Every finding on record at Greenwood Nursing & Rehabilitation Center

Based on observations and interviews, the facility failed to provide a dignified dining experience for Residents in the facility's dining room. Specifically, the facility to ensure dependent Residents were fed at the same time while sitting together in the dining room.Findings include:Review of the facility policy titled Residents' Rights, undated, indicated the following:- As a Resident of a long-term care facility you have the right: to be treated with dignity and respectReview of the facility policy titled Supervision of Resident Nutrition, undated, indicated:-Residents needing assistance in eating must be promptly assisted upon being served. The surveyor made the following observations throughout the survey period in the facility's main dining room:- On 8/5/25 at 12:21 P.M., during lunch service, two residents dependent on staff for eating were sitting at the same table in the dining room. A staff member sat down to help the first resident while the second resident sat at the table with his/her tray in front of him/her unable to eat. The second resident attempted to open the lid to his/her meal but was unable to. At 12:36 P.M., 15 minutes after, staff started to assist the other resident at the table, a different staff member sat down with the second resident to assist with eating lunch.- On 8/6/25 at 8:29 A.M., during breakfast service, at a table with three Residents, two independent residents were served breakfast at 8:18 A.M., at 8:23 A.M., a third resident who is dependent on staff was served breakfast at the same table. While the two independent residents were eating breakfast, the third dependent resident began falling asleep at the table with his/her meal in front of him/her. A staff member came to assist the resident at 8:30 A.M., 12 minutes after the two independent residents were served breakfast.- On 8/6/25 at 8:32 A.M., during breakfast service at a different table, two residents who were dependent on staff for assistance while eating were seated together. Both residents received their trays at 8:27 A.M., the first resident received assistance with eating at 8:27 A.M., the second resident sat at the table with his/her meal in front of him/her for seven minutes until a staff member came to provide assistance with eating.- On 8/6/25 at 12:13 P.M., during lunch service, two residents were sitting together. These two residents who are dependent on staff for assistance while eating, received their meals. At 12:16 P.M., the first resident received assistance from staff to eat while the second resident was sitting at the table with his/her meal in front of him/her. At 12:27 P.M., 14 minutes after receiving his/her tray and 11 minutes after his/her tablemate started receiving assistance, a staff member entered the dining room to provide assistance with the second resident's meal.- On 8/7/25 at 8:22 A.M., during breakfast service, two residents were sitting together. These two residents who are dependent on staff for assistance while eating, received their meals. The first resident had a staff member assist them with eating promptly. The second resident at the table, did not receive assistance from another staff member until 8:29 A.M., seven minutes later.During an interview on 8/7/25 at 10:41 A.M., Certified Nursing Assistant (CNA) #2 said if residents are sitting at the same table they should be eating their food at the same time.During an interview on 8/7/25 at 8:53 A.M., CNA #3 said staff members should be feeding residents at the same time if they are sitting at the same table.During an interview in 8/7/25 at 11:36 A.M., the Activities Assistant said dependent residents sitting at the same table should ideally be assisted at the same time so they can eat at the same time.During an interview on 8/7/25 at 12:31 P.M., the Director of Nursing said all residents deserve a dignified dining experience and should be fed at the same time as tablemates when sitting together.

Based on record review and interview, the facility failed to document in the medical record that residents above the age of [AGE] years old received Pneumococcal immunizations for 4 out of 5 sampled residents. Specifically, the facility failed to document in the medical record when the residents received the Pneumococcal vaccine, the vaccine name, the lot number, and the expiration date. Findings include: A review of the facility policy titled 'Pneumonia immunization policy' with no revision date indicated the following:-Licensed staff will review immunization consent form and educational materials with resident or responsible party being sure all risks and benefits are understood.-Check for allergies which may preclude vaccination.-Administer vaccine as ordered.-Document on MAR, medication administration and site.-Document in Nurse's notes, consent form, and immunization form resident vital signs, vaccine name, lot number, expiration date, injection site, resident response to injection, and resident/responsible party education, and if applicable, declination of the vaccine.CDC (Center for Disease Control and Prevention) guidelines for Pneumococcal vaccines indicate the following:The CDC recommends that adults aged 65 years and older residing in nursing homes or long-term care facilities receive both a pneumococcal conjugate vaccine (PCV) and a pneumococcal polysaccharide vaccine (PPSV23). For those who have not previously received a PCV, the recommendation is to start with PCV15 or PCV20, followed by PPSV23 at least one year later. For adults who have received a previous PCV (like PCV13), shared clinical decision-making with a healthcare provider is recommended to determine the best vaccination approach. Review of the 4 residents' immunization records indicated the following:-2 out of the 4 residents indicated that their Pneumonia vaccines were current on admission, but the medical record failed to include any information about what type of Pneumonia vaccine or date administered.-2 out of the 4 resident's HCPs (Health Care Proxies) indicated that the resident's Pneumonia vaccines were current on admission, but the medical record failed to include any information about what type of Pneumonia vaccine or date administered.During an interview and record review on [DATE] at 9:28 A.M., the Infection Preventionist/Director of Nurses (IP/DON) reviewed the immunization record with the surveyor, she said she had checked off in the immunizations report sheet dated 10/2024 that the 4 residents had received their Pneumonia vaccines but she did not have actual dates, vaccine name, lot number and expiration date of the vaccines documented in the immunization record. The IP/DON said she relies on responsible parties and resident families to provide the actual documentation of the residents' Pneumonia vaccines at admission. The IP/DON said she does not call the resident's health care providers in the community to obtain this information. She said she relies on the family members and responsible parties to do so. The IP/DON said she is not able to access the MIIS (Massachusetts Immunization Information System) because her access is expired so she cannot verify whether these 4 residents were offered Pneumonia vaccines.

Based on observations and interview, the facility failed to ensure staff members served meals to Residents in the facility's dining room under sanitary conditions with acceptable hand hygiene practices.Findings include:Review of the facility policy titled Feeding Policy, undated, indicated the following:- Feeding Technique: 2. Treat resident with dignity and respect, 3. Wash handsReview of the facility policy titled Hand Hygiene Policy, undated, indicated the following:- After Resident Contact: When? Clean your hands after touching a resident and his/her immediate surroundings when leaving the resident's side.The surveyor made the following observations throughout the survey period in the facility's main dining room:- On 8/5/25 at 12:22 P.M., during lunch, the Activities Assistant was sitting between two Residents at a dining room table. The Activities Assistant was alternating feeding two residents at the same time without performing hand hygiene between feeding each resident. The Activities Assistant then left the table to help another resident at a different table by adjusting his/her shoulders for positioning and then left to get a pillow with her bare hands to further help in positioning. The Activities Assistant then returned to the original two residents and continued to alternate feeding between them, no hand hygiene was done. At 12:36 P.M., the Activities Assistant left from feeding the two residents to help a different resident at a different table with feeding. No hand hygiene was completed.- On 8/6/25 at 8:34 A.M., during breakfast service, a staff member was observed setting up trays for Residents. The staff member touched multiple Resident's straws with bare hands where the Resident's mouth will touch the straw. The Residents were then observed being assisted with meals and drink from the straws where staff touched them with bare hands.- On 8/6/25 at 12:15 P.M., during lunch service, a staff member touched the resident's straw where the mouth will touch with bare hands. The Resident then proceeded to take a sip from the straw.- On 8/6/25 at 12:16 P.M., the Activities Assistant was sitting between two Residents alternating feeding them without performing hand hygiene between feeding each resident. One of the Resident's was observed coughing as the Activities Assistant's hand was near his/her mouth. At 12:19 P.M., the Activities Assistant left the table to assist another Resident at a different with cutting up his/her food using the resident's utensils, no hand hygiene was completed before this. The Activities Assistant then went back to the original table to alternate feeding the two residents, no hand hygiene was performed prior to this. At 12:26 P.M., the telephone rang in the dining room, the Activities Assistant picked up the phone with bare hands and then resumed assisting the two residents with feeding, no hand hygiene was done. The Activities Assistant then left the dining room to get ice cream, and then resumed assisting the two residents with feeding, no hand hygiene was done.- On 8/7/25 at 8:22 A.M., during breakfast service, staff members were observed setting up trays and touched Resident's straws with bare hands where the Resident's mouths would touch the straws. The Residents then proceeded to drink from the straws.During an interview on 8/7/25 at 10:04 A.M., the Housekeeping Manager who was observed assisting residents with meals said she used to be a Certified Nursing Assistant (CNA) in the facility, but she still helps assisting residents with meals. The Housekeeping Manager said staff need wash hands before assisting residents with meals and only one resident should be fed at once, she proceeded to say we (the facility) do not feed two residents at once.During an interview on 8/7/25 at 8:53 A.M., CNA #3 aid staff need to perform hand hygiene before assisting residents with meals and staff should not be touching utensils or straws where the resident's mouth will touch.During an interview on 8/7/25 at 10:41 A.M., CNA #2 said staff need to perform hand hygiene before assisting residents with meals and staff should not be touching utensils or straws where the resident's mouth will touch.During an interview on 8/7/25 at 11:36 A.M., the Activities Assistant said she should be performing hand hygiene between feeding residents, and she should not be feeding two residents at the same time. The Activities Assistant further said she should not be touching straws with her hands where the Resident's mouth will touch, and she said if she walks away from feeding residents then she should wash her hands before resuming feeding assistance.During an interview on 87/25 at 12:31 P.M., the Director of Nursing (DON) said Residents can be fed at the same time but only if the staff member is using different hands. The surveyor shared the dining observations, and the DON said staff should have been performing hand hygiene between feeding residents and upon leaving residents to perform another task. The DON then said staff member's hands should be touching where Resident's mouths will touch when setting up trays.

Based on observations, interviews and record review, the facility failed to maintain a safe environment for one Resident (#22) out of a total sample of 15 residents. Specifically, the facility failed to implement a padded side rail while Resident #22 was in bed to protect from injury.Findings include:Resident #22 was admitted to the facility in August 2023 with diagnoses including dementia and malnutrition.Review of the most recent Minimum Data Set (MDS) assessment, dated 6/30/25, indicated Resident #22 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. On 8/5/25 at 7:23 A.M., and 2:08 P.M., and on 8/6/25 at 6:43 A.M., the surveyor observed Resident #22 in bed with his/her right side rail in place. This right side rail had no padding during each of these observations.Review of Resident #22's physician's order, initiated 8/23/24, indicated:-Padded 1/2 (half) side rail: on right side up when in bed. Review of Resident #22's care plan, revised 1/21/25, indicated the Resident pushes staff away during hands on care. The care plan failed to indicate the use of a padded side rail.During an interview on 8/6/25 at 7:27 A.M., Certified Nurse Assistant (CNA) #2 said Resident #22 flails his/her arms while in bed. CNA #2 said Resident #22 requires a side rail pad on the right side to protect his/her skin from injury. CNA #2 said the side rail pad was not on when she started his/her shift today and so she had just applied it. CNA #2 showed the surveyor the blue side rail pad at this time.During an interview on 8/6/25 at 7:34 A.M., Nurse #2 said Resident #22 has fragile arm skin and requires a pad on his/her right side rail to protect his/her skin. Nurse #2 said it should always be in place when Resident #22 is in bed, but that sometimes CNAs forget to put it back on.During an interview on 8/6/25 at 8:45 A.M., CNA #2 and the surveyor visualized the skin on Resident #22's arms. There were two bruises on his/her left arm. There was one bruise and one scab on his/her right arm. CNA #2 said they were probably caused by Resident #22 flailing his/her arms.During an interview on 8/6/25 at 9:37 A.M., the Director of Nursing (DON) said Resident #22's right side rail pad should have been in place as ordered.During an interview on 8/7/25 at 1:14 P.M., the DON said the facility does not have a policy regarding padded side rails.

Based on observation, record review and interview, the facility failed to ensure staff maintained accurate medical records for one Resident (#14) out of a total sample of 15 Residents. Specifically, the facility documented that the Resident was wearing Geri Sleeves when he/she was not.Findings include:Resident #14 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease and dementia.Review of Resident #14's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is totally dependent on staff for all activities of daily living.The surveyor made the following observations:- On 8/5/25 at 8:23 A.M., 10:35 A.M. and 12:14 P.M., Resident #14 was sitting in his/her wheelchair in the dining room. Resident #14's forearms were visible, no Geri sleeves were being worn.- On 8/6/25 at 7:35 A.M., Resident #14 was observed being wheeled out of his/her room by a Certified Nursing Assistant (CNA) into the dining room. Resident #14's forearms were visible, and no Geri Sleeves were being worn. At 10:22 A.M. and 12:46 P.M., Resident #14 was observed sitting in the dining room in his/her wheelchair, his/her forearms were visible, and no Geri Sleeves were being worn.- On 8/7/25 at 8:22 A.M. and 9:23 A.M., Resident #14 was observed sitting in the dining room in his/her wheelchair, his/her forearms were visible, and no Geri Sleeves were being worn.Review of Resident #14's physician's order dated 2/27/25 indicated the following:- Apply Geri Sleeves to BUE (bilateral upper extremities) every shift, may remove for AM and PM (morning and evening) care and toileting after meals.Review of Resident #14's Kardex (a care card indicating the level of care a resident needs) failed to indicate the usage of Geri Sleeves.Review of Resident #14's pressure ulcer care development care plan dated 11/30/24 indicated the following intervention that was handwritten in:- apply Geri Sleeves to BUE every shift. May remove for AM and PM care.Review of Resident #14's medical record failed to indicate any documentation of Resident #14 removing his/her Geri Sleeves.Review of Resident #14's Treatment Record Sheet on 8/5/25, 8/6/25 and 8/7/25 indicated that staff signed off as Resident #14 wearing Geri Sleeves as ordered by the physician when the Resident was not wearing them.During an interview on 8/7/25 at 10:41 A.M., CNA #2 said if a resident requires Geri Sleeves then a CNA will put them on a resident during morning care. CNA #2 then said Resident #14 does not need Geri Sleeves anymore.During an interview on 8/7/25 at 11:14 A.M., CNA #1 said (with translation assistance from CNA #2) said she provided Resident #14 morning care this morning. CNA #1 then said Resident #14 is totally dependent on care and she did not put Geri Sleeves on Resident #14 and she did not know if the Resident is supposed to wear them.During an interview on 8/7/25 at 12:24 P.M., the Director of Nursing (DON) said Resident #14 should be wearing Geri Sleeves and if he/she is not then staff should not be documenting that he/she is.During an interview on 8/7/25 at 12:40 P.M., Nurse #1 said Resident #14 should be wearing Geri Sleeves and if he/she is not then staff should not be documenting that he/she is.

Based on observations, interviews and record review, the facility failed to provide the necessary activities of daily living (ADLs) for one Resident (#26) out of 15 total sampled residents. Specifically, the facility failed to provide necessary supervision and assistance with eating.Findings include:Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, undated, indicated:-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Dining (meals and snacks).Review of the facility policy titled Supervision of Resident Nutrition, undated, indicated:-Residents needing assistance in eating must be promptly assisted upon being served.Resident #26 was admitted to the facility in December 2024 with diagnoses including a history of aspiration pneumonia (a respiratory infection that occurs when food, saliva, or stomach acid enters the airway accidentally) and dementia.Review of the most recent Minimum Data Set (MDS) assessment, dated 7/7/25, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. This MDS also indicated Resident #26 required supervision or touching assistance with eating.Review of Resident #26's plan of care related to activity of daily living self-care performance deficit, revised 1/29/25, indicated:-EATING: Resident #26 is supervised.Review of Resident #26's plan of care related to nutritional problems, revised 1/29/25, indicated:-Resident has a history of aspiration pneumonia.-Monitor/document/report PRN (as needed) and s/sx (signs/symptoms) of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals.Review of Resident #26's plan of care related to nutrition risk, undated with last goal date of July 2025, indicated Resident #26 had a nutritional risk r/t (related to) swallowing disorder/aspiration risk and had a history of aspiration pneumonia. This plan of care further indicated:-Provide encouragement/cueing/assist with feeding if needed.Review of Resident #26's assessment titled Nutritional Quarterly Assessment, dated 7/16/25, indicated:-Feeding ability: Supervised.Review of Resident #26's current Certified Nurse Assistant (CNA) care card (a form indicating the level of assistance needed for resident care), undated, failed to indicate Resident #26 required supervision or assistance while eating.Review of Resident #26's active physician's order failed to indicate the level of assistance needed with eating.On 8/5/25 at 8:38 A.M., the surveyor observed Resident #26 eating rice crispies cereal in milk, and raisin bread toast alone in his/her room. Resident #26 said staff recently helped him/her with every meal because he/she often coughs during meals and is afraid of choking. Resident #26 said he/she was upset because he/she wants staff to help. On 8/5/25 from 8:42 A.M. to 8:47 A.M., the surveyor observed Resident #26 continue to eat breakfast without any staff within view of the Resident. At 8:47 A.M., the Housekeeping Manager entered Resident #26's room and began to assist him/her with eating. During a follow-up interview on 8/7/25 at 10:14 A.M., the Housekeeping Manager said she often assists with meals and used to be a Certified Nurse Assistant (CNA) in the facility. The Housekeeping Manager said she gets instructions about what type of assistance or level of supervision is required for each Resident from the nurse before she assists them with meals. The Housekeeping Manager said Resident #26 did not require supervision with meals, but since the facility policy is to check on every resident to and assist if necessary, during those rounds she determined Resident #26 was having trouble eating, as he/she does at times, so she began to assist him/her with breakfast on 8/5/25 at 8:47 A.M.On 8/6/25 at 8:24 A.M., Resident #26 had a breakfast tray in front of him/her and was eating raisin bread toast and rice crispies cereal in milk alone in his/her room when Nurse #2 entered the room to administer his/her medications. Resident #26 said he/she had trouble swallowing his/her pills and it took multiple swallow attempts and multiple sips of water to swallow the pills. Nurse #2 then exited the room and Resident #26 continued to eat his/her breakfast alone in the room without any staff within view.On 8/6/25 from 8:36 A.M. until 8:49 A.M., the surveyor observed Resident #26 eating raisin bread toast and rice crispies cereal in milk alone in his/her room without any staff within view of the Resident.On 8/6/25 at 12:12 P.M., the surveyor observed Resident #26 eating a hotdog on a bun, coleslaw, and beans in his/her room without any staff present or within view of the Resident. The Resident's son was present and said staff is supposed to sit with Resident #26 because he/she needs encouragement and assistance to eat. Resident #26's son said that the Resident will often not eat enough of the meal and instead of staff sitting with the Resident and assisting with the meal, they just take the tray away with much of it uneaten. On 8/7/25 from 8:18 A.M. to 8:30 A.M., the surveyor observed Resident #26 eating raisin bread toast alone in his/her room, there was also a bowl of rice crispies cereal in milk in front of him/her. There was no staff within view of the Resident. During this time, several staff members walked past Resident #26's room, but no one looked into the room or checked on the Resident. Resident #26's hands were shaking, and he/she appeared to be having trouble with bringing the raisin bread toast to his/her mouth. Resident #26 coughed six times during this observation.On 8/7/25 at 8:31 A.M., Resident #26 said he/she was coughing while eating and was afraid of choking. Resident #26 said he/she had been coughing for a few days. Resident #26 said he/she had a bad right shoulder and was right-handed, which makes it difficult to feed him/herself. Resident #26 said he/she often gets tired trying to feed him/herself and cannot finish the meal because he/she is too tired to continue. Resident #26 said his/her hands shake and it's difficult to bring the food to his/her mouth. Resident #26 said his/her drinks are too heavy and cannot lift them without assistance. Resident #26 demonstrated this to the surveyor with a full cup of hot coffee, which begun to spill when he/she tried to lift it. Resident #26 further said he/she really wants to eat the rice crispies but cannot because he/she can't find the spoon, which was sitting in the bowl of rice crispies. Resident #26 said he/she has told staff many times that he/she needs assistance with meals, but that staff keep leaving the tray and walking away. Resident #26 said I just wish they would help me eat. During an interview on 8/7/25 at 10:18 A.M., Nurse #1 said resident care needs, such assistance or supervision while eating, is communicated to the CNAs by the CNA care cards and through nursing report. Nurse #1 said if there are changes or increased needs required it is the nurse's responsibility to update both the care card and the Resident care plan. Nurse #1 said the CNA care card and Resident care plan should always match.During an interview on 8/7/25 at 10:39 A.M., Certified Nurse Assistant (CNA) #2 said she consistently cares for Resident #26 and knows him/her very well. CNA #2 said Resident #26 requires a staff member to always be in the room with him/her while eating because he/she requires supervision and assistance with meals. CNA #2 said Resident #26 has trouble eating because he/she has weakness in his/her right arm and his/her hands shake. CNA #2 said Resident #26 not only gets tired during meals but cognitively has trouble with eating and finding things on the tray, such as the spoon.During an interview on 8/7/25 at 10:54 A.M., Nurse #2 said she consistently cares for Resident #26 and knows him/her well. Nurse #2 said if a resident requires supervision with meals, that means someone should always be close by and within view of the resident in case they need help. Nurse #2 said CNAs get resident care information from the CNA care cards but was unsure where they were located. Nurse #2 was unaware that Residents had care plans or where they would be located. Nurse #2 said she had no idea how to find out what level of assistance Resident #26 required with meals but expected the CNAs to check in with each resident each meal and provide what level of care they required. Nurse #2 said she noticed Resident #26 often requested more assistance with meals during the last couple weeks. The surveyor and Nurse #2 reviewed Resident #26's medical record and visualized the care plan. Nurse #2 said they did not match because the care plan indicated Resident #26 should be supervised while eating, but the care card did not indicate the need for supervision. Nurse #2 said she was unaware of who is responsible for updating the Resident's care plan and ensuring that they matched the Resident's CNA care card.During an interview on 8/7/25 at 11:35 A.M., the Director of Nursing (DON) said the care plan is the most accurate reflection of care needed, and interventions listed on it should always be followed, or revised as necessary. The DON said CNA care cards and the care plan should always match and nursing should update them as necessary. The DON said if the care plan stated Resident #26 required supervision with eating, it should have been provided. The DON defined supervision as the Resident always being within direct view of a staff member while eating.

Based on observations, record review and interview, the facility failed to obtain a physician's order for treatment for a newly developed stage 2 pressure ulcer for one Resident (#13) out of a total sample of 15 Residents. Specifically, the facility failed to obtain an order for zinc oxide cream before using it to treat a newly developed stage 2 pressure ulcer on Resident #13's right buttock.Findings include:Review of the facility policy titled Physician Order Policy, undated, indicated the following:- Policy Statement: All physician orders must be documented, dated and signed by a licensed practitioner authorized to prescribe in accordance with applicable laws and facility protocols.- Procedure: Order Types - Physician orders may include: Medication orders, Treatment and therapy orders.- Documentation: Orders must be promptly transcribed to the resident's medical record and Medication Administration Record (MAR)/Treatment Administration Record (TAR).- All orders must be reviewed by the charge nurse before implementation.Review of the facility policy titled Pressure Ulcer Policy and Treatment Protocol, undated, indicated the following:- Stage II: Partial Thickness Skin Loss Involving Epidermis. - Call Physician or NP, Document on skin condition report weekly, and treatment record. Nurses notes as needed.Resident #13 was admitted to the facility in March 2025 with diagnoses including Parkinson's disease and dementia.Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident has a Brief Interview for Mental Status score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident was dependent on staff for all activities of daily living, had one stage 2 pressure ulcer and was at risk of developing pressure ulcers.During the survey period, Resident #13 was observed sleeping in his/her bed with an air mattress pump operating at the correct setting.Review of Resident #13's record indicated a document titled Wound or Pressure Ulcer Identification & Progress Notes with a date of onset of 7/28/25 which indicated the following:- Location: R (right) inner buttock- Date: 7/28/25, size: 1.5 cm Length x 0.5 cm width x 0.1 depth, deepest anatomical stage 2 (circled). Handwritten under the section periwound states inner buttocks red. Under the Comments sections indicated the following handwritten notes: 1.5 x 0.5 x 0.1 open area noted R inner buttock no drainage, area moist.- Date: 8/4/25: size 0.75 cm length x 0.25 width x 0.1 depth, deepest anatomical stage 2 (circled). Handwritten under the section periwound states moist slight redness.Review of Resident #13's treatment and medication record sheets for the month of August 2025 failed to indicate any treatment for the documented stage 2 pressure ulcer on the right buttock.Further review of Resident #13's treatment record sheets for July 2025 indicated the following order: L (left) buttocks apply zinc QD (every day) until healed. The order was documented as being healed on 7/24/25 and was discontinued.Review of Resident #13's weekly skin checks dated 7/29/25 and 8/5/25 indicated that Resident #13's skin was intact with no abnormalities documented.Review of Resident #13's care plan for potential for pressure ulcer development related to immobility dated 4/1/25 indicated the following:- Focus: 7/28/25 open area R inner buttock (this was handwritten in)- Goal: area will heal without complications (this was handwritten in)- Interventions: Air mattress on bed, check function and setting as ordered (this was handwritten in).Review of Resident #13's document titled Norton Plus Pressure Ulcer Scale indicated that the Resident scored a 10 on 6/16/25, the document stated that a score of 10 or below indicated high risk of pressure ulcers.During an interview on 8/6/25 at 11:09 A.M., Nurse #1 and Nurse #2 said Resident #13 had a new open area to his/her buttock that has been there for about a week, they said they are unsure if it is open. Nurse #1 and Nurse #2 said staff put on zinc when they change the Resident.During an observation of Resident #13's wound on 8/6/25 at 1:27 P.M., with the wound nurse and Nurse #2, the surveyor observed a pea-sized, dark pink open wound bed area with residual white surrounding it on the Resident's right buttock, no dressing was on the area. Nurse #2 said the area is open and has been open for over a week. Nurse #2 said when it opened she did not obtain a new order for zinc oxide cream. The Wound Nurse then said she is responsible for measuring wounds and she was notified on 7/28/25 that the wound opened and she assessed it. The Wound Nurse then said she did not notify the provider to get any new physician's orders because it is not her responsibility, it is the floor nurse's responsibility. The Wound Nurse then told the surveyor the right buttock wound is an open stage 2 wound and she asked the nurses who told her they previously had a physician's order for zinc but it was discontinued on 7/24/25 and no new order was reinstated when this wound open on 7/28/25 but an order should have been requested from the provider.During an interview on 8/6/25 at 1:27 P.M., the Director of Nursing (DON) said if a change in skin is noted then a nurse should notify the provider and get a physician's order and the physician's order needs to be documented in the Resident's record. The DON said because Resident #13's wounds open so frequently, she did not think a physician's order was needed for Resident #13's stage 2 pressure ulcer on his/her right buttock.During an interview on 8/7/25 at 7:10 A.M., Certified Nursing Assistant (CNA) #4 said she has worked in the facility for four years and she is Resident #13's primary CNA. CNA #4 said she applied zinc oxide cream to Resident #13's coccyx as a preventative measure, CNA #4 pulled out the zinc oxide cream from the Resident's dresser to show the surveyor. CNA #4 said if she were to notice any new skin conditions she would tell a nurse, CNA #4 said she does not know of any recent skin abnormalities on Resident #13.During a telephone interview on 8/7/25 at 9:18 A.M., the Nurse Practitioner (NP) said if any new skin area or pressure ulcer is observed on a Resident then the NP or Medical Doctor (MD) needs to be notified to obtain a physician's order for treatment, and she relies on the nurses to contact her. The NP told the surveyor she does not recall anyone telling her that Resident #13 has developed a skin opening on his/her right buttock. The NP said she was in the building on 7/29/25 but did not see Resident #13 because she did not know about the right buttock skin opening.During a telephone interview on 8/7/25 at 9:27 A.M., the facility's Medical Director (MD) said he would expect to be contacted if a Resident developed any new open skin area so he can put in a physician's order for treatment. The MD then said he does not remember being contacted by the facility regarding Resident #13's right buttock pressure ulcer and the facility should be documenting when they do contact the MD or NP. The MD then said if the facility is using zinc oxide as the primary treatment for a pressure ulcer then they need to contact the MD or NP to obtain an order so they can track the usage of it and the progress of the skin condition.During an interview on 8/7/25 at 10:10 A.M., Nurse #1 said she does not think a physician's order is needed to use zinc oxide cream as treatment for Resident #13's pressure ulcer.During an interview on 8/7/25 at 11:23 A.M., the DON said when nurses perform weekly skin checks it should be from a Resident's head to toe, therefore the right buttock area should have been documented. The DON then said she was only aware of Resident #13's left buttock pressure ulcer which healed in June. The DON said she just inputted an order for zinc yesterday but there should have been one implemented when the area was first identified.During the interview with the DON, the DON provided a fax from the MD dated and time-stamped 8/7/25 at 11:00 A.M. indicating that the right buttock area responds well to zinc ointment and should be continued as the treatment.

Based on observations, record review and interview, the facility failed to implement a physician's order for the use of Geri Sleeves as ordered for one Resident (#14) out of a total sample of 15 Residents. Specifically, the facility failed to ensure Resident #14 was wearing Geri Sleeves as indicated by the physician's order.Findings include:Review of the facility policy titled Physician Order Policy, undated, indicated the following:- Policy Statement: All physician orders must be documented, dated and signed by a licensed practitioner authorized to prescribe in accordance with applicable laws and facility protocols.- Procedure: Order Types - Physician orders may include: Medication orders, Treatment and therapy orders.- Documentation: Orders must be promptly transcribed to the resident's medical record and Medication Administration Record (MAR)/Treatment Administration Record (TAR).- All orders must be reviewed by the charge nurse before implementation.Resident #14 was admitted to the facility in December 2023 with diagnoses including Alzheimer's disease and dementia.Review of Resident #14's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 3 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is totally dependent on staff for all activities of daily living.The surveyor made the following observations:- On 8/5/25 at 8:23 A.M., 10:35 A.M. and 12:14 P.M., Resident #14 was sitting in his/her wheelchair in the dining room. Resident #14's forearms were visible, no Geri sleeves were being worn.- On 8/6/25 at 7:35 A.M., Resident #14 was observed being wheeled out of his/her room by a Certified Nursing Assistant (CNA) into the dining room. Resident #14's forearms were visible, and no Geri Sleeves were being worn. At 10:22 A.M. and 12:46 P.M., Resident #14 was observed sitting in the dining room in his/her wheelchair, his/her forearms were visible, and no Geri Sleeves were being worn.- On 8/7/25 at 8:22 A.M. and 9:23 A.M., Resident #14 was observed sitting in the dining room in his/her wheelchair, his/her forearms were visible, and no Geri Sleeves were being worn.Review of Resident #14's phsyician's order dated 2/27/25 indicated the following:- Apply Geri Sleeves to BUE (bilateral upper extremities) every shift, may remove for AM and PM (morning and evening) care and toileting after meals.Review of Resident #14's Kardex (a care card indicating the level of care a resident needs) failed to indicate the usage of Geri Sleeves.Review of Resident #14's pressure ulcer care development care plan dated 11/30/24 indicated the following intervention that was handwritten in:- apply Geri Sleeves to BUE every shift. May remove for AM and PM care.Review of Resident #14's medical record failed to indicate any documentation of Resident #14 removing his/her Geri Sleeves.During an interview on 8/7/25 at 10:41 A.M., CNA #2 said if a resident requires Geri Sleeves then a CNA will put them on a resident during morning care. CNA #2 then said Resident #14 does not need Geri Sleeves anymore.During an interview on 8/7/25 at 11:14 A.M., CNA #1 said (with translation assistance from CNA #2) said she provided Resident #14 morning care this morning. CNA #1 then said Resident #14 is totally dependent on care and she did not put Geri Sleeves on Resident #14 and she did not know if the Resident is supposed to wear them.During an interview on 8/7/25 at 12:24 P.M., the Director of Nursing (DON) said Resident #14 should be wearing Geri Sleeves as ordered. The DON said Resident #14 has purpura (purple spots or patches on the skin or mucous membranes, caused by bleeding under the skin) and his/her skin is very frail and thin, and the Geri Sleeves are meant to protect his/her skin from injury.During an interview on 8/7/25 at 12:40 P.M., Nurse #1 said Resident #14 should be wearing Geri Sleeves if that is what the physician's order says. Nurse #1 said CNAs and nurses put them on Resident #14 and if the Resident removes them it needs to be documented.REF F842

Based on observation and interview the facility failed to ensure infection control practices were maintained to prevent the spread of infection during 1) medication pass and 2) in the dinning room. Findings include: Review of the facility policy titled Nursing Equipment Cleaning Protocol and dated as revised 3/1/21, indicated that blood pressure (BP) cuffs and rolling BP monitor will be cleaned between residents with bleach germicidal wipes or 70% isopropyl alcohol. 1a. During medication pass on 4/19/23, at 8:11 A.M., the surveyor observed Nurse #1 bring the rolling BP monitor from the hall into a resident's room and without cleaning the BP cuff and the oximeter (used to take the oxygen level in the blood, SpO2) Nurse #1 obtained the BP and SpO2 of the resident. Nurse #1 then placed the contaminated rolling BP monitor unit back in the hall without cleaning it. 1b. During medication pass on 4/19/23, at 8:32 A.M., the surveyor observed Nurse #1 bring the rolling BP monitor from the hall into a resident's room and without cleaning the BP cuff and the oximeter. Nurse #1 obtained the BP and SpO2 of the resident. 1c. During medication pass on 4/19/23, the surveyor observed Nurse #1 place two fingers on the foil opening in the back of the medication card and guide the pills exiting the medication card with her fingers, contaminating all of the medications contained in medication cards that were dispensed during medication pass. During an interview on 4/19/23, at 8:42 A.M., Nurse #1 acknowledged that she had not disinfected the BP cuff or the oximeter between resident use. Nurse #1 then acknowledged placing her fingers in a manner that caused the medications exiting the medication cards to touch her fingers. 2. On 4/19/23, at 11:27 A.M. the surveyor observed Certified Nurse's Aide (CNA) #1 bending down to speak to a resident in the dining room, within 6 inches of the resident's face. The surveyor also observed CNA #1 with her mask beneath her mouth and nose during the encounter with the resident. During an interview on 4/19/23, at 11:27 A.M. CNA #1 acknowledged that her mask was not covering either her mouth or her nose and that she was very close to the resident's face.

Based on observation and interview, the facility failed to provide a dignified dining experience for 2 Residents (#11 and #4) out of a total sample of 15 residents. Findings include: Review of the undated facility policy, titled Feeding Policy, indicated the following: *Treat residents with dignity and respect *Assure proper positioning of resident 1. Resident #11 was admitted in September, 2018 with diagnoses including Alzheimer's Disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 was unable to participate in a Brief Interview for Mental Status (BIMS) as the Resident is seldom/never understood. Further review of the MDS indicated the Resident is totally dependent on staff for eating. Review of Resident #11's Activities of Daily Living care plan indicated the Resident is dependent on staff for eating. Review of Resident #11's Nursing Summary, dated 03/20/23, indicated the Resident is totally dependent on staff for eating. During an observation on 04/19/23 at 08:07 A.M., a staff member was feeding Resident #11 while standing over the Resident's bed. The bed was not raised, the staff member was not at the eye level of the Resident, and the staff had to bend at the waist in order to reach down to feed the resident. During an observation on 04/19/23 at 11:59 A.M., a staff member was feeding Resident #11 while standing over the Resident's bed. The bed was not raised, the staff member was not at the eye level of the Resident, and the staff had to bend at the waist in order to reach down to feed the resident. During an interview on 4/20/23 at 8:46 A.M., the Director of Nursing (DON) said staff feeding residents must be either sitting or standing with the bed raised so that the Resident and staff member are at eye level with each other. 2. Resident #4 was admitted in September, 2021 with diagnoses including Dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #4 scored a 10 out of 15 on a Brief Interview for Mental Status (BIMS), which indicates moderate cognitive impairment. Further review of the MDS indicated the Resident is totally dependent on staff for eating. Review of Resident #4's Activities of Daily Living care plan indicated the Resident is dependent on staff for eating. Review of Resident #4's Nursing Summary, dated 03/16/23 indicated the Resident is totally dependent on staff for eating. During an observation on 04/19/23 at 08:22 A.M., a staff member was feeding Resident #4 while standing over the Resident's bed. The bed was not raised, the staff member was not at the eye level of the Resident, and the staff had to bend at the waist in order to reach down to feed the resident. During an observation on 04/20/23 at 8:21 A.M., a staff member was feeding Resident #4 while standing over the Resident's bed. The bed was not raised, the staff member was not at the eye level of the Resident, and the staff had to bend at the waist in order to reach down to feed the resident. During an interview on 4/20/23 at 8:46 A.M., the Director of Nursing (DON) said staff feeding residents must be either sitting, or standing with the bed raised so that the Resident and staff member are at eye level with each other.

Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One out of one nurse observed made 2 errors in 26 opportunities on one of two units resulting in a medication error rate of 7.69%. These errors impacted 2 Residents (#11 and #7) out of 4 residents observed. Findings include: Review of the facility policy titled 6-1 Medication Administration Specific Procedures and dated 1/1/23, indicated that the nurse is to pour the correct number of tablets or capsules into the medication cup. 1. Resident #8 was admitted to the facility in January 2023 with diagnoses including type 2 diabetes, chronic back pain and high blood pressure. Review of the doctor's orders dated April 2023 indicated an order for Metformin (used to treat diabetes) 500 mg (milligrams) two tablets (1,000 mg) by mouth twice daily at 8:00 A.M. and 8:00 P.M. During medication pass on 4/19/23, at 8:32 A.M., the surveyor observed Nurse #1 give Metformin 500 mg one tablet. During an interview on 4/19/23, at 9:02 A.M., Nurse #1 acknowledged that she omitted the second tablet of Metformin 500 mg by mistake. 2. Resident #18 was admitted to the facility in March 2021 with diagnoses including heart disease, high blood pressure and chronic kidney disease. Review of the doctor's orders dated April 2023 indicated an order for Metoprol TAR (used to treat high blood pressure) 25 mg (milligrams) one tablet by mouth twice daily at 8:00 A.M. and 8:00 P.M. During medication pass on 4/19/23, at 8:11 A.M., the surveyor observed Nurse #1 omit the medication Metoprol TAR 25 mg. Nurse #1 did not tell the surveyor that the medication Metoprol TAR was being held secondary to a low SBp (systolic blood pressure). During an interview on 4/19/23, at 9:02 A.M., Nurse #1 said she omitted the Metoprol because Resident #18's systolic blood pressure (SBp) was below 100 mgHg (milligrams of mercury). Nurse #1 then acknowledged that the order for the medication did not include the directive to hold the medication for an SBp below 100 mgHg.

Based on observation, record review and interview the facility failed to change a wound dressing, as ordered, for 1 Resident (#12) out of a total 15 sampled residents. Findings include: Review of facility policy titled 'Wound Care Monitoring and Documentation' undated, indicated the following: Procedure: * F. Dressings shall be assessed each shift to ensure the wound is clean, dry and dressing is intact and dressing care documented in the progress note section of the medical record. * G. The dressing will be dated, timed and initialed by the nurses at the time of application and/or change. Resident #12 was admitted to the facility in August 2016 with diagnoses including, congestive heart failure, kidney disease, dementia and failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/16/23, revealed that on the Brief Interview for Mental Status exam (BIMS). Resident #12 scored a 3 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #12 had no behaviors and did not reject care. During an observation on 4/19/23 at 7:46 A.M., Resident #12 was seated in his/her room in a wheelchair with a bandage on his/her right ankle, dated 4/18/23. During an observation on 4/20/23 at 7:00 A.M., Resident #12 was in his/her bed with a bandage on his/her right ankle, dated 4/18/23. Review of the current physician order's for Resident #12 indicated an order, for Treatment to right lower leg stasis ulcer, normal saline wash, apply emulsion dressing cover with non adhesive dressing and kerlix daily until healed. Review of the Treatment Administration Record indicated, on 4/19/2023 there was no documentation of the treatment being completed. Review of Care plan indicated the following: - Actual skin breakdown related to open area right lower extremity stasis ulcer dated 2/23; interventions- Treatment as ordered. During an interview with Nurse #2 on 4/20/23 at 7:42 A.M., she said dressing changes should occur daily or per the physician's orders. During an interview with the Director of Nursing on 4/20/23 at 7:56 A.M., she said that it was her expectation that dressing changes should be done according to the physician orders.

Based on observation, record review and interview, the facility failed to ensure plan of care for use of side rail was followed for 1 Resident (#25) out of a total 15 sampled residents. Findings include: Review of facility policy titled 'Bed Rail Use Policy', undated indicated the following: Procedure: * f. The facility will document ongoing need for the use of a bed rail. * j. Resident care plan will include use of bed rails as assessed. - Based upon the individualized comprehensive assessment if it is determined that bed rails will be indicated to assist resident in maintaining or improving functional ability and do not constitute a restriction as defined as a restraint, bed rails may be utilized and care planned with consent of the resident/ resident representative to meet the individualized need. Resident #25 was admitted to the facility in April 2022 with diagnoses including dementia, anxiety disorder, glaucoma bilateral. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS further indicated he/she required extensive assist of one person for bed mobility and limited assistance of one person for transfers. During an observation on 4/19/23 at 7:28 A.M., Resident #25 was observed laying in his/her bed with bilateral half bed rails down. During an observation on 4/20/23 at 6:50 A.M., Resident #25 was observed laying in his/her bed with bilateral half bed rails down. Review of side rail assessment tool dated 3/27/23 indicated the following: - Side rails top right and left of the resident bed. -Side rails are used at all times when resident is in bed. Review of care plan dated 4/23 indicated the following: - Problem: physical mobility impaired: related to weakness and cognitive deficits related to dementia. - Interventions: Right and left half side rails up when in bed to facilitate bed mobility. During an interview with Nurse #2 on 4/20/23 at 7:33 A.M., she said she did not know if Resident #25 needed side rails. She further said that Resident #25 gets assistance from staff when getting in and out of bed. During an interview with the Director of Nursing on 4/20/23 at 7:50 A.M., she said Resident #25 was independent and should not have the side rails. She further said that Resident #25 should have been assessed to determine if he/she does no longer require side rails in place.

Based on observation and interview the facility failed to (1) ensure staff wore the required Personal Protective Equipment (PPE) and (2) conduct COVID-19 screening of a visitor, upon arrival to the facility. Findings include: The facility policy titled Use of Personal Protective Equipment (PPE), undated, indicated the following: * All [NAME] personnel should wear a face mask while they are in the facility and eye protection when providing direct care to residents. * See updated Department of Public Health (DPH) guidance 3/2/22. The facility policy titled Visitor Policy During COVID-19 Pandemic, revised Sept. 2021, indicated the following: 1. All individuals will be screened before entering the building beyond the nurse's station. 2. Individuals will be screened for elevated temperature, cough, SOB (shortness of breathe), myalgia, chills or new onset of loss of smell or taste. 3. All individuals must wear a mask while they are in the building regardless of vaccination status. On 3/16/22, at 1:30 P.M., the surveyors observed a staff person from the kitchen twice, walk out of the kitchen and walk up to the resident units to collect dirty food bins. The entire time he wore no face mask. On 3/16/22, at 1:49 P.M., the surveyors observed a visitor enter the facility onto the 1st floor resident unit. The visitor put on a facemask, took her temperature, then entered the facility into a resident area. There were no staff members at the nursing station, or within the vicinity, to instruct the visitor to fill out the daily symptom attestation for COVID-19 form, or to screen the visitor for signs or symptoms of COVID-19. On 3/17/22, at 11:38 A.M., the Food Service Director said that it was the expectation that kitchen staff wear a mask, at all times, when anywhere in the facility except the kitchen. On 3/17/22, at 12:32 P.M., the Nursing Home Administrator said that it was the expectation that visitors follow the instructions, on the sign on the front door of the facility. She also said that the sign instructs visitors to ring the bell at the front door and not enter the facility until they are screened for COVID-19 signs and symptoms by the nurse on the 1st floor.

Based on observation, interview and record review the facility failed to ensure the plan of care for two Residents (#17 and #21) was followed out of a total 12 sampled. Findings include: The facility policy titled Activities of Daily Living (ADLs, Supporting, undated, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. 1.) For Resident #17, the facility failed to provide the required supervision with meals. Resident #17 was admitted to the facility in January 2021, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/22, revealed that on the Brief Interview for Mental Status (BIMS) exam Resident #17 scored a 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #17's vision was Highly impaired-object identification in question, but eyes appear to follow objects, that Resident #17 did not reject care and required supervision with eating. On 3/16/22, at 7:55 A.M., a staff person set up Resident #17's meal tray on a tray table in front of him/her, told Resident #17 where items were on the tray and then exited the room, leaving Resident #17 unsupervised for the entire meal. Review of the medical record on 3/16/22, at 9:10 A.M., the following was indicated: * A visual impairment care plan, reviewed 1/2022, that indicated Resident #17 was legally blind, with the intervention Resident requires staff assistance with ADL's related to decreased vision. * A self care deficit care plan, reviewed 1/2022, that indicated Resident #17 had a self care deficit related to eating, with the intervention Resident eats with staff supervision 1:8 , cueing encouragement. Resident is legally blind and requires tray set up and description of location of items on the tray by staff. Resident may be unable to find items or not eat items because he/she cannot see them, requiring staff cueing to complete meals. * The past 2 months of clinical nurse progress notes failed to indicate Resident #17 refused supervision with meals. On 3/16/22 at 8:26 A.M., Resident 17 said that it was very frustrating because I don't get the help I need, my hands don't work like they used to to hold onto things and I have never in my life had to eat food with my hands, but I do all the time now, and it is embarrassing. On 3/17/22, at 7:56 A.M., the surveyor observed Certified Nursing Assistant (CNA) #1 bring Resident #17's breakfast tray to him/her. CNA #1 instructed Resident #17 where items were on the tray and walked out, leaving Resident #17 unsupervised for the entire meal. * At 8:10 A.M., the surveyor observed Resident #17 accidentally knock over and spill a cup of water all over his/her tray and lap. On 3/17/22, at 11:03 A.M., CNA #1 said that Resident #17 was blind and that when she brings Resident #17 his/her meals she tells him/her where everything is on the tray but does not stay with him/her. CNA #1 also she said that she had not been instructed that Resident #17 needed supervision with meals. On 03/17/22, 11:18 A.M., Nurse #1 said that she knows that Resident #17 needs to be supervised with her meals, but that she is only one person and there are a lot of residents that also need supervision so she just checks in on him/her. The surveyor shared the observation of Resident #17 spilling the drink on the tray and him/herself, and Nurse #1 responded that is why she needs someone there, sometimes he/she can do it and sometimes he/she needs to be fed. 2.) For Resident #21 the facility failed to provide the required supervision with meals. Resident #21 was admitted to the facility in August 2018, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the most recent Minimum Data Set (MDS) assessment, dated 2/14/22, revealed that on the Brief Interview for Mental Status (BIMS) exam Resident #21 scored a 1 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #21 required setup and supervision for meals. On 3/16/22, at 7:55 A.M., the surveyor observed a staff person set up Resident #21's breakfast tray and on a tray table directly in front of him/her and exit the room. No staff were present to supervise the meal. Review of the medical record on 3/16/22, at 8:59 A.M., the following was indicated: * An Activities of Daily Living (ADL) care plan indicating Resident #21 eats with staff supervision 1:8 cueing/encouragement. * The last three quarterly nutrition assessments dated 9/18/21, 12/1/21 and 2/14/22 indicated that Resident #21's required supervision with dining. * The last two months of nurse clinical progress notes failed to indicate Resident #21 refused supervision or cueing with meals. On 3/17/22, at 8:07 A.M., the surveyor observed a nurse deliver a breakfast to Resident #21 in his/her room. The nurse set up the meal tray and exited the room, leaving Resident #21 unsupervised for the meal. On 3/17/22, at 11:06 A.M. Resident #21's Certified Nursing Assistant (CNA) #1 said that Resident #21 was able to feed him/herself, but that he/she sometimes falls asleep while he/she's eating and needs reminders to eat his/her meal. CNA #1 also said that she had not been told Resident #21 required supervision with meals. On 3/17/22, 11:17 AM Nurse #1 said that she knows that Resident #21 needs to have cues and supervision with her meals, but that she is only one person and there are a lot of residents that also need cues and supervision so she just checks in on her.

Based on observation, record review and interview the facility failed to identify and report a bruise of unknown origin to the State Agency for 1 Resident (#7) out of a total sample of 12 residents. Findings include: Review of the facility's policy, entitled Suspected adult, disabled resident or elderly abuse/neglect/exploitation dated as revised 3/8/17, indicated the following under procedure: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #7 was admitted to the facility in February 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set assessment dated [DATE], indicated that Resident #7 scored 10 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. Further review indicated that Resident #17 required extensive assistance from staff for bed mobility, bathing, dressing and personal hygiene. On 3/16/22, at 8:50 A.M., the surveyor observed Resident #7 resting in his/her bed. Resident #7's right forearm was observed to have a circular purple area approximately four inches in length covering the width of his/her forearm. The area had a small red dot within the purple area. On 3/16/22, at 2:25 P.M., the surveyor observed Resident # 7 resting in bed. His/her right forearm was observed to have a large purple area with a small red dot within the purple area. On 3/16/22, the surveyor observed staff assisting Resident #7 throughout the 7:00 A.M. -3:00 P.M., shift. Review of the medical record indicated that Resident #7's weekly skin check sheets dated 3/4/22, and 3/11/22, did not indicate any skin injury areas. Further review of Resident #7's medical record indicated in a nursing monthly progress note dated 3/15/22, Resident #7's skin was dry and intact. During an interview on 3/16/22, at 4:41 P.M., Nurse #2 said that Resident #7 requires full care and mostly prefers to stay in bed. Nurse #2 said that staff provide incontinent care and address Resident #7's needs throughout the day. Nurse #2 said she did not receive in shift change report information about Resident #7's skin. At this time Nurse #2 and the surveyor went to see Resident #7 who was resting in bed. Nurse #1 observed Resident #7's right forearm and said it was a purple bruise and was unknown as to how it occurred. Nurse #2 then asked Nurse #3 to look at the area on Resident #7's right arm. On the way to Resident #7's room Nurse #3 said staff should have pointed it out. Nurse #3 looked at Resident #7's arm and said is was a bruise but could not tell the age of it. Nurse #3 said she would report it to the administrator. Nurse #3 said Resident #7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/17/22, at 10:55 A.M., the Administrator said staff are to report any incidents involving a resident, including bruises. The Administrator said she did not report the bruise to the State Agency. She said she interviewed Resident #7 after the bruise was brought to her attention and that Resident #7 said that he/she did not know what happened to his/her arm and the resident denied that anyone hurt him/her. The Administrator said she would be continuing to investigate the bruise and had five days to complete a report.

Based on observation and interview the facility failed to ensure the dignity and privacy of 1 Resident (#26) while urinating, out of a sample of 12 residents. On 3/16/22, at 7:55 A.M., the surveyor observed Resident #26 in the doorway of his/her bedroom urinating, in full view of passers by. Staff walked by the room, twice, passing breakfast to other residents without intervention. On 3/17/22 at 7:40 A.M., the surveyor observed from the hallway, Resident #26 urinating. Staff passed by the resident's room twice with no intervention. Review of facility policy, undated, indicated 2. GNRC ([NAME] Nursing and Rehabilitation Center) makes every effort to assist residents in exercising their rights and to assure that the resident is always treated with respect, dignity and kindness. On 3/17/22, at 9:52 A.M., Certified Nurse's Aide (CNA) #1 said that to ensure privacy, staff should close the resident's door or pull the privacy curtain for resident's who urinate privately. On 3/17/22, at 10:55 A.M., the Administrator acknowledged that staff should re-direct residents if they are exposing themselves to others from their doorway, pull the curtain or ask to close the door.

Based upon observation and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety on 1 of 2 resident units during meal tray pass. Findings include: The facility policy titled Safe Food Handling, undated, indicated the following: * All food purchased, stored and distributed is handled with accepted food-handling practices. * Food is not stored, prepared, handled and/or consumed in any area in which food may be contaminated, particularly around blood, body fluids or hazardous chemicals. On 3/16/22, the surveyor observed the following on the 2nd floor unit at lunchtime: * At 12:21 P.M., a Certified Nursing Assistant (CNA) removed a finished/contaminated lunch tray from a resident room and placed it on the food cart, above 2 unserved lunch trays. The CNA cleared the dirty dishes off the tray and placed them in a plastic bin that was on the cart below the 2 un-served lunch trays; * At 12:22 P.M., the CNA then removed one of the clean trays from the cart and served it to a resident. * At 12:24 P.M., the CNA removed a finished/contaminated lunch tray from another resident room and placed it on the food cart, above the 1 un-served lunch tray. The CNA then cleared the dirty dishes off of the tray and placed them in a plastic bin that was on the cart below the 2 un-served lunch trays; * At 12:25 P.M., after clearing off the dirty tray, and without performing hand hygiene, the CNA picked up the remaining resident tray and served it to a resident. On 3/17/22, at 8:00 A.M., a CNA was observed passing out breakfast trays. She delivered the trays one by one, and after exiting each resident room, placed the contaminated plate covers, from the trays she served, and placed them on the cart beside the un-served breakfast trays. During an interview with the Food Service Director (FSD) on 3/17/22, at 11:27 A.M., the surveyor shared observations of cross contamination between dirty and cleans trays. The FSD said that there was a shelf on the unit that the staff were expected to utilize for dirty/contaminated trays and service items.

Based on observation, interview and record review the facility failed to offer or provide assistance with feeding and drinking to one Resident (#19), who was totally dependent on staff, out of a total 12 sampled residents. Findings include: The facility policy titled Activities of Daily Living (ADLs), Supporting, undated, indicated the following: * Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #19 was admitted to the facility in December 2020, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the most recent Minimum Data Set (MDS) assessment, dated 2/4/22, revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #19 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #19 required extensive physical assistance from staff for eating. On 3/16/22, at 7:49 A.M., the surveyor observed Resident #19 asleep in bed. A staff person placed a breakfast tray on a tray table, out of reach, and exited the room. The staff person did not attempt to wake Resident #19, nor did she offer to assist with feeding. The surveyor continued to make the following observations: * At 8:02 A.M., the Nurse (#1) entered and exited the room. Nurse #1 did not attempt to wake Resident #19, nor did she offer to assist Resident #19 with feeding. * At 8:11 AM a Certified Nursing Assistant (CNA) #1 briefly entered then exited the room. CNA #1 did not attempt to wake Resident #19, nor did she offer to assist Resident #19 with feeding. * At 8:17 A.M., Nurse #1, passed by the room, briefly stopping to look in the room, then continued walking down the hall. Nurse #1 did not attempt to wake Resident #19, nor did she offer to assist Resident #19 with feeding. * At 8:23 A.M., a CNA entered and then exited Resident #19's room. The CNA spoke to Nurse #1 and asked about Resident #19's feeding needs. The surveyor overheard Nurse #1 say to the CNA Resident #19 does not eat anymore, I don't know why they give him/her a tray. During a record review on 3/16/22 at 8:41 A.M., the following was indicated: * An ADL care plan, dated 2/2022, with an intervention Resident eats with staff assistance. Resident is on aspiration precautions related to dysphasia and requires feeding assistance by staff. May participate in eating, but is not consistent. * A behavior care plan, dated 2/2022, failed to indicate Resident #19 had any behavior of refusing assistance with eating or drinking. * A nutrition care plan, revised 3/2022, that indicated Resident #19 required assist with eating. * A swallowing care plan, dated 2/2022, that indicated Resident #19 was fed by staff. * The most recent care plan summary review, dated 2/11/22, indicated that Resident #19 eats with staff assist. * The March 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22, between 11:57 P.M., and 12:33 P.M., the surveyor observed Resident #19 in bed, in his/her room. Two CNA's were present in the room several times during that time however neither offered or attempted to assist Resident #19 with eating. On 3/17/22, between 7:52 A.M., 8:43 A.M., the surveyor observed Resident #19's tray was on a cart in the hallway. Staff never brought the breakfast tray to Resident #19, or offered to assist him During an interview on 3/17/22, at 8:43 A.M., Nurse #1 said that Resident #19's tray was still on the cart because she was a feeder. On 3/17/22, at 8:59 A.M., the surveyor accompanied Nurse #1 to Resident #19's room. Nurse #1 offered Resident #19 Orange Juice, and Resident #19 nodded his/her head yes. Nurse #1, then assisted Resident #19, and Resident #19 drank the orange juice.

Based on interview, document review and observation, the facility failed to follow infection control procedures to contain the COVID-19 infection. 1) a Rehabilitation Staff did not wear a gown or eye protection while providing treatment to a quarantined resident (Resident #1) in their bedroom; 2) an Activity Aide did not wear eye protection while interacting with Resident #2 and Resident #3, both of whom had a COVID-19 negative status and 3) Certified Nurse Aide (CNA) #1 failed to wash or sanitize her hands after touching a bathroom door or before donning gloves and then touched a coffee carafe and cups, creating a risk for possible spread of infections. Findings included: Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, published by the Centers for Disease Control, dated 7/15/20, indicated: 1) when caring for a resident with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection personnel should keep the bedroom door closed, and health care personnel (HCP) entering the bedroom should use a facemask, gown, gloves and eye protection; 2) HCP working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters; 3) HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE (personal protective equipment), including gloves. 1) The Facility's COVID-19 listing, dated 10/20/20, indicated Resident #1 had not tested positive to [MEDICAL CONDITION]. During observations on 10/20/20 at 10:30 A.M. and at 10:50 A.M., a Rehab Staff Member provided treatment to Resident #1 in his/her bedroom. During both observations Resident #1's bedroom door was fully open and the Rehab Staff Member sat in a chair approximately three feet from Resident #1. The Rehab Staff Member wore a mask, but did not wear eye protection or gown. Resident #1's bedroom door had a sign affixed indicating full personal protective equipment was required on entry. During an interview with the Administrator on 10/20/20 at 11:30 A.M., she said that Resident #1 was in quarantine at this time because he/she recently transferred from the hospital. 2) The Facility's COVID-19 listing, dated 10/20/20, indicated Resident #2 and Resident #3 had not tested positive for [MEDICAL CONDITION]. During observations on 10/20/20 at 10:25 A.M. and 10:39 A.M., the Activity Aide sat with Resident #2 and Resident #3 in their bedroom, approximately three feet apart from each other. The Activity Aide wore a mask but did not wear eye protection. The Activity Aide wore prescription eye glasses. During an interview with the Activity Aide on 10/20/20 at 10:40 A.M., she said she was not wearing eye protection, but that she could obtain goggles if needed. 3) The Facility's COVID-19 listing, dated 10/20/20, indicated Resident #3 and Resident #4 had not tested positive for [MEDICAL CONDITION]. During an observation on 10/20/20 at 10:30 A.M., CNA #1 entered Resident #3's and Resident #4's bedroom, which was occupied by both residents. CNA #1 carried a pair of gloves in a hand, but did not don these. CNA #1 did not wash or disinfect her hands before entering the bedroom, or after leaving the bedroom. CNA #1 did not appear to touch any surfaces or either of these residents with her bare hands. A filled alcohol-based hand sanitizer dispenser was located in the hallway outside Resident #3's and Resident #4's bedroom. CNA #1 then knocked on a hallway bathroom door with her bare hands, contaminating her hands. CNA #1 then walked over to a cart which held a coffee carafe and disposable cups. CNA #1 then donned gloves but did not wash her hands before donning the gloves, and in doing so contaminated the gloves. CNA #1 then picked up the carafe and a sleeve of wrapped disposable cups with her dirty gloves, and contaminated these items. During an interview with CNA #1 on 10/20/20 at 10:34 A.M., she said that she had not washed or disinfected her hands before donning gloves.

Based on record review, documentation and staff interviews, the facility failed to provide assessed and planned services for 1 Resident (#5) to transfer the resident in a safe manner to avoid an accident resulting in injury in a total sample of 10 residents. Findings include: For Resident #5, the facility failed to provide two person assistance for transfers as per the resident's plan of care. Resident #5 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. The Resident also had an unstagable pressure ulcer on the left heel and great toe of the left foot. The Resident had highly impaired vision and hearing. The Resident was on hospice. The Resident's Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/29/16 indicated that this Resident had severely impaired cognitive skills, was non-verbal and did not respond to her/his own name. The Resident was dependent upon staff for all daily life activities, was non-ambulatory and required the assistance of two persons for transfers. The Resident had both upper and lower range of motion limitations. The Resident was assessed to have a falls risk of 12 which is high risk based on limited mobility and cognitive deficits. The Resident's prior Quarterly Minimum Data Set (MDS) assessment with reference dates of 1/29/16 and 11/9/15 both indicated the Resident required the assistance of two persons for transfers. According to review of the Nurse Practitioner's progress note dated 4/7/16, she was asked to evaluate a bruise and swelling to the Resident's left lower extremity. The Resident was transferred to the emergency room where an X-Ray was obtained that indicated there were acute fractures of the proximal left tibia and fibula. The Resident was determined not to be a surgical candidate and returned to the Nursing Home with comfort care/hospice and pain control. Review of documentation on the Nurses Aid Flow Sheet for April 2016 indicated that prior to the incident, from 4/1/16 through 4/5/16, the Resident required the assist of two for transfers. Review of the Facility's investigation of the incident indicated that on 4/6/16 at 6:15 P.M., the Resident was noted to have a bruise and swelling of the left lower extremity. Documentation indicated that previously, at 1:30 P.M., the Resident was placed in to bed for a nap by one Certified Nurse Assistant (CNA). According to the statement written by the CNA, CNA #1 documented that she had requested help in transferring the Resident because she knew the Resident was a two person assist, but was told by the nurse and other CNA (CNA #2) that she could do it by herself because they usually do it. CNA #1 documented that she stood in front of the Resident and put her arms under the Resident's arm pits and lifted. Review of the Facility's investigation of staff interviews indicated that CNA #2 documented that she was in another room tending to a Resident and could not respond to CNA #1's request for help in transferring the Resident, but documented that she did mention how I had transferred Resident myself in the past. The Administrator and Director of Nursing (DON) were interviewed on 9/30/16 at 10:20 A.M. The DON said that as part of the investigation of the fracture, she had the CNA demonstrate the transfer technique used on the Resident on herself. The DON said that CNA #1 braced the Resident against the bed frame during the transfer and the fracture was at the level of the bed frame. The DON said that the Resident was very small, so some staff transferred the Resident alone. The DON said that CNA #1 may have done this inadvertently and a gait belt was not used. The DON said that when she interviewed CNA #1, she got no answer as to why she performed the transfer alone. The Administrator and DON said that certainly supervision and education were an issue. The Administrator and DON provided documentation of the corrective actions taken to prevent subsequent similar accidents which included: re-education and training of staff on 4/7/16 and 4/8/16 regarding following the Resident's plan of care on proper transfers. The Facility also conducted quality assurance reviews in April, May and June 2016.

Based on record review, documentation and staff interviews, the facility failed to provide services in accordance with the medical plan of care for 1 Resident (#5) in a total sample of 10 residents. Findings include: For Resident #5, the facility failed to provide two person assistance for transfers as per the resident's plan of care. Resident #5 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. The Resident also had an unstagable pressure ulcer on the left heel and great toe of the left foot. The Resident had highly impaired vision and hearing. The Resident was on hospice. The Resident's Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/29/16 indicated that this Resident had severely impaired cognitive skills, was non-verbal and did not respond to her/his own name. The Resident was dependent upon staff for all daily life activities, was non-ambulatory and required the assistance of two persons for transfers. The Resident had both upper and lower range of motion limitations. The Resident was assessed to have a falls risk of 12 which is high risk based on limited mobility and cognitive deficits. The Resident's prior Quarterly Minimum Data Set (MDS) assessment with reference dates of 1/29/16 and 11/9/15 both indicated the Resident required the assistance of two persons for transfers. According to review of the Nurse Practitioner's progress note dated 4/7/16, she was asked to evaluate a bruise and swelling to the Resident's left lower extremity. The Resident was transferred to the emergency room where an X-Ray was obtained that indicated there were acute fractures of the proximal left tibia and fibula. The Resident was determined not to be a surgical candidate and returned to the Nursing Home with comfort care/hospice and pain control. Review of documentation on the Nurses Aid Flow Sheet for April 2016 indicated that prior to the incident, from 4/1/16 through 4/5/16, the Resident required the assist of two for transfers. Review of the Facility's investigation of the incident indicated that on 4/6/16 at 6:15 P.M., the Resident was noted to have a bruise and swelling of the left lower extremity. Documentation indicated that previously, at 1:30 P.M., the Resident was placed in to bed for a nap by one Certified Nurse Assistant (CNA). According to the statement written by the CNA, CNA #1 documented that she had requested help in transferring the Resident because she knew the Resident was a two person assist, but was told by the nurse and other CNA (CNA #2) that she could do it by herself because they usually do it. CNA #1 documented that she stood in front of the Resident and put her arms under the Resident's arm pits and lifted. Review of the Facility's investigation of staff interviews indicated that CNA #2 documented that she was in another room tending to a Resident and could not respond to CNA #1's request for help in transferring the Resident, but documented that she did mention how I had transferred Resident myself in the past. The Administrator and Director of Nursing (DON) were interviewed on 9/30/16 at 10:20 A.M. The DON said that as part of the investigation of the fracture, she had the CNA demonstrate the transfer technique used on the Resident on herself. The DON said that CNA #1 braced the Resident against the bed frame during the transfer and the fracture was at the level of the bed frame. The DON said that the Resident was very small, so some staff transferred the Resident alone. The DON said that CNA #1 may have done this inadvertently and a gait belt was not used. The DON said that when she interviewed CNA #1, she got no answer as to why she performed the transfer alone. The Administrator and DON said that certainly supervision and education were an issue. The Facility failed to ensure at the time that the Resident's plan of care was followed to prevent injury. The Administrator and DON provided documentation of the corrective actions taken to prevent subsequent similar accidents which included: re-education and training of staff on 4/7/16 and 4/8/16 regarding following the Resident's plan of care on proper transfers. The Facility also conducted quality assurance reviews in April, May and June 2016.