Every finding on record at Guggenheimer Health and Rehab Center

Based on resident interview, staff interview and facility document review, the facility staff failed to provide effective pest control on two of three nursing units (unit 2 and unit 3).The findings include:On 1/6/26 at 3:45 p.m., Resident #6 was interviewed about any concerns with pests in the facility. Resident #6 stated that he had recently seen mice in his room at night. Resident #6 stated bait boxes had been placed in the facility and in his room but that only a few mice were caught in the boxes and that the traps had not eliminated the mice. Resident #6 stated he had reported the issue to maintenance and that other residents on the unit reported seeing mice at times, especially at night. Resident #6 stated he had no mice droppings in his room, that housekeeping kept the facility/rooms very clean but that he continued to see mice at night. Resident #6 stated mice had been an ongoing problem for months in the facility.On 1/7/26 at 8:35 a.m., the licensed practical nurse unit 3 manager (LPN #1) was interviewed about any concerns with pests. LPN #1 stated she had not seen any signs of bugs or mice but that two of the residents on the unit had recently reported seeing mice in their room.On 1/7/26 at 8:40 a.m., Residents #7 and #8 were interviewed about pest control. Resident #7 stated she had seen a mouse run across the floor within the last month. Resident #7 stated she told maintenance about the mouse but it didn't do any good to report it. Resident #8 stated she had also seen a mouse in the last several weeks. Residents #7 and #8 stated they did not see mice droppings but had seen mice. Resident #8 stated there was a bait box in the room, but nothing was caught in it. On 1/7/26 at 8:54 a.m., the unit 1 manager (LPN #2) was interviewed about pest control. LPN #2 stated she had seen a mouse in the janitor's closet once in October 2025. LPN #2 stated she had heard some reports of mice since then. LPN #2 stated a pest log was maintained on each unit for reporting concerns with bugs/pests.The unit pest logs were reviewed from each unit of three units. The logs documented ongoing reports of mice, roaches and/or ants on unit 2 and unit 3 since December 2024. The logs documented thirty-three reports of mice on the units since 12/16/24 with the most recent report on 1/4/26. The log documented twenty reports of roaches and/or ants since 3/17/25 with the most recent report on 12/22/25. There were no reports of pests on unit 1.On 1/7/26 at 9:30 a.m., the maintenance director was interviewed about ongoing reports of mice and pests in the facility. The maintenance director stated an outside pest control company conducted monthly service to the facility for pest control and that since September 2025, the pest vendor serviced the facility weekly due to increased reports of pests. The maintenance director stated he started work in the facility in December 2025 and there had been an influx of pests due to colder weather. The maintenance director stated the pest control company used sprays, bait stations, rodent traps and gel to address the mice/roach issues. The maintenance director stated the bait stations had not been effective with few if any mice caught. The maintenance director stated he and the administrator were currently meeting with the vendor and pursuing other options for effective pest control.Monthly/weekly pest control service visits were documented throughout 2025. There were eight pest control service visits conducted since 10/7/25 with the most recent visit on 12/26/25. The pest reports documented 41 bait stations/traps in the facility in addition to gel and spray treatments with each visit. Pest control visits on 10/7/25, 10/21/25, 11/11/25, 11/25/25 and 12/26/25 documented no inspection of the bait stations/traps. Pest control visits on 10/15/25, 12/3/25 and 12/17/25 documented inspection of the bait stations/traps with no activity noted. Recommendations listed on the pest control reports included doors in need of repair or replacement to make rodent proof, hole in exterior wall allowing crawl space access near loading dock, removal needed of vine landscaping around the building, dumpsters too close to building, burrowing holes on both sides of loading dock needed filling with concrete and a crawl space door in the courtyard needed repair to prevent rodent access.On 1/7/26 at 9:40 a.m., the maintenance director was interviewed about the pest control vendor recommendations listed on the visit reports. The maintenance director stated work had been completed on the exterior doors, that dumpsters were moved further from the building and shrubs had been trimmed. The maintenance director stated the crawl space door and the holes around the loading dock had not been repaired.On 1/7/26 at 9:45 a.m., the administrator was interviewed about the ongoing mice/pest reports on unit 2 and unit 3. The administrator stated he had met with the pest control vendor as recently as last week and advised them additional interventions were needed as current actions had not been effective.This finding was reviewed with the administrator and director of nursing on 1/7/25 at 3:00 p.m. with no further information presented prior to the end of the survey.

Based on observations, interviews, clinical record review and review of the facility's policy titled, Personal Property the facility staff failed to provide tracking of the resident's personal property for one of eleven residents in the survey sample (Resident #4). This failure contributed to the loss or theft of several articles of clothing belonging to the resident. The findings include:Review of the electronic medical record (EMR) revealed resident #4 (R4) was admitted to the facility on [DATE] with pertinent diagnoses that include but was not limited to muscle weakness, benign prostatic hyperplasia without lower urinary tract symptoms, and quadriplegia, urinary incontinence, Type 2 diabetes mellitus without complication, pressure ulcer of sacral region, stage 3 pressure-induced deep tissue damage of other site, irritant contact dermatitis, Bacteriuria, gastro esophageal reflux disease without esophagitis, constipation, insomnia, lactose intolerance, moderate protein-calorie malnutrition, unsteady on feet, abnormal posture and limitation of activities due to disability.Review of the minimum data set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R4 was cognitively intact. The MDS assessed functional status for R4 as dependent for activities of daily living (ADL's), requiring assistance from staff. Review of the facility's policy titled Personal Property dated 10/01/2021, section: procedures/guidance, number 4, revealed the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished.On 1/6/2026 at 9:00 AM, observation of facility at entry. Hallways and rooms on all floors are observed to be clean. Multiple rooms observed during the facility visit and all clean with floors cleared and no major odors or trash. On 1/6/2026, review of the residential discharge instructions for R4 dated 12/24/2024 for transfer on 1/2/25, included a note stating that R4 reported missing clothing (one grey hoodie, one pair of Levi's, two pairs of grey sweatpants, and one grey shirt). No further record of follow up regarding missing items or record of resident's personal inventory upon admission or any time during stay at the facility.On 1/6/2026 at 4:20 PM, interview with Social Services Director, regarding the process for filing a grievance regarding missing property. SS was not working at the facility during the time of R4's stay at the facility and reports someone in the admission process would have made note of personal items brought to the facility. It was explained that when items are reported missing, she and staff look for the items before filing a grievance form. The resident's room is searched for missing items, along with other relevant places, such as the laundry. Housekeeping staff also assist with the search. There had been an issue with clothing being put in the linen bags (blue bags) that go to Richmond. She says there has been ongoing training with the staff, which has helped. If items are not located, they are replaced.On 1/7/2026, grievance log entries for missing items were reviewed with dates ranging from 09/2024 to 01/2025 revealing missing items either replaced or located and staff followed the facilities grievance process.On 1/7/2026 reviewed current resident's grievance report and investigation regarding missing item. No issues were found with the grievance process and item was confirmed to be replaced. The facility provided financial records to show confirmation of item purchased.On 1/7/2026 at 9:20 AM, observation of main hallway and washroom of the laundry area. Both areas were free of clutter, clean linens folded and placed on carts, all laundry hung and room was clean and organized.On 1/7/2026 at 9:25 AM, interview with the housekeeper assigned to laundry. She reported that clothing and items washed are supposed to be labeled by family members or CNAs. If items are reported lost, they first try and locate the items in the residents' room or common areas before checking the lost and found. They also keep clothing not labeled and recently washed, hanging in front of the dryers for two weeks before moving them to the lost and found. She reported that there was an issue with agency CNA's (from a year ago) placing items in the bluebags that go to Richmond. She reported assisting residents with keeping clothing in their closets, especially those who don't have family members to help when visiting.On 1/7/2026 at 9:30 AM, interview with Environmental Director. She reports that when clothing items go missing, they will backtrack and go to the resident's closet, then search the resident's room or check in the shower and laundry room. She reports issues in the past with CNA's not bringing the yellow barrel in the shower room to laundry at the end of their shift as required. They will often search the yellow barrel to see if missing items may still be there. She has housekeeping check the barrels during each shift. If missing items are not located, she reports back to Social Services and items should be replaced. Blue bags are used for linens that go to Richmond for cleaning, and shower rooms have instructions for both the blue and yellow bags to help with confusion. She also educates new staff and new CNAs about the procedure. She has not had many items missing lately.On 1/7/2026 at 11:15 AM, interview with Certified Nursing Assistant (CNA) #1 revealed that he has been educated on how to track missing items. As an agency CNA, he reports he was told about the two different types of bins to use and that they are color coded. He explained the procedure for missing items and was aware of who to alert if a resident had a loss of personal property. He was not aware of a list of personal items for residents.On 1/7/2026 at 3:02 PM, interview with Director of Nursing (DON) and the facility Administrator (ADM) revealed that the DON was unable to locate a paper copy of personal items at admission for R4. The DON reported no records found in Point Click Care (PCC) and there should have been a paper copy or record in PCC where the admitting nurse recorded the residents' personal items during admission. The DON explained there is a new unit manager, and no records for R4 regarding personal items brought into the facility upon admission can be found, including a possible notebook kept at the nurses' station for residents' personal inventories upon admissions. There have been many staffing changes, and they are working towards correcting the issue. The ADM agreed and stated they would work on developing a system and correct the issue going forward.This finding was reviewed with the administrator and director of nursing on 1/7/25 at 3:02 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of a room change for one of eleven residents in the survey sample (Resident #3).The findings include: Resident #3 (R3) was admitted to the facility with diagnoses that included Alzheimer's disease, non-traumatic brain dysfunction, dementia with agitation/behaviors, diabetes, anxiety and history of stroke. The minimum data set (MDS) dated [DATE] assessed R3 with severely impaired cognitive skills. R3's closed clinical record listed a room change on 10/2/24. The clinical record documented no written notice to the resident's representative prior to the room change, including reason for the room change. Nursing notes made no mention of the room change or of any situation surrounding or leading to the room change.On 1/7/26 at 9:50 a.m., the director of nursing (DON) was interviewed about any written documentation/notice to the resident's representative regarding the room change on 10/2/24. The DON stated she found no documentation to the resident's representative about the room change. The DON stated she felt sure the room change was related to resident's behaviors but that no reason for the change was documented. The DON stated she thought verbal notification was made to the representative but there was nothing documented about the notification and no written notice to the responsible party indicating reason for the room move. The DON stated their facility policy required documentation of room changes and advance notice to the responsible party.The facility's policy titled Room Change/Roommate Assignment (10/01/2021) documented, .Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives will be given advance notice of such change .Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate .Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with advance notice of the room change. Such notice will include the reason(s) why the move is recommended .Documentation of a room change is recorded in the resident's medical record . (sic)This finding was reviewed with the administrator and DON on 1/7/25 at 3:00 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interview and facility document review, the facility staff failed to properly store insulin on three out of five medication carts inspected. The findings include: A second-floor medication cart had an unopened insulin pen stored at room temperature and a vial of insulin stored with no date opened indicated on the label. Two medication carts on the third-floor unit had opened insulin pens stored beyond the 28-day limit and unopened insulin pens stored at room temperature. On 12/9/24 at 3:42 p.m., accompanied by licensed practical nurse (LPN) #1, two medication carts on the third-floor unit were inspected. Stored in the cart for rooms 300 to 311 were three Fiasp Flextouch insulin pens for a current resident. The pens had not been opened and had a pharmacy label stating to refrigerate until opened. Also on this cart was a Lyumjev Kwikpen insulin labeled as opened on 10/28/24. The pharmacy label on this pen documented to store at room temperature for 28 days after opening. The medication cart for rooms 312 to 320 had a Humalog Kwikpen insulin for a current resident labeled as opened on 10/21/24. The pharmacy label for this insulin pen stated to use within 28 days once opened. On 12/9/24 at 3:45 p.m., LPN #1 was interviewed about the improperly and out of date insulin stored on the medication carts. LPN #1 stated the unopened insulin was supposed to be kept in the refrigerator until opened. LPN #1 stated the nurse receiving the medication from the pharmacy usually placed insulin pens in the refrigerator. LPN #1 stated the insulin pens opened 10/21/24 and 10/28/24 were beyond the 28-day limit and should have been discarded. On 12/9/24 at 4:00 p.m., the 3rd floor unit manager (LPN #2) was interviewed about the improperly stored insulin on the third-floor carts. LPN #2 stated the nurse receiving medications from the pharmacy was responsible for placing the insulin pens in the refrigerator. On 12/9/24 at 4:15 p.m., accompanied by LPN #3, a medication cart on the second-floor unit was inspected. Stored in this cart was an unopened Lantus Solostar insulin pen. This pen was labeled to refrigerate until opened. Also available on the cart was an opened 10 milliliter vial of Lantus insulin with no date opened indicated on the label/container. The pharmacy label on this vial stated to discard 28 days after opening. LPN #3 stated she was not sure why the unopened insulin pen was stored in the cart. On 12/10/24 at 10:00 a.m., the director of nursing (DON) was interviewed about the improperly stored insulin. The DON stated the nurse receiving the insulin from the pharmacy was supposed to refrigerate the insulin until opened. The DON stated once opened, insulin was supposed to be dated and discarded when beyond the recommended use-by date. The facility's policy titled Storage of Medications (revised 8/2020) documented, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP [United States Pharmacopeia] guidelines for temperature ranges .Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 [degrees] F .and 46 [degrees] F . These findings were reviewed with the administrator and regional consultants during a meeting on 12/10/24 at 11:05 a.m.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders for two of twenty-one residents in the survey sample (Residents #105 and #111). The findings include: 1. Resident #105 was not administered the medications gabapentin, Wellbutrin and midodrine as ordered by the physician. Resident #105 (R105) was admitted to the facility with diagnoses that included heart failure, stroke, coronary artery disease, COPD (chronic obstructive pulmonary disease), hypotension, neuropathy and depression. The minimum data set (MDS) dated [DATE] assessed R105 with moderately impaired cognitive skills. R105's clinical record documented the following physician orders listed with the date ordered. 12/20/21 - Gabapentin 200 mg (milligrams) twice per day for treatment of neuropathy. 3/22/24 - Wellbutrin extended release 150 mg two times per day for treatment of depression. 6/12/24 - Midodrine 10 mg three times per day for treatment of hypotension. R105's medication administration record documented the 8:00 p.m. dose of Wellbutrin extended release 150 mg was not administered on 11/28/24. R105's evening dose of gabapentin 200 mg was not administered on 11/30/24 and the morning and evening doses were not administered on 12/2/24. R105's 8:00 a.m., 2:00 p.m. and 8:00 p.m. doses of midodrine 10 mg were not administered on 12/3/24. A nursing note documented on 11/28/24 that R105's Wellbutrin was on order from the pharmacy and not available for administration. Nursing notes on 11/30/24 and 12/2/4 documented R105's gabapentin was on order from the pharmacy and not available for administration. A nursing note dated 12/3/24 documented concerning R105's midodrine, Medication unavailable. Medication reordered. Omnicell [backup supply] checked; not in stock in omnicell. On 12/9/24 at 4:10 p.m., the registered nurse unit manager (RN #2) caring for R105 was interviewed about the gabapentin, Wellbutrin and midodrine not administered as ordered. RN #2 stated she was not sure why the medications were not available/administered. On 12/10/24 at 10:00 a.m., the director of nursing (DON) was interviewed about R105's missed doses of gabapentin, Wellbutrin and midodrine. The DON stated the gabapentin was stocked in the Omnicell and should have been accessed by the nurse. The DON stated she was not sure if the unavailability of the Wellbutrin and midodrine was caused by an ordering discrepancy or poor pharmacy delivery times. This finding was reviewed with the administrator and regional consultants during a meeting on 12/10/24 at 11:05 a.m. with no further information presented prior to the end of the survey. 41449 2a. For Resident #111 (R111), the facility staff failed to follow a physician's order regarding notification of the medical provider when the resident's blood sugar was below 70 and above 400. On 12/9/24, in the afternoon, a clinical record review was conducted of R111's chart. This review revealed that R111 had a physician order with the Humalog sliding scale insulin order that indicated to notify the MD [medical doctor] if the blood sugar was 70 or below, or greater than 400. According to the medication administration record, R111 had multiple instances of her blood sugar exceeding 400 and there was no indication that the doctor was made aware. On 12/1/24, at 4:30 p.m., the blood glucose level was 445. On 12/3/24, the resident's blood sugar readings were 459, 525, 408. On 12/6/24, the blood sugar was recorded as having been 500 and 435. On 12/7/24, the resident's blood sugar at 7:30 a.m., was 409, and on 12/9/24 the blood glucose was 410 and 428. Within the clinical record was no evidence of the doctor being made aware. According to the nursing notes, an entry dated 11/23/24, read, Pt observed clammy and diaphoretic, unable to arouse. Blood sugar check 24 via fingerstick. Emergency dose of Glucagon given from Emergency stock box. Second dose of glucagon given 15 after first, with blood sugar recheck at 37. Pt able to open eyes but remains lethargic and clammy. Again, there was no evidence that doctor was made aware. On 12/9/24 at approximately 3:45 p.m., an interview was conducted with registered nurse #2 (RN #2), who was the unit manager. When asked where staff would document that the doctor was notified when R111's blood sugar was outside of the parameters set, RN #2 said, a lot of times they will just call. They should always notify the provider, and it should be documented in the progress notes. On 12/9/24 at approximately 4:10 p.m., the surveyor was at the nursing station reviewing the provider communication book, where nursing writes notifications to the medical providers. The director of nursing (DON) approached the surveyor and asked if she needed assistance. The surveyor explained that she was looking to see if there was evidence of the facility staff notifying the doctor of blood sugars being outside of the range. The DON said, It should be documented in the progress notes. The MD book at the station is not a formal document. There was no indication within the provider communication book that they were made aware of R111's instances of the blood glucose being greater than 400 or the incident where the blood sugar was 24, as noted above. On 12/10/24 at 9:30 a.m., during a follow-up interview with the DON, she was made aware of the above findings. She stated that, I can't give orders and if their blood sugar is outside of parameters, it should give an indication of the need for additional orders by calling the doctor. On 12/10/24 approximately 10:30 a.m., an interview was conducted with the facility's nurse practitioner (NP). The NP was asked about R111 and reported that R111 is a type 1 diabetic and very brittle. The NP stated she was not aware of the incident where R111's blood sugar was 24 and 2 doses of glucagon had to be administered. The NP asked the surveyor if the resident was sent to the hospital, the surveyor explained that according to the clinical record the resident was not. On 12/10/24 at 11:10 a.m., during a meeting with the facility administrator and corporate staff, they were made aware of the above findings. No additional information was provided. 2b. For R111, the facility staff failed to follow physician orders by obtaining labs as ordered. On 12/9/24, a clinical record review was conducted of R111's chart. This review revealed a physician order that read, renal panel, every day-shift, every 2 weeks on Wednesday. According to the results tab of the chart, the renal panel was obtained on 10/30/24 and 11/13/24. There was no evidence that the renal panel was obtained on 11/27/24. The facility policy regarding physician orders was requested. The facility provided the survey team with a policy titled, Medication and Treatment Orders which was reviewed. The policy did not address that physician orders for labs or notifications. On 12/10/24 at 9:30 a.m., an interview was conducted with the director of nursing. She was made aware of the physician ordered lab that was not obtained on 11/27 as ordered for R111. On 12/10/24 at 11:10 a.m., during a meeting with the facility administrator and corporate staff, they were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care regarding medication administration for one resident, Resident #115 (R115) out of a survey of 21 residents. The findings included: The facility staff failed to ensure that medication was not left at bedside, in the resident's room after medication administration. On 12/9/24 at 12:00 p.m., a tour of the nursing facility's unit one was conducted. During the tour of the unit, the surveyor observed a medication cup sitting on the bedside table with the resident's name and room number written on the cup with a black marker. On 12/9/24 at 12:15 p.m., an interview was conducted with the charge nurse on unit one, licensed practical nurse, LPN#5. LPN#5 stated, it is medication in the cup. I am not sure what kind of cream it is. LPN#5 removed the medication cup filled with cream from the bedside and apologized to R115 for it being left in his room at bedside. On 12/9/24 at 12:20 p.m., an interview was conducted with R115 about the medication at bedside. R115 stated, I don't know the name of the cream, but they used it on my skin on my buttocks and it healed it right up after about a week or so. The aide would get it from the nurse to put on my butt in the mornings. On 12/10/24 a review of a facility document was conducted. The facility documentation titled, Administration Procedures for All Medications, read in part, .medications will be administered in a safe and effective manner. On 12/10/24 at approximately 11:30 a.m., an end of the day meeting was conducted with the administrator and corporate staff to discuss the above concerns. No additional information was provided prior to exit conference.

Based on observation and staff interview, the facility staff failed to knock on the door of resident rooms prior to entering on one unit of three units. The findings included: The facility staff failed to knock on approximately six room doors prior to entering the room on unit one. On 12/9/24 at 12:15 p.m. an observation was conducted on unit one. During the observation CNA#3 (CNA3) (certified nursing assistant) was observed serving lunch trays to the residents and did not knock on the doors prior to entering the residents' rooms. On 12/9/24 at 12:25 p.m. an interview was conducted with CNA3. CNA3 said, I knock on all the doors that are closed only. CNA3 stated she knew she was supposed to knock prior to entering and that the director of nursing had reeducated her on this. On 12/9/24 at 12:35 p.m., continued observations were made on unit one and CNA3 continued to enter multiple resident's rooms without knocking on the door prior to entering the rooms. On 12/10/24 a review of facility documentation was conducted. The facility document titled, Resident Rights, read in part, .the resident has the right to be treated with respect and dignity. On 12/10/24 at approximately 11:30 a.m., an end of day meeting was conducted with the administrator and corporate staff, and they were made aware of the above concerns. No new information was provided prior to exit.

2. For resident #107 (R107), the facility staff failed to review and revise the care plan when the air mattress and enhanced barrier precautions were discontinued. On 12/9/24 at approximately 11 a.m., R107 was visited in his room. It was noted that R107 was not on an air mattress and there was no signage to indicate the resident was on enhanced barrier precautions. R107 was noted to be confused, and responses were nonsensical, therefore the resident was not interviewed about when these items were discontinued. On 12/9/24 a clinical record review was conducted. This review revealed within R107's care plan, interventions that read, Enhanced barrier precautions to be maintained for the duration of the resident's stay due to active wounds. Staff to wear a gown and gloves while engaging in high contact patient care activities and 9/23/24 check air mattress. On 12/9/24 at approximately 4 p.m., an interview was conducted with a registered nurse (RN #2), who was the unit manager. When asked about care plans being reviewed and revised, the unit manager said, I have the ability. When notified that R107's care plan indicated he was on an air mattress and enhanced barrier precautions, but neither was noted at the time of survey, the unit manager said, That should have happened when he was downstairs, the manager downstairs should have updated. The unit manager confirmed she was not aware when R107 was taken off an air mattress. On 12/9/24 at approximately 4:20 p.m., an interview was conducted with Licensed practical nurse (LPN #4) who had previously been the unit manager for unit 1. When asked about R107 being taken off enhanced barrier precautions and the air mattress, LPN #4 said, I'm not sure when EBP ended. LPN #4 looked at R107's chart and said when he had surgery, [the amputation] all his wound were healed so the air mattress probably ended them. When notified that both items were still on R107's care plan, LPN #4 stated she though infection control would have updated the care plan when EBP ended. According to R107's physician orders the enhanced barrier precautions order was discontinued on 11/14/24. The order for an air mattress was discontinued on 11/7/24. The facility policy titled, Care Planning- Comprehensive Person-Centered was reviewed. The policy read in part, . 16. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans . On 12/10/24 at 11:30 a.m., during an end of day meeting, the facility administrator and corporate staff were made aware of the above findings. No additional information was provided. 49456 Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to review and revise the care plan for two resident's, Resident #103 (R103) and Resident #107 (R107), in a survey sample of 21 residents. The findings included: 1. The facility staff failed to review and revise R103's care plan when orders were discontinued. On 12/10/24, observations of R103 revealed no oxygen was in use. On 12/10/24 a review of the clinical record was conducted. The care plan was reviewed for R103. The most recent care plan read in part, .altered respiratory status - oxygen settings O2 via by nasal cannula per order. R103 had no active order for oxygen in his clinical record. R103 had a discontinued order for oxygen on November 13, 2024. On 12/10/24 at 9:20 a.m. an interview was conducted with the director of nursing (DON). The DON said that clinical meetings were held daily, that she runs an order summary report, and the clinical staff reviews the report, and updates are made to the care plans in the clinical meeting daily. The DON stated, an order that was discontinued in November should not still be on the care plan. On 12/10/24 at approximately 11:30 a.m., an end of day meeting was conducted, and the above concerns were discussed with the administrator and corporate staff. No additional information was provided prior to exit conference

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide ADL (activities of daily living) care to one resident (Resident #102- R102) in a survey sample of 21 residents. The findings included: For R102, the facility staff failed to provide routine showers. On 12/9/24, a clinical record review was conducted of R102's chart. This review revealed that from 11/20/24-12/9/24, R102 had only received one shower. According to R102's most recent minimum data set (an assessment) with an assessment reference date of 11/13/24, R102 was dependent on facility staff for bathing and showering. On 12/10/24 at 9:19 a.m., an interview was conducted with R102. The resident was asked about showers and said, I get them once a month, they act like they don't know what day I'm to get them. When asked if she wants them more often, R102 said, Yes, my head itches and it drives me crazy. On 12/10/24 at 9:23 a.m., an interview was conducted with a certified nursing assistant (CNA #2). CNA #2 reported that showers are given twice a week, and they have a schedule at the nurse's station. CNA #2 also reported that showers are documented in the computer/electronic health record of the resident. On 12/10/24 at 9:25 a.m., the surveyor reviewed the shower schedule at the nursing station which indicated R102 was to receive showers on Wednesday and Saturdays. On 12/10/24 at approximately 9:45 a.m., an interview was conducted with the director of nursing (DON). The DON confirmed that showers are given, twice weekly and then as needed. The DON accessed R102's clinical record and confirmed that the only shower documented was on 12/8/24. The DON did state that R102 received a bed bath on 11/27, 11/29, 12/1, 12/3, 12/4, 12/8. When asked if a bed bath was an acceptable alternative to a shower, the DON said, It depends on their preference and how they are feeling, if they refuse a shower, I encourage a bed bath, but a shower is always better. On 12/10/24 at approximately 11:30 a.m., during an end of day meeting, the facility administrator and corporate staff were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a physician ordered therapeutic diet for one resident (Resident #108-R108) in a survey sample of 21 residents. The findings included: For R108, who was on a pureed diet, the facility staff failed to provide a diet with a pureed texture. On 12/9/24 at approximately 11 a.m., R108 was visited in her room. R108 was asleep. In R108's room was a sign that read, Level 1 puree with NECTAR thick liquids. Compensatory Swallow Strategies: . Ensure the puree item is smooth & no pieces. On 12/9/24 at approximately 1 p.m., R108's lunch tray was observed, the food was noted to have what appeared to be ground chunks. The two CNA's passing the meal trays on the second floor were asked about the consistency of the food and reported that this was what the pureed foods usually look like. On 12/9/24 at approximately 1:10 p.m., the director of nursing (DON) was asked to view the document/sign posted in R108's room and then observe the meal tray. The DON confirmed that the food was what she considered a ground texture versus pureed. The DON then started educating the CNA's that pureed is supposed to be smooth and creamy texture. According to R108's diagnosis, it included but was not limited to: Dysphagia unspecified and dysphagia, pharyngeal phase. According to R108's physician orders, the diet order read, Regular diet, Puree texture, Nectar liquids consistency. According to R108's care plan, a focus area read, Mechanically altered diet 2* Decreased chewing, tolerating current diet. BMI > 24. Fed at meals. Dx [diagnosis]. of Failure to thrive. The interventions included, diet as ordered. The facility administration was asked to provide the speech therapy documentation for R108. The facility provided a progress note from the speech therapist that was dated 12/5/24. The note read in part, Patient screened by ST [speech therapy] due to CNA report of pt [patient] pocketing of food. Patient currently on a pureed diet with nectar thick liquids and is MAX assist for feeding The facility policy titled; Specialized Diets was reviewed. The policy read in part, . 2. A mechanically altered and/or therapeutic diet must be prescribed by the resident's attending physician . 7. Meals will be prepared and served according to the prescribed diet . On 12/10/24, during an end of day meeting the facility administrator and corporate staff were made aware of the above findings. No additional information was provided. 49456

2. For R117, the facility staff failed to administer oxygen at the rate ordered by the physician. On 12/9/24 at approximately 11 a.m., an observation was conducted of R117. R117 was lying in bed, oxygen was infusing via a nasal cannula. The oxygen concentrator was observed to be set between 2 1/2-3 liters per minute. On 12/9/24, a clinical record review was conducted of R117's chart. According to a physician order, which read, o2 2 liters continuous via nasal cannula . According to R117' care plan, an intervention read as, 02 as ordered as resident will allow. Resident often refuses. 02 during the day as needed as resident desires. On 12/9/24 at 3:54 p.m., another observation was made of R117, who was again in bed with oxygen being administered by nasal cannula. R117 stated she didn't know what rate her oxygen was supposed to be at when asked. The concentrator was observed again and was noted to be on 2 1/2 liters. On 12/9/24 at 3:56 p.m., the surveyor had licensed practical nurse (LPN #3) accompany her to R117's room. LPN #3 confirmed the oxygen was set at 2 1/2 liters and should have been 2 liters. The nurse was asked about oxygen being administered at a different rate than ordered and LPN #3 said, For 1 it's doctor's order. According to the facility policy titled, Oxygen Administration, which read in part, Preparation- 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . On 12/10/24 at approximately 11:30 a.m., during an end of day meeting, the facility administrator and corporate staff were made aware of the above findings. No additional information was provided. 49456 Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen at the physician ordered rate for two residents, Resident #115 (R115) and Resident #117 (R117) out of a survey of 21 residents and failed to store the respiratory equipment to prevent contamination for one resident, R115 out of a survey of 21 residents. The findings included: 1. For R115, the facility staff failed to ensure that the oxygen orders by the physician were being followed and failed to store respiratory equipment in a bag when not in use to prevent contamination. On 12/9/24 at 12:00 p.m., a tour of the nursing facility's unit one was conducted. During the tour of the unit, the surveyor observed a CPAP (continue positive airway pressure) mask laying in a bed bath basin on the bedside table. R115 oxygen concentrator setting was set on 1.5 liters per minute via nasal cannula. On 12/9/24 at 12:15 p.m., an interview was conducted with the charge nurse on unit one, licensed practical nurse, LPN#5. LPN#5 stated, the CPAP mask should be in a bag and not sure why it is not. LPN#5 left the room and did not place the mask in the bag to prevent contamination. Three other employees entered the room and did not correct the issue with the CPAP mask, so R115 placed the CPAP mask in the bag at bedside. LPN#5 checked the oxygen concentrator and said, the setting is at 1.5 liters but should be on 2 liters when he is using the oxygen. On 12/9/24 at 12:20 p.m., an interview was conducted with R115. R115 said, I remove the mask in the morning and place it in the bed bath basin because it is by the bedside, and I can reach it, but the bag is over here. R115 stated that he only used oxygen at bedtime and that it is 1.5 liters per minute, not 2 liters per minute, by nasal cannula. On 12/9/24 at 2:30 p.m., a review of the clinical record was conducted. There was an order in R115's clinical record that read, 11/15/24 at 16:29 Oxygen at 2 liters by nasal cannula due to hypoxia Check oxygen saturation each shift. On 12/9/24 at 3:00 p.m. an interview was conducted with the director of nursing (DON). The DON read the order in R115's clinical record that was written for the oxygen. The DON said, the frequency is missing and would expect the nurses to clarify orders. I think his was continuous, I do know that. I will have to get with the nurse practitioner and see what she wants his oxygen orders to be set at and for us to use. On 12/9/24 at 3:20 p.m., an interview was conducted with R115. R115 stated, I don't wear oxygen during the day. The tank on my wheelchair was used in therapy when I first came here. I only use oxygen at night at 1.5 liters at night and only use the concentrator I don't use this tank anymore at all it is just on my wheelchair. My normal oxygen reading is 93% and most of the time it is reading 93% or higher. On 12/10/24 a review of a facility document was conducted. The facility documentation titled, Infection Control Program, read in part, .development and implementation of written policies and procedures for the prevention and control of infections among residents and personnel. On 12/10/24 at approximately 11:30 a.m., an end of the day meeting was conducted with the administrator and corporate staff to discuss the above concerns. No additional information was provided prior to exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for two of twenty-one residents in the survey sample (Residents #105 and #111). The findings include: 1. Resident #105's medications Wellbutrin and midodrine were not available for administration as ordered by the physician. Resident #105 (R105) was admitted to the facility with diagnoses that included heart failure, stroke, coronary artery disease, COPD (chronic obstructive pulmonary disease), hypotension, neuropathy and depression. The minimum data set (MDS) dated [DATE] assessed R105 with moderately impaired cognitive skills. R105's clinical record documented the following physician orders listed with the date ordered. 3/22/24 - Wellbutrin extended release 150 mg two times per day for treatment of depression. 6/12/24 - Midodrine 10 mg three times per day for treatment of hypotension. R105's medication administration record documented the 8:00 p.m. dose of Wellbutrin extended release 150 mg was not administered on 11/28/24. R105's three scheduled doses of midodrine 10 mg were not administered on 12/3/24. R105's clinical record documented a nursing note dated 11/28/24 stating that R105's Wellbutrin was on order from the pharmacy and not available for administration. A nursing note dated 12/3/24 documented concerning R105's midodrine, Medication unavailable. Medication reordered. Omnicell [backup supply] checked; not in stock in omnicell. On 12/9/24 at 4:10 p.m., the registered nurse unit manager (RN #2) caring for R105 was interviewed about the unavailable Wellbutrin and midodrine. RN #2 stated she was not sure why the medications were not available. On 12/10/24 at 10:00 a.m., the director of nursing (DON) was interviewed about R105's unavailable Wellbutrin and midodrine. The DON stated she was not sure if the unavailability of the medications was caused by an ordering discrepancy or poor pharmacy delivery times. The DON stated medications were supposed to be reordered prior to running out and actions taken if medications were not available. This finding was reviewed with the administrator and regional consultants during a meeting on 12/10/24 at 11:05 a.m. with no further information presented prior to the end of the survey. 41449 2. For resident #111 (R111), the hydrocortisone tablet was not available for administration as ordered by the doctor. On 12/9/24, a clinical record review was conducted. According to the physician order dated 8/21/24, that remained an active order. The order read, Hydrocortisone Tablet 10 MG, Give 1 tablet by mouth one time a day for adrenal insufficiency. According to the nursing progress notes, R111 was not given a dose on 12/3/24 and 12/4/24, because the medication was not available. On 12/3/24 at 10:09 p.m., the administration note read, on order, not in Omnicell, pharm notified pervious shift per nurse [sic]. The nursing note dated 12/4/24 at 12:12 p.m., read, Medication not given, contacted pharmacy and medication will be delivered this evening. NP notified, no new orders. Resident is aware. On 12/10/24 at approximately 9:30 a.m., the director of nursing was interviewed about R111's medication not being available. The DON explained that when medications are not available the staff are to check the Omnicell [an emergency back-up supply], notify the doctor to see if there are any alternate treatment options available or obtain an order to hold the medication. When asked if an order to hold medication is acceptable in lieu of the facility ensuring medications are in house, the DON said no. On 12/10/24 at 11:10 a.m., during a meeting with the facility administrator and corporate staff, they were made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to assist one resident, Resident #121 (R121) out of a survey of 21 residents, with transportation arrangements to an appointment with radiology services. The findings included: The facility staff failed to assist R121 with transportation to a procedure he had been prepped for at the facility. On 12/9/24 at 2:44 p.m., an interview was conducted with facility's scheduler, OS5. OS5 said, there was some confusion about the appointments, but we didn't know about them. The appointment for September 28th we didn't have a time for the pre surgery, so they had to fax us a time, I do remember that. I remember that the transport driver called off and alternate transport was not available but cannot remember all the details and no note in his record about that appointment on 10/1/24. On 12/10/24 at 9:35 a.m., an interview conducted with OS5. OS5 looked up in R121 clinical record on her schedule and verified that R121 had an appointment on 10/1/24, and orders to be NPO (nothing by mouth) the night prior. OS5 was unable to find anything in her notes about why R121 did not go to the appointment. OS5 called to the radiology department at the hospital and had them on speaker phone for the surveyor to hear, the hospital employee confirmed that R121 didn't show up for his appointment on 10/1/24, and she had no notes about that appointment. On 12/10/24 at 9:40 a.m., an interview was conducted with the transport driver, OS8. OS8 said, I remember I was unable to take [R121 name redacted] to an appointment. When I cannot take them, we try to get another transport or family, but if unable we have to reschedule the appointment. On 12/10/24 at 9:50 a.m., an interview was conducted with the director of nursing (DON). The DON confirmed that R121 had an appointment on 10/1/24 according to his clinical record and that he was prepped for his appointment by being kept NPO the night before his procedure. The DON stated that she was not able to confirm that the appointment that he missed was rescheduled due to no documentation about the appointment was in his clinical record. The DON said, missed appointment you should notify provider, and responsible party, reschedule the appointment, notify provider and responsible party and document. Pretty simple, I think. Rearrange transport if ours is unavailable, we will use other transport. On 12/10/24 a review of facility documentation was reviewed. The facility document titled, Resident Rights, read in part, .the resident has the right to be treated with respect and dignity. The facility document titled, Resident Rights, read in part, .resident has the right to fully informed of, and participate in, his or her treatment. On 12/10/24 at approximately 11:30 a.m., an end of the day meeting was conducted with the administrator and corporate staff to discuss the above concerns. The regional nurse consultant stated she had called the vascular physician office and that R121 did not have an appointment there on 10/1/24. The surveyor let the regional nurse consultant the appointment was at radiology department, and she said she would investigate it some more. On 12/10/24 at 12:25 p.m., the nurse consultant gave the surveyor some copies of R121 physician notes. Both notes given to the surveyor were dated after R121's appointment date of 10/1/24, one note was dated 10/4/24, and one was dated 10/14/24. The custom information document of R121's visits to the hospital/physicians was just a summary of visits he had made to the hospital and physicians' offices during the year, but this document had no record of missed appointments, it was only a record of visits made by R121. No additional information was provided prior to exit conference.

Based on observations, resident interviews, staff interviews, and facility documentation review, the facility staff failed to follow the resident food preference for two residents, Resident #103 (R103) and Resident #106 (R106), in a survey sample of 21 residents. The findings included: 1. The facility staff failed to follow the meal ticket and R103's food preference. On 12/9/24 at 12:10 p.m., an observation of the lunchtime meal was conducted. R103's lunch tray was served, according to the meal ticket on his tray, he was supposed to receive salad and soup, neither of those items were present. On 12/9/24 at 12:10 p.m., an interview was conducted with R103 about his lunch meal and meal ticket. R103 stated he was supposed to get soup and salad with two meals every day. R103 said, that generally I will get one or the other and sometimes I don't get either one. On 12/9/24 at 12:15 p.m., an interview was conducted with licensed practical nurse, LPN#5 (LPN5). LPN5 stated that R103 is supposed to have salad and soup on his lunch tray according to the meal ticket. LPN5 stated she would check with the kitchen about the meal ticket and get the items for the resident. 2. The facility staff failed to follow the meal ticket with R106's beverages of choice on the lunchtime meal tray. On 12/9/24 at 12:15 p.m., an observation of the lunchtime meal was conducted. R106's lunch tray was served, and on his ticket, he was supposed to receive hot coffee, fruit punch, and milk. None of those items were present on his lunch tray. On 12/9/24 at 12:20 p.m., an interview was conducted with R106 about his lunch meal and meal ticket. R106 said, I am supposed to get hot coffee because cold coffee isn't good, and I like to get my milk and fruit punch too. Most of the time I don't have anything to drink on my meal trays. On 12/9/24 at 12:25 p.m., an interview was conducted with the certified nursing assistant, CNA#3 (CNA3). CNA3 stated that R106's meal ticket has hot coffee, fruit punch, and milk and these items were not on the lunch tray. CNA3 stated she would go to the kitchen and try to get the items for the resident. On 12/10/24 a review of facility documentation was conducted. The policy titled, Specialized Diets, read in part, .therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. On 12/10/24 at approximately 11:30 a.m., an end of the day meeting was conducted with the administrator and corporate staff to discuss the above concerns. No additional information was provided prior to exit conference.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #111- R111) in a survey sample of 21 residents. The findings included: 1a. For R111, who saw a dental provider outside of the facility, the facility staff failed to document that the resident attended the appointment and failed to have any documentation of the visit in the resident's clinical record. On 12/9/24 at approximately 2:30 p.m., R111 was visited in the dining room. R111 was noted to be non-verbal but able to nod yes and no to questions. On 12/9/24, a clinical record review was conducted. There was a physician order with a revision date of 11/12/24, that read, Appointment- November 20, 2024 @ 9am Affordable Dentures & Implants. There was no further documentation within the clinical chart to indicate if R111 went to the appointment or not, or if there were any recommendations. On 12/9/24 at approximately 3:45 p.m., an interview was conducted with a registered nurse (RN #2), who was the unit manager. When asked about R111's appointment on 11/20/24, at Affordable Dentures, RN #2 stated that the resident attended the appointment and returned with a written cost estimate for the recommended dental work. RN #2 confirmed that no information was within R111's clinical chart and would have expected nursing to document that the resident went to the appointment and returned. RN #2 was asked to provide the surveyor a copy of the estimate provided by the dental provider. RN #2 stated she would get it for the surveyor the next day. On 12/10/24 at approximately 8:30 a.m., the surveyor did not observe RN #2 on the unit and facility staff confirmed that RN #2 was not at the facility that day. On 12/10/24 at 9:02 a.m., the surveyor met with other employee #5 (OE#5), who makes medical appointments for residents. OE #5 recalled that R111 went to the appointment and said, She went because I was with her and they only paperwork they gave her was the cost of something and I gave it to [RN #2's name redacted]. OE #5 went on to show the surveyor that in a calendar system in the computer, that the surveyor didn't have access to, indicated the appointment was completed. On 12/10/24 at approximately 10 a.m., during a meeting with the director of nursing (DON), when asked about resident appointments, she said, There should be an in and out note [indicating when the resident left and returned], the consults are not always uploaded, or they may not have put the orders in until the in-house provider approves. When asked what the importance of documenting that the resident attended the appointment was, the DON said, if we have an emergency I need to know where they are at. The surveyor asked the DON to provide a copy of the estimate provided regarding recommended services for R111. On 12/10/24 at 11:04 a.m., during an end of day meeting with the facility administrator and corporate staff they were made aware of the above findings. The surveyor again requested a copy of the estimate for dental services for R111. No additional information was provided prior to conclusion of the survey. 1b. For R111, who had a blood glucose reading of 24 and was not able to be aroused, the nurse administered glucagon twice but failed to enter the standing order into the electronic record of R111, therefore rendering the record incomplete. On 12/9/24, during a clinical record review, it was noted that a progress note entry dated 11/23/24, read, Pt observed clammy and diaphoretic, unable to arouse. Blood sugar check 24 via fingerstick. Emergency dose of Glucagon given from Emergency stock box. Second dose of glucagon given 15 after first, with blood sugar recheck at 37. Pt able to open eyes but remains lethargic and clammy. According to the physician orders for R111 in the electronic health record, the last entry where Glucagon was ordered/administered was on 8/29/22. According to R111's medication administration record, there was no indication that R111 was administered two doses of glucagon on 11/23/24, as indicated in the progress notes. On 12/9/24 at 3:54 p.m., an interview was conducted with a licensed practical nurse (LPN #3). When asked about standing orders, LPN #3 reported that they do have standing orders but when used, they must enter them into the electronic record of the resident. LPN #3 reported that the surveyor could obtain a copy of the standing orders at the nursing station in the provider communication book. On 12/10/24 at 3:37 p.m., an interview was conducted with the facility's director of nursing (DON). The DON stated, standing orders are entered in the computer [electronic record of the resident] as needed [when executed]. On 12/9/24 at approximately 4 p.m., the surveyor looked in the provider communication book and was unable to find a copy of the standing orders. The surveyor made a request to the facility administration to provide a copy of the standing orders. On 12/9/24, the surveyor received the facility's standing orders that read in part, Diabetic Management (Blood Glucose LESS than 70) . If the patient is unresponsive or unable to swallow and does not have a feeding tube: Administer Glucagon 1 mg IM [intra muscular], Repeat BG [blood glucose] after approximately 10 minutes; if <70 and patient is still unresponsive, repeat Glucagon, After giving second Glucagon dose, if patient is still unresponsive, call 911 and notify provider immediately (unless contrary to advance directives), If BG remains ,70 but patient is conscious, initiate interventions for the conscious patient . On 12/10/24 at approximately 9:30 a.m., the above details with regards to R111 being administered glucagon was reviewed with the DON. The DON was asked again about standing orders and said, it has to meet the criteria, and they have to place the order in the computer before they can implement it. If they don't put the order in, then there is no order. On 12/10/24 at 11:04 a.m., during an end of day meeting with the facility administrator and corporate staff, they were made aware of the above findings. No additional information was provided.

Based on staff observation, staff interviews, and facility documentation the facility staff failed to follow infection control standards on one of three units. The findings included: The facility failed to follow the infection control standards regarding glove use, hand hygiene, and transporting of soiled linen in the hallways. On 12/9/24 at 12:15 p.m., a tour of the nursing facility on unit one was conducted. During the tour of unit one, the surveyor observed a certified nursing assistant, CNA#3 (CNA3) transporting dirty linen in the hallway and holding the linen against her body, with gloves on. CNA3 then removed her gloves and began serving lunch trays without performing hand hygiene. On 12/9/24 at 12:25 p.m., an interview was conducted with CNA3. CNA3 said, I didn't know not to carry dirty linen in the hallways or up against my body. I didn't know not to wear gloves in the hallway, and I just forgot to wash my hands. The director of nursing and the floor nurse educated me on gloves and linen in the hallway and to put dirty linen in trash bags earlier this morning. On 12/10/24 at 11:15 a.m., an interview with the director of nursing was conducted. The DON stated that she knew the surveyor heard her educating the staff on unit one yesterday morning about gloves in the hall, transporting of dirty linen and how to wear their surgical mask. The DON stated, she didn't listen. On 12/10/24 a review of facility documentation was conducted. The facility document reviewed was titled, Prevention of Infection - Laundry and Linen, read in part, .all laundry is handled, stored, processed, and transported in a safe and sanitary method. The facility documentation titled, Infection Control Program, read in part, .development and implementation of written policies and procedures for the prevention and control of infections among residents and personnel. On 12/10/24 at approximately 11:30 a.m., an end of the day meeting was conducted with the administrator and corporate staff to discuss the above concerns. No additional information was provided prior to exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide interventions for the prevention and/or treatment of pressure ulcers for two residents (Resident #15- R15 and Resident #24-R24) in a survey sample of 29 residents. The facility staff also failed to identify a pressure ulcer until at an advanced stage (stage III) for one resident- R15, which was harm. The findings included: 1a. For R15, who was total care, the facility staff failed to identify a pressure wound until it was at an advanced stage of III, with full thickness tissue loss. On 9/30/24 at 10:30 a.m., R15 was interviewed in their room. R15 was not verbally responsive with the surveyor and did not respond when spoken to. On 9/30/24 and 10/1/24, a clinical record review was conducted. According to the most recent Braden scale for predicting pressure score risk, dated 7/25/24, R15 scored 11 out of 23, which indicated high risk for development of pressure ulcers. This assessment also noted R15 was very limited in the ability to respond meaningfully to pressure-related discomfort, was bedfast, completely immobile, and required moderate to maximum assistance in moving. According to R15's care plan, which was last reviewed on 10/7/23, R15 .needs assistance for adl's [activities of daily living] and mobility because of weakness from recent hospitalization , dementia . The care plan also noted I have an actual impairment to skin integrity stage 3 to left buttocks r/t [related to] immobility. On 7/5/24, there was a revision that read, left buttock stage 3 pressure ulcer resolved. There was no indication on the care plan that a stage III pressure wound was identified on 9/24/24 to the sacrum. An additional focus area within R15's care plan read in part, is at risk for skin breakdown because of impaired mobility from weakness, impaired cognition from dementia, incontinence and nutrition status. Care plan interventions included but were not limited to: complete hand checks on LAL [low air loss] mattress to monitor for proper functioning and settings. Float heels while in bed. Follow facility policies/protocols for routine skin monitoring. Report any changes to MD/NP [medical doctor/nurse practitioner], pressure reducing mattress on bed . According to a weekly skin observation conducted on 9/17/24, R15's skin was noted to be intact without any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted. There was also a progress note from the wound care specialist that was dated 9/17/24, which noted, .wound care consulted today for sacrum/low back pressure due to bed deflating which is not found on today's assessment. No wounds noted. Sacrum and back are within normal limits. According to a weekly skin observation performed on 9/24/24, it indicated, an open area to the coccyx, with the additional information that read, buttock: apply NS [normal saline], honey fiber, foam once daily and as needed. A wound evaluation was conducted on 9/24/24, by a facility nurse. The form noted, Type of skin issue: pressure ulcer/injury or suspected deep tissue injury . location: sacrum . facility acquired . date acquired: 9/24/24 . Pressure ulcer/injury stage: Stage III: Full thickness tissue loss. The documented measurements were 4.0 centimeters (cm) in length, 3.5 cm width, and 0.3 cm depth. This evaluation noted that the wound measurements were obtained by a wound care provider and described the wound as follows: . epithelial tissue in the wound bed, serous wound exudate, heavy exudate, heavy dressing saturation, with no odor or tunneling noted. Additional comments on this wound form noted, .cluster measurement awaiting alternate mattress . R15 was seen by the wound care specialist - nurse practitioner on 9/24/24. This progress note read in part, Patient is being seen for evaluation and treatment recommendation regarding pressure ulcer to sacral region. Patient has history of pressure ulcers, is incontinent of bowel and bladder, is mostly bed bound, and depends on staff for assistance with ADLs. Patient's nurse reports some issues with patient's mattress which may have led to development of skin breakdown. Patient was seen last week by this provider with sacrum and back WNL [within normal limits]. Therefore new ulcer present for less than 7 days. Patient does endorse discomfort with cleansing/contact. Partially alleviated with repositioning. This note also evaluated the wound to be a stage III pressure ulcer of the sacral region. According to the nursing progress note dated 9/24/24 at 12:23 p.m., which read in part, Weekly skin observation completed. Stage III pressure ulcer to sacrum. Overall impression: new wound- first observation. See Wound Evaluation Weekly for additional details. On the afternoon of 10/1/24, R15 was observed to be out of bed in a geri chair [medical style recliner]. Facility staff were observed changing R15's air mattress in her room. On 10/2/24 at 8:51 a.m., an interview was conducted with a certified nursing assistant #8 (CNA #8). CNA #8 stated, When the power went out, the newer beds wouldn't work anymore. CNA #8 was asked about R15's bed. CNA #8 stated, [R15's] air mattress was deflating, so I got her up. They said it was fine, but it must have deflated on someone else, and they changed it out. The CNA stated that R15's bed had messed up previously and she was placed on a regular mattress. When asked about R15's skin, CNA #8 explained that R15 is total care for all care needs and was incontinent. CNA#8 said, [R15] got that wound about 2 weeks ago when the mattress was changed. When asked about the length of time R15 was on the regular mattress and without an air mattress, CNA #8 answered, Three to four days. 10/2/24 at 11 a.m., an interview was conducted with the nurse practitioner (NP). When asked if she was aware that R15 had a wound, the NP said, I knew about it because I sign off on it [the wound consultant reports]. When asked if she was aware that the wound was not identified until it was a stage III, the NP stated, I wasn't aware of that. That surprises me. The CNA's [certified nursing assistants] are usually good about identifying the start of skin breakdown. On 10/2/24 at 11:45 a.m., an interview was conducted with the registered nurse #6 (RN #6), who was the 2nd floor unit manager. When asked about R15 and her bed dysfunction, RN #6 stated, When the aide got her up, the air mattress was completely flat. I had put a work order in to have it replaced. I would imagine it was flat a while. When asked if there had been a prior issue with the mattress, RN #6 said, I don't know about the quality of the air mattresses we get around here. They don't inflate like they should. I switched out [R15's] bed and got a new air mattress yesterday. [R15] was put on a regular mattress over the weekend a few weeks ago when it messed up. When asked about R15's wound, RN #6 stated, [R15] had a previous stage III that healed. I'm sure the mattress contributed to the new wound developing. [R15] is totally dependent and incontinent. When asked how the wound was not identified prior to being a stage III, RN #6 said, I don't understand how it would get to a stage III like that because [R15's] skin is checked daily. When asked what interventions were put in place to prevent skin breakdown after being aware that the air mattress was not functioning, RN #6 was unable to identify any additional interventions that had been implemented. According to the maintenance work orders, R15's air mattress had been an ongoing issue. On 2/29/24, two maintenance work orders were entered that read, air mattress not inflating, low pressure, air mattress and air mattress not inflating all the way. On 3/7/24, a work order was entered that read, air mattress low pressure light on. On 4/18/24 another maintenance work order was entered that read, air mattress will not inflate. Pt [patient] is basically laying on metal bars. According to the maintenance work order entered on 9/15/24 indicated that R15 again had an air mattress malfunction. On 9/22/24, another work order was entered regarding R15's bed that read, air mattress needs to be replaced and it noted, placing resident on regular mattress til air mattress can be repaired. Thank you. The bed was not replaced until 9/24/24. R15 was not on an air mattress from 9/15/24 until the afternoon of 9/24/24, at which time the stage III pressure ulcer was identified. There was no indication within the clinical record of any additional or alternate interventions being implemented when the air mattress was noted to be malfunctioning, other than replacing it with a non-air matress. On 10/1/24, two maintenance work orders were entered that read, bed not working, needs to be switched out and needs bed switched out and air mattress. On 10/2/24 in the late morning, a surveyor made observations of R15's sacral wound with the treatment nurse (licensed practical nurse #6- LPN #6). The wound was observed to be open with full tissue loss, but appeared clean with healing tissue present. Also observed was a lightly discolored scar on the left buttock from a previously healed wound. When questioned, LPN #6 confirmed that the new wound was in fact a new wound and not an old wound that had re-opened. On 10/2/24 at 2:33 p.m., an interview was conducted with registered nurse #4 (RN #4). RN #4 reported that R15's bed went out on a weekend, and they had put R15 on a standard mattress. RN #4 said, It would pump up at the head and foot but at the sacrum it wouldn't pump up to support her. [R15] broke down a little bit after that. When asked if this is an ongoing problem with the air mattress, RN #4 said, Occasionally there is an issue, but not every day, but every few months. On 10/2/24 at approximately 2:45 p.m., an interview was conducted with licensed practical nurse #6 (LPN #6), who was the facility's treatment nurse. The treatment nurse explained that R15's .bed deflated and we were getting her a new one. I heard her mattress was changed again yesterday. The LPN #6 went on to explain about the sacral wound and said, This is the second week. The first week we [herself and the wound care specialist nurse practitioner] looked and nothing was there. Then I got a note that it was open, so I looked, and it was definitely open and was a stage III, so we started treatment. This week there has been a big decline, it is longer and there is a little granulation tissue with a little maceration around a small part of it. When asked what type of mattress R15 was on at the time the wound was discovered, LPN #6 identified that it was a regular mattress and not an alternating pressure mattress when the new developed to the sacrum. LPN #6 provided the surveyor with her notes from the wound care rounds performed with the wound care specialist. According to the wound care round notes, R15 was noted to have no wounds noted on 9/17/24. On 9/24/24, R15 was noted to have a stage III pressure wound on the sacrum, which measured 4.0 x 3.5 x 0.3 and had heavy wound drainage. These notes also indicated, . awaiting alternate mattress. According to the wound care round notes dated 10/1/24, R15's wound was documented to measure 6.5 cm. x 2.5 cm x 0.3 cm and also indicated the wound had deteriorated. The facility policy titled, Pressure Injury Prevention and Management was reviewed. The policy read in part, Definitions: . Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors; definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitoring or evaluation of the impact of the interventions; or revision of the interventions as appropriate . Preventative Measures: 1. Preventive interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences. Such interventions may include a. education to the resident/resident representative on risks associated with pressure ulcer/injury. b. Frequent encouragement and assistance with turning, repositioning, shift of weight, etc. c. Use of pressure reducing/relieving support surfaces or devices to assist with pressure redistribution and tissue load . Identification: 1. Staff will be encouraged to promptly report any observation of a change in the resident' skin integrity. 2. Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's clinical record. 3. Observations of new pressure ulcer/injury will be: a. reported to the physician/practitioner for further evaluation and treatment. b. Referred to the designated wound nurse as appropriate . On 10/2/24, during an end of day meeting, the facility administrator, director of nursing, and corporate staff were made aware of the above findings. On 10/2/24 at 7:09 p.m., the facility's corporate staff provided the surveyor with the maintenance work order's regarding R15's air mattress. The nurse consultant stated that R15's mattress was not completely deflated, it was just not functioning properly, she wasn't laying on the bed frame. They went on to explain that all of the mattresses are pressure reducing and she had a pressure reducing cushion when out of bed. When it was further explained that the only issue was not just the mattress dysfunction, but the fact that the wound was not identified until at an advanced stage was problematic and that no additional interventions were implemented when the bed was known to dysfunction, the survey team was then notified that the facility's medical director wanted to speak to the survey team regarding R15. On 10/2/24 at 7:12 p.m., a telephone call was placed to the facility's medical director/physician, as requested. The medical director stated that R15 had a previous wound in the area that had healed and re-opened. The surveyor explained that the resident had a prior wound on her left buttock that had healed, and the current wound was on the sacrum and above the prior wound area. The medical director was asked if he had seen the wound, to which he stated, No. When asked if he was made aware when the wound was identified, the medical director stated, No, I was made aware by reading the wound practitioner's note. The medical director stated that R15 would always have risk factors for development of wounds due to urine and fecal incontinence, recurrent wounds, and other comorbidities. When asked if he would expect staff to identify skin issues prior to them being noted at a stage III, the medical director stated, I would think staff observe the skin with frequent changes and with the location staff may be able to make changes. When asked about an air mattress for R15, the medical director stated, Any resources to help off load the surface areas coming into contact and to offload pressure points instead of one constant pressure point. When asked if the other mattress' that are not alternating pressure mattresses are as effective, the medical directed stated, Other mattresses would limit offloading. The air mattress was the right decision for this patient. 1b. For R15, the facility staff failed to implement preventative interventions to float the heels, and the resident was subsequently found during survey to have boggy heals indicating skin breakdown, at which time interventions were implemented. On 9/30/24 at 10:30 a.m., R15 was interviewed in their room. R15 was not verbally responsive with the surveyor and did not respond when spoken to. It was observed that R15 had a heels up device to offload pressure that was in the corner of the room, on the floor, and not in use. On 9/30/24 additional observations were conducted at 2:43 p.m., and at 4:15 p.m., and the heels up device remained in the corner of the room, on the floor and not in use. On 9/30/24 at 4:20 p.m., certified nursing assistant #6 (CNA #6) accompanied the surveyor to R15's room. CNA #6 confirmed that a pillow was under R15's legs but just under her calves and that R15's feet were resting directly on the bed. When gesturing to the heels up device sitting in the corner of the room, not in use, CNA #6 confirmed that this intervention should be in place/used to prevent pressure. On 9/30/24 and 10/1/24, a clinical record review was conducted. This review revealed that R15's care plan noted I have an actual impairment to skin integrity stage 3 to left buttocks r/t [related to] immobility. On 7/5/24, there was a revision that read, left buttock stage 3 pressure ulcer resolved. Interventions, included but were not limited to: .Float heels while in bed On 10/2/24 at 11:45 a.m., an interview was conducted with the registered nurse #6 (RN #6), who was the 2nd floor unit manager. During the interview, RN #6 was made aware of the multiple observations of R15's heels not being floated. While accompanying the surveyor to R15's room, RN#6 reported that R15 had been identified that day to have boggy heels and treatments had been ordered. When arriving at R15's room, R15's feet were observed to have bunny boots on, which RN #6 removed and confirmed that both heels were boggy, indicating skin breakdown. When asked what interventions were implemented to prevent skin breakdown, RN #6 said, Not enough. On 10/2/24 at approximately 2:45 p.m., an interview was conducted with licensed practical nurse #6 (LPN #6), who was the facility's treatment nurse. The treatment nurse was asked what the purpose of a heels up device is. LPN #6 stated, To make sure the heels are floated so they don't get red or break down. LPN #6 went on to explain that on 10/1/24, R15's . left heel was red. I put an order in today for skin prep and protective boots. When asked when the bogginess was first noted on R15's feet, LPN #6 responded, Yesterday. The facility policy titled, Pressure Injury Prevention and Management was reviewed. The policy read in part, Definitions: . Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors; definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitoring or evaluation of the impact of the interventions; or revision of the interventions as appropriate . Preventative Measures: 1. Preventive interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences. Such interventions may include a. education to the resident/resident representative on risks associated with pressure ulcer/injury. b. Frequent encouragement and assistance with turning, repositioning, shift of weight, etc. c. Use of pressure reducing/relieving support surfaces or devices to assist with pressure redistribution and tissue load . Identification: 1. Staff will be encouraged to promptly report any observation of a change in the resident' skin integrity. 2. Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's clinical record. 3. Observations of new pressure ulcer/injury will be: a. reported to the physician/practitioner for further evaluation and treatment. b. Referred to the designated wound nurse as appropriate . On 10/2/24, during an end of day meeting, the facility administrator, director of nursing, and corporate staff was made aware of the above findings. No additional information was provided. 21875 2. Resident #24's heels were not offloaded when in bed as required in the treatment plan for pressure ulcer care. Resident #24 (R24) was admitted to the facility with diagnoses that included osteomyelitis, chronic pressure ulcers, quadriplegia, heart failure, atrial fibrillation, methicillin resistant staphylococcus aureus and neurogenic bladder. The minimum data set (MDS) dated [DATE] assessed R24 as cognitively intact. On 9/30/24 at 12:02 p.m., R24 was observed in bed. The resident's feet/heels were observed with no elevation or off-loading. Two cushioned booties were observed in the window seal adjacent to the resident's bed. R24 was interviewed at this time about his feet/heels. R24 stated he had chronic pressure ulcers and currently had a pressure ulcer on the left heel. R24 stated he usually had the booties on his feet when in bed to protect the wound and prevent further breakdown. R24 stated staff did not put the booties on last night and he forgot to remind them. R24 stated he had socks on his feet but there had been no elevation or protective booties on since last evening (9/29/24). R24's clinical record documented the resident was currently treated for an unstageable pressure ulcer on the left heel. The most recent assessment by the wound consultant documented an unstageable ulcer measuring 0.5 x 0.8 x 0.1 (length by width by depth in centimeters). The treatment plan for the pressure ulcer included heel offloading with use of booties in addition to turning/repositioning and a pressure reducing mattress. R24's plan of care (revised 9/29/24) documented the resident had chronic pressure ulcers including the heel ulcer. Interventions to prevent complications included treatments as ordered and following facility protocols for prevention/treatment of skin breakdown. On 10/1/24 at 2:05 p.m., accompanied by the wound consultant nurse practitioner (other staff #6) and with the resident's permission, a dressing change to R24's left heel ulcer was observed. R24's left heel ulcer was irregularly shaped with beefy red tissue noted at the center of the wound. There were no signs of infection. The wound consultant was interviewed at this time about R24's heel ulcer. The wound consultant described the ulcer as improved and stated the resident's heels required continued offloading to prevent further breakdown and promote healing. On 10/1/24 at 2:15 p.m., the licensed practical nurse (LPN #1) was interviewed about R24 in bed without the protective booties. LPN #1 stated the booties were part of the treatment plan for the heel ulcer to promote healing and prevent further breakdown. LPN #1 stated R24 usually had them [booties] on. LPN #1 stated the heels should be floated because the resident had a current wound. The facility's policy titled Pressure Injury Prevention and Management (revised 10/19/22) documented, .The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcer/injury .Treatments will be ordered by the physician/practitioner. Treatment and interventions may include .Use of support devices . This finding was reviewed with the administrator, director of nursing, and regional nurse consultants during a meeting on 10/1/24 at 4:20 p.m., with no further information provided prior to the end of the survey.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for five residents (Resident #78, Resident #70, Resident #83, Resident #15, and Resident #106), in a survey sample of 29 residents. The findings included: 1. For Resident #78 (R78), who had a hernia and was scheduled for surgical repair, the care plan was not revised to reflect the hernia being present nor pre-operative instructions/care that the facility needed to provide. On 10/1/24 at 8:34 a.m., R78 was interviewed in his room. R78 reported that he had a knot in his lower abdomen/groin and was scheduled to have surgery. On 10/1/24 and 10/2/24, a clinical record review was conducted. There was no documentation within the progress notes with regards to an upcoming surgery. However, in the miscellaneous tab of the clinical record was a document titled, Doctor Order Sheet, which was uploaded into R78's chart on 9/16/24. The document itself was dated 9/11/24, and read in part, Patient is scheduled to have robotic right inguinal hernia repair possible bilateral with Dr. [name redacted] on [DATE] . According to R78's care plan, there was no documentation regarding the hernia, scheduled surgery or pre-operative measures the facility needed to follow prior to surgery for R78. On 10/2/24 at 11 a.m., an interview was conducted with the facility's nurse practitioner (NP). The NP reported that she was aware of the upcoming scheduled surgery. On 10/2/24 at 11:45 a.m., an interview was conducted with registered nurse #6 (RN #6), who was the unit manager. The unit manager was asked about R78. RN #6 was aware of R78's hernia and scheduled surgery. On 10/2/24 in the afternoon, an interview was conducted with registered nurse #1 (RN #1), who was the care plan coordinator. When asked about R78's hernia and scheduled surgery not being reflected on the care plan, RN #1 stated, I was not aware he was scheduled for surgery. 2. For Resident #70 (R70), who no longer used a white board to communicate, the facility staff failed to revise the care plan to reflect this change. On 9/30/24 at 11:29 a.m., R70 was visited in her room and was noted to be alert but non-verbal. When asked questions, R70 would shake their head yes or no. No communication book or board was observed in the room. On 9/30/24, at approximately 1:30 p.m., a nurse and certified nursing assistant #11 were both asked how they communicate with R70. Licensed practical nurse #5 and CNA #11 both stated that R70 would nod yes and no, in response to simple questions. On 10/1/24, a clinical record review was conducted. According to R70's care plan with a revision date of 1/20/23, R70 had a communication deficit, but . communicates with a white board . On 10/2/24 at 8:23 a.m., R70 was visited in her room again. Observations again revealed no white board being present. When asked about having a white board to write out responses, R70 shook head, indicating No. When asked about having one previously, R70 shook head, indicating No. When asked about ever using a white board, R70 shook head, indicating No. On 10/2/24 at 8:26 a.m., an interview was conducted with CNA #9. CNA #9 reported that R70 . used to have a white board but when her mother bought her the laptop, we use that to communicate. She types things out. CNA #9 revealed that R70 has had the computer for many months. On 10/2/24 in the afternoon, an interview was conducted with registered nurse #1 (RN #1), who was the care plan coordinator. When asked about R70's white board and it not being present, RN #1 stated, I've used the white board. When asked how long ago, RN #1 stated it had been several months ago. 3. For Resident #83 (R83), who sustained a laceration to his lower leg that required treatment and antibiotics, the facility staff failed to review and revise the care plan. On 9/30/24 at 10:34 a.m., R83 was interviewed in his room. R83 reported that he had hit his leg on a drawer, which caused a large gash on his leg. R83 stated that he thought they were going to have to send him out for sutures, since they don't do that at the facility. R83 said, They are dressing it daily, but it has been going on for several weeks. On 10/1/24, a review of R83's clinical record was conducted. According to a progress note by the wound care specialist, R83 sustained the laceration/skin tear on 9/1/24, which measured 5 cm length x 3.4 cm width x 0.2 depth and was noted to have heavy blood-tinged drainage and swelling encircling wound. The note read in part, This wound is expected to have delayed healing. According to R83's physician orders and medication administration record, the antibiotic Cephalexin was ordered three times daily for seven days from 9/17/24-9/24/24, for the treatment of a wound infection. According to R83's care plan, there was no evidence of the skin tear, wound treatment orders, antibiotic therapy, or any other interventions/goals pertaining to the skin tear noted on the care plan. On 10/2/24 in the afternoon, an interview was conducted with registered nurse #1 (RN #1), who was the care plan coordinator. When asked about R83's skin tear not being noted on the care plan, RN #1 didn't respond. 4. For Resident #15, who developed a stage III pressure ulcer, the facility staff failed to revise the care plan to indicate the presence of and the treatment of the wound and failed to revise the care plan when hospice services were discontinued on 11/24/23. On 9/30/24 and 10/1/24, a clinical record review was conducted. According to the weekly skin observation performed on 9/24/24, it indicated, an open area was noted on the coccyx, with the additional information that read, buttock: apply NS [normal saline], honey fiber, foam once daily and as needed. A wound evaluation was conducted on 9/24/24, by a facility nurse. The form noted, Type of skin issue: pressure ulcer/injury or suspected deep tissue injury . location: sacrum . facility acquired . date acquired: 9/24/24 . R15 was seen by the wound care specialist nurse practitioner on 9/24/24. According to the progress note it read in part, Patient is being seen for evaluation and treatment recommendation regarding pressure ulcer to sacral region. Patient has history of pressure ulcers, is incontinent of bowel and bladder, is mostly bed bound, and depends on staff for assistance with ADLs. Patient's nurse reports some issues with patient's mattress which may have led to development of skin breakdown. Patient was seen last week by this provider with sacrum and back WNL [within normal limits]. Therefore new ulcer present for less than 7 days. Patient does endorse discomfort with cleansing/contact. Partially alleviated with repositioning. The note also indicated the wound was a stage III pressure ulcer of the sacral region. According to R15's care plan, it noted I have an actual impairment to skin integrity stage 3 to left buttocks r/t [related to] immobility. On 7/5/24, there was a revision that read, left buttock stage 3 pressure ulcer resolved. There was no indication of the current stage III pressure wound which was identified on 9/24/24 on the sacrum noted on the care plan. According to R15's care plan, which was last reviewed on 10/7/23, it noted R15 needs assistance for adl's [activities of daily living] and mobility because of weakness from recent hospitalization , dementia and now is on hospice care. According to a hospice visit on 11/24/23, R15 was being discharged from hospice services because . no longer terminally ill. patient and family in agreement with discharge plan: yes. Condition at discharge/transfer: good . According to the census tab of R15's chart, R15 was not on hospice care since 11/24/23. On 10/2/24 at 11:45 a.m., an interview was conducted with registered nurse #6 (RN #6), who was the second-floor unit manager, where R78, R70. R83 and R15 resided. When asked about the purpose of care plans, RN #6 stated, care plans are a general picture of the care the patient is supposed to be getting. When asked who is responsible for updating the care plan, RN #6 said, mainly MDS [minimum data set] [the care plan coordinator] but it is also my job. When asked what time frame you can expect the care plan to be updated if a resident has a change, RN #6 said, it should be updated when it is discovered. On 10/2/24 in the afternoon, an interview was conducted with RN #1, the care plan coordinator, in the presence of the director of nursing. RN #1 explained that the care plan is developed to reflect the care the patient requires and receives. RN #1 explained that all staff use the care plan to know what care is ordered for the patient. RN #1 stated that she updates the care plans as well as the unit managers. When asked if a resident has a change or new condition, would that be noted on the care plan, RN #1 stated, yes, the care plan is updated as the resident's condition does change. Review of the facility policy titled, Care Planning- Comprehensive Person-Centered was conducted. The policy read in part, . Comprehensive care plan means an interdisciplinary communication tool developed after completion of a comprehensive MDS and review of the Care Area Assessments (CAAs) . 13. The comprehensive care plan will: a. incorporate identified program areas; b. incorporate risk factors associated with identified problems; . f. identify the professional services that are responsible for each element of care . 14. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan . On 10/2/24, during an end of day meeting the facility administrator, director of nursing and corporate staff was made aware of the above findings. No additional information was provided. 21875 The findings include: 5. Resident #106's plan of care was not revised to include problems or interventions in place regarding poor nutritional status and weight loss. Resident #106 (R106) was admitted to the facility with diagnoses that included osteomyelitis, schizophrenia, diabetes, chronic kidney disease, peripheral vascular disease, protein-calorie malnutrition, adult failure-to-thrive, above-knee amputation, prostate cancer, atrial fibrillation and anemia. The minimum data set (MDS) dated [DATE] assessed R106 with short and long-term memory problems and severely impaired cognitive skills. R106's clinical record documented the resident was assessed with poor intake and low body weight upon admission to the facility. R106 was ordered and administered Boost supplement twice per day staring in May 2024 and a pureed textured diet. Prostat supplement was added twice per day in June 2024. R106 experienced a significant weight loss in August 2024 and Medpass supplement was added twice per day. R106's therapeutic diet was changed on 9/4/24 to a liberalized pureed diet to improve intake. R106's plan of care (revised 9/12/24) documented the resident had dysphagia and body mass index less than 25. Interventions to maintain adequate nutrition and stable weight included dental consult if needed, determine likes/dislikes, diet as ordered, oral care and weight monitoring. R106's plan of care made no mention the resident had experienced significant weight loss and had not been revised to include the liberalized pureed diet or the multiple supplements provided. On 10/2/24 at 8:47 a.m., the licensed practical nurse unit manager (LPN #1) was interviewed about R106's plan of care. LPN #1 stated she initiated the baseline care plan and the MDS coordinator was responsible for care plan revisions/updates. On 10/2/24 at 9:48 a.m., the registered nurse (RN #1) responsible for MDS and care plans was interviewed about R106. RN #1 reviewed R106's plan of care and stated she did not see anything about weight loss or the dietary interventions. RN #1 stated the dietitian was responsible for updating the nutrition portion of the care plan. On 10/2/24 at 10:43 a.m., the registered dietitian (RD - other staff #4) was interviewed about R106. The RD stated the resident was on Boost supplement, Medpass and Prostat to address nutrition issues. The RD stated providers had reviewed and adjusted medications in addition to liberalizing the therapeutic diet. The RD stated she did not know why the weight loss and interventions had not been added to the plan of care. The RD stated she did not update care plans in the electronic health record, and she thought MDS was responsible for care plans. On 10/2/24 at 2:44 p.m., the MDS coordinator (RN #1) was interviewed again. RN #1 stated R106's plan of care had not been revised with nutrition interventions. This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 10/2/24 at 6:20 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interviews, resident interviews, clinical record review and facility documentation review the facility staff failed to provide activity of daily living (ADL) care for three residents (Resident #13 (R13), Resident #43 (R43) and Resident #56 (R56)) of 29 residents in the survey sample. The findings included: 1. The facility staff failed to provide showers for one resident (R13). R13 was admitted to the facility on [DATE]. Diagnoses for R13 included but are not limited to periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter. R13's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 9/6/24 coded R13 with no cognitive impairment. In addition, the Minimum Data Set coded R13 requiring maximal assistance on staff, for Activities of Daily Living care. On 9/30/24 at 10:00 a.m. a tour of the unit one nursing unit was conducted. R13 was observed in her room and sitting in her wheelchair. Her hair was oily in appearance and lower extremities had some dry skin noted. R13's bed was observed unmade and only had the fitted sheet on the bed. On 9/30/24 10:45 a.m. an interview was conducted with R13. R13 stated, the staff has given me one bath since I have been here and the rest of the time, I bathe myself the best I can. I have not had a shower since I have been here and staff is short especially on weekends and my bed has been like it is right now since Friday, unmade. On 9/30/24 12:34 p.m. an interview was conducted with CNA#2. CNA#2 said that we have a shower system. The residents are supposed to get a shower two times weekly. The shower list is divided between the first shift and second shift. The residents bed linen should be changed on shower days. If showers are refused, we are to report to the nurse. We are short staffed all the time and the residents are aware when we are short staffed. On 10/01/24 8:34 a.m. an interview was conducted with the unit manager LPN#1. LPN#1 stated, the showers should be given daily no matter the staffing. On 10/2/24 at 10:30 a.m. a clinical record review was conducted. The ADL documentation was reviewed, and it showed that a shower had been given on 9/5/24, 9/12/24 and 9/19/24. On 9/26/24 there was no documentation and on 9/30/24 NA [not applicable] was documented. The regional nurse consultant stated, NA means it didn't happen and the blank area's we cannot say it did or didn't happen. On 10/2/24 at 11:25 a.m. an interview was conducted with CNA#4. CNA#4 was the author of the showers documented on 9/5/24, 9/12/24, and 9/19/24. CNA#4 stated, I have never given this resident [R13] a shower because she is a second shift shower. The surveyor showed CNA#4 the ADL sheet with the documentation of three showers, that was documented by CNA#4. CNA#4 stated, that is wrong, I did it wrong because I have never showered her because she is a second shift shower. CNA#4 was very adamant about the fact she had never given R13 a shower since she had been at the facility. For 29 days R13 has not had a shower, since her admission. 2. The facility staff failed to get R43 out of bed daily. R43 was admitted to the facility on [DATE]. Diagnoses for R43 included but are not limited spinal stenosis and muscle weakness. R43's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 2/4/24 coded R43 with moderate cognitive impairment. In addition, the Minimum Data Set coded R43 is dependent on staff, for Activities of Daily Living care. On 9/30/24 at 10:30 a.m. an observation was conducted. During the tour of unit one R43 was observed in his room laying in the bed. On 9/30/24 at 3:00 p.m. an observation was conducted and R43 was observed in his room and laying in the bed. On 10/01/24 at 1:55 p.m. an interview was conducted with the unit one's manager, LPN#1. LPN#1 stated, we try to get him [R43] up daily but there are times we cannot I will be honest it's due to not enough staff when we cannot get him up. On 10/1/24 at 2:30 p.m. an interview with R43 was conducted. R43 stated, we have problems getting up every day and it's when they have no staff and I require a Hoyer lift and need 2 people and when they don't have enough staff we don't get up. On 10/2/24 at 9:45 a.m. an interview was conducted with the social service director. The social service director said that the activity director brought to my attention about a month ago that R43 wanted to attend activities daily, but staff refuses to get him up. The social service director said she sent an email with this concern to the director of nursing, activities director and the social worker for unit one. On 10/2/24 at 2:30 p.m. an interview was conducted with the activity's director. The activities director said that she goes and ask the staff to get him up to come to activities and most of the time the staff will. She said sometimes that R43 will decline to get up out of bed and at times there is two aides on the floor and he's not out of bed. On 10/2/24 a clinical record review was conducted. The ADL record showed that R43 remained in bed for 23 days in the month of September. The documentation noted NA on the 23 days by the facility staff. The regional nurse consultant stated, NA means it didn't happen. 3. The facility staff failed to get R56 out of bed daily. R56 was admitted to the facility on [DATE]. Diagnoses for R56 included but are not limited age-related physical debility and muscle weakness. R56's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 9/19/24 coded R56 with no cognitive impairment. In addition, the Minimum Data Set coded R56 requires maximal assistance from staff, for Activities of Daily Living care. On 9/30/24 at 10:30 a.m. an observation was conducted. During the tour of unit one R56 was observed in his room laying in the bed. On 9/30/24 at 4:30 p.m. an interview was conducted with R56. R56 stated, I like to get out of bed daily and I seem to only get up at the most 4 times weekly, due to lack of staff. On 10/01/24 at 1:55 p.m. an interview was conducted with the unit one's manager, LPN#1. LPN#1 stated, we try to get him [R56] up daily but there are times we cannot I will be honest it's due to not enough staff when we cannot get him up. On 10/1/24 at 2:30 R56 voiced a concern during resident council meeting about not being able to get out of bed daily. R56 stated, my preference is to get up daily but if the staff is short, I remain in the bed. On 10/2/24 a clinical record review was conducted. The ADL record showed that R56 remained in bed for 17 days in the month of September. The documentation noted NA [not applicable] on the 17 days by the facility staff. The regional nurse consultant stated, NA means it didn't happen. On 10/2/24, during an end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware of the above concerns. No further information was provided.

Based on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for seven of twenty-nine residents in the survey sample (Residents #20, #24, #56, #70, #27, #76 and #78). The findings include: 1. Resident #24 did not have weights obtained as ordered by the physician. Resident #24 (R24) was admitted to the facility with diagnoses that included osteomyelitis, chronic pressure ulcers, quadriplegia, heart failure, atrial fibrillation, methicillin resistant staphylococcus aureus and neurogenic bladder. The minimum data set (MDS) dated [DATE] assessed R24 as cognitively intact. R24's clinical record documented a physician's order dated 9/9/24 for daily weights for three days, weekly weight for four weeks then monthly weights. R24's clinical record documented a weight on 9/15/24. There was no other weight documented until 9/30/24. On 10/1/24 at 1:42 p.m., the licensed practical nurse unit manager (LPN #1) was interviewed about R24's weights not obtained as ordered. LPN #1 stated R24's weights were supposed to be obtained as ordered. LPN #1 stated the order for weights was listed on the resident's medication administration record so that nurses were aware of the needed weights. LPN #1 stated that nurses were expected to be sure the weights were obtained as ordered and that aides usually weighed residents. LPN #1 stated this order was standard for most new admissions and that all residents were supposed to be weighed at least monthly. This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 10/1/24 at 4:20 p.m. with no other information presented prior to the end of the survey. 2. Resident #76 was not administered the medications enoxaparin sodium, metoprolol, hydrocodone-acetaminophen and calcitonin nasal spray as ordered by the physician. Resident #76 (R76) was admitted to the facility with diagnoses that included hip fracture, coronary artery disease, Alzheimer's, psychosis, mood disturbance, anxiety, atrial fibrillation, and hypertension. The minimum data set (MDS) dated [DATE] assessed R76 with severely impaired cognitive skills. R76's clinical record documented the following physician orders. 9/9/24 - metoprolol tartrate 25 mg (milligrams) two times per day for treatment of coronary artery disease. 9/10/24 - enoxaparin sodium injection prefilled syringe 40 mg/0.4 milliliters - inject 1 syringe daily for 25 days for prophylaxis. 9/10/24 - calcitonin nasal solution 200 units/spray - one spray each day for history of compression fractures. 9/16/24 - hydrocodone-acetaminophen 5-325 mg - 1/2 tablet two times per day for pain management. R76's medication administration record (MAR) documented these medications were not administered as follows. Metoprolol tartrate 25 mg was not administered on 9/23/24, 9/26/24 (two doses), 9/27/24, 9/28/24 and 9/29/24. Enoxaparin sodium 40 mg/0.4 ml injection was not administered on 9/12/24. Calcitonin nasal spray was not administered on 9/27/24 and 9/28/24. Hydrocodone-acetaminophen 5-325 mg was not administered on 9/16/24, 9/17/24 (two doses), and 9/18/24 (two doses). Nursing notes documented these medications were not administered because the medications were on order or not in med cart. On 10/2/24 at 8:54 a.m., the licensed practical nurse unit manager (LPN #1) was interviewed about R76's missed medications. LPN #1 stated the metoprolol, enoxaparin injection and hydrocodone-acetaminophen were available in the Omnicell back-up supply and should have been accessed by the nurse for administration. LPN #1 stated the calcitonin spray was not kept in the back-up supply and was most likely not reordered timely from pharmacy. LPN #1 stated nurses were expected to enter a refill order when approximately five doses of a medication remained. LPN #1 stated some nurses order medications too early and others did not order quick enough to maintain a supply in the cart. LPN #1 stated she was not aware R76 had missed medications. LPN #1 stated there was always a nurse or supervisor in the building with access to the Omnicell back-up medicines. LPN #1 stated the hydrocodone-acetaminophen required a script for refills or Omnicell access but that there was a nurse practitioner available 24/7 for scripts. The facility's policy titled Medication and Treatment Orders (undated) documented, .Drugs and biologicals that are required to be refilled will be reordered from the issuing pharmacy in a timely manner prior to the last dosage being administered to ensure that refills are readily available . The facility's policy titled General Guidelines for Medication Administration (revised 8/2020) documented, .Medications are administered as prescribed in accordance with good nursing principles and practices .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .Medications are administered in accordance with written orders of the provider . These findings were reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 10/2/24 at 6:20 p.m. with no further information presented prior to the end of the survey. 41449 3a. For resident #78-R78, the facility staff failed to carry out a physician order to hold Coumadin, (an anticoagulant), which resulted in the resident having to have his surgery for hernia repair to be postponed. On 10/1/24 at 8:34 a.m., R78 was visited in his room. R78 reported that he had a knot in his lower abdomen/groin and was scheduled to have surgery. On 10/1/24 and 10/2/24, a clinical record review was conducted. There was no documentation within the progress notes with regards to an upcoming surgery. However, in the miscellaneous tab of the clinical record was a document titled, Doctor Order Sheet which was uploaded into R78's chart on 9/16/24. The document itself was dated 9/11/24, and read in part, Patient is scheduled to have robotic right inguinal hernia repair possible bilateral with Dr. [name redacted] on [DATE] and will need to hold his warfarin 5 days prior per verbal order by Dr. [name redacted] . Review of the physician orders revealed no order to hold R78's Coumadin. According to the medication administration record (MAR), R78 was administered the dose of coumadin daily through 10/1/24. On 10/2/24 at 11 a.m., an interview was conducted with the facility's nurse practitioner (NP). The NP reported she was aware of the upcoming surgery scheduled but was not aware that the blood thinner had not been held as ordered. The NP said, We will have to contact the surgery center. On 10/2/24 at approximately 11:30 a.m., the facility administrator and corporate staff were made aware of the above findings. On 10/2/24 at approximately 11:40 a.m., the facility's corporate nurse consultant reported to the survey team that R78's surgery was rescheduled because there was a conflict with the surgery and a dermatology appointment. On 10/2/24 at 11:45 a.m., an interview was conducted with registered nurse #6 (RN #6), who was the unit manager. The unit manager was asked about R78. RN #6 stated that R78 had missed his pre-op appointment on Friday, 9/27/24, but the resident's family was present for the appointment and completed the pre-op. The unit manager went on to say that on Monday, 9/30/24, she had talked with someone at the surgery center, and they asked about the coumadin being held. When RN #6 reported the resident had been receiving the coumadin, they said the doctor wanted to postpone surgery since the order to hold the coumadin had not been carried out. The unit manager went on to say, I think surgery would have been a go had that coumadin been held. His [R78's] son was in my office yesterday and I talked with him, he has another pre-op appointment October 9 and surgery [DATE]. On 10/2/24, during an end of day meeting, the facility administrator, director of nursing and corporate staff was made aware that R78's surgery was postponed due to an order to hold Coumadin not being carried out. No further information was provided. 3b. For R78, who was experiencing constipation, the facility nursing staff administered medication without a physician's order and failed to carry out an order for a fleet's enema timely. On 10/1/24 at 8:34 a.m., R78 was visited in his room. R78 reported that he had not been to the bathroom in 8 days and they were supposed to be in here at 6:30 this morning to give me something and haven't shown up. On 10/1/24 at 8:43 a.m., an interview was conducted with the licensed practical nurse #4 (LPN #4), who was assigned to R78. When notified the resident was reporting he had not had a bowel movement in eight days and reported they were supposed to administer an enema at 6:30 a.m. LPN #4 stated, it didn't show up for me [the order did not appear for her to administer the enema] and when I finish, I was going to check into it. On 10/1/24 a clinical record review was conducted, and a follow-up review was conducted on 10/2/24. On 10/1/24, the review revealed that there was a progress note written on 9/30/24, by the nurse practitioner (NP). This note read in part, . Per reports he has not had a bm in > 3 days. He is not currently on a bowel regimen. He was administered 2 Senna Plus tabs and Miralax yesterday without results . Plan: Start Miralax 17 gm dissolved in water daily Administer FE [fleets enema] now. Monitor for efficacy . According to the medication administration record, there was no evidence of senna, Miralax or an enema being administered. There were no nursing notes with regards to the resident's report of constipation, administration of any medications, or communication with the medical provider. According to a physician order dated 9/30/24, that read, Fleet Oil Enema, Insert 1 application rectally one time only for constipation. According to the medication administration record, this order was not carried out. On 10/1/24 at 9:39 a.m., LPN #4 reported back to the surveyor and stated, I spoke with the unit manager and she put the order in again and brought some fleets enemas up [referring to bringing them from the central supply room to the unit]. On 10/1/24 at 9:45 a.m., an interview was conducted with the unit manager, who was registered nurse #6. She was asked about R78's order for an enema. She stated, it looks like when the NP put it in, it was timed so when it fell off it wasn't communicated. I went yesterday to central supply and brought 2 up here, the nurse yesterday asked me for them, so I don't know why it wasn't given. On 10/2/24 at 11 a.m., an interview was conducted with the NP who had ordered the enema. When asked about the stool softener and laxative she documented was administered, the NP stated, it's a house order, they can do without calling us. The nurse told me she had given it, we have a communication book at each nursing station, where they write things down. So I ordered an enema. I put the order in and spoke with the nurse and gave a 1-hour window for it to be given. When asked if she was aware, it had not been given, the NP said, no. On 10/2/24, an interview was conducted with the facility administrator, director of nursing, and corporate clinical directors, all who reported the facility does not have standing orders or a bowel regime, the nurses have to the call the provider and get orders prior to administering any medications. On 10/2/24, a review of the communication book revealed an entry dated 9/29/24, that was regarding R78. The entry read, Pt [patient] reported to this nurse on 9/24 that he hadn't had a bm that shift. I waited til my next day of work to see if pt had stooled and he did not and that was on 9/26. I gave 2 senna and still no BM that shift. 9/28 pt still reported no BM so I gave a cap full of Miralax and 2 senna plus and pt still has not stooled as of 7-3 shift for today 9/29. Pt has not had BM for days. On 10/2/24, an additional clinical record review was conducted, which revealed R78 was administered an enema at 3:30 p.m. on 10/1/24. On 10/2/24 at 8:40 a.m., R78 was interviewed and reported he had two small bowel movements following administration of the enema on 10/1/24. 3c. For R78, the facility staff failed to carry out a physician order and failed to notify the provider it was not carried out, but to the medication not being ordered from the pharmacy. On 10/1/24 at 8:34 a.m., R78 was visited in his room. R78 reported he was being seen by a dermatologist for various skin issues. On 10/1/24, a clinical record review was conducted which revealed a physician order dated 8/2/24, with a start date of 8/5/24, which read, apply 10-15 drops Clobetasol 0.05% scalp solution to flaking on scalp and ears twice daily two times a day for flaking of scalp and ears for 2 Weeks. That order was noted as discontinued. There was another order dated 8/12/24, that read, apply 10-15 drops Clobetasol 0.05% scalp solution to flaking on scalp and ears twice daily two times a day for flaking of scalp and ears for 2 Weeks. Throughout the nursing progress notes were multiple entries with regards to the Clobetasol order dated 8/13/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, and 8/26/24 that read, on order. A progress note entry was made on 8/3/24, by the nurse practitioner that read in part, . [AGE] year-old gentleman with multiple medical problems seen today for follow up on a scalp abrasion. He has been evaluated by facility wound care team and treatments are in place. See wound care notes for details. He is not responding well to current treatments, and he does have pmh [past medical history] skin cancer of his scalp however details are not available for review. He was seen by Dermatology with new orders in place . Plan: . apply 10-15 drops Clobetasol 0.05% scalp solution to flaking on scalp and ears twice daily Monitor for acute changes/healing Follow up with Dermatology as scheduled Continue all medications as prescribed. According to the MAR, the physician order for Clobetasol was never administered. On 10/1/24, during an end of day meeting, the facility administrator, director of nursing and corporate staff was made aware of the above findings. On 10/2/24, it was reported by the facility administration to the survey team that the order for Clobetasol was not entered as a pharmacy order, and therefore the medication was never ordered from the pharmacy, which is why it was never received or administered. On 10/2/24 at 11 a.m., an interview was conducted with the nurse practitioner. When asked if she was aware that R78 was not administered the Clobetasol as ordered, the NP stated, no. I find out days later they are not getting medications when I go to do a follow-up. The communication really needs to improve. No further information was provided. 4. For resident #70- R70, the facility staff failed to administer insulin as ordered and failed to communicate to the physician that the insulin was being held. On 9/30/24 at 3:59 p.m. R70 was visited in her room. It was noted that R70 appeared to be alert, oriented and was non-verbal. R70 could communicate by nodding her head yes and no. R70 reported she is a diabetic, receives insulin and her blood sugars are not stable. R70 also reported the staff check her blood sugar three times daily. On 9/30/24 and 10/1/24, a clinical record review was conducted. According to R70's diagnosis she had type 1 diabetes. This review revealed an active physician order implemented on 8/30/24 that read, Insulin Glargine Solution 100 UNIT/ML Inject 24 unit subcutaneously two times a day for diabetes. There were no parameters associated with this order that indicated if the resident's blood sugar was under a certain amount to hold the insulin administration. According to the medication administration record (MAR) for September, the Glargine insulin was not administered on the 9 a.m., dose on 9/1/24, 9/7/24, 9/23/24, and 9/27/24. On 9/1/24, 9/23/24, and 9/27/24, a code to indicate parameters out of range was documented. According to the nurse progress notes, on 9/1/24, the entry read, B/S blood sugar] = 166. On 9/7/24, the nurse documented, on order as the reason it was not administered. On 9/23/24, the note indicated, BS 71 and on 9/27/24, the entry read, BS 110. On 10/2/24 at 11 a.m., an interview was conducted with the nurse practitioner (NP). The NP was asked about R70 and the order for Glargine insulin. It was discussed that the order had no parameters of when nursing was to hold the administration, but there were instances of nursing not administering the insulin. The NP stated, typically they will call me, but I was not aware in this case, it requires communication. That is long-acting so I would say give it unless the blood sugar was less than 100, then I would hold it. On 10/2/24, during an end of day meeting, the facility administrator, director of nursing and corporate staff was made aware of the above findings. No additional information was provided. 5. For Resident #27- R27, the facility staff failed to administer a blood thinner for a DVT (deep vein thromobis)/blood clot, as ordered by the physician. On 9/30/24 at 1:05 p.m., R27 was visited in his room. R27 reported he was on a blood thinner and denied any complications. When asked if he gets his medications on time, he said he gets no many he doesn't know what he gets. On 9/30/24, a clinical record review was conducted of R27's clinical chart. This review revealed a physician order dated 8/31/24 to give Xarelto 20 mg tablet daily for DVT (deep vein thrombosis) related to acute embolism and thrombosis. According to the medication administration record (MAR) the medication was not given 9/5/24, 9/21/24, nor 9/22/24. According to the progress notes on 9/21/24 and 9/22/24, it was noted as not given because not available. No explanation was given as to why it was not adminsitered on 9/5/24. On 10/2/24, a copy of the contents of the Omnicell (an emergency/back-up supply of medication) was reviewed. It was noted that Xarelto was available in 10 mg tablets. There was no indication within R27's chart that the provider was made aware that the medication was not available, nor given the opportunity to give an order to give two of the 10 mg tablets that was available in the Omnicell, to equal the scheduled dose. 49456 6. The facility staff failed to follow a physician's order for Resident #20's (R20) daily fluid restriction. On 9/30/24 at 11:00 a.m. an observation was conducted when touring the unit one nursing unit. R20 was observed sitting in her room and holding a cup in her hand drinking a soft drink. There was a full water pitcher on her overbed table observed. On 10/2/24 at 10:05 a.m. an observation made of R20's water pitcher was full and on her over bed table. The water pitcher had 800 milliliters of fluid in the pitcher. On 10/2/24 at 10:10 a.m. an interview was conducted with LPN#2. LPN#2 confirmed that R20 had an order for 1200 cc fluid restriction daily. LPN#2 stated that a full water pitcher should not be on her over bed table. LPN#2 stated that R20's fluids was given with her meals and with her medication pass. LPN#2 was asked if R20's fluids were monitored and LPN#2 stated, we are supposed to monitor. On 10/2/24 at 10:15 a.m. an interview was conducted with the unit one manager (LPN#1). LPN#1 stated, the nurse is supposed to monitor R20's [name redacted] fluid intake and she would not be able to monitor with a water pitcher on the overbed table. LPN#1 said she never thought about a full water pitcher should not be in R20's room because staff would not be able to monitor the fluid intake. On 10/2/24 at 11:00 a.m. a clinical record review was conducted. R20 had a physician's order that read, fluid restriction (1200 cc) BLD [breakfast, lunch and dinner] and med pass per shift that was written on 8/16/24. R20's care plan that was revised on 9/25/24 read in part, .encourage fluids of choice during meals and rounds within fluid restriction orders. R20's progress note written by the registered dietician read in part, .Resident has a 1200 ml fluid restriction in place. R20's treatment administration record (TAR) had the documentation for the monitoring of the fluid restriction daily. There were multiple days on the TAR that the amount of fluid intake was not documented: 9/1/24, 9/2/24, 9/3/24, 9/24/24 and 9/28/24. On 9/11/24 it was documented that R20 received 1680 ml's of fluid intake for the day and on 9/13/24 it was documented R20 had 3200 ml's of fluid for the day. On 10/2/24 at 2:00 p.m. a review of the facility documentation was conducted. The facility policy titled, Resident hydration and Prevention of Dehydration, read in part, .Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increase a risk for dehydration. Nursing will monitor and document fluid intake as ordered by the physician/practitioner or per facility protocol. 7. The facility staff failed to obtain daily weights for Resident #56 (R56) per physician orders. On 10/2/24 at 10:15 a.m. an interview was conducted with the unit one nurse manager. LPN#1 stated that she was not aware the daily weights on R56 was not being done daily. LPN#1 stated that it was not on their 24-hour reports and not one had told her. LPN#1 did confirm the order for the daily weights and that the weights were not being obtained daily. On 10/2/24 at 3:00 p.m. an interview was conducted with R56. R56 stated that he does not refuse daily weights. R56 stated, that the bed scale was broke and the facility had no Hoyer lift sling for him to be weighed with the Hoyer lift so the only way was to transfer him to the wheelchair and go the weigh station down the hall and they don't do that, and no one asks me about weighing me so I cannot refuse. On 10/2/24 at 3:30 p.m. a clinical record review was conducted. R56 care plan had weight per order. On 3/18/24 a physician's order was written to obtain daily weight in the morning and notify cardiology if any weight gain or loss of 3 pounds over night or 5 pounds in a week or increase in heart failure symptoms. R56 had a progress note from 9/10/24, 9/12/24 and 9/29/24 that the bed scale was broken or reading zero and no sling to safely weigh on the lift. R56's weight documentation had several missing days which were, x, x, x, (list the days). There were weights documented for 9/1/24, 9/3/24, 9/4/24, 9/6/24, 9/7/24 and 9/27/24. On 10/2/24 a facility policy titled, Medication and treatment orders, was reviewed and it did not address non-pharmacological physician orders. On 10/2/24, during an end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware of the above concerns. No further information was provided.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide supervision and ensure that safety devices were in place for two of 24 residents, Resident #12 and Resident #3; and failed to maintain a safe environment on one of three units, Unit #2. 1. Resident #12 had a fall in the shower resulting in hip and wrist fractures, and was observed without her tab alarm attached to her clothing on two separate occasions during the survey. 2. Resident #3 was left unattended by a facility CNA (certified nursing assistant), fell and broke her humerus. 3. The 2nd floor janitor's closet was unlocked and accessible to residents on the 2nd floor. Findings were: 1. Resident # 12 was originally admitted to the facility on [DATE] with the following diagnoses, but not limited to: Congestive heart failure, Parkinson's disease, COPD (chronic obstructive pulmonary disease), hypertension and atrial fibrillation. She was sent to the hospital on [DATE] following a fall at the facility and was readmitted on [DATE] after repair of a right hip fracture. The most recent MDS (minimum data set) was a quarterly assessment with and ARD (assessment reference date) of 06/19/2012. Resident #12 was assessed as having a cognitive summary score of 14 indicating she was cognitively intact. On 07/11/2012, at approximately 8:00 a.m., Resident #12 was observed sitting in her wheelchair at her bedside eating breakfast. This surveyor spoke with Resident #12 and asked her if it would be possible to discuss the fall that had occurred a few months ago. Resident #12 stated, "I can talk about that now. I'll tell you what happened. That little girl left me and I fell off the chair. I broke my hip and my wrist." On 07/11/2012 at approximately 8:15 a.m, the clinical record was reviewed. An X-ray report dated 03/30/3012 was observed. The X-ray report read: "Clinical Indication: Pain after fall in shower Findings: Two images of the right hip show a comminuted intertrochantic fracture of the right hip with angulation at the fracture site." Also observed was a second X-ray report dated 04/26/2012 which read: "Clinical Indication: Pain Impression: A transverse, potentially minimally impacted fracture of the distal right radial metaphysis with adjacent soft tissue swelling. A consultation report from a local hospital was also observed. The consult was dated 04/30/2012. It read: "(Name of Resident #12) ...admitted to (Name of facility) following open reduction internal fixation at the right hip... Past Medical History: ...She has relatively severe Parkinson's Disease....She has been undergoing therapy when she started complaining of right wrist pain. There was no history of trauma and x-rays were obtained...x-rays look to show a distal radius fracture that is essentially nondisplaced....there does appear to be some early callous formation radially and ulnarly with increased bone density at fracture...This could have well occurred at the time of her hip fracture or prior to that as well if there had been another fall..." The thinned record was requested and received. The nurse's note section was reviewed on 07/11/2012 at approximately 8:30 a.m. The note for 03/30/2012 was observed, "Called to shower room by CNA (certified nursing assistant) found resident sitting on the floor in front of shower chair. Resident denied pain stated I bumped my head against the wall...assisted off of floor and returned to room...resident noted to have (R) (right) leg shorter and rotated with increased pain..." A Morse Fall Risk assessment dated [DATE] was completed for Resident #12 with a total score of 60. High risk is identified with scores of 51 or higher. The Admission Interim Care Plan documented the following regarding falls: "Falls/Safety risk/elopement risk: Score from Morse Fall Scale: 60 High Risk." Interventions included : "Mobility/Wander alarm; Bed/chair alarms..." Under the physician's orders [REDACTED]. Check placement and function Q (every) shift." The current POS (physician's orders [REDACTED]. On 07/11/2012 at approximately 9:00 a.m., Resident #12 was observed sitting in her wheelchair in her room. There was an alarm box attached to the back of her wheelchair and the tab and the cord attached to the box was observed looped around the handle on the back of the wheelchair and dangling loosely from the chair. The tab was not attached to Resident #12. Resident #12 was asked is she had disconnected the tab from her shirt. She stated, "No, Ma'am!" LPN (licensed practical nurse) #1 was at the nurse's station and was asked to accompany this surveyor back to the resident's room. LPN #1 was shown the tab alarm and she stated, "They must have forgotten to hook that up. I will fix it." When LPN #1 returned to the nurse's station, this surveyor asked if there was a reason the alarm had not been attached to Resident #12. She stated, "No, there is no reason why that should ever be off." On 07/11/2012 at approximately 9:15 a.m. a copy of the facility's investigation regarding Resident #12's fall on 03/30/2012 was requested. Observed was a handwritten statement from the CNA that was assisting Resident #12 with her shower. The statement read: "This morning while giving (Resident #12) a shower she slid from the shower chair on to the floor hitting her head on the edge of the chair and landing on her left hip. The shower chair was locked and she was not moving or trying to reach for anything, but since the chair does not have a hole in the bottom the water and suds from the soap caused her to slip." Resident #12 also had a statement in the record. It had been typed and the resident had signed it. Her statement read, "In regard to the fall in the shower room, (Name of Resident #12) states that she was just sitting on the shower chair, she was not attempting to get up or reaching for anything. (Name of Resident #12) states she just slid off the chair." Per the facility's investigation, the fall was attributed to a shower chair being used at the time of Resident #12's fall. Also observed within the investigation was the following documentation: "(Name of Resident #12) is in a constant state of tremor due to her Parkinson's disease that involves her trunk/core and upper extremities. The fall that occurred in the shower is believed to have been precipitated by the presence of these tremors and the fact that she was soapy and wet in the shower. The fact that the shower seat was a solid cushion seat is also believed to have been a factor. (Name of Resident #12) stated in the interview, 'I wasn't trying to get up or reaching for anything. I just slid off the seat." A corrective action plan was included in the investigation and addressed the five points required for a plan of correction. They were: "1. First aid was administered, and the attending Physician and Responsible Party were notified. (Name of Resident #12) was sent to the ED (emergency department) for further evaluation... 2. The shower chair utilized had a soft cushion, solid seat which is believed to have played a part in her sliding off the chair. Resident states she was not trying to reach for anything or trying to get up. All shower chairs were assessed and this was the only shower chair like this one. This chair was sent to the dump. 3. The facility will only purchase shower chairs with open bottoms that allow water and soap to drain off the seat. Education was also provided to CNA staff regarding shower room safety and fall prevention. 4. Maintenance will not purchase shower chairs with sold surface seats". Also included in the facility investigation was documentation regarding "Falls-shower related" Education included: "Stay with the resident in the bathroom and shower rooms (safety trumps privacy); You may only have one resident in the shower room at a time for privacy, to provide them with constant supervision, and to ensure their safety; Check that all alarm boxes are in the "on: position once the resident has been repositioned in bed or chair; Gather all necessary items prior to going to the shower room with the resident; Allow the resident the opportunity, have the items he/she wants to take to the shower (his too will prevent having to go after items later); Check the shower room to be sure it is available/vacant prior to taking the resident to the area." Sign-in sheets were observed indicating that CNAs had received the training. The DON (director of nursing) was interviewed on 07/11/2012 at approximately 10:00 a.m. regarding the Resident #12's fall. The DON was asked if the CNA who had been in the shower room with Resident #12 was working that day. She stated, "No, she no longer works here...She was terminated for a number of reasons." The DON was asked if the CNA had been in the shower room with Resident #12 when the fall occurred. She stated, "She was in the room, but she had stuck her head around the corner to check on another resident who was on the other side. When she did, (Name of Resident #12) fell ." The DON was asked if the CNA had two residents in the shower at the same time. She stated, "The other resident was dressing, she was just checking on her." The DON also stated, "(Name of Resident #12) has Parkinson's and she shakes really bad. She was soapy and wet and the chair was a solid cushion so the water and soap pooled under her...she slid off the chair." The DON was told that Resident #12 had stated that the CNA had "left her." The DON stated, "She wouldn't know that she would have been facing the shower, not the doorway." The admission MDS was also reviewed with the DON. Resident #12 was assessed as a "3/2" for bathing; indicating she required physical help in part of bathing activity and required the support one person to assist. Under the section G0300, "Balance During Transition and Walking," Resident #12 was assessed as a "2-Not steady, only able to stabilize with human assistance," in the area of: "Moving from seated to standing, moving on and off toilet and surface-to-surface transfer." On 07/11/2012 at approximately 10:25 a.m., this surveyor returned to Resident #12's room. Resident #12 was observed sitting in her wheelchair. Resident #12 was asked if she and the surveyor could talk some more about the fall she had when she broke her hip. Resident #12 stated, "The little girl left me and I slid off the chair." Resident #12 was asked how she knew the girl left and she stated, "I couldn't see her anymore. She walked around the wall...I don't know why but she left me and I slid off the chair." Resident #12 was asked if normally the person assisting with her shower would leave and walk around the wall to the other side. She stated, "No, and it hasn't happened since." Resident #12 stated, "I told them that when it happened that she left me." During the interview the tab alarm was again observed looped around the handle on the back of the wheelchair and not attached to Resident #12. Resident #12 was asked if she had removed the alarm and she stated, "No, but they did take me to the bathroom earlier. I guess they didn't hook it back." LPN #1 was again notified that the alarm was not attached. LPN #1 stated, "It is suppose to be on her all the time." The shower room on on the first floor (where Resident #12 fell ) was observed on 07/11/2012 at approximately 10:45 a.m. When entering the shower room there were two open shower stalls observed on the far right hand side of the room. The stall were open areas divided by a tile wall. There were no doors on the stall. On the wall opposite of the opening was the shower spigot. A shower chair was in front of the spigot. This surveyor was unable to stand at the chair and see around the wall to the next stall. In order to look around the corner, this surveyor had to step away from the chair and walk to the corner to look around the wall. During a meeting with the administrator and the DON at approximately 3:30 p.m. on 07/11/2012 the above information was discussed. The administrator and the DON were told that the points on the plan of correction dealt with the problems with the shower chair and did not address the CNA remaining with the resident. They were also told that part of the education piece provided had dealt with alarms and the tab alarm for Resident #12 had not been attached to her clothing on two separate visits to her room that morning. No further information was received prior to the exit conference on 07/12/2012. 2. Resident #3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive MDS (minimum data set) was a significant change in status assessment with an ARD (assessment reference date) of 02/16/2012. Resident #3 was assessed as having problems with both short and long-term memory and as being severely impaired in cognitive skills for daily decision making. The clinical record was reviewed on 07/11/2012 at approximately 9:25 a.m. Observed within the clinical record was a "Senior Care Services Medicare Daily Documentation" form. The form was dated 2/3/12. Under "Nursing Documentation," at 1205 (12:05 p.m.) was a notation that stated,"Return from LOA (leave of absence)...Spoke with (name) @ (at) MD (physician's) office. While at office pt (patient) got up from w/c (wheelchair) in lobby and fell on sidewalk outside office. (R) (right) elbow noted to be red & (and) swollen. Able to move extremity. Scrape also noted to (R) knee...(Name) NP (nurse practitioner) notified and new order noted for X-ray of (R) elbow. Pt c/o (complains/of) pain when moving extremity..." At 1345 (1:45 p.m.) a notation was made stating, "Resident lying in bed with eyes closed. No c/o voiced. Elbow remains swollen. Will continue to monitor." Notation at 1530 (3:30 p.m.) stated, "Rt (right) elbow more edema. N.O. (new order) to send to ER (emergency room ) for eval (evaluation). Supervisor, (name), RP (responsible party) notified." 1545 (3:45 p.m.) notation, "Son in visiting with pt. (patient)." 1645 (4:45 p.m.) notation, "Transport p/u (pick/up) pt via stretcher's sent to ER. Son to meet pt there. Report called to ER." Resident #3's "ED Chart" record was reviewed 07/11/2012 at approximately 9:40 a.m. Observed within the ED chart was, "DOS (date of service): 2/3/2012 16:55 (4:55 p.m.). CHIEF COMPLAINT QUOTE: 'She fell today while getting her checkup today at the Dr's (doctor's) office and hit her elbow.' Notes: Per pt's son, pt was attempting to stand up from her wheel chair while at her physician's office when she fell over and hit her right elbow. No LOC (loss of consciousness) was witnessed. Onset of Signs/Symptoms, last known well: Friday, February 3, 2012 11:30" HPI (history and physical) text as documented in the ED chart by the ED physician: "Patient presents for evaluation of pain to the right elbow after a fall...This occurred just prior to arrival." Nursing notes as documented in the ED chart: "...02/03/12 16:50 (4:50 p.m.) Patient complains of joint swelling. ...signs and symptoms include swelling and pain in right elbow (s)... Patient complains of musculoskeletal pain. Findings: There is the right elbow (s) is/are painful and markedly swollen. ROM (range of motion) is limited. No dislocation is found..." Final Report of X-ray as noted in ED chart, dated 2/3/2012 17:47 (5:47 p.m.): "RIGHT ELBOW (4 VIEWS): 02/03/12, CLINICAL INDICATION: status [REDACTED]. The humerus is normal. The radius is normal. IMPRESSIONS: 1. Displaced fracture of the olecranon without evidence of dislocation." Discharge from ED documented: "February 3, 2012 20:50 (8:50 p.m.) Discharge plan: The patient is discharged to home after transport arranged. Patient's condition is stable. The patient is to follow-up with Orthopedics (phone number) 6 day (s) from today. The patient is to follow-up with (physician's name and phone number)." During further clinical record review on 07/11/2012 at approximately 10:15 a.m., a History and Physical dated 02/28/2012 was noted. This H&P was written during Resident #3's hospitalization and stated: "INDICATION: ... She had an episode of fall while out at an outside physician's office and suffered an olecranon fracture. She was followed in a splint and followed up with orthopedics who recommended surgical intervention for which she was admitted on ,[DATE]. She had a ORIF (open reduction internal fixation) of right olecranon fracture on 2/2/12 (typo in H&P). Stabilized postoperatively, transferred to LTC (long term care facility, facility name)." On 07/11/2012 at approximately 10:25 a.m., a Discharge Summary dated 02/28/2012 11:11 a.m. was noted and stated: "PROCEDURE/DATE: ORIF of right olecranon fracture on February 27, 2012. DATE OF DISCHARGE: 2/28/2012 - discharged back to (name of facility); her place of residence." A 30-day scheduled, MDS assessment with an ARD of 01/26/2012 was reviewed by the surveyor on 07/11/2012 at approximately 10:40 a.m., and showed no change in Resident #3's mental status in comparison to the significant change, MDS assessment with an ARD date of 02/16/2012. However, in section G0110, on the 30-day MDS, the resident was coded as needing limited assistance for transfers with two plus persons physical assist. Locomotion on the unit was coded as limited assistance with one person physical assist. Locomotion off the unit was coded as occurred only once or twice with one person physical assist. The significant change, MDS, section G0110, coded Resident #3 as needing extensive assistance for transfers with two plus persons physical assist. Resident #3 was coded as needing limited to extensive assistance for locomotion on and off the unit, both requiring one to two person physical assist. Comparison of the MDS with ARD of 01/26/2012 to the MDS with ARD of 02/16/2012 shows a decline of Resident #3's needed assistance with transfers and locomotion on and off the unit, from limited assistance with one person physical assist to then needing extensive assistance with two plus person physical assist. Care Plan's for Resident #3 were reviewed on 07/11/2012 at approximately 10:50 a.m. These care plans were dated 12/18/2011 to 02/03/2012. This resident was noted to have fallen six times during this time period. Interventions included: tab alarms, bed alarm, chair alarm, low bed, fall mats, assist with transfers, bed checks and orient as needed. On 07/11/2012 at approximately 11:00 a.m., surveyor asked the DON (director of nursing) for a copy of the fall investigation. On 07/11/2012 at approximately 11:20 a.m. copies of the fall investigation were reviewed by the surveyor. Included in this investigation were statements made by the receptionist at the physician's office where Resident #3 fell and CNA #3. The receptionist made both a verbal statement to the facility Administrator and also faxed a written statement to the facility. The receptionist's verbal statement to the facility Administrator was taken on 2/3/2012 and stated., "...The aide approached her desk and told her she was going to have to step out for a minute, indicating with her hands that she needed to smoke. The aide went outside the office. Resident (name) was left unattended in the waiting area. Receptionist (name) reported hearing the alarms going off on resident's (name) wheelchair and then seeing resident (name) walk across the waiting room floor to go out the door. The aide asked receptionist (name) to help her lift resident (name) into the wheelchair and then back into the physician office. Resident fell just outside the physician office door." The faxed statement to the facility from the physician's receptionist indicated a fax date of 02/20/2012 13:50 (1:50 p.m.). It stated: "February 7, 2012 (wrong date), To Whom It May Concern: Resident (name) was seen in the doctor's office on 2-6-12 (wrong date). After the patient was checked out the nursing assistant came to my window and said she was stepping outside for a quick 'you know' (smoke break). The patient's wheelchair alarm kept going off and the patient got up and went outside to find her assistant. The patient fell on pavement in which she hurt her arm and leg. The Nursing Assistant and myself had to pick resident (name) up and help her back in her chair. The whole time the assistant was fussing at the patient. Thank You, (Receptionist's Name)." CNA #3's written statement, dated 2/3/2012, stated, "Resident at appt. (appointment) sitting in wheelchair stand up (sic) and walk to door and fell . I as (sic) the receptionist to keep a eye on her. (Resident's name)." Signed by CNA #3. The Administrator was interviewed on 07/12/12 at approximately 10:25 a.m. and was asked if CNA #3 was still employed at the facility. The Administrator stated, "No that she (CNA #3) was immediately placed on suspension that day and never returned to work." Subsequently, CNA #3 was not available for interview. Page 3 of 3, of the "Resident Abuse Investigation Report Form," under corrective action plan was noted on 07/11/2012 at approximately 11:40 a.m. to state: "Employee was immediately suspended pending investigation. Employee was terminated on 2-4-2012." This form was signed by both the DON and the Administrator on 2-4-2012. The Administrator and DON were notified of the above findings at an afternoon meeting on 07/11/2012 with the survey team. No further information or documentation were provided prior to the exit conference on 07/12/2012. 3. On 7/12/12 at 10:50 a.m. the janitor's closet was observed unlocked, making it accessible to all staff, visitors and residents. The janitor's closet is located in a common hallway 15 feet from the nurse's station. At this time it was also observed that there was 1 resident in front of the nurse's station and in close proximity to the janitor's closet. Just after this observation was made, this surveyor requested to talk with the housekeeping staff on the floor. At 10:55 a.m. the housekeeper (OS #5 other staff) assigned to the 2nd floor came over to the unlocked janitors closet where this surveyor was standing and also observed the unlocked door. The contents of the closet included: Mop, bucket, floor cleaner, germicide, liquid soap, and floor stripper. During an interview with OS #5, OS #5 verbalized the janitors closet is supposed to be locked at all times. OS #5 also verbalized that she was the only housekeeper working the 2nd floor and she had forgotten to lock the door. The above finding was brought to the attention of the administrator and director of nursing during a facility/surveyor meeting on 7/12/12 at 11:30 a.m. The administrator gestured understanding but provided no other information prior to exit conference on 7/12/12.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to safely transfer one of 14 residents, Resident #1. Findings were: Resident #1, an [AGE] year old female, was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 06/12/2012. Resident #1 was assessed as having both short and long term memory loss as well as being severely impaired in daily decision making skills. Under the areas of Functional Status, Resident #1 was coded as being totally dependant and requiring the assistance of two persons to physically assist with toilet use. Under the area of Balance during Transitions and Walking, Resident #1 was coded as "Not steady, only able to stabilize with staff assistance" for "moving on and off toilet." Under the area of Functional Limitation in Range of Motion, Resident #1 was coded as having impairment on one side for upper extremities and both sides for lower extremities. On 09/05/2012 at approximately 2:10 p.m. the clinical record was reviewed. Observed on the POS (physician's orders [REDACTED]." The unit manager, LPN (Licensed Practical Nurse) #1 was asked what the order meant. She stated, "In the mornings (Name of Resident #1) wants to get out of bed and refuses help. She grimaces during transfers, I think it is due to her severe arthritis. We talked about it and thought the Sara Lift would be easier on her and not cause pain. She doesn't seem to mind it...we don't use it all the time." On 09/05/2012 at approximately 2:40 p.m. this surveyor walked to Resident #1's room, the door was closed. This surveyor knocked and after the knock was acknowledged this surveyor entered the room. Resident #1 was observed sitting in her wheelchair in the bathroom doorway, two staff members were in attendance with her. One was the hospice nurse, (Other staff #1) who was in the facility to see Resident #1 and the other was one of the floor nurses, LPN #2. The hospice nurse stated, "She is getting ready to go to the bathroom." This surveyor stated that she would like to observe the transfer. LPN #2 stated, "I am getting ready to go get the CNA (certified nursing assistant) because I have never transferred her before." The bathroom had two doors one leading to Resident #1's room and the other leading into another resident's room. LPN #2 left through the door going into the other resident's room. Three CNA's returned to the bathroom through the same door, CNA #3 left to go assist another resident, leaving CNA #1 and #2 in the bathroom with Resident #1 and the hospice nurse. Resident #1's wheelchair was backed up into her own room and the door was closed leading into the bathroom. CNA #1 and CNA #2 pulled a bedside toilet over beside the wheelchair. A walker was placed in front of Resident #1 and she was asked to stand up. Resident #1 placed her hands and on the walker and was assisted to a standing position by the two CNAs. The cushion alarm on the wheelchair did not sound when Resident #1 stood up. The bedside toilet was pulled up behind her and Resident #1 sat down. Her pants had not yet been pulled down and Resident #1 was asked to stand again. Resident #1 placed her hands on the walker and was assisted into a standing position with CNA #1 grabbing Resident #1 by the waistband on the back of her pants to lift her and CNA #2 putting her arm under the arm of Resident #1. The pants and brief were removed and Resident #1 sat back down on the toilet. A sign was observed over the head of Resident #1's bed which read: "Sara Lift @ times of agitation and refusal." CNA #1 and CNA #2 were asked what the sign meant. CNA #1 stated, "I have never used the lift with her. I can usually talk her into standing up and using her walker." CNA #2 stated, "Sometimes she doesn't want to get up or do things when we need her to do them, like get out of bed, so we use the lift." While Resident #1 was on the toilet this surveyor stood behind her at the head of her bed. Resident #1 was facing the bathroom door and the two CNAs were standing in front of her. An activities calendar for September was observed on the bathroom door. Resident #1 was reading the calendar and talking about the month of September. "September...2012...My sister's birthday..." During this time CNA #1 and CNA #2 were removing arm protectors from Resident #1. Resident #1 became distracted and began rolling the arm protectors up and at one point appeared to be trying to get them back on. CNA #2 offered Resident #1 toilet paper and stated, "I'll trade you." Resident #1 took the toilet paper and began rolling it up in the arm protectors, CNA #2 continued asking Resident #1, "Can you stand up...we need to get you back in your wheelchair...can you stand up...let's stand up (Name of Resident #1)." This continued for several minutes. Resident #1 was preoccupied with the sleeve protectors and would stop and make make comments to the CNAs "You can go marching...call my husband and he will tell you what I should do." At approximately 2:50 p.m., CNA #3 opened the door of Resident #1's room. Resident #1 was still sitting on the bedside commode facing the bathroom door. CNA #3 asked if the lift was needed and left the room to go retrieve it. She returned to the room with the lift. She asked CNA #1 and #2 how they were going to get the lift in front of Resident #1 to get her up. CNA #1 and CNA #2 picked the bedside commode up off of the floor and turned Resident #1 around to face the doorway where the Sara lift was located. Resident #1 became immediately agitated and started yelling, "I am not getting on the damn thing...I hate that damn thing...Help! Help!...I am not getting on that damn thing...Help! Help! Open the door...Help! Help!" CNA #3 attempted to calm Resident #1 down and stated, "Will you use your walker to stand up and get back in your wheelchair so we don't have to use the lift?...(Name of Resident #1) we can't open the door yet you're half naked, you don't want the men out there to see you..." Resident #1 continued to yell out that she was not getting on the lift, help and open the door. The three CNA's began working to get Resident #1 in the lift. CNA #2 and CNA #3 began pulling Resident #1 forward by her arms and pushing on her back to get her to lean forward so the lift sling could be placed behind her. Resident #1 was resisting the entire process. Resident #1 placed her feet on the floor and began pushing back on her bedside commode, she grabbed at the CNA's arms, she continued to yell, "Help! Help!" CNA #1 stated, "Watch her don't let her tip back." After the lift sling was in place, the lift was moved forward by CNA #1 and hooked to the Sara Lift. Resident #1's feet had been placed on the foot support and the leg strap had been applied. Resident #1 was then lifted into the air using the Sara Lift. Resident #1 never became erect or in a standing position. She was in a cradled position in the air while her new brief was applied and her pants pulled up. The lift was then repositioned and Resident #1 was carried in the air and lowered to her wheelchair. Resident #1 was unhooked from the lift, the sling removed and CNA #3 immediately opened the door and stated, "Look (Name of Resident #1) the door is open, let's go find you some help. Resident #1 was wheeled from the room in her wheelchair at 2:55 p.m. Her new arm protectors had not been applied. At approximately 3:05 p.m., the unit manager, LPN #1 was made aware of the transfer process that had just been observed by this surveyor. LPN #1 was asked if this was the way she expected the lift to be used. LPN #1 stated, "No ma'am." LPN #1 stated the lift was to be used to get her up because it caused her discomfort to stand. LPN #1 was asked if the bedside commode was to be used to lift residents up and turn them around when needed. She stated, "No, they should have called for help." A copy of the policy and procedure for Sara Lifts was requested. Resident #1 was observed in activities on the second floor at approximately 3:30 p.m. Her arm protectors were not on her arms. During an end of the day meeting on 09/05/2012 at approximately 4:00 p.m., the administrator, the DON (director of nursing) and Administrator #2 were informed of the above information. Administrator #2 stated that there was no policy or procedure on the use of the Sara Lift. The administrative team was asked how CNAs were educated on how to use the equipment. The administrator stated that the CNAs go through orientation and are taught about the lifts and then work with another CNA to observe and obtain hands on experience. She stated that they work with another CNA for a month before coming off of orientation. A copy of the orientation process was requested as well as a copy of the facility's operator's manual for the Sara Lift. Any screenings done by physical therapy for the use of the lift were also requested. On 09/06/2012 at approximately 7:45 a.m., the clinical record was again reviewed. Observed in the physician order [REDACTED]. "09/05/2012 PT (physical therapy) screen for transfer" "09/05/2012 D/C (discontinue) Sara lift as needed for transfers during times of agitation and refusal." At approximately 7:55 a.m., this surveyor observed a new sign above the bed of Resident #1. This sign read: "2 person assist" for the type of transfer. On 09/06/2012 at approximately 8:00 a.m. CNA #3 was interviewed about the transfer of Resident #1 the day before. CNA #3 stated, "It was a mess...everything that could have went wrong did...it was a mess." CNA #3 was asked about using the bedside commode to turn the resident around. She stated, "That was bad...we should have just given her more time...it was a mess." On 09/06/2012 at approximately 8:20 a.m., CNA #2 was interviewed about the transfer the previous day with Resident #1. She stated, "I felt pressured because you were in there...we should have called for help...I thought you were timing us." CNA #2 was asked if this surveyor had given any verbal or nonverbal communication to indicate that she was being timed or that she should hurry. She stated, "No, that is just how I felt." CNA #2 was asked about picking up the bedside commode to turn Resident #1 around so the Sara Lift could be used. She stated, "We were very careful...we didn't pick her up very far (CNA #2 indicated the distance with her thumb and forefinger to approximately 1-2 inches)...we weren't rushing her, we were taking our time..." While waiting to speak with CNA #1 the administrator was sitting at the nurse's station. She stated, "I have some information for you." The administrator was asked if this was verbal information or if she had documentation to present. She stated, "Both...I interviewed the three girls last night involved with (Name of Resident #1)." The administrator was asked if she had spoken to them on the phone. She stated, "No, I had them come in...I interviewed them and we talked about what they should have done and how they should have handled the situation...they each wrote a statement of what had happened...they also are assigned with other more experienced CNAs today so they can see how things can be done differently." CNA #1 was interviewed at approximately 8:40 a.m. on 09/06/2012. She was asked about the transfer process for Resident #1. She stated, "I feel bad about the whole thing...I can always get her to do for me...we had too many people in there...I really feel bad for (Name of Resident #1.)" CNA #1 was asked about picking up the bedside commode and using it to turn Resident #1 around in the room. She stated, "No, we don't do that...I feel bad about the whole thing...I felt pressured." At approximately 9:20 a.m., the DON and the administrator came to the conference room to speak with this surveyor. They stated that CNA #1 had worked at the facility since 08/15/2012, CNA #2 was hired 06/20/2012 and CNA #3 was hired 06/18/2012. The administrator stated that all three had completed orientation and had worked with another CNA for at least one month. It was pointed out to the administrator that CNA #1 had worked at the facility for only 3 weeks total. The Education Coordinator, RN (registered nurse) #1 was interviewed on 09/06/2012 at approximately 9:30 a.m. She stated that all CNAs are trained on all lifts and given hands on experience. RN #1 was asked how a new CNA would get information on how to do a lift if he/she were unsure of the process at the time the lift needed to be completed. She stated, "They would ask a more seasoned CNA." The Education Coordinator was asked how it was determined which type of lift/transfer should be used for each resident. She stated, "It would be discussed in the team meeting and decided. Usually a nurse and physical therapist would be present but not always." On 09/06/2012 at approximately 10:00 a.m., RN #1 returned to the conference room. She had a black book in her hand and stated, "This is one of the books we keep on each floor. It has the CNA care plans in it and there is a copy of the operating instructions for the Sara Lift in each one." No further information was provided prior to the exit conference on 09/06/2012.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to provide supervision to prevent accidents that resulted in injuries for two of 31 residents, Resident #4 and Resident #3. 1. Resident #4 was assessed as requiring extensive assistance of two to transfer on and off the toilet. On two separate occasions, one CNA (certified nursing assistant) transferred Resident #4 from the wheelchair to the toilet resulting in falls with fractures: a. 09/11/2010 impacted left femoral neck fracture b. 06/15/2011 nondisplaced distal ulnar fracture 2. Resident #3 was not provided supervision during toileting. The findings include: 1a. Resident #4 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. His [DIAGNOSES REDACTED]. The most MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 05/17/2011. Resident #4 was assessed as having problems with short term memory and moderately impaired with daily decision making skills. Om 06/28/2011 at approximately 3:30 p.m., the clinical record was reviewed. Observed in the clinical record was a history and physical from a local hospital dated 09/15/2010. According to the report, "on 09/11/2010 pt (patient) had an episode when he had been transferred from the toilet to the wheelchair. His left leg gave way and he sat on the floor...found to have a hip fracture. He underwent percutaneous screw fixation on 09/13/2010. The MDS assessments were reviewed at that time for functional status. An MDS with an ARD of 08/17/2010 assessed Resident #4 as requiring extensive assistance with one person to physically assist for transferring on and off the toilet. On 06/29/2011 at approximately 8:30 a.m., the clinical record review was continued. The thinned record was requested from the DON (director of nursing.) The record was received at approximately 9:30 a.m. The nurse's notes were reviewed. The monthly nursing summary completed on 08/16/2010 was observed. Resident #4 was assessed as as requiring extensive assistance with toilet use and the the physical assistance of two + (plus) persons. The following nurses' notes were reviewed: ? 09/11/2011 "1830 (6:30 p.m.) Res (resident) sat on floor when being transferred from toilet to wheelchair. No injuries noted. ROM (range of motion) good. VS (vital signs) stable. Family and physician notified. Will continue to monitor." ? 09/12/2011 "0210 (2:10 a.m.) Resident c/o (complaining of) L (left) leg very painful. Wants to go to ER (emergency room .) (Name of physician) notified. New order received to send to ER for eval (evaluation.) Message left on POA (power of attorney) phone. The care plan for the time period of the fall was reviewed. The care plan contained a problem to address falls: "Res requires extensive assistance for all ADLS (activities of daily living) d/t (due to) decreased mobility r/t (related to) CVA..." The start date for this problem was 12/23/2009. Under the approach section were ten interventions to address the problem. Intervention number four stated: "Up in w/c (wheelchair) daily as tolerated. Assist c (with) transfer-gait belt or 2 person assist." The second problem statement listed was: "Potential for falls and falling injury due to decrease in mobility d/t CVA, Lt hemiparesis. Has had some weakness and legs give way at times on him." The start date for this problem was 12/23/2009. There were ten interventions listed under the approach section for this problem. The eighth intervention stated: "Gait belt or 2 person assist for transfers." Both of the problems on the care plans had review dates of 03/17/2010, 06/07/2010 and 08/23/2010, indicating that the problems were to be continued. The administrator was interviewed on 06/29/2011 at approximately 10:00 a.m. She was asked how many CNAs had been with Resident #4 when he fell on [DATE]. She stated, "One." She was asked if the care plan and the monthly nursing summaries stated he needed two people to transfer why would one CNA be doing it alone? She stated, "He usually did pretty good with just one. We never had any problems before that fall." The administrator was asked if there were any investigations/documentation regarding the fall on 09/11/2011. The administrator presented three e-mails she had received regarding the fall. The first e-mail was dated 09/12/2010 and was written at 8:42 p.m., by the nursing supervisor. The e-mail stated: "At 6:30 p.m. (name of CNA #5) was attempting to transfer (Resident #4's name) from commode to w/c. She had (Resident #4's name) stand up and ask (sic) him to hold on to the railing while she pulled his pants up. (Resident #4's name) started to go down, sat on the arm of the wheelchair and continued to go down to the floor. (Names of staff) got (resident #4's name) up and into wheelchair....We were not able to identify any problems...I (writer of the e-mail) reported the fall to (name of staff member) at change of shifts." The second e-mail also dated 09/12/2010 and was written at 8:54 p.m. The e-mail was written by CNA #5. The e-mail stated: "I took (Resident #4's name) to the bathroom and he stood up fine to get on the commode. When he stood up to get back in his chair I instructed him to hold onto the rail so I could pull up his brief and pants. He began to go down slowly at first so I told him to wait and stand back up so I could help him get in his chair but he continued to go down. He sat on the arm of the wheelchair and slipped off and went down to the floor with his head and shoulders against the wall. The position I was in prevented me from stopping him from going down." The third e-mail was dated 09/16/2010 and was written at 7:04 p.m., by a staff member. The e-mail stated: "...this is in reference to (room number of Resident #4) fall. CNA called me into room, supervisor was called too. Resident was found on floor in bathroom, CNA states he sat in the floor trying to transfer to wheelchair..." An afternoon meeting was held at 3:00 p.m. 06/29/2011 with the administrative team including the DON (director of nursing) the administrator and the managing director of senior care services. They were notified of the above findings during that meeting. The team was asked how CNAs coming to work a shift knew what to do/how to care for each resident. The administrator stated, "They get report from the CNAs getting off, also sometimes from the nurses or the unit manager." She stated there was "no Kardex or care plan for the CNAs to follow. They take notes so they know what to do with each resident." The unit manager for unit #1, LPN (licensed practical nurse) was interviewed on 06/30/2011 at approximately 9:00 a.m., regarding the difference in the toileting/transfer recommendations from the MDS (ARD 08/17/2010) to the care plan to the monthly nursing summary dated 08/16/2010. The unit manager stated, "The monthly summary and the care plan are what we should go by...the monthly summary is done based on what is happening with the resident everyday...Jimmy is weak on his left side and always needs the assistance of two people." The unit manager was asked if the care plan interventions regarding transfer using a gait belt or two people included getting on and off the toilet. She stated, "Yes." The CNA (certified nursing assistant) #5, who was transferring Resident #4 on 09/11/2010 when he fell , was interviewed on 06/30/2011 at approximately 10:00 a.m. She stated that she had not cared for Resident #4 in months. She stated that she had always transferred Resident #4 by herself. She was asked if she had used a gait belt and she stated, "No." CNA #5 was asked if she had gotten report on Resident #4 the night he fell and she stated, "I don't really remember that has been so long ago...I'm sure I did." CNA #5 was asked if she had been told that two people were needed to transfer Resident #4 and she stated, "I don't think so...I really don't remember...but I always just did it by myself." No further information was obtained prior to the exit on 06/30/2011. 1b. On 06/28/2011 at approximately 1:15 p.m., during initial tour of the facility, Resident #4 was observed sitting in his wheelchair in the hallway. His left forearm was elevated on a pillow, a splint was present on the left forearm, an icepack was over the left forearm, the left hand was swollen, a skin tear present on the top of the hand and the hand was in a closed position. Per LPN (licensed practical nurse) #7, who was giving a brief description of the residents on the unit, Resident #4 had fallen a few days ago while transferring in the bathroom with a CNA in attendance and had broken his wrist. Resident #4 stated, "It hurts..." when asked about his wrist and swollen hand. On 06/28/2011 at approximately 3:30 p.m., the clinical record was reviewed. Noted in the history and physical section of the clinical record was a consultation report dated 06/19/2011 from a local hospital. According to the consultation, "He unfortunately suffered a fall in the bathroom striking his left hand and wrist...lateral and oblique (x-rays) indicate a nondisplaced ulnar fracture just proximal to the distal metaphysis." The MDS assessments were reviewed at that time for functional status. An MDS with an ARD date of 05/17/2011 coded Resident #4 as requiring extensive assistance and two persons to assist him with transfers on and off the toilet. On 06/29/2011 at approximately 8:30 a.m., the clinical record review was continued. The monthly nursing summaries were observed. The April 2011 assessment coded Resident #4 as needing extensive assistance with two persons for toilet use. The monthly assessments for May and June 2011 coded Resident #4 as needing extensive assistance and the help of one person for toileting. The unit manager, LPN #4 was interviewed at 8:45 a.m. about the monthly assessments. The unit manager was asked what had changed with Resident #4 to decrease the assistance needed for toilet use. She stated, "Those assessments are incorrect. He has always needed two people to transfer him on and off the toilet." She was then asked, how many CNAs were with him when he fell and fractured his wrist on 06/11/2011. She stated, "One...she is a new CNA. She didn't understand that there should be two people. She transferred him by herself and he fell ." The nurse's notes section was reviewed at that time. A note was written on 06/15/2011 which stated, "1710 (5:10 p.m.) Called to room observed resident in B.R. (bathroom) in floor. CNA states he lost balance & (and) fell when transferring from commode to w/c (wheelchair.) Noted left hand skin tear cleaned & steristrips applied... Notified (name of physician) order received to send to ED (emergency department) for eval (evaluation.) On 06/15/11 the following note was written: "2300 (11:00 p.m.) Resident returned from ED via transport. Resident has splint to L (left) hand...ice applied to L hand. Hand up on pillow. Some swelling noted to fingers on L hand." The care plan was reviewed at that time. The care plan contained a problem, "Potential for falls and falling injury due to decrease in mobility due to CVA (cerebral vascular accident/stroke.) Lt (left) hemiparesis. Approaches included "Transfer X (times) 2 assist." Per the Unit Manager this meant two people were to transfer him which included from the wheelchair to the toilet. The administrator was interviewed on 06/29/2011 at approximately 10:00 a.m. She was asked about the fall that occurred on 06/15/2011. She was asked how many CNAs had been assisting Resident #4 and she stated, "One." The administrator was asked why the CNAs were not following the recommendations on the assessments, the MDS summaries and the care plans, She stated, "Resident #4 usually does pretty good." The administrator was asked if there was any documentation/investigation regarding the fall. A summary was presented which stated, "On 06/15/2011, (name of Resident #4) was in bathroom being assisted to wc (wheelchair) from commode. CNA was present in bathroom with resident. Resident stated "he lost his footing." Resident has a contracted left hand. Resident does not have a history of falls. resident sustained [REDACTED]. Resident is now a 2 person transfer." This summary was discussed with the administrator. The administrator was reminded that Resident #4 had also fallen in September 2010 resulting in a Left femur fracture requiring surgery and that he had been care planned as a two person transfer since December 2009. The MDS with an ARD date of 05/17/2011 was also discussed which coded Resident #4 as requiring exstensive assistance of 2 + people for toileting. The administrator nodded her head, yes. On 06/29/2011 at approximately 2:00 p.m., Resident #4 was interviewed about his fall on 06/15/2011. Resident #4 stated that there was only one CNA with him when he fell . He stated, "I don't think she knew what she was doing. She put the wheelchair beside me instead of behind me...I fell in the floor." Resident #4 stated, "I am suppose to have two people with me to help me get on the toilet." An afternoon meeting was held at 3:00 p.m. 06/29/2011 with the administrative team including the DON (director of nursing) the administrator and the managing director of senior care services. They were notified of the above findings during that meeting. The team was asked how CNAs coming to work a shift knew what to do/how to care for each resident. The administrator stated, "They get report from the CNAs getting off, also sometimes from the nurses or the unit manager." She stated there was "no Kardex or care plan for the CNAs to follow. They take notes so they know what to do with each resident." On 06/29/2011 at approximately 3:45 p.m., CNA #2 was interviewed. CNA #2 was with Resident #4 when he fell . CNAs #2 was asked what she remembered about the fall. She stated, "It was my first time with that group of residents. I didn't know that he was suppose to be a two person transfer, no one told me that." CNA #2 was asked who she had gotten report from on the day of the fall and she stated, "The day shift CNAs. I would have remembered if she had told me he was a two person transfer...I write down everything they tell me and I keep my notes with me during the shift to look at." No further information was obtained prior to the exit conference on 06/30/2011. 2. Resident # 3 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to an Annual MDS (Version 2.0), dated 9/21/10, the resident was assessed under Section B (Cognitive Patterns) as having short and long term memory problems with moderately impaired daily decision making skills. According to a Quarterly Review MDS (Version 3.0), dated 3/8/11, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired. Review of the Nurse's Notes revealed the following entry: 3/30/11 - 12:10 p.m. "Res (Resident) found sitting on floor in the bathroom (with) her back against the wall. Res. stated she was sitting on the commode (and) felt dizzy (and) slid off the commode. VS (Vital Signs) T (temperature) 98.1, P (pulse) 90, Resp (respirations) 20, B/P (blood pressure) 102/60, O2 (oxygen) sat (saturation) 95% R/A (on room air). Skin warm (and) dry to touch. Denies pain. Res. assisted up to w/c (wheelchair) (without) difficulty (with) assist of 3 staff. Res. having difficulty standing, was assisted by 2 to stand res. No reddened area or bruising noted at this time. Will monitor for r/o (rule out) pain, bruising." Review of Resident # 3's care plan revealed the following problem, "Risk for falls with history of falls, occasionally attempts to transfer self from her wheelchair." The goal for the problem was, "Resident will have no significant injury from falls by the next review." Included as an approach to the stated problem was the following, "Toilet resident frequently, staff to remain in room with resident when on toilet." Following a similar fall in the bathroom on 11/2/10, a handwritten problem, goal and approaches was added to Resident # 3's care plan. The added problem was, "Found on floor in B. R. (bathroom), stated she was transferring from commode to w/c." The goal for the added problem was, "Res. will have no significant injury from fall next review." Included as approaches to the added problem were, "Continue interventions; and, Stay (with) res in B.R...." During an end of day meeting with the administrative staff at 4:00 p.m. on 6/29/11, which included the Administrator and Director of Nursing, the surveyor requested a copy of the investigation report of the resident's fall on 3/30/11. On 6/30/11, the surveyor was advised there was no investigation report, but a copy of a Post Fall Assessment Form was provided. The Post Fall Assessment Form included the following questions and responses: "Location: Bathroom Incident Was: Found on floor (unwitnessed) Time of Incident: 1210 (12:10 p.m.) Severity: No Injury Was Staff Present: No" During an end of day meeting with the administrative staff at 3:15 p.m. on 6/30/11, the surveyor pointed out that the presence of a staff member while the resident was in the bathroom had been in the resident's care plan since it was originally written on 9/28/10.