Every finding on record at Highlands, The

Based on observations, interviews, and record review, the facility failed to provide food and drink at a safe and appetizing temperature for residents on Three (Unit Two, Unit Three and Unit Five) of Four units observed and for one Resident (#11) out of a total sample of 31 residents. Specifically, the facility failed to: 1. Ensure that residents on Unit Two, Unit Three and Unit Five received food that was served at safe and appetizing temperatures.2. Ensure that Resident #11's meal preferences were honored when the meals tickets identified the Residents' choices of meal. Findings include: 1. Review of the facility policy titled Food Temperature Control, revised 4/28/25, included but was not limited to: -Food temperatures are maintained during mealtimes to ensure residents receive safe food served at acceptable temperatures.>Food prepared by methods that conserve nutritive value, flavor and appearance.>Food and drink that is palatable, attractive, and at a safe and appetizing temperature. >Food attractiveness - refers to the appearance of the food when served to residents.>Food palatability - refers to the taste and/or flavor of the food.>Proper (safe and appetizing) temperature - means both appetizing to the resident and minimizing the risk for scalding and burns.>Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food - means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacteria or viral organisms capable of causing a disease or toxin formation). -Food temperatures are checked at the completion of the cooking process and before food is placed on the serving line; if issues are identified, they are corrected, or the food is discarded. >Food temperatures are recorded prior to meal services on the Food Temperature Record Log.>If the food temperatures are unsatisfactory, the problem areas are corrected before serving the food item(s).>Hot foods are held at a minimum of 135 degrees Fahrenheit (F) or per state requirements.>Cold foods are held at or below 41 degrees Fahrenheit per Centers for Medicaid and Medicare Services (CMS) guidelines, unless state requirements are more stringent.>Food should not be placed on the steam table more than 30 minutes before meal services begin. >Maximum length of time food is held on the steam table is four hours. Review of the facility policy titled Food Preparation, revised 4/29/25, included but was not limited to: -Food is prepared by methods that conserve nutritive value, flavor and appearance. The food that is served to the residents is palatable, attractive and served at the appropriate temperature. The food is prepared in a manner in which the nutritive value is not compromised and destroyed because of prolonged food storage, light and air exposure, cooking in large volumes of water, or being held on the steam table. >Food is seasoned appropriately and acceptable to the residents.>Food is prepared in a manner and form that meets each resident's needs.>Food is prepared by methods that conserve nutritive value, flavor and appearance.>Food and drinks are palatable, attractive, and served at a safe and appetizing temperature while minimizing the risk for scalding and burns. Review of the facility policy titled Resident Dining Services, revised 4/29/25, included but was not limited to: -The facility has an established process to ensure food is served in accordance with professional standards for food service safety and in a safe, clean, home environment. Dining services will include food served timely, at proper temperatures, diets served according to physician orders and appropriate assistance provided to meet the individual needs of the residents to create a pleasant experience.>Food that accommodates resident allergies, intolerance, and preferences.>Food distribution - means the processes involved in getting food to the residents. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to resident's rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to resident's rooms or dining areas to be distributed, covering food is appropriate, either individually or in a mobile food cart. Review of the facility policy titled Nutrition Assessment, revised 4/29/25, included but was not limited to: -A representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences are obtained, and a nutritional history and visual assessment are completed and documented.>The Director of Food and Nutrition Services/Registered Dietician (RD) or designee completes appropriate sections of the electronic nutrition assessment and obtain food and beverages preferences. >During the initial visit, food and beverage preferences, intolerances, food allergies, weight history, percent of food intake, eating patterns and cultural/ethnic/religious food restrictions are discussed. If the resident cannot respond appropriately, a family member or representative for the resident is contacted, if possible. >Nutrition assessment also includes information such as route of intake, any special food formulation, meal and snack patterns, supplements, dislike and preferences. Review of the facility policy titled Resident Satisfaction with Food and Dining, revised 3/26/25, included but was not limited to: -Facility will have a process in place to monitor the quality of food and beverages delivered to the residents. >The Director of Food and Nutrition Services monitors the quality of food served and the level of resident satisfaction in regard to overall dining.>Delivered temperatures, palatability, appearance and accuracy of meals served are monitored by conducting test trays per facility guidelines.>The Director of Food and Nutrition Services will address concerns noted with food, dining, and meal service in a timely manner and record per facility guidelines. On 11/19/25 at 8:18 A.M., during the initial observation on Unit Two, multiple residents reported the following concerns to surveyor #4:-Hot food was always cold. -Hot food was never hot, food was always cold by the time it was served. -Hot food was tasteless and was always cold.-Staff would offer to warm food in the microwave when the hot food was cold. -Some residents mentioned that the hot food would come out of the meal cart lukewarm.-The residents mentioned that it did not matter whether it was breakfast, lunch or supper, the food was always cold. Review of the facility's Mealtime Schedule, last revised 3/18/19, indicated the following: >The lunch tray line started in the kitchen at 11:30 A.M. >The first lunch meal cart for Unit two was scheduled to be delivered to the Unit at 11:37 A.M. >The second lunch meal cart for Unit two was scheduled to be delivered to the Unit at 11:51 A.M. >The first lunch meal cart for Unit three was scheduled to be delivered to the Unit at 11:44 A.M. >The second lunch meal cart for Unit three was scheduled to be delivered to the Unit at 11:58 A.M.>The first lunch meal cart for Unit five was scheduled to be delivered to the Unit at 12:12 P.M. >The second lunch meal cart for Unit five was scheduled to be delivered to the Unit at 12:26 A.M. Review of the facility's Resident Council meeting minutes, dated 8/28/25, indicated: >Food was cold and needed to be microwaved. >Eggs are served hard again. >Seasoning and cooking pork differently.>Some chicken is served hard. Review of the Resident Council Concern Follow-Up, dated 8/28/25, indicated the New Food Service Director (FSD) attended the resident council meeting. The FSD educated staff on proper cooking. The FSD would also take food temperatures before the food left the kitchen. Review of the facility's Resident Council Meeting minutes, dated 10/7/25, indicated: >Training for kitchen staff.>Salty gravy. >Toast should be crispier. >Some residents want eggs over easy. Review of the Resident Council Concern Follow-Up dated 10/7/25, indicated the FSD would be spending more time training with kitchen staff. Review of the facility's Resident Council Meeting minutes, dated 10/30/25 indicated:>Chilli to be added to the alternative menu.>Some residents want over easy eggs. >Some residents reported cold food. Review of the Resident Council Concern Follow-Up dated 10/30/25, indicated the FSD attended the resident council meeting and took notes. The FSD said food temperatures were being monitored and were within acceptable temperature range. During the Resident Group Meeting on 11/20/25 at 10:25 A.M. with eleven residents present primarily from Units Two and Four, the following concern was shared with surveyor #1:>Hot food served at the facility was often served cold. On 11/20/25 at 11:35 A.M., surveyor #4 observed the following in the facility's Main Kitchen: -The lunch food had been prepared and was stored, covered with foil, in metal bins on the steam table. -The Food Temperature Log had been completed as follows for food items on the steam table: >Soup 182*F (Degrees Fahrenheit [F]) >Pork Roast 179*F >Chicken [NAME] 162*F >Green Beans 184*F >Mashed Potato 186*F >Gravy 190*F >Pureed Meat 187*F >Pureed vegetable 190*F >Ground Meat 174*F >Pureed Pork Roast 179*F >Dessert 35*F >Pureed Dessert 35*F >Diet Dessert 35*F >Milk and Thickened Milk 35*F -There was one [NAME] and four Dietary Aides in the Main Kitchen. >The [NAME] was removing food items from the oven and placing the items into metal bins on the steam table. >Two Dietary Aides were moving trays and assembling food carts in the kitchen. >One Dietary Aide was moving cold beverages from inside of the stand-up refrigerator to a cart in the food services area of the Kitchen. >One Dietary Aide was in the dish room, placing pots and pans into the dish machine.During an interview at the time, the [NAME] said the food items for lunch had been cooked, placed on the steam table, and the food temperatures had been recorded. The [NAME] said the tray line would start soon. On 11/20/25, at 11:49 A.M., surveyor #4 observed the following in the facility's Main Kitchen: >The tray line began at 11:49 A.M. (19 minutes after the facility scheduled time) >One Dietary Aide prepared trays with utensils and drinks. >One Dietary Aide called resident diets off to the [NAME] who plated the residents' food. -Meal carts for the units were prepared and dispatched from the kitchen at the following times:>Unit Two: 1st cart - 12:00 P.M. (23 minutes later than facility scheduled time).>Unit Three: 1st cart - 12:12 P.M. (28 minutes later than scheduled).>Unit Two: 2nd cart - 12:25 P.M. (34 minutes later than scheduled).>Unit Four: 1st cart - 12:48 P.M. (33 minutes later than scheduled).>Unit Four: 2nd cart - 1:01 P.M. (41 minutes later than scheduled). >Unit Five: 1st cart - 1:10 P.M. (48 minutes later than scheduled). >Unit Five: 2nd cart - 1:21 P.M. (55 minutes later than scheduled). On 11/20/25 at 11:52 A.M., surveyor #1 observed the following on Unit Two: >1st cart arrived on the unit at 12:01 P.M.>2nd cart arrived on the unit at 12:26 P.M. -Test Tray was completed with surveyor #1 and CNA #2 at 12:38 P.M., after the residents had received their lunch meal trays on Unit Two. The test tray results were as follows:>Mashed potatoes: 125.9*F, tasted like mashed potato, but not flavorful and was lukewarm. >Sweet potato: 112.4*F, flavor was good and tasted like sweet potato, caramel, not warm but not cold.>Green beans: 120.9*F, tasted like green beans. Cool to room temperature. >Chicken: 111.9*F, surveyor #1 was unable to taste the chicken due to dietary restrictions. CNA #2 declined to taste.>Pork Roast: 126.5*F, surveyor #1 was unable to taste the pork due to dietary restrictions. CNA #2 declined to taste.>Dinner Roll: 106.3*F, Room temperature and tasted like a dinner roll.>Cola: 51.6*F, Cold. >Whole milk: 45.3*F, cool, tasted like milk.>Apple juice: 54.1*F, cool to room temperature. >Dessert: 48.9*F, tasted like cheesecake, no whipped topping and cool. On 11/20/25 at 12:12 P.M., surveyor #2 observed the following on Unit Three: >1st meal cart arrived on the unit at 12:12 P.M. >2nd cart arrived on the unit at 12:30 P.M. -Test Tray was completed by surveyor #2 after the residents had received their lunch meal trays on Unit Three. The test tray results were as follows:>Roast Pork: 96.0*F, slightly warmer than room temperature but palatable>Chicken: 96.0*F, slightly warmer than room temperature but palatable>Mashed Potatoes: 100.0*F, slightly warmer than room temperature, did not taste like mashed potatoes.>Carrots: 102.0*F, slightly warmer than room temperature, did not taste like carrots. On 11/20/25 at 1:24 P.M., surveyor #3 observed the following on Unit Five: >1st meal cart was already on the unit.>2nd cart arrived at 1:24 P.M. 11/20/25 at 1:24 P.M., surveyor #3 observed the lunch meal delivery on Unit Five. Tray pass began immediately. All residents meal trays were served from both carts by 1:40 P.M. On 11/20/25 at 1:41 P.M., the test tray was completed by surveyor #3 and findings were as follows:>Pork Roast: 120.0*F, warm, tasty, meat looked like beef, brown in color. Pork Roast tasted good but did not realize it was pork roast, and facility staff were not able to identify what kind of meat it was by looking at it.>Chicken with gravy: 100.0*F, lukewarm to cool and tasted okay.>Carrots: 120.0 F, warm, a little sweet tasting, tasted good.>Green beans: 100.0*F, lukewarm to cool, tasted good.>Mashed potatoes: 110.0*F, very light taste of salt, kind of bland, lukewarm.>Dessert cheesecake pudding with graham cracker crumbs: 60.0*F, cool, tasted good.>Black Coffee: 130.0*F and hot, tasted like coffee.>Milk: 40.0*F, and cold. During an interview on 11/20/25 at 1:50 P.M., the Registered Dietician (RD) said the facility was aware of the residents' concerns and had been working towards resolution. The RD further said the facility had hired a new Food Service Director (FSD) who had been in the facility for three months. During an interview on 11/25/25 at 11:26 A.M., the FSD said she had been taking samples of food temperatures and noted that some of the food temperatures were fluctuating depending on the meal served. During an interview on 11/25/25 at 1:28 P.M., the Administrator said he had participated in all the resident council and food committee meetings. The Administrator further said he was aware of residents' cold food and palatability concerns and was working towards a resolution. 2. Resident #11 was admitted to the facility in February 2021 with diagnoses including Protein Calorie Malnutrition, Disorders of Plasma Protein Metabolism and Hyponatremia. Review of the Minimum Data Set (MDS) Assessment, dated 8/20/25, indicated Resident #11:-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15.-was understood by others and understands others. During an interview on 11/19/25 at 9:27 A.M., Resident #11 said that his/her two over easy eggs (fried eggs that are flipped briefly to cook the yolk slightly, resulting in a runny center) were very hard. On 11/20/25 at 8:29 A.M., Resident #11 was observed eating his/her breakfast in his/her room. The surveyor observed two slices of toast and what looked like fried eggs (over hard) on the meal tray. The surveyor observed the Resident's dietary ticket indicated a preference for eggs over easy. During an interview at the time, Resident #11 said he/she was supposed to receive two over easy eggs, but the eggs appeared fully fried and hard. Resident #11 said he/she does not eat the eggs over hard. Resident #11 further said he/she had reported his/her meal preference to the FSD, but this concern had not been resolved. On 11/21/25 at 8:24 A.M., Resident #11 was observed eating his/her breakfast in his/her room. The surveyor observed two slices of toast and over hard fried eggs on the meal tray. During an interview at the time, Resident #11 said he/she was supposed to receive two over easy eggs, but the eggs he/she received were fully fried and hard and he/she was not going to eat the eggs over hard. During an interview on 11/21/25 at 11:15 A.M., the FSD said the facility was able to give residents their meal preferences if the meal was within the resident's meal plan. The FSD said the facility had access to pasteurized eggs and were able to provide over easy eggs for residents. The surveyor reviewed a picture of Resident #11's breakfast eggs taken with Resident #11's permission and the FSD said the eggs were cooked through and not over easy eggs as preferred by the Resident. The FSD further said Resident #11 should have been provided with over easy eggs per his/her preferences but was not. During an interview on 11/21/25 at 12:21 P.M., the RD said she would typically meet with residents upon admission and during that time she would take the residents food and meal preferences and incorporate them into the resident's meal plan. The RD said after the admission assessment, she would send the food preferences to the FSD and the FSD would ensure that the residents meal preferences were communicated with the Cook. The surveyor and RD reviewed a picture of Resident #11's breakfast meal including the over hard eggs and the RD said that the eggs were not cooked as over easy eggs per the Resident's meal preference.

Based on observations, record review, and interview, the facility failed to adhere to infection control practices and standards for two (Unit Two and Unit Five) out of four resident units and for one Resident (#69) out of a total sample of 31 residents, increasing the risk of contamination and spread of infection for residents in the facility.Specifically, the facility failed to:1. conduct testing of residents and staff for COVID-19 infections, every forty-eight hours as required, when Unit Two and Unit Five were experiencing an outbreak of COVID-19 infections.2. for Resident #69, ensure that staff wore the required Personal Protective Equipment (PPE: items such as gown, N95 respirator, eye protection worn by the staff to decrease the spread of infection) while in the Resident's room when the Resident was on Isolation Precautions (interventions including use of PPE to prevent the spread of a communicable diseases).Findings include: 1. Review of Centers for Disease Control and Prevention (CDC) Infection Control Guideline: SARS-CoV-2, revised 6/24/24, retrieved from, https://www.cdc.gov/covid/hcp/infection-control/index.html, indicated: >Nursing Homes -The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. -Perform testing for all residents and health care personnel (HCP) identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at Day 1 (where day of exposure is day 0), Day 3, and Day 5. Review of the Facility Assessment, last reviewed 7/17/25, indicated but was not limited to: >Services provided: -infection prevention and control -identification and containment of infections -prevention of infections Review of the facility policy for COVID-19 Outbreak Investigation, last reviewed 8/7/25, indicated: -the facility will perform COVID-19 outbreak investigations in accordance with local, state, and federal regulations to mitigate the spread of COVID-19 within the facility. -an outbreak investigation is initiated when a new single case of COVID-19 occurs among residents or staff to determine if others have been exposed. -in an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. -upon identification of a single new case of COVID-19 infection in any associate (staff member) or resident, testing should begin immediately. Review of the facility's Long Term Care Respiratory Surveillance Line listing, undated, for COVID-19 positive residents and staff indicated the following: >the first COVID-19 positive resident tested positive on 11/16/25 on Unit Five >the second COVID-19 positive resident tested positive on 11/18/25 on Unit Two >the third COVID-19 positive resident tested positive on 11/20/25 on the Unit Five >seven more residents and one staff member tested positive for COVID-19 on 11/23/25 on Unit Five >two more staff members tested positive for COVID-19 on 11/24/25 on Unit Five Review of the documentation provided by the facility titled Outbreak Testing, undated, failed to indicate that all residents and staff on Units Two and Five had been tested for COVID-19 until 11/23/25 and 11/24/25, which is greater than 24 to 48 hours after the first residents tested COVID-19 positive on each unit. During an interview on 11/24/25 at 2:12 P.M., the Regional Director of Clinical Services said that all residents and staff on Units Two and Five should have been tested for COVID-19 after the first residents had tested positive and they were not. The Regional Director of Clinical Services also said that the outbreak testing for residents and staff had not started until 11/23/25 and that residents and staff should have been tested after the first positive case had been identified. 2. Review of the facility's policy titled Transmission-Based Precaution and Isolation Procedure, revised 8/19/25, included but was not limited to: The facility will implement and utilize transmission-based precaution to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. -Transmission-based precautions must be used when a resident develops signs and symptoms of a transmissible infection, arrives at a nursing home with symptoms of an infection (pending laboratory confirmation), or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. <Contact Precautions are intended to prevent transmission of pathogens that are spread by direct (e.g., person to person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or the resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed. <Droplet Precautions, the use of droplet precautions applies when respiratory droplets contain pathogens which may be spread to another susceptible individual. Respiratory pathogens can enter the body via the nasal mucosa, conjunctivae and less frequently the mouth. Examples of droplet-borne organisms that may cause infections include, but not limited to Mycoplasma pneumoniae, influenza, and other respiratory viruses. Resident #69 was admitted to the facility in September 2023 with diagnoses including Immunodeficiency, Chronic Obstructive Pulmonary Disease (COPD) and Emphysema. Review of the Minimum Data Set (MDS) Assessment, dated 8/20/25, indicated Resident #69: -was understood by others and understands others. -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible score of 15. Review of Resident #69's November 2025 Physician orders indicated: -Vital signs every shift for Covid, for 7 days, initiated 11/19/25, start 11/19/25, end 11/26/25 -Isolation: Contact and Droplet Precautions. Diagnosis: Covid Positive. Every shift for Covid positive - - was resident in room alone during isolation? Y=Yes N=No, initiated 11/18/25 -Isolation: Contact and Droplet Precautions. Diagnosis: Covid Positive. Every shift for Covid positive - - were all services provided in room during shift? Y=Yes N=No, initiated 11/18/25 -Ipratropium-Albuterol Solution (inhaled bronchodilator medication) 0.5 - 2.5 (3) milligrams (mg)/3 Milliliters (ml). 3 ml inhale orally via nebulizer every 8 hours for Covid. Document heart rate, respirations, and lung sounds before and after treatment. >Lung sounds (LS) = C-clear, W-wheezing, R-Rhonchi, CR-Crackles, D-Diminished, Document number of minutes spent with resident on treatment, initiated 11/18/25 -Paxlovid (antiviral medication used to treat Covid infection) (150/100) Oral Tablet Therapy pack 10x 150 mg & 100 mg (Nirmatrelvir-Ritonavir). Give 1 tablet by mouth two times a day for Covid for 5 days, initiated 11/20/25. End 11/25/25. Review of the Respiratory Care Plan, initiated 11/18/25, indicated Resident #69: -has an upper Respiratory Infection: Covid-19. >Contact plus Droplet Precaution >Door to residents' room should remain closed, if possible and does not create a safety hazard >Isolation as ordered. On 11/19/25 at 9:35 A.M., the surveyor observed the Director of Nursing (DON) standing at the entrance to Resident #69's room. During an interview at the time, the DON said Resident #69 was on isolation for COVID-19 infection. The surveyor observed a sign posted outside Resident #19's room that indicated: -STOP! ISOLATION IN ADDITION TO STANDARD PRECAUTIONS >STAFF AND PROVIDERS MUST: -clean hands: when entering & exiting -Gown: change between each resident -N95 Respirator (facemask acceptable if N95 not available; fit tested N-95 or higher required for Aerosol Generating Procedure (AGPs) -Eye protection (googles or face shield) -Gloves: change between each resident >KEEP DOOR CLOSED (Unless safety concern or not on physically separate unit) >Use patient dedicated or disposable equipment. -Clean and disinfect shared equipment -wear gloves and a gown for the following high contact resident care activities: >transferring >changing linens On 11/19/25 at 9:37 A.M., the surveyor observed CNA #1 put on (don) a gown, N95 mask, gloves, and entered Resident #69's room and closed the door behind her. During an interview on 11/19/25 at 9:57 A.M., the surveyor and CNA #1 reviewed the sign posted outside Resident #69's room. CNA #1 said Resident #69 was on isolation for COVID-19 infection. CNA #1 said she assisted Resident #69 to the bathroom and provided activities of daily living (ADL) care. CNA #1 said she was supposed to wear a gown, gloves, N95 and eye protection but when she looked inside the bin located outside of the Resident's room there was no eye protection or face shields. CNA #1 also said she should have had an eye protector on prior to caring for the Resident. CNA #1 said it was important that she covered her eyes using a face shield to prevent the transmission of infection to other residents. On 11/20/25 at 7:48 A.M., the surveyor observed from the hallway, Resident #69 was seated in his/her room. The surveyor observed Resident #69 sneeze and used the sleeve of his/her right hand to clean his/her nose. On 11/20/25 at 7:51 A.M. through 7:56 A.M., the surveyor observed from the hallway that CNA #2 was making Resident #69's bed. CNA #2 was observed to not be wearing a gown, N95 mask or eye protection. CNA #2 was observed removing dirty linen from the Resident's bed and placing the linen in a linen cart located outside Resident #69's room. The surveyor did not observe hand hygiene being completed by CNA #2 before exited Resident #69's room. During an interview immediately following the observation, the surveyor and CNA #2 reviewed the isolation sign posted outside Resident #69's room, and CNA #2 said she was only making Resident #69's bed and thought a gown, N95 mask and eye protection were not needed. CNA #2 said she was not providing ADL care for Resident #69 and did not think she needed to wear a gown, N95 mask and eye protection. When the surveyor asked CNA #2 why Resident #69 was on isolation precautions, CNA #2 said Resident #69 has COVID-19 infection and it was important that she wear a gown, N95 mask and eye protection to prevent the transmission of infection to other residents. During an interview on 11/20/25 at 9:00 A.M., the DON said Resident #69 was on isolation for Covid-19 infection and all staff entering the Resident's room to provide all forms of close contact care such as ADL care and changing bed linens needed to wear a gown, gloves, N95 respirator and eye protection to prevent the spread of infection to other residents. The DON said she had put out an alert yesterday (11/19/25) reminding all staff about the facility protocol and policy for residents who were on isolation precautions to ensure that the staff abide by the protocol. On 11/20/25 at 9:35 A.M., the surveyor observed CNA #3 enter Resident #69's room without donning eye protection. During an interview on 11/20/25 at 9:47 A.M., CNA #3 said she had assisted Resident #69 to the bathroom and did not wear eye protection when she entered the Resident's room. CNA #3 said she should have used eye protection when entering the room to prevent particles and pathogens from getting into her eyes.

Based on observations, interviews, and record review, the facility failed to implement a person-centered care plan relative to meal assistance for one Resident (#125) out of a total sample of 31 residents. Specifically, for Resident #125, the facility failed to implement care plan interventions of cutting up larger meal items to bite sized pieces, getting the Resident out of bed and in the dining room for meals, and staff supervision to eat as identified on Resident #125's person-centered care plan to address nutritional interventions for significant weight loss over a one-month period of time. Findings include:Review of the facility policy titled Nutrition Assessment, revised 4/29/25, included but was not limited to: -A representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences are obtained, and a nutritional history and visual assessment are completed and documented. Each resident receives a comprehensive nutrition assessment to determine nutritional needs on admission, annually, and when the resident becomes at risk for compromised nutritional status. <Is offered a therapeutic diet when there is a nutritional problem, and the health provider orders a therapeutic diet. Review of the facility policy titled Nursing Documentation, revised 8/29/25, included but was not limited to: -Nursing Services<Providing care includes, but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident needs. Resident #125 was admitted to the facility in July 2025 with diagnoses including Dysphagia oropharyngeal phase and dysarthria following other nontraumatic intracranial hemorrhage. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #125:-was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. -required set up or clean up assistance with eating. Review of Resident #125's November 2025 Physician's orders, indicated:-House Shakes two times a day for supplement. Give 4 ounce (oz). Document % (percent) taken, initiated 11/11/25. Review of Resident #125's Care Card, dated 11/25/25, included but was not limited to:<Supervision by staff to eat. Review of Resident #125's Weight Summary from 7/8/25 through 11/24/25, indicated the following:-7/8/25: 168.1 pounds (lbs.)-8/14/25: 166.7 lbs.-9/4/25: 168.6 lbs.-10/9/25: 165.0 lbs.-11/13/25: 145.3 lbs. (-19.7 in one month)-11/24/25: 148.0 lbs. Review of Resident #125's Nutrition Care Plan, revised 11/19/25, indicated:-at risk for alteration in nutrition related to acute on chronic medical conditions. Resident at risk for malnutrition as evidenced by Mini Nutritional Assessment (MNA) 7/9/25, 11/13 - significant weight loss. <assist to fully set up meal tray, cut larger items to bite size.<out of bed and in dining room for all meals and supervised. Review of Resident #125's Activity of Daily Living (ADL) Care Plan, revised 11/25/25, indicated:-the Resident has an ADL self-care performance deficit related to Activity Intolerance, Fatigue.<eating: the Resident requires intermittent supervision by staff to eat. Encourage out of bed (OOB) and to dining room for meals. Review of Resident #125's Speech Evaluation Summary of Daily Skilled Services dated 11/20/25, indicated:-initiated staff education-care plan update-positioning OOB for meals-assist to set up (s/u) tray On 11/20/25 at 8:25 A.M., the surveyor observed Resident #125 in his/her bedroom seated at the edge of the bed with a bedside table located in front of him/her and a breakfast tray on the bedside table. The surveyor observed the breakfast meal items included two French toast slices with syrup, cold cereal, a cup of milk, orange juice and tea and no staff members were present in the Resident's room. During an interview at the time, Resident #125 said that the meal tasted the same as always. On 11/20/25 at 8:30 A.M., the surveyor observed the Speech Therapist (ST) enter Resident #125's room and let the Resident know she had been asked to evaluate him/her to determine if he/she needed regular textured meals. The ST was observed asking the Resident if she could cut his/her meal into bite size pieces and the Resident agreed. The ST was observed to cut the French toast into bite size pieces, and the Resident began independently eating the bite size pieces. During an interview on 11/20/25 at 8:44 A.M., the ST said that she had been following Resident #125 for a while and is very familiar with the Resident. The ST said she evaluated Resident #125 to determine if the Resident's diet could be advanced to regular texture meals. The ST also said that upon entering the Resident's room, she observed Resident #125's breakfast tray, and the French toast was not cut into bite size pieces. The ST said she assisted and cut the food into bite size pieces and immediately observed the Resident independently began to eat his/her breakfast meal. The ST further said Resident #125 has weight loss and she would update the care plan to ensure that Resident #125's meal plan matches the Resident presentation. On 11/20/25 at 8:54 A.M., the surveyor observed Resident #125 eat a few bites of the French toast on his/her tray, and the cold cereal and milk were untouched by the Resident. On 11/21/25 at 8:42 A.M., the surveyor observed Resident #125 seated on his/her bed with the head of the bed elevated and a breakfast tray located on the bedside table placed in front of the Resident. The surveyor observed the breakfast meal items were scrambled eggs, muffin, a cup of orange juice, milk, tea, and cold cereal and the breakfast meal was untouched by the Resident. The surveyor further observed that no staff member was present in the Resident's room. On 11/21/25 at 1:17 P.M., through 1:25 P.M., the surveyor observed Resident #125 seated on his/her bed with his/her eyes closed, the lunch meal placed in front of him/her was untouched and no staff members were in the Resident's room. The surveyor observed the lunch meal items included rice, spinach, ground meat, a bowl of chocolate dessert, soup, a cup of water and ginger ale. The surveyor observed two staff members walking by Resident #125's room and picking up meal trays from other resident rooms. During an interview on 11/21/25 at 1:35 P.M., Unit Manager (UM) #1 said Resident #125 had been working with ST and required assistance to set up his/her meals. When the surveyor asked UM #1 what is required for a meal set up for residents, UM #1 said staff were expected to cut the Resident's meal into bite size pieces and set him/her up in a seated position during meals. UM #1 said Resident #125 should be out of bed for meals. UM #1 further said that Resident #125 typically sleeps through his/her meals when served if she/he was in his/her bed. UM #1 said that she met with the team on 11/20/25 and had in-services for 3:00 P.M.- 11:00 P.M. shift to ensure that nursing staff gets Resident #125 out of bed for meals. UM #1 further said that she failed to communicate the information to the other staff members that Resident #125 needed to be out of bed for meals, and it should have been done. During an interview of 11/21/25 3:09 P.M., the Director of Nursing (DON) said the expectation for all the Unit Managers was to identify weight loss and follow up with the necessary interventions, but they had not. The DON further said that Unit Managers were responsible for implementing and educating nursing staff on changes made to Residents #125's care plan.

Based on observations, interviews and records review, the facility failed to provide necessary care and services to ensure that abilities in activities of daily living (ADL's) did not diminish for two Residents (#12 and #16), out of a total sample of 31 residents.Specifically,For Resident #12, the facility staff failed to assist Resident #12 with applying his/her hearing aid during ADL care when the Resident had documented hearing deficits and required assistance with personal care, resulting in Resident #12 being unable to hear and communicate with others as required. For Resident #16, the facility failed to initiate the Restorative Nursing Program timely for upper extremity strengthening to maintain and increase bilateral upper extremity strength and independence with Activities of Daily Living (ADL's) for the Resident. Findings include: 1.Review of the facility policy titled, Vision and Hearing Devices, dated 9/18/25, included but was not limited to the following: >It is the facility policy to ensure residents receive proper treatment and assistive devices to maintain .hearing abilities. -Assess the residents use of assistive devices to maintain hearing upon admission. -Document use of assistive device in electronic health record and/or on care plan/care directive. Review of the facility policy titled, Activities of Daily Living, dated 9/4/25, included but was not limited to: -The resident will receive assistance as needed to complete ADLs. Resident #12 was admitted to the facility in September 2005 with diagnoses including Age Related Cognitive Decline, Hearing Loss, and Need for Assistance with Personal Care. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of a total possible score of 15. -hearing was adequate with a hearing device in place. Review of Resident #12's Person-Centered Care Plan included but was not limited to: >Focus- Activity of Daily Living (ADL) deficit, updated 9/4/25. >Goal- Resident will maintain highest level of ADL function possible through next review, updated 9/4/25. >Interventions - Resident requires extensive assist of another person to complete personal hygiene, dress, bathe and use the toilet, updated 9/4/25. Further review of Resident #12's Person-Centered Care Plan failed to indicate any intervention or direction to provide a hearing device. On 11/19/25 at 9:23 A.M., the surveyor observed Resident #12 sitting in the dining room, dressed for the day and eating breakfast. When the surveyor introduced herself to Resident #12 and began to ask questions, Resident #12 touched his/her right ear and said, I can't hear you, I need my hearing aid. I wish they would remember to help me with my hearing aid; I need them to hear. At the same time, a staff member left the unit dining room and returned with Resident #12's hearing aid. With the hearing aid in place, Resident #12 said he/she could then hear the surveyor's questions. On 11/20/25 at 7:48 A.M., the surveyor observed Resident #12 seated in the hallway dressed for the day. The surveyor began to speak to Resident #12 and the Resident said that he/she was unable to hear the surveyor and pointed to his/her right ear. During an interview at the time, Certified Nurse Aide (CNA) #5 said that she was the CNA assigned to Resident #12 today and that he/she had been provided with all morning care and dressed for the day. CNA #5 said Resident #12 needed assistance with personal care like washing and dressing, was hard of hearing and sometimes forgetful. CNA #5 said that she was not aware that Resident #12 had a hearing aid and that if Resident #12 needed a hearing aid, the hearing aid should have been listed in the Resident's Care Kardex so that CNA #5 would know to put the hearing aid in place for him/her. CNA #5 then provided Resident #12 with his/her hearing aid and the Resident said, that's better; now I can hear you both. CNA #5 further said if the Resident's hearing aid had been listed on the Resident's Care Kardex she would have known to assist the Resident to wear the hearing aid. During an interview on 11/24/25 at 12:41 P.M., UM #2 said Resident #12 required assistance for personal care, was hard of hearing, required a hearing aid and that the assigned CNA should put the hearing aid in place for the Resident during morning care. At the same time the surveyor and UM #2 reviewed Resident #12's medical record which failed to provide evidence that the Resident's care plan indicated a need for a hearing device. UM #2 said that Resident #12 should have a care plan in place for hearing deficit and a linked Kardex entry for the hearing device needed. UM #2 said that the nursing department was responsible to develop a person-centered care plan and care Kardex when Resident #12 was admitted . UM #2 further said that a hearing loss care plan and care Kardex would be important for Resident #12 so that the facility staff would know what services were needed. UM #2 said that Resident #12 could misinterpret conversations or misunderstand what was being said to him/her when the hearing device was not in place. 2. Review of the facility policy titled Restorative Nursing, effective 5/16/19 and revised 8/20/24, indicated but was not limited to the following: -Policy: To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. -Definitions:.Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. -Procedure:.Accurate and thorough assessment of the patient is fundamental in determining the patient's need for restorative services.The trained CNA will document provided techniques per the restorative care plan in the medical record. Resident #16 was admitted to the facility in July 2025, with diagnoses including fracture of the left humerus (upper arm bone), lack of coordination, difficulty in walking, muscle weakness, history of falling, chronic pain, and polyneuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #16 was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15 points. Review of Resident #16's Restorative Nursing Communication Tool, signed and dated 10/28/25 by an Occupational Therapist Practitioner, indicated but was not limited to the following: -Diagnosis: Falls; Left upper extremity shoulder fracture. -Focus Area: Ambulation; Upper extremity strengthening. -Frequency: Three days per week for 6 weeks. -Goals: 1) To maintain current function by ambulating in room/hallway with rolling walker, standby assist. 2)To maintain and increase bilateral upper extremity strength (especially left upper extremity shoulder flexion) to increase independence with Activities of Daily Living and self-propulsion with the wheelchair. Review of Resident #16's Physical Therapy Treatment Encounter Note, date of service 10/30/25, indicated discussion with the Resident regarding the Resident's discharge from Physical Therapy services, and the Resident agreed with the Restorative Program. Review of Resident #16's Physical Therapy Discharge Summary, signed and dated 10/31/25, indicated the Restorative Program was established for the Resident, and the Resident was on the Restorative Program for ambulation. Review of Resident #16's Restorative Nursing Communication Tool signed and dated on 11/13/25 by the Restorative Nurse, indicated but was not limited to the following: -Problem: Decreased range of motion (ROM) of left upper extremity related to fracture; Decreased mobility and activity tolerance. -Goal: Ambulate 50 feet (ft.) with rolling walker and one assist. Self-propel wheelchair 150 ft. -Six days per week, 15 minutes (min.) per day. -Individual program -Functional: -Upper extremity active ROM: Ball toss, bean bag toss, Wii games, Parachute games, etc. Three repetitions of six per exercise. -Lower extremity active ROM: Marching, leg stretches, ankle flexion. Self-propel in the wheelchair 150 ft. -Walking 50 ft with rolling walker and one assist. Review of Resident #16's Limited Physical Mobility Care Plan, initiated on 11/13/25, indicated but was not limited to the following: -Goals: -The Resident would increase level of mobility by ambulating 50 ft. with the rolling walker, one assist. -The Resident would increase strength and endurance of the upper extremities, self-propelling in the wheelchair 150 ft. -Interventions: -Nursing Restorative Program: Active ROM of the lower extremities. (Exercises: Three repetitions of six for 15 min., six days per week for 12 weeks). -Nursing Restorative Program: Active ROM of the upper extremities. (Exercises: Three repetitions of six, self-propel in wheelchair 150 ft. for 15 min., six days per week for 12 weeks.) -Nursing Restorative Program: Walking Program. (Ambulate with rolling walker, one assist, 50 ft. for 15 min. per day for six days weekly for 12 weeks.) -Frequency: As needed. -Target Date: 2/2/26. During an interview on 11/19/25 at 9:16 A.M., Resident #16 said he/she was supposed to be receiving Rehabilitation Services, but had not received services since the Resident had moved to this unit from another unit in the facility. During an interview on 11/21/25 at 3:17 P.M., Unit Manager (UM) #1 said Resident #16 was due to begin the Restorative Nursing Program on 11/13/25, with goals including increased ROM, increased upper extremity strength, and ambulation with assistance. UM #1 said there was no evidence that the Resident had received any Restorative Nursing Program services. During a follow-up interview with Resident #16 on 11/21/25 at 3:40 P.M., the Resident said he/she continued to question when Rehabilitation Services would begin, and said he/she did not feel like he/she had been getting exercise. The Resident said it made him/her feel weak and did not make him/her feel good. During an interview on 11/25/25 at 10:49 A.M., the Director of Nursing (DON) said the expectation was for Resident #16 to have received Restorative Nursing Program services according to his/her plan of care. During an interview on 11/25/25 at 1:13 P.M., Occupational Therapist (OT) #2 said Resident #16 was discharged from Rehabilitation Services at the end of October 2025. OT #2 said the purpose of the Restorative Nursing Program was for the Resident to maintain his/her functional status at the level at which he/she was discharged from Rehabilitation Services. OT #2 said she performed an evaluation of Resident #16 on 11/22/25 to determine whether the Resident had a decline in function from the time of the Resident's discharge from Rehabilitation Services, due to the lapse in time between the services. OT #2 said this evaluation occurred because a facility staff informed her that the Resident's Restorative Nursing Program services had not yet been initiated.

Based on observation, interview and record review, the facility failed to provide appropriate indwelling urinary catheter (also referred to as Foley catheter) care and services for one Resident (#10) of four applicable residents, out of a total sample of 31 residents.Specifically, for Resident #10, the facility failed to obtain Physician orders for the placement and size of an indwelling urinary catheter when the Resident had a functioning urinary catheter in place. Findings include:Review of the facility policy titled Physician Orders, reviewed 2/27/25, indicated:-A physician, physician assistant (PA) or nurse practitioner (NP) must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obliged to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.-Medications, diets, therapy and any treatment may not be administered to the resident without a written order from the attending physician. Resident #10 was admitted to the facility in October 2025 with diagnoses including Congestive Heart Failure and dislocation of the right hip. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #10:-had mild cognitive and memory impairment.-had an indwelling urinary catheter in place. On 11/24/25 at 9:24 A.M., the surveyor observed Resident #10 lying in bed with an indwelling urinary catheter drainage bag hanging from the bed frame. The surveyor further observed that the indwelling urinary catheter tubing contained clear yellow urine, and the drainage bag was protected with a privacy cover. On 11/25/25 at 9:39 A.M., the surveyor observed Resident #10 reclining in bed with an indwelling urinary catheter drainage bag in place, that was protected with a privacy cover and hooked to the Resident's bed frame. Review of Resident #10's Physician orders dated 11/25/25, failed to indicate any orders for the placement or size of an indwelling urinary catheter. During an interview on 11/25/25 at 9:49 A.M., the surveyor and Nurse #1 reviewed Resident #10's Physician orders. Nurse #1 said that there was no Physician order in place for the Resident's indwelling urinary catheter and that all medications, treatments and procedures required a physician's order. Nurse #1 also said that she didn't know what size catheter Resident #10 had in place because there was no physician order indicating the size of the catheter that should have been inserted for Resident #10. During an interview on 11/25/25 at 9:58 A.M., the Director of Nurses (DON) said that Resident #10 should have had a Physician's order in place for the indwelling urinary catheter, but the Resident did not have an order in place for the urinary catheter.

Based on record review, and interviews, the facility failed to ensure that laboratory services were completed as ordered for one Resident (#88) out of a total sample size of 31 residents. Specifically, for Resident #88, the facility failed to obtain laboratory testing as ordered by the Provider on 10/29/25, placing the Resident at risk for delayed assessment, management, and diagnosis of his/her medical symptoms based on the laboratory testing results. Findings Include:Review of the facility policy titled Laboratory Services dated 9/23/25 included but was not limited to the following: -The facility will ensure that laboratory services meet the needs of a resident, that the results are reported promptly to the ordering provider to address potential concerns and for disease prevention, for resident assessment, diagnosis, and treatment, and the facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside source. -The facility will be responsible for the timeliness of the laboratory services. Resident #88 was admitted to the facility in May 2025, with diagnoses including Malignant Neoplasm of the Brain, Hypothyroidism and Anemia. Review of Resident #88's Person-Centered Care Plan indicated: >Focus- Resident was at risk for re-hospitalization, with interventions that included to obtain labs as ordered, initiated 5/14/25. >Focus- Resident had increased nutrient needs, with interventions that included to obtain labs/diagnostic work as ordered, initiated 5/14/25. Review of Resident #88's Physician Assistant (PA) Progress Note, dated 10/29/25 indicated: -Will order blood work to assess for iron deficiency anemia and consider supplementation. Review of Resident #88's November 2025 Physician's orders indicated:-Bloodwork: TSH (Thyroid-Stimulating Hormone test), free T3 (Thyroid Hormone Test), T4 (Thyroxine), B12 (measures B12 vitamin blood levels) and folate (Vitamin B9) levels, Ferritin, Serum Iron and TIBC (Total Iron-Binding Capacity), effective 10/29/25. Review of Resident #88's medical record failed to indicate any evidence of laboratory results for the TSH, Free T3, T4, B12, Folate levels, Ferritin, Serum Iron and TIBC laboratory tests ordered on 10/29/25. During an interview on 11/25/25 at 9:14 A.M., Unit Manager (UM) #2 said Resident #88 was ordered for bloodwork of TSH, Free T3, T4, B12, Folate levels, Ferritin, Serum Iron and TIBC on 10/29/25. UM #2 said that the blood work should have been drawn the next day on 10/30/25. UM #2 said the Resident's bloodwork had not been drawn as ordered. UM #2 said Resident #88's labs ordered on 10/29/25 were important because those labs were specific to the Resident's diagnosis and disease monitoring. During an interview on 11/25/25 at 12:24 P.M., Physician Assistant (PA) #1 said she was unaware that the labs ordered on 10/29/25 for Resident #88 had not been obtained. PA #1 said that the labs ordered were important because supplementation would have been based on the results of the ordered labs. During an interview on 11/25/25 at 12:47 P.M., the Regional Director of Clinical Services said that laboratory services had been in the facility for lab services several times since 10/30/25 and therefore Resident #88's labs should have been drawn the next day following the order given for the Resident's bloodwork on 10/29/25.

Based on observations, interviews and record review, the facility failed to ensure that medical records were complete and accurate for two Residents (#7 and #61), out of a total sample of 31 residents.Specifically,For Resident #7, the facility failed to ensure the Physician orders obtained on 11/18/25 for wound care treatment to the Resident's right lower extremity were transcribed into the Resident's medical record, resulting in the potential risk for the Resident's right lower extremity wounds to worsen or become infected without timely and appropriate treatment and monitoring. 2. For Resident #61, the facility failed to ensure that the use of a physical restraint device (Enclosed Walker) was documented as required to determine the Resident's response and provide ongoing evaluation of the use of the physical restraint. Findings include:1.Review of the facility policy titled Physician Orders, effective August 2003 and revised 2/26/24, indicated but was not limited to the following:-Policy: .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.-Procedure:-All physician/practitioner orders, including verbal/telephone orders, are recorded on the Physician's Order Form.-The receiving nurse.immediately enters telephone or verbal orders into the clinical software.-Physician orders include the following:.Medications and Treatments. Resident #7 was admitted to the facility in April 2024, with diagnoses including Type 2 Diabetes Mellitus with diabetic neuropathic arthropathy, congestive heart failure (CHF), venous insufficiency, and peripheral vascular disease (PVD). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #7 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15. Review of the active Care Plan Report, reviewed on 10/30/25, indicated Resident #7:-had potential for impaired skin integrity related to edema and history of vascular ulcers (initiated on 2/4/25, revised on 2/4/25)-had a diabetic ulcer of the left plantar foot.(initiated on 7/11/24, revised on 9/10/25)-had a break in skin integrity.Vascular wound to the left lateral shin. (initiated 10/1/25)-had decreased nutrient needs .as evidenced by congestive heart failure.9/12/25 vascular wound to left lateral shin and diabetic ulcer to the plantar foot. (initiated on 4/23/24, revised on 10/16/25) Review of Resident #7's Wound Observation Tool-V4, effective 11/18/25 and signed 11/22/25, indicated the following:-On 11/18/25 the Resident had three unroofed blisters to the right medial shin.-The type of wound was identified as a venous ulcer.-The wound was identified to be partial thickness (extending into the first two layers of skin).-There was minimal, clear drainage present.-Wound measurements: -Right medial shin top: 4.0 centimeters (cm) by (x) 4.0 cm. -Right medical shin center: 2.0 cm x 1.75 cm. -Right medial shin bottom: 5.0 cm x 5.0 cm.-Treatment plan: Unna Boot (compression dressing made with guaze/ and zinc oxide paste, specifically designed to treat and manage venous ulcers) two times per week. Monitor weekly. Review of Resident #7's Weekly Skin Integrity Data Collection -V2 Tool, effective 11/19/25 and signed 11/19/25, indicated an open blister to Resident #7's lateral right lower extremity. Review of Resident #7's November 2025 Physician's orders failed to indicate any evidence of treatment orders for the right lower extremity wounds identified on 11/18/25 and 11/19/25. During an interview on 11/21/25 at 3:51 P.M., Resident #7 said he/she had an open area to the right shin and that an Unna Boot treatment was in place at that time. During an interview on 11/21/25 at 4:31 P.M., Unit Manager (UM) #1 said Resident #7 had a new open blister to the right lower leg, and that Resident #7 had an Unna Boot to the right lower extremity. UM #1 said that there was no evidence of a treatment order in the Resident's medical record for the right lower extremity wound at that time, but that there should have been. During an interview on 11/21/25 at 4:47 P.M., the Director of Nursing (DON) said that she had assessed Resident #7's lower extremities and performed wound care on 11/18/25. The DON said at that time the Resident had three superficial open blisters on the right shin related to edema, with weepy serous drainage. The DON said she obtained a Physician Order at that time to apply an Unna Boot to the right lower extremity wounds two times a week. The DON said that the Physician Order should have been entered into the Resident's Electronic Health Record at the time but had not been entered. During an interview on 11/25/25 at 10:37 A.M., the DON said that there was a risk to residents when Physician orders were not entered into the Electronic Health Records. The DON said that if a Physician order was not entered for a wound treatment, the nurses would not be able to follow the Physician order and would not know to perform the Physician ordered treatment or any appropriate monitoring of the treatment. 2. Review of the facility policy titled Physical Restraint Use, effective 11/1/17 and revised 9/3/25, indicated but was not limited to the following:-Policy: When a physical restraint is used, the facility must use the least restrictive restraint for the least amount of time and provide ongoing re-evaluation of the need for the physical restraint.-Procedure: A Physician Order is required for use of the specific type of restraint. The order should include the specific type of restraint, the condition and/or medical symptom that warrants restraint use, where and how the restraint is to be applied and used, and the time and frequency the restraint should be released.-Re-evaluation:-The need for the restraint is assessed quarterly and as indicated.-Documentation in clinical notes may include but is not limited to.Date and time of use, reason for use, resident tolerance, and the effectiveness of the restraint in treating the medical symptom(s). Resident #61 was admitted to the facility in March 2025, with diagnoses including metabolic encephalopathy, vascular dementia with anxiety, muscle weakness, and difficulty in walking. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #61's cognition was severely impaired, as evidenced by a Brief Interview for Mental Status (BIMS) exam score of four out of a possible 15. Review of the active Care Plan Report, reviewed on 9/30/25, indicated Resident #61:-used an enclosed framed wheeled walker to promote safe ambulation and prevent injury related to falls (initiated on 11/10/25, revised on 11/10/25).-restraint use would be evaluated every two hours. The risks/benefits of the restraint would be evaluated/recorded, as well as alternatives to the restraint, the need for ongoing use of the restraint, and the reason for the use of the restraint. (initiated on 11/10/25, revised on 11/10/25).-the enclosed frame wheeled walker was to be utilized after meals, and the Resident checked for proper positioning every one hour and the restraint released every two hours. Restraint use was to be documented and released per facility policy (initiated on 11/10/25, revised on 11/14/25). Review of Resident #61's Physical Restraint Informed Consent Form indicated:-Type of restraining device: Enclosed walker.-Frequency and Duration: Daily for two hours at a time.-Medical reason(s) for restraining device: unsteady gait, poor safety awareness.-The Legal Representative signed consent for use of the restraint on 11/13/25. Review of Resident #61's November 2025 Physician Order Summary Report indicated:-May use enclosed framed wheeled walker in supervised area to promote safe ambulation. Check Resident for proper positioning every one hour and release every two hours. Every one hour as needed to promote safe ambulation. Check for proper positioning every one hour (start date 11/14/25).-May use enclosed framed [NAME] walker in supervised area to promote safe ambulation. Check Resident for proper positioning every one hour and release every two hours. Every two hours as needed to promote safe ambulation. Release every two hours (start date 11/14/25). The surveyor observed Resident #61 utilizing the Enclosed [NAME] on the following days and times:-11/19/25 at 12:08 P.M.-11/20/25 at 8:29 A.M.-11/21/25 at 9:25 A.M.-11/25/25 at 9:42 A.M. Review of Resident #61's November 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate any documentation of the frequency of use of the Enclosed Walker, release of the restraint device, and positioning checks as required. During an interview on 11/25/25 at 9:54 A.M., UM #3 said there was no evidence that nursing staff recorded documentation in the MAR or in the TAR relative to Resident #61's Physician order for restraint use. During an interview on 11/25/25 at 10:52 A.M., the Director of Nursing (DON) said her expectation relative to restraint use for Resident #61 was that nursing staff was documenting the duration of the restraint use, the timing of the release of the restraint, and the timing of the positioning checks for Resident #61.

Based on interview, policy and record review, the facility failed to provide services according to professional standards of practice relative to medication administration for two Residents (#51 and #13) out of a total sample of 31 residents. Specifically, the facility staff failed to: 1. Administer Pantoprazole Sodium (prescription medication used to treat heartburn [burning, stabbing, or squeezing sensation in the chest, nausea] and conditions caused by too much acid in the stomach) to Resident #51 when the Pantoprazole Sodium was ordered by the Physician, was available to be administered, and the Physician was not notified of the missed doses of Pantoprazole Sodium, which increased the Resident's risk for discomfort. 2. Administer Lidocaine (topical [application to body surfaces such as skin or mucous membranes] medication used to treat symptoms of pain) External Patches to Resident #13 when the Lidocaine External Patches were ordered by the Physician, and were available to be administered, which increased the Resident's risk for experiencing pain. Findings include: Review of the facility's policy titled Administration of Medications dated 4/24/19, and revised 8/24/23, indicated the following: -The facility will ensure medications are administered . per Physician order to address residents' diagnoses and signs and symptoms. Review of the facility's policy titled Medication Shortages/Unavailable Medications, dated 12/1/07 and revised 1/1/22, indicated the following: -If a medication shortage is identified at the time of medication administration, facility staff should immediately take action to notify the Pharmacy. -The facility Nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record (MAR) . and in the Nurse's notes . -Such documentation shall include: a description of the circumstances of the medication shortage, a description of the Pharmacy's response upon notification, and actions taken. 1. Resident #51 was admitted to the facility in August 2021, with a diagnosis of gastroesophageal reflux disease (GERD: condition in which stomach acid repeatedly flows back up into the tube [esophagus] connecting the mouth and stomach resulting in irritation of the esophagus and heartburn) and Dementia (loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Review of Resident #51's clinical record indicated the following active Physician's order, initiated 4/11/24 with no stop date: -Pantoprazole Sodium Oral Suspension, give 10 milliliters (ml) by mouth two times a day for heartburn/GERD, 2 milligrams (mg)/1 ml dosing for total of 20 mg per dose. Further review of the Physician's order indicated the Pantoprazole Sodium Oral Suspension was stored in the refrigerator. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident's speech was unclear. -The Resident rarely/never made him/herself understood. -Staff assessment of the Resident's cognitive patterns indicated the Resident was severely cognitively impaired. Review of Resident #51's June 2024 MAR indicated the ordered dose of Pantoprazole Sodium Oral Suspension was not administered to the Resident for: -one of two ordered doses on 6/13/24. -two of two ordered doses on 6/16/24. -one of two ordered doses on 6/20/24. Further review of the Resident's June 2024 MAR indicated the doses were not administered due to other/see progress note. Review of Resident #51's June 2024 Progress Notes indicated on the Orders Administration Notes that the ordered Pantoprazole Sodium Oral Suspension was not administered on the following dates due to being unavailable: -once on 6/13/24 -twice on 6/16/24 -once on 6/20/24 Further review of the June 2024 Progress Notes indicated no evidence that the Pharmacy was contacted regarding the Resident's Pantoprazole Sodium Oral Suspension being unavailable and what action was taken. Review of Resident #51's Monthly Pharmacy Review dated 6/30/24, indicated a recommendation: -that education be provided to staff that the Resident's Pantoprazole Sodium Oral Suspension was stored in the refrigerator and had been documented as unavailable. -to make sure the Prescriber was aware of missed doses. Review of Resident #51's July 2024 MAR indicated the ordered dose of Pantoprazole Sodium Oral Suspension was not administered to the Resident for: -two of two ordered doses on 7/4/24. -one of two ordered doses on 7/16/24. -one of two ordered doses on 7/17/24. Further review of the Resident's July 2024 MAR indicated the doses were not administered due to other/see progress note. Review of Resident #51's July 2024 Progress Notes indicated on the Orders Administration Notes that the ordered Pantoprazole Sodium Oral Suspension was not administered on the following dates due to being unavailable: -twice on 7/4/24 -once on 7/16/24 -once on 7/17/24 Further review of the July 2024 Progress Notes indicated no evidence the Pharmacy was contacted regarding the Resident's Pantoprazole Sodium Oral Suspension being unavailable and what action was taken. 2. Resident #13 was admitted to the facility in March 2024, with diagnoses including Osteoarthritis (common form of degenerative arthritis found in the joints that can cause inflammation and result in pain, stiffness, and loss of mobility) and Dementia. Review of Resident #13's Pain Care Plan, initiated 3/23/24, and revised 4/2/24, indicated Pain meds (medications) as ordered. Review of Resident #13's active Physician's order, initiated 3/24/24, with no stop date, indicated the following: -Lidocaine External Patch 4% (Lidocaine), Apply to knee topically one time a day for pain. Review of Resident #13's March 2024 through June 2024 MARs indicated that the ordered dose of Lidocaine was not administered to the Resident on the following dates (a total of 10 days): -3/31/24. -4/4/24, 4/5/24, 4/10/24, 4/19/24, and 4/21/24. -5/13/24 and 5/20/24. -6/11/24 and 6/20/24. Review of Resident #13's Orders Administration Notes for March 2024 through June 2024, indicated the Resident's Lidocaine Patch was not administered on: -3/31/24, 4/4/24, and 4/10/24 - due to medication pending arrival. -4/5/24, 4/19/24 and 4/21/24 - with no description of why the medication was not administered. -5/13/24, 5/20/24, 6/11/24, and 6/20/24 - due to the medication being unavailable. Further review of the Resident's Orders Administration Notes indicated no information to what actions were taken relative to Lidocaine Patches being unavailable for administration to Resident #13. During an interview on 7/19/24 at 11:48 A.M., with Unit Manager (UM) #2 and the Physician, UM #2 said staff did not administer the doses of Pantoprazole Sodium Oral Suspension as ordered for Resident #51 on the dates indicated above. UM #2 said Pantoprazole Sodium had never been unavailable for Resident #51 since it had been ordered by the Physician, that the medication was stored in the refrigerator because it was in liquid form and required refrigeration. UM #2 said the Physician's order specified that the medication was stored in the refrigerator to alert Nurses at the facility that they needed to obtain the medication from the refrigerator to administer it to the Resident. UM #2 further said the Nurse should have obtained the Pantoprazole Sodium Oral Suspension from the refrigerator and administered it to the Resident as ordered. UM #2 also said Lidocaine Patches were ordered as house stock and were available on all Units and in the facility's Central Supply storage room, and if there were no Lidocaine Patches in the medication cart at the time of administration, the Nurse should have obtained the Lidocaine Patches either from the Medication Room or the Central Supply storage room. UM #2 said if medication was unavailable, the Nurse would be required to contact the Pharmacy, and if the medication was unable to be obtained from the Pharmacy, the Nurse would be required to notify the Physician of the missed dose(s) and obtain new orders. During an interview at the time, the Physician said he did not recall ever having been notified of any missed doses of Pantoprazole Sodium Oral Suspension for Resident #51. The Physician further said that he takes his own calls for residents whose care he supervised on the Unit, so staff at the facility were expected to contact him to make him aware of missed medications. The Physician further said he was not the Physician who supervised Resident #13's care. During an interview on 7/19/24 at 1:30 P.M., Nurse #1 said Resident #51's Pantoprazole Sodium Oral Suspension was stored in the refrigerator in the Medication Room on the Unit. Nurse #1 also said Lidocaine Patches were not ordered for specific residents but were ordered as house stock and were stored in the Medication Rooms on the Units and in the Central Supply storage room. At the time, the surveyor and Nurse #1 observed the Unit's Medication Room refrigerator and storage cabinet. The surveyor observed that the refrigerator contained Resident #51's bottle of Pantoprazole Sodium Oral Suspension which was approximately two thirds full, and the storage cabinet contained several boxes of unopened Lidocaine Patches. Nurse #1 said she had never been aware of a time when Resident #51's ordered Pantoprazole Sodium Oral Suspension was unavailable for administration. Nurse #1 further said she was not aware of any time Lidocaine Patches were not available to administer to Resident #13. Nurse #1 also said that the Nursing Supervisor always had access to the facility's Central Supply storage room, so if house stock medications were not available on the Units, the Nursing Supervisor could obtain the house stock medications from the Central Supply storage room. On 7/19/24 at 4:45 P.M., the surveyor and the Director of Nursing (DON) observed the facility's Central Supply storage room where the surveyor observed several unopened boxes of Lidocaine Patches on a shelf. During an interview at the time, the DON said Nurses administering medications were expected to adhere to the facility's policies relative to medication administration and missed medication doses.

Based on interview, record and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#29) out of a total sample size of 31 residents. Specifically, the facility staff failed to develop and implement timely a comprehensive person-centered care plan specific to required care and services for Resident #29 when the Resident was discharged from and then readmitted to the facility. Findings include: Review of facility's policy titled Comprehensive Care Plans and Revisions dated 8/22/23, indicated the following: -It was the facility's policy to ensure the timeliness of each resident's person-centered, comprehensive care plan .and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his/her care. -Comprehensive care plans must be developed within 7 days after completion of the comprehensive assessment. Resident #29 was readmitted to the facility in June 2024, with diagnoses including Diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), Asthma (a condition where the airways become inflamed and narrow making it difficult to breathe) and Congestive Heart Failure (CHF- caused when the heart is unable to pump blood effectively resulting in fluid build-up in the lungs, arms, feet and other organs). Review of Resident #29's clinical record indicated the following: -The Resident had a previous admission to the facility in May 2024 to June 2024. -The most recent comprehensive assessment had been completed on 5/13/2024. -The Resident was readmitted to the facility in June 2024 (within 24 hours). -No evidence the facility staff had developed and implemented a comprehensive person-centered care plan after Resident #29 was readmitted to the facility. During an interview on 7/22/24 at 4:52 P.M., MDS Nurse #1 said Resident #29's care plan had been deleted from the medical record when the Resident was discharged from the facility on 6/13/24. MDS Nurse #1 said Resident #29 was only discharged overnight and returned to the facility the day after discharge, therefore Resident #29 was classified as an interrupted stay. MDS Nurse #1 said Resident #29's comprehensive person-centered care plan should have been created on the date the Resident was readmitted to the facility. During an interview on 7/23/24 at 7:20 A.M., MDS Nurse #1 said Resident #29 did not have a comprehensive person-centered care plan in place from 6/14/24 through 7/21/24. MDS Nurse #1 said the comprehensive person-centered care plan should have been in place to ensure proper delivery of care and services to meet Resident #29's needs.

Based on observation, record review and interview, the facility failed to provide care and services according to professional standards for one Resident (#143) out of a total sample of 31 Residents, who had an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) and had been identified as being at risk for developing a urinary tract infection (UTI- an infection of the urinary system caused by bacteria entering the body through the urethra). Specifically, 1) The facility staff failed to change the indwelling urinary catheter according to professional standards of practice thereby increasing the risk of urinary infections for the Resident. 2) The facility staff failed to administer an antibiotic (medication that fights infection) to Resident #143 prior to changing an indwelling urinary catheter as ordered. Findings Include: Review of the 2009 Centers for Disease Contol (CDC) Healthcare Infection Control Practice Committee Guidelines last updated 6/6/19, indicated the folowing: -Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. -Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of the facility policy titled Indwelling Urinary Catheter (Foley) Maintenance Guidelines and Critical Notes last reviewed 8/24/23, indicated the following: -Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. -Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. -Inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter associated urinary tract infection. Resident #143 was admitted to the facility in April 2023, with a diagnosis of Obstructive and Reflex Uropathy (condition when urine cannot drain through the urinary tract due to obstructed urinary flow which can cause back-up of urine into the kidneys). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #143 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of a total score of 15. On 7/18/24 at 9:36 A.M., the surveyor observed a urinary drainage bag hanging from Resident #143's bed. Review of the Physician's active orders dated 7/22/24 indicated the following: -Foley change monthly, every day shift starting on the 10th and ending on the 10th every month, -Levaquin (antibiotic) 750 mg (milligrams) prior to Foley change, initiated 5/27/24 -Levaquin oral tablet 750 mg, give 750 mg by mouth one time a day starting on the 28th of the month for Foley change, give Levaquin 750 mg prior to Foley change monthly, initiated 4/27/24 Review of the Treatment administration Record (TAR) dated 5/1/24 - 5/31/24 indicated that Resident #143's Foley catheter was changed on 5/27/24. Review of the Medication Administration Record (MAR) dated 5/1/24 -5/31/24 indicated Resident #143 had been administered Levaquin 750 mg by mouth at 9:00 A.M. on 5/28/24 (1 day after the Foley catheter was changed). Review of the Treatment administration Record (TAR) dated 6/1/24 - 6/30/24 indicated that Resident #143's Foley catheter was changed on 6/10/24 (14 days after the Foley catheter was previously changed). Review of the Medication Administration Record (MAR) dated 6/1/24 - 6/30/24 indicated Resident #143 had been administered Levaquin 750 mg by mouth at 9:00 A.M. on 6/28/24 (18 days after the Foley catheter was changed). Review of the Treatment administration Record (TAR) dated 7/1/24 - 7/31/24 indicated that Resident #143's Foley catheter was changed on 7/10/24 (one month after the Foley catheter was previously changed). Review of the Medication Administration Record (MAR) dated 7/1/24 - 7/31/24 indicated that Resident #143 was scheduled to be administered Levaquin 750 mg by mouth at 9:00 A.M. on 7/28/24. Further review of the May 2024, June 2024 and July 2024 TAR and MAR records did not indicate that Resident #143 had been administered Levaquin 750 mg prior to changing the Foley catheter as ordered on the following dates: -5/27/24 -6/10/24 -7/10/24 Review of Resident 143's Physician and Nursing Progress Notes in the clinical record provided no evidence that the routine Foley catheter changes that were performed on 5/27/24, 6/10/24, and 7/10/24, were based on clinical indications such as infection, obstruction or a compromised closed drainage system. During an interview on 7/23/24 at 9:32 A.M., Unit Manager (UM) #1 said there was a Physician's order in place to change Resident #143's Foley catheter routinely on the 10th of every month and an order for Levaquin 750 mg to be administered prior to changing the Foley catheter. UM #1 said that the Levaquin administration was documented on the MAR and the Foley catheter change was documented on the TAR. UM #1 said she was unsure why Resident #143 required monthly Foley catheter changes and said the Levaquin was ordered to be given a few hours prior to each Foley catheter change to help prevent infections because Resident #143 had frequent UTI's. During a review at the time of Resident 143's May 2024, June 2024 and July 2024 MARs and TARs, UM #1 said that Resident #143 had not been administered Levaquin 750 mg as ordered prior to Foley catheter changes on 5/27/24, 6/10/24 and 7/10/24. UM #1 said the Resident should have been administered the Levaquin to prevent him/her from developing a UTI.

Based on observation and interview, the facility failed to maintain safe and sanitary conditions for two nourishment kitchens (Fifth Floor and Third Floor [Garden Terrace]) out of four applicable nourishment kitchens to prevent contamination and the spread of food borne infections. Specifically, 1. The facility failed to maintain the toaster in the Fifth Floor nourishment kitchen in a safe and sanitary manner. 2. The facility failed to maintain clean and sanitary conditions for the ice machine in the Third Floor nourishment kitchen. Findings include: Review of the facility's policy titled Ice Machines, dated 7/16/21 and revised 6/3/24, indicated the following: -Ice machines should be maintained in a clean and sanitary state . -Countertop ice makers sit on top of a counter and may also dispense water via touch control. 1. On 7/23/24 at 8:38 A.M., the surveyor observed that the Fifth Floor nourishment kitchen toaster had a buildup of crumbs and a butter packet wrapper inside the toaster. On 7/23/24 at 2:06 P.M., the surveyor observed that the Fifth Floor nourishment kitchen toaster still remained with a buildup of crumbs and a butter packet wrapper inside the toaster. During an interview on 7/23/24 at 3:32 P.M., Corporate Nurse #1 said the staff did not have a policy specific to cleaning of the kitchenettes. During an interview on 7/23/24 at 4:13 P.M., the Housekeeping Supervisor said that housekeeping cleaned the unit nourishment kitchens daily. The Housekeeping Supervisor further said that housekeeping cleaning included cleaning the outside of the ice machines and removing crumbs and debris from the toasters. 42761 2. On 7/23/24 at 1:25 P.M., the surveyor observed the following in the Garden Terrace Unit nourishment kitchen: -A countertop water and ice dispenser on top of the counter. -The grate over the water and ice dispenser's drain pan had areas that were coated with dried white debris and rust. -The bottom of the drain pan contained areas of brown, black and white debris. -The outer edges of the touchless dispenser indicator (area on the front of the water and ice dispenser used to improve sanitation when retrieving ice or water) were surrounded by dried white debris. -There were two areas of white debris that extended from under the spout (where ice and water are dispensed), down the front of the ice and water dispenser. -Crusty, dried white buildup of debris was observed where the spout was attached to the water and ice dispenser. During an interview on 7/23/24 at 1:28 P.M., Certified Nurses Aide (CNA) #1 said staff on the Unit used the countertop water and ice dispenser every day to provide residents on the unit with ice and water. During an interview on 7/23/24 at 1:30 P.M., Unit Manager (UM) #2 said Housekeeping staff were responsible for cleaning the Unit nourishment kitchen, including the outer surfaces of the ice machine. During an interview on 7/23/24 at 1:35 P.M., the Housekeeping Supervisor said Housekeeping staff were responsible for cleaning the Unit nourishment kitchens. The Housekeeping Supervisor said there was no written cleaning schedule, list of items to be cleaned, or cleaning logs maintained for the Unit Nourishment Kitchens and that the Housekeeping staff knew what was supposed to be cleaned. The Housekeeping Supervisor said the Housekeeping staff were required to clean the outside areas of the countertop water and ice dispenser daily. The surveyor and the Housekeeping Supervisor observed the countertop water and ice dispenser in the Garden Terrace Unit nourishment kitchen at the time. The Housekeeping Supervisor said the front outer surfaces of the countertop water and ice dispenser had areas of dried debris that should have been cleaned. The Housekeeping Supervisor also said these areas of debris looked like they had been there for a while and that the countertop water and ice dispenser had not been cleaned thoroughly. The Housekeeping Supervisor further said it was important to ensure the countertop water and ice dispenser was clean to prevent bacterial growth, so that residents could safely consume water and ice from the dispenser.

Based on interview, record and policy review, the facility failed to offer Pneumococcal Vaccinations for one Resident (#51), out of five applicable Residents, out of a total sample of 31 residents, putting the Resident at risk for developing facility acquired Pneumonia. Specifically, the facility failed to ensure that Pneumococcal Vaccination was provided to Resident #51 after obtaining consent from the Resident's Representative. Findings include: Review of the CDC (Centers for Disease Control) website: Pneumococcal Vaccine for Adults greater than or equal to [AGE] years, https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-schedule-notes.html#note-pneumo indicated: -Adults aged >65 (greater than 65) years who have received both Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) according to previous Pneumococcal Vaccine recommendations but have not yet received a final dose of PPSV23 at age >[AGE] years are recommended to complete their Pneumococcal Vaccine series by receiving either a single dose of Pneumococcal Conjugate Vaccine 20 (PCV20) or PPSV23. >If PCV20 is selected, it can be administered at least 5 years after the last Pneumococcal Vaccine dose. >If PPSV23 is selected, it can be administered at an interval >1 year since the PCV13 dose and >5 years since the last PPSV23 dose. Review of the facility policy titled Influenza Vaccine and Pneumococcal Vaccine Policy for Residents dated 9/13/23, indicated but was not limited to: -Guidance to follow CDC recommendations for Pneumococcal Vaccination timing. -Education is provided to the resident and/or representative regarding benefits and side effects or risks and a consent form is signed. -If, based on the Nurse's assessment contraindications are not noted, the Pneumococcal Vaccine is administered per Physician standing orders. Resident #51 was admitted to the facility in August 2021, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes restricted airflow from the lungs and difficulty breathing), Emphysema (a chronic lung condition where air is abnormally present in the lungs causing shortness of breath) and was over the age of 65. Review of Resident #51's Massachusetts Immunization Information System (MIIS) record indicated Unspecified Pneumococcal Vaccination on 10/1/10 and PCV13 vaccination on 4/26/19. Review of Resident #51's vaccination consents indicated Pneumococcal consent dated 8/19/21, requesting Pneumococcal Vaccination. Review of the Resident's July 2024 Physician's orders indicated an order dated 6/4/24, to give Pneumococcal Vaccine per CDC guidelines. Review of the Resident's clinical record did not indicate that the Resident had received any additional doses of Pneumococcal Vaccination. During an interview on 7/23/24 at 3:25 P.M., Corporate Nurse #1 said Resident #51 should have received the PCV20 vaccination. Corporate Nurse #1 further reviewed the clinical record and said she was unable to find evidence that the Resident had received the PCV20 vaccination.

Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the Resident's status for one Resident (#162) out of three applicable residents. Specifically, the MDS failed to accurately reflect that Resident #162 was discharged home. Findings include: Resident #162 was admitted to the facility in April 2024, with diagnoses that included traumatic arthropathy (a degenerative joint condition that can occur after an injury to the joint) of the left hip. Review of Resident #162's Nurses Progress Note dated 5/10/24, indicated that the Resident had been discharged home on the same day (5/10/24). Review of Resident #162's Discharge Summary assessment dated [DATE], indicated that the Resident had been discharged home. Review of Resident #162's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was discharged to a short-term hospital. During an interview on 7/23/24 at 3:16 P.M., the MDS Nurse said that the MDS had been inaccurately coded and should have marked the Resident as discharged home.

Based on record review, policy review, and interview, the facility failed to ensure that its staff notified the Physician regarding a change in the treatment plan for one Resident (#70), out of a total sample of 28 residents. Specifically, the facility staff failed to notify Resident #70's Physician when dialysis treatment was not administered as ordered. Findings include: Resident #70 was admitted to the facility in June 2017 with diagnoses including End Stage Renal Disease (when the kidneys can no longer filter the blood of waste and extra fluid) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly). Review of the facility policy titled Dialysis, revised 8/18/2022, indicated: -This facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice . -the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -The resident receiving dialysis shall receive consistent care pre and post dialysis. The vascular access site shall be checked daily with physician notification for any known or suspected problem. -Document in the clinical nursing record: dialysis treatment completed, order changes, condition of the shunt site, complaints from resident (if applicable), and whether physician and responsible party notification. Review of the Resident's March 2023 Physician's orders indicated to send the Resident to dialysis on Monday/Wednesday/Friday for dialysis treatment (start date 1/13/2023). Review of the Resident's March 2023 Medication Administration Record (MAR) indicated documentation that the Resident received dialysis treatment on Wednesday 3/15/23. Review of the Resident's progress notes dated 3/15/23 did not show any evidence that the Resident did not receive dialysis treatment as ordered, or that the Resident's Physician was notified of any changes to the treatment plan. During an interview on 3/16/23 at 7:49 A.M., Unit Manager (UM) #2 told the surveyor that the Resident did not receive dialysis treatment on 3/15/23 as planned, and so the Resident was being prepared for transport to the dialysis center on Thursday 3/16/23. UM #2 said that the Resident was transferred to the dialysis center on 3/15/23 but was returned to the facility without receiving dialysis treatment due to incontinence. The UM said that she was unable to provide any evidence that the charge nurse or any other staff member had notified the Physician regarding the missed dialysis treatment, but that the Physician should have been notified.

Based on record review, policy review, and interview, the facility failed to ensure that its staff provided care and services consistent with professional standards for one Resident (#70), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly) out of one applicable resident, in a total sample of 28 residents. Specifically, the facility staff failed to: 1) evaluate the resident pre and post dialysis treatment, 2) communicate and maintain ongoing documentation with the dialysis center, 3) ensure that the dialysis center received the most current information regarding Physician's orders for the Resident, and 4) maintain documentation regarding the Resident's weight per the plan of care. Findings include: Resident #70 was admitted to the facility in June 2017 with diagnoses including End Stage Renal Disease (ESRD-when the kidneys can no longer filter the blood of waste and extra fluid), dependence on renal dialysis, and Type 2 Diabetes Mellitus (DM II- a condition that affects the way the body processes blood sugar, and does not produce insulin or resists insulin). Review of the facility policy titled Dialysis, revised 8/18/22, indicated: -The facility assures that each resident receives care and services for the provision of hemodialysis and /or peritoneal dialysis consistent with professional standards of practice including: .ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. -The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -Document in the clinical nursing record: dialysis treatment completed, order changes, condition of the shunt site, complaints from the resident (if applicable), and whether physician and responsible party notification. -Pre Dialysis - initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis clinic with the resident. (Med Pass Form #LCCA-528) -Post-Dialysis - obtain vital signs of resident upon return from dialysis and complete the Pre/Post Dialysis Communication Form -Maintain dialysis transfer form in the resident's medical record - do not destroy. Review of the March 2023 Physician's orders indicated to send the Resident for dialysis treatment three times a week on Monday/Wednesday/Friday (start date 1/13/23). Review of the February and March 2023 Medication Administration Records (MARs) indicated the Resident attended dialysis treatments as ordered. 1) There was no evidence in the dialysis communication binder that the facility staff had completed evaluations pre and post dialysis treatments, or utilized the facility communication form (Med Pass Form #LCCA-528) as indicated in the facility policy for Dialysis. 2) There was no indication in the dialysis communication binder of regular communication and collaboration between the facility and the dialysis center. Review of the Resident's dialysis communication binder for 2023 included: -four notes from the facility staff to the dialysis center dated 2/22/23, 2/24/23, 2/27/23, and 3/15/23 -two notes from the dialysis center to the facility dated 3/1/23 and 3/6/23 3) The dialysis center did not have the most current Physician's orders related to Insulin. Review of the March 2023 Physician's orders indicated: -Insulin Glargine Solution (a long acting form of medical insulin to treat diabetes), Inject 8 unit(s) subcutaneously (medication administered under the skin by injection or infusion) at bedtime for Diabetes (start date 3/9/23). Review of the Resident's dialysis communication binder indicated the most recent Physician's orders were dated 2/22/2023 and included the following order for insulin: -Insulin Glargine Solution 100 Unit/Milliliters (U/ML), Inject 16 unit(s) subcutaneously at bedtime for Diabetes (twice the dose that was prescribed on 3/9/23). 4) There was no evidence of regular weight monitoring by the facility or from communication with the dialysis center. Review of the Resident's care plan revised 2/6/2023 indicated: -dry weights (weight without the excess fluid that builds up between dialysis treatments) obtained from dialysis center. Review of the facility form MED-PASS LCCA-528 indicated for the facility to weigh the Resident pre and post dialysis, and to obtain a pre and post dialysis weight from the dialysis center on dialysis days. Review of the the Resident's weight record for 2023 included the following weights: -1/12/2023 184 lbs (pounds) (Hoyer Lift) (a mechanical lift used for a person that is non-weight bearing) -1/19/2023 186 lbs (Dry Weight / Dialysis) -2/1/2023 186 lbs (Dry Weight / Dialysis) -3/3/2023 186.5 lbs (Dry Weight / Dialysis) During an interview on 3/16/23 at 8:23 A.M., Unit Manager (UM) #2 told the surveyor that the dialysis communication binder goes with the Resident each time to the dialysis center, and that the Resident had been attending his/her dialysis treatments regularly since January 2023. UM #2 and the surveyor reviewed the dialysis communication binder together and noted that there were only four notes written by facility staff for 2023. UM #2 said that facility staff were supposed to write something in the dialysis communication binder before the Resident leaves for treatment but that didn't always occur. UM #2 also said that there was no guidance for staff to write any specific information but rather to just indicate how the Resident was doing. UM #2 and the surveyor also reviewed the Physician's orders dated 2/22/23 located in the dialysis communication binder and noted that the updated Physician's order of 3/9/23 for a reduction in the Resident's Insulin Glargine was not reflected in the binder. UM #2 said that the Physician's orders in the dialysis communication binder should have been updated with any changes but they had not been. UM #2 told the surveyor that she was not aware of any guidance to monitor the Resident's weight relative to dialysis treatments.

Based on observation, policy review, record review and interview, the facility failed to ensure its staff assessed two Residents (#43 and #35) for the risk of entrapment related to bed rail use. Specifically, 1) for Resident #43 the facility failed to ensure its staff assessed the Resident for risk of entrapment related to bed rail use prior to the installation of bed rails and quarterly thereafter, and 2) for Resident #35 the facility failed to ensure its staff assessed the Resident for risk of entrapment related to bed rail use after a significant change in weight. Findings include: Review of the facility policy for Safe and Effective Use of Bed Rails, dated 11/16/21, indicated the following: -Policy: to prevent entrapment and other safety hazards associated with bed rail use. -Residents will be assessed upon admission, readmission, or upon initiation, utilizing the Evaluation for Use of Bed Rails Assessment. -If bed rails are determined to be appropriate for use with a resident, a reassessment of bed rail use will be assessed at a minimum quarterly and potentially with a change of condition. 1) Resident #43 was admitted to the facility in March 2016. Review of the current care plan for falls, with goal date of 3/19/23, indicated the Resident utilized 1/4 bed rails for assist with repositioning when he/she was in bed (initiated 12/9/19). During an observation on 3/16/23 at 3:59 P.M., the surveyor observed bilateral 1/4 bed rails on the Resident's bed. Review of the clinical record indicated no Resident assessment for the risk of entrapment related to bed rail use was completed prior to bed rail installation, or quarterly thereafter. During an interview on 3/16/23 at 10:55 A.M., Unit Manager (UM) #1 said that she thought the bed rail assessments were supposed to be done when bed rails were initiated and then annually (facility policy stated they were to be done quarterly). UM #1 reviewed Resident #43's clinical record and said she could not find a completed initial assessment or any other assessments for the risk of entrapment related to bed rail use. She said she thought there was an assessment for bed rail use in the Electronic Health Record (EHR) but when she reviewed the EHR she said there was not one and she would need to look into it. 2. Resident #35 was admitted to the facility in October 2015. Review of the clinical record indicated the Resident had a significant weight loss as evidenced by a weight of 140.2 pounds (lbs) on 8/10/22 and a weight of 125.8 lbs on 1/10/23, which resulted in a weight loss of 10.27% in five months. Review of the Minimum Data Set (MDS) assessments for Resident #35 indicated a Significant Change of Status assessment was initiated on 1/16/23. Further review indicated, under section K, that the Resident had a weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a Physician prescribed weight loss regimen. Review of the current care plan for Activities of Daily Living (ADLs), with goal date of 4/24/23, indicated the Resident utilized 1/4 bed rails to aid with bed repositioning. During an observation on 3/16/23 at 10:50 A.M., the surveyor observed bilateral 1/4 bed rails on the Resident's bed. During an interview on 3/16/23 at 10:54 A.M., UM #1 reviewed the clinical record and said there were no bed rail assessments done since 2018 and there should have been

Based on observations, interviews, and policy review, the facility failed to ensure its staff adhered to safe food practices relative to labeling/dating, and storage guidelines in order to reduce the risk of cross contamination/spoilage of food items for resident consumption in the main facility kitchen. Findings include: Review of the facility policy titled Food Safety, reviewed 4/27/22, indicated that food was to be stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. The policy also included the following: -pre-packaged food is placed in a leak-proof, pest proof, non-absorbent, sanitary container with a tight fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product when applicable. -associate (employee) food will not be stored with resident food. -Cold Food Storage: >leftovers are dated properly and discarded after 72 hours unless otherwise indicated >raw meat that is placed in the cooler is in a pan and dated when pulled, manufacturers' directions are followed in regard to how long the thawed meat can be kept under refrigeration. The date begins from the date the meat is thawed, which is approximately three days from the date pulled. -Dry Storage: >opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable >opened food items will be removed from the original packaging that it was delivered in before being placed in an ingredient bin or storage container >scoops will be stored in a manner that does not have the potential to contaminate the food ingredients. For example, the scoops will be stored outside of the bin or placed in a holder on the side of the bin. During the initial kitchen tour on 3/15/23 at 7:32 A.M., the surveyor observed the following: Reach-in refrigerator: -open and undated package of sliced orange cheese Walk-in refrigerator: - covered container of pasta and red sauce with no label or date, - covered container of meat sauce with no label or date - covered bowl of cold salad with no date - covered container of macaroni and cheese with no label or date - covered plate of meat loaf slices with no label or date - covered pan of raw thawed meat with no label or date - covered clear container with three uncooked ground beef logs with no label or date - pitcher of shredded cabbage mixture with no label or date - clear covered container of red sauce dated 2/15 Dry Storage Room: - wrapped open package of dry pasta with no date - loosely opened undated box of parboiled rice with a cup inside of the product - covered bin of open bags of flour with no date - clear covered container with dried product with no label or date. The top of the container had dried product that was brown debris. A scoop was placed on top of the dirty cover and was open to air. During a follow-up kitchen tour on 3/17/23 at 1:42 P.M. through 2:27 P.M., with the Food Service Director (FSD), the surveyor observed the following: Reach-in Refrigerator: - small covered pan of cut up ham that was undated - wrapped open undated bag of parmesan cheese - styrofoam container of food Walk-in Refrigerator: - covered undated container of cabbage salad - covered undated pan of meat loaf - covered undated bowl of lettuce - covered undated container of cut up onions - clear covered container with three uncooked ground beef logs that were undated, one of the packages was opened. Dry Storage Room - covered bin containing multiple bags of open flour that were undated - covered container with dried product which the FSD identified as Panko, that was unlabeled and undated. A scoop was placed on top of the clear container which had with dried brown residue/debris. - loosely opened undated chocolate morsels with a cup within the product - loosely opened undated box of parboiled rice with a cup inside of the product - loosely opened undated box of pureed bread with a cup within the product During an interview on 3/17/23 at 2:27 P.M., the FSD said that all food items in the refrigerators should be labeled/dated and used or be discarded within 3 days (72 hours). The FSD discarded the styrofoam container in the reach in refrigerator and said that it should not have been kept in there as she thought it belonged to an employee. She further said that opened boxes of product in the dry store room should be in sealed containers that should be labeled and dated. The FSD said that cups or scoops should not be kept within the food product because there would be a concern for contamination.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of falls and required extensive assistance from two staff members with all transfers for safety, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Activities of Daily Living (ADL) plan of care and on his/her Resident Care Card, related to the need for two staff members to assist with all transfers. On 02/05/23, during the evening shift, Certified Nurse Aide (CNA) #1 transferred Resident #1 without a second staff member present to assist her, the following day Resident #1 reported that CNA #1 was rough and twisted his/her wrist during the transfer, causing him/her discomfort. In addition, documentation on Resident #1's ADL Flowsheet (completed by the CNA's) for February 2023, indicated that there were multiple days on the evening shift, where staff transferred him/her alone, and did not have a second staff member there to assist with the transfer, as required. Findings include: Review of the Facility's Policy, titled Person-Centered Care Planning, dated 08/16/22, indicated the facility will develop a person-centered care plan that addresses the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline. The Policy indicated the care plan will be developed and implemented to ensure consistency with implementation across all shifts. Resident #1 was admitted to the facility in January 2020, medical diagnoses included dementia, history of falls, and muscle weakness. Review of Resident #1's most recent Minimum Data Set (MDS) Assessment, dated 02/01/23, indicated that his/her cognitive patterns were severely impaired, with a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS, score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, 13-15 indicates intact cognition). The MDS indicated Resident #1 required extensive physical assistance from two staff members for transfers. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated as reviewed 02/01/23, indicated he/she required assistance of two staff members for all transfers. Review of Resident #1's Care Card (reference guide used by CNA's, identifies residents specific care needs, including number of staff required to provide assistance during tasks), in effect on 02/05/23, indicated he/she required assistance from two staff members for all transfers. However, review of Resident #1's Activity of Daily Living (ADL) Flowsheets, dated February 2023, indicated that he/she was transferred with assistance from one staff member during the evening shift (as documented by the CNAs), on 18 out of 28 days. During an interview on 03/09/23 at 11:55 A.M., Resident #1 said that a Certified Nurse Aide (CNA, later identified as CNA #1) twisted his/her arm while transferring him/her back to bed. Resident #1 was not able to recall the exact date of the alleged incident. Review of the Facility's Incident Report, dated 02/06/23, indicated staff observed a bruise to Resident #1's right hand. The Report indicated Resident #1 told Nurse #1 that the female CNA who put him/her to bed on 02/05/23 (during the 3:00 P.M. to 11:00 P.M. shift) was rough. During an interview on 03/09/23 at 1:55 P.M., Nurse #1 said that while she was passing medications during the day shift, on 02/06/23, she noticed Resident #1 had a bruise on his/her right hand. Nurse #1 said that when she asked Resident #1 how he/she got the bruise, said he/she told her (Nurse #1) that CNA #1 was rough when transferring him/her to bed last night (2/05/23 on the evening shift). During an interview on 03/09/23 at 3:15 P.M., Certified Nurse Aide (CNA) #1 said that during the evening shift on 02/05/23, she transferred Resident #1 into bed without assistance from a second staff member. CNA #1 said she was often assigned to Resident #1 for care and routinely transferred him/her without assistance from a second staff member. CNA #1 said she did not realize Resident #1 required assistance of two staff members for transfers, and said she had not checked his/her (CNA) Resident Care Card or Care Plan. CNA #1 said when she is unfamiliar with a resident, she knows to look at the Care Card/Care Plan. During an interview on 03/09/23 at 2:05 P.M., Certified Nurse Aide #3 said Resident #1 required assistance from two staff members to safely transfer into and out of bed. During an interview on 03/09/23 at 2:15 P.M., Unit Manager #1 said that on the morning of 02/06/23, Resident #1 told her that CNA #1 transferred his/her back to bed on 2/05/23 (during the evening shift), and that CNA #1 twisted his/her arm when transferring him/her into bed. Unit Manager #1 said Resident #1 told her CNA #1 did not have another staff member there to help with the transfer. Unit Manager #1 said Resident #1 required assistance from two staff members for safety with all transfers, and that it was indicated on his/her Care Plan and on his/her Resident Care Card that the CNA's reference. During an interview on 03/09/23 at 4:38 P.M., the Director of Nurses (DON) said that based on Resident #1's assessments and the care planned interventions, Resident #1 was to be provided assistance of two staff members for all transfers. The DON said the outcome of his investigation into the incident on 02/05/23, was that CNA #1 should not have transferred Resident #1 without a second staff member. The DON further said he thought that Resident #1's allegation that CNA #1 was rough during the transfer may have been because she (CNA #1) transferred him/her without a second staff member. The DON said he was also concerned that based on review of Resident #1's February 2023 CNA Flowsheet, that the Care Plan intervention and Resident Care Card instructions for the need for two staff members to assist with all transfers, was not consistently being implemented by staff.

Based on policy and testing log reviews, and interview, the facility failed to ensure two unvaccinated COVID-19 staff members were tested for COVID-19 prior to their shift, out of 4 applicable staff. Findings include: Review of the facility's policy, COVID-19 Testing, dated 8/19/21, indicated the facility will conduct surveillance and outbreak testing for COVID-19 in accordance with the Massachusetts Department of Public Health (DPH) requirements and Centers for Medicare and Medicaid Services regulations. Review of the DPH Memorandum, Update to Caring for Long-Term Care Residents during the COVID-19 Response, dated 8/4/21, indicated to test all staff who are not fully vaccinated at the beginning of each shift using BinaxNOW (rapid) test kits. Review of the staff vaccination record indicated Employee #1 and Employee #2 were not vaccinated for COVID-19. 1. Review of Employee #1's payroll record indicated the employee worked on 9/6, 9/7, 9/14 and 9/18/21. Review of the COVID-19 rapid test logs, for the dates listed above, indicated Employee #1 had not been tested prior to the beginning of the assigned shifts. 2. Review of Employee #2's payroll record indicated the employee worked on 9/13, 9/14 and 9/19/21. Review of the COVID-19 rapid test logs, for the dates listed above, indicated Employee #2 had not been tested prior to the beginning of the assigned shifts. During an interview on 9/22/21 at 3:10 P.M., the Director of Nurses said it was the responsibility of the unvaccinated staff to get tested prior to their shift, no one oversees it. He said there was no evidence that the employees were vaccinated and they were not tested for the days in question.

Based on observation, policy review and interview the facility failed to ensure staff implemented proper use of Personal Protective Equipment (PPE) during a COVID-19 outbreak, on two out of four units. Findings include: Review of the facility's policy for Infection Prevention and Control Program and Plan, dated 12/31/20, indicated one of the goals of the program was to ensure compliance with state and federal regulation. During the entrance conference on 9/22/21, the Infection Preventionist (IP) said a staff member tested positive for COVID-19 on 9/17/21 and through contact tracing it was determined the staff member had close contact with several residents on the second floor unit. She said they moved those residents to an isolated area on the fourth floor unit for their quarantine time. She said the PPE protocols for the units were as follows: -Second floor unit- masks and eye protection at all times, gowns and gloves for high contact care -Fourth floor unit (quarantine area)- masks, eye protection, gown, gloves to enter resident rooms. -Fifth floor unit- masks and eye protection at all times. (No COVID positive or quarantine on this unit). Review of the Department of Public Health Memorandum, Update to Caring for Long-Term Care Residents during the COVID-19 Response, dated 8/4/21, indicated the following for PPE use: -COVID-19 negative or recovered (greater than 3 months from infection)-when there are resident or staff cases identified within that last 14 days on a unit-full PPE to include facemask, eyeshield/goggles, gown and gloves. Gowns can be prioritized for high contact (dressing, bathing, transfers, hygiene, changing linens .) care. -Quarantine- full PPE upon room entry to include N95 respirator or alternative, faceshield/goggles, gown and gloves. 1. On 9/22/21 the surveyor observed the following on the second floor unit: All of the resident rooms had droplet/precaution signs that indicated to wear mask, eye protection, gowns and gloves (for high contact care). - At 9:36 A.M., Certified Nurse Aide (CNA) #1 entered a resident's room with a gown and gloves on but had no eye protection. - At 9:43 A.M., CNA #1 came out of the same room, had removed his gown and gloves, still had no eye protection on. During an interview on 9/22/21 at 9:45 A.M., CNA #1 said said he hadn't been wearing any eyewear that day because they didn't give him any. 2. On 9/22/2021 at 10:04 A.M., on the fifth-floor nursing unit, the surveyor observed a phlebotomist drawing blood in a resident room without wearing eye protection. During an interview on 9/22/2021 at 10:10 A.M., the phlebotomist said she didn't know if she was supposed to wear eye protection. She said she was screened when she entered the facility, but no one ever said anything to her about eye protection. During an interview on 9/22/2021 at 10:16 A.M., unit manager #1 said that the phlebotomist should be wearing eye protection in the facility as required. 3. On 9/22/21 the surveyor observed the following on the fourth floor unit (quarantine area): -At 10:44 A.M., CNA #2 entered a resident room with a gown, gloves, eye protection and a surgical mask on. She entered the room and closed the door behind her. -At 10:53 A.M., CNA #2 came out of the resident room without gown and gloves on. She still had eye protection and surgical mask on. During an interview on 9/22/21 at 10:55 A.M., CNA #2 said she was assigned to work on a different part of the unit that day but came to the quarantined area to help do a resident transfer. She said she could wear a surgical mask because the resident's weren't COVID-19 positive. During an interview on 9/22/21 at 3:27 P.M., the IP said the staff, including vendors, were supposed to wear eye protection. She said she thought the staff only had to wear N95s for aerosol generating procedures on the quarantine unit. During an interview on 9/22/2021 at 10:16 A.M., unit manager #1 said that the phlebotomist should be wearing eye protection in the facility as required. 2. On 9/22/21 the surveyor observed the following on the fourth floor unit (quarantine area): All of the resident rooms doors are shut, the assigned staff to the unit were wearing N95 masks. -At 10:44 A.M., CNA #2 entered a resident room with a gown, gloves, eye protection and a surgical mask on. She entered the room and closed the door behind her. -At 10:53 A.M., CNA #2 came out of the resident room. During an interview on 9/22/21 at 10:55 A.M., CNA #2 said she was assigned to work on a different part of the unit that day but came to the quarantined area to help do a resident transfer. She said she could wear a surgical mask because the resident's weren't COVID-19 positive. During an interview on 9/22/21 at 3:27 P.M., the IP said the staff, including vendors, were supposed to wear eye protection. She said she thought the staff only had to wear N95s for aerosol generating procedures on the quarantine unit.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a midline intravenous (IV) catheter (an IV placed in a peripheral vein with the distal tip located just proximal to the axilla (where the arm connects to the shoulder) that delivers fluids and/or medications directly into the vein), the Facility failed to ensure nursing staff provided adequate care and services that meet professional standards of practice. On 03/30/2021, Nurse #1 failed to ensure Resident #1's needleless hub remained on his/her midline IV and that the clamp on the IV was securely closed, after she disconnected Resident #1's IV antibiotic medication, and as a result, Resident #1 bled out of his/her midline. On 03/31/2021, Resident #1 experienced a syncopal episode (temporary loss of consciousness) that required him/her to be transferred to the Emergency Department (ED) for further evaluation. Upon arrival in the ED, Resident #1 appeared pale, had complaints of feeling fatigued, and his/her hospital laboratory blood work revealed he/she was anemic (lack of blood) due to acute blood loss. During Resident #1's hospitalization , he/she required several blood [CONDITION(S)] and received a total of 4 units of blood. Findings include: The Facility Policy, titled Short Peripheral Catheter Needleless Connector Change, dated 05/01/15, indicated: - Licensed nurses caring for residents receiving infusion therapies were expected to follow safety compliance procedures. - A needleless connector would be utilized at the hub of all IV access devices to decrease the risk of infection or injury. Resident #1 was admitted to the Facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's TridentCare Laboratory Report, dated 03/27/21, indicated the following laboratory values: - Red Blood Cell (RBC) value (amount of red blood cells in blood) of 3.39 million per microliter (M/UL). Normal range for RBC is 4.0-5.10 M/UL. - Hemoglobin (HGB) (carries oxygen to the body) value of 10.1 Grams per deciliter (G/DL). Normal range for HGB is 12.1-15.7 G/DL. - Hematocrit (HCT) (proportion of red blood cells in the blood) percentage of 32.9 percent. Normal range for HCT is 35.0-45.0 percent. The Infusion Therapy Consult Documentation Note, dated 03/29/21, indicated a non valved midline IV was inserted in Resident #1's right arm for the purpose of administering intermittent IV antibiotics. The Nurse Progress Note, dated 03/31/21, indicated Resident #1 was found by staff to have blood loss from his/her right arm midline. The Nurse Progress Note, dated 04/03/21, (later identified as a late entry note for 03/31/21) indicated Resident #1 was observed to be bleeding from his/her midline IV site, the needleless hub was observed hanging from the IV tubing on the pole across the room and the midline was not clamped. The Facility's Investigation Summary, dated 03/31/21, indicated that on 03/31/21, at 3:00 A.M., staff observed what appeared to be blood on Resident #1's blankets and bedding. The Summary indicated staff found Resident #1's midline unclamped, and the needleless hub was not on the end of the midline, resulting in an open venous line. The Summary indicated the needleless hub was found still attached to the IV medication tubing on the other side of Resident #1's room. The Summary indicated, later that same morning, Resident #1 had a syncopal episode, was sent to the Hospital Emergency Department for further evaluation, was diagnosed with acute blood loss, admitted to the Hospital, and required transfusion of four units of blood during his/her hospitalization . Review of Resident #1's Emergency Department (ED) Provider Note, dated 03/31/21, indicated Resident #1 was transferred to the Hospital Emergency Department after a syncopal event at the Facility. The ED Note indicated Resident #1 appeared pale, was complaining of fatigue, had bled from his/her midline IV overnight. The ED Note indicated Resident #1's laboratory values, dated 03/31/21, timed 12:34 P.M., indicated the following: - RBC value of 2.30 M/UL (critically low) - HGB value of 7.1 G/DL (critically low) - HCT value of 20.9 percent (critically low) The ED Note indicated Resident #1's laboratory values, dated 03/31/21, timed 5:28 P.M., indicated the following: - HGB value of 6.9 G/DL (critically low) - HCT value of 20.9 percent (critically low) The ED Note indicated Resident #1 was admitted to the Hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Discharge Summary, dated 04/02/21, indicated, Resident #1 was transfused a total of four units of blood during his/her hospitalization . During interview on 04/14/21 at 3:02 P.M., Nurse Supervisor #1 said at 10:30 P.M. on 03/30/2021, she connected Resident #1's IV antibiotic for Nurse #1 and told Nurse #1 to disconnect the IV when it completed infusing. Nurse Supervisor #1 said that at 11:00 P.M., she heard Resident #1's IV pump beeping, and told Nurse #1 to go and disconnect the IV. During interview on 04/14/21 at 10:58 A.M., Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. shift on 03/30/21, and said she was assigned to care for Resident #1 on that day. Nurse #1 said Nurse Supervisor #1 connected Resident #1's IV antibiotic at 10:30 P.M., and said that at 11:00 P.M., she disconnected Resident #1's IV antibiotic from his/her midline once the medication had infused. During interview on 04/15/21 at 9:32 A.M., Certified Nurse Aide (CNA) #1 said that on 03/31/21 at 3:00 A.M., she responded to Resident #1's call light and saw that his/her blankets were drenched in blood. CNA #1 said she immediately alerted Nurse Supervisor #2, and together they removed Resident #1's fleece jacket and hospital gown and said the jacket and hospital gown were stuck together by clotted blood. CNA #1 said Resident #1 had blood down his/her right side from the armpit to his/her waist, that there was blood soaked into in his/her incontinence brief, and on the mattress. During interview on 04/14/21 at 12:05 P.M., Nurse Supervisor #2 said she worked the 11:00 P.M. to 7:00 A.M. shift on the night of 03/30/21. Nurse Supervisor #2 said when she arrived on the unit, she entered Resident #1's room at the same time Nurse #1 was about to disconnect his/her IV, and said she observed that Resident #1's midline site was intact, that there was no bleeding, and said that the IV had not been disconnected yet. Nurse Supervisor #2 said she checked Resident #1's neurological signs and took his/her vital signs using his/her left arm at 1:00 A.M. on 03/31/21 and said she did not turn on the light in the room or check Resident #1's midline site at that time. Nurse Supervisor #2 said that on 03/31/21 at 3:00 A.M., she was alerted by CNA #1 that Resident #1 was bleeding. Nurse Supervisor #2 said she observed a layer of blood on Resident #1's sheet and hospital gown and said Resident #1's hospital gown and fleece jacket were stuck together with blood under his/her right armpit. Nurse Supervisor #2 said when she took off Resident #1's fleece jacket and hospital gown she observed that the clamp on the midline was open, the needleless hub was not attached to the end of the midline IV and said there was blood dripping from the end of the midline. Nurse Supervisor #2 said she found the needleless hub attached to the IV tubing on the pole across the room. During interview on 04/14/21 at 8:30 A.M., the Director of Nurses (DON) said IVs should have a needleless hub attached to the end of them at all times, said that the midline should have been clamped, and therefore Resident #1 would not have had blood loss from the IV. On 04/14/2021, the Facility was found to be in Past Non-Compliance, effective 04/12/2021 and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A) Resident #1 was transferred to the Hospital Emergency Department on 03/31/21 for evaluation, was admitted for acute blood loss, and did not return to the Facility. B) Nurse #1 has not worked at the Facility since 03/31/2021 and will not be returning. C) The Director of Nurses conducted an audit of all residents in the Facility for any resident with Intravenous catheters (IV) on 03/31/2021. No other residents were identified. D) The Director of Nurses or designee will conduct audit of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E) The results of the audits for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . F) The Director of Nurses and Staff Development Coordinator reviewed the Facility's policies for IV administration on 04/07/21. G) The Facility's QAPI meeting minutes, dated 04/08/21, indicated the incident involving Resident #1's IV was discussed, and a Plan of Correction was initiated. H) Nursing Staff were re-educated by the Staff Development Coordinator or designee regarding the Facility's IV policies and procedures, specifically to ensure IV clamps were closed and the needleless hub remains on the resident's IV line. The education was completed on 04/12/21. I) The Facility will initiate an orientation protocol for all agency staff to review before beginning their first shift that will ensure they are educated regarding the Facility's IV policies and procedures. J) The DON/designee is responsible for overall continued compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a midline intravenous (IV) catheter (an IV placed in a peripheral vein with the distal tip located just proximal to the axilla (where the arm connects to the shoulder) that delivers fluids and/or medications directly into the vein), the Facility failed to ensure nursing staff provided adequate care and services that meet professional standards of practice. On 03/30/2021, Nurse #1 failed to ensure Resident #1's needleless hub remained on his/her midline IV and that the clamp on the IV was securely closed, after she disconnected Resident #1's IV antibiotic medication, and as a result, Resident #1 bled out of his/her midline. On 03/31/2021, Resident #1 experienced a syncopal episode (temporary loss of consciousness) that required him/her to be transferred to the Emergency Department (ED) for further evaluation. Upon arrival in the ED, Resident #1 appeared pale, had complaints of feeling fatigued, and his/her hospital laboratory blood work revealed he/she was anemic (lack of blood) due to acute blood loss. During Resident #1's hospitalization , he/she required several blood [CONDITION(S)] and received a total of 4 units of blood. Findings include: The Facility Policy, titled Short Peripheral Catheter Needleless Connector Change, dated 05/01/15, indicated: - Licensed nurses caring for residents receiving infusion therapies were expected to follow safety compliance procedures. - A needleless connector would be utilized at the hub of all IV access devices to decrease the risk of infection or injury. Resident #1 was admitted to the Facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's TridentCare Laboratory Report, dated 03/27/21, indicated the following laboratory values: - Red Blood Cell (RBC) value (amount of red blood cells in blood) of 3.39 million per microliter (M/UL). Normal range for RBC is 4.0-5.10 M/UL. - Hemoglobin (HGB) (carries oxygen to the body) value of 10.1 Grams per deciliter (G/DL). Normal range for HGB is 12.1-15.7 G/DL. - Hematocrit (HCT) (proportion of red blood cells in the blood) percentage of 32.9 percent. Normal range for HCT is 35.0-45.0 percent. The Infusion Therapy Consult Documentation Note, dated 03/29/21, indicated a non valved midline IV was inserted in Resident #1's right arm for the purpose of administering intermittent IV antibiotics. The Nurse Progress Note, dated 03/31/21, indicated Resident #1 was found by staff to have blood loss from his/her right arm midline. The Nurse Progress Note, dated 04/03/21, (later identified as a late entry note for 03/31/21) indicated Resident #1 was observed to be bleeding from his/her midline IV site, the needleless hub was observed hanging from the IV tubing on the pole across the room and the midline was not clamped. The Facility's Investigation Summary, dated 03/31/21, indicated that on 03/31/21, at 3:00 A.M., staff observed what appeared to be blood on Resident #1's blankets and bedding. The Summary indicated staff found Resident #1's midline unclamped, and the needleless hub was not on the end of the midline, resulting in an open venous line. The Summary indicated the needleless hub was found still attached to the IV medication tubing on the other side of Resident #1's room. The Summary indicated, later that same morning, Resident #1 had a syncopal episode, was sent to the Hospital Emergency Department for further evaluation, was diagnosed with acute blood loss, admitted to the Hospital, and required transfusion of four units of blood during his/her hospitalization . Review of Resident #1's Emergency Department (ED) Provider Note, dated 03/31/21, indicated Resident #1 was transferred to the Hospital Emergency Department after a syncopal event at the Facility. The ED Note indicated Resident #1 appeared pale, was complaining of fatigue, had bled from his/her midline IV overnight. The ED Note indicated Resident #1's laboratory values, dated 03/31/21, timed 12:34 P.M., indicated the following: - RBC value of 2.30 M/UL (critically low) - HGB value of 7.1 G/DL (critically low) - HCT value of 20.9 percent (critically low) The ED Note indicated Resident #1's laboratory values, dated 03/31/21, timed 5:28 P.M., indicated the following: - HGB value of 6.9 G/DL (critically low) - HCT value of 20.9 percent (critically low) The ED Note indicated Resident #1 was admitted to the Hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Discharge Summary, dated 04/02/21, indicated, Resident #1 was transfused a total of four units of blood during his/her hospitalization . During interview on 04/14/21 at 3:02 P.M., Nurse Supervisor #1 said at 10:30 P.M. on 03/30/2021, she connected Resident #1's IV antibiotic for Nurse #1 and told Nurse #1 to disconnect the IV when it completed infusing. Nurse Supervisor #1 said that at 11:00 P.M., she heard Resident #1's IV pump beeping, and told Nurse #1 to go and disconnect the IV. During interview on 04/14/21 at 10:58 A.M., Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. shift on 03/30/21, and said she was assigned to care for Resident #1 on that day. Nurse #1 said Nurse Supervisor #1 connected Resident #1's IV antibiotic at 10:30 P.M., and said that at 11:00 P.M., she disconnected Resident #1's IV antibiotic from his/her midline once the medication had infused. During interview on 04/15/21 at 9:32 A.M., Certified Nurse Aide (CNA) #1 said that on 03/31/21 at 3:00 A.M., she responded to Resident #1's call light and saw that his/her blankets were drenched in blood. CNA #1 said she immediately alerted Nurse Supervisor #2, and together they removed Resident #1's fleece jacket and hospital gown and said the jacket and hospital gown were stuck together by clotted blood. CNA #1 said Resident #1 had blood down his/her right side from the armpit to his/her waist, that there was blood soaked into in his/her incontinence brief, and on the mattress. During interview on 04/14/21 at 12:05 P.M., Nurse Supervisor #2 said she worked the 11:00 P.M. to 7:00 A.M. shift on the night of 03/30/21. Nurse Supervisor #2 said when she arrived on the unit, she entered Resident #1's room at the same time Nurse #1 was about to disconnect his/her IV, and said she observed that Resident #1's midline site was intact, that there was no bleeding, and said that the IV had not been disconnected yet. Nurse Supervisor #2 said she checked Resident #1's neurological signs and took his/her vital signs using his/her left arm at 1:00 A.M. on 03/31/21 and said she did not turn on the light in the room or check Resident #1's midline site at that time. Nurse Supervisor #2 said that on 03/31/21 at 3:00 A.M., she was alerted by CNA #1 that Resident #1 was bleeding. Nurse Supervisor #2 said she observed a layer of blood on Resident #1's sheet and hospital gown and said Resident #1's hospital gown and fleece jacket were stuck together with blood under his/her right armpit. Nurse Supervisor #2 said when she took off Resident #1's fleece jacket and hospital gown she observed that the clamp on the midline was open, the needleless hub was not attached to the end of the midline IV and said there was blood dripping from the end of the midline. Nurse Supervisor #2 said she found the needleless hub attached to the IV tubing on the pole across the room. During interview on 04/14/21 at 8:30 A.M., the Director of Nurses (DON) said IVs should have a needleless hub attached to the end of them at all times, said that the midline should have been clamped, and therefore Resident #1 would not have had blood loss from the IV. On 04/14/2021, the Facility was found to be in Past Non-Compliance, effective 04/12/2021 and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A) Resident #1 was transferred to the Hospital Emergency Department on 03/31/21 for evaluation, was admitted for acute blood loss, and did not return to the Facility. B) Nurse #1 has not worked at the Facility since 03/31/2021 and will not be returning. C) The Director of Nurses conducted an audit of all residents in the Facility for any resident with Intravenous catheters (IV) on 03/31/2021. No other residents were identified. D) The Director of Nurses or designee will conduct audit of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E) The results of the audits for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . F) The Director of Nurses and Staff Development Coordinator reviewed the Facility's policies for IV administration on 04/07/21. G) The Facility's QAPI meeting minutes, dated 04/08/21, indicated the incident involving Resident #1's IV was discussed, and a Plan of Correction was initiated. H) Nursing Staff were re-educated by the Staff Development Coordinator or designee regarding the Facility's IV policies and procedures, specifically to ensure IV clamps were closed and the needleless hub remains on the resident's IV line. The education was completed on 04/12/21. I) The Facility will initiate an orientation protocol for all agency staff to review before beginning their first shift that will ensure they are educated regarding the Facility's IV policies and procedures. J) The DON/designee is responsible for overall continued compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a midline intravenous (IV) catheter (an IV placed in a peripheral vein with the distal tip located just proximal to the axilla (where the arm connects to the shoulder) that delivers fluids and or medications directly into the vein), the Facility failed to ensure nursing staff were competent for providing necessary care and services. On 03/30/2021, Nurse #1 failed to ensure Resident #1's needleless hub remained on his/her midline IV after she disconnected Resident #1's IV antibiotic medication and that the midline IV clamp was securely closed, as a result Resident #1 bled out of his/her midline. On 03/31/2021, Resident #1 experienced a syncopal episode (temporary loss of consciousness) that required him/her to be transferred to the Emergency Department (ED) for further evaluation. Upon arrival in the ED, Resident #1 appeared pale, had complaints of feeling fatigued, and his/her blood work revealed he/she was anemic (lack of blood) due to acute blood loss. During Resident #1's hospitalization he/she required several blood [CONDITION(S)] and received a total of 4 units of blood. Findings include: The Facility Policy, titled Short Peripheral Catheter Needleless Connector Change, dated 05/01/15, indicated: - The nurse was responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice, and competence validation is documented in accordance with organizational policy. - Licensed nurses caring for residents receiving infusion therapies were expected to follow safety compliance procedures. - A needleless connector would be utilized at the hub of all IV access devices to decrease the risk of infection or injury. Resident #1 was admitted to the Facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse Progress Note, dated 03/31/21, indicated Resident #1 was found by staff to have blood loss from his/her right arm midline IV. The Nurse Progress Note, dated 04/03/21, (later identified as a late entry note for 03/31/21) indicated Resident #1 was observed to be bleeding from his/her midline IV site, the needleless hub was observed hanging from the IV tubing on the pole across the room and the midline IV was not clamped. The Facility's Investigation Summary, dated 03/31/21, indicated that on 03/31/21, at 3:00 A.M., staff observed what appeared to be blood on Resident #1's blankets and bedding. The Summary indicated staff found Resident #1's midline unclamped, and the needleless hub was not on the end of the midline, resulting in an open venous line. The Summary indicated the needleless hub was found still attached to the IV medication tubing on the other side of Resident #1's room. The Summary indicated that, later that same morning, Resident #1 had a syncopal episode, was sent to the Hospital Emergency Department for further evaluation, was diagnosed with acute blood loss, admitted to the Hospital, and required transfusion of four units of blood during his/her hospitalization . Review of Resident #1's Emergency Department (ED) Provider Note, dated 03/31/21, indicated Resident #1 was transferred to the Hospital Emergency Department after a syncopal event at the Facility. The ED Note indicated Resident #1 appeared pale, was complaining of fatigue, had bled from his/her midline IV overnight. The ED Note indicated Resident #1's laboratory values, dated 03/31/21, timed 12:34 P.M., indicated the following: - Red Blood Cells (RBC) value (amount of red blood cells in blood) of 2.30 million per microliter (M/UL) (critically low). Normal range for RBC is 4.0-5.10 M/UL. - Hemoglobin (HGB) value (carries oxygen to the body) of 7.1 Grams per deciliter (G/DL) (critically low). Normal range for HGB is 12.1-15.7 G/DL. - Hematocrit (HCT) value (proportion of red blood cells in the blood) of 20.9 percent (critically low). Normal range for HCT is 35.0-45.0 percent. The ED Note indicated Resident #1's laboratory values, dated 03/31/21, timed 5:28 P.M., indicated the following: - HGB value of 6.9 G/DL (critically low) - HCT value of 20.9 percent (critically low) The ED Note indicated Resident #1 was admitted to the Hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Discharge Summary, dated 04/02/21, indicated, Resident #1 was transfused a total of four units of blood during his/her hospitalization . During interview on 04/14/21 at 3:02 P.M., Nurse Supervisor #1 said she had worked as the nurse supervisor for the entire Facility on the 3:00 P.M. to 11:00 P.M. shift on 03/30/21, and said that on 03/30/21, Nurse #1 was assigned to provide care for Resident #1. Nurse Supervisor #1 said at 10:30 P.M. she connected Resident #1's IV antibiotic for Nurse #1 and told Nurse #1 to disconnect the IV when it completed infusing. Nurse Supervisor #1 said that at 11:00 P.M., she heard Resident #1's IV pump beeping, and told Nurse #1 to go and disconnect the IV and said she did not supervise Nurse #1 as she disconnected the IV. Nurse Supervisor #1 said that she was aware that the 3:00 P.M. to 11:00 P.M. shift on 03/30/21 was the first time Nurse #1 worked at the Facility, said she never asked Nurse #1 if she was IV certified (trained in proper care of IVs), and said she did not review the process of disconnecting IV's with Nurse #1. During interview on 04/14/21 at 10:58 A.M., Nurse #1 said she worked the 3:00 P.M. to 11:00 P.M. shift on 03/30/21, said that this was the first time she had ever worked at the Facility, and said she was assigned to care for Resident #1 on that day. Nurse #1 said Nurse Supervisor #1 connected Resident #1's IV antibiotic at 10:30 P.M., and said that at 11:00 P.M., she disconnected Resident #1's IV antibiotic from his/her midline once the medication had infused. During interview on 04/15/21 at 9:32 A.M., Certified Nurse Aide (CNA) #1 said that on 03/31/21 at 3:00 A.M., she responded to Resident #1's call light and saw that his/her blankets were drenched in blood. CNA #1 said she immediately alerted Nurse Supervisor #2, and together they removed Resident #1's fleece jacket and hospital gown and said the jacket and hospital gown were stuck together by clotted blood. CNA #1 said Resident #1 had blood down his/her right side from the armpit to his/her waist, there was blood soaked into in his/her incontinence brief, and on the mattress. During interview on 04/14/21 at 12:05 P.M., Nurse Supervisor #2 said she worked the 11:00 P.M. to 7:00 A.M. shift on the night of 03/30/21. Nurse Supervisor #2 said when she arrived on the unit, she entered Resident #1's room at the same time Nurse #1 was about to disconnect his/her IV, and said she observed that Resident #1's midline site was intact, that there was no bleeding, and said that the IV had not been disconnected yet. Nurse Supervisor #2 said she checked Resident #1's neurological signs and took his/her vital signs using his/her left arm at 1:00 A.M. on 03/31/21 and said she did not turn on the light in the room or check Resident #1's midline site at that time. Nurse Supervisor #2 said that on 03/31/21 at 3:00 A.M., she was alerted by CNA #1 that Resident #1 was bleeding. Nurse Supervisor #2 said she observed a layer of blood on Resident #1's sheet and hospital gown and said Resident #1's hospital gown and fleece jacket were stuck together with blood under his/her right armpit. Nurse Supervisor #2 said when she took off Resident #1's fleece jacket and hospital gown she observed that the clamp on the midline was open, and the needleless hub was not attached to the end of the midline IV, and there was blood dripping from the end of the midline. Nurse Supervisor #2 said she found the needleless hub attached to the IV tubing on the pole across the room. During interview on 04/14/21 at 8:30 A.M., the Director of Nurses (DON) said IVs should have a needleless hub attached to the end of them at all times, said that the midline should have been clamped, and therefore Resident #1 would not have had blood loss from the IV. On 04/14/2021, the Facility was found to be in Past Non-Compliance, effective 04/12/2021 and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A) Resident #1 was transferred to the Hospital Emergency Department on 03/31/21 for evaluation, was admitted for acute blood loss, and did not return to the Facility. B) Nurse #1 has not worked at the Facility since 03/31/2021 and will not be returning. C) The Director of Nurses conducted an audit of all residents in the Facility for any resident with Intravenous catheters (IV) on 03/31/2021. No other residents were identified. D) The Director of Nurses or designee will conduct audit of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E) The results of the audits for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . F) The Director of Nurses and Staff Development Coordinator reviewed the Facility's policies for IV administration on 04/07/21. G) The Facility's QAPI meeting minutes, dated 04/08/21, indicated the incident involving Resident #1's IV was discussed, and a Plan of Correction was initiated. H) Nursing Staff were re-educated by the Staff Development Coordinator or designee regarding the Facility's IV policies and procedures, specifically to ensure IV clamps were closed and the needleless hub remains on the resident's IV line. The education was completed on 04/12/21. I) The Facility will initiate an orientation protocol for all agency staff to review before beginning their first shift that will ensure they are educated regarding the Facility's IV policies and procedures. J) The DON/designee is responsible for overall continued compliance.

Based on observation, record review and staff interview, the facility failed to provide care in accordance with the written plan of care and/or physician's orders [REDACTED].#6, #10 and #16). Findings include: 1. For Resident #10, the facility failed to ensure that preventative measures were initiated for an unstageable area on the resident's right heel including the bottom of the foot for a total of 5 days. When a care plan was developed for the right heel, the facility did not follow the interventions. Patient #10 was readmitted to the facility in 8/2015 after a 28 day hospitalization . [DIAGNOSES REDACTED]. Review of the Nursing Admission Progress Note and Nursing Assessment, indicated the resident was readmitted with a large scabbed area (necrotic tissue) on the bottom of the right foot that involved the entire right heel. There were no measurements taken or preventative interventions put into place until the area had deteriorated, and found on 9/5/15 as a large, opened draining blister measuring 10.2 cm. (centimeters) x 8.5 cm. The Interim Care Plan of 9/1/15 indicated the resident had a break in Skin Integrity (coccyx only and did not address the area on the right heel) due to Incontinence and a Pressure Ulcer on the coccyx. There was no goal/target date. Interventions included: - Pressure reduction mattress/overlay/specialty bed/seat cushion (said to circle one, but not completed). - Elevate heels off bed surface and float heels - no pressure on heels. - The reposition schedule section of the care plan was not completed. - Schedule time out of bed as tolerated. - Skin treatment section not completed. - The section for protective equipment was not completed. On 9/5/15, the Physician was contacted and treatment orders were received and entered into the treatment book. The Care Plan for Actual Skin Breakdown dated 9/8/15 indicated the resident was noted to have a stage 2 area on the right heel. 10 cm. x 8.8 cm. debrided blister. The goal was that the area would be reduced in size by 0.5 cm. thru the next 14 days. Approaches included: - Assess skin integrity with cares and notify nursing of changes. - Reposition per protocol, for comfort and as needed with 2 staff assist. - OT/PT (Occupational Therapy/Physical Therapy) consult as needed. - Elevate calves on pillows -- keep legs elevated off of surface. On 9/17/15 during the Initial Tour of the facility, the surveyor observed Resident #10 at 8:00 A.M., sitting in the wheelchair in front of the Nurses' Station. The surveyor observed that the resident had a dressing on the right foot covered with a tight white sock. The right heel was directly on the hard plastic foot pedal of the wheelchair (creating pressure on the heel). On 9/21/15 at 6:55 A.M., the surveyor observed Resident #10 sitting in the wheelchair in front of the nurses' station waiting for breakfast. The surveyor observed the resident had a dressing on the right foot covered with a tight white sock with the heel directly on the hard foot pedal of the wheelchair (putting direct pressure on the area). On 9/21/15 at 10:40 A.M. and 2:10 P.M., the surveyor observed the resident lying in bed on his/her back. The resident's right heel was wrapped in gauze and was directly on the mattress and not off-loaded per care plan. On 9/21/15 at 3:45 P.M., the surveyor observed Nurse #2 change the dressing on the right foot with UM #3's assistance. The surveyor pointed out to both nurses that the resident's right heel was not floating, but was lying directly on the bed creating more pressure on the area. UM #3 said the resident had a tendency (for some time now) to pull the heels back, dragging the pillow back as well, then extend the legs back, leaving the heels directly on the bed. Nurse #2 removed the tight sock with much difficulty, causing shearing and pressure as the sock was removed. The surveyor observed that the area on the right heel was a large, green/black necrotic area with thick yellow/brown exudate. The heel was cleaned and redressed. Before leaving the room, UM #3 placed pillows under the resident's calves, but the right heel was still touching the bed when we left the room and not floated per care plan. On 9/23/15 at 2:30 P.M., the surveyor observed Resident #10 lying in bed with the right foot lying directly on the mattress. On 9/23/15, after discussion with the surveyor, UM #3 requested that Physical Therapy evaluate the resident for a solution that would prevent the resident placing pressure and shearing the heels on the bed and wheelchair foot rests. During discussion on 9/24/15 at 11:00 A.M., the Rehabilitation Manager said that the resident was issued a pressure-relieving boot yesterday that would keep the resident's heel in a suspended state and relieve all pressure from the heel. The Rehab Manager also told the surveyor that she had not received any requests regarding the resident's heel until yesterday (Rehab was not consulted when the area was first identified, per care plan). 2. For Patient #16, the facility failed to implement measures to ensure that as much pressure as possible was relieved when up in the wheelchair, and to follow the back to bed schedule after meals. The facility also failed to ensure the resident received the ordered pain medication prior to dressing changes. Resident #16 was admitted to the facility in 8/2001. [DIAGNOSES REDACTED]. The care plan for Incontinence/risk UTI (urinary tract infection) and Alteration Skin Integrity (7/9/14) was the one in use when the resident developed a new pressure area (Unstageable when found on 6/11/15) included the following interventions: - Toilet/change with cares, before and after meals, upon returning from activities and on rounds during the 11:00 P.M.-7:00 A.M. shift. - Provide pericare as needed with periods of incontinence. House barrier cream to buttocks/periarea every shift and as needed for protection. - Reposition per protocol, for comfort and as needed with staff assist-use of pull/lift sheet to aid with repositioning in bed. - HeelPro to bed for heel elevation. - Skin Prep to heels nightly. - Comprehensive skin checks on shower day. - Pressure relieving mattress (standard facility mattress with a layer of foam). - Out of bed in custom wheelchair with gel pressure relief cushion. Review of the Pressure Ulcer Status Record indicated that on 6/11/15, the resident presented with a Stage 2 Pressure sore on the left ischial tuberosity that measured 2.0 cm. x 1.5 cm. and 0.3 cm. deep. Physician #1 ordered (6/11/15) to apply a moisture barrier cream to the affected area every shift and as needed until healed. Physician #2's order of 6/12/15 was to cover the wound with an Allevyn dressing and change every 5 days. A nurse's note of 6/16/15 indicated the resident was seen by the wound team. The pressure sore measured 1.8 cm. x 1.7 cm. The wound bed was described as moist with yellow slough (unstageable), no surrounding redness (deteriorated). Resident was encouraged to go back to bed in the afternoons. Physician #1's Progress Note dated 7/7/15 indicated the resident had a new pressure area on the ischium (found on 6/11/15), and that pressure relieving measures (standard facility mattress with a built in layer of foam) were in place. The Physician indicated that he wanted the resident to go back to bed after meals. The wound was Unstageable, and measured 1.6 cm. x 0.4 cm. x 0.2 cm. deep. The care plan of 7/10/15 for Actual Skin Breakdown included the following interventions: - Assess skin daily with cares and report changes to nursing. - Assess Pressure area daily and document per protocol (clinical record or Treatment Record) - Pressure relieving mattress (standard facility mattress with foam insert) and pressure relief chair pad (gel cushion). - House barrier cream for protection. - Adult briefs for dignity. - Consult with wound team weekly. - Treatment per physician's orders [REDACTED].>Wound measurements on 8/11/15 indicated the wound had deteriorated again. The Physician ordered a more effective mattress (an overlay alternating air mattress) to replace the standard facility mattress, but not until the ischial wound had become necrotic. The overlay was ordered 2 months after the wound was found. On 8/19/15, Physician #2 ordered that a Foley Catheter be inserted to aid in wound healing. A Nurse's Note of 9/8/15 indicated the patient verbalized no pain, however was becoming more resistant to the dressing change. The wound measured 1.9 cm. x 2.2 cm. x 2.3 cm. deep (deeper than on 9/1/15) with a moderate amount of tan, foul smelling drainage (deteriorated). On 9/17/15 at 8:30 A.M., the surveyor observed the resident sitting in the dayroom eating breakfast. The resident was in the wheelchair sitting on a thick soaker pad with a Hoyer Lift pad on top of that. Sitting in a chair with the pressure relief cushion covered with 2 layers, negates the purpose of the cushion, so that pressure is not relieved. On 9/18/15, Physician #2's Progress Note indicated the resident's wound had surrounding [MEDICAL CONDITION] (infection) which was quite painful. The note indicated the resident screams out when nurses change the dressing. A new order was to administer the narcotic pain relieving medication [MEDICATION NAME] 5 mg. before dressing changes, and to finish the current antibiotics. On 9/21/15 at 9:00 A.M. and 9/22/15 at 8:45 A.M., the resident was observed sitting up in the wheelchair in the dayroom. There was a pressure relieving cushion on the chair, however, as before a soaker pad was placed on top with the Hoyer pad over that, thus eliminating the benefits of the cushion. On 9/23/15 at 8:35 A.M., the surveyor observed the resident sitting in the wheelchair in the day room eating breakfast. A thick soaker pad and the Hoyer Lift pad were on top of the pressure relief cushion in the chair. After breakfast (9:15 A.M.), instead of going back to bed per schedule, the resident was brought downstairs to the hairdresser, and was returned to the unit at 10:25 A.M. The resident was brought to the dayroom to wait for lunch to arrive on the unit. After lunch (1:30 P.M.), the resident was placed in bed. On 9/24/15 at 8:00 A.M., the surveyor observed Nurse #6 perform a dressing change to the pressure ulcer. Nurse #6 began by removing the old dressing. The resident was yelling, Ouch, Ouch and striking out to hit Nurse #6. Nurse #6 said that the wound was getting larger and deeper, and that the facility was working on making an appointment at the Wound Clinic. Nurse #6 began to pack the wound with [MEDICATION NAME] AG and the resident began to yell out again. The surveyor asked Nurse #6 when the resident was medicated, and Nurse #6 told the surveyor that she had not medicated the resident yet, and that it was scheduled to be given at 9:00 A.M. Nurse #6 told the surveyor that the dressing change is done around 8:00 -8:15 A.M. every morning, and the Resident was receiving the pain medication at 9:00 A.M. During discussion on 9/23/15 at 3:45 A.M., the Rehab Manager said that that staff should never cover a pressure relieving cushion with a thick soaker pad and hoyer lift pad, because it eliminates the benefits of the pad. During interview on 9/24/15 at 8:50 A.M., Unit Manager #3 said the resident should have been medicated prior to the dressing change as ordered. When the surveyor and UM #3 reviewed the resident's Medication Administration Record [REDACTED].M. and 9:00 P.M. regardless when the dressing change was done. UM #3 said the MAR indicated [REDACTED]. 3. For Resident #6, the facility failed to follow the care plan to provide supervision and toileting to prevent a fall. Resident #6 was admitted to the facility in 4/2015 with [DIAGNOSES REDACTED]. The resident's Admission MDS Assessment of 4/8/15 indicated the resident had minimal difficulty hearing, was severely impaired cognitively with a Brief Interview for Mental Status (BIMS) score of 3/15, had psychomotor [MEDICAL CONDITION], required extensive assistance of one for ambulation, extensive assistance of two for transfers, was frequently incontinent of bladder and always incontinent of bowel, and had fallen in the month prior to admission. Review of Progress Notes and the Incident Follow Up and Recommendation Form of 4/28/15 at 2:00 P.M., indicated staff responded to an activated alarm and observed the resident on his/her right side in front of the wheelchair in the unit's main dining room. The resident said that he/she was going to the bathroom, and attempted an unassisted transfer in an unsupervised area. No injury was observed. The Falls care plan was updated on 4/28/15 to include the following interventions: offer the resident toileting upon rising, before and after meals and at Hour of Sleep, and for the patient to remain in a supervised therapeutic area when out of bed. Review of Progress Notes and the Incident Follow Up and Recommendation Form of 5/8/15 at 10:00 A.M., indicated staff responded to an activated alarm in the main unit dining room and observed the resident positioned on the floor towards the right side. On interview, the resident said he/she was going to the bathroom. The resident had a hematoma on the right forehead 5 centimeters (cm) by 2 cm. and a right shoulder abrasion. The resident had attempted an unwitnessed, unassisted transfer in an unsupervised area. The fall investigation indicated the resident had neither been supervised in a therapeutic area, nor toileted after breakfast, as planned. During interview on 9/24/15 at 10:55 P.M. the Director of Nursing said that the care plan to prevent an unwitnessed resident fall was not followed on 5/8/15, as written.

Based on observation, facility policy, record review, and staff interview, the facility failed to ensure that 2 of 7 applicable residents with new or worsening pressure sores (#10 and #16), in a total sample of 24, received the necessary treatment and services to promote healing, and to prevent new sores from developing. Findings include: 1. Resident #10 was admitted to the facility in 8/2015 after a month long hospitalization . [DIAGNOSES REDACTED]. Review of the, Pressure Ulcer Stages Revised by National Pressure Ulcer Advisory Panel (2007) indicated that an Unstageable Pressure Ulcer is: - Full Thickness tissue loss in which the base of the sore is covered by slough (dead tissue separated from living tissue) of yellow, tan, gray, green or brown color, and/or eschar (scab) of tan, brown or black color in the wound bed. - Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] (abnormal redness) eschar on the heels serves as the body's natural (biological) cover and should not be removed. The facility failed to assess and treat a scabbed (unstageable) area on the resident's right heel after it was identified on the Initial Nursing Assessment of 8/31/15. There was also no evidence this area was reported to the Physician until 5 days later when it was identified as a large open blister which measured 10.2 centimeters x 8.5 centimeters (cm.) on the Weekly Skin Integrity Data Collection Sheet and Pressure Ulcer Status Record. The Interim Care Plan of 9/1/15 indicated the resident had a break in Skin Integrity (coccyx) due to Incontinence and a Pressure Ulcer on the coccyx. There was no goal/target date. Interventions included: - Pressure reduction mattress/overlay/specialty bed/seat cushion (said to circle one, but not completed). - Elevate heels off bed surface and float heels - no pressure on heels. - The reposition schedule section of the care plan was not completed. - Schedule time out of bed as tolerated. - Skin treatment section not completed. - The section for protective equipment was not completed. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated the patient had long and short term memory impairments, and was unable to make decisions; was sometimes understood and could sometimes understand; required total assistance from staff for bed mobility, transfers, dressing, toilet use, hygiene and bathing; required extensive assistance from staff for eating, did not ambulate; was always incontinent of bladder and frequently incontinent of bowel. Review of the Initial Nursing Assessment and Nursing Notes from 8/31/15 through 9/4/15 indicated the resident was admitted with a large scabbed area on the heel, however, there were no measurements, treatments or monitoring documented on the Treatment Records regarding the area on the right heel. Neither was there any evidence of documentation on the Treatment Record that the resident's heels were floated per care plan. A Nursing Note of 9/5/15 at 8:40 P.M., indicated that while caring for Resident #10, staff found a large blister on the right heel, blister is open and draining with open area to inner part of heel/ankle. Review of the Pressure Ulcer Status Record initiated on 9/5/15, described the right heel blister as open and measured 10.2 cm. x 8.5 cm. The Physician ordered the following treatment to begin on 9/5/15: - Atrac-tain cream (protective barrier cream) to bilateral feet twice daily. - Allevyn heal (protective foam heel piece) to right heel and change every 3 days. - Xeroform (Vaseline infused gauze) to right heel and cover with dry clean dressing (DCD) and change 2 times daily. Review of the updated care plan of 9/8/15 indicated, Elevate the resident's calves on pillows--keep legs elevated off of surface. The Pressure Ulcer Status Record of 9/15/15 indicated the patient's open blister on the right heel measured 6.8 cm. x 5.2 cm. The area was moist, red and peeling at the edge. On 9/17/15 during the Initial Tour of the facility, the surveyor observed Resident #10 at 8:00 A.M., sitting in the wheelchair in front of the Nurses' Station. The surveyor observed that the resident had a dressing on the right foot covered with a tight white sock. The right heel was directly on the hard plastic foot pedal of the wheelchair (creating pressure on the heel). Unit Manager (UM) #3 said the resident had a facility acquired pressure area on the right heel that had been staged as a Stage Two. On 9/21/15 at 6:55 A.M., the surveyor went to Resident #10's unit. The resident was sitting in the wheelchair in front of the nurses' station waiting for breakfast. The surveyor observed that the resident had a dressing on the right foot covered with a tight white sock with the heel directly on the hard foot pedal of the wheelchair (putting direct pressure on the area). On 9/21/15 at 10:40 A.M. and 2:10 P.M., the surveyor observed the resident lying in bed on his/her back. The resident's right heel was directly on the mattress and not off-loaded per care plan. During discussion on 9/21/15 at 3:10 P.M., UM #3 told the surveyor that the resident's dressing was going to be changed. The surveyor asked permission to observe. On 9/21/15 at 3:45 P.M., the surveyor observed Nurse #2 change the dressing on the right foot with UM #3's assistance. The surveyor pointed out to both nurses that the resident's right heel was not floating, but was lying directly on the bed creating pressure on the area. UM #3 told the surveyor that the resident had been in bed since after breakfast and could not be roused for lunch today. Nurse #2 removed the tight sock with much difficulty, causing shearing and pressure as the sock was removed. Before the old dressing was removed, the surveyor observed that the bottom of the foot above and around the wound dressing was red and inflamed. After the dressing was removed, the surveyor observed a large amount of thick yellow exudate on the old dressing. Nurse #2 said that the wound had more drainage than before and much more redness. Nurse #2 indicated the area was very warm to touch with much swelling. The large blister on the heel was black, green and unstageable. Both nurses agreed that the area looked infected due to the extreme redness and swelling around the outside of the wound, going up towards the toes. During the dressing change the resident was yelling ouch, ouch! The heel was cleaned and redressed. Before leaving the room, UM #3 placed pillows under the resident's calves, but the heel was still touching the bed. New physician's orders [REDACTED].) by mouth for 10 days and to culture the wound. Review of the Pressure Ulcer Status Record of 9/22/15 indicated the resident was calling out in pain during the dressing change, and that the size of the wound had increased dramatically to 10.2 cm. x 7.8 cm. (9/22), from 6.8 cm. x 5.2 cm. on 9/15/15. On 9/23/15 at 2:30 P.M., the surveyor observed Resident #10 lying in bed with the right foot lying directly on the mattress. The surveyor discussed this with UM #3, who said that it would be resolved right away. On 9/23/15, after surveyor intervention, UM #3 put in a consult to Physical Therapy who issued a Prevalon Pressure-Relieving Heel Protector to the patient. During discussion on 9/24/15 at 11:00 A.M., the Rehabilitation Manager said that this particular heel protecting boot would keep the resident's heel in a suspended state and relieve all pressure from the heel. 2. For Resident #16, the facility failed to implement preventative measures to ensure that Resident #16 did not develop any pressure sores and/or that any pressure area did not deteriorate and become necrotic and infected. Resident #16 was admitted to the facility in 8/2001. [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment of 4/8/15, indicated the resident: scored a 03 on the BIMS (Brief Interview of Mental Status) cognitive assessment, indicating the resident was severely impaired (the highest score is 15); could usually understand and was understood by staff; required limited assistance from staff for eating; required extensive assistance from staff for bed mobility, dressing and personal hygiene; total assistance from staff for transfers, toileting and bathing; did not ambulate; utilized a wheelchair as a mode of transportation; incontinent of bowel and bladder; free of pressure areas, but at risk; had a pressure relieving device for the bed (standard house mattress) and chair, and was not on a turning and repositioning schedule. Review of the Weekly Skin Integrity Data Collection Sheet of 6/7/15 indicated the resident's skin was dry and intact. Review of the Pressure Ulcer Status Record indicated that on 6/11/15, the resident presented with a Stage 2 Pressure sore on the left ischial tuberosity that measured 2.0 cm. x 1.5 cm. and 0.3 cm. deep. A Physician's (#2) order of 6/11/15 was to apply a moisture barrier cream to the affected area every shift and as needed until healed. Physician #2's order of 6/12/15 was to cover the wound with an Allevyn dressing and change every 5 days. The Physician also ordered 2000 units of Vitamin D and 500 milligrams (mg) of Calcium daily. A nurse's note of 6/16/15 indicated the resident was seen by the wound team. The pressure sore measured 1.8 cm. x 1.7 cm. The wound bed was described as moist with yellow slough, no surrounding redness. Resident was encouraged to go back to bed in the afternoons. The Dietitian's Note of 6/18/15, indicated the wound was unstageable and that the resident's diet would be modified with extra protein meals and supplements to help with wound healing. The Dietitian also indicated that the resident's appetite was poor, but weight was stable. Physician #1's Progress Note dated 7/7/15 indicated the resident had a new pressure area on the ischium (found on 6/11/15), and that pressure relieving measures (standard facility mattress with a built in layer of foam) were in place. The order was to apply an Allevyn dressing (highly absorbent [MEDICATION NAME] pad) and change every 3 days and as needed, and back to bed after meals. Unstageable wound measures 1.6 cm. x 0.4 cm. x 0.2 cm. deep (increased depth). Review of the Annual MDS Assessment of 7/7/15, indicated the following changes since the previous assessment of 4/8/15: was unable to complete the BIMS cognitive test; had short and long term memory loss and was unable to make decisions; was rarely/never understood and could sometimes understand; required total assistance from staff for bed mobility, and now had an Unstageable pressure sore on the left ischium that measured 1.6 cm. x 0.4 cm. and 0.2 cm. deep. The wound bed was filled with slough. Physician #1's Progress Note of 7/14/15 indicated the resident's pressure sore had worsened since 7/7/15. The new order was to add [MEDICATION NAME] AG (antimicrobial rope infused with ionic silver, used to treat wounds at high risk for infection or actual infection), and to cover with an Allevyn dressing. Change every 3 days and as needed. The note included, The patient does have urinary incontinence which may inhibit the healing of this wound However, if area does not improve, may consider the placement of a Foley (catheter) for wound healing purposes. Unstageable wound measures 2.0 cm. x 1.7 cm. x 0.2 cm. deep. Wound team measurements on 8/4/15 indicated the wound had deepened and measured 0.3 cm. deep with a moderate amount of tan drainage. The overall wound (width and length) got smaller, but increased in depth. A Physician's Progress Note (Physician #1) dated 8/4/15 indicated the resident was evaluated by Occupational Therapy for a more effective cushion in the wheelchair. The patient was issued a gel cushion for pressure relief two months after development of the Unstageable pressure sore. Wound measurements on 8/11/15 indicated the wound has deteriorated again. Measurements were 2.2 cm. x 2.0 cm. x 0.3 cm. deep. The wound was now necrotic and filled with moist black eschar. The dressing was changed by Physician #2, to the [MEDICATION NAME] agent Santyl ointment to the wound bed and cover with a 2x2 gauze and [MEDICATION NAME] (clear dressing). Change daily and as needed. Physician #2 ordered an overlay air mattress to replace the standard facility mattress. On 8/18/15 the wound was measured as 1.8 cm. x 1.9 cm. x 0.4 cm. (deeper). The Pressure Ulcer Status Record indicated the wound was necrotic and had deteriorated. On 8/19/15, Physician #2 ordered that a Foley Catheter be inserted to aid in wound healing, because, The urine is inhibiting healing of his/her ulcer. (despite the wound being contaminated by urine from the onset on 6/11/15, but a catheter was not ordered until the wound became necrotic). A Physician's Progress Note (8/25/15) (Physician #1) and review of the Pressure Ulcer Sheet of 8/25/15 indicated the wound had again deteriorated and measured 2.4 cm. x 2.3 cm. x 1.4 cm. deep. Physician #1 included in her note, Left ischial wound is covered with thick green slough with foul odor. She indicated the wound had significantly increased in size since the week before. Physician #1 wrote in her 8/25/15 note that the wound is worse with current therapy, and to change to Santyl (which was the current treatment since 8/11/15, thus the treatment order was not changed) and cover with [MEDICATION NAME] daily. A Progress Note from Physician #1 dated 9/1/15 included, The ulceration on the left ischium is full with thick green/black slough and eschar. Measurements reviewed and significantly increased in size. Foul green drainage. Physician #1 changed the current dressing from Santyl to [MEDICATION NAME] AG covered with [MEDICATION NAME]. Change twice daily and as needed. If no improvement within the week, may require surgical debridement and possible antibiotic therapy. Measurements on 9/1/15 were 2.0 cm. x 2.9 cm. x 2.1 cm. deep. A Nurse's Note of 9/8/15 indicated the resident verbalized no pain, however, was resistant to the dressing change. The wound measured 1.9 cm. x 2.2 cm. x 2.3 cm. deep (deeper than on 9/1/15) with a moderate amount of tan, foul smelling drainage. The wound bed was still 80% slough. Despite the Physician's Progress Note of 9/1/15, indicating that action would be taken within the week if there was further deterioration in the wound, there was no change in orders and no anti-infective medications ordered. Review of the 9/2015 Treatment Administration Record indicated the resident's wound had a very foul odor from 9/5/15-9/15/15. A physician's orders [REDACTED]. daily for 10 days (discontinued on 9/22/15) and [MEDICATION NAME] 250 mg. three times daily for 14 days for wound infection. The wound measurements for 9/15/15 were 1.8 cm. x 2.3 cm. x 2.6 cm. (deeper than a week earlier) with redness surrounding the wound and increased pain noted. The wound was described on the care plan as moist, gray/green slough, foul odor, 100% slough. On 9/17/15 at 8:30 A.M., the surveyor observed the resident sitting in the dayroom eating breakfast. The resident was in the wheelchair sitting on the gel cushion, but covering the pressure relief pad was a thick soaker pad (despite the resident having a Foley Catheter), and a Hoyer Lift pad on top of that. Sitting in a chair with the pressure relief cushion covered with 2 layers, negates the purpose of the cushion, so that pressure is not relieved. On 9/18/15, Physician #2's Progress Note indicated the resident's wound had surrounding [MEDICAL CONDITION] (infection) which was quite painful. The note indicated the resident screams out when nurses change the dressings. A new order was to administer the narcotic pain relieving medication [MEDICATION NAME] 5 mg. before dressing changes, and to finish the current antibiotics. On 9/21/15 at 9:00 A.M. and 9/22/15 at 8:45 A.M., the resident was observed sitting up in the wheelchair in the dayroom. There was a pressure relieving cushion on the chair, however, as before, a soaker pad was placed on top with the Hoyer pad over that, thus eliminating the benefits of the cushion. On 9/22/15 the wound measured 3.4 cm. x 2.9 cm. x 3.2 cm. x 3.2 cm. with black edges and gray necrotic slough. A surgical consult was ordered to have the wound debrided at a local wound clinic. On 9/23/15 at 8:35 A.M., the surveyor observed the resident sitting in the wheelchair in the day room eating breakfast. A thick soaker pad and the Hoyer Lift pad were on top of the pressure relief cushion in the chair. After breakfast (9:15 A.M.), instead of going back to bed per schedule, the resident was brought downstairs to the hairdresser, and was returned to the unit at 10:25 A.M. The resident was immediately brought to the dayroom activity program to wait for lunch to arrive on the unit. After lunch (1:30 P.M.), the resident was placed in bed. On 9/24/15, at 8:25 A.M., Nurse #6 told the surveyor that she was going to change the resident's dressing. The physician's orders [REDACTED]. Nurse #6 began by removing the old dressing. The resident was yelling, Ouch, Ouch and striking out to hit Nurse #6. When the old [MEDICATION NAME] AG was removed, it was saturated with brown drainage. The wound was cleaned per order. The surveyor observed that the wound was approximately 3.0 cm. round and very deep. Nurse #6 said that the wound was getting larger and deeper, and that the facility was working on making an appointment at the Wound Clinic.

Based on observation, record review and interview the facility failed to provide services to prevent worsening of an existing pressure ulcer, or prevent the development of a new pressure ulcer for 3 (#1, #6 and #10) of 4 applicable residents in a total sample of 24 residents. Findings include: 1. For Resident #1, the facility failed to prevent a new pressure ulcer on a toe. Resident #1 was admitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of the Physician's admission orders [REDACTED]. Continued review indicated the resident did have an order for [REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 1/10/14, indicated the resident was cognitively impaired, required assistance with walking, dressing and eating, was incontinent of bowel and bladder, and did not have a pressure ulcer or any foot problems. Review of the physician's orders [REDACTED]. Review of the corresponding Treatment Administration Record (TAR), dated 3/2014, indicated the order was not transcribed onto the TAR. Review of the TAR, dated 4/2014, indicated a transcription for lambs wool to the toes of both feet, every shift. The TAR was initialed for everyday and every shift, but circled, meaning the resident did not receive the treatment. On the reverse side of the TAR, the resident's refusal of care was documented. Review of the Care Plan did not indicate a plan for addressing the Resident's refusal of care. Review of a weekly skin check, dated 4/4/14, indicated the resident had redness between the toes. Review of a weekly skin check, dated 4/17/14, indicated the resident had redness between the 3rd and 4th toe of the left foot. Review of the Pressure Ulcer Status Record, dated 4/21/14, indicated the resident developed an unstageable pressure ulcer to the left foot, 4th medial toe. The pressure ulcer measured 0.4 centimeters (cm.) x 0.4 cm. Review of the physician's orders [REDACTED]. This order was obtained 3 days after the pressure ulcer was noted. Review of the 4/2014 TAR indicated: - Lambs wool between the toes was refused every day, - DFC was started on 4/25/14, - Left foot soapy water soaks were started on 4/25/14, and - Corn pad to 4th medial toe left foot was started on 4/25/14. Review of the Pressure Ulcer Status Record, dated 4/30/14, indicated the unstageable pressure ulcer to the left foot 4th medial toe had deteriorated and measured 1.0 cm x 1.0 cm. Review of the physician's orders [REDACTED]. Continued review of the Pressure Ulcer Status Record indicated the pressure ulcer had healed on 8/26/14. On 10/22/14 at 8:10 A.M., the surveyor observed Nurse #3 remove the resident's non skid socks and remove a 2 x 2 gauze pad that was between the 3rd and 4th toes on the left foot. Between the toes, the skin was pink and intact. The resident's toenails were very thick and long. During an interview on 10/22/14 at 11:50 A.M. with Unit Manager (UM) #4, she said that on admission, she should have obtained an order for [REDACTED].#4 said that when they received the order (3/2014) for lambs wool between the resident's toes, it was not transcribed onto the TAR until the following month. In addition, she said the lambs wool really wasn't doing anything because the resident kept removing it. She said she was not sure why a treatment for [REDACTED]. Please see F328 and F514. 2. For Resident #10, the facility failed to relieve pressure on the resident's heels (resident had a history of pressure ulcers). The resident's right heel was observed to be red and boggy. Resident #10 was admitted to the facility 10/2014, with [DIAGNOSES REDACTED]. Review of the Initial Data Collection Tool/Nursing Service document of 10/3/14 indicated the resident was admitted to the facility with red, boggy heels. Review of the Norton Plus Pressure Ulcer Scale assessment of 10/3/14 indicated the resident was at high risk for pressure ulcers. Review of the Treatment Sheets of 10/3/14 indicated a treatment was in place to off load the resident's heels when the resident was in bed. Review of the Nurse's Note of 10/6/14 indicated the resident was transferred to the local hospital for an evaluation of lethargy and mental status changes. Review of the Hospital Transfer Form indicated the resident was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Norton Plus assessment of 10/10/14 indicated the resident was a high risk for pressure ulcers. Review of the Initial Data Collection Tool/Nursing Service of 10/10/14 indicated the resident's right heel was red, but blanchable. However, there was no documentation in the clinical record that the facility off loaded the resident's heels when he/she returned to the facility on [DATE]. Review of the Nurse's Notes of 10/17/14 indicated the resident fell , sustained a laceration of the right foot, and was sent to the local hospital for evaluation. Review of the Nurse's Note of 10/18/14 indicated the resident returned to the facility with a new [DIAGNOSES REDACTED]. A laceration on the toe of the right foot was also treated in the hospital. Review of the treatment orders of 10/21/14 indicated the resident was to have the #3, #4, and #5 toes, of the right foot (the area lacerated during the fall 10/17/14), cleansed with Wound Cleanser, patted dry and a gauze wrap was to be applied daily. During observation on 10/21/14 at 10:00 A.M., the resident was in bed, lying on his/her back. The resident's heels were observed to be resting directly on the bed and were not off loaded. During observation on 10/22/14 at 10:00 A.M., the resident was in bed, lying on his/her back. The resident's heels were observed to be resting on the bed and were not off loaded. During observation, on 10/22/14 at 10:30 A.M., of the treatment to the resident's right foot/ toes, Resident #10's right foot was observed to be red and boggy. During interview on 10/22/14 at 10:30 A.M., Nurse #1 (the nurse who had performed a treatment to the resident) described the resident's right heel as "red and boggy." This nurse said that the resident's heels should have been off loaded. During interview, on 10/22/14 at 10:55 A.M., Nurse #2 (the desk nurse) said that when the resident was first admitted to the facility, he/she had an intervention in place to off load the resident's heels. Nurse #2 said when the resident was readmitted from the hospital (on 10/10/14) there was no intervention put in place to off load the resident's heels. During interview on 10/22/14 at 11:20 A.M., Unit Manager #3 said that she would assess Resident #10's right heel. Review of the physician's orders [REDACTED].M.. The resident was now to wear off loading boots (blue booties) while in bed. This was to be monitored and documented every shift. 3. For Resident #6, the facility failed to provide necessary care and services to promote healing of an existing pressure ulcer. Resident #6 was admitted to the facility in 11/2013 with a [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 12/7/13, indicated the resident was cognitively intact, required extensive assistance for bed mobility and transfers, and had a pressure ulcer. Review of the Certified Nurses' Aide (CNA) Care Card, updated 3/25/14, indicated the resident was to be repositioned every 2 hours. Review of the Quarterly MDS Assessment, dated 9/9/14, indicated the resident was cognitively intact, required extensive assistance with bed mobility and transfers and had a pressure ulcer. Review of a Physician's progress note from a plastic surgery clinic, electronically signed on 9/24/14, indicated the resident was being seen for evaluation of a Stage III sacral pressure ulcer. The assessment and plan included instructions for the resident to have a position change from side to side every half hour and keep all pressure off the ulcer. Review of a physician's orders [REDACTED]. During an interview on 10/21/14 at 2:20 P.M. with CNA #1, she said she took care of the resident regularly. She said the resident was positioned every 2 hours. During an observation/interview with Resident #6 on 10/21/14 at 2:30 P.M., he/she was observed in bed, on an air mattress, lying on his/her back with the head of the bed elevated. He/she said he/she was positioned every 2 hours until he/she went to sleep, and was not awakened for position changes during the night. During an interview on 10/21/14 at 2:45 P.M. with Nurse #4, she said staff go in to see the resident for all sorts of reasons, but not specifically to reposition the resident from side to side every half hour. She said the CNA Care Card had not been updated to reflect the current positioning order. During an interview on 10/21/14 at 4:00 P.M. with the Director of Nurses (DON), she was unable to explain the resident's current positioning program but said the resident was alert and very reliable. Please see F514.

Based on record review, observation, and staff interviews, the facility failed to follow the residents' plan of care regarding falls interventions and physician's orders [REDACTED].#18), out of a total sample of 24 residents. Findings include: 1. For Resident #18, the facility failed to follow the resident's falls care plan relative to the following: resident was not in a standard chair, supervision by staff was not being provided, resident was not in the common area with supervision and the resident's eye glasses were not on, as planned. Resident #18 was admitted to the facility in 9/2012. The falls care plan of 6/15/13 included the following interventions: to standard chair in Main Dining Room (also, referred to as first floor Dining Room/first floor Main Activity area and Main Living Room per facility progress note documentation and investigation documentation), use of wheelchair for transfers to toileting only, stay up in common area with supervision, and ambulate with rolling walker with 1 to 2 assist. Review of the 9/10/13 Progress Note indicated the resident experienced a witnessed fall, with no injuries. Review of the progress note and falls investigation with Unit Manager (UM) #1 (on 9/30/13 at 10:45 A.M.) indicated the following: a. the resident was in the first floor Dining Room/Main Living Room/Main Activity area when he/she attempted to sit back down in the wheelchair and fell ; (resident was not in a standard chair, as planned), and b. the action plan included a rehabilitation (rehab.) screen. Further review of the Therapy Referral Form of 9/10/13 indicated the Physical Therapist said the resident continued to require supervision for safety. Review of the staff in-service sheet, of 9/13/13, regarding Resident # 18, indicated staff education was provided (by UM #1) regarding the following interventions: a. resident should always be in standard chair with alarms at all times, b. wheelchair may only be used for toileting and off unit activities, and c. must be transferred to chair when done with activities. The falls care plan of 9/16/13 remained essentially unchanged. Review of the 9/22/13 Progress Note indicated the resident experienced an unwitnessed fall, sustaining a fractured pelvis. Review of the progress note and falls investigation with UM #1 (on 9/30/13 at 10:45 A.M.) indicated the following: a. the resident was not being supervised by staff, as planned (per rehab. screen on 9/10/13), as the resident was found on the floor, in another resident's room, after he/she had wandered in his/her wheelchair down the hallway; b. the resident was not in the common area, in a standard chair, with supervision and engaged in activities, as planned, and c. action plan: staff education regarding following the plan of care and physical therapy screen. The falls care plan was updated on 9/26/13 to also include: high-back recliner wheelchair and offer rest period in bed after lunch. On 9/30/13 at 8:50 A.M., the surveyor observed the resident sitting in a high-back recliner wheelchair, in the unit dining/day room, with his/her breakfast on the table in front of him/her. His/her eye glasses were not on, as planned. During interview on 9/30/13 at 10:10 A.M., CNA (certified nursing assistant) #1 said the resident utilizes eye glasses every day. During interview on 9/30/13 at 10:45 A.M., UM #1 said the facility failed to follow the resident's plan of care relative to the falls interventions. Please refer to F323. 2. For Resident #13, the facility failed to follow the care plan/physician's orders [REDACTED]. Resident #13 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. However, review of the physician's orders [REDACTED]. This physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. a total of 12 times PRN during the month of 8/2013. Although the resident had a physician's orders [REDACTED]. Review of the documentation on the 8/2013 MAR indicated [REDACTED]. The [MEDICATION NAME] was documented as given on 8/15 and 8/16/13 for intrusive behavior. During interview on 9/26/13 at 11:00 A.M., Unit Manager #1 said that the resident received PRN [MEDICATION NAME] 12 times in August/2013 without first attempting [MEDICATION NAME] as ordered by the Physician. Please refer to F329.

Based on record review, observation, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 11 applicable residents (#18), out of a total sample of 24 residents. Findings include: Resident #18, with [DIAGNOSES REDACTED]. The falls care plan of 6/15/13 identified the resident as having a history of frequent falls related to cognitive deficits, poor safety awareness, impulsivity and unsteady gait. The falls care plan included the following interventions: to standard chair in Main Dining Room (also, referred to as first floor Dining Room/first floor Main Activity area and Main Living Room per facility progress note documentation and investigation documentation), use of wheelchair for transfers to toileting only, stay up in common area with supervision, non skid footwear, bed and chair sensor pad alarms, hip protectors, and ambulate with rolling walker with 1 to 2 assist. Review of the quarterly Minimum Data Set (MDS) assessment of 8/25/13 identified the resident as having highly impaired vision, utilizing eye glasses, exhibiting severe cognitive impairment; requiring assistance during transfers, ambulation and locomotion on/off unit, and exhibiting unsteady balance during transitions and ambulation. Review of the 9/10/13 Progress Note indicated the resident experienced a witnessed fall, with no injuries. Review of the progress note and falls investigation with Unit Manager (UM) #1 (on 9/30/13 at 10:45 A.M.) indicated the following: a. the resident was in the first floor Dining Room/Main Living Room/Main Activity area when he/she attempted to sit back down in the wheelchair and fell ; (resident was not in a standard chair, as planned); b. the resident was re-educated about safety (UM #1 said re-educating the resident about safety was inappropriate as the resident is unable to retain safety education due to his/her dementia); c. conditions documented that may have contributed to the fall included; non-compliance (UM #1 said the resident was not capable of being "compliant" due to his/her dementia, and d. action plan: rehabilitation (rehab.) screen and staff education to offer toileting prior to leaving unit to activities. Further review of the Therapy Referral Form of 9/10/13 indicated the Physical Therapist said the resident continued to require supervision for safety. Review of the 9/11/13 Progress Note indicated the resident exhibited multiple attempts at unsafe mobility. Review of the Annual MDS Assessment of 9/13/13 remained essentially unchanged from the previous assessment except to note that the resident had experienced a fall, without injury, since the prior assessment. Review of the staff in-service sheet, of 9/13/13, regarding Resident #18, indicated staff education was provided (by UM #1) regarding the following interventions: a. resident should always be in standard chair with alarms at all times, b. wheelchair may only be used for toileting and off unit activities, and c. must be transferred to chair when done with activities. Review of the 9/14/13 Progress Note indicated the resident attempted unsafe mobility twice. The Behavior Care Plan of 9/16/13 indicated that the resident would remain safe while wandering on a daily basis with staff interventions. The Falls Care Plan of 9/16/13 remained essentially unchanged. Review of the 9/22/13 Progress Note indicated the resident experienced an unwitnessed fall, sustaining a fractured pelvis. Review of the progress note and falls investigation with UM #1 on 9/30/13 at 10:45 A.M., indicated the following: a. the resident was found, on the floor, in another resident's room. UM #1 said the resident had wandered in his/her wheelchair down the hallway into the other resident's room; b. the resident was not being supervised by staff, as planned (per rehab. screen on 9/10/13); c. the resident was not in the common area, in a standard chair, with supervision and engaged in activities, as planned, and d. action plan: staff education regarding following the plan of care and physical therapy screen. The Falls Care Plan was updated on 9/26/13 to also include: high-back recliner wheelchair and offer rest period in bed after lunch. On 9/30/13 at 8:50 A.M., the surveyor observed the resident sitting in a high-back recliner wheelchair, in the unit dining/day room, with his/her breakfast on the table in front of him/her. His/her eye glasses were not on, as planned. During an interview on 9/30/13 at 10:10 A.M., CNA (certified nursing assistant) #1 said the resident has bed and chair alarms in case (he/she) try's to get up and (he/she) utilizes eye glasses every day. During an interview on 9/30/13 at 10:45 A.M., UM #1 said the resident exhibits very poor memory, unsafe mobility and was (prior to 9/23/13 fall) only to utilize a wheelchair for transfers to toileting and off unit activities. It was discussed with UM #1 that the facility failed to provide effective interventions and adequate supervision to prevent falls for this resident. Please refer to F282, Example #1.

Based on interview and record review for three of five sampled residents (Resident #1, Resident #3 and Resident #5), the Facility failed to ensure that the suspected abuse of Resident #1 on 1/7/13 at 5:00 A.M. by Certified Nurse Aide #1 was reported immediately to a supervisor or charge nurse, in compliance with Facility policy. Immediate reporting of the abuse of Resident #1 may have prevented the abuse of Resident #3 and Resident #5 on 1/7/13 at 5:30 A.M. and 6:00 A.M. respectively. Findings include: Resident #1's Care Plan for ADLs (Activities of Daily Living), dated 3/8/12, indicated that Resident #1 required extensive assistance with ADLs due to decreased functional mobility and poor safety awareness. Interventions included transfer with two assists, using a Sabina lift. Resident #1's Care Plan for falls/mobility, dated 3/8/12, indicated that Resident #1 was at risk for falls due to a history of falls and status [REDACTED]. Resident #3's Care Plan for Cognition/Communication, dated 9/12/12, indicated Resident #3 had a [DIAGNOSES REDACTED]. The Care Plan indicated that Resident #1 was hard of hearing and wore a right hearing aid. Interventions included: provide a calm, quiet environment; and monitor for increased anxiety and redirect as needed. Resident #5's Care Plan for Cognition/Communication, dated 4/18/12, indicated Resident #5 had cognitive deficits with poor judgment and safety skills due to dementia. The Care Plan for ADLs, dated 4/18/12, indicated staff should encourage independence, but offer assistance as needed. The Long Term Care Fax Report Forms, dated 1/7/13, indicated that three alleged incidents of abuse involving CNA #1 and Resident #1, Resident #3 and Resident #5 took place between 5:00 A.M. and 6:00 A.M. on 1/7/13. According to the Form, at 5:00 A.M., Certified Nurse Aide #1 (CNA #1) smacked Resident #1 on the left elbow, while telling Resident #1 to get up. At approximately 5:30 A.M. on the same morning, CNA #1 was frustrated that Resident #3 was ringing the call bell, so she got Resident #3 up and she sternly told Resident #3 that Resident #3 must sit in his/her chair. At 6:00 A.M., CNA #1 indicated that Resident #5 was acting like a possum (hiding under the blankets) and CNA #1 roughly grabbed Resident #5's arms and pulled him/her up into a sitting position. The Surveyor interviewed CNA #2 on 1/17/13 at 12:45 P.M. CNA #2 also wrote a statement, dated 1/7/13, for the Facility's internal investigation. CNA #2 said she worked with CNA #1 on the morning of 1/7/13. CNA #2 said CNA #1 was in a bad mood and took out her frustration and bad mood on Residents #1, #3 and #5. Although the alleged abuse of Resident #1 took place at about 5:00 A.M., CNA #2 did not report her observations of suspected abuse until 6:00 A.M. By this time, CNA #2 witnessed three separate incidents of suspected abuse by CNA #1. The Surveyor interviewed Nurse #1 on 1/22/13 at 3:10 P.M. Nurse #1 said she worked the 11:00 P.M. to 7:00 A.M. shift on 1/6/13 into 1/7/13. Nurse #1 said the allegations were not reported to her on the morning of 1/7/13 and she had was unaware of the alleged abuse. The Facility's policy and procedure on reporting suspected abuse indicated that any person observing an incident of resident abuse or suspected resident abuse will immediately report such incidents to their immediate supervisor and/or charge nurse. The immediate reporting of the suspected abuse of Resident #1 may have prevented the abuse of Resident #3 and Resident #5 on 1/7/13.