Every finding on record at Helen Porter Healthcare & Rehab

Based on observation and interview, the facility failed to take and record food temperatures prior to meal service in accordance with professional standards for food service safety. This has the potential to impact all residents. This is a repeat deficiency for this facility, with the violation cited during the previous two recertification surveys, dated 8/27/25 and 6/5/24. Findings include: Per record review, the facility maintains temperature logs verifying that the temperature of foods meets professional food safety standards. Temperatures are supposed to be logged for both cold and hot foods for each meal that is served in the facility. Standards for acceptable temperatures are listed on the documentation log form used by facility kitchen staff, stating Cold food temperature is 40 F [Fahrenheit) or below. Please alert cook if food is not at satisfactory temperatures. Their documentation log form further lists by food type the minimum temperatures that must be met if food is to be served safely to residents. Review of facility logs showed missing hot and cold temperature documentation on all of the following dates from May through July of 2026. 5/1, breakfast and lunch. 5/2, breakfast and lunch. 5/3, breakfast and lunch.5/8, breakfast and lunch. 5/16, breakfast and lunch. 5/17, breakfast and lunch. 5/17, breakfast and lunch. 6/5, lunch. 6/9, supper.6/24, breakfast and lunch. 6/28, breakfast and lunch. 6/29, breakfast and lunch. 6/30, breakfast and lunch. 7/2, breakfast and lunch. 7/3, breakfast and lunch. 7/8, supper.7/14, supper. 7/20, breakfast and lunch. 7/21, breakfast and lunch. 7/25, breakfast and lunch. 7/26, breakfast and lunch. 7/29, supper. The Nutrition Services Manager confirmed in an interview on 8/4/2026 at 1:23 PM that facility policy is to log food temperatures before serving to residents as part of food safety. He confirmed that the temperatures were missing on the above dates. He attributed it to staffing changes and that training had been given and remained ongoing to complete the food temperature logs.

Based on interview and record review, the facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets to provide care and respond to each resident's individualized needs for 5 of 5 sampled Licensed Nursing Assistants (LNAs) and 1 sampled Licensed Nurse. This has the potential to affect all residents. Findings include: Per review of employee training and competency files 3 LNAs had no documented evidence that they had been assessed for any competencies of skills required to care for residents in their care, and 2 LNAs had only hand hygiene and personal protective equipment (PPE). Per review of one Licensed Nurse's training and competency file, there was no documented evidence that he had been assessed for skills competency, including medication administration on hire or while an employee. Per interview with the Administrator on 8/5/2026 at 8:50 AM, she had identified that staff had not been onboarding with facility specific information. She confirmed that nursing staff had not been being assessed for facility specific competencies on hire and annually. Per interview on 8/5/2026 at 11:38 AM with the Nurse Educator and Administrator, during orientation facility nursing staff were given a packet of competencies during orientation and told to get them signed off when they were training however, there was no process in place to ensure staff was actually being assessed and no one responsible to ensure they were being completed.

Based on observation, record review, and interview, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures for 2 of 4 units. Findings include:Observation of the public restroom, which is unlocked, located in a common area, and accessible to all residents, revealed sink water temperature that was too hot for 4 surveyors to leave their hands under the water for more than 5 seconds; the running hot water produced observable steam.On 8/5/26 at 12:34 PM, the Maintenance worker and the Administrator met with 3 surveyors in the public bathroom to check the hot water temperature, which appeared/felt very hot and was too hot for 4 surveyors to leave their hands under for more than 5 seconds. The Maintenance worker used a thermometer to check the water temperature, which revealed 122 Fahrenheit (F), and one surveyor verified the temperature with a calibrated thermometer to be 124 Fahrenheit. Resident room [ROOM NUMBER]'s water temperature was checked next, which revealed a temperature of 122 F for the Maintenance worker and the surveyor's result being 125 Fahrenheit. Resident room [ROOM NUMBER]'s water temperature was checked next, which revealed a temperature of 121.6 F with the Maintenance worker's thermometer and 124 Fahrenheit with the surveyor's thermometer. Per interview on 8/5/26 at 12:39 PM, the Maintenance worker and the Administrator confirmed that the water was above a safe temperature of 120 Fahrenheit.

Based on observations, interviews, and record review, the facility failed to ensure that residents have a comprehensive, person-centered care plan for 2 of 20 residents (Residents #2 and #11). This is a repeat deficiency for this facility, with the violation cited during a previous partial survey, dated 7/20/26. Findings include:1. Per record review, Resident #2 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys cannot). The Resident has a central venous catheter (a soft plastic tube, tunneled under the skin and placed in a vein in the neck, chest, or groin, which enters a central vein that leads to the heart). Review of Resident #2's care plan reveals a problem area for the resident is hemodialysis with a goal of monitor for dialysis related complications: Bleeding at access site, which was initiated on 5/5/26, but lacked any information of having or caring for their central line catheter. During observations on 8/4/26 at 9:35 AM, no smooth clamps (used if a central venous catheter is damaged) were located at the bedside in the resident's room. Per interview on 8/4/26 at 9:56 AM, the Charge Nurse confirmed there are no smooth clamps in the patient's room and stated she would need to review the policy regarding the need for clamps to be available. Per interview on 8/4/26 at 2:34 PM, the Unit Manager confirmed Resident #2's care plan doesn't include the resident's central line catheter or any interventions for addressing damage to their central venous catheter. The Unit Manager confirmed this should be included in the resident's care plan. Per interview on 8/4/26 at 4:23 PM, the Nurse Practitioner (NP) stated that if the catheter were damaged, a pressure dressing (bandage that is used to apply pressure to a wound) would be applied, and the resident would be transferred to the hospital. Per the facility's Central Venous Access Device Management policy [last revised 1/2026], the intervention for catheter damage is clamp catheter near exit site with non-serrated clamp and place sterile gauze over break or hole until removed. Per interview on 8/5/26 at 9:15 AM, with the Charge Nurse and the NP confirmed no smooth clamps are available, and Resident #2's care plan doesn't include interventions if there is damage to the central venous catheter. The Charge Nurse and the NP confirmed the facility policy states that if a catheter is damaged or breaks, the intervention would be clamping it and notifying a provider. Reference National Kidney Foundation. 2023, January 1. Dialysis (https://www.kidney.org/kidney-topics/dialysis) MedlinePlus. 2024, October 28. Daily assessment of the vascular access site is necessary to avoid infection, blood clots, and other problems. (https://medlineplus.gov/ency/patientinstructions/000591.htm) The American College of Surgeons. 2017. What Is a Central Venous Access Device (CVAD)? (https://www.facs.org/media/2tcnbb4f/understanding_your_central_line.pdf) 2. Per record review, Resident #11 has a diagnosis of chronic venous insufficiency (condition that can create skin ulcers) and a Brief Interview of Mental Status (BIMS; a cognitive assessment) score of 15 indicating cognitive intactness. Per interview on 8/3/26 at 2:08 PM, Resident #11 explained that s/he had a Tuesday and Saturday schedule but was not getting showers at all at this time because they were on contact precautions (Infection control measures) for Clostridioides difficile (C. diff; a highly contagious bacterium). Per interview on 8/3/26 at approximately 3:00 PM, the Unit Manager stated that a resident on contact precautions can receive showers. Per record review, Resident #11 was receiving sponge baths and peri care in their room instead of being showered as they were scheduled or requested. Per interview on 8/5/26 10:45 AM, Resident #11 stated that they did not get a shower yesterday (8/4/26) which was a Tuesday and that a nurse washed their hair in the room. Per interview on 8/5/26 at 11:37 AM, LNA #1 reported that she was assigned to Resident #11 yesterday ( 8/4/26) and did not shower them because they have C. diff and were not supposed to take them out of the room for showers while on contact precautions. Per interview on 8/5/26 at 8:30 AM with the Unit Manager, Resident #11 is scheduled to have their showers on Tuesdays and Saturdays. When asked if they could show this in the resident's care plan, they indicated that it should be in there, but it was not. Review of a facility policy titled, Resident Hygiene/Activities of Daily Living Policy Effective Date 6/12/26, indicated PURPOSE: To ensure all residents receive routine bathing and personal hygiene services in a manner that promotes comfort dignity, infection prevention, skin integrity, and overall well-being while honoring resident choice and preferences.POLICY STATEMENT: The facility shall provide bathing and personal hygiene services that meet each resident's assessed needs and preferences. Bathing services will be provided in accordance with the resident's care plan, clinical condition, and personal choices while maintaining privacy, dignity, and safety.1. Bathing schedules shall be individualized and based on resident preference whenever possible. 2. Residents shall be offered bathing at a minimum frequency consistent with their care plan and personal preference.Shower Frequency: Residents shall be offered: A minimum of two showers or baths weekly, unless otherwise specified in the care plan or requested by the resident. Additional bathing as needed for: Incontinence episodes, Excessive perspiration, Soiling of skin or clothing, Infection prevention needs, Wound management considerations, and Resident request.

Based on a record review, observation, and interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised for 2 of 20 residents to address a newly identified alteration in skin integrity involving the right heel (Resident #44) and following significant weight loss (Resident #71). Findings include: 1. Review of Resident #44's medical record revealed diagnoses including type 2 diabetes mellitus, anasarca (a severe medical condition involving extreme, generalized swelling across the entire body due to fluid buildup in the tissues), morbid obesity, decompensated biventricular heart failure, and stage III chronic kidney disease. The resident required a Hoyer lift (a mechanical full-body lift used to transfer residents who are unable to transfer safely without mechanical assistance) for transfers and had very limited mobility. A Braden Scale assessment performed on 7/7/26 identified potential problems with friction and shear, with a total score of 15, indicating an increased risk of impaired skin integrity. Review of Resident #44's nursing progress note dated 7/10/26 revealed a pressure ulcer involving the resident's right heel. The nurse described the area as blanchable, painful, and red. Review of the comprehensive care plan [last revised on 6/23/26] revealed that it did not identify the right heel condition and did not include measurable goals or individualized interventions for treatment, heel offloading, or pressure reduction. During an interview on 8/4/26 at 2:34 PM, the Unit Manager confirmed that the medical record did not contain implementation of interventions or revision of the resident's comprehensive care plan to address the newly identified right heel condition. During an interview on 8/5/26 at 9:04 AM, the Charge Nurse confirmed that interventions should have been added to the resident's task or worklist, and the comprehensive care plan should have been revised. The Charge Nurse further confirmed that Resident #44's comprehensive care plan had not been revised to include interventions addressing the resident's right heel condition. Review of the facility's Care Planning policy, effective 10/1/25, states that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy further states that the comprehensive, person-centered care plan will incorporate identified problem areas, and incorporate risk factors associated with identified problems. 2. Record review shows that Resident #71 has diagnoses that include Alzheimer dementia with behavioral disturbance, diverticular disease of colon (digestive track disorder), Type 2 diabetes mellitus, and major depressive disorder. Record review shows that Resident #71 weighed 200 pounds on 6/7/26. The weight documented for Resident #71 on 7/8/26 was 154 pounds. The weight loss of 46 pounds or 22.5% in a 31-day period between 6/7/26 and 7/8/26 is a significant weight loss. Per record review, a care plan for Resident #71 was not implemented to address the documented weight loss. Review of the facility policy titled Care Planning, effective 10/1/25, states A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for reach resident. Section 8 of the procedure for this policy states in section f, that the care plan will Incorporate identified problem areas and in section g, that the care plan will Incorporate risk factors associated with identified problems. Review of the facility policy titled Weights & Heights, effective 4/9/26, includes under Section 3 that the interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight change. Per interview with RN #1 (Registered Nurse) and RN #2 on 8/4/26 at 2:21 PM, RN #1 and RN #2 both confirmed that nursing had not implement a care plan for Resident #71 to address his/her documented weight loss.

Based on observation, interview, and record review, the facility failed to notify the resident's physician of a significant health change, weight loss, for 1 of 2 sampled residents (Resident #71). Findings include: Record review shows that Resident #71 has diagnoses that include Alzheimer dementia with behavioral disturbance, diverticular disease of colon (digestive track disorder), Type 2 diabetes mellitus, and major depressive disorder. Resident #71 has an MDS (Minimum Data Set, a resident assessment tool) dated 6/9/26, showing a BIMS (Brief Interview for Mental Status) result as non-completed due to the resident being rarely or never understood. Record review shows that Resident #71 weighed 200 pounds on 6/7/26. The weight documented for Resident #71 on 7/8/26 was 154 pounds. The weight loss of 46 pounds or 22.5% in a 31-day period between 6/7/26 and 7/8/26 is a significant weight loss. There is no documentation that Resident #71's physician or physician extender was notified of or subsequently addressed the significant weight loss recorded on 6/7/26. Review of the facility policy titled Change in Condition and Notification, effective 10/1/2025, Procedure, 2. Physician/Practitioner Notification states that The attending physician, nurse practitioner, or physician assistant will be notified promptly of significant changes, including Resident assessment findings, Vital signs, Interventions provided, Current resident status. All practitioner notifications and resulting orders will be documented in the medical record. Section 4, Documentation, further states that Nursing staff will document: Description of the condition change, Assessment findings, Interventions performed, Practitioner notifications and orders received. Review of the facility policy titled Weights & Heights, effective 4/9/26, includes under Section 2.2.1 that the licensed nurse will notify the physician/APP of significant weight changes. Per interview with RN #1 (Registered Nurse) and RN #2 on 8/4/26 at 2:21 PM, RN #1 and RN #2 both confirmed that nursing had not notified Resident #71's physician or physician extender about this significant health change and that there was no subsequent documentation or intervention with regard to the documented weight loss.

Based on observation, interview, and record review the facility failed to determine whether it is clinically appropriate for residents to self-administer medications for 1 of 20 residents (Resident #69). The findings include:Per observation on 8/3/26 at 11:55 AM, Resident #69 had a box of Triamcinolone cream (prescription only cream) was on their bed. The resident verbalized that they apply the Triamcinolone cream themselves in the mornings and the evenings. Per interview on 8/3/26 at approximately 12:00 PM, the Unit Manager confirmed that the Resident #69 should not have the Triamcinolone cream in their possession and Resident #69 was not assessed to self-administration medications and should have been. Per review of a facility policy titled, Med Self Administration Policy Effective Date 4/9/2025 indicated It is the policy of this facility to allow residents to self-administer medications when it has been determined to be safe, appropriate, and in the resident's best interest. All self-administration must be approved by the interdisciplinary team, documented in the resident's care plan and periodically reviewed for continued appropriateness. PROCEDURE: 1. Assessment: Upon admission and whenever there is a change in condition, or a request for self-administration the Nurse will conduct a Resident Assessment to determine if the resident is capable of safe self-administration of their medications.

Based on interview and record review, the facility failed to ensure interventions were implemented to address a significant weight loss for 1 of 2 sampled residents (Resident #71). Findings include: Record review shows that Resident #71 has diagnoses that include Alzheimer dementia with behavioral disturbance, diverticular disease of colon (digestive track disorder), Type 2 diabetes mellitus, and major depressive disorder. Record review shows that Resident #71 weighed 200 pounds on 6/7/26. The next weight documented for Resident #71, on 7/8/26, was 154 pounds. The weight loss of 46 pounds or 22.5% in a 31-day period between 6/7/26 and 7/8/26 is a significant weight loss. Review of the facility policy titled Weights & Heights, effective 4/9/26, includes under purpose to identify significant weight change and to determines possible causes of significant weight change. Under Section 1.2.1, Weights will be reviewed by a licensed nurse with follow-up indicated by the dietician. It is states under Section 2.1.1.1 that a significant weight change is defined as 5% in one month. Section 2.2.1 states the licensed nurse will notify the physician/APP of significant weight changes. Section 3 states the interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight change. Per record review, the care plan was not revised to include goals or interventions for Resident #71 to reflect this significant weight loss. Resident #71's medical record did not contain documentation that his/her physician had noted or addressed this significant weight loss. It did not include documentation that the dietitian had noted or addressed the significant weight loss. It did not include documentation that nursing had noted or addressed the significant weight loss. Per interview with RN #1 (Registered Nurse) and RN #2 on 8/4/26 at 2:21 PM, RN #1 confirmed that Resident #71's medical record did not contain documentation addressing his/her weight loss. RN #2 confirmed Resident #71's medical record did not contain documentation noting or addressing the significant weight loss.

Per interview and record review, the facility failed to provide showers per a resident's preference and per facility policy or 1 of 20 sampled residents (Resident #11). Findings include:Per record review, Resident #11 has a diagnosis of chronic venous insufficiency (condition that can create skin ulcers) and a Brief Interview of Mental Status (BIMS; a cognitive assessment) score of 15 indicating cognitive intactness.Per interview on 8/3/26 at 2:08 PM, Resident #11 explained that s/he had a Tuesday and Saturday schedule per their preference but was not getting showers at all at this time because they were on contact precautions (Infection control measures) for Clostridioides difficile (C. diff; a highly contagious bacterium).Per interview on 8/3/26 at approximately 3:00 PM, the Unit Manager stated that a resident on contact precautions can receive showers.Per record review, Resident #11 was receiving sponge baths and peri care in their room instead of being showered as they were scheduled or requested. Per interview on 8/5/26 at 10:45 AM, Resident #11 stated that they did not get a shower yesterday (8/4/26) which was a Tuesday and that a nurse washed their hair in the room. Per interview on 8/5/26 at 11:37 AM, LNA #1 reported that she was assigned to Resident #11 yesterday (8/4/26) and did not shower them because they have C. diff and were not supposed to take them out of the room for showers while on contact precautions.Review of a facility policy titled, Resident Hygiene/Activities of Daily Living Policy Effective Date 6/12/26, indicated PURPOSE: To ensure all residents receive routine bathing and personal hygiene services in a manner that promotes comfort dignity, infection prevention, skin integrity, and overall well-being while honoring resident choice and preferences. POLICY STATEMENT: The facility shall provide bathing and personal hygiene services that meet each resident's assessed needs and preferences. Bathing services will be provided in accordance with the resident's care plan, clinical condition, and personal choices while maintaining privacy, dignity, and safety. 1. Bathing schedules shall be individualized and based on resident preference whenever possible. 2. Residents shall be offered bathing at a minimum frequency consistent with their care plan and personal preference. Shower Frequency: Residents shall be offered:A minimum of two showers or baths weekly, unless otherwise specified in the care plan or requested by the resident.Additional bathing as needed for: Incontinence episodes, Excessive perspiration, Soiling of skin or clothing, Infection prevention needs, Wound management considerations, and Resident request.

Based on observation, interview, and record review the facility failed to ensure that physicians orders related to vital sign parameters were followed prior to medication administration for 1 of 3 sampled residents (Resident #86). Findings include:Per record review, Resident #86 has a Physicians order with a start date on 6/5/2026 for lisinopril (prescribed to lower high blood pressure) 50 mg at bedtime including parameters to hold for systolic blood pressure less than 110. Review of the Resident's medication administration record (MAR) from 6/6/2026- 8/4/2026 revealed that they received the lisinopril each day. Further review reveals that there are no documented blood pressure results recorded in the MAR. Per review of a vital sign flow sheet provided by the Unit Manager from 6/1/2026 to 8/4/2026 Resident #86's blood pressure was recorded on only 13 occasions with only 4 occasions being in the evening. During a medication pass observation with a Licensed Practical Nurse (LPN) on 8/4/2026 at 2:17 PM she explained that when administering a medication with blood pressure parameters, the nurse would take the resident's blood pressure prior to administration of the medication. The LPN navigated to a resident's MAR who had an order for parameters and showed where there was a field that comes up to enter the blood pressure results and whether or not the medication was held or administered. Per interview on 8/4/2026 at 2:50 PM, the Unit Manager confirmed that the prescribed lisinopril was administered each day reviewed and that there was no documented blood pressures for the dates not noted on the vital sign flow sheet from 6/1/2026 to 8/4/2026. She stated that the Physicians order can be set up in the MAR to alert staff to obtain the blood pressure and document the results prior to administration however, the order for the lisinopril had not been entered with the alert. Per review of the Lippincott Manual of Nursing, Common Departures from the Standards of Nursing Care include: failure to follow physician orders, follow appropriate nursing measures, communicate information about the patient. Ref: [Lippincott Manual of Nursing Practice-11th Edition 2018]

Based on interview and record review the facility failed to ensure that two of six sampled residents (Resident #1 and Resident #2) care plans were revised following an incident of resident-to-resident abuse. Findings include:Per review of the facility's internal investigation documentation, Resident #1 and Resident #2 were involved in an altercation on 2/15/26. Per review of a witness statement from LNA#1 it states, At 9:10 PM [ on 2/15/26] I was sitting at the nurses station charting in watching resident I overheard screaming and yelling from resident number one and resident #2 coming from the living area I came out of the nursing station and observed both [Resident #1] and [Resident #2] punching and slapping each other around the arms. I removed [Resident #2] from the area and immediately told [Licensed Nurse #1] what happened. She told me to put [Resident #2] to bed. I told her [Resident #2] does not go to bed until 12:00 AM. I told her both residents names and she looked at me and said nothing. I told her she has to make her a nursing incident report. She ignored me. I kept [Resident #2] with me, until I had to do rounds. [Licensed Nurse #2] came back from break and I told him what happened. He immediately took charge and told both nurses how to document this situation.Per record review Resident #1 has a BIMS [Brief Interview of Mental Status] of 3 as of 3/11/26, indicating s/he has severe cognitive impairment. Resident #1 has diagnoses of vascular dementia, adjustment disorder with anxious mood, Type II Diabetes mellitus, generalized weakness, and expressive aphasia (A brain-related language disorder with difficulty speaking or writing). Resident #1's care plan dated of 8/20/24 states, [Resident #1] will not be physically or verbally aggressive with others. There are interventions such as Provide frequent checks on [Resident #1], watch for signs of increasing anxiety, watch for signs of increasing agitation, approach calmly, remove from setting, administer prescribed medications, observe for side effects such as lethargy, loss of appetite, establish routines, inform social worker. There is a care plan goal documented on 4/11/25 stating [Resident #1] will not harm self or others. Per record review, Resident #2 has a BIMS score of 1 as of 6/12/26, indicating severe cognitive impairment. Resident #2 has diagnoses of severe late onset Alzheimer's dementia with mood disturbance, anxiety, hypertension (high blood pressure), and insomnia. Per review of Resident #2's care plan documented on 1/14/26 it states, Risk for physical harm and psychosocial distress related to resident-resident altercation 1/14/26 (another resident grabbed this resident). Goal: Resident will remain free from physical harm and will feel safe. There were no additional interventions added to the care plans for Resident #1 and Resident #2 after the date of the resident-to-resident incident on 2/15/26.An interview was conducted with the Administrator on 7/20/26 at 12:17 PM. The Administrator confirmed that the care plans for Resident #1 and Resident #2 did not have any additional documentation of interventions after the incident that occurred on 2/15/26.Per review of the facility's Care Planning policy [date effective 10/1/25] it states, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review the facility failed to ensure two of three sampled residents (Resident #3 and Resident #4) had narcotics appropriately documented and signed in from the pharmacy. Findings include:1. Per record review, Resident #3 has an order for Oxycodone [a medication used to treat pain] IR [Immediate Release] 5 mg [milligram] tab [tablet]: Take one tab po [by mouth] q4h p [every four hours] prn [as needed] for pain.Per review of the facility's internal investigation report dated 6/6/26 it states, On 6/6/26, I received a call to inform me [RN#1] reported to [RN#2] the narcotic count was off by one in the East Cart during count. The narcotic log indicated that there should have been 37 tablets but there only 36. The pill was unable to be located. [RN#1] further state that she believed that she had accepted four cards of narcotics from the pharmacy on a previous shift but had not signed them in and that she could not find the cards. [RN#2] (on call manager) verified the count was 36 and not 37 and searched the cart for the missing pill which was unable to be found. She went through the entire cart and located the four cards of narcotics. These were verified against the manifest and found to be accurate. They were then logged into the narcotic record and signed off with another nurse. Per review of the facility's five-day investigation it states, No evidence of medication diversion was identified during the investigation. The discrepancies were determined to be the result of documentation errors and medication removal from an incorrect resident-specific narcotic sleeve.Per review of the facility's Medication Ordering and Receiving From Pharmacy policy [no revision date] it states, K. Only licensed personnel may receive controlled substances from the pharmacy driver/courier. Procedures for receiving controlled substances include: 1) A nurse signs for the medications, including the controlled substances, on the pharmacy delivery ticket and inspects the medications. 2) A nurse reconciles controlled substance orders and refill requests against what has been received from the pharmacy. 3) A nurse notifies the pharmacist if controlled substance orders or doses are missing or incorrect. 4) The receiving nurse transfers medication and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the medication). 5) Two nurses witnessed placement of the controlled substances in the secured compartment of the medication cart. 6) controlled substance inventory sheets are completed, if necessary, and filed appropriately. A hard bound log book is utilized to track the controlled substance from delivery to disposition.An interview was conducted with the Administrator on 7/20/26 at 12:03 PM. The administrator confirmed they could not find the oxycodone pill and RN #1 did not follow the appropriate protocol for signing in narcotics.A telephone interview was conducted with RN#2 on 7/20/26 at 12:23 PM. RN#2 states RN#1 and RN#2 were initially unable to find the tablet of oxycodone, but it was subsequently found that Monday morning (6/8/26). RN#2 confirmed RN#1 took the four cards of narcotics and threw them into cart and planned on signing them later in her shift. RN#2 confirmed RN#1 then forgot where she put the cards of narcotics. RN#2 confirmed the four cards were found in the medication cart. RN#1 verified two nurses are supposed to do the narcotic count prior to the courier leaving and did not do this and should have.2. Per record review of the narcotic log located on the medication cart in the Post-Acute Care Unit, Resident #4 had an order for Oxycodone 5 mg [ milligram] tab: Take one half tab po [by mouth] q6h [every six hours] prn [as needed] pain. On 7/14/26 an additional 20 oxycodone were added to the narcotic count. The additional 20 pills were only signed out by one Licensed Nurse.An interview was conducted with RN#3 on 7/20/26 at 12:45 PM. She confirmed the additional 20 oxycodone 5 mg tablets added to the narcotic log for Resident #4 was only signed by nurse. When asked if two licensed nurses needed to sign off narcotics added to a log she stated, I don't know, I've been told different things.

Based on interview and record review, the facility failed to ensure that 2 of 3 sampled residents (Resident #1 and Resident #2) were free from mental abuse by staff by failing to protect Resident #1 from verbal abuse from staff in the form of mocking, insulting, and ridiculing, and failing to protect Resident #2 from being deprived of necessary services necessary to avoid emotional distress. Findings include: 1. Per record review, Resident #1 had an MDS (Minimum Data Set, a resident assessment tool) dated 1/8/26, showing a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment (the ability to perceive, learn, remember, reason, and problem-solve). Per review of a facility investigative summary report dated 1/27/26, submitted to the State Agency on 1/27/26, Resident #1 was receiving care from LNA #1 (Licensed Nursing Assistant) and LNA #2 on 1/23/26. Per LNA #1 and LNA #2, Resident #1 had been incontinent of his/her bowels. During care, Resident #1 was noted to be yelling and could be heard outside of his/her room. LNA #3 and LNA #4 both responded to check on Resident #1. Per the facility investigative summary report, LNA #3 stated, that when she popped into [Resident #1]'s room to check on [him/her], [LNA #1 and LNA #2] were laughing, and they said that [Resident #1] screams like a little girl. LNA #4 said in her statement dated 1/27/26 attached to the facility investigation that when she went into Resident #1's room, LNA #1 and LNA #2 were laughing and said that Resident #1 screams like a little girl. They said to LNA #3 when they left the room that Resident #1 is funny and screams like a little girl. Per review of the statement given by LNA #4 during the facility investigation, she stated that she could hear Resident #1 screaming from down the hall during care by LNA #1 and LNA #2. When she entered the room, LNA #1 was by the wall, LNA #2 was on the other side of the bed, and Resident #1 was yelling and kicking. LNA #1 and LNA #2 stated that the resident was mad that they had to use the patient lift. Then they mocked [him/her] hehehehehe and laughing. LNA #4 further stated that LNA #1 and LNA #2 were mimicking [Resident #1] kicking and screaming and something about [Resident #1] being a baby. Per interview with LNA #4 on 7/8/26 at 11:00 AM, she confirmed her prior statement from the facility investigation and stated it was not okay to make fun of a resident. Per review of the statement given by Resident #1 as part of the facility investigation on 1/26/26, s/he recalled the incident three days after it occurred and stated s/he recalled people laughing and mocking him/her. Resident #1 stated s/he recalled hearing his/her name and then laughing and mocking him/her from the hallway and was afraid they were going to hurt me after they were done laughing. Per review of the facility policy titled Prevention of Abuse, not dated, Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. It also states Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written or gestured communication or sounds to residents within hearing distance, regardless of age, ability to comprehend or disability. The facility failed to protect Resident #1 from verbal abuse from staff in the form of mocking, insulting, and ridiculing. 2. Per record review, Resident #2 has an MDS (Minimum Data Set, a resident assessment tool) dated 2/11/26, showing a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition (the ability to perceive, learn, remember, reason, and problem-solve). Per review of a facility investigative summary dated 2/4/26, submitted to the State Agency on 2/4/26, it stated the following, On February 4, 2026, at approximately 7:45 AM, [LNA (License Nursing Assistant) #6] found [Resident #2] heavily soiled with urine during morning care. The brief, pad, chuck, sheet, and mattress were all saturated, and [Resident #2] had placed tissues between [her/his] legs in an attempt to manage the urine. [Resident #2] told LNA #6 that [s/he] had rung for assistance but an LNA allegedly told [him/her], I just toileted you 10 minutes ago. I'm not toileting you again, you have a diaper on. When asked about the prior evening, [Resident #2] stated that staff member [LNA #5] dismissed [her/his] request to use the bathroom, turned off [her/his] call light, left the room, and did not return-resulting in [Resident #2] urinating in [her/his] underwear. Per the statement of Resident #2 on 2/4/26, s/he stated that when LNA #5 answered her/his call bell, she came in and I told her that I had to go to the bathroom and she said that I went 20 minutes ago and didn't have to go again. She turned off the light and left the room and never came back. When asked if s/he used the call light again, Resident #2 stated, I just peed in my underwear. Per interview with LNA #6 on 7/8/26 at 12:10 pm, she stated she believed Resident #1 was telling the truth when Resident #1 told her what happened. The evidence in the room supported Resident #1, urine-soaked clothing, linens and the smell of urine. The facility investigative summary report sent on 2/5/26 stated that Resident #3, the roommate of Resident #2, corroborated the events including the reference to diapers. Per review of the facility investigation summary report dated 2/5/26, Resident #3 has a BIMS of 15, indicating fully intact cognition. Resident #3's statement on 2/4/26 said that LNA #5 responded to his/her roommate's call light and refused to take Resident #2 to the bathroom. S/he also stated that a few times during the night, LNA #5 indicated that Resident #1 needed to wear diapers. Per interview with Resident #3 on 7/8/26 at 10:50 AM, s/he confirmed his/her statement s/he gave at the time of the incident stating it was the truth. Per interview with a family member of Resident #1 (also a facility social worker) on 7/8/26 at 11:25 AM, s/he stated that s/he believed the incident did occur. The family member stated in regard to Resident #3, that s/he is cognitively intact and pays great attention to what Resident #2 is doing, intrusively so. Per interview with the Administrator on 7/8/26 at 11:40 AM, Resident #3 is intrusive, very interested in what is happening with Resident #2. The Administrator stated that Resident #2 was truthful in that her/his perception of the incident with LNA #5 was truth to her/him The facility failed to protect Resident #2 from being deprived of a necessary service resulting in emotional distress and impacting Resident #2's dignity. Based on corrective actions completed prior to the onsite survey, this citation is designated as past non-compliance. The following actions were completed by the facility: Following an investigation, LNA #5 no longer works at the facility. Alert and oriented residents on the affected units were interviewed after the incident (s) and there were no additional findings. They were interviewed weekly x4 and monthly x3 to assure compliance. Facility staff have been re-educated on residents' rights, and the facility abuse policy and procedure, including timely reporting of incidents of alleged abuse. Education on residents' rights was added to the facility's weekly newsletter, dated 1/30.26. Weekly audits of timely reporting of allegations of abuse were implemented weekly x4 and then monthly x3. The facility's corrective actions were completed on 2/13/26.

Based on interview and record review, the facility failed to report an incident of alleged abuse for 1 of 3 sampled residents, Resident #1. Findings include:A facility investigative summary report dated 1/26/26 revealed an allegation of staff to resident abuse. The incident occurred on 1/23/26 at 7:00 PM and was not reported to Survey & Certification until 1/26/26 at 3:31 PM, exceeding the required 2-hour reporting window. Per interview with the Administrator on 7/8/26 at 11:40 AM, she confirmed that the incident was reported late, it was nor reported to her at the time and that she had learned about it when reading an internal incident report. Based on corrective actions completed prior to the onsite survey, this citation is designated as past non-compliance. The following actions were completed by the facility: Alert and oriented residents on the affected units were interviewed after the incident (s) and there were no additional findings. They were interviewed weekly x4 and monthly x3 to assure compliance. Facility staff have been re-educated on residents' rights, and the facility abuse policy and procedure, including timely reporting of incidents of alleged abuse. Weekly audits of timely reporting of allegations of abuse were implemented weekly x4 and then monthly x3. The facility's corrective actions were completed on 2/13/26.

Based on interviews and record review, the facility failed to maintain dignity and respect for 1 of 6 residents sampled (Resident #1). Findings include: Per interview on 1/13/26 at 11:20 AM, Resident #1 described their experience during a transfer to bed. According to the resident, as their feet began to slide on the floor, the LNA assisting them said, shh. The resident told the LNA to call for assistance, then yelled out for the staff themselves. After this, the LNA called for help. The resident recalled feeling rushed during the transfer. Once in bed, the staff member asked, Do I have anything to worry about? The resident felt this exchange was disrespectful. Per interview with the Administrator on 1/13/26 at 12:15 PM, she confirmed the resident's perspective of the interaction. Per the facility policy titled Resident Rights, effective date 7/8/24, states, You have the right to be treated with dignity and respect. The facility addressed the noncompliance before the investigation visit. Per the Administrator, a Plan of Correction (POC) was implemented around 12/25/25. The POC included the employee being dismissed, an in-service for all staff on 12/30/25 regarding Resident Rights and Abuse, a staff newsletter dated 1/2/26 that included one page on Resident Rights and Abuse, and audits on 1/6/26 and 1/12/26, which documented interviews and observations with residents regarding staff care. The plan is to continue completing audits. Based on corrective actions completed by 1/12/26, prior to the onsite investigation, this citation is designated as past non-compliance.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety. Findings include:Per review of the facility's Food Safety Systems: Surveillance, Prevention, and Control policy [last revised 7/2024] states, b. All opened or prepared foods will be stored in an approved container (with the appropriate cover), labeled with a description of the food item and the date prepared or opened.C. Labeling.b. TCS [Temperature Controlled for Safety] foods shall be labeled with common name of the food, date the food was made and use by date.TCS food is discarded if not used within 7 days.Per observation of the kitchen freezer on 8/25/25 at 10:41 AM, there was a five-pound bag of diced strawberries that was opened and undated. There was a bag of cut chicken and a bag of frozen meatballs that were opened and not dated. Per interview with the Dietary Manager on 8/25/25 at approximately 10:43 AM it was confirmed that these items in the freezer were opened and not dated. Per observation of the dry storage room on 8/25/25 at 10:45 AM there were two cans of chickpeas with an expiration date of 7/2025. There was a bag of prunes dated 8/17/25. Per interview with the Dietary Manager on 8/25/25 at 10:45 AM it was confirmed that the cans of chickpeas were expired, and the bag of prunes was past its used by date. Per observation of the memory care unit refrigerator on 8/26/25 at approximately 10:30 AM, three 8-ounce carts of milk were found to have an expiration date of 8/23/25. There was a block of [NAME] cheese that was open and had no date. Per interview with LNA [Licensed Nursing Assistant] on 8/26/25 at 10:42 she confirmed these items were expired as well as opened and not dated. Per observation of the kitchen on 8/27/25 at approximately 2:55 PM 16 cranberry sauce packets were found in the refrigerator to have a used date of 7/27/25. Per interview with the Dietary manager on 8/27/25 at approximately 2:56 PM she confirmed these items should have been discarded.Per observation of the kitchen freezer on 8/27/25 at approximately 2:56 PM, there was a package of chicken breast, a packet of chicken patties, and a package of chicken tenders that were opened and not dated. The Dietary Manager confirmed on 8/27/25 at 2:56 PM that these items were opened and not dated.

Based on observation and interview, the facility failed to store medications and biologicals within expiration dates, and safely for 1 of 6 residents (resident #17). Per observation and interview on [DATE] at 11:28 AM of the Medication Storage room on Memory Care Unit, with the Unit Manager, the following items were found and confirmed expired: 28 Vacutainer blood collection tubes (a sterile glass or plastic test tube with a colored rubber stopper facilitating the drawing of blood) expired on [DATE] 15 ESwab collection and transport sampling tubes (is used to collect clinical specimens containing aerobic (are bacteria that can grow and live when oxygen is present), anaerobic (are germs that can survive and grow where there is no oxygen) and fastidious bacteria (are microorganisms that are difficult to cultivate in the lab due to their complex or limited nutritional and/or environmental requirements) from the collection site, and transport them to the testing laboratory) expired on [DATE] 2 Micro-Kill Bleach Germicidal Bleach Wipes (Premoistened wipes with solution equivalent to 1:10 dilution of 6.5% bleach and is effective against 62 microorganisms including Acinetobacter baumannii-MDR, Klebsiella pneumoniae, E. coli, MRSA, VRE, VRSA, and VISA) expired on [DATE] and [DATE] Per interview on [DATE] at 11:28 AM, the Unit Manager confirmed items are expired. References: https://medlineplus.gov/ency/article/003437.htm https://medlineplus.gov/ency/article/002230.htm https://www.biologyonline.com/dictionary/fastidious Per review of the facility's Medication Administration policy [last date effective [DATE]] states, 9. Assist the patient to a comfortable position. If oral medication is being administered, the clinician administering the medication will observe the patient taking the medication. Mouth checks may also be warranted for some medications or patients. Per review of Resident #17's EMR [Electronic Medical Record] Resident #17 has a BIMS [Brief Interview of Mental Status] score is 11, indicating there is mild cognitive impairment. Resident #17 had diagnoses of DM Type II [Diabetes Mellitus Type II], COPD [Chronic Obstructive Pulmonary Disease], edema, chronic pain syndrome, and a closed compression fracture of L1 lumbar vertebrae. Per observation on [DATE] at 1:00 PM 2 white tablets were found to be left at Resident # 17's bedside. An interview was conducted with RN #1 at approximately 1:01 PM. She confirmed the two tablets left at the bedside were Torsemide [a medication known as a loop diuretic that is used to treat fluid retention] 20 mg [milligram] tablets. Per record review, Resident #17 takes Torsemide 20 mg tablets: Take two tablets po [by mouth] BID [twice a day] and 3 tabs po QHS [Every Night]. Per interview with RN#1 on [DATE] at approximately 1:02 PM she confirmed that the medication was left at the bedside and should not have been, stating, I walked out of the room and thought [s/he] took them.

Based on observation, interview, and record review, the facility failed to ensure medication error rates were not 5% or greater. The total error rate for all observations was calculated at 6.45%. There were 31 medication administration opportunities observed, resulting in 2 errors for 1 of 5 sampled residents (Resident #71) due to not following administration recommendations and not accurately documenting medication administration. Findings include:Per observation on 8/27/25 at 8:34 AM, a Licensed Practical Nurse (LPN) began the process of administering medications to Resident #71. Five medications were crushed together, poured into a medicine cup with yogurt, and Polyethylene glycol 3350 (MiraLAX, a drug prescribed for constipation) was mixed into a half-full 9-oz cup of water. The mixed crushed medications were administered to the resident, and the resident marginally consumed the Polyethylene glycol 3350 and water mixture. The LPN disposed of the remainder of the Polyethylene glycol 3350 and water mixture. Per interview on 8/27/25 at 8:41 AM, the LPN confirmed Polyethylene glycol 3350 was documented as administered, which should have been documented as partially administered. Per review of Resident #71's physician orders, levothyroxine 75mcg (a medication used to treat an underactive thyroid, hypothyroidism) states give 30-60 minutes before breakfast, separate from food and other medications. Separate 4 hours from antacids, iron, or calcium products. Per interview on 8/27/25 at 9:00 AM, the LPN confirmed the medication had been mixed with the resident's other pill medications and added to yogurt. Per interview on 8/27/25 at 9:21 AM, the Unit Manager confirmed that mixing levothyroxine 75mcg with other medications and in yogurt constitutes a medication error. Facility policy Medication Administration, effective date 4/9/2025, reads, It is the responsibility of the person administering the medication to be knowledgeable about the medication, including its use, side effects, toxicity, and interactions, and Check the electronic medication administration record/medication order/protocol for drug to be administered.

Based on observation, interview, and record review, the facility failed to provide treatment and services for 1 applicable resident (Resident #79) diagnosed with post-traumatic stress disorder (PTSD). Findings include:Per record review, Resident #79 has a diagnosis of post-traumatic-stress disorder (PTSD) and, as a result, suffers from nightmares and sleep disturbances. Per review of Resident #79's Plan of care meeting notes dated 7/7/25, it mentions how Patient said [he/she] continues to have nightmares and wants to follow-up with provider. Nursing agreed to direct that concern to provider.Per interview with Resident #79 on 8/25/25 at 12:39 PM, s/he reported that nobody here is following up with him/her for psychological services. S/he reports that they have asked many times to have a psychologist to support them with their PTSD. The Resident reports s/he asks every care meeting to get a psychologist or someone from psych services to talk to, but they have not initiated it. Resident #79 reports s/he has tried to keep themselves busy, but s/he really wants to get psychological services and care to help support them with this diagnosis that resulted from a traumatic accident. Per observation of Resident #79 during the interview on 8/25/25 at 12:39 PM, Resident #79 is tearing up while talking about how they have PTSD and have been unable to get psychological services to help support them in coping with how PTSD has impacted them.Per interview with the Unit Manager Nurse (UNM) on 8/27/25 at 12:56 PM, s/he reported that Resident #79 hasn't seen anyone for psychological services and that nobody on the unit is receiving services. The UNM reported that there are no psychological providers, including telehealth, and that the Administrator has been working on it since she started at the facility in November.Per interview with the Administrator on 8/27/25 at 1:24 PM, s/he revealed that the residents have been without psychological services since at least November of 2024. Per interview with the Administrator and Director of Nursing on 8/27/25 at 2:20 PM, they reported that they use social services, palliative care services, a Chaplain, and a psychiatric provider at [NAME] Medical Center who doesn't see or treat patients but offer advice to the facility's provider to help address any psychological needs. The Administrator also reported that s/he has informed the [NAME] President (VP) that residents are unable to receive services and of the regulations that require this. The Administrator shared a facility evaluation binder addressing the lack of behavioral health services.Per interview with the Social Worker on 8/27/25 at 2:35 PM, s/he reported that s/he doesn't ask residents if they want psychological services because they are unable to provide them, but s/he keeps a list of those who would benefit from services. S/he stated that it has been at least three years since psychological services have been provided and that it's due to their internet security department being unable to give clearance to outside providers. The social worker also stated that they have residents who need psychological services and deserve it and that while the social workers can reflect and listen, they really need a licensed psychologist. Additionally, s/he stated the physician there often recommends people for psychological services, but then they can't provide the services.Per review of Resident #79's social services notes, the most recent visit was on 5/20/25, despite this being used as a method in place of psychological treatment and services. Per interview with the Administrator on 8/27/25 at 4:40 PM, s/he confirmed that the last documented time Resident #79 saw social services was on 5/20/25. Per review of the facility policy titled Behavioral Health Care & Services dated 4/8/2025, it states the purpose is To provide the necessary behavioral health care and services to attain or maintain the highest practical, physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Each patient/resident (hereinafter patient) must receive, and [NAME] Health & Rehab Center (HPHRC) must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a patient's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.1. Patients will be provided the necessary behavioral health care and services to include: 1.1 Ensuring that the necessary care and services are person-centered and reflect the patient's goals for care, while maximizing the patient's dignity, autonomy, privacy, socialization, independence, choice, patient rights, and safety.

Based on observation, interview, and record review the facility failed to ensure that food was stored in accordance with professional standards for food safety by leaving a used ice scoop in the ice machine. The facility also failed to monitor the temperatures of refrigerators and freezers daily and report abnormal values for further intervention. Findings include: During the initial tour of the kitchen on 6/3/24 at 10:32 AM with the lead chef it was discovered that the ice scoop was found lying on the ice in the ice machine that is used for 3 out of 3 kitchenettes. Per facility policy of Storage of Food and Non-Food Items reads, Store scoop in storage bin .Do not store the provided ice scoop in the machine. The lead chef confirmed that the ice scoop was in the ice machine per interview at 10:35 AM and 11:06 AM. On 6/3/24 at 10:47 AM in the main dining room meal service area it was discovered that the refrigerator temperature log for 6/3/24 was documented as 44 [degrees] in the AM temperature log. The AM freezer log temperature was not documented. Per record review of the Recording and Maintaining Nutritional Services Logs policy states, Freezer temperature range is 0 degrees [Fahrenheit] and lower .Cooler and refrigerator ranges are 33-41 degrees .Any reading noted to be out of specified ranges shall be reported to a Nutrition Services Leader and recorded on the log sheet. Per interview on 6/3/24 at 10:55 AM the lead chef confirmed that the temperature was recorded as 44 [degrees] and was not reported to a Nutrition Specialist. S/he also confirmed that the AM freezer log for 6/3/24 was not documented. Review of the kitchen refrigerator and freezer temperature logs for the months of December 2023 through April 2024 shows five abnormally high freezer temperatures in December 2023, five abnormally elevated freezer temperatures in January 2024, and one abnormally high freezer temperature in February 2024. There is no documentation that the abnormal temperatures were addressed. In December 2023 there were 87 undocumented temperatures for the refrigerator and 91 undocumented temperatures for the freezer. In January 2024 there were 95 undocumented temperatures for the refrigerator and 91 undocumented temperatures for the freezer. Per interview on 6/3/24 at 12:32 PM the Nutrition Specialist confirmed that there is missing documentation in December 2023 and January 2024 temperature logs. Further record review of February 2024 temperature logs shows 29 undocumented temperatures for the refrigerator and 30 undocumented temperatures for the freezer. Temperature logs for the refrigerator and freezer for March 2024 shows 51 undocumented temperatures for the refrigerator and 25 undocumented temperatures for the freezer. There are 21 undocumented temperatures for the refrigerator and 18 undocumented temperatures for the freezer for April 2024.

Based on record review and staff interviews, the facility failed to provide sufficient staff who have the training to address behavioral health care needs for 1 of 2 residents [Resident #1] Findings include: Record review reveals that Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] following a hospital stay. At the time of this readmittance his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A readmission note written by Resident #1's physician describes Resident #1 as having a problem with anxiety and depression and that s/he has had issues related to dysregulated behavior, verbal abuse and aggression directed toward staff in nursing home setting. A geriatric psychiatry evaluation and request for behavioral management was made by Resident #1's physician, conducted on 7/6/2022 revealed the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . The following recommendations were made to Resident #1's plan of care: Implement DICE approach [method used by dementia behavior experts] to address problematic behaviors in the long-term care setting. We recommend that you revisit behavioral plans frequently to evaluate for efficacy, and staff psychoeducation around patient's diagnosis. Specifically that the difficult behaviors and statements resultant from [his/her] underlying personality structure have been exacerbated by disinhibition resultant from [his/her] [CONDITION(S)]. The facility assessment as of December 31, 2021, states The facility provides care and services based upon the needs of our resident population. Our facility embraces a person-centered care culture in which we provide care and services based upon our resident population, including the following: Behavior health, psycho social support, and dementia care. The Staff Education, Training, and Competencies section states additional competencies are determined according to the job role, job specific knowledge, skills and abilities and those needed to care for a specific resident population. Per interview on 10/18/22 at 12:45 PM, a Registered Nurse stated that travel nursing staff do not get adequate training to work with residents with dementia. Per interview on 10/19/22 at approximately 11:25 AM, the Director of Nursing stated that staff were given a handout titled [Resident #1] Tip Sheet as education around Resident #1. Review of this document does not reveal any staff psychoeducation around Resident #1's diagnosis. Per interview on 10/19/22 at approximately 2:00 PM, a Licensed Nursing Assistant stated s/he did not receive special training regarding Resident #1. Per interview on 11/1/2022 at 11:24 AM, a Licensed Nurse Aide (LNA) stated that the behavior training s/he received from the facility was computer-based training and s/he only got one day of training on the floor and the was on his/her own. S/he confirmed that she did not get any training about Resident #1 and that it would have been valuable to get more training about Resident #1 specifically. On 11/1/2022 at 11:55, the Director of Nursing confirmed that there was no staff psychoeducation around patient's diagnoses. On 11/1/2022 at 1:04 PM, a Charge Nurse stated that travelers have less training than permanent staff, as they do not have a full-blown training. On 11/1/2022 at 2:15 PM, an LNA stated that they did not have any specific training about Resident #1 or his/her diagnoses. Record [NAME] reveals that Resident #1 was transferred to an acute facility on 9/7/2022 with physical aggressive behaviors for an evaluation. A progress note written by Resident #1's physician on 9/8/2022 states the facility initiated discharge, discussed on 9/8/2022, is due to safety concerns for staff and vulnerable residents and that the facility does not feel they can meet his/her care needs. The notice of discharge reveal that Resident #1 was discharged from the facility on 9/7/2022. An appeal for discharge was sent to the Administrator on 9/16/2022 by Resident #1's representative. As of 11/1/2022 Resident #1 was still residing at the hospital awaiting placement to a nursing facility.

Based on record review and staff interviews, the facility failed to develop individualized interventions related to a resident's diagnosed conditions, recommendations from a geriatric psychiatric consultation, and identified triggers in order to attain or maintain their highest practicable physical, mental and psychosocial well being for 1 of 3 residents [Resident #1]. Findings include: Record review reveals that Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] following a hospital stay. At the time of this readmittance his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A readmission note written by Resident #1's physician describes Resident #1 as having a problem with anxiety and depression and that s/he has had issues related to dysregulated behavior, verbal abuse and aggression directed toward staff in nursing home setting. Progress notes reveal instances on 9/24/2020, 10/27/2020, 11/16/2020, 7/1/2021, 5/13/2022, 9/4/2022, 9/6/2022, and 9/7/2022 where s/he was physically aggressive towards staff including hitting, slapping, striking, grabbing, shoving, along with frequent verbal abuse. Instances of verbal aggression and threats towards staff are frequent in Resident #1's progress notes. Record review reveals that verbal threats towards a specific resident neighbor began in early July 2022. A geriatric psychiatry evaluation and request for behavioral management was made by Resident #1's physician, conducted on 7/6/2022 revealed the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . The following recommendations were made to Resident #1's plan of care: Implement DICE approach [method used by dementia behavior experts] to address problematic behaviors in the long-term care setting. We recommend that you revisit behavioral plans frequently to evaluate for efficacy, and staff psychoeducation around patient's diagnosis. Specifically that the difficult behaviors and statements resultant from his underlying personality structure have been exacerbated by disinhibition resultant from his [CONDITION(S)]. The report from this visit was signed by the Psychiatry Resident on 7/7/2022 and signed by the Attending Provider on 7/13/22. Notes from this visit are automatically in the resident's medical record. Nursing notes state that Resident #1's care plan was reviewed on 7/17/2022. Care plan has been reviewed by all departments and has been updated as needed as of this date. Complete Care Plan is reviewed and continued. Review of a Care Plan Event Log shows that Resident #1's care plan was revised on 7/19/22 but the facility was unable to produce the revisions that were made. The Care Plan Event Log also revealed that Resident #1's care plan had not been updated since 8/2/2022. This was confirmed by the Administrator on 10/20/2022 at 2:33 PM. Review of Resident #1's most recent care plan does not reveal interventions for: dementia, the DICE approach, preventing Resident #1 from being triggered by the resident neighbor who yells, or verbal threats to other residents. Record review reveals that it wasn't until an 8/29/2022 multidisciplinary staff meeting, held to formulate a patient behavior plan, that the recommendation to implement the DICE method and develop a plan for staff psychoeducation around Resident #1's behaviors was discussed as part of Resident #1's behavior plan. Progress notes reveal Resident #1 made a complaint to social services about the nightly noise of a resident neighbor [Resident #2] on 7/7/2022. On 7/8/2022, Resident #1 complained to social services again and expressed a desire to hurt Resident #2. Progress notes continue to reveal that Resident #1 transfer reveal that s/he was triggered by this resident neighbor and threats by Resident #1 were only made about Resident #2. Per interview on 11/1/2022 at 11:55 AM, when asked why the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he stated that it would ultimately be the Physicians and Director of Nursing's responsibility to incorporate diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview on 11/1/2022 at 1:04 PM the Charge Nurse confirmed that Resident #1's care plan did not address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he also stated that interventions were not put into Resident #1's care plan to address how the resident neighbor triggers aggressive behaviors for Resident #1. This was later confirmed on 11/1/2022 at 4:30 PM by the Director of Nursing. Per interview on 11/1/2022 at 6:15 PM, the Medical Director stated that the team did have meetings about the geriatric psychiatric consult, and it would be the DON and nurses to incorporate the information into his/her chart and care plan. S/he confirmed that the information from this consult is part of Resident #1's medical record, including the new diagnoses. Per interview on 11/2/2022 at 4:01 PM, Resident #1's representative stated that s/he did not believe that the facility exhausted all options for interventions. Resident #1 did not get care based on his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he stated that they did not update any interventions except medications changes since Resident #1's geriatric psychiatric consultation and that s/he was told by the facility that he did not have dementia. Record [NAME] reveals that Resident #1 was transferred to an acute facility on 9/7/2022 with physical aggressive behaviors for an evaluation. A progress note written by Resident #1's physician on 9/8/2022 states the facility initiated discharge, discussed on 9/8/2022, is due to safety concerns for staff and vulnerable residents and that the facility does not feel they can meet his/her care needs. The notice of discharge reveal that Resident #1 was discharged from the facility on 9/7/2022. An appeal for discharge was sent to the Administrator on 9/16/2022 by Resident #1's representative. As of 11/1/2022 Resident #1 was still residing at the hospital awaiting placement to a nursing facility.

Based on interview and record review the facility did not ensure a resident's discharge was completely assessed, evaluated, and documented for 1 of 1 [Resident #1] residents who were involuntarily discharged from the facility. The facility initiated Resident #1's discharge based on the facility's inability to meet the resident's needs and because the behavioral status of the resident endangered the safety of other individuals in the facility. However, upon complaint investigation, it was determined by interview and record review that, while Resident #1 had challenging aggressive behavior requiring staff attention, s/he did not have needs which could not be met in that facility, and there was evidence that the facility was caring for other residents with aggressive behaviors. It was also determined that the facility did not do everything possible to prevent aggressive behaviors for Resident #1. The facility based Resident #1's discharge on their status at the time of transfer, did not have the required documentation specified in the regulation, and discharged the resident while an appeal to discharge was pending. Findings include: Record review reveals that Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] following a hospital stay. At the time of this readmittance, his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 transferred from the rehabilitation unit into a room on the long-term care unit on 5/17/2022. A geriatric psychological consult from 7/6/2022 reveals that Resident #1 has the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was verbally and physically aggressive. Resident #1 was then transferred to the emergency department for evaluation. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. It was established that while Resident #1's had aggressive behaviors, these behaviors had been ongoing since his/her initial admission on 7/23/2020. A readmission note written by Resident #1's physician on 3/28/2022 describes Resident #1 as having a problem with anxiety and depression and that s/he has had issues related to dysregulated behavior, verbal abuse and aggression directed toward staff in nursing home setting. Progress notes in Resident #1's record reveal instances at the facility on 9/24/2020, 10/27/2020, 11/16/2020, 7/1/2021, 5/13/2022, 9/4/2022, 9/6/2022, and 9/7/2022 where s/he was physically aggressive towards staff including: hitting, slapping, striking, grabbing, shoving, along with frequent verbal abuse. Instances of verbal aggression and threats towards staff are frequent in Resident #1's progress notes. Record review reveals that verbal threats towards a specific resident neighbor [Resident #2] began 7/8/2022. Per interview on 10/18/2022 at 5:00 PM, a Licensed Practical Nurse stated that when s/he worked with Resident #1 on the rehabilitation unit, Resident #1 was very aggressive and mean. Per interview on 11/1/2022 at 12:30 PM, a Social Worker confirmed that Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. It was established that the facility is able to care for residents with aggressive behaviors. The facility assessment as of December 31, 2021, states The facility provides care and services based upon the needs of our resident population. Our facility embraces a person-centered care culture in which we provide care and services based upon our resident population, including the following: Behavior health, psycho social support, and dementia care. Per interview on 11/1/2022 at 10:55 AM, a Nurse Practitioner stated there were other residents in the facility that have aggressive behaviors, but not at the same frequency as Resident #1. Per interview on 11/1/2022 at 2:15 PM, a Licensed Nurse Aide stated that there are residents in the facility that are physically aggressive. Review of a list of residents with aggressive behaviors in the facility revealed that 16 residents with aggressive behaviors reside at the facility as of 11/1/2022. Of the 16 residents listed, at least one resident was physically aggressive with other residents and two residents were admitted after Resident #1 was discharged for aggressive behaviors. This was confirmed by the Director of Nursing on 11/1/2022 at 4:30 PM. The DON stated that Resident #1's care team had discussions prior to 9/7/2022 about at what point they would discharge Resident #1. The facility decided that Resident #1 would need to be discharged when his/her behavior impacted the safety of other residents. The DON stated that Resident #1 had never hurt another resident, but because s/he had threatened to hurt another resident on 9/6/2022, the facility was concerned there was a risk to that resident's safety. Record review shows that verbal threats to hurt another resident [Resident #2] began 7/8/2022. The DON confirmed that 9/6/2022 wasn't the first time Resident #1 made threats about hurting Resident #2. 3. It was established that Resident #1 was discharged based on his/her status at the time of transfer. Review of a metal health service consultation from the hospital completed on 9/7/2022 reveals that Resident #1 is rated low for harm to self and others. The consultation plan states: As of this interview, [s/he] is not a danger to [himself/herself] or others, and Due to lack of supports in the community, it is not clear to this writer that there is a less restrictive environment that can adequately support [him/her] better than [the nursing facility]. Progress notes dated 9/7/2022 and 9/8/2022 by Resident #1's physician pertaining to Resident #1's transfer and discharge do not contain assessment information about Resident #1 at the time of discharge. Review of a hospital discharge summary [from hospital emergency room to a swing bed in the hospital] reveals the following: o Reason for Admission (chief complaint): aggressive behavior, Principal/Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] o Hospital Course: The staff at [the nursing facility] felt they could no longer care for [Resident #1] and [s/he] was taken to the [hospital] ED on 9/7/22 and then admitted . During [his/her] stay [s/he] was calm and redirectable. [S/he] wanted to return to [the nursing facility] where [s/he] lived for 2 years. o Clinical Issues Needing Follow-up: 1. Pertinent medication changes: n/a, 2. Recommended follow-up tests/procedures needs: work on placement, 3. Anticoagulation on discharge: No 4: Changes to goals care at time of discharge (if applicable): n/a o Assessment: [Resident #1 is] here for placement as [s/he] is displaying behaviors at [the nursing facility]. [S/he] will remain at [the hospital] awaiting placement. Per interview with members of Resident #1's hospital care team on 11/1/2022 at 4:01 PM, a Registered Nurse from the admitting hospital stated that Resident #1 was calm for the first few days s/he arrived at the hospital. The Director of Case Management stated that there had been no discussions with the nursing facility about what it would take for Resident #1 to go back to the nursing facility, rather the nursing facility and hospital have been discussing how best to support him/her in the hospital. Per interview on 11/1/2022 at 4:30 PM, the Director of Nursing stated that there was no expectation for Resident #1 to return to the facility after s/he left on 9/7/2022. The Director of Nursing and Chief Nursing Officer both confirmed that discharge from the facility was based on his/her behavior when s/he was transferred to the hospital. 4. It was established that Resident #1's care plan was not revised to include interventions based on new behaviors or new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Progress notes reveal Resident #1 made a complaint to social services about the nightly noise of a resident neighbor [Resident #2] on 7/7/2022. On 7/8/2022, Resident #1 complained to social services again and expressed a desire to hurt Resident #2. Progress notes continue to reveal that Resident #1 was triggered by Resident #2 and threats by Resident #1 were only made about Resident #2. A note from 9/6/22, the last reported incident of Resident #1 making threats about hurting a resident stated that Resident #1 started heading back to [his/her] room when [s/he] made comments at staff and a patient who was talking out loud [Resident #2]. [Resident #1] made the comment about [Resident #2] saying '[s/he] was going to take a brick and knock [him/her] in the head with it.' There was no documentation in record review from 7/1/2022 through 9/7/2022 that Resident #1 made threats about hurting any resident other than Resident #2 and staff did not reveal threats to any other residents in any of the interviews conducted. Per interview on 11/1/2022 at 1:04 PM, a Charge Nurse confirmed that the Resident #2's yelling was a trigger for Resident #1. S/he stated that the facility put interventions into Resident #2's care plan to address the noise and confirmed that no interventions were added into Resident #1's care plan to address this. A geriatric psychiatry evaluation and request for behavioral management was made by Resident #1's physician, conducted on 7/6/2022 revealed the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . The following recommendations were made to Resident #1's plan of care: Implement DICE approach [method used by dementia behavior experts] to address problematic behaviors in the long-term care setting. We recommend that you revisit behavioral plans frequently to evaluate for efficacy, and staff psychoeducation around patient's diagnosis. Specifically that the difficult behaviors and statements resultant from his underlying personality structure have been exacerbated by disinhibition resultant from his [CONDITION(S)]. The report from this visit was signed by the Psychiatry Resident on 7/7/2022 and signed by the attending provider on 7/13/22. Notes from this visit are automatically in the resident's medical record. Nursing notes state that Resident #1's care plan was reviewed on 7/17/2022. Care plan has been reviewed by all departments and has been updated as needed as of this date. Complete Care Plan is reviewed and continued. Review of a Care Plan Event Log shows that Resident #1's care plan was revised on 7/19/22 but the facility was unable to produce the revisions that were made. The Care Plan Event Log also revealed that Resident #1's care plan had not been updated since 8/2/2022. This was confirmed by the Administrator on 10/20/2022 at 2:33 PM. Record review reveals that it wasn't until an 8/29/2022 multidisciplinary staff meeting, held to formulate a patient behavior plan, that the recommendation to implement the DICE method and develop a plan for staff psychoeducation around Resident #1's behaviors was discussed as part of Resident #1's behavior plan. Review of Resident #1's most recent care plan does not reveal interventions for: dementia, the DICE approach, preventing Resident #1 from being triggered by Resident #2, or verbal threats to other residents. 5. Review of a progress note written by Resident #1's physician on 9/8/2022 regarding his/her discharge indicate the basis for discharge is based on safety concerns for staff and that the facility does not feel that they can meet [his/her] care needs in this setting. This progress note does not document the following required information in the resident's medical record: the specific resident needs the facility could not met and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. 6. Resident #1 suffered harm by not being able to return to the nursing facility. Per observation at the hospital on 11/1/2022 at 3:45 PM, Resident #1 was in bed. S/he was agitated and made comments about wanting to die and wanting to leave and go home. Per interview at the hospital on 11/1/2022 at approximately 4:00 PM, a Registered Nurse stated that Resident #1 does not have a chance to hurt other residents at the hospital because s/he is mostly in his/her room. Staff do try to bring him/her out for a walk once a day. Per interview with Resident #1's representative at 4:01 PM on 11/2/2022, s/he stated that s/he believes Resident #1 is getting less care at the hospital than s/he was at the nursing home. At the hospital Resident #1 stays in his/her room most of the time and does not have access to activities or other residents. The representative stated that the nursing facility was Resident #1's home for the past 2 year and s/he should be able to go back to his/her home. A 9/9/2022 hospital physician note serving as both a discharge summary from the emergency room and admission summary for hospital swing bed status reveals that Resident #1 wanted to return to [nursing facility] where [s/he] lived for 2 years. Under Assessment it states that s/he will remain at the hospital awaiting placement.

Based on interview and record review the facility failed to establish a protocol on permitting resident to return to the facility after they are hospitalized or placed on therapeutic leave and failed to allow one of one sampled residents [Resident #1] to return to the facility while pending an appeal for discharge. Findings include: Record review reveals that Resident #1 was transferred to an acute facility on 9/7/2022 for an evaluation due to physical aggressive behaviors. A progress note written by Resident #1's physician on 9/8/2022 states the facility initiated discharge, discussed on 9/8/2022, is due to safety concerns for staff and vulnerable residents and that the facility does not feel they can meet his/her care needs. The notice of discharge reveal that Resident #1 was discharged from the facility on 9/7/2022. An appeal for discharge was sent to the Administrator on 9/16/2022 by Resident #1's representative. As of 11/1/2022 Resident #1 was still residing at the hospital awaiting placement to a nursing facility. 1. Record review and interview reveal that Resident #1 was discharged based on his/her status at the time of transfer. Review of a metal health service consultation from the hospital completed on 9/7/2022 reveals that Resident #1 is rated low for harm to self and others. The consultation plan states: As of this interview, [s/he] is not a danger to [himself/herself] or others, and Due to lack of supports in the community, it is not clear to this writer that there is a less restrictive environment that can adequately support [him/her] better than [the nursing facility]. Progress notes dated 9/7/2022 and 9/8/2022 by Resident #1's physician pertaining to Resident #1's transfer and discharge do not contain assessment information about Resident #1 at the time of discharge. Review of a hospital discharge summary [from hospital emergency room to a swing bed in the hospital] reveals the following: -Reason for Admission (chief complaint): aggressive behavior, Principal/Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Hospital Course: The staff at [the nursing facility] felt they could no longer care for [Resident #1] and [s/he] was taken to the [hospital] ED on 9/7/22 and then admitted . During [his/her] stay [s/he] was calm and redirectable. [S/he] wanted to return to [the nursing facility] where [s/he] lived for 2 years. -Clinical Issues Needing Follow-up: 1. Pertinent medication changes: n/a, 2. Recommended follow-up tests/procedures needs: work on placement, 3. Anticoagulation on discharge: No 4: Changes to goals care at time of discharge (if applicable): n/a -Assessment: [Resident #1 is] here for placement as s/he is displaying behaviors at [the nursing facility]. [S/he] will remain at [the hospital] awaiting placement. Per interview with members of Resident #1's hospital care team on 11/1/2022 at 4:01 PM, a Registered Nurse from the admitting hospital stated that Resident #1 was calm for the first few days s/he arrived at the hospital. The Director of Case Management stated that there had been no discussions with the nursing facility about what it would take for Resident #1 to go back to the nursing facility, rather the nursing facility and hospital have been discussing how best to support him/her in the hospital. Per interview on 11/1/2022 at 4:30 PM, the Director of Nursing stated that there was no expectation for him/her to return to the facility after s/he left on 9/7/2022. The Director of Nursing and Chief Nursing Office both confirmed that discharge from the facility was based on Resident #1's behavior when s/he was transferred to the hospital. Per interview on 11/1/2022 at 2:59 PM, Resident #1's representative stated that s/he never heard back as to whether Resident #1 could return back to the facility. At 4:01 PM on 11/2/2022, s/he stated that s/he believes Resident #1 is getting less care at the hospital than s/he was at the nursing home. At the hospital Resident #1 stays in his/her room most of the time and does not have access to activities or other residents. The representative stated that the nursing facility was Resident #1's home for the past 2 year and s/he should be able to go back to his/her home. 2. Per interview on 11/1/2022 at 2:45 PM the Director of Nursing confirmed that the facility did not have a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave.

Based on staff interview and record review, the facility failed to provide necessary treatment and services to promote healing of pressure sores and prevent new sores from developing for 1 of 4 residents (Resident #62) in the sample group. Findings include: Per record review on 12/10/12 at 3:44 P.M., the Care Plan for Resident #62, who has a history of pressure ulcers developing on h/her coccyx and buttocks, included interventions under "Impairment of Skin Integrity". Interventions listed include for Nursing: "treat as ordered...Update MD as needed." For Nurse Assistants, the interventions include "reposition (the resident) every two hours with nurse present, or get a nurse to verify position has been changed". Per record review, a physician's orders [REDACTED]. Per record review, Nursing Notes for Resident #62 starting on 11/13/12 report an "open lesion present to area between rectum and coccyx 0.5 centimeters (cm) center with split coming off side 1 cm long, approx. 0.3 cm wide." On the next day, 11/14/12, Nursing Notes record "[MEDICATION NAME] spray/ointment to open area coccyx as ordered." Nursing Notes from 11/14/12 through 11/25/12 repeat the assessment "open area crease in buttocks" and repeat that [MEDICATION NAME] was applied. On 11/27/12 the Nursing Note reads "open area on coccyx looking improved and smaller from 11/25". The next Nursing Note on 12/3/12 reports Resident #62's pressure ulcer "on coccyx appears larger in size. [MEDICATION NAME] (applied). Open area to coccyx 2.5 cm x 1.5 cm". (Original size of the open area was 1 cm long x 0.3 cm wide) Additionally, Resident #62 now has 2 openings in h/her skin "to back of left upper thigh. First is 1.5 cm x 0.5 cm, one below is 1 cm x 0.5 cm. [MEDICATION NAME]" (applied). Nursing Notes on 12/4/12 through 12/11/12 record Resident #62 "continues with areas on left upper thigh and coccyx" with both [MEDICATION NAME] ointment and spray being used for treatment. Per interview on 12/12/12 at 1:40 P.M. Resident #62's Unit Manager stated that if a resident's skin condition worsened the Nurse Practitioner would be notified or nursing staff would let the resident's Physician know about the change. The Unit Manager stated that if a treatment is not working or a condition worsened, the resident's Care Plan would be reviewed and updated, and revisions would be reflected on both the Care Plan and the Treatment Record. During the interview on 12/12/12 the Unit Manager confirmed the condition of the area on Resident #62's coccyx had worsened since the discovery on 11/13/12 in addition to new open areas on the left upper thigh. The Unit Manager confirmed that despite the documented worsening of Resident #62's skin condition, there was no revision to the resident's Care Plan and no change in treatment recorded on the Treatment Record. The resident's Unit Manager also confirmed that Resident #62's Medication Administration Record (MAR) lists the physician's orders [REDACTED]. The Unit Manager stated that the [MEDICATION NAME] applications should be documented on the MAR twice a day after completion per facility policy. Per record review, and confirmed by the Unit Manager on 12/12/12 at 1:40 P.M., Resident #62's MAR records only a single application of the [MEDICATION NAME] treatment over the 30 days since the initial pressure ulcer was discovered. The Unit Manager also reported there was no documentation on Resident #62's written or electronic record that the Nurse Practitioner or the resident's Physician had seen or was notified after the resident's pressure ulcer had worsened. Additionally, the Unit Manager confirmed that although Resident #62's Care Plan for Impairment of Skin contained the intervention for Nurse Assistants to "reposition (Resident #62) every two hours with nurse present, or get a nurse to verify position has been changed" there was no documentation in Resident #62's record of the repositioning ever being done or of nurse verification.

Based on observation, record review and staff interviews the facility failed to assure that services provided by the facility met professional standards of quality regarding following physician's orders [REDACTED].#187) reviewed in Stage 2. Findings include: 1) Per record review on 12/10/12 at 3:44 P.M., the Care Plan for Resident #62, who has a history of pressure ulcers developing on h/her coccyx and buttocks, included interventions under "Impairment of Skin Integrity". Interventions listed include for Nursing: "treat as ordered...Update MD as needed." For Nurse Assistants, the interventions include "reposition (the resident) every two hours with nurse present, or get a nurse to verify position has been changed". Per record review, a physician's orders [REDACTED]. Per record review, Nursing Notes for Resident #62 starting on 11/13/12 report an "open lesion present to area between rectum and coccyx 0.5 centimeters (cm) center with split coming off side 1 cm long, approx. 0.3 cm wide." On the next day, 11/14/12, Nursing Notes record "[MEDICATION NAME] spray/ointment to open area coccyx as ordered." Nursing Notes from 11/14/12 through 11/25/12 repeat the assessment "open area crease in buttocks" and repeat that [MEDICATION NAME] was applied. On 11/27/12 the Nursing Note reads "open area on coccyx looking improved and smaller from 11/25". The next Nursing Note on 12/3/12 reports Resident #62's pressure ulcer "on coccyx appears larger in size. [MEDICATION NAME] (applied). Open area to coccyx 2.5 cm x 1.5 cm". (Original size of the open area was 1 cm long x 0.3 cm wide) Additionally, Resident #62 now has 2 openings in h/her skin "to back of left upper thigh. First is 1.5 cm x 0.5 cm, one below is 1 cm x 0.5 cm. [MEDICATION NAME]" (applied). Nursing Notes on 12/4/12 through 12/11/12 record Resident #62 "continues with areas on left upper thigh and coccyx" with both [MEDICATION NAME] ointment and spray being used for treatment. Per interview on 12/12/12 at 1:40 P.M. Resident #62's Unit Manager stated that if a resident's skin condition worsened the Nurse Practitioner would be notified or nursing staff would let the resident's Physician know about the change. The Unit Manager stated that if a treatment is not working or a condition worsened, the resident's Care Plan would be reviewed and updated, and revisions would be reflected on both the Care Plan and the Treatment Record. During the interview on 12/12/12 the Unit Manager confirmed the condition of the area on Resident #62's coccyx had worsened since the discovery on 11/13/12 in addition to new open areas on the left upper thigh. The Unit Manager confirmed that despite the documented worsening of Resident #62's skin condition, there was no revision to the resident's Care Plan and no change in treatment recorded on the Treatment Record. The resident's Unit Manager also confirmed that Resident #62's Medication Administration Record (MAR) lists the physician's orders [REDACTED]. The Unit Manager stated that the [MEDICATION NAME] applications should be documented on the MAR twice a day after completion per facility policy. Per record review, and confirmed by the Unit Manager on 12/12/12 at 1:40 P.M., Resident #62's MAR records only a single application of the [MEDICATION NAME] treatment over the 30 days since the initial pressure ulcer was discovered. The Unit Manager also reported there was no documentation on Resident #62's written or electronic record that the Nurse Practitioner or the resident's Physician had seen or was notified after the resident's pressure ulcer had worsened. Additionally, the Unit Manager confirmed that although Resident #62's Care Plan for Impairment of Skin contained the intervention for Nurse Assistants to "reposition (Resident #62) every two hours with nurse present, or get a nurse to verify position has been changed" there was no documentation in Resident #62's record of the repositioning ever being done or of nurse verification. Per record review, the facility's Skin Care Guidelines state the "protocols have been organized to correspond with the pertinent aspects of the current standards in skin care according to the American Medical Directors Association". Under 'Prevention/Treatment' in the Skin Care Guidelines, interventions include "Recognize and communicate ulcer complications - monitor the patient for possible complications and notify practitioner", "Decide whether to change the approaches to managing the ulcer - reassess current treatments to ensure they are being properly implemented", and "Utilize prevention measures: create a turning and repositioning schedule based on the individual risk factors (e.g. every two hours)". . 2. Per medical record review on 12/12/12, the record indicated that Resident #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per direct observation on 12/12/12 at 0910 AM, Resident #187 was observed to be sitting up in bed with both feet in socks. Per direct observation on 12/12/12 at 0910 AM with the Registered Nurse (RN), the RN removed the socks from Resident #187's feet and it was noted that there was no dressing covering the left heel of Resident #187. The area on the left heel was noted to be a healing Stage 3 area circular in shape that was crusty in appearance, pink and looked slightly open on the right side of the wound. Per interview with the RN on 12/12/12 at 0910 am, he/she indicated he/she did not know why there was no dressing/treatment on Resident #187's left heel per physicians order and that no changes to the order or Resident condition was communicated to him/her in the verbal report provided by the out-going night nurse on 12/12/12. Per review of the physicians orders dated 12/6/12 indicated that the staff is to "apply elta silver gel to open left heel wound and cover with [MEDICATION NAME] in the AM two times per week on Monday and Thursday." Per review of the treatment record the last time the treatment had been performed and signed for by the nurse was 12/10/12 on the AM shift. Review of the nurses notes dated 12/12/12 at 04:33 AM, the nurse indicates that "[MEDICATION NAME] dressing intact to left heel." Per interview with the Registered Nurse assigned to Resident #187 on 12/12/12, he/she confirmed that the expectation is that Resident #187 was, per physician order, to have elta silver gel applied to open left heel wound and covered with [MEDICATION NAME] and that the dressing should have been intact when observed on 12/12/12 at 0910 AM, or communicated to the nurse in report it was not intact. The RN also indicated that if it comes off it is to be replaced. The RN confirmed she had not seen the left heel since his/her shift began on 12/12/12 and was not aware as to why there was no dressing on the left heel when observed at 0910 AM on 12/12/12. Reference: Lippincott Nursing Manual, Williams and Wilkins, 8th Edition. .

Based on observation, interview, and record review, the facility failed to provide services in accordance with the written plan of care for 2 of 23 residents (Residents #62 and #187) in the sample group. Findings include: 1) Per record review on 12/10/12 at 3:44 P.M., the Care Plan for Resident #62, who has a history of pressure ulcers developing on h/her coccyx and buttocks, included interventions under "Impairment of Skin Integrity". Interventions listed include for Nursing: "treat as ordered...Update MD as needed." For Nurse Assistants, the interventions include "reposition (the resident) every two hours with nurse present, or get a nurse to verify position has been changed". Per record review, a Physician's Order for Resident #62, dated 8/22/12, states [MEDICATION NAME] ointment and spray (medications used for treatment of [REDACTED]. Per record review, Nursing Notes for Resident #62 starting on 11/13/12 report an "open lesion present to area between rectum and coccyx 0.5 centimeters (cm) center with split coming off side 1 cm long, approx. 0.3 cm wide." On the next day, 11/14/12, Nursing Notes record "[MEDICATION NAME] spray/ointment to open area coccyx as ordered." Nursing Notes from 11/14/12 through 11/25/12 repeat the assessment "open area crease in buttocks" and repeat that [MEDICATION NAME] was applied. On 11/27/12 the Nursing Note reads "open area on coccyx looking improved and smaller from 11/25". The next Nursing Note on 12/3/12 reports Resident #62's pressure ulcer "on coccyx appears larger in size. [MEDICATION NAME] (applied). Open area to coccyx 2.5 cm x 1.5 cm". (Original size of the open area was 1 cm long x 0.3 cm wide) Additionally, Resident #62 now has 2 openings in h/her skin "to back of left upper thigh. First is 1.5 cm x 0.5 cm, one below is 1 cm x 0.5 cm. [MEDICATION NAME]" (applied). Nursing Notes on 12/4/12 through 12/11/12 record Resident #62 "continues with areas on left upper thigh and coccyx" with both [MEDICATION NAME] ointment and spray being used for treatment. Per interview on 12/12/12 at 1:40 P.M. Resident #62's Unit Manager stated that if a resident's skin condition worsened the Nurse Practitioner would be notified or nursing staff would let the resident's Physician know about the change. The Unit Manager stated that if a treatment is not working or a condition worsened, the resident's Care Plan would be reviewed and updated, and revisions would be reflected on both the Care Plan and the Treatment Record. During the interview on 12/12/12 the Unit Manager confirmed the condition of the area on Resident #62's coccyx had worsened since the discovery on 11/13/12 in addition to new open areas on the left upper thigh. The Unit Manager confirmed that despite the documented worsening of Resident #62's skin condition, there was no revision to the resident's Care Plan and no change in treatment recorded on the Treatment Record. The resident's Unit Manager also confirmed that Resident #62's Medication Administration Record (MAR) lists the Physician's Order for [MEDICATION NAME] ointment and spray to be applied twice daily as needed, and the Care Plan calls for Nursing to "treat as ordered...Update MD as needed". The Unit Manager stated that the [MEDICATION NAME] applications should be documented on the MAR twice a day after completion per facility policy. Per record review, and confirmed by the Unit Manager on 12/12/12 at 1:40 P.M., Resident #62's MAR records only a single application of the [MEDICATION NAME] treatment over the 30 days since the initial pressure ulcer was discovered. The Unit Manager also reported there was no documentation on Resident #62's written or electronic record that the Nurse Practitioner or the resident's Physician had seen or was notified after the resident's pressure ulcer had worsened. Additionally, the Unit Manager confirmed that although Resident #62's Care Plan for Impairment of Skin contained the intervention for Nurse Assistants to "reposition (Resident #62) every two hours with nurse present, or get a nurse to verify position has been changed" there was no documentation in Resident #62's record of the repositioning ever being done or of nurse verification. 2. Per medical record review on 12/12/12, the record indicated that Resident #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the Nurses Notes, Resident #187 was admitted to the facility with a Stage 3 open area located on the left heel. Per review of the nursing orders dated 11/16/12 indicated that the staff is to "float patient's heels at all times while in bed daily, nights, days and evenings." Per review of the Braden Skin assessment dated [DATE] indicates Resident #187 is at risk for skin integrity issues. Per review of the Comprehensive Assessment ((MDS) dated [DATE], Resident #187 is at risk for skin integrity issues and currently has a Stage 3 area. Per review of the comprehensive care plan titled 'Impaired physical mobility' and 'Impairment of skin integrity' both initiated on 11/16/12, they indicated that the staff is to "float heels while in bed." Per direct observation on 12/12/12 at 0813 AM, Resident #187 was observed to be sitting up in bed with both heels touching directly on the mattress surface. It was noted there was no pillow in place or other device keeping the heels/ feet off the mattress surface. Per continuous observation, Resident #187 had his/her feet directly touching the mattress surface from 8:13 AM until 09:15 AM when staff recognized that Resident #187's feet were not being "floated". Per interview with Licensed Nursing Assistant #1 (LNA #1) on 12/12/12 at 8:31 AM, he/she indicated that the care plan for each resident is reviewed before care is provided each day and that the verbal report received at the change of shift from the nurses indicates any changes to a resident's care. LNA #1 indicated that on the post acute unit all aides work together as a team and provide care to all the residents as per there individual plans of care. LNA #1 indicated that he/she and another aide (LNA #2) were providing care to Resident #187 on 12/12/12. Per interview with LNA #2 on 12/12/12 at 8:50 AM, he/she indicated that he/she had reviewed the care plan of Resident #187 prior to providing care to the resident. Per interview with LNA #1 and LNA#2, both reviewed the care plan for Resident #187 that was initiated on 11/16/12 and confirmed that the care plans titled skin impairment and impaired mobility both indicated that Resident #187's heels are to be "floated when in bed". Per direct observation with LNA #1 and LNA #2 , they confirmed that Resident #187 on 12/12/12 at 8:50 am, was in bed and Resident #187's feet had socks on them and that both heels were not floated and having direct contact with the mattress. LNA #1 and #2 confirmed that there was no pillow in place to provide floating to Resident #187's heels per the care plan. Per review of the facility policy and procedure titled "Skin Care Guidelines" with an effective date of 11/15/2010, the policy indicates that in Step 2 to "manage pressure, patients who have or are at risk of developing ulcers will require offloading or pressure redistribution devices (e.g. heel boot, heel elevator, heel lift, suspension boot, or a device that "floats" the heel) to relieve the pressure on the heels and prevent skin breakdown." Per interview with the Registered Nurse assigned to Resident #187 on 12/12/12, he/she confirmed that Resident #187 was in bed at 8:50 AM and that his/her socked feet were making direct contact with the bed mattress and not floated as per Resident #187's care plan. The RN confirmed that the expectation is that the LNA's follow the resident's care plan when providing care and that Resident #187 should have had his/her heels floated off of bed.

Based on observation, record review, and staff interview the facility failed to assure that services provided for 3 of 6 residents with pressure ulcers reviewed in the revisit sample were provided in accordance with the resident's plan of care. (Residents #62, #63, and #19) Findings include: 1. Per record review and staff interview the facility failed to assure that services for Resident #62 were provided in accordance with the resident's plan of care. In record review on 01/28/2013, the resident's care plan for skin integrity calls for turning and repositioning every two hours by the LNA. Additionally the care plan stated that nursing was to develop and monitor a turning/repositioning schedule. In a review of nursing documentation there are daily skin checks monitored in the Treatment Administration Record (TAR), however there is no documentation of the every two hour position changes and/or monitoring of position changes. In review of the LNA charting, starting on 01/01/2013, in CNA Access, position changes are not consistently documented for the month of January 2013. This was confirmed with the Waits River wing nurse and the Memory Care Charge Nurse on 01/28/2013 at 11:50 AM and 12:30 PM respectively. In interview at 11:50 AM the Waits River wing nurse stated that s/he often observes and/or assists the repositioning of the resident but that nursing does not record the monitoring or observation of repositioning. S/he stated that s/he is not aware of a turning/repositioning schedule for this resident. In an interview on 01/28/2013 the LNA assigned to care for the resident stated that the resident is to be turned every two hours. S/he stated that s/he does not document the repositioning of the resident until the end of his/her shift and does not write note the time at the time she does the task. In an interview on 01/28/2013 the Unit Charge Nurse confirmed that the resident care plan was as documented above and that in review of the LNA documentation, there is not evidence that turning and repositioning was done as required by the plan of care. S/he further stated that s/he monitors the completion of turning by observation of care and review of the LNA documentation. S/he further confirmed that there had not been a turning/positioning schedule developed by the nursing staff for this resident. 2. Per interview and record review, the facility failed to assure Resident #63's services were provided according to the written care plan. Per the revised care plan dated 01/18/13 states "reposition every 2-3 hours, follow turning schedule". An addition to the care plan dated 01/25/13 further directs staff to ''assist repositioning every 3-4 hours while in bed during sleep hours per (resident) request''. Per the Plan of Correction (POC) e-mail note of 01/02/13 to the Nursing staff from the DNS states ''from this point forward anytime turn and reposition, float heels, ted hose on, heel protectors or elbow protectors is selected as an LNA intervention on the care plan it must be activated on the CNA access screen so that there is documentation that these interventions are being performed.'' Per review on 01/28/12 of the CNA Access Record under skin from 01/02/13 - 01/27/13 staff did not consistently document the intervention for repositioning. The documentation for each of these days was on average of two - three times out of a possible eight to twelve times daily documentation. On 01/23/13 repositioning had been documented five times. Per interview on 01/28/12 at 11:15 a.m. the resident stated s/he gets ''changed and repositioned several times a day''. Per interview at 2:26 p.m. the DNS confirmed that LNA staff had not documented that the resident had been repositioned as care planned. 3. The care plan for Resident #19 reflects that s/he is to be positioned every 2 hours and this was verified by the charge nurse on 1/28/13. The LNA charting does not reflect that the resident has been turned and positioned as indicated by the charge nurse or as outlined in the care plan. This was confirmed by the charge nurse during review of documentation on 1/28/13. There were 25 out of 111 opportunities where more than 2 hours had elapsed between turning or positioning, sometimes with an entire shift without documentation, per care plan, and 6 times with no time indicated for positioning. The time frames were inconsistent over all three (3) shifts.