Every finding on record at Hewitt Health & Rehabilitation Center, Inc

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for resident rights, the facility failed to honor the residents right to refuse care when a resident requested staff to stop providing incontinent care. The findings include: Resident #1 had a diagnosis of vascular dementia, altered mental status, and failure to thrive. Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognitive skills, no behaviors, and was dependent for toileting, showering, and transfers. The Resident Care Plan (RCP) dated 4/8/26 identified an alteration in activities of daily living (ADL). Interventions directed to assist resident with personal care as needed, and two (2) staff for all care. Facility reportable event dated 6/10/26 at 9:45 AM identified an allegation of staff to resident abuse without injury. The resident alleged that at 6 AM, a NA inserted her fingers into the resident's private area during incontinent care. Social Services note dated 6/10/26 at 8:58 AM identified the social worker and MDS coordinator met with Resident #1 after the allegation was made. Resident #1 stated the NA came in for care and Resident #1 declined the care and the NA continued to provide care despite the refusal. Reportable event summary dated 6/15/26 identified on 6/10/2026 at approximately 9 am Resident #1 reported a NA touched him/her inappropriately and was rough with care. Resident #1 was transferred to the hospital for evaluation and no injury was identified. Facility interview with NA #1 identified she provided incontinent care for Resident #1 at approximately 5:30 AM and NA #1 indicated Resident #1 was verbally resistant during care. NA #1 denied the allegation. Facility statement from NA #2 identified the did not observe anything inappropriate. Interview with NA #1 was attempted but could not be conducted due to a language barrier during the interview. Review of facility obtained statement from NA #1 dated on 6/11/26 identified she went in to provide care for Resident # 1 on 6/10/26 and the resident was extremely wet and needed to be changed. NA #1 got all the supplies and proceeded with care, and Resident #1 told NA #1 to stop, but NA #1 told Resident #1 that she needed to provide the care and NA #1 continued to clean Resident #1. Further, NA #1 denied touching Resident #1 inappropriately. Interview and record review with the Director of Nursing (DNS) and Administrator on 7/6/26 at 1:53 PM identified NA #1 continued to give Resident #1 after the resident told NA #1 to stop because the resident was wet. The DNS stated NA #1 should have stopped giving care after Resident #1 told her to stop. The DNS and Administrator stated residents have the right to refuse care and staff should not continue to provide care after a resident tells them to stop. Review of facility resident rights policy (no date) directed residents have the right to refuse treatment.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in accordance with the plan of care. The findings include: Resident #1 had a diagnosis of vascular dementia, altered mental status, and failure to thrive. Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognitive skills, no behaviors, and was dependent for toileting, showering, and transfers. The Resident Care Plan (RCP) dated 4/8/26 identified an alteration in activities of daily living (ADL). Interventions directed to assist the resident with personal care as needed, and two (2) staff for all care. Facility reportable event dated 6/10/26 at 9:45 AM identified an allegation of staff to resident abuse without injury. The resident alleged that at 6 AM, a NA inserted her fingers into the resident's private area during incontinent care. Interview with NA #1 was attempted but could not be conducted due to a language barrier. Review of facility obtained statement from NA #1 dated on 6/11/26 identified she went in to provide care for Resident # 1 on 6/10/26 and the resident was extremely wet and needed to be changed. NA #1 got all the supplies and proceeded with care, and Resident #1 told NA #1 to stop, but NA #1 told Resident #1 that she needed to provide the care and NA #1 continued to clean Resident #1. Further, NA #1 denied touching Resident #1 inappropriately. Interview with NA #2 on 7/6/26 at 12:48 PM identified she worked during the 11 PM to 7 AM shift from 6/9 into 6/10/26. NA #2 stated she heard Resident #1 yelling get toward the end of her shift. NA #2 then proceeded to Resident #1's room and when she entered the room, NA #1 was the only staff member present in the room. When NA #2 walked into the room Resident #1 asked her to clean him/her up. NA #2 told NA #1 that she would finish cleaning the resident, and NA #1 remained in the room, standing off to the side while NA #2 provided Resident #1 with care. Interview and record review with the Director of Nursing (DNS) and Administrator on 7/6/26 at 1:53 PM identified the care plan directed two (2) staff members to provide care for Resident #1, and they did not know why NA #1 provided care by herself. Interview identified two (2) staff should have been in the room for care, in accordance with the plan of care. Review of the undated facility Care Planning Policy directed in part, the care plan directed the care that will be provided.

Based on facility documentation review and staff interviews for one of three residents (Resident #1) reviewed for Administration review, the facility failed to ensure a staff member spoke effectively to communicate with a resident when providing care. The findings include: Resident #1 had a diagnosis of vascular dementia, altered mental status, and failure to thrive. Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognitive skills, no behaviors, and was dependent for ADLs, and the preferred language was English. The Resident Care Plan (RCP) dated 4/8/26 identified an alteration in activities of daily living (ADL). Interventions directed to assist with personal care as needed, and two (2) staff for all care. Additional review failed to identify any language barrier was identified. Facility reportable event dated 6/10/26 at 9:45 AM identified an allegation of staff to resident abuse without injury. The resident alleged that at 6 AM, a NA inserted her fingers into the resident's private area during incontinent care. Review of facility obtained statement from NA #1 dated on 6/11/26 identified she went in to provide care for Resident # 1 on 6/10/26 and the resident was extremely wet and needed to be changed. NA #1 got all the supplies and proceeded with care, and Resident #1 told NA #1 to stop, but NA #1 told Resident #1 that she needed to provide the care and NA #1 continued to clean Resident #1. Further, NA #1 denied touching Resident #1 inappropriately. Additional review of the statement from NA #1 identified the facility utilized a translator to interview NA #1 regarding the allegation of abuse. Review of employee file identified communication between the facility staff sent to NA #1 dated 4/23/26 and 5/11/26 utilized a translator service to communicate. Interview with Police Officer #1 on 7/6/26 at 11:41 AM identified when he attempted to speak with NA #1 a translator was needed because NA #1 understood very little English. Interview with NA #1 was attempted but could not be conducted due to a language barrier during the interview; NA #1 stated she did not understand English very well. Interview with the Director of Nursing (DON) and Administrator on 7/6/26 at 1:53 PM identified they were aware Resident #1's primary language was not NA #1's primary language. NA #1 understood some of Resident #1's primary language, but the facility needed a translator to obtain her statement after the allegation. The DON stated she wanted to be sure NA #1 understood what she was asking when she asked about the perineal area, and stated any nursing department employee should be able to speak, read and understand well enough to understand how to provide specific care, and should understand the words used to describe a male or female anatomy. Interview failed to identify how a NA that did not understand the resident's primary language would be able to understand directions from a nurse, or comments from a resident, or refusal of care by a resident. Review of facility Certified Nursing Assistant job qualifications directed staff should have the ability to read, write and follow oral and written instructions by others.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to notify the State Agency timely after they were aware of an allegation of abuse. The findings include: Resident #1 had a diagnosis of vascular dementia, altered mental status, and failure to thrive. Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognitive skills, no behaviors, and was dependent for toileting, showering, and transfers. The Resident Care Plan (RCP) dated 4/8/26 identified an alteration in activities of daily living (ADL). Interventions directed to assist resident with personal care as needed, and two (2) staff for all care. Facility reportable event (RE) dated 6/10/26 at 9:45 AM identified an allegation of staff to resident abuse without injury. The resident alleged that at 6 AM, a NA inserted her fingers into the resident's private area during incontinent care. The RE indicated the event was alleged to have occurred at 6 AM, and the facility was first aware of the allegation at 9:45 AM. Review of the State Agency FLIS (Facility Licensing and Investigation Section) on-line portal for Reportable Events identified the facility notified the State Agency of the allegation on 6/10/2026 at 2:13 PM (4 hours and 28 minutes after the facility was aware of the allegation). Interview with RN #1 on 7/6/26 at 1:03 PM identified she was notified of the allegation about 9:22 AM she was notified the Director of Nursing (DNS) and Administrator immediately. Interview and record review with the DNS and Administrator on 7/6/26 at 1:53 PM identified the DNS was informed of the incident around 9AM and the Administrator was informed at around 9:30 AM to 9:45AM, but the State Agency was not notified until later in the afternoon. The DNS and Administrator stated an allegation of abuse needs to be reported in two (2) hours and they were too busy to notify the State Agency timely. Further, interview identified to ensure timely notice, an initial report could have been submitted timely with a minimum of information and then additional information could have been added later. Review of the undated facility Abuse Policy directed in part, the Administrator, DNS, or designee will submit an online report to FLIS within two (2) hours of notification of an allegation of abuse.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a change in condition, the facility failed to ensure the provider was notified at the time a change in behavioral symptoms was noted. The findings include:Resident #1's diagnoses included dementia with behavioral disturbances, anxiety, major depressive disorder, centrilobular emphysema (damage to the air sacs in the center area of the lungs which can spread outwards and leads to difficulty breathing and reduced oxygen supply to the bloodstream) and congestive heart failure. The Resident Care Plan dated 10/9/25 identified Resident #1 had chronic progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process' related to dementia with psychotic disturbances, displayed inappropriate behavior and at times refused to wear supplemental oxygen, refused medication and could be resistive to care. Interventions included administering medications as ordered by the provider, observing for and reporting changes in cognitive status to the provider, redirecting the resident's undesirable behavior and if he/she was resistive to or refuses care, leave and reapproach the resident in five (5) to ten (10) minutes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating some memory recall deficits, disorganized thinking, difficulty focusing attention, had not exhibited behavioral symptoms in the past seven (7) days and was independent with bed mobility, transfers and ambulating. The nurse's note dated 12/27/25 at 12:57 AM identified a nurse aide changed Resident #1's bed sheets due to the sheets being soiled and Resident #1 became angry and threw the linens out into the hallway stating he/she did not want new linens. The note reported that staff attempted to redirect Resident #1 twice. The nurse's note dated 12/27/25 at 1:09 PM identified Resident #1 was given fluids with the lunch meal and threw them all over the floor and began screaming at the nurse aide. Review of the clinical record from 11/28/25 through 12/26/25 failed to identify any previous angry outbursts from Resident #1 or that the nursing supervisor or the provider were notified on 12/27/25 of Resident #1's change in behavior. The nurse's note dated 12/29/25 at 2:25 AM identified Resident #1 became very upset when the oxygen tubing was changed and the charge nurse later re-approached Resident #1 and explained why the tubing had to be changed and Resident #1 settled down. The Advanced Practice Registered Nurse (APRN) note dated 12/29/25 at 4:42 AM identified nursing called her to report Resident #1 became agitated when the oxygen tubing was changed and the extension set to make the tubing longer was thrown away. The note indicated Resident #1 returned to the bedroom and may have lit a part of his/her bed on fire and the fire was self-extinguished by the time the nursing staff responded to the room. The note identified Resident #1 was placed on one (1) to one (1) monitoring and no other matches were found and she ordered a continuation of the 1 to 1 monitoring, a psychiatric evaluation to be completed in the morning and to notify the provider of any further change in condition. The nurse's note dated 12/29/25 at 1:45 PM identified at 7:00 AM Resident #1 was transferred to the hospital after making a threatening statement towards the building. The note indicated Resident #1 was extremely agitated, throwing things, yelling at staff and the provider and Resident #1's responsible party were made aware. The hospital documentation dated 12/29/25 identified Resident #1 presented to the emergency department for evaluation of agitation, complaints of feeling unwell, and concerns for a bladder infection. The emergency department note identified the crisis team was consulted regarding Resident #1's agitation and the report that Resident #1 had set his/her bed on fire. The note indicated Resident #1 was diagnosed with a urinary tract infection and started on antibiotics and Resident #1 was cleared by the crisis team and deemed safe to return to the facility. The nurse's note dated 12/31/25 at 8:21 PM identified Resident #1 returned to the facility. Interview with the charge nurse, Licensed Practical Nurse (LPN) #2, on 1/2/26 at 11:56 AM identified although Resident #1 was unusually angry on 12/27/25, she did not report Resident #1's outbursts to either the nursing supervisor or provider, stating she attributed Resident #1's behaviors to not liking change. LPN #2 stated she documented Resident #1's behaviors in the psychiatric APRN book even though she knew they were not set to visit the facility again for three (3) more days. LPN #2 reported looking back, she should have notified the nursing supervisor on 12/27/25 so the on-call provider could have been notified of Resident #1's change in behavior, explaining Resident #1 was unable to be redirected and had no available as needed medication to calm him/her down. Interview with LPN #1 on 1/2/26 at 1:47 PM identified although Resident #1 had a history of refusals, on 12/29/25, Resident #1 was angrier and agitated than she had ever observed before. Interview with the APRN on 1/2/26 at 11:41 AM identified a provider should have been notified of Resident #1's behaviors on 12/27/25, reporting that what was documented by LPN #2 was not the resident's baseline. The APRN identified Resident #1 had a history of urinary tract infections and recently had a Gradual Dose Reduction (GDR) of Seroquel (an anti-psychotic medication) in November and had a provider been notified, a urine and blood work could have been ordered as well as an as needed medication. Interview with the Director of Nursing (DON) on 1/2/26 at 1:22 PM identified the nursing supervisor and a provider should have been notified of Resident #1's behaviors on 12/27/25, reporting it was not appropriate for LPN #2 to only write the behaviors in the psychiatric APRN book, stating the medical APRN or psychiatric APRN should have been contacted for a telehealth appointment. Review of the Change in Resident Condition/Family/MD Notification policy dated July 2018 directed, in part, that when there is a significant change in the condition of a resident's physical, mental or emotional status the resident's attending physician shall be notified. If the resident's physician is not available, the covering physician shall be notified. If the attending or covering physician is not available, the medical director or associate shall be called. A RN assessment will be conducted, and the nurse will document in the nurse's notes that the physician and family or responsible party have been notified of the change in condition.

Based on interviews and review of the Payroll Based Journal (PBJ) submissions, the facility failed to provide the appropriate number of weekend staff for Quarter 1 and Quarter 2 of Fiscal Year (FY) 2024 (October 1, 2023 through March 31, 2024). The findings include: PBJ submissions for Quarter 1 and Quarter 2 of FY 2024 (October 1, 2023 through March 31, 2024). indicated the facility had triggered for excessively low weekend staffing. An interview with the Scheduler on 5/16/25 at 9:36 AM identified she was not responsible for submitting staffing reports to PBJ and was not aware that the facility had triggered for low weekend staffing for Quarters 1 and 2 of FY 2024. The Scheduler indicated weekend staffing during that time was a challenge due to nursing staff calling out for their schedule shifts, retainment of staff, and agency staff calling out before scheduled shifts. The Scheduler identified more staff have been hired, retainment of staff is better, and they rarely need to call agency staff to help with covering scheduled shifts. Interview with the HR coordinator at 05/16/25 09:54 AM identified that she was responsible for submitting staff data to the PBJ, but she was not employed at the facility during Quarters 1 and 2 of FY 2024 when low weekend staffing was triggered. An interview with the [NAME] President (VP) of Clinical Operations on 5/16/25 at 10:04 AM identified that he was aware the facility triggered for during Quarter 1 and Quarter 2 of FY 2024. The VP of Clinical Operations indicated that in response to the low weekend staffing, the facility offered various shifts, per diem shifts, weekend only part-time shifts, offered bonuses, and held hiring events. The interview identified that after the various recruitment efforts, weekend staffing has greatly improved. Review of the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Reporting Long Term Care Facility Policy Manual, dated June 2022, directed Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information. Additionally, it identified that facilities that do not meet requirements will be considered noncompliant and subject to enforcement actions by CMS.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 residents (Resident #6, Resident #98, and Resident #110) reviewed for smoking, the facility failed to ensure timely completion of smoking assessments, to secure smoking materials per the resident plan of care (Resident #6), and failed to provide supervision to a resident smoking (Resident #6) per the smoking assessment. The findings include: 1. Resident #6's diagnoses included end stage heart failure, asthma, and acquired absence of the left leg. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was cognitively intact and was independent with toileting, bed mobility, and transfers. The MDS indicated Resident #6 used a motorized wheelchair and was not ambulatory. Additionally, the sections of the MDS identifying tobacco use was not completed. An admission smoking assessment dated [DATE] at 10:01 PM identified Resident #6 wanted to smoke but did not have the potential to violate the smoking policy. The assessment indicated Resident #6 required supervision with smoking and the resident was going outside with another resident that smoked. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was cognitively intact and was independent with toileting, bed mobility, and transfers. The MDS indicated Resident #6 used a motorized wheelchair and was not ambulatory. A physician's order dated 5/1/25 directed Resident #6 may go on a leave of absence and to medical appointments independently and with medications. The orders directed the resident may be up in his/her power custom wheelchair as tolerated and was non-ambulatory but independent with all transfers and indoor and outdoor mobility. An admission smoking assessment dated [DATE] at 9:54 AM identified Resident #6 was a current smoker who wanted to smoke but did not have the potential to violate the smoking policy. The assessment indicated Resident #6 required supervision with smoking. The Resident Care Plan (RCP) dated 5/7/25 identified Resident #6 was an active and independent smoker who agreed to not smoke on facility property (as the facility was a non-smoking facility) and to not have any smoking materials in his/her possession. Interventions included to provide the resident with a copy of the facility's smoking policy and the resident would return his/her lighter, matches and cigarettes to the nursing staff when he/she was finished smoking. An observation on 5/13/25 at 8:45 AM identified Resident #6 was outside in a wheelchair on the sidewalk bordering the building of the facility and he/she was smoking a cigarette unsupervised. Interview on 5/13/25 at 11:45 AM with Resident #6 within his/her room, indicated that although he/she was made aware this was a non-smoking facility when admitted , the facility was aware he/she was smoking outside, and he/she did not keep smoking materials on his/her person and had given them to the nursing staff. Resident #6 then proceeded to display a black cigarette lighter which was kept in the right-hand pocket of his/her sweatshirt. Resident #6 indicated he/she was not smoking on facility property and that to obtain smoking materials he/she independently went to a local store in the power wheelchair. Interview with the Administrator on 5/13/25 at 11:55 AM identified she was aware Resident #6 was smoking outside of the facility and the resident was supposed to give the nurse her smoking materials to secure in the medication cart. The Administrator was informed that Resident #6 displayed having a black cigarette lighter on her person. The Administrator indicated the resident should not have a lighter in her possession and she would go and speak to the resident and confiscate the lighter and any other smoking materials found with the resident. A nursing note dated 5/13/25 at 1:43 PM identified Resident #6 was smoking on a leave of absence and the DNS later met with the resident and reviewed the prohibited smoking items policy. The resident stated she purchased the items and forgot to give them to the nurse. The nursing note indicated the prohibited items were taken and stored in the medication cart. Subsequent to surveyor inquiry, a smoking assessment dated [DATE] at 9:47 AM identified Resident #6 was a current smoker and wanted to smoke but did not have the potential to violate the smoking policy. The assessment indicated the resident was able to smoke independently. Subsequent to surveyor inquiry, the RCP was updated on 5/13/25 to reflect a prohibited items violation had occurred with Resident #6 and interventions included a room and package search with the residents consent to determine the presence of any prohibited items and to try to determine the cause of the violation. Interview with LPN #5 on 5/14/25 at 1:00 PM identified she was the charge nurse for Resident #6 and she was aware the resident went outside multiple times a day to smoke cigarettes. LPN #5 indicated she was not responsible for Resident #6's smoking materials and was not sure where they were stored. LPN #5 identified she did not have or handle smoking materials for Resident #6 and believed that the resident's smoking materials were kept at the front desk and given to the resident when he/she went out to smoke. An observation on 5/14/25 at 1:05 PM identified Resident #6 was outside in a wheelchair on the facility sidewalk, which was adjacent to the side of the building, and the resident was smoking a cigarette. Interview with the front desk secretary on 5/14/25 at 1:09 PM identified the facility was a non-smoking facility and he does not have or keep resident's smoking materials at the front desk. The front desk secretary was aware that Resident #6 would sign out of the facility and go outside to smoke cigarettes multiple times per day, but he believed the resident kept smoking materials on his/her person and the resident purchased them in the community. The front desk secretary indicated he was not responsible for resident's smoking materials and was not sure who was. Another interview on 5/14/25 at 2:20 PM with Resident #6, seated in the wheelchair and back in his/her room, indicated he/she was smoking outside earlier, and he/she had given the nurse his/her smoking materials which were secured in the medication cart. Resident #6 indicated he/she did not have smoking materials in his/her possession or in his/her room. Another interview with LPN #5 on 5/14/25 at 2:22 PM indicated that although she had observed Resident #6 leaving the unit multiple times today and the resident had returned smelling like cigarette smoke, she did not have Resident #6's smoking materials in the medication cart and did not know where they were kept. LPN #5 indicated Resident #6 had not asked her for nor had she provided the resident with his/her smoking materials that day. Interview and review of the clinical record with the DNS on 5/14/25 at 2:30 PM identified the charge nurse was responsible to secure Resident #6's smoking materials and the resident should not be smoking on the sidewalks on or around the facility, as those were considered facility property. The DNS was informed LPN #5 did not have Resident #6's smoking materials in the medication cart and had indicated it was the front desk that kept them however, the front desk secretary did not have the smoking materials either, so the resident likely still had smoking materials on his/her person. The DNS indicated she would speak to the resident and complete a room search now. Additionally, the DNS identified that she or the nursing staff were responsible to complete resident smoking assessments on admission and on a quarterly basis. Review of the clinical record indicated Resident #6's smoking assessments were completed only on 5/22/24 and 5/1/25 and both indicated the resident required supervision with smoking (smoking assessments were not completed in August 2024, December 2024, and March 2025). The DNS indicated she was unsure why smoking assessments were not completed quarterly as required, and the most recent smoking assessment she completed for the resident on 5/13/25, determined the resident was independent with smoking. The DNS identified that Resident #6 had been observed outside of the facility and on facility property smoking cigarettes unsupervised prior to 5/13/25. An observation made on 5/15/25 at 12:40 PM identified Resident #6 was outside in a wheelchair smoking a cigarette at the back side of the building at the end of the facility's rear entrance driveway. 2. Resident #98's diagnosis included diabetes, falls, and osteoarthritis. Resident #98 was admitted to the facility in November 2023. The Resident Care Plan (RCP) dated 11/22/23 identified that prior to admission Resident #98 was an active smoker, resident was told the facility was smoke free, and he/she agreed while at the facility not to have any smoking materials on his/her possession. Interventions directed to provide Resident #98 with smoking cessation material if requested, provide a copy of the facility's smoking policy, and off to obtain a physician order for nicotine patch, gum, or lozenges. A smoking assessment was not completed on admission in November 2023, and only one smoking assessment was completed on 3/8/24 which identified Resident #98 was able to smoke independently, had a history of smoking, had the potential to violate the smoking policy, and had a desire to continue to smoke. Further, identified that Resident #98 declined to provide the nurse with his/her lighter. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #98 was cognitively intact, used tobacco and was independent for transfers, dressing and toileting. Also, identified was Resident #98 required set up for eating and showering. Physician orders dated 10/24/24 identified that Resident #98 directed independent with a leave of absence from the facility. 3. Resident #110's diagnosis included substance abuse, acute kidney failure, and acute respiratory failure. Resident #110 was admitted to the facility in April 2025. The admission Minimum Data Set assessment dated [DATE] identified Resident #110 had intact cognition, was independent for eating, supervision assistance for toileting, showering, and transfers. Also, identified Resident #110 required moderate assistance for personal hygiene. Further, identifying Resident #110 used tobacco. The Resident Care Plan dated 5/1/25 identified Resident #110 was actively smoking, aware the facility was smoke free, and agreed to not have any smoking materials in his/her possession. Interventions directed to offer to obtain a physician order for nicotine patch, gum or lozenges, provide the resident with the facility's smoking policy, and provide the resident with smoking cessation materials if requested. An observation made on 5/13/25 at 8:45 AM of Resident #6 and Resident #98 with smoking materials outside on the sidewalk of the facility (each had a cigarette and they shared a lighter). Review of the Smoking assessment dated [DATE] (29 days after admission to the facility) at 9:46 AM identified that Resident #110 was a current smoker and was able to smoke independently. A nursing note dated 5/13/25 at 10:12 AM identified that the resident was a current smoker, policy was reviewed, and a smoking assessment was completed. Also, identifying that Resident #110 had an order for independent leave of absence from the facility. An interview on 5/14/25 at 9:50 AM with Resident #110 identified that he/she smoked, did not have any smoking materials in his/her possession, the facility asked upon admission if he/she was a smoker and the facility was aware. Also, Resident #110 identified that he/she had smoked since being admitted to the facility An interview on 5/14/25 at 12:57 PM with the Director of Nursing (DNS) identified that she was unaware that Resident #110 was a smoker and that a smoking evaluation was not completed upon admission to the facility. The DNS also identified that the MDS identified Resident #110 was a smoker and evaluation should have been completed at admission. Further, identifying the facility was a non-smoking facility but if the facility was made aware that a resident chooses to smoke order would be obtained for independent leave of absence. An interview on 5/14/25 at 10:05 AM with Licensed Practical Nurse (LPN) #10 identified that Resident #98 was a smoker, she does not hold Resident #10's smoking materials, that a smoking assessment was to be completed upon admission and the resident was told it was a nonsmoking facility. An interview on 5/14/25 at 1:03 PM with the DNS identified that she was not aware that Resident #98 was a smoker although he/she had a Resident Care Plan for smoking, and Resident #98's annual MDS identified Resident #98 as a smoker. Also, identified that Resident #98 last smoking evaluation was completed on 3/8/24 and a smoking evaluation was to be completed every quarter or with a significant change in condition. An observation made 5/15/25 at 12:40 PM Resident #98 and Resident #6 observed smoking on back side of building at the end of the facility driveway. An interview on 5/15/25 at 2:33 PM with LPN #10 identified that she does not hold smoking materials for any residents and the Assistant Director of Nursing Service had the smoking materials. Subsequent to this surveyor's inquiry the facility performed a smoking assessment for Resident #110. Review of the facility policy, Smoking, dated 10/1/24, directed that except for facilities that are designated to allow smoking, all other company facilities were non-smoking and only residents who reside in a smoking facility may participate in a supervised smoking program. The policy directs that a smoking assessment is to be completed on admission and with any change or violation of the smoking policy. The policy further directs that residents who obtain smoking materials while on a leave of absence will be instructed to provide materials to staff upon returning to the facility. Review of the facility's policy (from the admission packet), Smoking, undated, directed the facility is a smoke free environment for all employees, residents and visitors and all smoking will be prohibited anywhere on grounds, including parking areas, access roads, and in vehicles parked on the property.

Based on review of the clinical record, facility policy and interviews for 4 of 32 residents (Resident #31, Resident #94, Resident #214 and Resident #315) reviewed for Advance Directives, the facility failed to follow facility policy for completion of resident's choices for advance directives. The findings include: 1. Resident #31's diagnoses included paranoid schizophrenia, malignant neoplasm of the kidney, and lymphedema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was cognitively intact and was independent with eating, bed mobility and transfers. The Resident Care Plan (RCP) dated [DATE] identified Resident #31 required staff assistance with his/her activities of daily living. Interventions included Advance Directives per resident/representative and per physician orders and please ensure Resident #31 was accompanied to medical appointments as necessary. Review of Resident #31's clinical record on [DATE] at 9:47 AM failed to identify a Medical Interventions Consent Form (which identified Advanced Directives) was included and signed by the resident/responsible party. A physician order in effect on [DATE] (original order dated [DATE]) directed the administration of Cardiopulmonary Resuscitation (CPR) as Resident #31's code status. Although requested, a current Medical Interventions Consent Form filled out with Resident #31's choices for administration of life support systems and medical interventions was not provided. 2. Resident #94's diagnoses included dementia, adjustment disorder with mixed anxiety and depressed mood, and chronic kidney disease. The Resident Care Plan (RCP) dated [DATE] identified Resident #94 required staff assistance with his/her activities of daily living. Interventions included Advance Directives per resident/representative and per physician orders and assist with feeding as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #94 was moderately cognitively impaired and was independent with eating, bed mobility and transfers. Review of Resident #94's clinical record on [DATE] at 11:03 AM failed to identify a Medical Interventions Consent Form (which identified Advanced Directives) was included and signed by the resident/responsible party. A physician order dated [DATE] (original order dated [DATE]) directed administration of Cardiopulmonary Resuscitation (CPR) as Resident #94's code status. Although requested, a current Medical Interventions Consent Form completed with Resident #94's choices for administration of life support systems and medical interventions was not provided. Interview with Social Worker (SW) #1 on [DATE] at 3:00 PM identified she did not routinely review the Advance Directives with residents upon admission for those residents with resident representatives. SW #1 identified that the Advance Directives were reviewed on admission by the nursing supervisor who would reach out to the resident representative by phone and leave a message requesting a call back to review the Advance Directives. 3. Resident #214's diagnoses included paranoid schizophrenia, diabetes, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #214 was severely cognitively impaired, used a walker, and was independent with eating, bed mobility, and transfers. The Resident Care Plan (RCP) dated [DATE] identified Resident #214 required assistance/supervision with his/her activities of daily living: bathing, dressing, transfers, toileting, ambulation, eating/drinking and mobility. Interventions included Advance Directives per resident/representative and per physician orders. A Medical Interventions Consent Form (which identified Advanced Directives) dated [DATE] identified per the resident's representative via telephone conference, the choices for administration of life support systems and medical interventions for Resident #214 were: Do not resuscitate (DNR)/Do not intubate (DNI), do not administer artificial means of nutrition, intravenous fluids, hospitalization. The form further identified Resident #214 was comfort measures only (CMO). Review of physician orders identified while Resident #214 was hospitalized for a psychiatric admission under a Psychiatric Express Clinic (PEC) (emergency psychiatric care) on [DATE], all physician orders including Advance Directives were discontinued. Review of physician orders in the clinical record failed to identify a physician order for Advance Directives from [DATE] through [DATE] (upon Resident #214's re-admission). Interview with the Director of Nursing (DNS) on [DATE] at 12:55 PM identified the nursing supervisor was responsible for obtaining the Advance Directives on the Medical Interventions Consent Form and entering the physician order into the electronic medical record (EMR). The DNS identified if the resident representative did not come to the facility on admission/re-admission of the resident, the nursing supervisor would reach out to the resident representative by phone and the Medical Interventions Consent Form would be flagged in the chart if no response was received. The DNS identified that audits and chart reviews were completed on charts for admissions/re-admissions to ensure that the Medical Interventions Consent Form and the physician order in the electronic record match. The DNS could not identify the reason Resident #31's, Resident #94's Medical Interventions Consent Form was not in the chart, or the reason Resident #214 did not have re-admission Advanced Directive physician orders. Subsequent to surveyor inquiry, an Advance Practice Registered Nurse (APRN) order dated [DATE] directed Resident #214's Advance Directives: Do not resuscitate (DNR)/Do not intubate (DNI)/Do not hospitalize (DNH)/No artificial nutrition or hydration/Comfort measures only (CMO). Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:30 AM identified if there was not physician orders for Advance Directives in the electronic medical record (EMR) she would refer to the Medical Interventions Consent Form in the resident's paper chart. LPN #2 identified she preferred to check the chart to verify the Advance Directives, but that if there were no physician orders for Advance Directives in the EMR it was policy to administer Cardiopulmonary Resuscitation. 4. Resident #315 was admitted to the facility on [DATE] with diagnoses that included sepsis, congestive heart failure, and endocarditis. An admission nursing assessment dated [DATE] identified Resident #315 was cognitively intact and required a 2 person assist for transfers. Also identified that Resident #315 required assistance with dressing, bathing, eating and oral hygiene. The Resident Care Plan dated [DATE] identified Resident #315 required assistance with activities of daily living. Interventions included to provide advance directives as per physician orders, assist with mouth/dental care, and assist with feeding as needed. Physician orders dated [DATE] directed that Resident #315 had a code status of do not resuscitate (DNR). An interview on [DATE] at 2:36 PM with Licensed Practical Nurse (LPN) #10 identified that Resident #315 code was a DNR and the order was obtained on [DATE], 8 days after admission on [DATE]. Also, identifying that a code status should be completed upon admission by the admitting nurse, that any resident without a code status would be provided with cardiopulmonary resuscitation (CPR) and that there was no physician order regarding code status for 8 days. An interview on [DATE] at 10:26 AM with the Director of Nursing (DNS) identified that Resident #315's code status was obtained on [DATE] (8 days after admission) and would be classified as a full code and given CPR. Further, identifying that a code status was to be in place 24 to 48 hours after admission and if a resident could not sign, a verbal consent could be obtained with the responsible party with 2 registered nurses acting as witnesses. The DNS was unsure of the reason there was a delay in obtaining a code status for Resident #315. Review of the Advance Directives policy directed, in part, licensed nursing staff and/or the resident's attending physician would review advance directives with the capable resident or the responsible party. The policy identified the advance directive consent form would be signed and dated by the person who reviewed the advance directives with the resident or responsible party and a physician's order would be obtained related to the resident's advance directives and refusal of treatment.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #1, Resident #53, Resident #78 and Resident #85) reviewed for nutrition, the facility failed to notify the resident representative (Resident #1, Resident #53 and Resident #78) and failed to notify the physician (Resident #85) of a weight loss. The findings include: 1. Resident #1's diagnoses included dementia, depression, and anemia. Review of the face sheet in the clinical record identified Resident #1 was not responsible for him/herself and a family member was the resident representative. The Resident Care Plan (RCP) dated 11/7/24 identified Resident #1 had the potential for a nutritional decline related to multiple medical diagnoses and the need for an altered consistency diet. Interventions included to provide fortified foods as ordered, provide supplements as ordered, and offer different foods and fluids. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, weighed 131 pounds (lbs.), had no weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. The MDS further identified Resident #1 was independent with eating, required supervision or touching assistance with bed mobility, and was independent with transfers. Review of the Weights and Vitals Summary identified Resident #1 weighed 130.5 pounds (lbs.) on 11/18/24, weighed 123.8 lbs. on 11/21/24 (a 6.7 lb./5.13% loss in 3 days), weighed 127.6 lbs. on 12/11/24 and 1/16/25. On 2/12/25, Resident #1 weighed 113.0 lbs. (a 14.6 lb./11.4% loss in 27 days and/or a 17.5 lb./13.4% loss in 3 months). A Dietician progress note dated 2/21/25 at 8:02 AM identified Resident #1 had a 13.3 lbs. (10%) weight loss in 1 month from 1/16/25 (127.6 lbs.) through 2/20/25 (114.3 lbs.). The note further identified Resident #1's weights had previously been stable for the past year within a range of 128 lbs. to 136 lbs. A Dietician progress note dated 4/8/25 at 2:53 PM identified Resident #1 had a 16.7 lbs. (12.8%) weight loss in 6 months from 10/2/24 (130.5 lbs.) through 4/6/25 (113.8 lbs.). Review of nursing notes in the electronic medical record (EMR) from 2/1/25 through 5/16/25 failed to identify documentation that the resident representative was notified of Resident #1's significant weight loss. 2. Resident #53's diagnosis included Parkinson's disease, dementia, and depression. Review of the face sheet in the clinical record identified Resident #53 was not responsible for him/herself and a family member was the resident representative. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #53 was severely cognitively impaired, required moderate assistance for eating, and personal hygiene. Also, identified Resident #53 required maximal assistance for transfers, toileting, and was dependent for bathing. Further, identified Resident #53 had a weight loss of 5% in the last month or loss of 10% or more in the last 6 months. Review of the Weight and Vitals Summary identified that Resident #53 on 10/1/24 weighed 108.9 pounds (lbs), on 11/2/24 weighed 107.9 lbs., on 12/2/24 weighed 101.8 lbs. (a 6.1 lb./5.6 loss in 1 month), on 1/7/25 weighed 107.3 lbs., on 2/8/25 weighed 103.4 lbs., on 3/2/25 weighed 97.3 lbs. (a 6.1 lb./5.8% loss) with a steady decrease in weight noted until 5/1/25 when Resident #53 weighed 93.6 lbs. (a 14.3 lb./13.2% loss in 6 months/from 11/2/24 to 5/1/25. A Dietician progress note dated 3/14/25 identified that Resident #53 triggered for a 6 lb. weight loss which equaled 5.9% in 30 days and a 10 lbs weight loss which equals 9.3% in 60 days. A Dietician progress note dated 5/2/25 identified that Resident #53 triggered for a 9 lb. weight loss which equaled 9.5% in 3 months. The Resident Care Plan (RCP) dated 5/2/25 identified weight loss with interventions directed weigh Resident #53 as ordered, provide supplements as ordered, and provide diet as ordered. A Dietician progress note dated 5/16/25 identified that Resident #53 triggered for a 8.2 lb. weight loss which equaled 8.4% in 2 months. An interview on 5/19/25 at 9:52 AM with Licensed Practical Nurse (LPN) #10 identified that Resident #53 has had a significant weight loss over the past 6 months of 13.25 % and that the family was not notified. Further, identifying that the nurse was responsible for notifying the responsible party of a significant weight loss. 3. Resident #78's diagnoses included early onset Alzheimer's disease, diabetes, and epilepsy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was severely cognitively impaired, weighed 127 pounds (lbs.), had no weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. The MDS further identified Resident #78 was independent with eating, required substantial/maximal assistance with personal hygiene, and required partial/moderate assistance with bed mobility and chair/bed transfers. The Resident Care Plan (RCP) dated 2/6/25 identified Resident #78 had the potential for a nutritional decline related to medications, multiple medical diagnoses, and poor appetite. Interventions included offering to set up meals, provide diet as ordered, and obtain weights as ordered. Review of the Weights and Vitals Summary identified Resident #78 weighed 130.5 lbs. on 11/13/24 and 11/18/24, weighed 126.9 lbs. on 12/1/24, weighed 125.8 lbs. on 4/6/25, weighed 118.8 lbs. on 5/2/25 and weighed 117.2 on 5/9/25 (a 13.3 lb./10.1% loss in less than 6 months). A Dietician progress note dated 4/4/25 at 11:33 AM identified Resident #78 had been re-admitted from the hospital on 3/28/25 and the monthly/re-admission weight was pending. The note further identified Resident #78's weight had been stable with a range between 127 lbs. to 130 lbs. A Dietician progress note dated 4/11/25 at 9:07 AM identified Resident #78 had a 8.4 lbs. (6.6%) weight loss in 16 days from 3/23/25 (127.9 lbs.) through 4/9/25 (119.5 lbs.). The note identified the weight loss was following Resident #78's hospitalization and identified Resident #78's weights would be changed to weekly weights. Review of nursing notes in the electronic medical record (EMR) dated 4/1/25 through 4/30/25 failed to identify documentation that the resident's representative was notified of Resident #78's significant weight loss. Review of nursing notes in the electronic medical record (EMR) from 2/13/25 through 5/19/25 failed to identify documentation that the resident representative for Resident #44 was notified of Resident #44's weight loss. Review of the Weights and Vitals Summary dated 5/19/25 identified Resident #44 had a severe weight loss of 7.68% in 1 month from 2/13/25 through 3/11/25, and a severe weight loss of 15.4% in 6 months from 10/1/24 through 4/6/25. Interview with the Dietician on 5/16/25 at 11:30 AM identified it was the responsibility of the nurses to update the family/responsible party of a resident's weight loss, and that weight losses were discussed at the weekly risk meetings. Interview with Director of Nursing Services (DNS) on 5/16/25 at 12:05 PM identified it was the responsibility of the nurses to notify the family/responsible party of a resident's weight loss. DNS identified the nurses receive an alert triggered within the EMR when they entered the resident's weight into the computer which alerted them to a weight loss. DNS identified the nurse was then expected to call the family/responsible party to notify of the weight loss. Interview with Licensed Practical Nurse (LPN) #7 on 5/19/25 at 9:50 AM identified weights were obtained by the nurse aides and then entered into the EMR by the nurse. LPN #7 identified when weights were entered into the EMR through the weight tab she would see an alert/flag of a percentage of weight loss if it reached a reportable level. LPN #7 identified if a weight was flagged for weight loss she would obtain a re-weight to verify the weight. LPN #7 identified it was the responsibility of the nurse to report a weight loss to the family/responsible party and that it would be documented in a progress note by the nurse that the family/responsible party had been notified. LPN #7 identified that she only wrote a nursing note regarding a resident's weight loss after she had notified the family/responsible party, and if she didn't write a progress note, then she didn't update the family/resident representative. LPN #7 further identified that she looked for the triggered alert when she entered resident's weights in order to identify a weight loss. 4. Resident #85's diagnosis included congestive heart failure, pleural effusion, and cardiomyopathy. The Resident Care Plan (RCP) dated 2/3/25 identified Resident #85 was at risk for cardiac issues with interventions to obtain weight as ordered/per policy, watch for signs/symptoms associated with cardio-respiratory issues and report to the physician, and diet as ordered. The physician orders dated 2/7/25 are directed to weigh Resident #85 daily in the morning (am), and to call the physician for a gain of 3 pounds (lbs) or more in 24 hours and 5 lbs in 1 week. Also, Resident #85 orders dated 2/8/25 directed congestive heart failure protocols assessments on Monday, Wednesday, and Friday. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #85 was cognitively intact, independent for eating, toileting, showering, dressing, and transfers. Review of the daily weights identified that Resident #85 weighed 382.3 pounds (lbs.) on 1/31/25 and weighed 386 lbs. on 2/1/25 (a 3.7 lb. weight gain in 1 day). Additionally, Resident #85 weighed 377.6 lbs. on 2/28/25 and weighed 382.0 lbs. on 3/1/25 (a 4.4 lb. weight gain in 1 day). An interview on 5/15/25 at 2:41 PM with Licensed Practical Nurse (LPN) #10 identified that Resident #85 was to be weighed daily, if a weight gain of 3 lbs or more in 24 hours or 5 pounds in 1 week the physician was to be notified, she could not provide documentation that the physician was notified of the weight gain. An interview on 5/19/25 at 10:30 AM with the DNS identified that Resident #85 had protocols in place to call the physician for a gain of 3 pounds in 24 hours and 5 lbs. in 1 week, that congestive heart failure (CHF) protocols were in place for Resident #85 which provide directions to notify the physician. Also, identified if the resident gains 3 lbs or more he/she could be experiencing fluid overload, heart failure, or respiratory failure and that would be the fault of the facility for not notifying the physician of the weight gain. An interview on 5/19/25 at 12:19 PM with Advance Practice Registered Nurse (APRN) #3 identified that she was covering for the APRN that wrote the initial order for notification of weight parameters and her expectation for a resident who was on CHF protocols was to be notified of a weight gain of 3 lbs in 24 hours or 5 lbs in 1 week and would expect a reweight to be completed. Also identified that a full assessment of the resident would be completed to rule out any issues, to rule out shortness of breath, and edema. Review of the facility weight monitoring policy identified accurate and timely measurements of weight changes in all residents was an important tool in assessing the resident's nutritional status. Also, identified charge nurses should review the weight and compare to the previous weights to determine a 5% weight loss change in 30 days or 10% weight loss in 180 days. Further, identified significant weight changes to be reported to the physician and family. Review of the facility heart failure clinical protocol identified the physician will review and make recommendations for relevant aspects of the nursing care plan for obtaining weights and when to report findings to the physician.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #44) reviewed for pressure injury, and 1 of 3 residents (Resident #264) reviewed for falls, the facility failed to ensure completion of an Registered Nurse (RN) assessment after a resident fell (Resident #44) and the identification of a new pressure ulcer (Resident #264). The findings include: 1. Resident #44's diagnoses included dementia, fibromyalgia, and anxiety. The Resident Care Plan (RCP) dated 11/1/24 identified Resident #44 was at risk for skin breakdown due to decreased mobility, incontinence, poor nutrition and poor circulation. Interventions included offer and/or encourage Resident #44 to reposition as needed, provide incontinent care as needed, and check Resident #44's skin weekly with scheduled bath/shower. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and was at risk for developing pressure ulcers. The MDS further identified Resident #44 was independent with eating, required partial/moderate assistance with bed mobility, and supervision or touching assistance for transfers. A nursing note written by Licensed Practical Nurse (LPN) #9 on 1/19/25 at 3:21 PM identified Resident #44 had a newly identified open area to the coccyx measuring 2.5 centimeters (cm) by 1.0 cm. The note identified the wound was cleansed with Normal Saline and covered with a dry clean dressing. The note further identified the nursing supervisor was notified and she would obtain a treatment order but failed to identify a subsequent Registered Nurse (RN) assessment of the coccyx open area. Review of the Nursing Daily Attendance Report dated 1/19/25 identified LPN #9 worked the 7:00 AM to 3:00 PM shift that day, and Registered Nurse (RN) #7 was the nursing supervisor for the 7:00 AM to 3:00 PM shift. Interview with the Director of Nursing Services (DNS) on 5/19/25 at 1:05 PM identified there should be an RN assessment documented in the electronic medical record (EMR) following report of a new pressure ulcer, and all new pressure ulcers require completion of an accident and injury (A&I) report. The DNS further identified RN #7 was no longer employed by the facility. Interview with RN #7 on 5/20/25 at 10:51 AM identified she was the nursing supervisor working 1/19/25 during the 7:00 AM to 3:00 PM shift. RN #7 identified she could not recall being informed of a new pressure ulcer for Resident #44 on 1/19/25. RN #7 identified that when notified of a new wound she would fill out a wound tracker, notify the family, and obtain orders from the Advanced Practice Registered Nurse (APRN). RN #7 further identified she did not recall this event, and if there wasn't any documentation from her in the EMR related to this event it was likely LPN #9 forgot to notify her even though LPN #9 documented in her note that she did update RN #7. Attempts to contact LPN #9 were unsuccessful. Review of the Change in Resident Condition/Family/MD Notification policy directed, in part, when there is a significant change in the condition of a resident's physical status an RN assessment will be conducted. 2. Resident #264's diagnoses included fracture of the left femur, autistic disorder, and unspecified convulsions. The admission Minimum Data Set assessment dated [DATE] identified Resident #264 was severely cognitively impaired and required partial/moderate assistance with bed mobility and was dependent with toileting and transfers. The Resident Care Plan dated 5/7/25 identified a fall risk with multiple risk factors and a seizure disorder. Interventions included to transfer the resident per the physician's orders and to maintain safety in the environment. A nursing note written by Licensed Practical Nurse (LPN) #8 and dated 4/21/25 at 10:58 PM identified Resident #264 was found on the floor and the resident's family member reported the resident had slid off the recliner and onto the floor. The nursing note indicated that 4 staff with a gait belt assisted Resident #264 off the floor and into bed. Review of the facility schedule for 4/21/25 indicated RN #6 was the nursing supervisor for the 3:00 PM-11:00 PM shift. Interview with LPN #8 on 5/19/25 at 10:03 AM identified she was the charge nurse for Resident #264 on 4/21/25 for the 3:00 PM-11:00 PM shift. LPN #8 indicated the resident's family member notified her that Resident #264 was on the floor around 10:00 PM and when LPN #8 entered the room, the resident was found sitting on the floor. LPN #8 identified that it took her and 3 other staff to assist the resident off the floor and back into bed. LPN #8 indicated she never informed RN #6 about Resident #264's fall because it was the end of her shift, and she could not find RN #6. Additionally, LPN #8 identified she had made a mistake, did not follow facility policy, should have informed RN #6 of the fall and made sure Resident #264 was assessed after the incident. Interview and review of the clinical record with the DNS on 5/19/25 at 11:00 AM identified she was aware LPN #8 did not inform RN#6 about Resident #264's fall on 4/21/25 and because of that a post fall RN assessment of the resident was never done. The DNS indicated LPN #8 should have informed RN #6 about the incident and made sure the resident was assessed by RN #6 before the resident was assisted off the floor. The DNS stated she did not know why LPN #8 did not inform RN #6 of the fall and LPN#8 was later issued a disciplinary write up by the DNS for not following the facility's policy and protocols. The DNS identified that Resident #264 was not assessed until the following day (4/22/25) by the Advanced Practice Registered Nurse (APRN). Attempts to contact the RN Supervisor (RN #6) were unsuccessful. Review of the facility policy, Falls: Minimizing Risk of Injury, undated, directed after a resident falls, a RN assessment occurs and when the resident is deemed safe by the supervisor to remain in the facility the resident will be transferred off the floor to appropriate seating per the plan of care. Review of the facility policy, Change in Resident Condition/Family/MD Notification, undated, directed in the event of an accident involving the resident, a RN assessment will be conducted.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #18) reviewed for abuse, the facility failed to report an injury of unknown origin to the State Agency (SA) timely. The findings include: Resident #18's diagnoses included dementia, anemia, and non-thrombocytopenic purpura. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was severely cognitively impaired and was dependent for transfers, toileting, and bed mobility. The Resident Care Plan dated 4/15/25 identified skin issues and skin breakdown related to venous ulcers and skin tears. Interventions included to inspect skin when providing care and gentle handling during all care. Observation on 5/12/25 at 12:30 PM identified Resident #18 was in bed and his/her right upper extremity, which was partially outside of the bed covers, had a large area of light purple colored bruising to the top of the hand and wrist area. The skin of the exposed area of the resident's right upper extremity appeared to be intact. The nursing supervisor (RN #6) progress note dated 5/12/25 at 4:45 PM identified Resident #18 had a change in condition with a skin tear to his/her right forearm and discoloration of the extremity from mid-hand to elbow with swelling in the wrist area noted. The APRN was made aware, and a wound treatment and x-ray were ordered. A Reportable Event form signed as filed on 5/12/25, identified Resident #18 had an area of discoloration and swelling noted to the right wrist. The form indicated the physician and family were notified and an investigation was not initiated. A nursing progress note dated 5/13/25 at 12:23 PM identified an x-ray of the right forearm had been ordered by the APRN for Resident #18, secondary to a hematoma. Nursing progress notes dated 5/13/25 at 1:15 PM and 5/13/25 at 7:16 PM identified the bruising to Resident #18's right hand had increased and become more swollen. Interview and record review with the DNS on 5/14/25 at 3:05 PM identified that Resident #18 had sustained a skin tear with a large area of bruising and swelling to his/her right upper extremity which was first observed on 5/12/25. The DNS indicated that although Resident #18's injury was considered an injury of unknown source, she had not reported the resident's injury to the SA because it was still being investigated. The DNS identified it would have been her responsibility to report Resident #18's injury to the SA timely. Another interview with the DNS on 5/16/25 at 2:40 PM identified that although an investigation of Resident #18's injury of unknown source (from 5/12/25) was being conducted, she had still not reported the injury to the SA. The DNS indicated she had not reported the injury because it was still being investigated and she was overwhelmed with work this week. The DNS further identified that she was aware that Resident #18's injury of unknown source was not reported timely to the SA (within 24 hours) and that it would have been her responsibility to have reported the injury timely. Subsequent to surveyor inquiry, on 5/19/25, the DNS reported Resident #18's injury of unknown origin (from 5/12/25) to the SA. Attempts to contact the nursing supervisor (RN #6) were unsuccessful. Review of the facility policy, Injuries of Unknown Origin, undated, directed an injury of unknown origin is an injury where the source is not observed or cannot be explained by resident or staff. The policy further directed all injuries of unknown source will be promptly reported in accordance with federal and state regulations and within the required time frame.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #25) reviewed for medication administration, the facility failed to administer medications per the physician's order resulting in a medication error rate greater than 5%. The findings include: Resident #25's diagnoses included dementia, atrial fibrillation and history of venous thrombus and embolism (blood clot). The annual Minimum Data Set assessment dated [DATE] identified Resident #25 was severely cognitively impaired and required substantial/maximal assistance with bed mobility and toileting and was dependent with transfers. The Resident Care Plan dated 3/6/25 identified constipation and a history of deep vein thrombosis (blood clot). Interventions included to administer medications as ordered and initiate bowel regimen as per the physician's orders. A physician's order dated 5/1/25 directed to administer Aspirin EC 81mg by mouth one time a day for atrial fibrillation and Miralax powder 17 gram/scoop by mouth two times daily for constipation. Observation of medication administration on 5/15/25 at 8:11 AM with Licensed Practical Nurse (LPN) #5 identified she had prepared and dispensed all ordered and scheduled oral medications for 9:00 AM for Resident #25. Prior to administration of medications to the resident, LPN #5 confirmed there were 9 pills in the medication cup as follows: 1. Amlodipine 5mg, 1 tablet 2. Atorvastatin 40mg, 1 tablet 3. Gabapentin 100mg, 1 tablet 4. Gerikot 8.6mg, 2 tablets 5. Quetiapine 50mg, 1 tablet 6. Quetiapine 25mg, 1 tablet 7. Acetaminophen 500mg, 1 tablet 8. Tradjenta 5mg, 1 tablet Medication reconciliation for Resident #25 identified LPN #5 failed to dispense and administer Aspirin EC 81mg by mouth and Miralax 17gm by mouth with the 9:00 AM medication administration observation. Review of the Medication Administration Record (MAR) for 5/15/25 for Resident #25 identified Aspirin EC 81mg and Miralax powder 17 gram/scoop were signed as administered by LPN #5 at 9:00 AM. Interview with LPN #5 on 5/15/25 at 10:35 AM identified that although she had signed for the Aspirin EC 81mg and Miralax 17 gram/scoop on Resident #25's MAR for 5/15/25 at 9:00 AM, she did not administer either medication to the resident. LPN #5 indicated she was nervous and forgot to dispense and administer the Aspirin EC and Miralax to the resident and would need to notify the nursing supervisor to obtain a new order from the physician to administer the medications now. Interview with the Registered Nurse Supervisor (RN #2) on 5/15/25 at 10:45 AM identified LPN #5 was responsible to administer all Resident #25's medications as ordered. RN #2 indicated LPN #5 should not have signed for medications in the MAR that she did not administer, but she was likely nervous. RN #2 identified she would contact Resident #25's physician and would speak to LPN #5 further. Interview with the Director of Nursing Services (DNS) on 5/15/25 at 10:50 AM identified LPN #5 was responsible to administer all Resident #25's medications as ordered. The DNS indicated LPN #5 should not have signed for medications in the MAR that she did not administer and if she was not administering a medication, she should have identified a reason in the MAR. The DNS indicated LPN #5 was likely nervous and she would provide further education to LPN #5. Review of the facility policy, Medication Administration, undated, directed all medications shall be administered safely and accurately in accordance with physician orders, facility protocols, and applicable state and federal regulations. The medication error rate was 7.14% based on the medication administration observation task.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #85) reviewed for edema, the facility failed to weigh the resident per physician orders. The findings include: Resident #85's diagnosis included congestive heart failure, pleural effusion, and cardiomyopathy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 had intact cognition, and was independent with eating, oral hygiene, toileting, upper/lower body dressing and personal hygiene. Additionally, the MDS identified Resident #85 had no significant weight loss and had a diagnoses of heart failure. A physician order dated 12/1/24 directed for Resident #85 to be weighed daily. Review of the weight record from 12/1/24 to 5/15/25 identified a daily weight was not obtained 38 times out of 166 occasions. The Resident Care Plan dated 2/3/25 identified Resident #85 was at risk for cardiac issues with interventions weight as ordered/per policy, watch for signs/symptoms associated with cardio-respiratory issues and report to the physician, and diet as ordered. An interview on 5/15/25 at 2:41 PM with Licensed Practical Nurse (LPN) #10 identified that Resident #85 was to be weighed daily and that Resident #85 was not weighed daily. Further, identifying that she was responsible for making sure the resident was weighed according to the physician orders. An interview on 5/19/25 at 10:30 AM with the Director of Nursing (DNS) identified that Resident #85 was a daily weight and that the resident was not weighed daily according to the weight record. Also, identifying that the nurse was responsible for obtaining the daily weight and for the documentation of the weight. Review of the facility weight monitoring policy identified that residents will be weighed weekly for 4 weeks on admission and readmission then monthly, unless otherwise indicated by the physician's order.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews, for the only sampled resident (Resident #21) reviewed for activities of daily living, the facility failed to maintain clean and trimmed fingernails. The findings include: Resident #21's diagnoses included hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke) affecting the right dominant side, dementia, and end stage renal disease. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #21 was severely cognitively impaired and dependent with transfers, toileting and personal hygiene. The Resident Care Plan (RCP) dated 3/11/25, identified Resident #21 had a history of a stroke with hemiparesis (partial paralysis or weakness of the right side) and needed assistance with activities of daily living (ADL's). Interventions included to anticipate and meet the residents needs and to provide daily skin care and hygiene. Review of the nurse aide (NA) care card for Resident #21 identified he/she was to be showered on the Thursday, 3:00 PM-11:00 PM shift and the resident required total assistance with bathing and to keep his/her nails trimmed and clean. Interview and observation with LPN #1 on 5/13/25 at 11:24 AM identified Resident #21's right hand was contracted and his/her fingernails on both hands were lengthy and unclean with a dark brown substance underneath them. A lengthy thumb nail on the resident's right hand was pressing into the side of his/her 4th finger of the same hand. LPN #1 indicated that, although the nurse aides (NA) were responsible to provide nail hygiene, the facility did not always have enough staff to take care of the resident's fingernails. LPN #1 further identified that nail care should have been completed during the resident's weekly shower, and she was unsure why it was not done. LPN #1 proceeded to assist Resident #21 with opening his right hand and the skin of the inside of the resident's hand appeared dry and intact. Observation on 5/15/25 at 12:55 PM identified the fingernails of Resident #21's bilateral hands remained lengthy and unclean with a dark brown substance underneath them. The resident's right hand was noted to be resting in the resident's lap with the fingers open (hand was not contracted). Interview with NA #3 on 1:00 PM on 5/15/25 at 1:00 PM identified nail trimming and cleaning was to be done on weekly on shower day and Resident #21 was scheduled on the Thursday, 3:00 PM to 11:00 PM shift. NA #3 indicated that although she saw the resident's fingernails were long and dirty and had told the nurse about it 2 weeks ago, she became busy and was unable to take care of it on her shift. NA #3 further identified that because Resident #21's nails remained lengthy and unclean with a dark brown substance underneath and since the resident has never refused to have his nails trimmed or cleaned, she would try to take care of them today. Subsequent to surveyor inquiry, on 5/16/25 at 9:45 AM Resident #21 was seated in the wheelchair in the hallway and his fingernails on both hands were trimmed and clean. When asked about his/her fingernails, Resident #21 responded by smiling and nodding his head up and down (resident non-verbal). Interview with NA #4 on 5/16/25 at 10:40 AM identified that she was assigned Resident #21 on 3:00 PM to 11:00 PM shift on Thursday, 5/8/25 but did not recall giving the resident a shower and did not provide the resident nail hygiene. NA #4 indicated that she does not provide nail hygiene on her shift because it is done by the NA on the morning shift. NA #4 identified that although she took care of the resident almost every day and continued to notice (after 5/8/25) that Resident #21's fingernails on both hands remained lengthy and unclean with a dark brown substance underneath, she was too busy and told the nurse she would have to take care of them another time. Interview with the DNS on 5/16/25 at 2:40 PM identified the policy on nail hygiene was that it was provided for residents as needed and with daily ADL care by the NA. The DNS indicated nail hygiene should have been completed by the NA for Resident #21 when his/her nails were observed to be lengthy and/or unclean, and she would have expected the NA's to have paid special attention to ensure the resident's fingernails were not pressing into his/her right-hand contracture. The DNS, although unsure why nail hygiene had not been provided for Resident #21, indicated she would need to further address the issue with the nursing staff. Interview with the Director of Rehab on 5/16/25 at 2:55 PM identified Resident #21 was admitted to the facility after experiencing a stroke with hemiplegia on his/her right side and the resident was unable to tolerate a splint or orthotic for the right upper extremity. The Director of Rehab indicated Resident #21 did not have functional use of his/her right hand and would be unable to trim or clean his/her own nails. The Director of Rehab identified she had made the nursing staff aware of the need to keep Resident #21's nails shorter due to the right-hand contracture and the risk of skin breakdown and the resident should have had his/her fingernails trimmed and cleaned on a regular basis. The Director of Rehab further indicated she was not made aware of the resident had ever refused to have his/her nails trimmed and cleaned. Review of the facility policy, AM Care/ADL's, undated, directed to provide individualized assistance, nursing staff would assist with AM care for each resident daily and fingernail care including trimming of nails if needed was to be provided.

Based on observations, interviews, record and policy reviews for 1 of 3 residents (Resident #106) sampled for pressure injuries, the facility failed to provide treatment for a wound per physician's order and failed to transcribe wound orders accurately. The findings included: Resident #106's diagnoses included a stage 3 pressure ulcer of the sacral region, muscle weakness and osteomyelitis of vertebral, sacral and sacrococcygeal region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact, and required substantial/maximal assistance for dressing, toileting and changing position in bed. Additionally, the MDS identified Resident #106 had a Stage 3 pressure ulcer defined as full thickness loss, with subcutaneous fat visible but bone, tendon or muscle was not exposed. Slough was present but did not obscure the depth of tissue loss, may include undermining and tunnelling. The Resident Care Plan dated 3/12/25 identified Resident #106 had a pressure ulcer or potential for pressure ulcer development related to immobility. Interventions included administering treatment as ordered and following facility policies/protocols for the prevention/treatment of skin breakdown. The physician's order dated 4/23/25 directed to cleanse the sacrum stage 3 wound with ¼ strength Dakin's solution (an antiseptic), apply prep to peri wound area-let dry, then apply calcium alginate with silver (an antiseptic dressing that absorbs wound drainage) followed by dry clean dressing daily and as needed. a.Observation of the wound treatment on 5/15/25 at 11:46 AM identified LPN # 5 apply gloves then a gown without the benefit of hand hygiene. Nurse Aid (NA) #2 assisted with Resident #106's positioning in bed by standing on the residents' left side while LPN #5 was on the right. While Resident #106 was lying on his/her left side, LPN #5 applied the Dakins solution to gauze that was placed in a medicine cup and set it aside. She then removed the dressing dated 5/14/25 that was on Resident #106's sacral wound and removed the dressing packed inside the wound, disposing of both in the trash receptacle. LPN #5 then removed her right glove, without the benefit of removing her left glove, reached her right hand under her gown and pulled out a clean glove that she then applied to her right hand without the benefit of hand hygiene or removal of the left glove. She cleaned the sacral wound with the Dakins saturated gauze, dried the area and then used skin prep around the wound. LPN #5 then removed both gloves and applied clean gloves without the benefit of hand hygiene, opened the collagen matrix dressing (a dressing that promotes a moist wound environment), at which point the surveyor intervened and called the Infection Preventionist Nurse for clarification. Interview with LPN #5 on 5/15/25 at 11:56 AM identified she was going to use the collagen matrix dressing because it was in her treatment cart, even though the physician's order directed for a calcium alginate with silver dressing, stating the dressings were the same thing. Interview with the Infection Prevention Nurse (IPN) on 5/15/25 at 12:01 PM identified the collagen matrix dressing LPN #5 was ready to apply was not an appropriate substitute for the calcium alginate with silver dressing that was ordered by the physician, and that the facility did not use those two dressings interchangeably. LPN #5 then proceeded to clarify with the IPN nurse if the collagen matrix dressing could be used for Resident #106, to which he responded no. Observation of the wound treatment on 5/15/25 at 12:05 PM by the IPN identified appropriate application of PPE, hand hygiene and completion of wound treatment per physician's order (calcium alginate with silver dressing followed by a dry clean dressing). b.Review of the wound report from 4/23/25 identified the wound APRN recommended Resident #106's stage 3 sacrum wound to be cleaned with ¼ strength Dakin's solution (an antiseptic), apply skin prep to the peri wound area-let dry, then apply calcium alginate with silver (an antiseptic dressing that absorbs wound drainage), followed by dry clean dressing twice a day and as needed (the order was transcribed as once a day for dressing frequency). Interview and record review with IPN on 5/15/25 at 12:11 PM identified that he accompanied the wound APRN on weekly rounds, she made recommendations, and they were transcribed by him. A review of the 4/23/25 APRN wound note identified Resident #106's Treatment Recommendations were to cleanse with 0.125% Dakin's solution (1/4 strength), apply calcium alginate with silver to base of the wound, secure with a dry clean dressing and change twice a day and as needed for soiling, saturation, or accidental removal. The IPN identified the order was incorrectly transcribed as once a day. Subsequent to surveyor inquiry the order was changed to reflect the wound APRN recommendations of changing Resident # 106's sacral wound dressing frequency to twice a day. Review of the Physician's Orders Policy directed in part the purpose was to ensure physician's orders are complete and accurate. Review of the Treatment Process directed in part to cleanse the wound according to the physician's order-assess/evaluate/measure appearance as appropriate and apply the new dressing per physician's order.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #264) reviewed for abuse, the facility failed to ensure a medication was administered as indicated by the physician's order which resulted in Resident #264 receiving a psychotropic medication. The findings include: Resident #264's diagnoses included autistic disorder, developmental disorder, and unspecified convulsions. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #264 was severely cognitively impaired and required partial/moderate assistance with bed mobility and was dependent with toileting and transfers. The MDS assessment indicated Resident #264 received antipsychotic, antianxiety, antidepressant and anticonvulsant medications. The Resident Care Plan dated 5/7/25 identified a seizure disorder with interventions that included to administer medications as ordered. A physician's order dated 5/7/25 directed Lorazepam (a psychotropic medication) 1 mg by mouth every 24 hours as needed for seizures. A nursing note written by Licensed Practical Nurse (LPN) #7 and dated 5/9/25 at 7:47 AM identified Resident #264 was agitated throughout the night and Lorazepam was given which was effective (physician orders directed to administer for seizures). Review of the Medication Administration Record (MAR) for Resident #264 on 5/9/25 indicated Lorazepam 1 mg oral tablet was administered at 3:42 AM by LPN #7 and the dose was effective. Interview with LPN #7 on 5/16/25 at 8:36 AM identified that although Resident #264's Lorazepam order was indicated to be administered for seizures, she administered Resident #264's Lorazepam on 5/9/25 because the resident was agitated and not sleeping. LPN #7 indicated because Resident #264 had not had a seizure, she asked the nursing supervisor (RN #4) if she could administer the medication for agitation and she was told by RN #4 to go ahead and give it. LPN #7 identified she documented her administration of the Lorazepam on the MAR for 5/9/25 under the order which was indicated for seizures because a new order indicated for agitation was not obtained from the physician by RN #4. LPN #7 further indicated that she now realized she should not have administered Lorazepam to Resident #264 if it was not ordered for agitation and she had made a mistake. Interview with the nursing supervisor (RN #4) on 5/16/25 at 9:09 AM identified she was notified on 5/9/25 by LPN #7 that Resident #264 was agitated and not sleeping and although the Lorazepam order was only indicated for seizures, she gave permission to LPN #7 to administer the medication to the resident. RN #4 indicated that she was aware that Resident #264 had not had a seizure on 5/9/25 and although she tried to reach the physician for a new order, the physician did not call back. RN #4 was unable to recall which physician she tried to contact but she did not obtain a new order for Resident #264's Lorazepam to indicate administration for agitation or insomnia. RN #4 identified she realized she should not have authorized the administration of Lorazepam to the resident if it was only indicated for seizures. Interview and review of the clinical record with the DNS on 5/16/25 at 2:35 PM identified Resident #264's Lorazepam should have only been administered as indicated for seizures and it should not have been administered for agitation or insomnia. The DNS indicated that RN #4 should not have authorized the administration of the medication without contacting the provider for a new order and if RN #4 was unable to reach the provider the medication should not have been administered to the resident. The DNS identified that although Resident #264 had not had a seizure on 5/9/25, LPN #7 documented her administration of the Lorazepam on the order indicated for seizures because a new order indicated for agitation was never obtained. The DNS stated she would need to provide further education to LPN #7 and RN #4 regarding this incident. Review of facility policy, Medication Administration, undated, directed all medications shall be administered safely and accurately in accordance with physician's orders and facility protocols and all medications must be administered only with a valid physician's order.

Based on observation(s), review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #18) reviewed for skin condition (non-pressure), and for 1 of 4 residents (Resident #106) reviewed for pressure injury, the facility failed to ensure proper personal protective equipment (PPE) were donned ( placed on ) during wound care for a resident on enhanced barrier precautions (EBP) and the facility failed to ensure proper hand hygiene was performed during wound care. The findings include: 1. Resident #18's diagnoses included dementia, anemia, and non-thrombocytopenic purpura. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was severely cognitively impaired and was dependent for transfers, toileting, and bed mobility. Additionally, the MDS identified Resident #18 had venous/arterial ulcers and skin tears. The Resident Care Plan dated 4/15/25 identified venous ulcers and a skin tear to the lower extremities and EBP related to wounds. Interventions included donning of gown and gloves when providing wound treatment. The physician orders dated 5/12/25 directed to cleanse the right arm, right shin and left thigh skin tears with normal saline, apply xeroform and wrap with kerlix gauze daily. The orders further directed to cleanse the left lower leg venous ulcer daily with normal saline, apply iodosorb followed by adaptic and apply a dry clean dressing daily. Observation of Resident #18's room on 5/13/24 at 10:30 AM identified EBP signage was posted on the door frame which directed staff must wear gloves and a gown for wound care. A cart containing disposable isolation gowns and other PPE was located outside of Resident #18's room. Interview, observation, and review of facility documentation with LPN #1 on 5/13/25 at 10:50AM identified she provided Resident #18 wound care without the benefit of an isolation gown. LPN #1 acknowledged she did not don an isolation gown when she provided Resident #18's wound care and indicated she did not know she needed to. Review of the EBP signage (posted outside of Resident #18's room) with LPN #1 directed an isolation gown and gloves are to be worn during wound care. LPN #1 stated although the EBP signage was posted outside of Resident #18's room and she had been provided training on EBP, she didn't know she had to don an isolation gown during wound care. Interview with the DNS on 5/15/25 at 10:05 AM identified that for resident's on EBP, nursing staff should don an isolation gown and gloves when providing wound care. The DNS indicated that she (together with the staff development nurse) has conducted ongoing education with all the nursing staff regarding EBP and LPN #1 should have known what PPE was required and should have donned an isolation gown when providing Resident #18's wound care. The DNS identified she would need to provide further education to LPN #1. Review of the facility policy, Enhanced Barrier Precautions, undated, directed targeted gown and glove use during high contact resident care activities, such as wound care. The policy further directed staff will don PPE (gown and gloves) before providing high contact care to the resident. 2. Resident #106's diagnoses included stage 3 pressure ulcer of the sacral region, muscle weakness, and osteomyelitis of vertebral, sacral and sacrococcygeal region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact, and required substantial/maximal assistance for dressing, toileting and changing position in bed. Additionally, the MDS identified Resident #106 had a Stage 3 pressure ulcer defined as full thickness loss, with subcutaneous fat visible but bone, tendon or muscle was not exposed. Slough was present but did not obscure the depth of tissue loss, may include undermining and tunnelling The Resident Care Plan dated 3/12/25 identified Resident #106 had a pressure ulcer or potential for pressure ulcer development related to immobility. Interventions included administering treatment as ordered and following facility policies/protocols for the prevention/treatment of skin breakdown. The physician's order dated 4/23/25 directed to cleanse the sacrum stage 3 wound with ¼ strength Dakin's solution (an antiseptic), apply skin prep to the peri wound area-let dry, then apply calcium alginate with silver (an antiseptic dressing that absorbs wound drainage) followed by dry clean dressing daily and as needed. Observation of Resident #106's room on 5/15/25 at 11:41 AM identified Enhanced Barrier Precautions signage posted outside the door identifying that everyone was to clean their hands prior to entering, and after leaving the room. Additionally, the sign directed that gloves and gowns were applied for high contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, assisting with toileting, device care, and wound care. Observation of Nurse Aide (NA) 2 on 5/15/25 at 11:42 AM identified her outside Resident #106's room applying a gown then gloves (per the signage posted for enhanced barrier precaution), without the benefit of hand hygiene prior to entering the room. Observation of the wound treatment on 5/15/25 at 11:46 AM identified LPN # 5 apply gloves then a gown (per the signage posted for enhanced barrier precaution), without the benefit of hand hygiene. NA # 2 assisted with Resident #106's positioning in bed by standing on the residents' left side while LPN #5 was on the right. With Resident #106 lying on her left side, LPN #5 applied the Dakins solution to sterile dressing that was placed in a medicine cup, she set it aside, then removed the dressing dated 5/14/25 that was covering the sacral wound and disposed of it in the trash receptacle, then removed the dressing packed inside the wound and disposed of it in the trash receptacle as well. LPN # 5 then removed her right glove, without the benefit of removing her left glove, reached her right hand under her gown and pulled out a clean glove that she then applied to her right hand without the benefit of hand hygiene or removal of the left glove. She cleaned the sacral wound with the Dakins saturated gauze, dried the area and then used skin prep around the wound. LPN #5 then removed both gloves and applied clean gloves without the benefit of hand hygiene, opened the collagen matrix dressing (a dressing that promotes a moist wound environment, which is the opposite of the intent of the dressing the physician ordered), at which point the surveyor intervened. Interview with LPN #5 on 5/15/25 at 11:56 AM identified it was facility policy to perform hand hygiene when going in and out of a resident's room and after performing care. Additionally, she identified the facility policy on glove use was to change gloves between residents. LPN # 5 could not identify if hand hygiene should be performed between glove changes or prior to applying personal protective equipment (PPE). Interview with NA # 2 on 5/15/25 at 11:56 AM identified it was facility policy to perform hand hygiene before and after resident care, as well as prior to applying PPE. She could not identify a reason why she did not perform hand hygiene prior to applying the gown and gloves. Interview with the Infection Prevention Nurse on 5/15/25 at 12:01 PM identified that it was facility policy to perform hand hygiene prior to applying PPE and between glove changes, as well as after removal of PPE. Review of the Enhanced Barrier Precautions policy directed in part that staff will perform hand hygiene and apply PPE prior to high contact activities (which included wound care). Review of the Hand Hygiene policy directed in part that healthcare workers should perform hand hygiene to disrupt the transmission of microorganisms and should be performed before and after resident care, and after handling contaminated items. Review of the Treatment Process directed in part to perform hand hygiene, then apply clean gloves prior to starting the treatment, and perform hand hygiene between removing soiled gloves and applying clean ones.

Based on review of the clinical record, facility policy and interview for one of one resident (Resident #80) reviewed for timeliness of care planning, the facility failed to conduct a quarterly care conference. The findings include: Resident #80 diagnosis included diabetes, anxiety, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #80 was cognitively intact and was independent for eating, transferring, showering, dressing, and toileting. The Resident Care Plan (RCP) dated 1/3/25 identified that Resident #80 was at risk for changes in mood related to the diagnosis of anxiety, and depression with interventions directed to encourage Resident #80 to converse and express his/her feelings, attend group activities, and offer to discuss feelings on being placed at the facility. The Resident Care Conference (RCC) note dated 4/1/25 at 1:44 PM identified that Resident #80 was out of the building on leave of absence and that the meeting was postponed. An interview on 5/14/25 at 12:41 PM with Licensed Practical Nurse (LPN) #6 identified that there was not a RCC meeting for the month of April 2025 for Resident #80 and that it was postponed because the resident was out of the building. Also, identified that a care plan meeting should take place every 92 days or if there was a significant change. Further, identifying the RCC was not rescheduled from the April 2025 postponed meeting. An interview on 5/19/25 at 10:41 AM with the Director of Nursing (DNS) identified that a RCC should be held quarterly with the Resident, and the one scheduled for April 2025 was canceled and not rescheduled as it was an oversight. Although a policy on RCC meeting was requested, one was not provided. Subsequent to this surveyor's inquiry a RCC meeting had been scheduled for 5/19/25.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #44) reviewed for pressure injury, and for 1 of 4 residents (Resident #78) reviewed for nutrition, the facility failed to complete a significant change in status (SCSA) Minimum Data Set (MDS) assessment for a resident with a decline in 2 or more areas. The findings include: 1. Resident #44's diagnoses included dementia, pressure ulcer of sacral region (Stage 3), and anxiety. The Resident Care Plan (RCP) dated 11/1/24 identified Resident #44 was at risk for skin breakdown due to decreased mobility, incontinence, and poor nutrition. Interventions included to offer and/or encourage Resident #44 to reposition as needed and provide incontinent care as needed. The RCP further identified Resident #44 had the potential for nutritional decline related to pain and Resident #44 did not like to eat breakfast per his/her choice. Interventions included encourage Resident #44 to eat as much of his/her meal independently and assist if needed with completing his/her meal, and providing snacks as ordered. a. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired, had no weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months, and was at risk for developing pressure ulcers. The MDS further identified Resident #44 was independent with eating, required partial/moderate assistance with bed mobility, and supervision or touching assistance for transfers. A note written by Social Worker #1 on 1/14/25 at 8:26 AM identified Resident #44 had been admitted to hospice care on 1/14/25. A nursing note written by Licensed Practical Nurse (LPN) #9 on 1/19/25 at 3:21 PM identified Resident #44 had a newly identified open area to the coccyx measuring 2.5 centimeters (cm) (length) by 1.0 cm (width). A wound progress note written by Advanced Practice Registered Nurse (APRN) #4 on 1/22/25 at 9:28 PM identified Resident #44 was seen for consultation for evaluation and management of his/her Stage 2 coccyx pressure ulcer which measured 2.0 cm (length) by 2.0 cm (width) by 0.1 cm (depth). A note written by Social Worker #1 on 1/23/25 at 12:18 PM identified Resident #44's family had reconsidered the enrollment of Resident #44 in hospice services. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was cognitively intact, weighed 154 lbs., had no weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. The MDS assessment identified Resident #44 had 1 unhealed Stage 2 pressure ulcer that was not present on admission/reentry. The MDS assessment identified Resident #44 required partial/moderate assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for transfers. The MDS assessment further identified Resident #44 received physical therapy services starting on 1/24/25, received occupational therapy services starting on 1/27/25, and received speech therapy services starting on 1/28/25. A decline in at least 3 functional mobility areas plus a new pressure ulcer were identified when compared with the previous quarterly MDS assessment and a significant change MDS had not been completed. b. A nutritional note written by the Dietician and dated 2/21/25 at 8:49 AM identified Resident #44 had a 9.8 lbs. (6.4%) weight loss in 1 month from 1/13/25 (154.4 lbs.) through 2/13/25 (144.6 lbs.). The note further identified Resident #44's weight loss was 20.7 lbs. (13%) after a reweight on 2/20/25 (133.7 lbs.). A nutritional note written by the Dietician and dated 3/14/25 at 8:29 AM identified Resident #44 had an 11.1 lbs. (7.7%) weight loss in 1 month from 2/13/25 (144.6 lbs.) through 3/11/25 (133.5 lbs.). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired, weighed 131 lbs., had no weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. The MDS assessment identified Resident #44 had 1 unhealed Stage 3 pressure ulcer that was not present on admission/reentry. The MDS assessment identified Resident #44 required setup or clean-up assistance with eating and required substantial/maximal assistance with bed mobility and transfers. A sustained decline in at least 3 functional mobility areas plus a weight loss with worsening of a pressure ulcer were identified when compared with the previous 2 quarterly MDS assessments and a significant change MDS had not been completed. 2. Resident #78's diagnoses included early onset Alzheimer's disease, diabetes, and epilepsy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was severely cognitively impaired, had no weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months. The MDS further identified Resident #78 was independent with eating, required partial/moderate assistance with upper body dressing and lower body dressing, and required partial/moderate assistance with toilet transfers. The Resident Care Plan (RCP) dated 2/6/25 identified Resident #78 had the potential for nutritional decline related to medications, multiple medical diagnoses, and poor appetite. Interventions included to provide the diet as ordered and obtain weights as ordered. The RCP further identified Resident #78 required staff assistance with his/her activities of daily living (ADLs). Interventions included to assist with feeding as needed and Resident #78 fluctuated in his/her ability to perform ADLS due to his/her diagnoses/cognitive status which required assistance as needed. An Advanced Practice Registered Nurse (APRN) progress note written by APRN #1 on 3/28/25 at 3:43 PM identified Resident #78 was seen for a post-hospitalization visit. The note identified Resident #78 had been hospitalized from [DATE] through 3/28/25 with altered mental status, delirium, toxic encephalopathy, mild dehydration, and suspected urinary tract infection (UTI). The note further identified Resident #78 was newly dependent on staff with ADLs and he/she required assistance with eating and transfers. A nutritional note written by the Dietician on 4/11/25 at 9:07 AM identified Resident #78 had a 8.4 lbs. (6.6%) weight loss in 16 days from 3/23/25 (127.9 lbs.) through 4/9/25 (119.5 lbs.). The note identified the weight loss was following Resident #78's hospitalization, Resident #78's appetite was less since his/her hospitalization and Resident #78 required more assistance for meals sometimes Resident #78 even needing to be fed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was severely cognitively impaired, weighed 118 lbs., had weight loss of 5% or more in the last month or weight loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. The MDS assessment identified Resident #78 required supervision or touching assistance with eating, substantial/maximal assistance with upper body dressing and lower body dressing, and toilet transfers. A decline in 4 functional mobility areas plus weight loss were identified when compared with the previous annual MDS assessment and a significant change MDS had not been completed. Interview with the Director of Nursing Services (DNS) on 5/16/25 at 12:05 PM identified weekly risk meetings were attended by the DNS, RN #3, LPN #6, Social Worker #1, Dietician, and Administrator. Interview and clinical record review with LPN #6 on 5/19/25 at 11:05 AM identified that she had just learned subsequent to surveyor inquiry, in an earlier interview with a surveyor, that criteria for completing a SCSA MDS assessment included weight loss and 1 change in ADLs. LPN #6 identified that she had previously understood that a significant change required a decline in 2 ADLs or a resident going on hospice or having a gastrostomy tube placed. LPN #6 identified resident weight losses were reviewed at the weekly risk meetings, and she attended the weekly risk meetings. LPN #6 identified she was unaware Resident #44 and Resident #78 experienced weight loss, and indicated the Dietician had not informed her of the weight loss. LPN #6 identified that although she attended the risk meetings, she looked to see if weight loss was coded by Dietician in Section K of the MDS. LPN #6 identified there was a 14-day window for completing a SCSA MDS assessment after identifying a significant change, but that she hadn't previously been aware that weight loss plus one additional area of decline would qualify as a significant change. LPN #6 identified for Resident #44 and Resident #78 she needed to reevaluate after learning of additional criteria for a significant change. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual which contained instructions the facility must follow when submitting MDS assessments directed, in part a significant change was a decline or improvement in a resident's status that will not normally resolve itself without intervention by staff, impacts more than 1 area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan. The manual directed an SCSA is appropriate if there are either two or more areas of decline and when a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met.

Based on observation, interviews, facility documentation, and review of facility policy for 1 of 2 medication storage rooms, the facility failed to maintain proper refrigerator temperatures for medication storage. The findings include: Observation of Unit 1C medication storage room with the ADNS and LPN #10 on 5/19/25 at 11:25 AM identified that the medication refrigerator was documented on the temperature logs to be out of range on 5/1/25, 5/2/25, 5/3/25, 5/5/25, 5/6/25, 5/8/25, 5/9/25, 5/10/25 5/12/25, 5/14/25, 5/15/25 5/16/25, and 5/17/25. The refrigerator temperature log identified ranges should be between 36 degrees Fahrenheit (F) through 46 degrees F and were documented between 28 degrees F and 32 degrees F. The refrigerator contained 2 vials of Lispro 100units/ml, 2 Lispro Kwik pens 100units/ml, 1 Lantus Solostar pen 100units/ml, 3 Insulin Glargine pens, 1 Ozempic pen, 67 Bisacodyl 10 mg suppositories, 4 Acetaminophen 650mg suppositories,1 bottle of Brimonidine Tartrate ophthalmic solution, 1 Vancomycin Iso-osmotic 1gm/200mls, and 1 0.9% Sodium Chloride 100mls. An interview with LPN #10 on 5/19/2025 at 11:30 AM identified that it is the responsibility of the 11:00 PM - 7:00 AM nurse to document the refrigerator temperature on the monitoring log. Additionally, the interview identified that she was not aware of the out-of-range temperatures and that if she found the refrigerator to be out of range, she would notify the nurse supervisor. An interview and facility documentation review with the DNS on 5/19/2025 at 11:33 AM identified that the medication refrigerator in Unit 1C medication storage room was documented as being out of range and that she was not aware. The DNS indicated she would expect to be notified of out-of-range medication temperatures. Additionally, the interview identified that maintenance should have been notified to troubleshoot the out-of-range findings and that it was the responsibility of the 11:00 PM to 7:00 AM nurse supervisor to record the refrigerator temperatures. An interview and facility documentation review with the Maintenance Director at on 5/19/2025 at 11:52 AM identified that he was not made aware of the out-of-range temperature findings for the medication refrigerator in the medication storage room on Unit 1C. Additionally, he identified if he was made aware that he would trouble shoot the refrigerator and if the issue was not corrected, he would reach out to the vendor for them to come on site and repair. An interview with the Pharmacist on 5/19/2025 at 12:21 PM identified that the medications located in the Unit 1C medication refrigerator were still effective and had not been compromised with the out-of-range temperatures. An interview with the 11:00 PM to 7:00 AM Nurse Supervisor, RN #4 on 5/19/2025 at 12:52 PM identified that the policy for monitoring refrigerator temperatures indicated refrigeration temperatures to be in range between 30 degrees F and 42 degrees F. Additionally, RN #4 indicated that if she noticed temperatures to be out of range, she would notify maintenance to assess the equipment. Although requested from the DNS, temperature logs for the Unit 1C medication refrigerator from 5/1/2024 through 4/30/2025, were not provided. Review of the refrigerator and freezer temperature logs policy, dated 8/2018, identified that temperatures for refrigerators should be between 38 degrees F and 40 degrees F. Additionally, it indicated in the event the temperatures do not meet these requirements to notify maintenance and the supervisor on duty.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents reviewed for falls, (Resident #1 and Resident #2), the facility failed to ensure a safety device was utilized for transfers and ambulation in accordance with facility policy resulting in falls with injuries. The findings include: 1. Resident #2 had diagnoses that included dementia and osteoporosis. A physician's order dated 3/7/24 directed an assist of one for transfers with rolling walker. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition and required extensive assistance of one staff for transfers. The care plan dated 4/25/24 identified Resident #2 had multiple risk factors for falls such as deconditioning, unsteady gait, and poor safety awareness with interventions that included to transfer Resident #2 in accordance with physician's orders. A nurse's note written by Registered Nurse (RN) #1 dated 6/1/24 at 12:19 PM identified Resident #2 had a witnessed fall at 11:50 AM during a transfer off of the toilet. Resident #2's leg gave out and the resident was lowered to the floor. An external rotation was noted to Resident #2's left leg, the APRN was notified, and Resident #2 was transferred to the hospital. The accident and incident form (A & I) dated 6/1/24 identified at 11:50 AM Resident #2 had a witnessed fall in the bathroom. The fall scene investigation identified there was not a gait belt in use at the time of the fall. A hospital discharge summary dated 6/4/24 identified Resident #2 was found to have a displaced oblique fracture of his/her left distal femur; the fracture was to be managed with conservative treatment. Interview with NA #1 on 7/3/24 at 11:28 AM identified on 6/1/24 she ambulated Resident #2 to the bathroom with the walker . Resident #2 stood up for NA #1 to pull up his/her pants, and Resident #2's legs buckled under him/her and Resident #2 fell , and NA #1 heard a crack. She identified that although she is aware a gait belt must be used during transfers and ambulation, she did not use it because she had lost it. Interview with RN #1 on 7/1/24 at 12:40 PM identified she was the nurse who responded to the event on 6/1/24. She identified when she entered Resident #2's bathroom, she identified NA #1 had lowered Resident #2 to the floor and had not used the gait belt. She identified Resident #2's left thigh was noted to be rotated, so she called emergency services immediately. 2. Resident #1 had diagnoses that included osteoarthritis and osteoporosis. A physician's order dated 3/2/23 directed an assist of one for transfers with a rolling walker. The care plan dated 8/3/23 identified Resident #1 had a fall with several fractures prior to admission and had multiple risk factors for falls such as deconditioning, unsteady gait, decreased safety awareness with interventions that included to transfer Resident #1 in accordance with physician orders. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition and required extensive assistance of one staff for activities of daily living (ADL's) including transfers. A nursing note written by RN #2 dated 9/23/23 at 9:31 AM identified Resident #1 had a witnessed fall with a head strike. Resident #1 was sent to the hospital for an evaluation due to a fall with a laceration to the back of his/her head. The accident and incident form (A & I) dated 9/23/23 identified at 4:20 AM Resident #1 had a witnessed fall in the bathroom. After Resident #1 used the bathroom, he/she washed and dried his/her hands. NA #2 was to Resident #1's right side when Resident #1 suddenly fell on his/her buttocks and hit his/her head on the wall. Resident #1 was sent to the emergency department and required two staples to the back of Resident #1's head. The fall scene investigation identified there was not a gait belt used at the time of the fall. In-service education dated 9/25/23 identified staff were in-serviced by the therapy director on the gait belt policy. The education directed to ensure the safety of the residents and staff, the use of a gait belt is mandatory by all nursing personnel and rehabilitation staff while transferring and/or ambulating residents. Although multiple attempts were made, an interview with NA #2 was not obtained. Interview with the Rehabilitation Director (RD) on 7/1/24 at 12:30 PM identified that the gait belt is used to help direct a resident if they are losing their balance, and the NA should have their hand on the gait belt during transfers and ambulation. The RD identified that any resident that requires assistance of one staff member for transfers or ambulation requires the use of a gait belt during transfers and ambulation. Resident #1 and Resident #2 both required assistance of one staff member for transfers and ambulation and therefore required the use of a gait belt. Review of the gait belt policy identified to ensure the safety of residents and staff, the use of a gait belt is mandatory by all nursing personnel and rehabilitation staff while transferring or ambulating a resident. It directed each NA will have a gait belt on his/her person, or readily available, gait belts will be used for transfers of residents who need the assist of 1 or 2 staff and the ambulation of residents who need an escort of 1 or 2 staff or who are unsteady with ambulation. The policy further directed staff to stand close to the resident and grasp the belt firmly to control the resident's movement using the gait belt.

Based on clinical record review, facility documentation, and interviews, for one resident with a history of inappropriate sexual behaviors, (Resident #1), the facility failed to ensure that resident's were free from abuse and failed to ensure increase supervision was provided to a resident who exhibited sexually inappropriate behaviors. The findings include: Resident #1 had a [DIAGNOSES REDACTED]. A care plan dated 8/16/18 and revised on 2/20/19 identified that the resident had a past history of sexually inappropriate behaviors with interventions that included psychiatric consults, monitor effectiveness of medication, and to observe for behaviors. Resident #2 had a [DIAGNOSES REDACTED]. a) Review of a reportable event and investigation dated 2/14/19 identified that Resident #1 had entered Resident #2's room, and was noted to be holding Resident #2's shirt down and was touching Resident #2's breasts. The residents were immediately separated and Resident #1 was sent to the hospital for evaluation and admitted with a urinary tract infection. A nurse's note dated 2/19/19 identified that the resident was readmitted to the facility. Review of hospital documentation dated 2/19/19 identified that Resident #1 was not a danger to self or others and recommended to increase [MEDICATION NAME] to 30 milligrams. A stop sign was placed on Resident #2's door to prevent Resident #1 from entering his/her room. Review of the clinical record failed to identify that any increased supervision was provided to the Resident #1 upon return from the hospital to ensure others were free from abuse. b) Review of a nurse's note dated 2/21/19 identified that Resident #1 had grabbed the breast of a female nurse aide, the physician was notified, a Physician's Emergency Certificate was completed, and the resident was placed on one to one observation until transport to the hospital could be arranged. Review of a nurse's note dated 2/22/19 at 11:25 AM identified that the resident was transferred to the hospital. Review of a nurse's note dated 2/23/19 at 10:38 PM identified that the PEC was rescinded by the hospital and Resident #1 was readmitted to the facility. Review of the clinical record failed to identify any changes to the plan of care and/or increased supervision of Resident #1 upon re-admission to the facility. c) Resident #3 had a [DIAGNOSES REDACTED]. A reportable event dated 3/1/19 identified that Resident #3 had entered Resident #1's room, Resident #1 unbuckled Resident #3's seatbelt and was attempting to place his/her hand up Resident #3's shirt. The residents were immediately separated and Resident #1 was sent to the emergency department for evaluation. A nurse's note dated 3/1/19 at 9:12 PM identified that the resident returned from the hospital with recommendations to keep Resident #1 separated from residents of the opposite sex and that a stop sign would be placed on Resident #1's door. Review of hospital paperwork dated 3/1/19 identified that increased supervision and awareness of where Resident #1 was needed as to avoid allowing the resident to wander into other resident's rooms, and to consider having a staff member of the same sex care for Resident #1. Review of the clinical record failed to identify any increased supervision was provided to Resident #1 after return to the facility on [DATE] to ensure others were free from abuse. A nurse's note dated 3/15/19 at 12:52 PM identified that Resident #1 was found in another resident's room (opposite sex) sitting alongside the bed. No inappropriate behaviors were noted. Interview with Advance Practice Registered Nurse #1 on 5/24/19 at 12:00 PM identified that although Resident #1 was sent to the hospital on 2/14, 2/21, and 3/1/19, the resident had been seen by psychiatric services, and medication changes had been made. It would be her expectation for the resident to have increased supervision upon return to the facility to prevent any sexually inappropriate behaviors from re-occurring. Interview with the Director of Nursing (DON) on 5/21/19 identified that on 2/14, 2/21, and 3/1/19 the resident had paperwork upon return from the hospital that the resident was not a danger to self or others. The staff were educated to increase the supervision of the resident, but the DON was unable to find documentation of the education. The DON identified that she was not informed that Resident #1 was found in another resident's room on 3/15/19. Further interview with the DON on 5/24/19 identified that subsequent to surveyor inquiry on 5/21/19, the facility provided education to the staff that Resident #1 must be in staff view at all times when awake, and not to be in the vicinity of residents of the opposite sex. The resident was also placed on every 15 minute checks. The DON identified that she put education and increased checks into place to ensure that the resident had increased supervision by staff.

Based on clinical record review, staff interviews, review of facility documentation, and review of facility policies and procedures for 4 of 6 sampled residents reviewed for accidents (Resident #500, #206, #107, #106), the facility failed to transfer the resident in a safe manner to prevent an injury and/or failed to provide adequate supervision to prevent a fall, and/or failed to ensure an accurate fall assessment was completed with fall risk care plan/interventions, and/or failed to implement interventions in accordance with the Speech and Language Pathologist recommendations. The findings include: 1. Resident #500 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The fall risk assessment dated [DATE] identified Resident #500 was a high risk for falls due to a history of falls, unable to independently come to a standing position, exhibited loss of balance while standing, and required hands on assistance to move from place to place. Physician orders [REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #500 was severely cognitively impaired, had no behaviors, required extensive assistance with transfers, toilet use and personal hygiene, unsteady, and only able to stabilize with staff assistance moving on and off the toilet. The resident care plan (RCP) dated [DATE] identified a risk for falls. Interventions included to encourage him/her to ask for and wait for staff assistance for transfers and/or toileting, and to encourage him/her to transfer and change positions slowly. Nurses notes dated [DATE] at 10:04 AM noted Registered Nurse (RN) #9 was called to Resident #500's room by Licensed Practucal Nurse (LPN) #3 who stated Nurse Aide (NA) #9 assisted Resident #500 to the bathroom, NA #9 was outside the bathroom with the door mostly closed when Resident #500 stood by him/herself and fell in the bathroom. Resident #500 complained of increased pain with slight movement of the left lower extremity, external rotation of the left lower extremity noted. The physician was notified and directed to send to the hospital for evaluation. Resident #500 was admitted to the hospital and diagnosed with [REDACTED]. Intraoperatively, Resident #500 expired. Nurses notes dated [DATE] at 1:30 PM identified LPN #3 was called to Resident #500's room and observed Resident #500 lying on the floor in the bathroom. Interview and review of the Reportable Event (RE) form dated [DATE] with the Administrator on [DATE] at 2:45 PM indicated he/she reviews all RE's. Once the RE is completed by staff he/she will sign the RE indicating the incident was reviewed by the interdisciplinary team to determine the cause of the incident and if changes to the plan of care are needed. The Adminstrator identified even though NA #9 left Resident #500 alone in the bathroom with the door half closed he/she felt Resident #500 was not left unattended since NA #9 remained in Resident #500's room. Further review of the RE with the Adminstrator identified NA #9 probably should not have left Resident #500 alone in the bathroom Interview and review of the RE with Director of Rehabilitation Services on [DATE] at 9:10 AM identified that although the therapy department doesn't determine if a resident can be left alone in the bathroom, if a resident was assessed to require an assist of one for transfers/toileting (as Resident #500 was), that resident should not be left alone in the bathroom. Interview and review of the RE with the DNS on [DATE] at 10:00 AM identified that although NA #9 was attempting to provide privacy to Resident #500, NA #9 should not have left Resident #500 alone in the bathroom. Multiple attempts to contact NA #9 were unsuccessful. 2. Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing to Therapy Communication form dated [DATE] identified Resident #206 was having a decline/difficulty with transfers. Staff state resident is weak in the AM and has difficulty transferring out of bed in the am. The Restorative-Functional Maintenance Program form dated [DATE] direct staff to utilize the Etac Turner Pro Patient transfer device with an assist of two staff members for transfers from bed to CWC and CWC to bed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #206 with severe impaired cognition, required extensive assistance of two staff members for bed mobility and transfers. The Resident Care Plan dated [DATE] identified a risk for falls. Interventions include to anticipate and meet his/her needs, and rehabilitation evaluation and treat as ordered. A Reportable Event (RE) form dated [DATE] at 8:30 PM identified Nurse Aide (NA) #10 was attempting to transfer Resident #206 from the wheel chair to the bed using the Etac Pro transfer device, when Resident #206 lost his/her strength and NA #10 lowered Resident #206 to the floor. Resident #206 sustained a 6 inch x 1 inch scratch to the mid right side of the back, and complained of right hip pain. The physician was notified and directed to obtain an X-ray of the right hip. Nurse notes dated [DATE] at 10:27 PM noted at 8:30 PM Registered Nurse (RN) #6 was called to Resident #206's room by NA #10. NA #10 indicated Resident #206 was lowered to the floor due to not being able to maintain standing on his/her legs while using the transfer device. Resident #206 complained of pain in outer aspect of his/her right upper extremity. Provider contacted and ordered an X-ray. Nurses notes dated [DATE] at 8:14 AM (twelve hours later) identified Resident #206 complained of pain to the right hip, right hip and thigh swollen. [MEDICATION NAME] one tab at 4:00 AM with fair effect. Right leg with limited range of motion. Resident seen by MD #3 and directed to send Resident #206 to the hospital for evaluation. Nurses notes dated [DATE] at 10:33 PM identified that Resident #206 was admitted to the hospital with [REDACTED]. Interview and review of the RE with RN #3 on [DATE] at 1:37 PM identified he/she was the free floating 3:00 PM to 11:00 PM Nursing supervisor on [DATE] when he/she was called to Resident #206's room due to a fall. When RN #3 arrived Resident #206 was already back in bed. NA #10 reported he/she told LPN #7 that Resident #206 slid to the floor while attempting to transfer Resident #206 back to bed. LPN #7 and NA #10 lifted Resident #206 off the floor and placed him/her back to bed prior to the RN assessing Resident #206, additionally LPN #7 waited about 30 minutes before he/she reported the incident to the 3:00 PM to 11:00 PM RN supervisor. Interview and review of the RE with The Rehabilitation Director (RD) on [DATE] at 9:10 AM identified the Etac Turner Pro Transfer device is utilized when a resident can bear weight and assist with the transfer, additionally a gait belt should always be used while transferring the resident. The RD identified Resident #206 should have had one staff member assist with standing/transfer support and the second staff member only manage the Etac Turner device. Interview and review of the RE with the DNS on [DATE] at 10:30 AM identified NA #10 should have utilized a gait belt and should have had another staff member assist while transferring Resident #206 in accordance with the residents plan of care. Additionally the DNS identified LPN #7 should not have moved Resident #206 until being assessed by an RN. Multiple attempts to contact NA #10 were unsuccessful. 3. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. The fall risk assessment dated [DATE] completed by LPN #2 identified Resident #106 with a fall risk score of 10 (no risk of falling). Further review of the fall risk assessment identified that sections were not completed related to medication usage ([MEDICATION NAME], antihypertensives, antipsychotic, etc), functional gait analysis and blood pressure and therefore the fall risk assessment was not accurate to identify Resident #106 was a fall risk. The Nursing admission assessment form dated [DATE] identified Resident #106 was oriented to person and place, required the assistance of one staff for transfers, ambulation and positioning, and was partial weight bearing. Physical therapy (PT) notes dated [DATE] identified Resident #106 was a high risk for falls and unable to perform any gait maneuvers for distance, level/uneven surfaces, deviation or gait on stairs. PT notes further identified Resident #106 was unsteady on his/her feet. Physician orders/Physical Therapy orders dated [DATE] directed assist of 1 with bed mobility, transfers with rolling walker, ambulate only with therapy. A nurses note dated [DATE] at 7:48 AM identified that at 12:30 AM a nurse aide (NA) heard a resident yelling for help and observed Resident #106 lying face down on the floor near his/her bed, alert, confused, no level of consciousness change but noted to have a 2.5 cm long and deep laceration near the right outer eye with a small amount of bleeding, able to move all extremities but complaining of right leg pain with movement. Vital signs: blood pressure ,[DATE], pulse 96, respirations 20, temperature 97.1, pulse-oximetry 95 %. Advanced Practice Registered Nurse , emergency contact notified, 911 called. Resident sent to hospital for evaluation at 1:45 AM. A Reportable Event (RE) form dated [DATE] with a time of event of 12:30 AM identified Resident # 106 was on the floor by the bedside in his/her room complaining of pain in the right lower extremity and a laceration around the right eye, with no witnesses of the event. The RE form further identified that mental status was alert and confused before and after the event, and assist of one for activities of daily living and mobility in wheelchair before and after the event. A nurses note dated [DATE] at 10:28 PM identified Resident #106 was admitted to the hospital with [REDACTED]. Interview and record review with the DNS on [DATE] at 8:43 AM identified that the fall risk assessment dated [DATE] identified that Resident #106 was not at risk for falls (however on [DATE] PT identified Resident #106 was a high fall risk), however, this assessment does not accurately reflect medication use related to falls and/or information related to gait/ambulation. The DNS identified that it was a nursing responsiblity to accurately complete the fall risk assessment. Additionally, the DNS failed to identify an interim/baseline care plan was developed for falls, with interventions to prevent Resident #106 from falling. Interview with LPN #2 on [DATE] at 2:31 PM identified he/she completed the fall risk assessment dated [DATE] and the missing information (identification of medication related to fall risk, funcional gait analysis, blood pressure, etc) was to be entered by the Registered Nurse (RN) when orders were verified with the physician. Interview and review of the information provided by LPN #2 with the DNS on [DATE] at 8:00 AM identified the RN was responsible to ensure admission assessments are complete and accurate, and the LPN should inform the RN of an areas of assessments that are not completed. Interview with RN #6 on [DATE] at 2:18 PM identified that RN #6 recalls the admission for Resident #106 because multiple calls were needed to reconcile the medications. RN #6 further identified that he/she did not review the assessments, evaluations or interim/baseline care plans that LPN #2 had completed, and was not aware that the admitting RN was responsible to review any LPN completed documents. RN #6 cannot recall if he/she ensured that all required documents were completed for Resident #106. RN #6 identified that no LPN ever informed him/her that any part of an assessment was not completed, or he/she would have assisted them. The facility Policy for Falls: Minimizing Risk of Injury identified that upon admission a fall risk assessment will be done, Residents who are at risk shall have a care plan that addresses interdisciplinary measures to prevent falls and any environmental/equipment recommendations to prevent injuries. The facility policy for Admission of a Resident identified that the unit nurse was responsible for completing necessary nursing documentation including nursing assessments. The facility failed to develop a comprehensive interim baseline care plan related to fall prevention for a resident at a high risk for falls, Resident #106 fell 5 days post admission, sustaining a fracured left femur. 4. Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #107 had severe cognitive impairment, required the supervision of one person for eating, and had no swallowing difficulties. The resident care plan dated [DATE] identified that Resident #107 had a problem with a potential for nutritional decline related to [DIAGNOSES REDACTED]. Interventions dated [DATE] identified new feeding instructions from the therapist (instructions were not identified) and to watch for signs of trouble chewing and swallowing, and report to the physician. A speech and language therapy (SLT) screening form dated [DATE] identified a request for screening was made related to Resident #107 having a 10 pound weight loss in 12 months, variable by mouth intake, to assess swallowing function and to determine the need for skilled Speech Therapy intervention/diet modification. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. A Feeding Instructions Restorative Nursing/Functional Maintenance Program (FMP) document dated [DATE] identified that the special techniques/instructions were to cut all food into bite sized pieces prior to serving, supervision with meals, and soak/cleanse dentures nightly as resident allows. The FMP document further identified with signatures, that on [DATE], LPN #8, NA #3, NA #4, and NA #12 had received training on the FMP instructions which included staff to cut all food into bite sized pieces prior to serving, supervision with meals and soak/cleanse dentures nightly as resident allows. Speech therapy discharge plans and instructions dated [DATE] directed discharge to Long Term Care on a regular solid, thin liquid diet; functional maintenance program in place (supervision, food cut into bite-sized pieces, denture care). Physician orders [REDACTED]. A nurses note dated [DATE] at 12:30 PM identified that at 8:30 AM, Resident #107 was observed choking on his/her breakfast meal (French toast). Resident #107 was unable to speak but was holding his/her neck and shook his/her head when asked if he/she was choking. [MEDICATION NAME] maneuver performed, stat called, after several minutes Resident #107 started to cough and speak, Resident #107 was sent to the hospital at 9:15 AM and returned at 11:30 AM on [DATE] with no changes in the plan of care. A facility Reportable Event (RE) form date [DATE] at 8:30 AM, identified that Resident #107 appeared to be choking on breakfast. The RE form further identified that the diet was regular diet, thin liquids, meal cut into small pieces. LPN #3 witnessed the incident and gave abdominal thrusts, airway clear, remains at baseline, speaking and coughing, airway clear. Resident #107 was sent to the Emergency Department (ED) for evaluation. Facility incident investigation documentation dated [DATE] identified that Resident #107 was sent to the ED for evaluation on [DATE], was examined, had a chest x-ray that was negative, and returned to the facility two hours after being sent to the ED. The RE form further failed to identify Resident #107 was provided with supervision during the meal and/or if the french toast had been cut into bite sized pieces as directed . Interview with Nurse Aide (NA) #2 on [DATE] at 10:35 AM identified that the dietary staff deliver the mealtray, place the trays in front of the residents, and leave. NA #2 further identified that dietary staff will not always cut up resident's food when they deliver trays. NA #2 did not know which kitchen staff served Resident #107 his/her mealtray on [DATE] or if the food was cut up prior to serving the tray. NA #2 further identified that he/she was unaware that Resident #107 required someone to be present while Resident #107 fed him/herself. NA #2 identified that he/she was assigned to Resident #107 in the past but was unaware the he/she was to stay with Resident #107 during mealtime and therefore was not present for Resident #107's choking episode. Interview with NA #3 at [DATE] at 11:08 AM identified he/she was present on Resident #107's unit when Resident #107's choking episode occured but was not supervising Resident #107 during the meal. Kitchen staff had passed out the trays after the NAs had passed the drinks. NA #3 further identified that if a resident was ready to eat, the dining staff put the tray in front of the resident and uncover the tray. NA #3 did not see the tray passed to Resident #107, and did not know which kitchen staff passed the tray. NA #3 provided Resident #107 his/her her morning care and transferred Resident #107 into his/her wheelchair to wait for breakfast and then went to pass the drinks for breakfast. NA #3 gave Resident #107 a drink and then went on to assist other resident with feeding. NA #3 identified that Resident #107 required supervision for meals, which meant to cut his/her food but not having to stay with him/her while he/she eats, just check on him/her about every five minutes. NA #3 further identified that no staff stayed in Resident #107's room to watch him/her eat. Interview with the ADNS on [DATE] at 11:40 AM identified he/she was an RN supervisor on [DATE], was called to Resident #107's room and found LPN #3 and RN #7 had performed abdominal thrusts to Resident #107. Resident # 107 was alert and talking at the time he/she had arrived. Additionally, the ADNS identified that supervision for meals means to stay with the resident and observe the resident, help as needed, to have staff present for the entire meal. Interview with Registered Nurse (RN) #4 on [DATE] at 1:26 PM identified supervision for dining means staff should be present in the room during the meal, however for some residents the staff may not be required to be present even if noted as supervision for meals. Additionally, RN#4 indicated that staff will know which residents are aspiration risks and will remain present for those residents. RN #4 further identified that the facility had no standard definition for supervision with meals. Interview and record review with the Rehabilitation Director on [DATE] at 2:13 PM identified that the Speech therapy discharge report dated [DATE] identified Resident #107 was discharged with a FMP in place which included regular solid diet, thin liquid diet, meal supervision, food cut up into bite sized pieces and denture care. The Rehabilitation Director further identified that the FMP documented that nursing had been in-serviced by the speech therapist, as required. Interview with SLP #1 on [DATE] at 2:21 PM identified that a Speech therapist (SLP) recommendation for meal or eating supervision means that a staff person must be present in the room or dining room during the entire meal. Interview with the DNS on [DATE] at 3:06 PM identified that not all staff are aware that supervision (per SLT) always means to remain with the resident for the entire meal. The DNS further identified that supervision should have been provided and that nurse aides should notify nursing if assistance was needed because of staffing issues. The DNS identified that he/she had felt that no continuous supervision was needed with a regular diet, and because of this, he/she did not identify a concern that no aides were in the room while Resident #107 was eating. The DNS was unable to identify a policy, procedure or practice regarding dietary staff and placement or set up of trays for residents who required feeding or supervision. Interview with Dietary Aide (DA) #1 on [DATE] at 10:39 AM identified he/she worked on [DATE], recalled Resident #107's choking incident and recalled that he/she did cut up Resident #107's food when making the tray on the steam table. DA#1 identified that the dietary staff plate the food as the diet slip directs and recalled that Resident # 107 needed his/her food cut. DA#1 identified that he/she cut up the food, then gave the tray to another dietary staff to deliver to Resident #107, but could not recall the exact dietary staff that delivered the tray. DA #1 further identified a list was present in the kitchen that identified if a resident needed to be supervised and/or fed by nursing. It a resident required feeding or supervision, dietary staff would leave the tray covered and away from the resident but could not remember if Resident #107 was identified as requiring supervision on the dietary list. Interview and review of staffing with the Dining Facility Manager (DFM) on [DATE] at 10:58 AM identified that the dietary list sheet did not consistently identify supervision requirements for all residents, and that that information is being added subsequent to surveyor inquiry. Interview with SLP #2 on [DATE] at 12:36 PM identified SLP #2 did work with Resident #107, and identified that when supervision was recommended, it was to be provided for the duration of the meal. SLP #2 further identified that having a regular diet does not mean there is no swallowing risk. SLP #2 further identified that the least restrictive diet was the goal, to increase safety without having to downgrade the diet, staff supervision may be used. Interview with LPN #3 on [DATE] at 10:00 AM identified that he/she was passing medication on [DATE] during breakfast and was not supervising Resident #107 during the meal. LPN #3 further identified that witnessed Resident #107 choking and started abdominal thrusts and called for assistance. The facility Guidelines for Aspiration Precautions and Term of Meal Supervision identified any terms describing meal supervision written by the speech therapist should be regarded as black and white, a resident either needs supervision when eating, or they do not; see the following examples: To indicate that supervision is needed, it should be written as supervise when eating.

Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of three sampled residents reviewed for mistreatment by staff (R#128), the facility failed to ensure the resident remained free from verbal abuse by staff. The findings included: Resident #128's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident as severely cognitively impaired, without behaviors and requiring extensive assistance for most ADL's and supervision to limited assistance from staff for some activities of daily living. The RCP updated on 12/15/16 identified cognition and communication as a focus. Interventions included approach calmly with a positive attitude, be patient and reassure as needed, in simple terms explain to resident what is going to take place prior to hands on care, speak and include resident in conversation during care, offer a consistent daily routine and introduce yourself to the resident, assist with all decision making and cueing to complete task and psych consult and follow-up as needed. A review of the reportable event (RE) dated 2/23/17 at 2:00 P.M. identified in part, that a Student Nurse (SN#1) reported hearing a Nurse Aide (NA#1) call the resident an expletive (b .h) and being rough. A review of SN#1 investigative statement dated 2/23/17 identified that on the same day at 10:00 A.M. NA#1 requested the student nurse's assistance with a stand and privot transfer with R#128. As the NA#1 attempted to transfer the resident NA#1 became frustrated when he/she was unable to transfer the resident out of bed to the wheelchair and uttered and/or called R#128 a (b .h). Although SN#1 noted NA#1 called the resident a (b .h) loud enough for the resident to hear, SN#1 was unable to determine if the resident had a reaction to the NA#1's statement. Attempts to contact SN#1 on 11/16/17 at 11:40 A.M. and 2:20 P.M. and on 11/17 at 9:20 A.M. and 12:12 P.M. were unsuccessful. On 11/16/17 at 11:42 A.M. an interview and review of the reportable event and/or facility's investigation with NA#1 indicated that nothing had happened, between NA#1 and R#128. Although NA#1 admitted to having difficulty in remembering what had occurred during the provision of care with RN#128 and SN#1, NA#1 indicated that he/she didn't call or refer to the resident with an expletive (b .h) as SN#1 alleged. On 11/16/17 at 11:06 A.M. an interview with NA#2 indicated that although he/she had not witnessed the allegation of verbal mistreatment between NA#1 and R#128, but does remember seeing NA#1 during the shift and in the hallway after being told he/she had to cut R#128's nails. NA#1 appeared to be rushed and overworked at the time and was complaining that he/she didn't have time and wasn't going to clip that crazy resident's (R#128) nails. On 11/16/17 at 12:35 P.M. an interview and review of the clinical record and reportable event with LPN#2 indicated that although he/she was made aware of SN#1 allegation, he/she recalls the resident being at his/her baseline for behavior and NA#1 reported the resident being agitated and refused to allow the NA#1 to cut R#128's fingernails. On 11/16/17 at 9:52 A.M. an interview and review of the reportable event with the DNS indicated that the facility substantiated the allegations of verbal abuse because after talking with SN#1, the DNS believed him/her to be credible. The DNS further noted that SN#1 was in the facility to provide care to the residents and would have no reason to make the allegation up. The DNS further indicated that subsequent to the facility's investigation into the matter, NA#1 was terminated According to the facility's Abuse policy it was noted in part that abuse or mistreatment of [REDACTED].

Based on clinical record reviews, interviews, and observations for 5 of 6 sampled residents reviewed for abuse allegations (R#54, R#35, R#60, R#175, R#198), the facility failed to ensure that staff treated the residents appropriately. The findings include: 1. Resident #54's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident had mild cognitive impairment, and required extensive assistance from one staff for transfers and toileting. The care plan dated 12/3/12 noted the resident had made a report of "perceived abuse". Interventions included providing reassurance of ongoing care, safety and security. Facility documentation/investigation identified that on 12/2/12, the resident was noted crying and upset. LPN #2 spoke with the resident who voiced being afraid and fearful for his/her safety at night during the 11 - 7 shift. The resident reported he/she rang the bell for assistance with toileting and that NA #2 came into the room at 1:30 AM and upon seeing tissues on the floor, asked the resident if she/he knew what the waste basket was for. NA#2 proceeded to assist the resident to the bathroom and then when he/she was done told the resident that she thought the resident had to use the bathroom; "where is it because I don't see anything". The resident stated that later when he/she rang the bell again, the same NA came in and said "ugh you again". The resident asked the NA her name and reported that the NA said "Dawn" and turned her name badge over so it was not visible to the resident. The resident reported that it was not the first time the nurse aide gave him/her a hard time. The resident repeated the incident to several staff members during interviews. Interview with R#54 on 2/25/2013 at 12:01 PM noted that one night, he/she needed to use the bathroom. The resident stated that he/she took a long time sometimes and the NA was snippy, rude, and spoke to the resident inappropriately. R#43 stated that he/she reported it immediately and the facility responded. Interview and review of the facility investigation with the DNS on 2/27/13 at 11 AM noted that NA#2 was terminated as a result of the investigation. 2. Resident # 35's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident was alert and oriented and required moderate assistance for ADL's including personal hygiene. 3. Resident # 175's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident was alert and oriented and required extensive assistance with ADL's. 4. Resident # 198's [DIAGNOSES REDACTED]. The RCP dated 11/30/12 identified the resident was alert and oriented and required extensive assistance with ADL's. Facility investigation documentation identified that on 12/4/12, the above three residents reported to the 11:00 PM to 7:00 AM shift supervisor that they no longer wanted to be cared for by NA #1. Social Worker #1 interviewed all three residents after the incident and documented the resident's statements: Resident #35 stated "all I have to say is the NA is not a happy worker and I don't want her taking care of me". Resident #175 stated that the NA grabbed the pad underneath her/him and "yanked" it causing severe back pain. Resident #198 stated that the NA was rough, "she/he threw me around in the bed when giving care" She/he caused unnecessary pain and was not sensitive to the resident's needs. Interview and review of facility documentation with SW#1 on 2/27/13 at 11:30 AM identified that although the residents did not appear to be in distress after the incident, Resident #35 and #196 felt they were disrespected and "abused". Resident # 178 felt the NA was "mean". Interview and review of the clinical records and facility documentation on 2/27/13 at 11:00 AM with the DNS identified that the NA was suspended pending investigation of the incident and because the residents were alert and oriented, the allegations of abuse were substantiated and the NA was terminated. 5. Resident #60's [DIAGNOSES REDACTED]. A 30 day minimum data set ((MDS) dated [DATE] identified the resident with intact cognition, BIM's score of 15, no behaviors exhibited, and required extensive assist with transfers and toileting. A care plan dated 2/28/13 identified "I need assistance with transfers and toileting". Interventions included offer to assist me with tasks I may not able to complete. A facility investigation dated 1/27/13 identified that the resident received a skin tear to the left forearm while being transferred to the toilet. Facility internal investigation dated 1/27/13 identified at the time of the incident R# 60 verbalized to the nurse "they squeezed my arm and my skin opened up". Interview with R#60 on 2/26/13 at 10:45 am identified that about a month prior, while being transferred to the bath room, the staff was rough and squeezed my arm causing my arm to bleed and open up. R# 60 indicated the area is now healed except for a few scabbed areas. Observation of the area at that time identified a healed over scabbed area to the left forearm. physician's orders [REDACTED]. Nurse's notes dated 1/27/13 at 3:00pm noted a skin tear occurred during transfer to toilet measuring 2.5cm x 1.5cm with a small amount of blood noted. The clinical record including nurses notes, and social service notes failed to reflect an allegation of mistreatment was reported. Facility policy for Abuse identifies all allegations must be reported immediately to the supervisor, thoroughly investigated and acted upon. Additionally an accident/incident report will be completed and a description of the incident will be documented in the residents nursing notes. Interview with NA#6 on 2/28/13 at 10:00am indicated on 1/27/13 she transferred R# 60 to the bath room and during the transfer resident sustained [REDACTED].# 60's arm at any time during the transfer. NA#6 was unable to explain how the skin tear occurred. Interview with LPN # 7 on 2/28/13 at 9:45 am identified she interviewed the resident at the time of the incident and the resident indicated the NA's squeezed her arm while being transferred, causing it to open up. LPN# 7 indicated she reported the incident to the supervisor for follow up and was unaware of the conclusion. Interview and review of the clinical record and investigation with the DNS on 2/27/13 at 3:15 pm identified she is responsible for reviewing incident /accident reports and for ensuring completion of the followup. The DNS indicated she reviewed this as a skin tear caused during transfer not as an allegation of mistreatment. Interview and review of the facility documentation with Social Service on 2/27/13 at 3:00 pm identified when there is allegation of mistreatment she will interview the resident and offer support and re-assurance and will continue to visit for at least the week or until the resident feels comfortable. SS identified she did not speak with the resident or document any visits regarding this allegation because she was unaware of the allegation.

Based on clinical record reviews, review of facility documentation and interviews for three of six sampled residents (Residents #25, #66 and #117) who had sustained an injury, the facility failed to provide the adequate supervision when transferring the resident via a mechanical lift, and/or to utilize the appropriate transfer device in accordance with the physician's orders [REDACTED]. The findings include: 1. Resident #66's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified that Resident #66 had moderate cognitive impairment, was totally dependent on two staff for transfers between surfaces, non-ambulatory, the resident's balance during transitions was not steady and only able to stabilize with human assistance when moving from surface to surface during transfer, and/or moving from seated to standing position and a wheel chair was utilized for mobility. The Resident Care Plan (RCP) dated 8/18/11 identified the resident was at risk for falls. Interventions directed to transfer in and out of the bed and/or chair with the assist of two via a mechanical lift. A physician's orders [REDACTED]. The Individualized Resident Assignment directed to transfer the resident via a mechanical lift to the wheel chair, the assignment did not reflect the physician's orders [REDACTED]. The nurse's note dated 9/18/11 at 4:00 PM identified that the 3-11 PM Nurse Aide (NA) #7 told Licensed Practical Nurse (LPN) #4 that she had received in report from the 7-3 PM NA that Resident #66 complained of right shoulder pain after the shower when care was provided and the resident was in obvious pain. When assessed Resident #66's right shoulder was swollen, tender to touch and subsequent to physician notification an x-ray was obtained. The 9/18/11 at 7:20 PM note identified that the physician was updated with the x-ray results and Resident #66 was transferred to the hospital for an evaluation. The radiology report dated 9/18/11 identified that Resident #66 had sustained an impacted fracture of the surgical neck of the right proximal humerus. Interview with NA #7 on 1/18/12 at 10:45 AM identified that on 9/18/11 without assistance she positioned Resident #66 on the edge of the bed and attached the sling from the Sarita lift around the resident. While NA #7 proceeded to leave the room to get assistance, she looked back and observed that the resident had slide off the bed and was hanging from the sling supported by the lift. NA #7 indicated that again without assistance she removed the sling and moved Resident #66 back onto the bed. Further interview NA #7 identified that when provided with mechanical lift transfer directions she will independently make the decision when to utilize a Sarita (standing type transfer device) or to utilize a Hoyer (total lift) device. NA #7 indicated that it was her practice to utilize the Sarita when the resident was to be transferred to a shower chair. Interview and review of the clinical record and facility documentation with the Director of Nurses on 1/18/12 at 11:40 AM indicated that it was the charge nurse's responsibility to ensure that the individualized resident assignment accurately reflected the physician's orders [REDACTED]. 2. Resident #25's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that Resident #25 had severe cognitive impairment, required total assistance of one person with bed mobility and transfers in and out of the bed and/or chair, and no behavioral symptoms or rejection of care. The RCP dated 5/11/11 identified that the resident was at risk for falls related to decreased mobility. Interventions directed to transfer the resident via a mechanical lift with two person assist from the bed to an adaptive wheelchair. The nurse's note dated 5/14/11 at 11:00 AM identified that Licensed Practical Nurse (LPN) #2 was called to Resident #25's room. LPN #2 observed that Resident #25's left ankle was purple and swollen and subsequent to physician notification an x-ray was obtained. The radiology results identified that Resident #25 had sustained a distal fibula fracture of the left lower extremity. The Reportable Event Form dated 5/14/11 at 9:45 AM identified that Nurse Aide (NA) #1 reported to LPN #2 that Resident #25's left ankle was bruised and painful. An x-ray was obtained and the radiology results indicated that Resident #25 had sustained a distal fibula and tibia fracture extending into the intra-articular ankle of the left lower extremity. Review of the facility's investigation indicated that although abuse was not substantiated, the nursing staff was reeducated regarding osteoporosis, osteoarthritis, the fragility of all residents, particularly those with osteopenia, and the technique for repositioning and transferring fragile residents. During interviews with several nursing staff (LPN #2, NA #1, NA #3 and NA #4) on 1/19/12 during the 7-3 PM shift, each had indicated that although they have previously cared for Resident #25 and knew the resident well, LPN #2, NA #1, NA #3 and NA #4 were unable to verbalize specific safety precautions and/or interventions related to the [DIAGNOSES REDACTED].#25 sustained was not of a spontaneous nature. MD #1 indicated that a comminuted fracture was most likely sustained from trauma, such as a fall and/or impact of some sort. 3. Resident #117's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified that Resident #117 had no memory or cognitive impairments, was totally dependent on staff for most activities of daily living, non-ambulatory and had functional limitation in range of motion on both sides of the lower extremity. The RCP dated 11/3/11 identified that the resident at risk for falls. Interventions directed to encourage the resident to wear appropriate foot wear and clothing during transfers to avoid injury and that the resident was receiving physical and occupational therapies to increase strength. The nurse's note dated 11/2/11 at 1:00 PM identified that during a physical therapy session Resident #117 had sustained a skin tear on the right foot third toe and a moderate amount of blood was noted. Subsequent to physician notification Resident #117 was transferred to the hospital for an evaluation. Resident #117 returned back to the facility at 4:45 PM with four sutures were in place to the second toe. Orders directed to wash with soap and water followed by a dry protective dressing daily times ten days and Doxycycline oral 100 milligrams twice a day for seven days. The Reportable Event Form dated 11/2/11 at 11:40 AM identified that while on therapeutic exercise equipment for the arms, the Omnicycle, Resident #117's right foot got stuck on the feet of the Omnicycle which tore the skin between the big and second toe that required four sutures. The facility's conclusion dated 11/6/11 identified that Resident #117 was positioned on the Omnicycle for the arms only and during a rest the resident pushed the start button which automatically defaulted the machine to the feet. Time had lapsed for seven (7) minutes causing the feet to start. Resident #117's family member was present and pulled the wheelchair away from the machine causing the second toe on the right foot to get stuck. The investigation failed to reflect information regarding appropriate foot wear as outlined in the plan of care. Interview with COTA #1 on 1/18/12 at 8:25 AM she indicated that she had stopped/paused the Omnicycle and then left the resident unattended while she assisted another resident to the bathroom. Upon returning to Resident #117 after a period of time, COTA #1 identified that the resident had turned the device back on. Interview with the Director of the Therapy Department on 1/18/12 at 8:42 AM identified that the Omnicycle device when left for a period of time in the stop/paused mode will return to the default setting when turned back on. She identified that the default setting causes the device to start both the upper and lower extremity pedals to operate. Further review and interview with the Director of the Therapy Department failed to provide a policy/procedure and/or documentation that any on-going safety instruction and/or in-services related to maintaining resident safety while utilizing devices such as the Omnicycle was provided to the therapy department's staff.

Based on review of the clinical record, facility documentation and interviews for one of three residents reviewed for weight loss (Resident #138), the facility failed to communicate and/or implement the Dietitian's recommendations to prevent further weight loss. The findings include: Resident #138 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The nutrition progress note dated 9/22/10 identified "no new weight" and referenced a weight of 140.9 pounds on the 14 day review. The nutrition progress note dated 10/1/10 identified a weight loss of 9.5% and recommended to implement House Supplement 120 cubic centimeters (cc) twice a day. The Minimum Data Set assessment dated [DATE] identified intact cognition, independence for eating, and a 5% or more weight loss in the last month. The care plan dated 11/3/10 identified a poor appetite due to weight loss. Interventions included to weigh as ordered and offer alternative meal when the resident dislikes the meal served. The nutrition progress note dated 10/6/10 and the nutrition progress note dated 10/13/10 identified R #138 experienced a 10 % weight loss in thirty days. A subsequent nutrition progress note dated 10/18/10 identified recommendations that included considering administering [MEDICATION NAME] because the resident reported a loss of appetite. The nutrition progress note dated 11/3/10 identified a 12.5% weight loss since admission and recommended notifying the physician to consider addition of [MEDICATION NAME] (appetite stimulant). The nutrition progress note dated 12/8/10 identified that on 12/3/10 the resident's weight had decreased to 120.4 pounds and again the Dietitian recommended notifying the physician to consider implementation of [MEDICATION NAME]. The weight record noted R #138's weight was 131 pounds on 10/6/10, 127 pounds on 11/1/10 and 120.4 pounds on 12/3/10 (11 pound weight loss and/or approximately 8% weight loss). The physician's orders [REDACTED]. The nutrition progress note dated 12/20/10 noted that R #138 started on [MEDICATION NAME] on 12/9/10 and noted the resident's intake was now 100% at most meals. Further review of weight documentation dated 12/21/10 noted a weight of 121.6 pounds (7 pound weight gain since initiation of [MEDICATION NAME]). Interview with Dietitian #1 on 12/22/10 at 1:07 PM indicated she communicated the recommendations to initiate [MEDICATION NAME] with nursing staff via the interdisciplinary communication form. Dietitian #1 indicated the resident's appetite improved since the addition of [MEDICATION NAME] and the resident gained weight since taking the medication. Interview with Physician #1 on 12/23/10 at 8:43 AM indicated if the facility had notified him of the resident's weight loss when it was first noted, he would have implemented the Dietitian's recommendations at that time. Review of facility Registered Dietician Recommendations and procedure identified in part that " the Registered Dietitian will make recommendations to improve the overall nutritional needs of the resident." The Registered Dietitian will communicate those needs to the nursing staff and the nursing staff will notify the physician of the recommendations."