Every finding on record at Glastonbury Center for Health & Rehabilitation

Based on the review of facility documentation and interviews, the facility failed to submit complete and accurate direct care staffing for PBJ during the quarter of 10/1/24 to 12/31/24. The findings include:The facility CMS PBJ Staffing Data Report dated 10/1/24 to 12/31/24 identified the facility triggered for one star staffing rating, no RN coverage, and failed to have licensed nursing coverage 24 hours a day. Interview with HR #1 on 9/22/25 at 7:30 AM indicated she had started at the facility on 8/24/25. HR #1 indicated that she will start training for PBJ tomorrow. HR #1 indicated that corporate was doing PBJ for the facility prior to her starting. Interview with the DNS on 9/22/25 at 9:48 AM indicated the prior owner did not do the submission of the payroll hours for the period of 10/1/24 to 10/10/24. The DNS indicated that there is always an RN in the facility. The DNS indicated if there was a registered nurse that had called out that another register nurse or manager would fill in for that shift. The DNS indicated that she was aware that the facility was a 1 star for staffing recently and after she investigated, she was informed it was from the prior owner not submitting staffing to PBJ. Review of the nursing schedules dated 10/1/24 to 10/10/24 identified there was not an RN assigned on the schedule for the following days.Wednesday 10/2/24 from 3:00 PM to 11:00 PM.Saturday 10/5/24 from 7:00 AM to 3:00 PM and from 3:00 PM to 11:00 PM.Sunday 10/6/24 from 7:00 AM to 3:00 PM and from 3:00 PM to 11:00 PM.Monday 10/7/24 from 7:00 AM to 3:00 PM and from 11:00 PM to 7:00 AM.Tuesday 10/8/24 from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and from 11:00 PM to 7:00 AM.Wednesday 10/9/24 from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and from 11:00 PM to 7:00 AMThursday 10/10/24 from 7:00 AM to 3:00 PM and from 11:00 PM to 7:00 AM.Interview with the DNS on 9/22/25 at 8:58 AM indicated that she works every other Wednesday to supervise on the 3:00 PM to 11:00 PM shift. The DNS indicated that she worked on 10/2/24 as the supervisor on the 3:00 PM to 11:00 PM shift. Review of the nursing schedules (actual working schedules) dated 10/1/24 to 10/10/24 with the DNS identified there were a lot of empty spots where an RN should have been listed as the supervisor, but she is positive there was an RN in the facility for those shifts. The DNS indicated there is always an RN in the facility even if a manager must come in. The DNS indicated she would not be able to show a punch detail for the Wednesday's she had picked up. Interview with the Administrator on 9/22/25 at 11:30 AM indicated that he was aware that the DNS picks up shifts on Wednesdays every other week for the 3:00 PM to 11:00 PM shift. The Administrator indicated that they do post overtime for staff to sign up for. The Administrator indicated he was not aware of any shift that did not have RN coverage. The Administrator indicated the RN managers will come in if needed to cover shifts.Review of the Employee Transactions and Totals Forms provided identified RN names and dates but did not provide punch details, only the amount paid to each nurse. Interview with the Administrator on 9/23/25 at 9:30 AM indicated that the prior owners were responsible to submit to CMS the PBJ from 10/1/24 through 10/10/24. The Administrator indicated the new company does not have access to the prior payroll system. Review of the Punch Detail Forms dated 10/1/24 to 10/10/24 identified that 10/6/24 from 7:00 AM to 3:00 PM and 10/10/24 from 11:00 PM to 7:00 AM did not have a punch detail. There was no punch details for the Wednesdays dated 10/2/24 or 10/9/24 from 3:00 PM to 11:00 PM. Interview with the DNS on 9/23/25 at 12:30 PM indicated she had worked the dates of 10/2/24 and 10/9/24 from 3:00 PM to 11:00 PM. The DNS indicated she does not have punch details for the 2 dates missing 10/6/24 and 10/10/24. Although requested, the PBJ staffing policy was not provided.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to maintain a clean and sanitary kitchen, failed to ensure refrigerated food items were dated, and failed to ensure staff used beard guards according to infection control standards. The findings include: 1. A tour of the facility kitchen on 9/21/25 at 7:12 AM with the Food Service Director (FSD) identified the following.a. Reach in refrigerator next to the oven contained a pint-sized metal container of chopped onion/tomatoes and a large container of gravy, both undated.b. Beverage refrigerator: 10 of 14 pitchers of juice were undated.c. Left side of the warming oven adjacent to the stove had a large amount of dried white and brown buildup extending down the side next to oven.d. Right side of the reach in refrigerator had a moderate amount of white buildup.e. Right side of refrigerator adjacent to the stove had a large amount brown buildup down the sides.f. Large, uncovered bucket of grease set in front of stove, large open grease funnel extending from stove to bucket.g. Stove knobs with a large amount of crusted brown buildup including surrounding surface area. Interview with the FSD on 9/21/25 at 7:12 AM identified all food items must be dated by dietary staff prior to refrigeration and kitchen equipment should be cleaned daily by the dietary staff with the grease bucket emptied daily. The FSD further identified it was his responsibility to ensure tasks were completed but had not set up a routine cleaning schedule, adding he was new to the facility and still familiarizing himself with daily operations.Review of the facility policy for Sanitation of Kitchen, Food Service Equipment and Work Surfaces directed equipment and work surfaces are to be cleaned and sanitized to reduce the risk of pathogens and food contamination. Surfaces are to be washed, rinsed and sanitized. Although requested, a policy for dating refrigerated food items was not provided. 2. A tour of the facility kitchen on 9/21/25 at 7:12 AM with the FSD during breakfast preparation identified Dietary Aide #2 with a full beard approximately 3/4 to 1 inch in length at the chin, in the area where food was being prepared, without a beard guard. Interview with Dietary Aide #2 on 9/21/25 at 7:12 AM identified he was unaware of a requirement for a beard guard had never used one previously. Interview with the FSD on 9/21/25 at 7:12 AM identified he would need to refer to the policy regarding use of beard guards. The FSD subsequently purchased beard guards for the kitchen staff.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #10) reviewed for activities of daily living, the facility failed to file a grievance and ensure a prompt response after the resident reported concerns with incontinent care. The findings include:Resident #10 was admitted to the facility in August 2025 with diagnoses that included fecal impaction, functional diarrhea, and retention of urine. The APRN note dated 8/24/25 at 11:49 AM identified Resided #12 was admitted to the facility with moisture associated skin damage to the buttocks, the gluteal area, and the buttock cleft. Recommendations included to apply Triad cream to buttocks twice a day and as needed after each incontinent episodes, reposition resident every 2 hours, and limit sitting in a chair to less than 2 hours. A physician's order dated 8/24/25 directed to apply Triad cream to the buttocks area twice a day and as needed after incontinent episodes.The nurse's note dated 8/24/25 at 1:30 PM identified Resident #10 was admitted from the hospital with a diagnosis of fecal impaction. Resident #10 is alert and oriented to person, place, time, and event. Resident #10 is incontinent of bowel and bladder.The nurse's note written by RN #2 dated 8/26/25 at 10:50 AM indicated Person #1 was visiting with Resident #10. Resident #10 had complained of burning on urination and difficulty voiding. The APRN was updated and a new order for urinalysis with culture and sensitivity was obtained. Person #1 was made aware. The physician order dated 8/27/25 directed to obtain a flat plate (x ray) of the abdomen due to loose stools. The admission MDS dated [DATE] identified Resident #10 had intact cognition, was frequently incontinent of bowel and bladder and required maximum assistance with toileting, transfers, and rolling side to side in bed.The care plan dated 9/10/25 identified Resident #10 has incontinence of bowel and diarrhea, with interventions that included staff to document bowel movements amount, describe the color, and consistency. Nurses will follow the facility bowel protocol and apply barrier cream to the coccyx for prevention of skin breakdown. Interview with Resident #10 on 9/21/25 at 8:16 AM indicated he/she and Person #1 were upset a couple of weeks ago regarding care not being provided. Resident #10 indicated that Person #1 had called the facility to speak with the DNS regarding the lack of care. Resident #10 indicated he/she and Person #1 were upset because he/she was left sitting in a soiled brief and staff would not change him/her during the dinner meal. Resident #10 indicated staff had refused to change him/her a couple of times after admission during mealtimes but did not recall the staff person's names. Resident #10 indicated if you did not go to the bathroom before a meal, you then must wait an hour and a half or longer to get changed. Resident #10 indicated the complaint was given to the head nurse he/she believes is the DNS, but was not sure if a grievance form was filled out. Interview with the DNS on 9/22/25 at 9:28 AM indicated she does not recall Person #1 calling her regarding Resident #10's concerns with incontinent care. The DNS indicated that during any mealtime, a resident should be toileted or changed if requested or needed. The DNS indicated if she was informed of the complaint, she would have started a grievance form, started the investigation, and talked with Resident #10 directly. The DNS indicated the investigation would start immediately and should be completed within a few business days. The DNS indicated Resident #10, and Person #1 would be informed of the outcome of the investigation once completed. The DNS indicated that the information would be documented on the grievance form. The DNS indicated she was never made aware that Resident #10 and Person #1 had made any complaints or wanted to file a grievance. Interview with the Administrator on 9/22/25 at 9:31 AM indicated he was not informed by staff or Person #1 that Resident #10 had complaints regarding care. The Administrator indicated there was not a grievance form filed for Resident #10 that he was aware of. Interview with ADNS on 9/22/25 at 9:37 AM indicated that Person #1 had not called her. Interview with SW #1 on 9/23/25 at 8:30 AM indicated that Resident #10 has only had compliments regarding the facility and has not had any complaints regarding care or being changed for incontinence during meals. SW #1 indicated that she has never received a call from Person #1. SW #1 indicated there was not a grievance form filed on behalf of Resident #10 from admission until now. Interview with Person #1 on 9/23/25 at 8:42 AM indicated that he/she had not called the DNS but did speak with the evening supervisor RN #2. Person #1 indicated that he/she visits every evening and on approximately day 3 after admission, Resident #10 was sitting in the wheelchair and had requested to be changed due to incontinence of stool, but it was dinner time. Person #1 indicated that a staff member had entered the room and informed Resident #10 he/she could not be changed until after dinner. Person #1 indicated that he/she was upset because Resident #10 had to sit in a stooled brief until after dinner to be changed. Person #1 indicated he/she does not know the name of that person. Person #1 indicated that he/she had gone to the nurse's station and had spoken to RN #2, the evening nursing supervisor. Person #1 indicated he/she had informed RN #2 he/she was upset that a urine sample was supposed to be done a couple of days prior and was not done yet and Resident #10 had to sit in a soiled brief through dinner because staff would not change Resident #10 during meals. RN #2 asked Person #1 was he/she wanted a grievance to be initiated and Person #1 indicated she informed RN #2 he/she did want a grievance filed. Interview with the DNS on 9/23/25 at 10:08 AM indicated that the resident, family member, or staff can fill out the grievance form and it would go to the social worker. The DNS indicated if it has to do with nursing it would be given to her by the social worker. The DNS indicated that if the resident representative informed the supervisor of the concerns related to not being provided incontinent care during meals, the supervisor would be responsible to fill out the grievance form and/or call her to report the issue. The DNS indicated if the supervisor had called her, she would have filled out the grievance form.Although attempted, an interview with RN #2 it was not obtained. Review of the Grievance Policy identified the residents have the right to voice grievances without discrimination or reprisal of fear of discrimination. Such grievances may include issues of care or treatment that has been received or not received, the behavior of staff or other resident's and other concerns regarding the residents stay at the facility. The facility will make prompt efforts to resolve any grievances in accordance with this policy. The facility will appoint a grievance officer (the social worker) who is responsible for overseeing the grievance process including: receiving and tracking the grievance until conclusion, conducting any necessary investigations, maintaining the confidentiality of information associated with the grievance, and issuing written grievance decisions to the resident if requested. Residents will be notified individually or through postings in prominent locations throughout the facility of the following: the right to file a grievance orally or in writing, the right to file the grievance anonymously, the contact information of the grievance officer, a reasonable expected time frame for completing the review of the grievance, and the right to obtain written decision regarding his/her grievances. Upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. The grievance officer shall begin the grievance process by logging a summary of the grievance, the date the grievance was received and by initiating an investigation. The grievance officer will be responsible for ensuring that the resident's rights are protected while the grievance is being investigated. This may include, but not limited to, suspending any staff person alleged to have violated a resident's rights or limiting access to the resident by another resident. Review of any grievances filed should be completed within 7 days. If the review cannot be completed within this timeframe, the grievance officer should communicate the status of the review and an updated time in which it is expected review will be completed. Upon completion of the review, the grievance officer should document the following: the date the grievance was received, a summary of the resident's grievance, steps taken to investigate, a summary of the pertinent findings or the conclusion, and any corrective action taken. Review of the Resident Rights Policy identified residents have the right to be treated with dignity and respect. Residents have the right to have prompt efforts made by the facility to resolve any grievances you may have, including those about other residents, staff, or other concerns regarding the residents stay at the facility.

Based on review of the clinical record, facility documentation, facility policy and interviews, for 1 resident (Resident #36) reviewed for dysphagia, the facility failed to develop a comprehensive care plan with interventions to address the residents swallowing disorder to ensure the resident received the correct consistency liquid. The findings include:Resident #36 was admitted to the facility in August 2025 with diagnoses that included dysphagia, pain in the left arm, malignant melanoma of the skin, and malignant neoplasm of the pancreas and bronchus or lung. The admission MDS dated [DATE] identified Resident #36 had moderately impaired cognition, required set-up or clean-up assistance with eating, had a mechanically altered diet requiring a change in texture of food or liquids, and had the following signs and symptoms of a possible swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals and complaints of difficulty or pain when swallowing.A physician's order dated 9/3/25 directed for a house (regular) diet easy to chew (L7 texture), mildly thick (nectar) consistency liquid, allow fruit plate, and recommend alternating bites and sips; patient must clear throat and re swallow following liquid intake.The care plan dated 9/11/25 failed to identify interventions and goals for Resident #36's dysphagia diagnosis, had been developed.Review of Resident #36's Visual/Bedside Kardex Report dated 9/22/25 identified the following eating/nutrition special instruction: set-up and clean-up help only (1 staff member), encouraging and providing fluid intake throughout the day, and providing feeding/dining assistance as need; the report failed to identify special instructions related to his/her physician's order for mildly thick (nectar) consistency liquids.Observation with LPN # 2 on 9/22/25 at 9:10 AM identified a water pitcher, approximately half full of water and a plastic cup approximately one quarter full of water on top of Resident #36's bedside table; LPN #2 verified the water in both the pitcher and cup were thin consistency. LPN #2 removed the water pitcher and cup containing thin liquids from the bedside table.Interview with LPN #2 on 9/22/25 at 9:11 AM indicated Resident #36 had swallowing issues and was followed by the SLP. LPN #2 further identified that Resident #36 should only receive nectar thick liquids, per the physician's order, and he/she should not have thin liquids, at the bedside. LPN #2 indicated that the 11:00 PM - 7:00 AM nurse aide was responsible for filling the residents' water pitchers, every morning. LPN #2 further indicated that Resident #36 had issues with pain to his/her arm, but when his/her pain was controlled Resident #36 would have the physical capacity to pour water from the pitcher into a cup and drink it.Interview with the Tally Clerk/Dietary Aide (DA #1) on 9/22/25 at 2:08 PM identified that with each meal pass, a list of residents, by unit, identifying the resident's diet, allergies/adaptive equipment, and fluid consistency was included on the beverage service cart. DA #1 indicated that the list does not go up to the units on the water pitcher cart, but she would be happy to include the list with the water pitcher cart, in the future.Clinical record review with the DNS on 9/22/25 at 2:29 PM failed to identify a comprehensive care plan, including interventions and goals for Resident #36's dysphagia diagnosis, had been developed and failed to identify Resident #36's Visual/Bedside Kardex Report included special instructions related to his/her physician's order for mildly thick (nectar) consistency liquids.Interview with the DNS on 9/22/2025 at 2:29 PM identified that she would expect a comprehensive care plan to have been developed for Resident #36's dysphagia diagnosis and would have expected the special instructions for the thickened liquids to have carried over to the Kardex. The DNS further identified that the nursing supervisor or MDS coordinator were responsible for updating resident care plans; whoever took off the order was responsible for notifying the supervisor of the change or updating the care plan. The DNS indicated that it was the responsibility of the 11:00 PM - 7:00 AM nurse aide to fill the water pitcher, and her expectation would have been for the nurse aide to read the Kardex or double check with the nurse to verify a resident's liquid consistency; since the Kardex did not reflect the order for thickened liquids the 11:00 PM - 7:00 AM nurse aide may not have known to thicken Resident #36's water pitcher.Although attempted an interview with the 11:00 PM - 7:00 AM nurse aide (NA #3) was not obtained.The facility's Baseline/Comprehensive Person-Centered Care Plan policy directs that the interdisciplinary team will utilize the comprehensive person-centered care planning process to address resident strengths, needs and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the health care provider, dietary team, therapy, social services, and MDS. The person-centered care plan is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge. The comprehensive person-centered care plan will be implemented by qualified members of facility staff and will periodically be reviewed and revised based on the MDS assessments, reassessments, and upon any changes in status.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #12) reviewed for activities of daily living, the facility failed to ensure a resident was offered and provided showers weekly. The findings include: Resident #12 was admitted to the facility in August 2025 with diagnoses that included post laminectomy and spinal stenosis. Review of the nurse's notes dated 8/25/25 to 9/21/25 failed to reflect Resident #12 was offered or had refused showers. The admission MDS dated [DATE] identified Resident #12 had intact cognition and was totally dependent on staff for showers and needed maximum assistance for transfers. The shower transfers were not attempted due to medical condition or safety concerns. Review of the nurse aide flow sheet dated 8/25/25 to 9/22/25 identified Resident #12 had a bed bath on the 7:00 AM to 3:00 PM shift on 9/8/25 and 9/15/25 by NA #4. Additionally, Resident #12 did not receive a shower from 8/25/25 to 9/22/25. The care plan dated 9/16/25 identified Resident #12 has self-care deficits, with interventions that included Resident #12 needed assist of 1 for showering and bathing. The nurse's note dated 9/19/25 at 2:34 PM identified Resident #12 had returned from the follow-up surgical appointment with the surgeon. Recommendations included to continue with physical and occupational therapy and continue with wound care. The facility staff were instructed to call the spine surgeon if they had any questions or concerns regarding Resident #12's care. A physician's order dated 9/19/25 directed to call spine surgeon if there are any questions. The physician's orders did not reflect that Resident #12 could not take showers. Interview with Resident #12 on 9/21/25 at 8:15 AM indicated he/she has not had a shower since admission and must go to the hairdresser and pay to have his/her hair washed. Resident #12 indicated she would take a shower if it was offered and the staff could assist him/her in the shower stall or tub. Resident #12 indicated he/she could not stand for a shower. Resident #12 indicated he/she could not step over the hump to get into a stand-up shower or step over the edge of a tub. Resident #12 indicated if there was a shower chair he/she would take a shower. Resident #12 indicated staff have not offered him/her a shower. Interview with NA #4 on 9/21/25 at 8:25 AM indicated there was a shower with a bench to sit on in every resident room on the rehab unit. NA #4 showed there was a shower with a bench in Resident #12's room. NA #4 indicated if a resident needed or preferred a shower chair on wheels there are a couple available on the unit. NA #4 indicated Resident #12 has not had a shower since admission because therapy must do an assessment to determine that Resident #12 can go in the shower safely and Resident #12 would have to be able to do toilet transfers first. Additionally, NA #4 indicated she has not offered Resident #12 a shower because Resident #12 has a wound with a dressing, and she did not want to get it wet. Interview with NA #4 on 9/21/25 at 2:30 PM indicated that when therapy was working with Resident #12 this morning, she asked the therapist if she could evaluate Resident #12 for safe transfers in the bathroom and in the shower. NA #4 indicated that after therapy worked with Resident #12 the therapist said Resident #12 would be safe in the bathroom for toilet transfers and the shower. NA #4 indicated that once the orders from therapy were updated in the EMR she would give Resident #12 a shower. NA #4 indicated she did not realize Resident #12 really wanted a shower. NA #4 indicated that Resident #12 is due for a shower on Tuesday's during the 7:00 AM to 3:00 PM shift and she would be responsible to give the shower. Interview with LPN #3 on 9/21/25 at 2:37 PM indicated NA #4 had talked to the OTA this morning regarding whether Resident #12 was safe to transfer for a shower. LPN #3 indicated that when a resident refuses a shower the nurse must document the refusal. LPN #3 indicated she had not documented that Resident #12 has refused a shower, but she had encouraged Resident #12 in the past to take showers. Interview with OT #1 (Director of Rehab Services) on 9/22/25 at 8:46 AM indicated the nursing staff are to follow a resident's transfer status from the hospital discharge paperwork unless nursing uses its judgement and felt a resident needed more assistance. OT #1 indicated showers can be given based off the nursing policy and the resident's transfer status. After reviewing the OTA progress note dated 9/21/25, OT #1 indicated the therapist worked on toilet transfers with Resident #12 yesterday and it does not mention showers. Interview with DNS on 9/22/25 at 9:02 AM indicated that the rehab residents have showers in their rooms. The DNS indicated residents are assigned showers based on their room and bed assignment. The DNS indicated Resident #12 was assigned to have a shower Tuesdays during the 7:00 AM to 3:00 PM shift. The DNS indicated there was a shower book at the nurse's station for the nurse aide to be informed which residents get a shower each day and on which shift. The DNS indicated the shower day, and time are on the resident's care card. The DNS indicated that all residents are offered a shower at least weekly unless there was a physician order directing a resident not to have showers until seen by the surgeon. After reviewing the physician orders, the DNS indicated there was not an order for Resident #12 not to have a shower. The DNS indicated the nurse aide could have covered the dressing with plastic and taped it on the resident to provide the shower. The DNS indicated when the shower was completed the nurse could go and do a dressing change. The DNS indicated if a resident had refused a shower her expectation was the nurse would go speak to the resident and find out why the resident was refusing the shower. The DNS indicated her expectation was that the nurse would educate the resident on importance of showers for skin integrity and encourage the resident to take a shower. The DNS indicated the nurse must document the education and if the resident still refused the shower. After reviewing the clinical record, the DNS indicated she did not see that Resident #12 had refused a shower or was educated regarding showers. The DNS indicated NA #4 had documented a bed bath was given twice since admission but no showers. Interview with NA #4 with the DNS present on 9/22/25 at 9:24 AM indicated she could have given Resident #12 a shower using the mechanical lift, but Resident #12 has wounds, so she did not offer a shower. NA #4 decided to give Resident #12 a bed bath and assumed Resident #12 could not have showers due to the dressing on Resident #12's body. NA #4 indicated she did not offer Resident #12 a shower and she did not ask any of the nurses if Resident #12 could or could not receive showers. NA #4 indicated she did not wash Resident #12's hair as part of the bed bath. The DNS indicated the wounds could have been covered with plastic and the showers could have been given. The Recovery Shower Sheet identified Resident #12 was scheduled for showers weekly on Tuesdays during the 7:00 AM to 3:00 PM shift. Review of the Activities of Daily Living identified ADLs are the essential tasks that each person needs to perform, on a regular basis, to sustain basic survival and well-being. The term, ADL's helps healthcare professionals quickly communicate the level of assistance an individual might need or how their health is impacting their day-to-day life. The purpose is to provide the level of care required by each individual resident. Staff who provide assistance to complete ADL activities are broken down into eight areas they are bathing/showering, toileting, dressing, eating, feeding, functional mobility, personal devices, and personal hygiene.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents, (Resident #13 and 52) reviewed for contractures, for Resident #13 the facility failed to ensure palm protectors were applied in accordance with physician orders, and for Resident #52, the facility failed to ensure a resident with a known contracture was re-evaluated for continued use following readmission after a hospitalization. The findings include: 1. Resident #13 was admitted to the facility in January 2021 with diagnoses that included contracture of the left hand and dementia.The quarterly MDS dated [DATE] identified Resident #13 was severely cognitively impaired and required two person assist with bed mobility, dressing and did not utilize a splint or brace.The care plan dated 8/1/25 identified Resident #13 had an ADL deficit with interventions that included bilateral hand rolls in place at all times, to be replaced for skin checks and hand hygiene.Physician's order dated 9/10/25 directed bilateral palm protectors at all times per tolerance, except for care, nursing to check skin every shift.Occupational Therapy Discharge summary dated [DATE] identified Resident #13 had plateaued regarding the application of palm protectors with caregivers receiving training on their use.Observation on 9/21/25 at 8:11 AM identified Resident #13 was in bed sleeping, without the benefit of the bilateral palm protectors which were at the bedside.Subsequent observation on 9/22/25 at 10:23 AM identified Resident #13 was up sitting in the wheelchair without bilateral palm protectors in place.The Long-Term Care Refusal Log for nurse aide documentation dated 9/18/25 through 9/23/25 noted no documented refusals regarding the application of the palm protectors.Interview with LPN #4 on 9/22/25 at 11:50 AM identified she was the assigned nurse for Resident #13 during the 7:00 AM to 3:00 PM on 9/22/25. LPN #4 was unsure if Resident #13 was supposed to be wearing palm protectors and indicated it was the responsibility of the nurse aides to place the devices.Interview with NA #11 on 9/22/25 at 11:55 AM identified that she was not assigned to Resident #13 during the 7:00 AM to 3:00 PM shift on 9/22/25 but was aware Resident #13 wore palm protectors. NA #11 provided assistance to the assigned aide in applying the palm protectors to Resident #13's hands prior to getting Resident #13 up for the day. NA #11 further identified nurse aides were responsible for applying the palm protectors prior to getting Resident #13 up for lunch.An interview with NA #10 on 9/22/25 at 11:59 AM identified she was the assigned nurse aide for the 7:00 AM to 3:00 PM shift on 9/22/25. NA #10 identified she provided personal care to Resident #13 at 9:00 AM but did not check the care card to see if palm protectors were required for Resident #13. NA #10 observed the devices on Resident #13's wheelchair when getting him/her up for lunch and asked NA #11 for assistance with their application which Resident #13 tolerated well without refusing. NA #10 identified she should have reviewed the care card in morning and ensured the palm protectors were worn according to scheduled times.An interview and facility documentation review with Certified Occupational Therapy Assistant ([NAME] #1) on 9/22/25 at 1:14 PM identified Resident #13 had contractures and increased tone. Bilateral palm guards were recently added to the treatment plan to decrease further contractures and were to be worn at all times with skin checks and skin hygiene. [NAME] #1 identified staff were educated and reference materials were placed in the room, care card, chart, and provided to the DNS. Facility documentation noted NA #10 and NA #11 participated in training.An interview with the DNS on 9/23/25 at 10:15 AM identified she would expect Resident 13's palm protectors to be maintained according to physician orders.Although requested, a policy for the use of assistive devices for limited mobility was not provided.Attempts to interview NA #12, assigned 11:00 PM to 7:00 AM, 9/20/25 overnight to 9/22/25, were unsuccessful. 2. Resident #52 was admitted in April 2024 with diagnoses that included hemiplegia and hemiparesis (weakness and paralysis) and dementia.The quarterly MDS dated [DATE] identified Resident #52 was severely cognitively impaired and required one person assist with bed mobility, dressing, and did not utilize a splint or brace.The care plan dated 2/24/25 identified Resident #52 had an ADL deficit related to hemiparesis and hemiplegia affecting the right dominant side. Interventions included OT evaluation and treatment as ordered.Occupational Therapy Evaluation dated 2/26/25 identified Resident #52 was receiving services that included trialing a new hand splint to prevent further contractures.Occupation Therapy Treatment Notes dated 3/7/25 through 3/20/25 identified Resident #52 was agreeable to trialing a splint, tolerated range of motion and splinting over two hours with no documented refusals.Nurse's note dated 3/23/25 at 4:25 PM identified Resident #52 was transferred to the hospital for further evaluation for left sided face and neck swelling.Occupational Discharge summary dated [DATE] identified Resident #52 was receiving services which included right hand and wrist splinting and that progress was slow prior to hospitalization.Nurse's note dated 4/5/25 at 2:50 PM identified Resident #52 was readmitted back to the facility following care and treatment of a neck mass.A review of the clinical record failed to identify an occupational therapy assessment following readmission back to the facility on 4/5/25 or thereafter to determine continued use of the splint.Observation of Resident #52 on 9/23/25 at 9:36 AM identified he/she was not wearing a splint.Interview with the Director of Rehabilitation on 9/23/25 at 9:30 AM identified all residents readmitted from the hospital including those with contractures, were to be screened by occupational therapy. Resident #52 had been trialing a right-hand splint prior to hospitalization. Upon re-admission, the Director of Rehabilitation, also the occupational therapist at the time, could not recall if a screen was completed but indicated it should have been documented in the clinical record.Interview with the DNS on 9/23/25 11:11 AM identified she expected all residents to be re-evaluated by rehabilitation services hospitalization.Although requested, a policy for resident re-evaluation post hospitalization by rehabilitation services was not provided.Although requested, a policy for the use of assistive devices for limited mobility was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #106) reviewed for a specialty medical treatment, the facility failed to ensure the arteriovenous fistula (AVF) was monitored every shift per facility policy and failed to ensure there was an emergency kit in the resident's room. The findings include:Resident #106 was admitted to the facility in March 2025 with diagnoses that included end stage renal disease and was dependent of dialysis. The Nursing admission Evaluation dated 3/2/25 at 1:15 PM identified Resident #106 had an AVF (abnormal connection between an artery and a vein) to the right upper extremity for hemodialysis three times a week. The care plan dated 3/2/25 identified Resident #106 requires dialysis. Interventions include monitoring the AVF site access dressing and checking for a bruit and thrill daily and as needed. Additionally, observe the AVF access site for signs and symptoms of infection or bleeding, and if bleeding occurs apply pressure and notify the physician.A physician's order dated 3/2/25 directed for Resident #106 to go to hemodialysis three times a week on Monday, Wednesday, and Friday. The admission MDS dated [DATE] identified Resident #106 had intact cognition. Resident #106 required moderate assistance with dressing. Additionally, Resident #106 receives hemodialysis. a. Review of the physician's order dated 3/2/25 until 9/22/25 failed to direct the monitoring of the AVF for a bruit or thrill. Review of the MAR and TAR dated 3/2/25 - 9/22/25 failed to reflect the monitoring of the AVF for a bruit and thrill every shift. Interview with LPN #5 on 9/21/25 at 10:57 AM indicated Resident #106 goes to dialysis on Monday, Wednesday, and Friday. LPN #5 indicated Resident #106 leaves the facility between 3:00 PM and 3:30 PM on dialysis days. LPN #5 indicated that she fills out the pre dialysis form with a set of vital signs and if there were any medication changes. Interview with the DNS on 9/22/25 at 9:52 AM identified Resident #106 goes to dialysis in the afternoon and comes back later in the day on Monday, Wednesday, and Friday's. The DNS indicated the nurses were responsible to fill out the communication form prior to Resident #106 leaving for dialysis and when Resident #106 returns the nurses are responsible to see if there are any new orders on the form from dialysis. The DNS indicated Resident #106 has a dialysis communication book that the forms are kept in. The DNS indicated the form requires a set of vital signs and notation if there were any changes. The DNS indicated the communication form does not require an assessment of the AVF for a bruit and thrill. Interview with the DNS on 9/23/25 at 7:10 AM indicated on admission the supervisor was responsible to input the admission orders from the hospital. The DNS indicated that the admission nurse does the medication reconciliation and puts in the dialysis orders. The DNS indicated another nurse will verify and check the orders for accuracy and completeness. The DNS indicated the next day the ADNS will review the new admission chart including the physician orders to make sure it was accurate and complete. The DNS indicated the nurse was responsible for checking and assessing the AVF site every shift, checking for the bruit and thrill every shift, and documenting the assessments on the TAR. The DNS indicated these assessments would be part of the admission orders. The DNS indicated that when Resident #106 returns from dialysis the nurse is responsible to check the communication book and check the AVF site for bleeding. After reviewing the medical record, the DNS indicated the physician orders did not direct to check of the bruit and thrill at the AVF site since the residents admission in March 2025. The DNS indicated that with the prior company there was a premade template for dialysis residents that the nurse just had to click on for the admission physician orders. The DNS indicated the new system does not have the template premade for dialysis residents, so the admission nurse did not put all the orders for dialysis residents. b. Observation on 9/21/25 at 10:57 AM failed to reflect an emergency kit in Resident #106's room. Interview with the DNS on 9/23/25 at 7:25 AM indicated the expectation was there would always be an emergency kit in the room in case the AVF site starts bleeding or swelling. The DNS indicated the kit includes a set of blue clamps and absorbent pads. The DNS indicated the emergency kit would be found above Resident #106's bed on the wall. Observation with the DNS on 9/23/25 at 7:30 AM identified entered room and the DNS indicated the kit was not present and probably did not get moved when Resident #106 had changed rooms either in April 2025 or July 2025. Review of the Hemodialysis Policy identified a resident who is admitted to the facility requiring hemodialysis will have their dialysis needs met. The residents will not have blood work or blood pressures taken in the av fistula arm. If the AV site begins to bleed apply firm pressure with a clean gauze pad until it stops. Do not press so hard that the blood flow through the graft stops. You should be able to feel the thrill or buzz while you are holding pressure. Notify the physician and send resident to the emergency room. If swelling suddenly begins around the fistula, apply firm pressure over the stick site until swelling stops. You should still feel the thrill or buzz while you hold pressure. The licensed nurse will obtain the physician orders for hemodialysis which would include the following: dialysis days, with the scheduled time, possible fluid restriction, labs if needed, clarify with physician the dialysis medications to be given pre-dialysis, and a renal diet. After initial assessment the care plan will include which arm to use for blood pressures, obtaining post weights as dialysis will do a pre-weight, and vital signs and assessing dialyzing site. The licensed nurse assesses the AVF daily for signs or symptoms of infection and documents it on the TAR which includes redness, warmth, swelling, drainage, fever, or pain, or tenderness. The licensed nurse will assess the AVF for a thrill and bruit every shift and document on the TAR. The licensed nurse will feel for the thrill by palpation every shift and the bruit with a stethoscope every shift. Notify the physician immediately if you cannot feel the thrill or buzz or hear the bruit. If bleeding or sudden swelling occurs, or if you notice any signs of infection.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #36) reviewed for food, the facility failed to ensure fluids were served in a consistency that was in accordance with the physician's order. The findings include:Resident #36 was admitted to the facility in August 2025 with diagnoses that included dysphagia, pain in the left arm, malignant melanoma of the skin, and malignant neoplasm of the pancreas and bronchus or lung.A physician's order dated 8/28/25 directed for a house (regular) diet pureed (L4 texture), mildly thick (nectar) consistency, allow fruit plate, and recommend alternating bites and sips.The admission MDS dated [DATE] identified Resident #36 had moderately impaired cognition, required set-up or clean-up assistance with eating, had a mechanically altered diet requiring a change in texture of food or liquids, and had the following signs and symptoms of a possible swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals and complaints of difficulty or pain when swallowing.The Functional Fiberoptic Endoscopic Evaluation of Swallowing (FEES) report dated 9/3/25 identified Resident #36's oral containment was intact; control of thin liquids was challenging with resultant secondary aspiration of residues that migrated into the airway before he/she could trigger a re swallow. Thicker liquids, even a slightly thick health shake, were consumed without pharyngeal residual and no airway invasion occurred. Most impressive was Resident #36's excellent clearance of solids.A physician's order dated 9/3/25 directed for a house (regular) diet easy to chew (L7 texture), mildly thick (nectar) consistency, allow fruit plate, and recommend alternating bites and sips; patient must clear throat re swallow following liquid intake.The care plan dated 9/11/25 failed to identify interventions and goals for Resident #36's dysphagia diagnosis. The care plan identified Resident #36 was at risk for malnutrition related to metastatic cancer, dysphagia, weight loss prior to admission, diagnosis of protein calorie malnutrition, and variable oral intake, with interventions that included encouraging and providing intake of fluids throughout the day and providing safe swallow strategies, per the Speech-Language Pathologist's (SLP) recommendation.The Speech-Language Pathologist Discharge summary dated [DATE] identified Resident #36's received services from 8/27/25 through 9/8/25. Over the course of therapy, Resident #36's diet was advanced to level 7EC with minced and moist meats, with mildly thick liquids. Trials of thin liquids were provided; however, Resident #36 remains on a modified diet for maximum safety during oral intake. Positive response to training in swallow strategies and oropharyngeal strengthening exercises, and he/she has reached the highest practical level and will be discharged from speech therapy services on 9/8/25.Observation with LPN # 2 on 9/22/25 at 9:10 AM identified a water pitcher, approximately half full of water and a plastic cup approximately one quarter full of water on top of Resident #36's bedside table; LPN #2 verified the water in both the pitcher and cup were thin consistency. LPN #2 removed the water pitcher and cup containing the thin liquids from the bedside table.Interview with LPN #2 on 9/22/25 at 9:11 AM indicated Resident #36 had swallowing issues and was followed by the SLP. LPN #2 further identified that Resident #36 should only receive nectar thick liquids, per the physician's order, and he/she should not have thin liquids, at the bedside. LPN #2 indicated that Resident #36 had issues with pain to his/her arm, but when his/her pain was well controlled Resident #36 would have the physical capacity to pour water from the pitcher into a cup and drink it. LPN #2 further indicated that the 11:00 PM-7:00 AM nurse aide was responsible for filling the residents' water pitchers, every morning.Interview with the Director of Rehabilitation Services (OT#1) on 9/22/25 at 9:40 AM identified that Resident #36 should be served mildly thick nectar liquids, based off his review of the physician's orders, SLP evaluation, and the results of the FEES report. OT #1 indicated that while he was not a SLP, he would be concerned for Resident #36 being at risk for dysphagia pneumonia following the consumption of thin liquids.Interview with the Dietitian (RD #1) on 9/22/25 at 1:26 PM identified that all of Resident #36's liquids should be thickened, including the water in the bedside water pitcher, unless an exception was identified by the SLP and written in the physician's orders. RD #1 indicated that she was not aware of Resident #36 being allowed thin liquids by the SLP.Interview with the DNS on 9/22/25 at 1:34 PM identified that she would expect that only nectar thick liquids would be served to Resident #36, and that she had already begun education with the nursing staff to ensure residents were served their therapeutic diet/drink orders. The DNS further identified that it was the responsibility of the 11:00 PM - 7:00 AM nurse aide to fill the water pitchers, and that she would expect the nurse aide to read the resident's care card to ensure the liquid consistency being served matched the physician's order. The DNS indicated that the 11:00 PM to 7:00 AM nurse aide (NA #3) that worked on Resident #36's unit was hired within the last year and had received education on therapeutic diets during orientation, including food and liquid consistencies and the significance of why the therapeutic diet orders matter.Interview with the Tally Clerk/Dietary Aide (DA #1) on 9/22/25 at 2:08 PM identified that with each meal pass, a list of residents, by unit, identifying the resident's diet, allergies/adaptive equipment, and fluid consistency was included on the beverage service cart. DA #1 indicated that the list does not go up to the units on the water pitcher cart, but she would be happy to include the list with the water pitcher cart, in the future.Although attempted an interview with the 11:00 PM - 7:00 AM nurse aide (NA #3) was not obtained.Although multiple attempts were made, an interview with SLP #1 was not obtained.The facility's Culinary and Nutrition policy directs that the facility maintains acceptable parameters of nutritional status, such as usual or desirable body weight range, and electrolyte balance, for the residents unless the resident's clinical condition demonstrates that it is not possible or resident preferences indicate otherwise. Therapeutic diet refers to a diet ordered by a physician or other delegated provider that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated. The interdisciplinary team facilitates communication of the implementation and evaluation of nutrition interventions amongst the team and other facility personnel through established communication tools and meetings.Although requested a therapeutic diet policy was not provided.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #37) reviewed for food, the facility failed to ensure food preferences were accommodated. The findings include: Resident #37 was admitted to the facility in August 2025 with diagnoses that included type 2 diabetes mellitus, chronic diastolic heart failure (CHF), and Parkinson's disease. A physician's order dated 8/24/25 directed that Resident #37 receive a 2-gram Sodium (2 GM Na+) diet, regular texture.The Nutrition Screening and Food Preferences document dated 8/27/25 identified Resident #37 did not like the following foods: eggs, rice, spinach, pot pie, and soup. The Nutrition Screening and Food Preferences document further identified that Resident #37's preferences included toast, banana, muffin, pancakes, or waffles, when available.The admission MDS dated [DATE] identified Resident #37 had intact cognition, required set up or clean up assistance for eating, and was on a therapeutic diet, while a resident at the facility.The care plan dated 9/16/25 identified that Resident #37 had type 2 diabetes mellitus, with interventions that included a dietary consultation for nutritional regimen and monitoring, documenting, and reporting signs and symptoms of hypoglycemia or hyperglycemia. The care plan further identified that Resident #37 was at risk for malnutrition related to his/her diagnoses of CHF and Parkinson's disease and being on a therapeutic diet, with interventions that included providing a diet per the physician's order and obtaining, providing, honoring, and monitoring his/her food and beverage preferences and eating patterns.Interview with Resident #37 on 9/21/25 at 8:43 AM identified that he/she hates eggs and that he/she had been served eggs every day, and he/she has sent the eggs right back to the kitchen. Resident #37 indicated that he/she has told multiple staff members that he/she does not like eggs. Resident #37 further indicated that he/she was served baked eggs for breakfast and told the nurse aide to send it back to the kitchen.Interview with NA #1 on 9/21/25 at 8:45 AM identified that Resident #37 did not like the baked eggs that were served for breakfast, and he/she sent them back to the kitchen. NA #1 was not sure if Resident #37 did not like the baked eggs served for breakfast or if he/she disliked eggs, in general. Review of Resident #37's Dietary Profile dated 9/22/25 identified the following: do not serve hot cereal, hard cooked eggs, visible eggs, or rice and please include a banana when available (breakfast), meal notes included no eggs.Observation with LPN #2 on 9/22/25 at 8:15 AM identified that Resident #37's 9/22/25 breakfast ticket read 4 fluid ounces of juice of choice, 3/4 cup of corn flakes, scrambled eggs, 1 slice of cinnamon wheat toast, and 8 oz of choice beverage; the ticket identified no eggs. Observation of Resident #37's breakfast tray included 4 half pieces of toast, corn flakes, and juice. Interview with LPN #2 on 9/22/5 at 8:15 AM identified that she was not sure why scrambled eggs were listed on Resident #37's breakfast ticket if he/she doesn't like eggs, and that she would expect that another protein would have been served as a substitute for the scrambled eggs; LPN #2 immediately notified the kitchen staff of concern.Interview with Resident #37 on 9/22/25 at 8:17 AM identified that he/she was served cold toast for breakfast, did not want corn flakes, and would have liked a substitute for the scrambled eggs. Resident #37 indicated that his/her representative had filled out the weekly Heart Healthy Dietary Menu, and he/she had written, on the top of the menu, that Resident #37 does not want eggs but that he/she would like a banana with breakfast.Interview with the Food Service Director on 9/22/25 at 1:04 PM identified that he had worked at the facility for approximately 4 weeks, and that he would expect food preferences that were communicated to nursing or dietary staff, by residents or resident representatives, to be entered into the facility's electronic system which generates the meal tickets. The Food Service Director indicated that resident food dislikes should be listed on the meal tickets, so the cooks, dietary staff, and nursing staff know not to serve food items that have been identified as a dislike. The Food Service Director further indicated that a plate of toast would not be an acceptable breakfast for Resident #37, and that an alternative heart healthy item or protein should have been served. The Food Service Director identified that he would expect resident preferences to be honored.Interview with the Dietitian (RD #1) on 9/22/2025 at 1:17 PM identified that the Tally Clerk rounds on all new admissions to determine food preferences and enters residents' dislikes, allergies, and intolerances into the electronic system. RD #1 indicated that Resident #37's dislikes of hot cereal, hard boiled eggs, and rice were listed in the electronic system, so she would expect those preferences to be honored. RD #1 further indicated that fresh fruit, cottage cheese, and yogurt would be acceptable items to substitute for eggs for a resident on a heart healthy diet.Interview with the Tally Clerk/Dietary Aide (DA #1) on 9/22/25 at 2:08 PM identified that she conducts dietary preference interviews on all the new admissions, completes the Nutrition Screening and Food Preferences document, and enters all the relevant information, including preferences, dislikes, allergies, and intolerances, into the facility's electronic system. DA #1 further identified that she also updates the system, as needed, when nurse aides, a resident, or family member identify new food preferences or dislikes. DA #1 indicated that Resident #37's dislikes were listed under his/her profile in the electronic system, and she was unsure why eggs would continue to show up on the printed ticket. DA #1 further indicated that there may be a glitch in the system; she would work with the Food Service Director to fix the issue, and in the meantime, she would manually cross off eggs from Resident #37's printed meal tickets, to ensure his/her food preferences were met.The facility's Menu Development and Nutrition Adequacy policy directs that planned menus are developed and used to provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Menus are: planned in advance for both regular and therapeutic diets according to established national guidelines and the National Health Care Associates approved diet manual, reflect based on the facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population, as well as, input received from residents and resident groups, updated periodically, and followed. The policy further directs the facility to make a reasonable and good faith effort to develop a menu to meet resident preferences. Residents provide input into menu development through resident council or a separate food committee, interviews with residents, their families and significant others by the Food Service Director, Registered Dietitian, or their designee, and throughout resident satisfaction surveys. Resident food and beverage preferences are obtained directly from the resident and/or a family/legal representative or indirectly by center staff. Additionally, culinary services determine food and beverage preferences based on resident observation at mealtimes. Food preferences are documented on the resident tray card/ticket and other applicable documents. Reasonable alternative food items that reasonably accommodate individual resident needs, allergies, intolerance and preferences are available and offered to residents at each meal if the primary menu or immediate selections for a particular meal are not to the resident's liking. Alternate options are appealing and of similar nutritive value.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure refuse was properly contained in outside dumpsters. The findings include:A tour of the outside grounds on 9/21/25 at 7:12 AM with the FSD identified a dumpster with a large opening on the side with a moderate amount of debris including dirty food containers, paper, and foil wrap which was scattered around the area.An interview with the FSD on 9/21/25 at 7:12 AM identified it was the responsibility of dietary staff to empty the garbage to ensure the surrounding areas were clear of debris. It was his responsibility to oversee but was new to the facility still familiarizing himself with daily operations.Review of the facility policy for Environmental Management directed a process in place to inspect and maintain clean grounds including areas where compacters, dumpsters or collection containers are located.

Based on review of facility documentation, facility policy, and interview for 4 of 6 nurse aides, the facility failed to ensure annual performance evaluations were completed. The findings include:Interview with the Administrator on 9/22/25 at 11:25 AM indicated that all employees receive an annual performance evaluation from the department head that oversees the employees. The Administrator indicated each department was responsible to make sure the employee evaluations were completed annually based on hire date and placed in the employee file. Review of the employee files identified the following.a. NA #1 date of hire was 6/16/22. There were no annual performance evaluations on file for 2023, 2024, or 2025. b. NA # 6 date of hire was 6/6/24. There was not an annual performance evaluation on file. c. NA #17 date of hire was 7/18/22. There were no annual evaluations on file for 2023, 2024, or 2025. d. NA #19 dated of hire 7/19/22. There was no employee file or annual performance evaluations for 2023, 2024, or 2025. Interview with HR #1 on 9/23/25 at 11:51 AM indicated the department heads were responsible to do the annual performance evaluations for all employees in their departments. HR #1 indicated the annual performance evaluations are to be completed on the employee's anniversary date every year. Interview with the DNS on 9/23/25 at 12:08 PM indicated she was responsible to make sure all nursing staff have their annual performance evaluations in the month they were hired every year. The DNS indicated that she has a spread sheet to keep track of when employees were due for their annual performance evaluation. The DNS indicated NA #1 and NA #6 were due for their annual performance evaluations in June 2025 and NA #17 and 19 were due in July 2025. The DNS indicated they were not done. The DNS indicated that she was a little behind with getting the annual performance evaluations completed. The policy identified the purpose of a performance review is to assure the employee that his/her efforts are being recognized by the facility and to assure the facility that the employee is properly placed in his/her current position. The facility strives to review the performance of each staff member at the end of the first 3 months of employment and at least once a year thereafter. Regular attendance, attitude, and job performance will be among the most important factors considered in the review. Review of the Performance Evaluation policy identified the performance review period as annual. Performance factors included knowledge of work duties, dependability and reliability, communication skills, customer service, teamwork, interpersonal skills, motivation and interest in position and role, initiative and openness to learning. These areas will receive a rating, and the managers can make overall comments. The employee can add comments at the end. The manager and the employee will sign and date the performance review.

Based on review of facility documentation, facility policy, facility assessment and interviews, the facility failed to provide nurse aide training of no less than 12 hours per year. The findings include:Interview with LPN #1 (staff development nurse) on 9/22/25 at 7:38 AM indicated that she is responsible for education and competencies of all the nurse aides. LPN #1 indicated the facility just had a change of ownership in October 2024 and since the change of ownership she had just been working on all the mandatory education which includes the dementia training education for all staff, and competencies for the nursing staff. LPN #1 indicated that since October 2024 she did not have a tool for keeping track of the nurse aide education hours. LPN #1 indicated the nurse aide mandatory education, including dementia training as part of the mandatories, and competencies takes about 8 hours. LPN #1 indicated that it was the only education she has been working on. LPN #1 indicated she did not have any sheets or spreadsheets tracking the number of hours for the nurse aides for 2024 or 2025. LPN #1 indicated she would ask the ADNS if she has any tracking took for the nurse aide educational hours. Interview with the ADNS on 9/22/25 at 9:40 AM indicated she was responsible for the oversight of LPN #1 for the staff development of the nurse aides. The ADNS indicated that LPN #1 does mandatory education, and she was responsible to check and making sure the post tests were completed and corrected. The ADNS indicated she does not have a tracking system in place for the year 2024 or 2025 for the nurse aides to make sure they have received the minimum required 12 hours per year of education. The ADNS was unable to verify the nurse aides received 12 hours of education for 2024 or 2025.Interview with the DNS on 9/22/25 at 9:44 AM indicated that they did education, but they do not tally the number of hours per nurse aide to make sure they meet the minimally required 12 hours per year for 2024 or 2025.Review of the Facility assessment dated [DATE] identified the facility staffing training and education and competencies include the following topics:*Communication - effective communication for all staff.*Resident rights and facility responsibilities- ensure that staff members are educated on the rights of the resident and the responsibility of the facility to properly care for its residents.*Abuse, neglect, and exploitation- training that at a minimum activity that constitutes abuse, neglect, exploitation, or the misappropriation of resident's property, Additionally, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of residents' property.*Infection Control -training on the infection control program, written standards and policies*Required in-service training for nurse aides. In-service training must be sufficient to ensure the continuing competence of the nurse aides but must be no less than 12 hours per year.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #3) who were reviewed for medication administration, the facility failed to ensure Resident #3did not receive medications that were prescribed for another resident. The findings include: Resident #3's diagnoses included hypertension, depression, anxiety, and history of acute renal failure. The admission Minimum Data Set assessment dated [DATE] identified Resident #3 was alert and oriented to person, place, time and situation. A physician's order dated 3/3/25 directed to administer the following medications at 9:00 AM: Acetaminophen 500 milligrams (mg), Allopurinol 100 mg, Atorvastatin Calcium 20 mg, Buspirone HCI 10 mg, Duloxetine HCI 10 mg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Losartan 25 mg, Magnesium Oxide 400 mg, Multivitamin one (1) tablet, and Oxybutynin ER 5mg. The nurse's noted dated 3/21/25 at 2:12 PM identified the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, was called into Resident #3's room by the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, due to a medication error. The note indicated upon assessment no adverse reactions were noted, Resident #3 was awake, alert, and oriented times four (4), was made aware of the error and verbalized understanding. The note identified the Advanced Practice Registered Nurse (APRN) was notified and directed to monitor Resident #3's vital signs every four (4) hours for three (3) days, to schedule lab work, and to monitor Resident #1 for bleeding or bruising each shift. The Nurse Practitioner's order dated 3/21/25 directed to hold the morning medications on 3/21/25. Review of the nurse's notes from 3/21/25 through 3/23/25 identified Resident #3 had no ill effects from receiving another resident's medication. The physician's progress notes dated 3/24/25 and 3/27/25 identified the APRN reviewed the lab work, and no further orders were given. The Facility Reported Incident form dated 3/21/25 identified Resident #3 received another resident's 9:00 AM medications on 3/21/25. The investigation identified the following medications were ordered for Resident #4 at 9:00 AM and administered to Resident #3: Vitamin B12 2000 mcg, Proscar 0.5 mg and Flomax 0.4 mg (medications to treat enlarged prostrate), Ferrous Gluconate 324 mg, Folic Acid 1 mg, Losartan 50 mg and Metoprolol 25 mg, (medications to treat hypertension), Protonix 40 mg (a medication to reduce the amount of acid in the stomach, and (blood thinner medications) Clopidogrel 75 mg and Eliquis 5 mg. Interview with the 7AM-3PM Nursing Supervisor, RN #1, on 5/14/25 at 9:50 AM identified on 3/21/25 at approximately 11:00 AM, the 7AM-3PM charge nurse, LPN #1, reported to her immediately after he had given another resident's, Resident #4, medications to Resident #3 in error. RN #1 identified LPN #1 did not follow the standards of practice or company policy when administering medications. Interview with the 7AM-3PM charge nurse, LPN #1, on 5/14/25 at 10:00 AM identified on 3/21/25 he had prepared Resident #4's medications to administer. Resident #4 was in the bathroom and it was taking a long time, so he proceeded to prepare the medications for Resident #3. LPN #1 explained while at the medication cart, a physical therapist, who was working with Resident #3, called for help because the therapist was having difficulty getting Resident #3 back to bed safely. LPN #1 stated he ran into the room, with both medication cups filled with Resident #3 and #4's medications, placed the cups down on the bedside table and proceeded to assist getting Resident #3 back into bed. LPN #1 identified once back in bed, Resident #3 asked for his/her medications and he administered the wrong pills that were at the bedside. LPN #1 identified he did not look at the medications before handing Resident #3 the pills and immediately realized the mistake and had RN #1 come to the room. LPN #1 indicated he should have locked Resident #4's medications up in the medication cart before proceeding to prepare Resident #3's medications and stated that he did not follow company protocol for the administration of medication. Interview with the Director of Nursing (DON) on 5/14/25 at 2:00 PM identified the APRN directed not to administer Resident #3 the 9:00 AM medications on 3/21/25. The DON identified LPN #1 did not follow company policy for the administration of medication. Review of the Medication Administration policy directed that the six (6) rights of a medication pass which included right resident, right drug, right dose, right dosage form, right route and right time would be followed.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for nutrition, the facility failed to ensure provider was notified timely of a weight loss. The findings include: Resident #1's diagnoses included dementia and nutritional deficiencies. The quarterly MDS Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, required set up for meals and received a mechanically altered diet. The Resident Care Plan (RCP) dated 11/4/2024 identified a nutrition and weight maintenance problem. Interventions directed to help with eating, provide dietary assessments and referrals as needed. Record review identified a weight on 11/26/2024 was 171.9 pounds (lbs). The next weight recorded on 12/10/2024 was 147.8 lbs, indicating a loss of weight loss of 24.1 pounds in 15 days. Review of nutrition/dietary note dated 12/13/2024 indicated a weight warning of a significant weight loss in 30, 90 and 180 days. The note indicated Resident #1 was [AGE] years old, recently treated for pneumonia, and working with speech therapy (ST) for dysphagia management. Resident #1 was receiving a mechanical soft consistency diet with variable intake. Accepts supplements of ensure clear and liquid protein supplements, nutritional needs increased and receives magic cup two times per day with meals. Physician note dated 12/16/2024 identified resolved pneumonia and nursing without concerns. Record review from November through December 2024, failed to identify the physician/APRN was notified of the weight loss identified on 12/10/2024. Additional weight recorded on 12/31/2024 was 146.8 lbs, indicating one (1) additional lb loss since 12/10/2024, and a total loss since 11/26/2024 of 25.1 lbs. On 3/6/2025 at 1:45 PM interview and clinical record review with APRN #1 and PA #1 identified they were not notified of Resident #1's weight loss of 24.1 pounds identified on 12/10/2024, and they were not notified of the weight loss identified on 12/31/2024 (total loss 25.1 pounds between 11/26 and 12/31/2024). Interview identified APRN #1 was first aware of the weight loss on 1/3/2025, and PA #1 was not aware of the loss. Interview identified APRN #1 and PA #1 should have been notified of the change in the resident's weight, and they would have wanted to be notified to review the plan. Interview, and review of clinical record and facility documentation on 3/6/2025 at 2:07 PM with DNS identified that the provider should have been notified of Resident #1's weight loss when it was identified. Interview failed to identify why the provider/APRN #1/PA #1 were not notified prior to 1/3/2025. Review of facility Change of Condition Notification policy directed in part, the facility will inform the resident, resident's healthcare provider, and the resident's family/legal representative when there is a change in condition. Facility documentation review identified staff education was initiated on 1/15/2025 and included to notify the physician of any weight discrepancy. Audits were initiated on 1/10/2025, and a QAPI meeting was held on 1/31/2025. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for ADLs, the facility failed to ensure the clinical record was complete and accurate to include personal care provided. The findings include: Resident #1's diagnoses included dementia, nutritional deficiencies, and unstageable pressure ulcer of sacral region. The quarterly MDS Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, had a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, required assistance with ADLs and transfers, and was incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 11/4/2024 identified an Activities of Daily Living (ADL) deficit. Interventions directed to assist with care as needed. The Nurse Aide Care Card directed assistance of one with personal hygiene, bathing, transfers, wheelchair use, and limited assistance with mouth care. Review of ADL flowsheet dated 1/1 to 1/23/2025 failed to identify NA documentation for the following personal care: ADLs (bathing, bed mobility, dressing, toilet use, transfers) - the documentation was blank (missing to indicate care was provided) seven (7) times during the night shift, nine (9) times during the day shift, and eight (8) times during the evening shift (total blanks 24 out of 93 opportunities). Bed mobility - the documentation was blank (missing to indicate care was provided) seven (7) times during the night shift, nine (9) times during the day shift, and seven (7) times during the evening shift (total blanks 23 out of 93 opportunities). ADL dressing - the documentation was blank (missing to indicate care was provided) nine (9) times during the day shift and eight (8) times during the evening shift (total blanks 17 out of 93 opportunities). ADL oral hygiene - the documentation was blank (missing to indicate care was provided) nine (9) times during the day shift and eight (8) times during the evening shift (total blanks 17 out of 63 opportunities). ADL transfers - the documentation was blank (missing to indicate care was provided) nine (9) times during the day shift and eight (8) times during the evening shift (total blanks 17 out of 63 opportunities). Bladder elimination - the documentation was blank (missing to indicate care was provided) seven (7) times during the night shift, nine (9) times during the day shift, and seven (7) times during the evening shift (total blanks 23 out of 93 opportunities). ADL eating - the documentation was blank (missing to indicate care was provided) nine (9) times during the breakfast meal, ten (10) times during noon meal, and eight (8) times during the dinner meal (total blanks 27 out of 93 opportunities). Nutrition snack - - the documentation was blank (missing to indicate care was provided) eight (8) times during the month for the daily 2 PM snack (8 out of 31 opportunities). Interview and record review with the DNS on 3/6/2025 at 12:28 PM identified that NA staff provided the care scheduled to be provided during the month of January 2025, and the NAs should have documented the care provided, according to facility policy. Interview failed to identify why the documentation, as listed above, was blank. Review of facility Charting and Documentation policy directed in part, to shall document services provided in the patient's medical record. Further, the Policy directed documentation shall be completed at the time of service, but no later than the shift in which the care service occurred.

Based on review of the clinical record, facility policy, and interviews for the one (1) of three (3) resident (Resident #3) reviewed for refusals, the facility failed to develop a comprehensive care plan indicating refusals related to wound and incontinent care. The findings include: Resident #3's diagnoses included pain, polyneuropathy (disease affecting multiple nerves throughout the body causing weakness, numbness and burning pain), severe malnutrition, anxiety disorder and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was cognitively intact, incontinent of bowel and bladder, and was dependent on staff for bed mobility and toileting hygiene. A care plan dated 4/11/24 identified that the resident had stage three (3) pressure ulcers on the bilateral heels and a stage three (3) pressure ulcer on the right medial and lateral buttock with interventions to provide incontinent care, administer treatments as ordered, and to assist with positioning changes. A Nurse Practitioner's (NP) note dated 5/21/24 at 12:00 AM identified Resident #3 had pressure ulcers to both the left and right heels and continued to be very non-compliant with getting out of bed on a regular basis. Education was provided regarding the importance of physical activity as well as frequent repositioning and its role in wound prevention and healing. A nurse's note dated 5/29/24 at 11:08 AM identified that Resident #3 was educated on the importance of offloading and was encouraged to use pillows but refused to offload at that time. Review of the Resident Care Plan (RCP) failed to include a care plan for behaviors indicating refusal of care, the resident frequently refused incontinent care, getting out of and re-positioning in bed. Interview with NP #1 on 9/16/24 at 10:22 AM identified that a contributing factor to Resident #3's pressure ulcers not improving was due to Resident #3's refusals. She indicated that the resident refused to let the staff get him/her out of bed and consistently refused to be repositioned in the bed. She identified that RN #2 had educated Resident #3 numerous times on the importance of offloading the pressure ulcers but that the resident continued to refuse. Interview with LPN #1 on 9/16/24 at 2:22 PM identified that he was Resident #3's nurse regularly on the 7:00 AM to 3:00 PM shift. He identified that although he did not document refusals, Resident #3 consistently refused personal care, incontinent care, repositioning, and dressing changes at times, and that NP #1 and RN staff were aware of the refusals. In an interview and clinical record review with the DNS on 9/16/24 at 2:25 PM, it was identified that the clinical record failed to reflect a care plan regarding Resident #3's refusals of dressing changes, incontinent care ,transfer out of bed and refusals to be repositioned and offload the pressure ulcers while in bed. She indicated that Resident #3 had a refusal care plan, however, unrelated to the pressure ulcers and incontinent care. Additionally, the DNS reported that the MDS nurse was responsible for the noncompliance care plan, and she was unsure why an RCP for Resident #3's refusals did not exist. Review of the Comprehensive Care Plan policy dated 11/2017 directed, in part, that the care plans are oriented towards preventing avoidable decline in clinical and functional levels, maintain a specific level of functioning and reflect resident preferences and the right to refuse certain services or treatment. Care plans include acute/chronic events, behaviors and/or illness. Based on the above, the Interdisciplinary Team develops a comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs. The Care Plan is evaluated and revised as needed, but at least quarterly.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 (two) of 2 (two) residents (Residents #2 and #3) reviewed for physician follow up appointments, the facility failed to document in the clinical record communications to outside provider offices regarding appointments. The findings include: 1. Resident #2's diagnoses included dissection of descending thoracic aorta (a tear in the wall of the aorta occurring in the descending section which runs through the chest and abdomen) and polyneuropathy (disease that affects multiple nerves throughout the body causing weakness, numbness and burning pain). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact and required maximal assistance for bed mobility and was dependent for transfers. The Resident Care Plan dated 4/18/24 identified that Resident #2 requires assistance with Activities of Daily Living (ADLs) with interventions that included to participate in Physical Therapy (PT) and Occupational Therapy (OT) and provide staff assistance of 2 with a rolling walker for mobility. A physician's order dated 4/8/24 directed for Resident #2 to follow up with vascular surgery on 4/29/24 at 8:00 AM. Review of progress notes failed to identify that Resident #2 had been transported to the 4/29/24 appointment. Interview with the Appointment Scheduler on 9/13/24 at 12:35 PM identified that the 4/29/24 vascular surgery appointment was canceled by the vascular surgery staff stating that Resident #2 required a CT scan completed prior to the appointment and they would call to reschedule the appointment for after the CT was completed. An appointment for the CT scan was set up for a radiology facility in Glastonbury on 5/16/24. On 5/16/24, although the facility booked the transport as a wheelchair van, the transportation company sent a sedan to pick up the resident. When the facility called the radiology location to notify them, they reported that they could not accommodate a resident who required a Hoyer lift (mechanical lift), so the appointment was canceled. On 7/5/24, the Appointment Scheduler received a phone call from the vascular surgery office stating they needed new blood work sent to them prior to rescheduling the CT scan appointment. She reported that the labs were done in the facility on 7/7/24 and sent to Person #3 as requested. An appointment for the CT scan was scheduled for 7/19/24, but his/her transportation arrived late and the radiology facility was unable to accommodate the resident's late arrival so Resident #2 did not get transported to the appointment. On 8/19/24, the Appointment Scheduler and the DNS called and spoke with Person #3 and the CT scan was booked for 9/10/24. On 9/10/24, Resident #2 had the CT scan completed and the vascular surgery follow-up was scheduled for 9/19/24. Review of the progress notes failed to identify documentation regarding the canceled appointment on 4/29/24 due to the CT scan not being completed, the canceled appointment on 5/16/24 due to transportation, the canceled appointment on 7/19/24 due to transportation or the communication on 8/19/24 between Person #3 and the DNS. Review of facility documentation identified that Resident #2 had blood work completed on 4/16/24, 4/24/24, 4/30/24, 5/3/24, 7/7/24, 7/31/24 and 8/20/24. Interview with Person #3 (vascular surgery staff) on 9/13/24 at 1:14 PM confirmed that the 4/29/24 vascular surgery appointment was canceled by their office on 4/25/24 due to not having results of the CT scan prior to the appointment but reported that he/she had not communicated to the facility prior to that date. Person #3 reported that he/she then spoke with the Appointment Scheduler on 5/21/24 and requested new blood work be sent to them, as it had to be current within 30 days of the CT scan. He/she reported that they did not receive the blood work, so they reached out again on 6/21/24 and spoke with the Appointment Scheduler. He/she reported that they did not receive the blood work, so they reached out again on 6/26/24 and left a voicemail for the Appointment Scheduler. Person #3 reported that on 7/5/24 they reached out to the Appointment Scheduler again because they still had not received the blood work and again left a voicemail. He/she identified that they then notified their manager of the communication issues they were having with the facility. Person #3 reported that the received the blood work on 7/9/24 so he/she reached out to the Appointment Scheduler to schedule the CT scan for 7/19/24. He/she reported that the resident did not show up for the appointment on 7/19/24 so they reached out to the Appointment Scheduler again on 8/12/24 and left a voicemail and received no call back. Further, he/she identified that the DNS reached out to him/her on 8/19/24 and the CT scan was booked for 9/10/24, which the resident had completed. Person #3 identified that Resident #2 has an appointment scheduled for 9/19/24 at 9:00 AM for the vascular surgery follow-up. Interview with the DNS on 9/16/24 at 11:05 AM identified that the Appointment Scheduler does not have a voicemail within the facility and that the vascular surgery office never reached out to her reporting that they were having difficulty obtaining requested blood work. She reported that when she contacted them on 8/19/24, everything was sorted out and the CT scan was booked, but stated she was unaware of the issues prior to the Appointment Scheduler notifying her on 8/18/24. Re-interview with the Appointment Scheduler on 9/16/24 at 1:04 PM confirmed that she does not have a voicemail within the facility. She denied receiving any correspondence with Person #3 on 5/21/24, 6/21/24, 7/9/24 or 8/12/24. 2. Resident #3's diagnoses included pain, polyneuropathy (disease affecting multiple nerves throughout the body causing weakness, numbness and burning pain), severe malnutrition, anxiety disorder and depression. The Resident Care Plan dated 3/25/24 identified that Resident #3 had pain related to impaired mobility with interventions that included to assist with positioning changes as needed for comfort, administering pain medications as ordered and discussing with the resident factors that precipitate pain and how to reduce it. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was cognitively intact and was dependent on staff for bed mobility and toileting hygiene. A physician's order dated 5/13/24 directed to schedule a non-joint Magnetic Resonance Imaging (MRI) of both heels to evaluate for osteomyelitis. A physician's order dated 5/15/24 directed to schedule an appointment for consultation with orthopedic surgery related to severe contractures of the left hip and knee and persistent pain, to call neurology and schedule appointment for consultation related to severe contractures to the left hip and knee, and to call sports medicine to schedule an appointment for a consultation related to severe contractures to the left hip and knee. Review of progress notes from 5/13/24 through Resident #3's discharge on [DATE] failed to identify that the resident was transported out of the facility for any appointments or that outside consultation appointments had been scheduled. Interview with Appointment Scheduler on 9/16/24 at 11:02 AM identified that she did schedule appointments for the MRI, the orthopedic and neurology. She identified that the resident had an orthopedic appointment on 5/20/24 and was seen by the provider. She reported that the resident had a neurology appointment scheduled for 6/5/24 but that the transportation could not accommodate a stretcher and it was canceled on 6/3/24. She reported that the MRI had been scheduled for 6/14/24 but that the resident canceled the appointment and subsequently discharged home the same day. She identified that she documented the appointments and their outcome on her spreadsheet but that it is not part of the clinical record. Interview with the DNS on 9/16/24 at 11:05 AM identified that she expects nursing staff to document in the clinical record any time a resident leaves the building for an appointment, any recommendations made from an outside provider appointment and any reasons as to why a resident is not seen or an appointment is canceled. She reported that she was unsure why they had not been documenting related to resident appointments. Further, she identified that the Appointment Scheduler does not currently have access to document in the electronic clinical record system and that corporate stated they are trying to develop an Appointment Scheduler note for documentation. She indicated that the Appointment Scheduler keeps a spreadsheet to track appointments but that she also did not write any paper notes that were then filed in the clinical record. Subsequent to surveyor interview, an in-service education on appointment documentation was initiated. Review of the Nursing Documentation policy dated 2/2016 directed, in part, that licensed nursing personnel documents information related to the resident's condition and care provided in the resident's medical record. All resident/patient record forms are kept in the resident's/patient's medical record. Although requested, a policy on outside provider appointments was not obtained.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure the clinical record was complete and accurate to include notification of a positive lab result timely. The findings include: Resident #1's diagnoses included Myasthenia Gravis with acute exacerbation and clostridium difficile (C-Diff). Record review identified Resident #1 was responsible for him/herself. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and was always incontinent of bowel. The Resident Care Plan (RCP) dated 4/27/2024, interventions directed to provide incontinent care as indicated. Physician order dated 4/29/2024 directed to obtain a stool sample for C-diff. Nursing note dated 4/29/2024 at 11:55 PM identified a stool sample was obtained for C-diff. The APRN note dated 5/1/2024 at 10:49 AM identified Resident #1 had a history for C-Diff and watery stools on admission. The note further identified a stool sample for clostridium difficile (C-Diff) was obtained with results that were positive for C-Diff. The nursing note dated 5/1/2024 at 2:30 PM identified Resident #1 was moved to private room due to tested positive for C-Diff. Additional review failed to identify Resident #1 was notified of positive lab result. Record review failed to identify Resident #1 was notified of the positive C-Diff results. Interview, record review, and facility documentation review with the DNS on 6/5/2024 at 9:45 AM identified she was the RN supervisor on 5/1/2024, and she notified Resident #1 that he/she was being moved to another room due to the positive C-Diff results. The DNS further indicated it should have been documented in the nursing notes by either her, or she should have directed the charge nurse (LPN # 3) to document that the Resident #1 had been notified why he/she was moving. Interview failed to identify why the notification was not documented. Review of the facility Condition: Significant Change Policy dated 1/26/2024 directed in part, the facility professional staff will communicate with resident/patient, and family regarding change in condition to provide timely communication of resident/patient status change. Procedure direct in part this notification shall be documented in the clinical record.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #2's diagnoses included paranoid schizophrenia, schizoaffective disorder, depressive type and dementia. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #2 had severe cognitive impairment, and required supervision/assistance with ADLs and transfers, and received antipsychotic and antidepressant medications. Physician orders dated 3/12/2022 directed Soothe XP solution (artificial tears) one drop both eyes two times a day, Lamotrigine (for schizophrenia) 100 mg by mouth two times a day, Clozapine (for schizoaffective disorder depressive type) 75 mg by mouth once a day, Ferrous Sulfate (iron deficiency anemia) 325 mg 1 tablet by mouth one time a day, Pepcid (for peptic ulcer) 20 mg 1 tablet by mouth in the morning, Timolol Maleate Solution 0.5% (for glaucoma) one drop to left eye, Vitamin C (for anemia) one tablet by mouth once a day, MiraLAX powder (for constipation) 17 gm by mouth every morning and bedtime for constipation, PreserVision AREDS tablet 1 tablet by mouth two times a day for eye health,Trazodone HCI (for paranoid schizophrenia/anxiety) 12.5 mg tablet by mouth every 12 hours as needed, Acetaminophen (pain) 500 mg 1 tablet one time a day for chronic left shoulder pain, administer a 4-ounce Dessert cup with lunch in the afternoon for supplement and Ensure clear 240 cc three (3) times per day for supplement and to monitor for paranoid behaviors every shift and behavior monitoring for auditory hallucinations every shift. The Resident Care Plan (RCP) dated 4/19/2022, identified Resident #2 had history of schizophrenia with paranoid delusions with anxiety. Interventions directed medicate as ordered, monitor and document response. Review of the Medication Administration Record (MAR) for April 2022 identified Resident #2 did not receive the following morning medications on 4/3/2022 at 7:30 AM: Soothe XP solution (artificial tears) one drop both eyes, at 8 AM, Lamotrigine 100 milligrams (mg) at 9 AM, Clozapine 75 mg, Ferrous Sulfate 325 mg, Pepcid 20 mg, Timolol Maleate Solution 0.5% one drop to left eye, Vitamin C one tablet, MiraLAX powder (for constipation) 17 gm, PreserVision AREDS one tablet, and Trazodone HCI 12.5 mg, at 10 AM: Acetaminophen 500 mg. Review of the Medication Administration Record (MAR) for April 2022 identified Resident #2 did not receive the following supplements on 4/3/2022: Ensure Clear 240 cc at 8 AM, a 4-ounce dessert cup with lunch for supplement at 12:30 PM, and Ensure Clear 240 cc at 2 PM. Review of the Medication Administration Record (MAR) for April 2022 identified behavior monitoring was not provided for Resident #2 on 4/3/2022 during the 7 AM to 3 PM shift for the following behaviors: auditory hallucinations, and behaviors: paranoid behavior. Facility documentation review identified LPN #2 was the charge nurse on 4/3/2022 when the medications, supplements were not administered, and behavior monitoring was not completed. Interview, review of clinical record with LPN #2 on 6/4/2024 at 10:58 AM identified that if she had given Resident #2 medications, supplements, and monitored behaviors she would have documented them in Resident #2's MAR. LPN #2 stated if she did not document the, it was not completed; she stated it could have been overlooked by accident. LPN #2 was unable to explain why the medications, supplements were not administered, and behavior monitoring was not completed. Interview, clinical record review, and facility documentation review with DNS on 6/5/2024 at 9:40 AM the DNS identified that a nurse should document as soon as a medication is given. The DNS stated she was aware that LPN #2 failed to document administration of medications, supplements or behavior monitoring on 4/3/2022. The DNS was unable to verify the medications, and supplements were administered and the behavior monitoring was completed, in accordance with physician orders, and indicated they should have been. Although requested, the facility did not provide a facility policy regarding medication administration for surveyor review during the survey.

Based on review of the facility documentation, facility policy, and interviews the facility failed to ensure resident council funds and the corresponding financials records were maintained according to generally accepted accounting principles and were utilized per resident council policy and following the employee code of ethics policy. The findings include: 1. Review of the resident council meeting minutes dated 2/7/23 failed to reflect that the members of the resident council discussed/voted on or approved an Amazon purchase dated 2/9/23 (whiteboard for the recreation room). Resident council bank statement identified on 2/9/23 a purchase from Amazon in the amount of $141.25. Interview with the Director of Recreation on 2/6/24 at 1:55 PM indicated she had made the purchase for a whiteboard for the recreation room to do programs on 2/9/23. The Director of Recreation indicated it was for resident group activities like crossword games. The Director of Recreation did not recall if the committee discussed it or had approved the purchase of the whiteboard. Interview with Administrator #1 on 2/9/24 at 10:05 AM indicated if recreation needed a white board for activities the facility would have purchased it. Administrator #1 indicated he was not aware that the Director of Recreation used the resident council funds to purchase a whiteboard. Administrator #1 indicated that is why recreation has a petty cash fund provided by the facility to purchase items like that for recreation if it is reasonable. 2. Review of the resident council bank statement identified on 9/1/23 there was a withdrawal for $100.00. Interview with Director of Recreation on 2/6/24 at 10:25 AM indicated she was responsible for the resident's resident council funds but does not receive monthly statements from the bank. The Director of Recreation indicated she calls occasionally to get the balance of the resident council account. The Director of Recreation indicated she did not keep a log of when she called the bank. The Director of Recreation indicated she was not able to print out the monthly statements because there were 2 other facility accounts attached to the resident council account. Interview with the Director of Recreation on 2/6/24 at 11:37 AM indicated that Administrator #2 left the facility quickly on 8/25/23. The Director of Recreation indicated that there was $100 dollars taken out of the resident council money to purchase a gift card to a restaurant for Administrator #2 when he was leaving. The Director of Recreation indicated it was not discussed at resident council prior to or after getting the gift card. The Director of Recreation indicated the Resident Council President had approached her and asked her to get a gift card for Administrator #2. The Director of Recreation indicated there was nothing in writing per the policy, but it was done verbally. The Director of Recreation indicated she purchased the gift card on her personal credit card then went to the bank and withdrew the money from the resident council funds. Review of the resident council meeting minutes, the Director of Recreation indicated there was nothing written in the minutes for June, July, August, or September 2023 because it was never discussed the gift card at resident council and was not voted on or approved by the members of resident council. Interview with the Administrator on 2/6/24 at 2:30 PM indicated that staff should not receive gifts from residents or families. Administrator #1 indicated if a resident or resident council offered him a $100 gift card, he would not accept it. Administrator #1 indicated that all staff learn during general orientation about not accepting gifts and through corporate compliance training. Administrator #1 indicated he started at the facility in September 2023 was in possession of the resident council funds. Administrator #1 did not understand why he had resident council funds, so he gave it to the Director of Recreation. Administrator #1 did not know how much money he handed over to the Director of Recreation from the resident council funds. Administrator #1 indicated Resident council money can be used for anything the residents want if it was brought to the resident council meeting and all the residents discuss it and make a determination as a group to approve or deny it. Administrator #1 indicated he would expect to see all that in the resident council meeting minutes. Interview with Administrator #2 on 2/7/24 at 2:03 PM indicated he had started March 2022 and left the end of August 2023. Administrator #2 indicates he was educated on Resident Rights, corporate compliance, and ethics in general orientation. Administrator #2 indicated that no staff are allowed to receive money from the residents or resident families. Administrator #2 indicated his final day at the facility the management team had a party for him and there was a card from the residents, and the staff gave him a card, but he did not recall the residents giving him a $100 gift card. Administrator #2 indicated if there was a gift card from the residents, he would have given it back. Administrator #2 indicated he does recall getting a gift card, for a restaurant, but does not recall dollar amount. Interview with Admissions Director #1 on 2/7/24 at 2:54 PM identified on last day for Administrator #2 the staff gave him a cake. The Admissions Director #1 indicated she chipped in with Business Office Manager #1 for a $50 gift card to a restaurant. The Admissions Director #1 indicated she was not aware if the residents did anything, but staff got the cake. Interview with Resident #54 on 2/7/24 at 3:15 PM indicated he/she did remember that he/she was informed that the prior Administrator #2 was leaving and something about him getting a $100 gift card from the residents, but she does not recall how all that came about. Resident #54 does not know where or what the gift card was for and identified she did not instruct the Recreation Director or anyone else to get a gift card for Administrator #2. Resident #54 indicated she was told about it but does not recall that being discussed at resident council. Review of Administrator #2's personnel file indicated a hire date of 3/14/23. Further, corporate compliance section of the job description was signed on 3/14/23 indicating he would demonstrate adherence to the employee code of ethics and conduct. Review of the facility Code of Ethics Policy identified that an employee shall not exchange gifts or gratuities with residents or their families at the facility. 3. Review of a reservation request for a banquet hall dated 10/12/23 signed by the Director of Recreation indicated the facility was to hold a Thanksgiving lunch on 11/16/23. A check from the resident council fund dated 11/16/23 made out to a banquet hall for $75 signed by the Director of Recreation for Thanksgiving dinner. Review of the resident council bank statement identified on 11/22/23 a check withdrawal for $75. Additionally, the statement did not reflect the $75 had been returned to the account. Interview with the Director of Recreation 2/6/24 at 12:08 PM indicated in November usually the marketing team from the facility pay for a banquet hall for some for the residents and their families. The Director of Recreation indicated that the facility should pay for it, but the banquet hall would not take cash, so she decided to write a check from the resident council funds. The Director of Recreation indicated that Administrator #1 gave her the $75 in cash but instructed her to use the money to buy residents presents for Christmas instead. An interview with the Director of Recreation indicated she did not replace the $75 back in the resident council funds. Interview with the Administrator #1 on 2/6/24 at 12:45 PM indicated the facility was supposed to pay for the banquet hall for a Thanksgiving dinner event but the hall would not except the cash from the facility petty cash fund. Administrator #1 indicated that he instructed to write a check from the resident council account and reimbursed from the petty fund. Administrator #1 indicated he did not recall who wrote out the check from resident council fund. Administrator #1 indicated that he handed the money to the Recreation Director and did not recall the specifics of the transaction but believes it was to place the $75 back into the resident council funds bank account. Administrator #1 indicated he did not instruct the Recreation Director to purchase the residents Christmas presents using the resident council funds. 4. Interview with the Director of Recreation 2/6/24 at 12:14 PM indicated that every year just before Christmas the facility staff are asked to donate Christmas presents for the residents. The Director of Recreation indicated if there were residents left that did not have a present from the staff, recreation was responsible to purchase gifts for those residents. The Director of Recreation indicated she did not ask the resident council president or resident council if she could use their funds to buy presents for other residents, she followed the directive of Administrator #1. The Director of Recreation indicated that the Administrator told her to use the $75 (petty cash to pay back the resident council fund for the banquet hall) to go buy resident presents. The Recreation Director indicated there were 11 residents that she used the money to buy presents for. The Director of Recreation indicated she did not have the resident council approval to use the funds for the whiteboard, the administrators gift card, the banquet hall, or for the Christmas presents. Interview with the Administrator on 2/6/24 at 1:45 PM indicates he thinks there was confusion between the recreation director and himself. Administrator #1 indicated he did not realize that resident council had their own funds. Administrator #1 indicated he thought when he would tell the Recreation Director to use the resident funds and that the recreation director was using the residents petty cash funds that the facility provides, and he did not realize that she was using the resident council funds. 5. Interview with the Director of Recreation on 2/9/24 at 9:42 AM indicated that the resident council does fund raising, and she keeps the money they raise in her office. The Director of Recreation indicated she recalls Administrator #2 in the past would hold onto the resident council cash from the fundraisers and when she had received it in September 2023 from Administrator #1 there were no records of the money that had been raised. The Recreation Director indicated she does not keep track of how much money is made at each fundraiser and does not deposit the money into the resident council bank account. The Recreation Director indicated she does not know how much money she had in her office. Interview with the Director of Recreation on 2/9/24 at 10:00 AM indicated she had $170 and some coins in her office that were the resident council money. The Director of Recreation recalls there was an ice cream sale that made $60, a lemonade sale, a chocolate sale, a pretzel bite sale, a plant sale that made $35, a donut hole sale, and at Christmas a soda and chip sale. The Recreation Director indicated there were no records of what profits there were from any of the resident council fundraising. The Director of Recreation indicated that today Administrator #1 informed her that she must deposit the money she has in her office into the resident council fund bank account. Review of the facility Resident Council Funds Policy identified a checking account for the Resident Council shall be established. Authorized signatures for disbursements shall be the facility Administrator, Social Service Director, and Recreation Director, in accordance with bank policy. All expenditures shall be approved by a majority vote of residents at the scheduled meeting and documented in the minutes. The Resident Council President shall authorize all purchases in writing for which monies are withdrawn from the account. The Recreation Director shall keep all receipts from purchases, bank statements, cancelled checks, deposit receipts, and tax charges. Receipts for purchased items shall include date, check number, and reason.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #34 and 72) reviewed for accidents, the facility failed to provide supervision to prevent an accident, and/or provide supervision to an out of facility appointment. The findings include: 1. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A reportable event form dated 5/30/17 at 10:00 AM identified that another resident entered Resident #34's room and pushed Resident #34, which resulted in a fall. The facility investigation identified Resident #52 and/or Resident #250 had the highest potential of pushing Resident #34 due their history of wandering into other resident's rooms. The care plan dated 5/30/17 identified Resident #34 had the potential for a sad mood due to a peer entering his/her room and pushing him/her. Interventions included to place a stop sign across Resident #34's doorway. The quarterly MDS dated [DATE] identified Resident #34 was severely cognitively impaired and required limited assistance to walk in his/her room. A reportable event form dated 9/30/17 at 10:15 AM identified Resident #34 was lying on his/her back on the floor with the rolling walker on top of him/her. Resident #34's hands were positioned on handle bars of the walker. Resident #34 was yelling out that someone just pushed him/her. Resident #34 sustained an open area to the back of the head, and the resident complained of back pain. Resident #34 was sent to the hospital for an evaluation. The nurse's note dated 9/30/17 at 11:19 AM identified that a nurse heard a resident yelling and screaming to get out of my room, stop, go away. Upon entering Resident #34's room, Resident #34 was lying on his/her back with the rolling walker over his/her lap and blood running from head. Resident #250 was in the room telling Resident #34 to be quiet. In addition, the nurse's note identified Resident #34 stated somebody pushed me, I don't know why, I want to get out of here. Further, the nurse's note identified Resident #34 complained of severe pain to head and left hand. Subsequent to APRN notification, Resident #34 was sent to hospital for evaluation. Review of hospital documentation dated 9/30/17 identified that Resident #34 sustained a laceration of the scalp which was repaired. The nurse's note dated 9/30/17 at 6:14 PM identified Resident #34 returned from the hospital at approximately 5:15 PM with 4 staples to the back left side of the head. Interview with LPN #3 on 3/12/18 at 10:25 AM identified he/she has observed Resident #250 many times go under Resident #34's stop sign prior to Resident #250 pushing Resident #34 to the floor. Additionally, when a cardboard bookcase was placed at Resident #34's door, Resident #250 would move and get in. Resident #250 was all around the building and was quick and he/she was always going into Resident #34's room. LPN #3 indicated that the DNS was aware that the interventions were not working to keep Resident #250 out of Resident #34's room. LPN #3 indicated that staff were directed to redirect Resident #250. Interview with NA #2 on 3/12/18 at 10:35 AM identified Resident #250 and Resident #34 did not like each other. Resident #250 would wander and staff would redirect him/her, but from time to time he/she would slip into resident rooms. The stop sign across the door would not stop Resident #250 from getting into Resident #34's room and the nursing staff all knew. Interview with LPN #1 on 3/12/18 at 11:10 AM identified the stop sign across Resident #34's room would only stop Resident #250 from getting in sometimes. Other times, Resident #250 would rip the sign down or go under it. We were directed by the DNS to redirect Resident #250. Interview and review of clinical record with DNS on 3/12/18 at 11:30 AM identified that DNS was aware of the potential of Resident #250 going into Resident #34's. The DNS was unable to provide documentation that staff supervised Resident #250 to prevent him/her from gaining access to Resident #34's room. In a subsequent interview with the DNS on 3/12/18 at 2:40 PM identified he/she was not aware that Resident # 250 was frequently getting into the other residents rooms. The DNS indicated that had he/she been aware, other interventions would have been attempted to ensure Resident #250 did not wander unsupervised into other resident rooms. 2. Resident #72's [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] identified Resident #72's was moderately cognitively impaired and required extensive assistance with care. The care plan dated 2/20/18 identified Resident #72 had impaired cognition related to dementia with interventions that included to cue, reorient and supervise as needed, and engage the resident in simple, structured activities that avoid overly demanding tasks. The care plan also identified Resident #72 was at risk to try and leave the facility. Interventions included to encourage Resident #72 to come with staff if seen at an exit, and apply a wander guard bracelet. The (MONTH) (YEAR) monthly physician's orders directed a wander guard bracelet to be worn at all times, and to provide assistance of a stand aid and gait belt for transfers. Interview with Person #1 on 3/5/18 at 11:00 AM identified that on 2/12/18 approximately 11:45AM, Resident #72, who has dementia, was sent to an off-site doctor appointment without staff supervision. Person #1 received a phone call from the doctor's office staff indicating Resident #72 had mistakenly been brought to their office, (resident did not have an appointment), and dropped off by the driver. Person #1 indicated that the office staff person notified the facility that Resident #72 did not have an appointment, needed transportation back to the facility, and was sitting in the waiting room unaccompanied. Person #1, who was in Colorado at the time, identified that he/she spoke with facility staff who ensured him/her that Resident #72 would be picked up immediately. Resident #72 did not return to the facility until approximately 4:30PM, over 4 hours later. Interview with RN #1 on 3/7/18 at 9:30 AM identified that when appointments are scheduled, the unit secretary completes a form with details about requirements needed including whether family or staff are needed to accompany the resident and/or if already set up. RN #1 further identified that on the day of Resident #72's appointment, he/she did not know who was going to the appointment with the resident. Interview with LPN #2 on 3/7/18 at 9:45 AM identified that although he/she was aware Resident #72 was scheduled for an appointment, and required an escort, he/she did not know who was scheduled to accompany the resident. Interview with NA #3 on 3/7/18 at 11:00 AM identified that although he/she had taken an envelope from the nurse's station to accompany the resident, and driver to the appointment, he/she only wheeled resident out to the lobby. Interview with the Receptionist on 3/7/18 at 1:30 PM identified that he/she did let Resident #72 out of the building on 2/12/18 around lunchtime despite the wander guard alarm because the resident was with transportation staff. Additionally, he/she assumed nursing staff was aware that Resident #72 left without nursing staff and/or family. Interview with the DNS on 3/8/18 at 9:00 AM identified that Resident #72 and any resident with dementia, or safety concerns, should be accompanied by staff or family when leaving the facility. Review of the facility policy on accompaniment of residents to scheduled appointments identified that the facility will attempt to maintain resident's safety on appointments scheduled by the facility which occur outside the facility. If the resident is not deemed safe and competent to attend the appointment alone, the facility will assist in providing accompaniment. Additionally, the resident's responsible party will be contacted to determine if they would like to accompany the resident to the scheduled appointment. Further, in the event that no responsible party not employed by the facility is able to accompany the resident, the facility will provide accompaniment to the scheduled appointment.

Based on clinical record reviews, observation and interviews for 1 of 4 residents who were identified with food allergens and/or food sensitivities, (R#5), the facility failed to ensure that the resident received an allergen free breakfast. The finding includes: Resident #5 was admitted to the facility of 7/29/16 after a hospitalization for enterocolitis due to failure to adhere to the hospital's recommended treatment for [REDACTED]. A 7/29/16 dietary assessment on admission (revised on 8/3/16 after the allergic response to being served eggs on 8/2/16, but was not dated as to when the allergy to eggs was identified) obtained by Dietary Aide #1 identified that the resident on admission stated he had no food allergies [REDACTED]. Review of facility documentation dated 8/2/16 identified that the Nursing Supervisor, RN #3 was called to Resident # 5's room, where she found the resident breathing rapidly holding his throat. Upon several inquries, Resident #5 pointed twice at dime size piece of scrambled eggs on his/her breakfast tray and on the third inquiry stated, I'm allergic to eggs. 911 was notified, arrived and Epinephrine 0.45 mg and Benedryl 25 mg IM were administered for an audible wheeze. The resident was transferred to the hospital ED. The resident's hospital documentation dated 8/2/16 identified that the resident who had a [DIAGNOSES REDACTED]. Interview with RN # 4 on 8/4/16 at 11:45 AM identified that on 7/30/16, he/she went down to the room to look at an unrelated body rash and found the resident had pushed his/her breakfast tray aside. The plate contained eggs and a muffin. Resident # 5 told RN# 4 that he/she had an egg allergy, that he hadn't eaten any of the eggs, that if he/she consumed egg, it resulted in severe respiratory distress. He/she further identified that he/she was able to eat eggs in baked food items. According to RN # 5 at that time, she removed the plate containing the egg and muffin from the resident's room and sent a dietary slip down to the kitchen identifying the egg allergy. Interview on 8/4/16 at 11:05 AM with Dietary Aide # 1 identified that that she interviewed the resident on 7/29/16 and that Resident #5 told her he had no food allergies [REDACTED]. She further identified that she reflected the egg allergy on the diet slip on 7/30/16 after she saw the dietary slip from the nursing staff indicating the food allergy. Interview on 8/4/16 at 1:10 PM with Chef # 1who plated R#5's food on 8/2/16 identified that the dietary slip said no eggs and that the resident got a piece of coffee cake and that the only thing he could think of was that someone gave R#5 the wrong tray. Interview on 8/4/16 at 1:55 PM with Dietary Aide # 2 identified that she did not serve R#5 his/her breakfast tray but had checked his plate and there were no eggs on his/her plate. She put six breakfast covered plates on a cart and the nursing assistant took them to the residents' rooms from there. Interview on 8/4/16 at 2:30 PM with Nurse Aide (NA) #1 who served the resident his/her breakfast on 8/2/16 identified that there was nothing on the dietary slip that identified an egg allergy, that she took the cover off the plate and the resident told her to take the eggs off the plate. However, the resident did not tell her he/she had an egg allergy. She further identified that she took the knife and brushed the egg into the cover and removed the cover from the room. She stated that she left the plate with the muffin and the knive that was used to scrape the eggs off the plate in the resident's room. The corporate person identified at this time that the dietary slip could not be found subsequent to the incident. Subsequent to the event and upon being transferred to the ED, Resident # 5 was admitted to the hospital to a telemetry monitored bed.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to safely transport a resident with combative behavior to prevent a fall with injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #1 had severe cognitive impairments, physical behavioral symptoms exhibited by hitting, kicking and scratching others and self, rejection of care, required extensive two person assistance with transfers, had functional limitation in range of motion on one side of the upper extremity and both sides of lower extremity, and utilized a wheelchair and walker for ambulating. The resident care plan dated 1/3/14 identified Resident #1 was at risk for falls secondary to impaired sense of balance and unsteady gait, generalized weakness, cognitive impairment and decreased neuromuscular coordination. Interventions directed to utilize a bed alarm and chair alarm as indicated and assist out of bed to wheelchair. The resident care plan also identified an anxiety disorder. Interventions directed to monitor the resident for safety, observe for periods of anxiety, provide a calm quiet environment and place resident up in a wheelchair at the nurse's station when agitated. The nurse's note dated 3/17/14 identified that Resident #1 was seated in the wheelchair and in the process of being wheeled from the room by the private duty nurse aide and a facility nurse aide into the hallway, Resident #1 suddenly fell from the wheelchair, onto the right side. Resident #1 was noted to be agitated and upset at the time. Resident #1 complained of pain on the right lower extremity, the right leg was somewhat shortened and rotated outward. Subsequently Resident #1 was transferred to the hospital and admitted with a right hip fracture. Review of the Reportable Event Form and investigation dated 3/17/14 identified that Resident #1 had appeared upset, restless, had agitated with poor safety awareness and there were no medications ordered for anxiety. Resident #1 was in the wheelchair being pushed into the hallway and fell to the floor on the right side. Subsequent to the incident a half table was added to the wheelchair when up in the wheelchair. Review of the care plan date initiated 3/18/14 directed to add half-table to the wheelchair when resident is in the wheelchair to prevent forward falling. Interview with NA #1 on 11/3/14 at 11:45 AM identified on 3/17/14 she was not assigned to Resident #1 but was asked to assist the private duty nurse aide (NA#4) with caring for Resident #1. NA #1 recalled that she was called back from break to assist NA #4 because Resident #1 was very agitated and "all over the place". Resident #1 was shaking, moving around and touching at everything. NA #1 recalled that Resident #1 was seated in an upright wheelchair, the leg rests had been removed and did not recall that the leg rests had been on the wheelchair. Interview with RN #1 on 11/3/14 at 12:00 PM identified that she was at the medication cart when Resident #1 was wheeled out of the room by the two nurse aides. RN #1 indicated that Resident #1 fell forward out of the wheelchair on the right side. RN#1 did not recall having been alerted that Resident #1 was agitated and/or if leg rests had been applied to the wheelchair. Interview with the Director of Rehabilitation on 11/4/14 at 8:45 AM identified that Resident #1 required an adapted custom wheelchair with leg rests. NA #4 was unable to be contacted, but review of her statement reflected that Resident #1 was very upset that morning, pulling at the sheets, scratching at self and combative with care. NA#4 reported the resident's behavior to the charge nurse and a second nurse aide came in to assist. When morning care was completed, Resident #1 was transferred into the wheelchair and the resident became more agitated "flinching" in the chair. Resident #1 was then pushed out the door, still "flinching" and fell out of the wheelchair. Interview with the Director of Nurses on 11/5/14 at 11:00 AM identified that Resident #1 was often positioned at the nurse's station while exhibiting anxiety however, review of the facility's investigation failed to reflect that the interventions of measures to keep the resident safe while being transported in the wheelchair.

Based on clinical record reviews, review of facility documentation and interviews for two of six sampled residents (Residents #100 and #172) who were at risk for falls, the facility failed to provide adequate supervision and/or assistive devices to prevent accidents. The findings include: 1 a. Resident #172's [DIAGNOSES REDACTED].#172 had severe cognitive impairment, did not exhibit any behavioral symptoms, required extensive assist with transfer, walk in room and corridor, locomotion on and off unit and toilet use, balance during transitions and walking was not steady and the resident was only able to stabilize with staff assistance and had no recent falls. The resident care plan dated 7/3/12 identified that the resident was at risk for falls related to the dementia and a history of falls. Interventions directed to transfer and ambulate with assistance of one and a rolling walker and to attend the recreational VIP program daily. The Reportable Event Form dated 8/5/12 identified that at approximately 3:30 PM during the VIP program Resident #172 fell to the floor landing on his/her bottom, complained of left hip pain with movement and was transferred to the hospital for an evaluation. Review of the facility's investigation identified that Resident #172 was seated in the wheelchair placed behind another resident. Resident #172 stood up, held onto the other resident's wheelchair and while pulling on the other resident's wheelchair, Resident #172 lost control of his/her balance and fell to the floor. The hospital discharge summary dated 8/9/12 identified discharge [DIAGNOSES REDACTED]. Review of the safety guidelines for the VIP program directs staff never to leave residents unattended in the program room. Residents should be accompanied by a staff member. This safety guideline was noted to be signed on 8/13/12 by Nurse Aide (NA) #4. Interview and review of the facility documentation with the Director of Nurses (DON) on 9/27/12 at 9:50 AM identified that NA #4 had left the VIP program unattended and was not able to intervene when Resident #172 stood up to prevent the fall. Subsequent to the incident NA #4 was removed from the VIP program. b. The resident care plan dated 8/27/12 identified that Resident #172 was at risk for combative behavior and increased agitation. Interventions directed to approach in a friendly, calm manner and when agitated leave the resident in a safe environment and reapproach later. The Reportable Event Form dated 9/22/12 at 10:20 PM identified that Resident #172 pushed NA #3 away during a transfer, fell and hit his/her head. Resident #172 sustained a laceration to the forehead, a pressure dressing was applied to forehead and the resident was transferred to the hospital for an evaluation. Review of the facility's investigation identified that Resident #172 was calm with care and became resistive when the nurse aide attempted to transfer Resident #172 back to bed. In the written statement NA #3 indicated that she stood in front of Resident #172 to begin a stand pivot transfer from the wheelchair to the bed when Resident #172 began to pull then push. NA #3 indicated that she lost her grip and Resident #172 fell . The nurse's note dated 9/22/12 at 10:20 PM identified that Resident #172 was observed lying on the floor, on the right side of the bed face down, a 2.5 by 2.0 centimeter skin tear to left shin and laceration to forehead were noted, and Resident #172 was transferred to the hospital. The hospital discharge summary date 9/23/12 identified that Resident #172 had sustained a laceration that required two sutures. Interview with NA #3 on 9/27/12 at 10:35 AM identified that Resident #172 become agitated during an attempt to transfer the resident from the wheelchair to the bed so she sat Resident #172 back down in the wheelchair. NA #3 indicated that she again attempted to transfer Resident #172, however, the resident become even more agitated and NA #3 lost her grip and let go causing Resident #172 to fall. Interview with the Director of Nurses (DON) on 10/1/12 at 11:20 AM identified that NA #3 did not utilize a gait belt during the transfer. The DON also indicated that NA #3 should had left Resident alone when he/she become agitated and reapproach later. Review of the facility's policy directs in the interest of safety and welfare of residents and staff, the facility requires that all employees use a gait belt when transferring and/or ambulating residents, unless contraindicated, or unless "supervision only" or "independent for transfers" . 2. Resident #100's [DIAGNOSES REDACTED]. The Rehabilitation Fall Screen dated 10/26/11 identified that Resident #100 would benefit from a Merry Walker with anti-tippers to maximize the resident's safety during ambulation. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #100 had memory deficits, severe cognitive impairments, and required extensive assistance with activities of daily living. A physician's orders [REDACTED]. The resident care plan dated 12/22/11 identified that the resident was at risk for falls. Interventions directed to place the resident in a Merry Walker for ambulation only, to place the resident in a chair for meals and the VIP program and to provide one person physical assistance during ambulation in the Merry Walker. The nurse's note dated 1/19/12 at 7:15 AM identified that at 12:45 AM Resident #100 was heard yelling for help and the resident was found in another resident's room lying on his/her left lateral side with the Merry Walker on top. Resident #100 was noted to be bleeding profusely, the Nursing Supervisor was called and 911 summoned. The Reportable Event Form dated 1/19/12 identified that Resident #100 had sustained facial, nasal and dental fractures. Interview with the Director of Nurses (DON) on 9/27/12 at 3:10 PM identified that Resident #100 required one person physical assistance while in the Merry Walker as directed in the at risk for falls care plan and the nurse aide assignment sheet dated. The DON indicated that on 1/19/12 NA #2 failed to provide the necessary assistance and/or supervision that the resident required as outlined in the plan of care. Interview with the Rehabilitation Director on 9/27/12 at 4:10 PM identified that Resident #100 required verbal cueing and supervision while in the Merry Walker with anti-tippers to ensure safety during ambulation secondary to the resident's cognitive status. Interview with NA #2 on 10/1/12 at 10:10 AM identified that on 1/19/12 he had toileted Resident #100 twice and then transferred the resident into the Merry Walker. NA #2 stated that he left Resident #100 at the nurse's station with the licensed nurse, provide the resident a snack, and then proceeded to continue his rounds. NA #2 identified that he usually leaves Resident #100 in the Merry Walker so that the resident could ambulate independently in the hallway and that he was not aware that Resident #100 required one person physical assistance while in the Merry Walker until after the 1/19/12 fall.