical lift and the facility's disposition was to exchange the mechanical lift pad (sling). A nurse's note dated 5/27/24 at 3:19 PM identified that Resident #17 was slowly lowered to the floor because the clip attachment of the mechanical lift pad had become loosened (during a transfer using the mechanical lift machine). Interview with Nurse Aide (NA) #1 on 8/15/24 at 3:00 PM identified that both herself and NA #4 were using the mechanical lift during a transfer of Resident #17 on 5/27/24 when the pad became unclipped from the lift. NA #4 was able to hold Resident #17 and Resident #17 was lowered to the floor. NA #1 further indicated that there was a chipped opening in one of the top clips of the mechanical lift pad that had not been noticed prior to the transfer. NA #1 demonstrated where the chipped opening was on a black clip of a mechanical lift pad. NA #1 identified that the black clip was not the same clip that was used during the incident. Interview with the Director of Maintenance on 8/16/24 at 9:21 AM identified that maintenance does not check the mechanical lift pads routinely, however the pads are checked prior to use by the staff member performing the transfer via the mechanical lift. Maintenance checks the mechanical lift machine monthly and an outside medical supply company completes annual assessments. Interview with the Director of Nursing Services (DNS) on 8/16/24 at 9:55 AM identified that he had taken the mechanical lift pad after the incident on 5/27/24 to try and identify the problem. The DNS further indicated that the mechanical lift pad appeared intact and that the clip was not broken. Additionally, the DNS indicated that the pad was taken out of circulation, even though there was no default with the pad. Observation with two surveyors on 8/16/24 at 10:15 AM demonstrated the completion of a safe transfer for a resident using the mechanical lift by NA #4 and NA #5. Interview with NA #4 on 8/16/24 at 10:30 AM identified that both herself and NA #1 were using the mechanical lift during a transfer of Resident #17 on 5/27/24 when the pad became unclipped from the lift. NA #4 identified that the mechanical lift pad had been inspected in the morning before it was used, and that Resident #17 continued to sit on the pad throughout the day. Resident #17 was being transferred from the chair to the bed in the afternoon for incontinent care. NA #1 had pulled Resident #17 back in the mechanical lift and the mechanical lift pad became unclipped. NA #4 was able to hold Resident #17 and Resident #17 was lowered to the floor. NA #4 demonstrated where the chipped opening was on the gray clip of a mechanical lift pad that another resident was sitting on. NA #4 identified that the gray clip was the same clip that was used during the incident. Interview with the Northeast Regional Territory Manager for the medical supply company used by the facility on 8/16/24 at 11:30 AM identified that mechanical lift pads with gray clips were recalled approximately [AGE] years ago and should not be in use. The Northeast Regional Territory Manager further indicated that the gray clips could become dislodged from the mechanical lift machine even if a resident sneezes. Additionally, he identified that the gray clips could become dislodged with or without a chipped opening on the clip. The Northeast Regional Territory Manager identified that when the gray clips are compared to the black clips, there is a slant in the opening of the black clip that secures it to the mechanical lift machine. The gray clips do not have slanted openings. The Northeast Regional Territory Manager identified that the facility would have been notified several times over a 2 year period regarding the recall of the mechanical lift pads with gray clips. Interview with the Administrator on 8/16/24 at 11:45 AM identified that the facility purchased the mechanical lift pads directly through the medical supply company. The Administrator further indicated that a complete sweep of the facility would be completed to ensure all mechanical lift pads with gray clips were removed. Review of the Sling Inspection policy updated 12/2/21 directed, in part, that the integrity of a sling will be visually and manually inspected by the nursing assistant prior to use on a resident for a mechanical lift transfer. If any alteration in the integrity of the sling is noted, the sling must not be used and immediately removed from service.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #42) reviewed for pressure injuries, the facility failed to ensure off-loading for a dependent resident according to the plan of care and failed to ensure a hospice recommendation was reviewed by a provider. The findings include: Resident # 42's diagnoses included Alzheimer's disease, Lupus, peripheral vascular disease, and diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 was severely cognitively impaired, was dependent with eating, required substantial/maximal assistance with rolling left and right, was dependent for bed to chair transfer, and was at risk for pressure ulcer development. a. The Resident Care Plan dated 5/24/24 identified Resident #42 was at risk for pressure injuries. Interventions included to follow the facility protocol for treatment of pressure injuries, offload heels as appropriate, and turning and repositioning per nursing standards of care and facility policy. Physician's orders in effect from 8/1/24 to 8/13/24 directed booties be placed to Resident #42's bilateral heels, at all times, for heel protection, remove booties for care, and check for placement every shift. Registered Nurse (RN) #1 hospice note dated 8/8/24 identified that Resident #42 had a new open area to the right heel where a previously noted deep tissue injury had occurred. New orders were recommended for treatment. A renewed physician's order dated 8/9/24 directed facility staff to treat Resident #42's unstageable left heel pressure ulcer. Review of the physician's orders from 8/8/24 through 8/13/24 failed to identify a physician order related to the newly identified open right heel wound per the hospice recommendation. RN #1 hospice note dated 8/13/24 identified that Resident #42 had a macerated right heel wound measuring 4.5 centimeters (cm) by 5 cm by 0.1 cm and RN #1 placed a pillow for offloading. Recommendations included, in part, to make sure heel booties were in place bilaterally. Observation on 8/13/24 at 2:59 P.M. identified a pillow was in place behind Resident #42's heels, dressings were in place to both feet including the heels and a heel bootie was noted in place to the left foot only. A physician's order dated 8/14/24 directed to discontinue booties to bilateral heels and a new order was added for offloading heels at all times for protection. A physician order dated 8/14/24 directed to apply skin-prep (protective barrier) to the right heel every shift for a prior right heel Deep Tissue Injury (DTI). A late entry nurse's note dated 8/14/24 at 11:30 AM identified a right heel wound heel area measuring 4.0 centimeters (cm) by 6.0 cm by 0.0 cm. A clarification nurse's note written by LPN #7 dated 8/14/24 at 11:37 AM identified a prior right heel DTI that was reported to the wound care specialist, with initiation of treatment with skin-prep every shift, and further noted Resident #42 would be seen by the wound care specialist the following day. A Doctorate of Nurse Practice wound note dated 8/15/24 at 8:44 AM identified a new unstageable pressure injury to the right heel containing 100% eschar (non-viable tissue) and measuring 4.0 centimeters (cm) by 6.0 cm by 0.0 cm with no drainage. Treatment recommendations included to apply betadine (topical wound treatment) to the base of the wound, then secure with a dry clean dressing daily and as needed. A physician's order dated 8/15/24 discontinued skin-prep to the right heel every shift for prior right heel DTI. A physician's order dated 8/16/24 directed to cleanse the right heel with normal saline followed by betadine and a protective dressing daily and as needed for an unstageable pressure injury. Observations on 8/16/24 at 6:15 AM, 6:30 AM, 6:45 AM, 7:00 AM, and 7:15 AM identified Resident #42 lying supine in bed, knees bent and leaning to the right on a pillow, both feet were on the mattress and the heels failed to be offloaded. Continued observations at 7:30 AM and 7:45 AM identified Nursing Assistant (NA) #8 provided care and dressed Resident #42. When NA #8 left, Resident #42 was noted to be lying on his/her left side with the left outer heel and right inner heel on the mattress and not offloaded. (1 and 1/2 hours since the observation began.) During observations on 8/16/24 at 8:00 AM, 8:15 AM, 8:30 AM, 8:45 AM, 9:00 AM, and 9:15 A.M (1 hour and 15 minutes) Resident #42 was noted to be out of bed and in an adaptive custom wheelchair with both heels offloaded and free floating. Out of bed observations on 8/16/24 at 9:30 AM, 9:45 AM, 10:00 AM, 10:15 AM, 10:30 AM, 10:45 AM, 11:00 AM, At 11:35 AM, 11:45 AM, 12:45 PM, 1:15 PM, and 1:30 PM identified Resident #42 in his/her wheelchair. Although Resident #42's pillow was still placed on the wheelchair leg rests, the pillow had shifted and was no longer providing pressure relief. Resident #42's heels were resting against the pillow without the benefit of offloading from 9:30 AM through 1:40 PM (4 hours and 10 minutes). Direct observations identified a failure to offload Resident #42's heels according to the physician order and Resident Care Plan. Interview with NA #8 on 8/16/24 at 11:45 A.M. identified she did not place the pillow behind Resident #42's legs. NA #8 indicated NA's are instructed to not place items in the wheelchair with residents. Interview with LPN #6 on 8/16/24 at 1:20 P.M. identified she did not place the pillow behind Resident #42's legs, and further indicated pillows are ineffective in reducing pressure if directly against the feet. On 8/16/24 at 1:40 PM Resident #42 was transferred back to bed, positioned on his/her back and both heels were noted to be in direct contact with the mattress without the benefit of offloading. Observation and interview with LPN #6 and #7 on 8/16/24 at 1:40 P.M. identified Resident #42 lying supine in bed, without heel offloading. LPN #6 was observed performing a dressing change to the bilateral heels. On observation Resident #42's heel wounds extended from the lower Achillies (back of the ankle) over the back of the heel to the edge of the sole of the residents foot. LPN #7 indicated she had placed the pillow in the wheelchair but did not place the pillow behind Resident #42's feet and that the pillow must have shifted. LPN #7 indicated that the pillow should not have been behind or touching Resident #42's heels. LPN #7 indicated that the facility practice was to identify the need for offloading on the Treatment Administration Record (document directing licensed nurses sign as complete) and the NA Resident Care Card (Individualized Resident Assignment) which was updated by herself (LPN #7) or the MDS Coordinator following new concerns/orders discussed during the facility morning report. A review of the NA Resident Care Card failed to identify offloading. Subsequent to surveyor the Resident care card was updated to include offloading. Review of the Positioning policy directed, in part, that residents are to be repositioned every 2 hours and as needed, and that the Resident Care Plan and Resident Care Card would indicate the resident need for assistance with positioning. b. The 5/8/24 Resident Care Plan (RCP) identified Resident #42 was receiving hospice level of care for anticipated death due to Alzheimer's disease with interventions including encourage rest periods as needed and repositioning for comfort as needed. Review of the Hospice recommendation document by Registered Nurse (RN) #1 dated 8/8/24 identified a prior right heel suspected deep tissue injury (DTI) that had appeared to have re-opened. A recommendation for the right heel wound included the application of calcium alginate (an absorptive topical wound treatment) followed by a padded covering and gauze wrap to be changed daily and as needed. The recommendation was signed as reviewed by facility LPN #10; however, no order was noted in the physician's orders. Further clinical record review failed to identify that the physician had been made aware of the new recommendation. Review of the Hospice recommendation document dated 8/13/24 by RN #1 identified Resident #42 had a macerated right heel wound measuring 4.5 centimeters (cm) by 5 cm by 0.1 cm and a pillow was placed for offloading. Recommendations included, in part, to make sure heel booties were in place bilaterally. This document was signed as reviewed by facility LPN #6. A physician order dated 8/14/24 directed to discontinue heel booties and a new order was added directing heel offloading at all times for protection. Interview with the Hospice Registered Nurse (RN) #1 on 8/16/24 at 11:40 AM indicated he first identified Resident #42's right heel wound on 8/8/24 and made a wound care recommendation. RN #1 indicated that a visit note, in triplicate, is written at the completion of each facility visit, 2 copies are provided to the facility supervisor (one for the chart and another for the supervisor use), and 1 copy is kept by the hospice provider. Further RN #1 indicated he had frequent care discussions with LPN #7 which worked well for him. Interview and review of the clinical record with LPN #7 on 8/19/24 at 2:18 PM identified that Resident #42 had a hospice recommendation dated 8/8/24 for the right heel that was never addressed or implemented. LPN #7 indicated, per the facility policy, the floor nurse should have called the APRN, clarified if the recommendation would be accepted or declined, and add a new order if approved. LPN #7 indicated this had not occurred and the ball was dropped. Further, a review of a body audit dated 8/14/24 failed to identify the wound. LPN #7 stated if a wound was evident on 8/8/24 and 8/13/24 and a body audit had been completed on 8/14/24, the area should have been identified during the body audit. Subsequent to surveyor inquiry the facility began education with facility staff. Review of the facility education, with an effective date of 8/13/24 identified that all hospice recommendations are brought to the supervisor/infection control nurse after each visit and the supervisor/infection control nurse would review the recommendations with the facility APRN/MD for confirmation. Review of the Handling and Implementation of Hospice Recommendations policy directed, in part, that hospice recommendations would be reviewed by the facility APRN/MD (provider) in a timely manner, that if a recommendation was deemed clinically inappropriate the provider would document the rationale for non-implementation, and documentation should clearly state whether a recommendation was accepted, modified, or declined, along with the clinical rationale.

Based on observations, review of the clinical record, facility policy, and interviews for 3 of 5 residents (Resident #8, #33 and #46) reviewed for a limited range of motion, the facility failed to apply positioning devices according to the physician orders and rehabilitation plan of care. The findings include: 1. Resident #8's diagnoses included osteoarthritis, contractures, rheumatoid arthritis, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was severely cognitively impaired and required partial/moderate assistance with eating, substantial/maximal assistance with upper body dressing, and was dependent for toileting, and transfers. The Resident Care Plan dated 7/22/24 identified Resident #8 had rheumatoid arthritis. Interventions included to monitor/document and report to the physician, any joint stiffness, decline in mobility, and contracture formation/joint shape change. Physician orders in effect from 8/1/24 to 8/14/24 directed to apply a left elbow splint to be on after care every morning (AM), off prior to bedtime (PM) and to check skin before and after application every shift. A review of the Resident Care Card (Individualized Resident Assignment) for Resident #8 identified and instructed the left elbow splint be applied after AM care every morning and off prior to PM care at bedtime and to check the skin before and after application every shift. Observations of Resident #8 on 8/14/24 at 10:00 AM and 8/16/24 at 10:56 AM noted the resident to be up in his/her wheelchair, after morning care, with no left elbow splint applied. Observation of Resident #8 on 8/16/24 at 12:13 PM identified the DNS applying the left elbow splint on the resident (several hours after Resident #8 received morning care). An interview with the DNS on 8/16/24 at 12:18 PM identified he does not usually apply the splints and that the nurse aid was responsible for applying the splints, per policy it should be applied in the morning and taken off at bedtime. It was not applied because there was a float or new nurse aid, and they have a hard time applying the split due to the contracture. The DNS identified the nurse aid would know to apply the left elbow splint on Resident #8 per the Resident Care Card and should have done so as part of Resident #8's AM care. An interview and record review with the Occupational Therapist (OT #1) on 8/19/24 at 9:17 AM identified deficits associated with not applying the splint include potential decreased range of motion and potential increase in the current contracture. 2. Resident #33's diagnoses included cerebral infarction, hemiplegia of the left side (loss of function on 1 side) and left hand muscle contracture. The annual Minimum Data Set (MDS) assessment dated [DATE], identified Resident #33 had no cognitive impairment and was dependent with bed mobility, toileting, and transfers. The Resident Care Plan dated 7/8/24 identified contractures of left upper and left lower extremities related to history of cerebrovascular accident (CVA/stroke). Interventions included left hand resting splint per physician orders. Physician's orders in effect from 8/1/24 through 8/13/24 directed a left palm guard to be worn after AM care and off prior to PM care. The Nurse Aide Resident Care Card (Individualized Resident Assignment) for Resident #33 identified a left palm guard as ordered. The Medication Administration Record (MAR's) dated August 2024 identified a palm guard to be worn after AM care and off prior to PM care. Check skin before and after application and every shift, every morning and at bedtime. Observations on 8/13/24 at 1:10 PM, 8/14/24 at 9:30 AM, and 8/15/24 at 12:40 PM failed to identify Resident #33's left hand palm guard in place. Although observations of Resident #33 not wearing his/her left hand splint on 8/13/24 at 1:10 PM, 8/14/24 at 9:30 AM, and 8/15/24 at 12:40 PM failed to identify placement of Resident #33's left hand palm guard hand, review of the facility MAR documentation dated 8/13/24, 8/14/24 and 8/15/24 identified staff signatures indicating that Resident #33 was wearing his/her left palm guard. Interview and observation with NA #4 on 8/16/24 at 10:00 AM identified that Resident #33 did not have his/her left hand palm guard in place. NA #4 indicated that she was not aware that Resident #33 required a left hand palm guard as she did not normally work on Resident #33's unit. Further, NA #4 was unable to locate the palm guard in Resident #33's room. Interview, observation and record review with LPN #1 on 8/16/24 at 10:06 AM identified that although Resident #33 did not currently have the left hand palm guard in place she had signed the Medication Administration Record indicating placement. LPN #1 was unable to identify the current location of Resident 33's left hand palm guard and would have to contact the Occupational Therapist (OT). Interview and observation with OT #1 on 8/16/24 at 12:15 PM identified that Resident #33 did not have the left hand palm guard hand splint in place but that he/she should have. OT #1 indicated that Resident #33 was to wear the left hand palm guard daily to maintain functional positioning of his/her left hand and that if the resident was refusing to wear the palm guard or the left hand palm guard was missing, nursing should have documented the information and notified her. After locating Resident #33's left hand palm guard, OT #1 placed it on the resident and indicated that she would need to re-educate and conduct an in-service with the nurse aides and nurses regarding Resident #33's hand splint placement. 3. Resident #46's diagnoses included contracture of the left hand, CVA (stroke) with spastic hemiplegia, and intercranial injury. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had short-term and long-term memory problems, and was totally dependent on staff for eating, bathing, dressing, and toileting. Additionally, the MDS identified impaired functional range of motion on one side for both upper and lower extremities. Review of the Resident Care Plan dated 8/14/24 failed to identify Resident #46's left-hand contracture or the need for a left palm guard. The Resident Care Card (Individualized Resident Assignment) for Resident #46 identified left hand palm guard to be on after morning care and off prior to evening care. A current Physician order in effect on 8/15/24 directed facility staff to apply a left palm guard after morning care and remove prior to evening care. Observations on 8/15/24 at 11:20 AM, 12:09 PM, 12:44 PM, and 2:35 PM identified Resident #46 in his/her room, the left hand palm guard had not been applied to the resident's left hand and was noted to be located on the resident's nightstand. Observation on 8/16/24 at 10:46 AM identified Resident #46 attending an activity program without the benefit of the left palm guard. The palm guard was noted to be located on the nightstand in the same location as noted on 8/15/24. Interview with NA #3 on 8/16/24 at 11:41 AM identified that Resident #46's palm guard was not applied because Resident #46 can become combative, and she required assistance to place the palm guard. Subsequent to surveyor inquiry, NA #3 and NA #7 applied Resident #46's palm guard. Interview with LPN #4 on 8/16/24 at 11:43 PM identified that the physician's order directed a left palm guard be placed every morning after AM care. LPN #4 identified that she was responsible to ensure that the NA had placed Resident #46's palm guard but she had not yet had the opportunity to check for placement. LPN #4 indicated that NA #3 was responsible for Resident #46's palm guard placement and had not reported that the resident had refused palm guard placement during her shift. Additionally, since the physician's order directed the left palm guard be placed after morning care, then Resident #46 should have had the palm guard in place prior to attending the activity. Interview with the Rehabilitation Director (PT #1) on 8/19/24 at 12:12 PM if the palm guard was not worn as ordered, the resident's fingernails could cause open areas in the palms of the hands, maceration (skin breakdown) due to sweat. Additionally, PT #1 identified that if splints are not applied as directed, joint contractures could worsen. Review of the Splints and Orthotic Devices policy directed, in part, to obtain an order for the device and should include the type of device and wear schedule. The resident's care plan and care card will reflect the use of the device. Nursing staff will be educated on the proper application, wearing schedule and any special care related to the device being used. In addition, therapy and nursing staff that have been educated on the device will apply and remove per physician's orders and that devices are given to residents to maintain range of motion, enable proper joint alignment, enhance functional ability and prevent further deformity. 50249 51102

Based on clinical record reviews, facility documentation, facility policy and interviews, for 2 of 6 sampled residents who were reviewed for elopement risk (Resident #1 and Resident #2), the facility failed to provide the necessary supervision for Resident #1 to prevent an elopement resulting in a finding of Immediate Jeopardy. Further, the facility failed to implement their policy for the use of wanderguard devices or other interventions based on the interdisciplinary team's assessment for Resident #2 when identified to be at risk for elopement. The findings include: 1.Resident #1 was admitted from a retirement housing community with diagnoses that included dementia. The Preadmission Screening and Resident Review (PASRR) form dated 8/30/23 identified Resident #1 required supervision while ambulating for safety. The Brief Mental Status (tests for cognitive impairment) dated 8/30/23 identified Resident #1 had severe cognitive impairment. An Elopement Risk Assessment initiated on 8/30/23 and completed on 8/31/23 identified Resident #1 was mobile, did not have a history of elopement, repeatedly expressed a desire to leave, was observed packing belongings and was observed seeking out exit areas. The assessment noted that an answer Yes to any of the questions identified the Resident was at risk for elopement and would require a wander device (a bracelet worn to detect movement through an alarmed egress) to be applied, or if determined by the interdisciplinary team (IDT), the resident's behavior did not constitute a risk for elopement, a care plan would be written to reflect appropriate interventions. The clinical record failed to identify that a wander guard device was implemented or that the IDT determined Resident #1 was not at risk for elopement. The Resident Care Plan (RCP) dated 8/30/23 identified Resident #1 had impaired cognition related to dementia and was at risk for elopement. Interventions directed to offer gentle reminders if confused or forgetful and if seen lingering near an exit door offer to escort to another area of the building. Review of the facility Reported Event summary dated 9/7/23 identified on 9/1/23, at approximately 3:30 PM a call was received reporting an elderly female outside by the road. A search was immediately conducted that identified Resident #1 was unaccounted for. Resident #1 was returned to the facility at 3:35 pm. A body audit was conducted, and no apparent injuries were noted. Resident #1 had a wandering device applied to his/her right ankle and was placed on 1:1 enhanced monitoring for 24 hours then checks every 15 minutes for 48 hours until Resident #1 was moved to the secure unit on 9/6/23. An interview with Licensed Practical Nurse, LPN #1, on 9/20/23 at 12:33PM and 2:22PM identified she worked on 8/30/23 and 8/31/23 during the 7:00AM-3:00PM shift. LPN #1 indicated she completed the Elopement Risk Assessment on 8/31/23 when it was reported by LPN #2, the charge nurse from the 11:00PM -7:00AM shift, that during the night (8/30/23), Resident #1 was exit seeking, stated s/he wanted to leave, and was packing belongings. LPN #1 reported the information to RN #1 (7AM-3PM Nursing Supervisor) on 8/31/23 and stated his/her room should be moved because s/he could be passed off as a visitor. RN #1 indicated the issue was being addressed. LPN #1 further indicated it was the Nursing Supervisors responsibility to review the Elopement Risk Assessments to determine if any other interventions were needed, including the placement of a wandering device. An interview with RN #1 on 9/20/23 at 12:05PM and on 9/21/23 at 9:40AM identified he was working as the Nursing Supervisor on 9/1/23 during the 7:00AM shift -3:00PM shift. RN #1 denied having been previously notified of Resident #1's increase in exit seeking behaviors and stated it was the DNS and MDS coordinator's responsibility to review the results of the Elopement Risk Assessments to put any additional immediate interventions in place that included alerting staff. An interview with RN #2, the MDS coordinator, on 9/21/23 at 9:45AM identified she was responsible for taking information from the elopement assessments to develop a care plan. RN #2 reported on 8/31/23, upon arriving for work at 6:00AM, Resident #1 made statements about wanting to leave. The 11:00PM -7:00AM staff also reported Resident #1 was exhibiting exit seeking behaviors during the overnight shift. RN #2 reported this information in the staff morning meeting but did not indicate what plan was implemented to address the increase in exit seeking behaviors. RN #2 indicated the Nursing Supervisor and DNS were responsible for reviewing the assessments once completed in determining any further immediate action. There were no recorded notes from the morning meeting on 8/31/23. An interview with the (former) Receptionist on 9/20/23 at 2:54PM identified she was working on the afternoon of 9/1/23 in the front reception area. The Receptionist stated she was normally able to distinguish a resident from a visitor as visitors were required to sign in and out at the reception area when entering and exiting the building. The Receptionist described the afternoon as crazy busy and did not observe Resident #1 go to the sign out log. There was no information including a photo previously provided to her that would have alerted her that Resident #1 was at risk for elopement so when Resident #1 attempted to leave, the Receptionisist overrode the locked keypad at the entrance and allowed Resident #1 to exit the facility without first verifying whether she was a resident or visitor. An interview with the Director of Nursing (DNS) on 9/20/23 at 10:32AM identified she was working on the evening of 9/1/23 when at approximately 3:25PM, the business office manager came to her to report receiving a phone call from a person in the community inquiring if there were any missing residents. A search immediately ensued in and outside the facility to determine if there were any missing resident(s). Resident #1 was located 0.8 miles away and returned to the facility at approximately 3:35PM by a staff member from his/her previous residence who happened to have been driving by and recognized him/her. A review of video surveillance identified Resident #1 was let out through the front door by the Receptionist who overrode the locked keypad at the entrance of the building in order to let Resident #1 out without first verifying if s/he was a resident or visitor. The receptionist was subsequently terminated. The DNS stated Resident #1 had no previous known history of elopement risk and was unaware Resident #1 had been identified at risk for elopement. The DNS indicated it was the interdisciplinary team's decision to be discretional when determining the needs of a resident at risk for elopement. A subsequent interview with the DNS on 9/21/23 at 10:15AM identified she could not recall being informed of Resident #1's increase in exit seeking behaviors during the morning meeting on 8/31/23 The DNS indicated she would expect the Nursing Supervisor to review the completed Elopement Risk Assessment and determine any further immediate action including alerting staff and providing photos. Attempts to interview LPN #2 were unsuccessful. A review of the facility Elopement Risk policy directed when there was an answer of yes to any screening questions, a resident was considered at risk and an elopement device (wander guard) was to be placed on the wrist or ankle and documented in the treatment administration record. Or, if determined by the interdisciplinary team, the resident's behavior did not constitute a risk for elopement, a care plan would be written to reflect appropriate interventions. During an expansion of the sample the following was identified: 2. Resident #2 had diagnoses that included schizophrenia and dementia and had a previous elopement attempt on 7/28/22. The Nursing Quarterly assessment dated [DATE] identified Resident #2 was at risk for elopement related to cognitive impairment and would leave the unit without staff knowledge. The annual MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairment, had not exhibited wandering behaviors, and was independent with locomotion on and off the unit. The RCP dated 7/17/23 identified Resident #2 had impaired cognition and was at risk of eloping from the building with a previous elopement attempt on 7/28/22. Interventions directed to provide reality orientation and offer to escort to another area of the building if lingering near an exit door. During the onsite visit, Resident #2 was observed to not utilize a wander guard device and the clinical record failed to reflect that the interdisciplinary team assessed this resident to determine the resident's behavior did not constitute a risk for elopement resulting in a finding of Immediate Jeopardy. An interview with the DNS on 9/20/23 at 10:32AM and at 4:43PM identified the interdisciplinary team made decisions based on the needs of a resident at risk for elopement and could be discretional when determining interventions. The DNS indicated Resident #2 was known to linger near exits when a visit from a family member was scheduled, however, did not exhibit any other exit seeking behaviors. The DNS indicated Resident #2 had a previous elopement attempt on 7/28/22 but was unable to provide any details. Subsequent to surveyor inquiry on 9/20/23, the facility conducted an Elopement Risk Assessment that identified Resident #2 was no longer at risk for elopement. A review of the facility Elopement Risk policy directed when a resident was identified at risk, an elopement device was to be placed on the wrist or ankle and documented in the treatment administration record.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #23) reviewed for accidents, the facility failed to ensure food was served according to the physician's orders [REDACTED]. The findings include: Resident #23's [DIAGNOSES REDACTED]. A speech therapy order dated 4/3/18 directed a dysphagia (difficulty swallowing) evaluation. The treatment [DIAGNOSES REDACTED]. Additionally, the order directed to discontinue the use of the right handled side cutter for all meals. The annual MDS dated [DATE] identified that Resident #23 was moderately cognitively impaired, on a therapeutic diet, and required supervision of 1 staff with eating after set up. Review of speech therapy feeding instructions (written by ST #1) dated 4/6/18 directed to provide a regular consistency, thin liquid diet. Additionally, the instructions directed to provide Resident #23 with minimal assistance with pre-cutting food into small pieces prior to oral intake, and cue as needed for increased use of liquid wash. A physician's speech therapy order dated 4/18/18 directed Resident #23 was to remain on current diet of regular consistency with thin liquids. Additionally, Resident #23 was discharged to a functional maintenance program and/or restorative nursing program. The care plan dated 4/24/18 identified Resident #23 had a swallowing problem, coughed and/or choked during meals and/or when swallowing medication. Interventions included to alternate small bites and sips, use a tea spoon for eating, do not use straws, be aware of difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallowing per bite, coughing, throat clearing, drooling, and pocketing food in mouth. Resident #23 was to eat only with supervision, slowly in an upright position, and to chew each bite thoroughly. Additionally, the care plan identified staff to cut Resident #23's food. physician's orders [REDACTED]. Additionally, Resident #23 was to utilize a plate and scoop bowl at all times, and staff were to assist with bolus. Review of a reportable event form dated 6/15/18 at 12:15 PM identified Resident #23, who was seated in custom wheelchair in the dining room, had difficulty talking/breathing. ST #1, who was in the doorway of the dining room, observed Resident #23's difficulty, and notified LPN #2. LPN #2 attempted the [MEDICATION NAME] maneuver without effect. Resident #23 was gasping, his/her color was pasty but he/she remained awake and conscious during the incident. Resident #23 was moved to a vacant room directly across from the dining room and EMS (911) was called. Additionally, the [MEDICATION NAME] maneuver attempts continued without success. Resident #23 was transferred from the custom wheelchair into a bed, and the [MEDICATION NAME] maneuver was again attempted without effect. Resident #23 was suctioned, and a 3 inch by 1 inch long lasagna noodle was removed. After the lasagna noodle was removed, Resident #23 became more responsive, his/her color improved, and the resident began talking and returned to baseline. Resident #23 was transferred to hospital emergency room for further evaluation. Review of a statement by the DNS dated 6/15/18 identified he/she was paged and observed Resident #23 barely responsive but breathing. Attempts were made to suction, and a large lasagna noodle was dislodged. Once the noodle was dislodged, Resident #23 became more responsive and back to baseline. Review of a statement by NA #1 dated 6/15/18 identified Resident #23 had just received his/her food and usually askes for it to be cut up. NA #1 did not witness Resident #23 consume any food. Review of a statement by LPN #2 dated 6/15/18 identified he/she was called into the dining room. Resident #23 became less responsive and LPN #2 performed the [MEDICATION NAME] maneuver in the dining room with no effect. Resident #23 was put in a bed, and the [MEDICATION NAME] maneuver was performed with no effect. Resident #23 was suctioned and an approximately 3 inch lasagna noodle came out. Resident #23 immediately came back to baseline and indicated he/she swallowed without chewing. Review of hospital documentation dated 6/15/18 identified Resident #23 presented with an oxygen saturation of 89% mm/Hg (normal range 95% - 100% mm/Hg) on room air. He/she was placed on 2 liters via nasal cannula, and several sounds of gurgling suggestive of aspiration were heard. Admitting [DIAGNOSES REDACTED]. Review of the hospital history and physical note dated 6/15/18 identified Resident #23 had a deep phlegmy cough and may have an early [MEDICAL CONDITION] starting due to the aspiration event. Antibiotics were started in anticipation pneumonia would develop. A chest x ray dated 6/15/18 was negative, however, a chest x ray dated 6/17/18 identified a left lower lob infiltrate. A [MEDICAL CONDITION] consultation dated 6/20/18 identified Resident #23 was status [REDACTED]. Interview with LPN #2 on 6/27/18 at 9:15AM identified that on 6/15/18 at lunch time he/she was called to the dining room on by ST #1 who indicated there was a problem with a resident. Upon arrival, LPN #2 indicated he/she observed Resident #23 was awake, alert, gasping and saying help. Resident #23's color was ashen and the resident appeared to be choking. LPN #2 identified there were 2 nurse aides in the dining room at the time. Additionally, the dietary staff with steam table were just exiting the dining room indicating the residents had just been served. LPN #2 identified that he/she gave the walky-talky to ST #1, and instructed him/her to page the nursing supervisor stat. LPN #2 began attempting [MEDICATION NAME] maneuver. LPN #2 identified that because Resident #23 was still conscious and the dining room was full of residents, they moved the resident to a vacant room directly across the hall from the dining room to continue. [MEDICATION NAME] maneuver attempts continued without success by another nurse. Resident #23 was then transferred onto the bed, and the [MEDICATION NAME] maneuver was attempted again without success. LPN #2 identified that because 911 was called, he/she then left room to prepare resident paperwork for discharge. Upon return to resident in room, Resident #23 was awake, talking, color returned and LPN #2 was told resident that a 3 inch long lasagna noodle had been suctioned from Resident #23's airway. LPN #2 identified that he/she was aware that the resident required food to be cut up into small pieces prior to eating, and was unable to physically do this him/herself, but was surprised that the resident didn't wait for a nurse aide as he/she usually does. LPN #2 further identified that Resident #23 had never done this before, and had never had a choking episode before. Interview with NA #1 on 6/27/18 at 10:20 AM identified that on 6/15/18 he/she and another nurse aide were assisting residents who had just been served their lunch meals by the dietary staff via the steam table in the dining room. While setting up and assisting another resident, NA #1 identified Resident #23 was having difficulty talking and asked ST #1 to help, and also to call for LPN #2. NA #1 identified that Resident #23 had just been served his/her plate, and had not observed the resident eat anything. NA #1 further identified that dietary staff deliver the plates to the residents, and place on them on the table in front of them. Additionally, that it was the nurse aide's responsibility to cut up the resident's food before they eat. NA #1 also identified that Resident #23 would always wait for them to cut up the food before he/she ate independently, and indicated he/she was surprised when Resident #23 began choking. Interview with the DNS on 6/27/18 at 11:30 AM identified that although it was unusual for Resident #23 not to wait for a nurse aide to cut his/her food up before eating. Additionally, the DNS indicated had the lasagna been cut up prior to Resident #23 eating, the resident would not have choked on a 3 inch long lasagna noodle. Interview with ST #1 on 6/27/18 at 12:30 PM identified that Resident #23 required his/her food to be cut up into small pieces to ensure safety during meal intake because the resident could not cut the food up him/herself. ST #1 further identified that had the resident's food been cut up before being placed in front of him/her, it would have prevented the resident from consuming the large lasagna noodle, and subsequently choking on it. Interview with MD #2 on 6/28/18 at 12:20 PM identified he/she would have expected Resident #23's food to be cut up prior to the resident receiving it, and that the probability of the resident choking on a smaller piece of lasagna would have been lessened. Review of the facility's feeding policy directed to bring meal to the resident, being sure the resident receives prescribed diet, ensure any adaptive equipment is in use per plan of care, and prepare meal as needed; i.e., cut meat, prepare beverages, etc. The facility failed to cut up Resident #23's food, according to the physician's orders [REDACTED]. Subsequently, Resident #23 required hospitalization and was diagnosed with [REDACTED].

Based on clinical record reviews, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who required staff assistance with personal care, the facility failed to ensure that the resident was free from verbal abuse. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, difficulty focusing attention, was easily distracted, required one person extensive assistance with personal hygiene and toilet use, and was frequently incontinent of bowel and bladder. The Resident Care Plan dated 4/4/17 identified the resident had dementia with behavioral disturbances, could be forgetful, was able to make needs known and could understand what was being said to him/her. Interventions directed to use short, simple sentences, offer support and reassurance if anxious, offer one step at a time directions and offer gentle reminders. The Reportable Event Form dated 6/15/17 at 8:40 PM identified a charge nurse overheard a nurse aide make derogatory comments towards a resident. The nurse's note dated 6/15/17 at 9:40 PM identified the charge nurse had notified the Nursing Supervisor that a nurse aide made derogatory statements to Resident #1. The note identified the nurse aide was advised to write a statement and then instructed to leave the facility. The nurse's note identified an assessment was completed, no injuries were noted, and the resident was unable to provide a valid statement of the event due to the [DIAGNOSES REDACTED]. The nurse's note dated 6/15/17 at 10:10 PM identified the charge nurse, while charting at the nurse's station, overheard the assigned nurse aide make derogatory statements to Resident #1. The note identified the nurse aide said, you are f- - -ing disgusting, and f- - -ing gross digging in your private area, you are old enough to know better, you are f- - -ing nasty. The note indicated the nurse aide then repeated the statements and the charge nurse immediately went to the room to see what was going on. The note identified the nurse aide stuck her head out of the door and stated the resident is just nasty, digging in his/her private area, I'm fine. The note reflected the Nursing Supervisor was immediately contacted. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1 on 7/5/17 at 12:00 PM identified that while charting at the nurse's station she heard the assigned nurse aide, Nurse Aide (NA) #1, yelling at Resident #1. LPN #1 stated NA #1 made derogatory comments, you are f- - -ing disgusting, and f- - -ing gross digging in your private area, you are old enough to know better, you are f- - -ing nasty. LPN #1 stated when she first heard the comments, she was not sure she heard correctly, but a few seconds later when NA #1 had repeated the words, she heard Resident #1 state I'm not disgusting. LPN #1 stated she immediately went to Resident #1's room and found NA #1 in the bathroom providing incontinent care to Resident #1 who was seated on the toilet. LPN #1 identified she asked NA #1 what was going on, NA #1 that stated that she was fine and the resident was just nasty, digging in his/her private area. LPN #1 stated NA #1 seemed very defensive. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 7/5/17 at 1:00 PM identified that after LPN #1 had reported the incident, he told NA #1 of the allegation, asked for a written statement and instructed NA #1 to leave the facility. RN #1 stated he assessed the resident both physically and emotionally, no issues were identified, and the resident did not seem to recall the incident. Interview with the Director of Nursing (DON) on 7/5/17 at 12:30 PM identified NA #1 was suspended pending the investigation and was terminated on 6/26/17 for inappropriate language with a resident. The facility abuse policy identified that abuse or mistreatment of [REDACTED].

Based on review of the clinical record, facility documentation, and interview for 1 of 3 sampled residents (Resident #73), reviewed for accidents, the facility failed to ensure the resident was supervised, according to the plan of care, to prevent a fall. The findings include: Resident #73's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified Resident #73 had severely impaired cognition, required extensive 1 person assistance with transfers and walking, and a history of falls. The care plan dated 10/20/16 identified Resident #73 was at risk for falls related to an unsteady gait, macular degeneration, and a history of falls. Interventions included for the staff to ensure Resident #73 was in a supervised area while up in the wheelchair. physician's orders [REDACTED]. Additionally, to utilize a wheelchair with an anti-roll back device for independent mobility. Accident/incident report dated 12/30/16 at 3:45 PM identified Resident #73 was found lying on the floor in his/her room. Review of a written statement by the Recreation Director dated 12/30/16 identified he/she had transported Resident #73 from the entertainment program to his/her room after the program ended. The Recreation Director exited Resident #73's room to escort other residents back to the unit. The Recreation Director documented that he/she was unaware that Resident #73 needed to be seated by the nursing station. Nurses notes dated 12/30/16 identified Resident #73 indicated he/she was attempting to turn off the light and fell from the wheelchair. The RN assessment conducted at the time of the fall identified Resident #73 had full range of motion of the lower extremities, but had pain in the left elbow. Bruising was noted on the left hand and elbow. Nurse's note dated 12/30/16 at 6:30 PM identified Resident #73's left elbow was swollen and painful. Additionally, subsequent to APRN notification, Resident #73 was transferred to the hospital for evaluation. Nurse's note dated 12/31/16 identified Resident #73 returned to the facility at 7:15 AM with a [DIAGNOSES REDACTED]. A splint and sling was in place. Interview with the Recreation Director on 6/13/17 at 11:45 PM identified that on 12/30/16, he/she transported Resident #73 back to his/her room after the entertainment program ended. The Recreation Director indicated he/she put the light on for Resident #73 and left the room to assist other resident back to their units. The Recreation Director indicated he/she was not aware that Resident #73 had to be placed by the nursing station in a supervised area while seated in the wheelchair. The Recreation Director indicated that had he/she know that that Resident #73 required supervision while in the wheelchair, the Recreation Director indicated he/she would have placed Resident #73 by the nursing station for supervision. Interview, review of the clinical record and facility documentation on 6/13/17 at 1:45 PM with the DNS identified that the recreation staff attend care plan meetings where resident care and services are discussed. Additionally, the DNS indicated that the Recreation Director and recreation staff were provided with education to ensure residents who require supervision are seated in supervised areas. Review of the policy on minimizing risk of injury due to falls identified that residents who experience a fall will be evaluated following the occurrence using the interdisciplinary assessment tool to identify the potential causes of the fall. An individualized care plan will be developed and updated as needed to identify interventions to prevent falls and minimize injuries.

Based on review of the clinical record, facility documentation and interviews for a (R#1) resident reviewed who sat outside unattended, the facility neglected to ensure interventions were in place to monitor and/or intervene while the resident was exposed to extreme heat. The findings include: Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] indicated R#1 had a BIMS score of 15 indicating he/she had intact cognition and no deficits with short and long term memory. According to the MDS R#1 required extensive assist of two staff members for transfer and was independent with mobility on and off the unit. A resident care plan (RCP) dated [DATE] indicated R#1 had a potential for dehydration. Interventions included: awareness of fluid and meal intakes, offer water and encourage fluids with and between meals, encourage fluid intake during hot months, ensure R#1's room is cool and he/she has proper attire/bedding. In addition the RCP indicated R#1 exhibited decreased mobility (non-ambulatory) with interventions that included to reinforce safety awareness, check for safety and anticipate R#1's needs. An occupational therapy evaluation/plan of care, implemented to promote R#1's independence and socialization, indicated R#1 was safe to be outside unattended with interventions that included he/she would carry a charged cell phone allowing R#1 to communicate with staff when he/she was ready to come in to the building from outside. During an interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 12:55 PM, LPN#1 indicated on [DATE] at approximately 1:00 PM R#1 indicated he/she was going outside to the garden. LPN#1 inquired if R#1 had sunscreen on and his/her charged cell phone to which R#1 responded Yes. During an interview with the Recreation Director on [DATE] at 10:10 AM, the Recreation Director indicated shortly after 1:00 PM on [DATE] he/she brought R#1 outside to the garden area at R#1's request. During an interview with NA#1 on [DATE] at 10:50 AM, NA#1 indicated between 1:30 PM and 2:00 PM NA#1 went to the outside garden and asked R#1 if he/she needed anything. R#1 indicated he/she was fine and did not need anything. NA#1 indicated R#1 was alert, oriented and not diaphoretic or red in the face. NA#1 indicated he/she did not see R#1 again during the remainder of the shift (7:00 AM to 3:00 PM). During an interview with NA#4 on [DATE] at 1:05 PM, NA#4 indicated between 2:00 PM and 2:30 PM he/she asked LPN#1 if R#1 was on any fluid restrictions and NA#4 provided cold water to R#1 at his/her request. NA#4 indicated R#1 indicated he/she was fine. R#1 conversed with NA#4 for approximately five minutes taking sips of water. R#1 was not diaphoretic or showed any signs of distress. NA#4 indicated he/she did not see R#1 during the remainder of the shift (7:00 AM to 3:00 PM). During an interview with LPN#2 and NA #3 on [DATE], LPN#2 and NA#3 indicated they had received report from the off going shift (7:00 AM to 3:00 PM) at approximately 3:00 PM. They indicated during report they had not been notified R#1 was outside although that was R#1's usual routine. LPN#2 and NA#3 indicated they did not see R#1 on [DATE] between 3:00 PM and 5:00 PM. NA#3 indicated at 5:00 PM R#1 had not called to come in for dinner as he/she usually did so NA#3 proceeded outside to check on R#1 and found R#1 sitting in his/her wheelchair unresponsive. NA#1 stayed with R#1 and called for assistance. According to a nurses note by Registered Nurse (RN) #1 dated [DATE] at approximately 5:00 PM R#1 was found outside unresponsive and immediately brought into the facility and placed into bed. His/her pupils were fixed and dilated with agonal respirations. Vital signs at the time were blood pressure ,[DATE], pulse rate was 126, respirations were 26 and oxygen saturation was 94%. R#1's temperature was 105.7 degrees fahrenheit. Emergency Medical Services (EMS) was called and as EMS arrived R#1's respirations and pulse rate ceased. R#1's code status was do not resuscitate/do not intubate. Resident #1 was pronounced deceased at 5:41 PM on [DATE]. During a review of facility video with the Director of Maintenance on [DATE] at 10:30 AM the facility could not substantiate that staff from R#1's assigned unit made contact with R#1 and/or evaluated R#1's condition from 2:30 PM to 5:00 PM. According to National Climatic Data Center (NCDC) on [DATE] at 3:54 PM the outside temperature was recorded as 95 degrees Fahrenheit (F.).

Based on observation, review of clinical records, manufacturer recommendations for use of sit-stand lift, review of facility policies and procedures, and interviews for one of five residents reviewed for accidents, Resident #29, the facility failed to ensure measures were in place to ensure a resident was safe from injury. The findings include: 1a. Resident #29 was admitted with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified severely impaired cognition, was non-ambulatory and required total assistance of two staff for bed mobility and toilet use, extensive assistance of two staff for transfer and personal hygiene, and total assistance of one staff for locomotion. An individualized resident assignment directed to leave geri-legs on at all times, pad sit-to-stand lift with towels during transfer, and use shin tubes for transfer with standing lift to prevent tears. Physician's orders dated 05/13/15 directed to leave geri-legs on at all times, remove for care (04/24/15), apply skin tubes for protection during transfer, then remove and transfer via standing mechanical lift with assist of two staff. A RCP identified the problem of risk for skin breakdown/skin tears related to altered mobility, PVD, resistance to care, and combativeness. Interventions included geri-legs to bilateral lower extremities at all times (4/24/15), shin tubes during transfers (5/09/15), and pad needed areas on mechanical lift (1/6/15). Review of a facility conducted investigation dated 04/17/15 identified that a skin tear measuring 2 centimeters (cm) by 2 cm was noted on Resident #29's right lower leg on 4/17/15 at 6:40 AM. Although multiple staff interviews were conducted, the investigation was inconclusive regarding the origin of the skin tear. A new intervention included wearing the geri-legs at all times, removing for care only. Interview with the Director of Nursing (DNS) on 07/14/15 at 11:30 AM identified that the skin tear sustained on 04/17/15 was similar in size, shape and location to the skin tear identified on 05/09/15. 1b. A facility investigation identified that following a transfer into bed by NA #5 and NA #6 on 05/09/15 at 8:00 PM, a laceration measuring 5 cm long and 0.5 cm in depth was noted on Resident #29's right lower leg. The resident was transferred to the emergency department (ED) and received 15 sutures. The facility concluded that the laceration was caused by the fastening device on the lower leg strap on the transfer lift. Inter-agency patient referral report instructions dated 05/09/15 identified to be careful with transfers. Interview with NA #5 on 07/14/15 at 9:45 AM identified that he/she was assigned to care for Resident #29 on the 3:00 PM to 11:00 PM shift on 05/09/15. NA #5 identified that he/she had not checked the resident assignment (care card) prior to providing care to the resident. Resident #29 was not wearing geri-legs at the time of the occurrence and NA #5 was unable to recall if he/she padded the knee supports with towels prior to transfer. Interview and review of the Occupational Therapy (OT) screen dated 05/11/15, with the Director of Rehab Services on 07/13/15 at 1:45 PM identified that the lower leg strap which included a seatbelt-like fastening device with a plastic slide to adjust the length of the strap was threaded incorrectly, causing the lower leg strap to be inverted when fastened, with the exterior of the plastic slide coming in direct contact with the resident's leg and/or exterior clothing. When inverted, the plastic slide protruded creating a pressure point/sharp edge. The director of Rehab identified that Resident #29's laceration was consistent with the size, location, and shape of the plastic slide. Subsequent to 05/09/15 the maintenance department checked all sit-to-stand lifts to ensure proper threading of the fastening device and slide. Additionally, on 05/12/15, 33 NA's from all shifts were educated on the need to check proper placement of the fastening device and slide prior to each transfer. 1c. Review of the facility policy and procedure titled Mechanical Lift (stand) failed to identify the proper use of the lower leg straps including the need to fasten the straps, and/or the need to check the fastening device and plastic slide for proper placement prior to transfer.

Based on observations, clinical record reviews and interview for two of three (Resident#10 and Resident#20) sampled residents reviewed for accidents, the facility failed to provide adequate supervision to prevent an accident. The findings include: 1. Resident#10 ' s [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment dated [DATE] identified severely impaired cognition, required extensive assistance for transfers, required staff assistance for stability when moving from seated to standing position and the use of walker for mobility. The care plan dated 7/29/13 identified a self-care deficit with interventions that included transferring and ambulating with assist of one with a wheeled walker. The nurse ' s notes dated 9/16/13 identified a skin tear measuring 4.5cm x 1cm with a depth of 1.5cm on the left lower leg that occurred during transfer. The physician orders [REDACTED]. A review of the interagency referral report dated 9/16/13 indicated that 18 sutures were placed to approximate the laceration on the left lower leg and directed to remove them after ten days and monitor the site for infection. Interview with LPN#1 on 10/9/13 at 10:15AM indicated that a student nurse (SN) notified him/her of a problem on 9/16/13; he/she noticed blood on the right side of the wheelchair where the leg rest attaches. Interview with SN#1 on 10/9/13 at 11:05AM indicated that he/she transported Resident #10 to the bathroom for morning care with a wheelchair. SN#1 further indicated Resident #10 requested to transfer from the wheelchair to the toilet; SN#1 did not provide hands-on assistance and/or use a gait belt during the transfer. SN#1 indicated Resident #10 stood up, grabbed the mobility bars, pivoted to the right and then sat on the toilet at which timeSN#1 noticed blood on Resident #10 ' s sneakers. Interview with the Physical Therapist (PT) on 10/7/13 at 10:29AM indicated Resident #10 was not provided enough clearance to complete the transfer which resulted in the left lower leg bumping against the device on the wheelchair where the leg rest attaches which resulted in the laceration. Further interview with the PT identified Resident #10 required a wheeled walker for transfers for upper body support and stability. Interview with the DNS on 10/9/13 at 2:00PM identified the Student Nurse failed to follow the plan of care and/or facility policy regarding providing assistance and the use of a gait belt and walker during transfer resulting in an injury to Resident #10's lower extremity. A review of the facility gait belt policy identified to ensure the safety of our residents and staff, the use of a gait belt is mandatory by all nursing and rehabilitation staff while transferring or ambulating residents. 2. Resident#20 ' s [DIAGNOSES REDACTED]. The MDS dated [DATE] identified moderately impaired cognition, required limited assist of one for transfers and ambulation and poor vision. The care plan dated 8/26/13 identified poor vision due to macular degeneration with interventions that included providing adequate lighting, orient me to surroundings as needed and transfer and ambulate with assist of one with a wheeled walker. The nurse ' s notes dated 10/3/13 at 3:45PM identified Resident #20 was in the movie theater, went to sit down, missed the chair then knelt on floor and sustained redness to the knee and complaints of back pain. The APRN was notified and directed to administer Tramadol 50mg as needed for back pain. Interview with NA#1 on 10/7/13 at 1:30PM indicated he/ she observed Resident #20 ambulating in the hallway independently with a rolling walker, he/ she intervened by assisting Resident #20 to the movie theater. NA#1 indicated a movie being shown at the time and the room was dark. NA#1 further indicated he/she held the seat down then directed Resident #20 to sit down but did not provide hands on assistance to ensure the resident was properly seated. Resident#20 instead sat on the chair next to the seat being held down and immediately knelt on the floor. Interview with the Physical Therapist on 10/7/13 at 10:29AM identified Resident #20 was not provided physical assistance during the transfer on 10/3/13 as directed in the plan of care.

Based on clinical record reviews, interviews, and review of facility policies for 2 of 6 sampled residents reviewed for nutrition (R# 131, 41), the facility failed to ensure that weight loss was reported to the dietitian and/or physician, and/or that the dietitian assessed the weight loss, and/or that interventions to prevent further weight loss were intimated. The findings include. 1. Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was severely cognitively impaired, had disorganized thinking, difficulty concentrating and altered level of consciousness. The resident was identified as an independent eater with supervision with no weight loss identified. The care plan dated 10/17/12 identified the potential for weight loss related to dementia. Interventions included weights as ordered, offer alternatives, offer supplements, and to encourage to finish meals, snacks and fluids. Weekly weights identified that on 10/18/12, the resident's weight was recorded as 172.2 lbs and on 10/25/12, the weight was recorded as 163.8 for an 8.4 lb/5% weight loss in one week. Interview and review of the weekly weights and clinical record with LPN#3 on 12/6/12 at 12 noon identified that the staff were unable to explain why the dietician and/or physician had not been notified of the weight loss on 10/25/12 or interventions to prevent further weight loss initiated. Review of the clinical record and plan of care failed to identify a review and/or revision of the plan of care with new interventions until 11/8/12. Physician orders [REDACTED]. Review of the resident meal intakes for October noted a decline from 100% completion to a fluctuation from 0% to 25-50%. November 2012 meal intakes noted intakes of 50%. Although the resident was seen by the psychologist, the weight loss was not addressed in the progress notes and/or physician orders [REDACTED]. On 11/23/12, the resident's weight had further declined to 154.8 lbs. for a 9.8% weight loss in less than 6 weeks. Review of the dietary notes failed to identify any dietitian assessment related to the weight loss until subsequent to surveyor inquiry on 12/7/12. Interview and review of the clinical record, facility weight loss policy and dietary notes with the RN#1, on 12/7/12 at 2 PM, failed to provide documentation that the weight loss had been recognized, and/or reported to the dietitian or physician, and/or that assessment and interventions to prevent further weight loss were initiated timely. The physician was notified on 12/7/12 ordered an increase in the amount of house supplement to 120 cc three times a day, and the addition of "power" (high calorie/high protein) cereal with breakfast. Interview and review of the clinical record, weekly weights and physician orders [REDACTED]. 2. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated that the resident required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and had moderate cognitive impairment. The care plans dated 8/29/12 and 9/2/12 identified that the resident had poor intake, was not meeting his/her fluid goals and was at risk for weight loss. Interventions included weights as ordered. A dietitian's progress note dated 8/16/12 indicated the resident's weight was 142.8 pounds on admission. A subsequent note on 11/15/12 indicated the resident's intake was poor with 25% consumed for breakfast, 25-50% at lunch, and dinner was not documented. Recommendations included weekly weights and 4 ounces of house supplement twice a day. Interview with LPN #4 on 12/7/12 at 2:30 PM noted that the dietitian posts her recommendations at the nurse's station and does not speak directly with staff. Review of the clinical record at that time failed to provide documentation that the supplements had been initiated or that LPN#4 was aware of the recommendations made by the dietician. During an interview with Dietician #1 on 12/10/12 at 10:10 am, the dietician failed to provide documentation that the resident's weight loss was assessed and interventions were put in place from 9/5/12 to 11/11/12. As a result, the resident sustained [REDACTED].

Based on clinical record reviews, observations, interviews, and review of facility investigations for 3 of 6 sampled residents reviewed for incidents/accidents (R#2, 7, 8 ), the facility failed to ensure that the resident was supervised to prevent elopement and/or failed to secure windows on the dementia unit to prevent elopement and/or the facility failed to ensure assistive devices were used appropriately and safely to prevent a fall, and/or failed to ensure an appropriate plan of care was in place to handle a contracted resident appropriately to prevent a fracture. The findings include: 1. Resident #7's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified that the resident was severely cognitively impaired, had no problem behaviors, and was totally dependent on staff for ADL's including eating, bed mobility and transfers. The resident required 2 staff for transfers. The care plan dated 4/11/12 identified a history of lower back pain and osteoporosis. Interventions included to provide pain mediation as needed, use pain scale to determine level of pain, and to be aware of non-verbal signs of pain. The care plan also identified that the resident may be prone to fractures due to osteoporosis and osteoarthritis. Interventions included to transfer via mechanical lift with the assist of two staff to a custom wheelchair. Review of nurse's notes noted no entries from 4/25/12 until 5/30/12 when it was documented that the resident complained of pain in the legs at 9 AM, and was given Tylenol with no relief. The note identified that the resident was assessed and sent to the hospital at 2:35 PM and admitted with a fracture. A late entry dated 6/1/12 for 5/29/12 noted that at 2:30 PM, while being put back to bed, the resident yelled out " my leg " . The note identified no change in range of motion. A CT scan of the pelvis and right hip dated 5/30/12 identified an impacted intertrochanteric right hip fracture likely acute. The CT scan describes surrounding soft tissue swelling and intramuscular edema. Review of the facility investigation noted the following: -LPN#2, the 7-3 nurse on 5/29/12 noted that the NA told her the resident yelled about his/her leg while being put back to bed at 2:30 PM. She noted that she assessed the resident and there were no issues. -NA#4, the day shift NA on 5/29/12 and 5/30/12 noted that the resident had more pain than normal on both days. -LPN#3, the 7-3 nurse on 5/30/12, noted the resident had leg pain and was medicated with Tylenol at 9 AM. -NA#5, the 11-7 NA from 11 PM 5/29 through 7 AM on 5/30/12 noted that she informed the nurse that the resident had more pain than normal. Interview with NA#4 on 10/16/12 at 12:30 PM noted that Resident #7 was unable to move on his/her own, unable to self propel in the wheelchair and was not combative or resistive to care. NA#4 demonstrated that the resident's legs were very contracted and he/she would sit in the chair with the legs drawn up and crossed over. Interview and clinical record review with the DNS on 10/16/12 at 12:30 PM noted that during the surgery to repair the right hip fracture, the orthopedist performed a right knee tenotomy to release the "flexion contracture". Review of the clinical record and care plan failed to identify that the resident had a flexion contracture of the right knee/leg and/or directions for care and treatment to prevent injury or decline in the contractures. 2. Resident #2's [DIAGNOSES REDACTED]. The resident had been hospitalized from [DATE] through 5/11/12 for behavioral issues including aggressive behavior, combativeness, and elopement attempts. He/she was transferred to another nursing facility from which the resident eloped. The resident was admitted to the facility on [DATE]. The nursing admission note dated 5/25/12 noted that the resident was ambulatory, a wanderguard was applied, and the resident was placed on 15 minute checks due to the history of elopement. On the 3-11 PM shift the day of admission, the resident was caught making 2 attempts to elope through the windows, using a trash can to climb through the sliding windows. The resident became combative when approached and struck two nurse aides that evening. On 5/29/12, NA#1 asked LPN#1 if she had seen the resident. NA#1 did not inform LPN#1 that the resident was missing. At 6:15 PM, another NA informed LPN#1 that they could not find the resident. The resident had been last observed at 5:15 PM. As LPN#1 went to inform the supervisor, the Police called the facility to inform them that the resident was found wandering on a busy road approximately 1 mile away. Interview and review of the record and documentation with the DNS on 10/15/12 at 12 PM noted that she was not aware that the windows were not secure on the "secure unit" until after the resident eloped through them. Further review noted that the NA failed to inform the charge nurse (LPN#1), that the resident was missing for over half an hour. 3. Resident #8's [DIAGNOSES REDACTED]. The resident care plan dated 10/4/11 identified the risk for falls and transfers with a mechanical lift. Interventions included transfer with an assist of 2 persons via a mechanical lift. Nurse's notes dated 12/21/11 at 2 pm identified R#8 was being transferred from the bed to the wheelchair via the mechanical lift when the resident fell from the lift, landing on the his/her right side at the base of the lift. The resident sustained [REDACTED]. The resident was transferred to the hospital and received 4 staples to the right side of the head. Review of facility documentation dated 12/21/11 at 12:40 PM identified R#8 fell during a Hoyer lift transfer, sustaining approximately a 4 cm laceration to the right side of the head. Further review identified the lift and pad used were checked for problems and found to be in good working condition. Interview with NA#8 on 10/17/12 at 2:15 PM noted that after she and NA#7 hooked the sling pad to the lift, they pulled the resident away from the bed and one side of the top part of the lift came undone causing the resident to fall. Interview with LPN#4 on 10/18/12 at 11:25 am noted that she looked at the lift and pad after the incident and did not see anything wrong with either piece of equipment. Additionally, LPN #4 stated that she spoke to both NA #7 and NA# 8 after the incident and were told some pads were not locking onto the lift. Interview with RN#1 on 10/18/12 at 10:40 am noted that after the resident fell , she looked at the lift and the pad, and saw nothing wrong with either of them. Interview with the ADNS on 10/18/12 at 11:30 am noted that although she checked both the pad and lift after the incident and found nothing wrong with either, she pulled them out of service until they could be looked at by maintenance and an independent company. Review of documentation dated 12/29/11 from an outside source specializing in mechanical lifts identified that marks on the sling clip indicate the pad was not secured properly to the lift before raising the resident, causing the resident to fall.

Based on clinical record review and interviews for one of three sampled residents with pain (R#7), the facility failed to assess the root cause of the resident's pain, and/or document the resident's complaints of pain for follow up by subsequent staff members. The findings include: Resident #7's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified that the resident was severely cognitively impaired, had no problem behaviors, and was totally dependent on staff for ADL's including eating, bed mobility and transfers. The resident required 2 staff for transfers. The care plan dated 4/11/12 identified a history of lower back pain and [MEDICAL CONDITION]. Interventions included to provide pain mediation as needed, use pain scale to determine level of pain, and to be aware of non-verbal signs of pain. The care plan also identified that the resident may be prone to fractures due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included to transfer via mechanical lift with the assist of two staff to a custom wheelchair. Review of nurse's notes noted no entries from 4/25/12 until 5/30/12 when it was documented that the resident complained of pain in the legs at 9 AM, and was given Tylenol with no relief. The note identified that the resident was assessed and sent to the hospital at 2:35 PM and admitted with a fracture. A late entry dated 6/1/12 for 5/29/12 noted that at 2:30 PM, while being put back to bed, the resident yelled out "my leg". The note identified no change in range of motion. A CT scan of the pelvis and right hip dated 5/30/12 identified an impacted intertrochanteric right [MEDICAL CONDITION]ly acute. The CT scan describes surrounding soft tissue swelling and intramuscular [MEDICAL CONDITION]. Review of the facility investigation noted the following: -LPN#2, the 7-3 nurse on 5/29/12 noted that the NA told her the resident yelled about his/her leg while being put back to bed at 2:30 PM. She noted that she assessed the resident and there were no issues. -NA#4, the day shift NA on 5/29/12 and 5/30/12 noted that the resident had more pain than normal on both days. -LPN#3, the 7-3 nurse on 5/30/12, noted the resident had leg pain and was medicated with Tylenol at 9 AM. -NA#5, the 11-7 NA from 11 PM 5/29 through 7 AM on 5/30/12 noted that she informed the nurse that the resident had more pain than normal. Interview and review of the clinical record and 24 hour reports with the DNS on 10/16/12 at 12:30 PM failed to provide documentation that the resident's complaints of increased pain had been assessed, documented and/or communicated to the doctor or subsequent staff from 5/29/12 on the day shift through 2:30 PM on 5/30/12 when the resident was sent to the hospital with the fracture.