Every finding on record at Hunt Nursing & Rehab Center

Based on observation, record review and interview, the facility failed to ensure treatment and care in accordance with professional standards of practice were implemented for one Resident (#35) out of a total of 29 sampled Residents. Specifically, the facility failed to obtain an initial treatment order for an open skin area and failed to ensure Resident #35 was seen timely by the wound physician. Subsequently, Resident #35 had an open area for approximately 12 days before being seen by the wound physician and having an ordered treatment. Findings include: Review of the National Library of Medicine article titled Wound Dressings dated 1/23/24 indicated: When the skin is compromised due to wounds, a complex healing process is triggered by various cell types and microenvironments. Choosing the proper wound dressing is crucial to accelerate healing, reduce treatment costs, and improve the patient's overall well-being.Review of the facility's Skin Integrity Management policy dated as revised 12/3/25 indicated: When a skin breakdown is identified, report this timely to medical practitioner and resident representative as required by policy. Obtain wound treatment order. Obtain referral to wound consultant who will partner with facility nurse in conducting wound assessment and treatment review. Every treatment recommendation will be reviewed timely with the resident's primary Medical Practitioner.Resident #35 was admitted to the facility in April 2013 with diagnoses including cerebral palsy, dysphagia and cognitive communication disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #35 is mildly cognitively impaired, as evidenced by a score of 11 out of a possible 15 on the Brief Interview for Mental Status exam. During an interview on 2/10/26 at 7:49 A.M., the surveyor observed Resident #35 resting on an air mattress (a specialty mattress utilized to redistribute pressure on the body). Resident #35 said he/she had a wound on his/her buttock that the nurses come in daily to take care of it. Resident #35 said the wound was new. Review of Resident #35's care plans indicated: Resident is at high risk for pressure ulcer development r/t (related to) incontinence of bowel and bladder and physical limitations. Interventions: Observation of skin condition during care - report pink, red or open areas to nurse. Update physician of new skin conditions and obtain orders. Review of the progress note written by Nurse #2, dated 12/3/25, indicated: Resident had a large bowel movement and went to bed with call light within reach, it was also noticed that resident had an open area around the coccyx area, which was cleaned with normal saline and covered with border foam. During an interview on 2/11/2026 at 7:49 A.M., Nurse #2 said the Certified Nursing Aides (CNAs) had alerted her that Resident #35 had identified a skin area after receiving care on the 3:00 - 11:00 evening shift. Nurse #2 said the area wasn't open but was reddened (contradicting the written note) and she put a dressing in place and alerted the oncoming staff. Review of the Dietary Progress note dated 12/4/25 indicated: Alerted by nursing re: open area to coccyx. Resident eats well. Plan is for resident to been by wound MD, will follow for any changes in skin. Review of the Risk Meeting Notes indicated: 12/4/26: Resident with new open area, will see wound MD Monday, (12/8/25).12/12/26: Resident not seen by wound MD, will be seen on Monday (12/15/25). Review of the Wound Physician note dated 12/15/25 indicated: Non-pressure wound to the left buttock, full thickness. Etiology unknown2 CM (centimeters) x 3 CM x .1 CM Exudate: moderate sero-sanguinous (a type of wound drainage that is a combination of serous fluid (clear or yellow) and sanguineous fluid (blood), light pink, watery mixture)Grimacing notedDressing Treatment Plan: Alginate Calcium with silver (an absorbent wound dressing), apply twice daily and as needed. Gauze sponge sterile apply twice daily and as needed. Review of the physician order dated 12/15/25 indicated: To open area L (left) buttock day and evening: wash with NS (normal saline) apply calcium alginate with silver, cover with gauze skin prep peri wound. Review of Resident #35's clinical record indicated that Resident #35 was not seen by the Wound Physician until 12/15/25; approximately 12 days after the area was identified. Additionally, there were no treatment orders to the area implemented prior to 12/15/25. During an interview on 2/11/2026 at 9:34 A.M., Physician #1 said that initial treatment orders are implemented until a resident can be seen by the Wound Physician. Physician #1 said that he defers treatment recommendations for wounds to the Wound Physician. Physician #1 said that he was not aware there were no initial treatment orders for Resident #35's open area or the delay in Resident #35 being seen by the Wound Physician. During an interview on 2/11/26 at 9:43 A.M., Unit Manager #1 said that the Wound Physician comes in on Mondays and rounds with the Wound Nurse who then inputs the recommendations into the electronic record as orders. Unit Manager #1 said that initial treatment orders implemented until the Wound Physician can see the Resident and open areas require a dressing. Unit Manager #1 said she did not know why Resident #35 did not have initial treatment orders implemented when the wound was first noted and did not know why the Wound Physician did not see the Resident until 12/15/25. The Wound Physician was unavailable for interview. During an interview on 2/11/2026 at 11:53 A.M., the Wound Nurse said she rounds with the Wound Physician in the facility on Mondays. The Wound Nurse said that Resident #35 has had a chronic area that drains, and an open area does require a dressing. The Wound Nurse said she did not know why Resident #35 was not seen until 12/15/25 by the Wound Physician. During an interview on 2/12/2026 7:11 A.M., the Director of Nursing (DON) said that the facility is working on developing a new system related to skin management and treatment orders. The DON said she did not know why Resident #35 was not seen by the Wound Physician until 12/15/25 or why an initial treatment was not implemented.

Based on record reviews and interviews, the facility failed to implement a recommendation by the optometrist for one Resident (#26) out of a total sample of 29 residents. Findings include:Resident #26 was admitted to the facility in May 2022 with diagnoses including spina bifida, colostomy, hypertension, major depressive disorder, and anxiety. Review of Resident #26's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) examination score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #26 is dependent in staff for activities of daily living and wears corrective lenses. During an interview on 2/10/26 at 8:02 A.M., Resident #26 said he/she was seen by the eye doctor a few months back and recommended cataract surgery for his/her left eye. Resident #26 said he/she has not been informed if an appointment has been made and is worried his/her vision is getting worse.Review of Resident #26's medical record indicated a consent for ophthalmology services was signed 5/6/22.Review of Resident #26's medical record indicated he/she was last seen by optometrist on 5/15/25 and 10/24/25 with the following recommendations:-5/15/25: PLAN:1. Cataract surgery recommended, ophthalmology consult, follow up 5-6 months, Referral Ophthalmology Consult: Please make next available appt for cataract surgery, can try OCB [NAME] [PHONE NUMBER]. 2. Monitor IOP, follow up 5-6 months, Referral Ophthalmology Consult: pt needs further testing, OCT/VF can try OCB [NAME] [PHONE NUMBER]. 3. Monitor Follow up, Comprehensive 5/15/26.-10/24/25: PLAN-1. Cataract surgery recommended: Ophthalmology consult, follow up: Priority Comprehensive 5/15/25, Referral-Ophthalmology Consult please make next available ophthalmology appointment for cataract surgery consult. 2. Monitor IOP, follow up: Priority Comprehensive 5/15/25, Referral Ophthalmology Consult-please also make glaucoma testing appointment.Further review of Resident #26's medical record failed to indicate the recommendations made by the optometrist on 5/15/25 and 10/24/25 were implemented.During an interview on 2/12/26 at 7:22 A.M., Unit Manager #1 said when the eye doctor has recommendations, the doctor will let us know before leaving the facility and we will review the recommendations with the resident. The appointment is then made with the recommended doctor or a local doctor that takes the resident's insurance. Unit Manager #1 said it is the expectation that we would follow the doctor's recommendations and she was unaware that an appointment had not been made for Resident #26.During an interview on 2/12/26 at 9:26 A.M., the Director of Nursing said all recommendations made by the optometrist are reviewed by the unit manager and if the resident agrees the appointment would be made. The Director of Nursing said she would expect the appointment to be made after receiving the recommendation from the provider.

Based on observation, record review and interview, the facility failed to implement treatment orders as recommended by the Wound Physician for one Resident (#85) out of a total of 29 sampled Residents. Specifically, the facility failed to implement betadine treatment to a right heel deep tissue injury (DTI; a wound that occurs related to pressure) for approximately 43 days. Findings include: Review of the Skin Integrity Management policy dated as revised 12/3/25 indicated: When a skin breakdown is identified, report this timely to medical practitioner and resident representative as required by policy. Obtain wound treatment order. Obtain referral to wound consultant who will partner with facility nurse in conducting wound assessment and treatment review. Every treatment recommendation will be reviewed, timely with the resident's primary Medical Practitioner.Resident #85 was admitted to the facility in August 2025 with diagnoses including neuro cognitive disorder with Lewy bodies and Parkinsons disease. Review of the Minimum Data Set Assessment 11/18/25 indicated Resident #85 was unable to participate in the Brief Interview for Mental Status Exam and is severely cognitively impaired. On 2/10/26 at 8:11 A.M. the surveyor observed Resident #85 resting on an air mattress (a specialty mattress utilized to redistribute pressure on the body). Resident #85 was unable to participate in the interview process. Review of Resident #85's care plans indicated: 9/24/25: Suspected Deep Tissue Injury (DTI) Interventions: Treatment to area per physician's order. Refer to wound specialist if indicated/ordered. Review of the Wound Physician note dated 12/15/25 indicated: Unstageable DTI of the right medial heel. Treatment plan: Betadine apply once daily and as needed, ABD (abdominal) pad apply once daily and as needed gauze roll 4.5 apply once daily and as needed, paper tape once daily and as neededAdditional review of the Wound Physician notes dated 12/22/25, 12/29/25, 1/5/26, 1/12/26, 1/19/26, all indicated betadine apply once daily and as needed if saturated soiled or dislodged. ABD pad apply once daily, gauze roll and paper tape as the primary treatment for Resident #85's right heel. Review of the physician orders and Treatment Administration Records dated December 2025 and January 2026 indicated the following treatment orders for Resident #85's right heel: Skin Prep Wipes Pad 1 pad topical day shift for alteration in skin integrity. Wash R medial heel with NS (normal saline) Apply skin prep cover with ABD pads. Wrap with gauze roll secured with tape. effective 12/1/25-1/26/26.On 1/27/26, Resident #85's orders changed to: R (right) medial heel DTI oint (ointment) with betadine over with ABD, gauze roll and secure with tape; approximately 43 days after the Wound Physician initially recommended the use of betadine. During an interview on 2/11/26 at 9:34 A.M., Physician #1 said that he defers to the Wound Physician for treatment orders for skin injuries.During an interview on 2/11/2026 at 9:43 A.M., Unit Manager #1 said that the Wound Nurse rounds with the Wound Physician on Monday's and inputs the treatment recommendations as orders into the electronic recordUnit Manager #2 and the Wound Physician were unavailable for interview.During an interview on 2/12/26 at 9:09 A.M., the Wound Nurse said that she was not aware that the Betadine Treatment was not implemented for Resident #85.During an interview on 2/12/2026 at 7:11 A.M., the Director of Nursing said that there had been issues with transcription of orders and the facility was rolling out a new program related to wounds and inputting orders. The DON said she was not aware that Resident #85's orders for betadine were not implemented.

Based on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in six of six medication carts observed. Findings include: Review of the facility policy titled Storage of Medications, dated [DATE], indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. On [DATE] at 8:43 A.M., the surveyor observed the third floor west side medication cart. The surveyor observed with Nurse #3 the following: - one Fluticasone Propionate inhaler opened, in use and undated. - one Advair Diskus inhaler opened, in use and undated. - one Breo Ellipta inhaler opened, in use and undated. - one Combivent Respimat inhaler opened, in use and undated. During an interview on [DATE] at 8:44 A.M., Nurse #3 said the expectation is the nurse who opens the inhalers should be dating them so each nurse knows then they are expired after opening. Nurse #3 said these four inhalers are not dated and should be. On [DATE] at 8:48 A.M., the surveyor observed the third floor east side medication cart. The surveyor observed with Nurse #4 the following: - one Albuterol Sulfate inhaler opened, in use and undated. - one Budesonide-Formoterol Fumarate inhaler opened, in use and undated. - two Spiriva Respimat inhalers opened, in use and undated. During an interview on [DATE] at 8:49 A.M., Nurse #4 said the expectation is the nurse who opens the inhalers should be dating them so each nurse knows then they are expired after opening. Nurse #4 said these four inhalers are not dated and should be. On [DATE] at 8:54 A.M., the surveyor observed the second floor west side medication cart. The surveyor observed with Nurse #5 the following: - two Trelegy Ellipta inhalers opened, in use and undated. - one Anoro Ellipta inhaler opened, in use and undated. - one Ventolin inhaler opened, in use and undated. - one Albuterol Sulfate inhaler opened, in use and undated. During an interview on [DATE] at 8:55 A.M., Nurse #5 said the expectation is the nurse who opens the inhalers should be dating them so each nurse knows then they are expired after opening. Nurse #5 said these five inhalers are not dated and should be. On [DATE] at 9:11 A.M., the surveyor observed the second floor east side medication cart. The surveyor observed with Nurse #6 the following: - two Albuterol Sulfate inhalers opened, in use and undated. - one Incruse Ellipta inhaler opened, in use and undated. - one Fluticasone Propionate inhaler opened and undated. During an interview on [DATE] at 9:12 A.M., Nurse #6 said the expectation is the nurse who opens the inhalers should be dating them so each nurse knows then they are expired after opening. Nurse #6 said these four inhalers are not dated and should be. On [DATE] at 9:14 A.M., the surveyor observed the first floor east side medication cart. The surveyor observed with Nurse #1 the following: - one Trelegy Ellipta inhaler opened, in use and undated. - one Albuterol Sulfate inhaler opened, in use and undated. - one Stiolto Respimat inhaler opened, in use and undated. During an interview on [DATE] at 9:15 A.M., Nurse #1 said the expectation is the nurse who opens the inhalers should be dating them so each nurse knows then they are expired after opening. Nurse #1 said these three inhalers are not dated and should be. On [DATE] at 9:17 A.M. the surveyor observed the first floor west side medication cart. The surveyor observed with Nurse #7 the following: - one Albuterol Sulfate inhaler opened, in use and undated. During an interview on [DATE] at 9:18 A.M., Nurse #7 said the expectation is the nurse who opens the inhalers should be dating them so each nurse knows then they are expired after opening. Nurse #7 said this inhaler is not dated and should be. During an interview on [DATE] at 9:13 A.M., Unit Manager #1 said she expects all inhalers to be labeled by nursing staff with a date when opened as these inhalers have a shortened life after opening. During an interview on [DATE] at 10:23 A.M., the Director of Nursing (DON) said she expects all inhalers to be labeled with a date when opened.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#60) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Advanced Directives and MOLST (Medical Orders for Life Sustaining Treatment)/Do Not Resuscitate Orders), dated [DATE], indicated To respect each resident's right to participate in and/or make his/her treatment decisions. Advanced Directives will be reviewed with resident/resident representative at the time of admission and thereafter at least quarterly during care planning meetings. A MOLST and/or DNR Order, if available, will be included in resident's care planning and records and reflect a resident's directive to receive or not receive CPR in the event of cardiac or respiratory arrest. In order for an Advanced Directive relative to a DNR status to be valid, a valid MOLST and/or MD (medical doctor) order indicating DNR must be noted in the resident's chart with evidence of participation from the resident or their representative. If a valid MOLST or DNR order is not present in the resident's medical record, resuscitation will be started. Resident #60 was admitted to the facility in [DATE] with diagnoses that included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage, aphasia, dysphagia, dementia, and epilepsy. Review of Resident #60's most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated Check all that apply - Advanced Directives: A. Guardian was the only advanced directive checked off. Review of Resident #60's MOLST for, located in the medical record and signed on [DATE], indicated DNR (Do Not Resuscitate). Review of Resident #60's physician order, dated [DATE], indicated Code Status: Full Code. Review of Resident #60's advanced directives care plan, dated [DATE], indicated Full Code guardian his/her mother is designated Guardian. The Resident and her/his family's decisions regarding Advanced Directives will be respected. MOLST will be signed by Resident, Guardian or Health Care Agent. Review of Resident #60's social services note, dated [DATE], indicated The Resident has a legal guardianship that names his/her mother. Full Code Status. Review of Resident #60's active Certified Nurse Aide (CNA) Kardex (form indicating the needs of each resident) indicated Code Status: Full Code. During an interview on [DATE] at 10:22 A.M., Nurse #2 said the expectation is that the nurses follow each Resident's MOLST, and that the doctor's order and the care plan should match what the MOLST indicates. During an interview and medical record review on [DATE] at 10:23 A.M., Unit Manager #2 said nurses are to follow the MOLST form and it could have been missed. Unit Manager #2 said the Resident's MOLST says they are to be a DNR, but his/her physician order reads as a full code. Unit Manger #2 said that the guardian said the facility lawyer told her the Resident has to be a full code. During an interview on [DATE] at 11:46 A.M., the Social Worker said family members who are guardians have the right to make a Resident a DNR/DNI (Do Not Intubate) and said we missed the MOLST form from 2018 and the Resident has been here in the facility since 2017. The Social Worker said the Resident should be a DNR code status and not a full code.

Based on observations, record review and interviews, the facility failed to ensure a comprehensive resident centered care plan was developed and/or implemented for two Residents (#48 and #95) out of a total sample of 24 Residents. Specifically, 1. For Resident #48, the facility failed to develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker. 2. For Resident #95, the facility failed to implement the Resident's care plan for elevating his/her feet while in bed and for the use of Darco shoes when ambulating. Findings include: Review of the facility policy titled Pacemaker, Care of Permanent, revised May 2005, indicated the following: Procedure -Include an entry for pacemaker on the resident's Care Plan. -Enter on the resident's Care Plan, the type of pacemaker, date of insertion, rate, pacemaker check, lab and phone number. -Report to physician any rate change of more than five impulses per minute, missed beats or any unaccustomed sensations associated with the pacemaker. -If pacemaker does not need to be checked, indicate that on the resident's Care Plan. 1. Resident #48 was admitted to the facility in July 2022 with diagnoses that included chronic diastolic congestive heart failure, asthma, syncope with collapse, bradycardia, atrioventricular block, second degree, and presence of a cardiac pacemaker. Review of Resident #48's most recent Minimum Data Set (MDS) assessment, dated 1/21/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 1 out of a possible 15, indicating severe cognitive impairment. Further review of the MDS indicated Resident #48 requires dependent assistance with functional daily activities and has an active diagnosis of a cardiac pacemaker. Review of Resident #48's physician orders and care plans failed to indicate a paced rate, serial number, frequency of pacemaker checks and cardiologist information. During an interview on 2/6/25 at 7:02 A.M., Unit Manager #2 said she would expect a care plan to be put in place on admission with all the pacemaker information, including paced rate, serial number, make and model. During an interview on 2/6/25 at 7:20 A.M., the Director of Nursing said a pacemaker care plan should include the paced rate, frequency of checks, make and model, and the serial number so the nurses are aware. 45984 2. Review of the facility policy titled Care Planning, revised and dated 10/28/22, indicated the following: - The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical needs. Resident #95 was admitted to the facility in August 2023 with diagnoses including end stage renal disease, bipolar disorder, dementia, obstructive and reflux uropathy and peripheral vascular disease. Review of Resident #95's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident had a Brief Interview for Mental Status exam score of 5 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated the Resident does not reject care and is dependent on staff for all activities of daily living. Review of Resident #95's physician's orders indicated the following: - Start date 9/8/23: Elevate. Offload bilat (bilateral) heels when in bed every shift. - Start date 2/16/24: Info: Information only Resident should be wearing Darco shoes when ambulated or transferred (Darco shoes are specialized shoes to assist with offloading areas of the feet and to aid in balance while ambulating). The surveyor made the following observations: - On 2/5/25 at 6:43 A.M., Resident #95 slept in his/her bed. The Resident's feet were directly on his/her mattress. There was no pillow or orthotic on the end of the bed to encourage the Resident to elevate his/her feet. - On 2/5/25 at 9:50 A.M., Resident #95 slept in his/her bed. The Resident's feet were directly on his/her mattress. There was no pillow or orthotic on the end of the bed to encourage the Resident to elevate his/her feet. - On 2/6/25 at 6:46 A.M., Resident #95 was lying in his/her bed. The Resident's feet were directly on his/her mattress. There was no pillow or orthotic on the end of the bed to encourage the Resident to elevate his/her feet. The surveyor made the following observations: - On 2/5/25 at 7:54 A.M., Resident #95 was leaving his/her bathroom wearing non-slip socks only. No Darco shoes were observed in the Resident's room. - On 2/5/25 at 11:44 A.M., Resident #95 was eating his/her lunch in the dining room. The Resident was wearing regular slip-on shoes. No Darco shoes were observed in the Resident's room. - On 2/6/25 at appropriately 7:40 A.M., Resident #95 was awake and dressed waiting to be transported to a medical appointment. The Resident was wearing regular, slip-on shoes. No Darco shoes were observed in the Resident's room. Review of Resident #95's falls care plan dated 12/7/23 indicated the following: Resident #95 is at-risk for major injury from falls. The following risk factors have been identified: fell in the past year, recent toe amputations, resident attempts to transfer without assistance as well as ambulate. The following interventions for Resident #95's falls care plan indicated the following: - Dated 8/5/22: use devices that eliminate pressure on the heels: offload as tolerated. - Dated 12/3/23: off-loaf bilateral heels while in bed as tolerated. - Dated 2//3/25: Proper footwear, remind to ask for assistance when needed. During an interview on 2/6/25 at 8:23 A.M., Unit Manager #1 said Resident #95 should be elevating his/her feet while in bed with pillows. The Surveyor informed Unit Manager #1 that no pillows have been observed at the end of the Resident's bed, and she said there should be pillows there. Unit Manager #1 continued to say that Resident #95 has had multiple foot surgeries in the past for venous ulcers and has balance issues. Unit Manager #1 said the Darco shoes are for offloading his/her feet. Unit Manager #1 said all physician orders should be followed as written. During an interview on 2/6/25 at 8:42 A.M., the Director of Nursing (DON) said all physician orders should be followed as written. The DON continued to say that Resident #95 should have his/her feet elevated when in bed and he/she should be wearing Darco shoes when ambulating.

Based on observation, record review and interview, the facility failed to ensure residents were provided with the appropriate treatment and services to maintain activities of daily living for one Resident (#40) out of a total sample of 24 residents. Specifically, the facility failed to ensure Resident #40's recommendations for a functional maintenance program from physical therapy were maintained resulting in the Resident only using his/her wheelchair for mobility. Findings include: Review of the facility policy titled Physical Therapy and Occupational Therapy, dated September 2011, indicated the following: - It is the policy of the facility to provide rehabilitation services to all residents whose plan of care includes such services. These services will be administered in a safe, clean environment. Resident #40 was admitted to the facility in September 2021 with diagnoses including polyneuropathy, polyarthritis and chronic pain syndrome. Review of Resident #40's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident uses a wheelchair for mobility and was unable to walk 10 feet due to his/her medical condition. During an observation and interview on 2/4/25 at 9:26 A.M., the surveyor observed a wheelchair next to Resident #40's bed. In the corner of the Resident's room, a rolling walker was folded up behind belongings of the Resident. Resident #40 said he/she uses his/her wheelchair to move around and does not use his/her walker anymore. Resident #40 said he/she used to use his/her walker to use the bathroom and go short distances, but he/she does not now. Resident #40 said his/her back pain hurts, so he/she stopped seeing therapy a while ago. The Resident said he/she would be willing to try physical therapy again, but no one has asked him/her. Review of Resident #40's physician's order dated 9/1/21 indicated the following: Consult Physical Therapy. Review of Resident #40's Kardex (a care card displaying the needs of the resident) indicated that the Resident uses a wheelchair for adaptive devices. Review of Resident #40's falls care plan indicated the following intervention dated 9/2/21: Rehab services as needed. Review of Resident #40's alteration in ability to provide self-care/perform ADL's (activities of daily living) r/t (related to) declined motor strength indicted the following intervention dated 9/2/21: Encourage participation in therapy. The surveyor requested all Physical Therapy (PT) visits for 2024 and 2025 for Resident #40. The Director of Nursing said the Resident has not been seen by PT in 2024 or 2025. Review of Resident #40's physician's visit note dated 2/19/24 indicated the following: - He/she goes out in a wheelchair. He/she can walk short distances with a walker. Review of Resident #40's physician's visit note dated 6/27/24 indicated the following: - He/she goes out in a wheelchair. He/she can walk short distances with a walker. Review of Resident #40's document titled Physical Therapy PT recertification dated from 6/19/23 - 7/18/23 indicated the following: LTG (long term goal) - Goal Met: The patient will demonstrate improved ambulation to 50 feet, SBA (stand by assist), pain no greater than 7/10, in order to improve his/her ability to negotiate his/her environment with improved independence, and quality of life. Current Status (6/19/23): 60-75 feet, SBA, pain 7/10. Review of Resident #40's document titled Physical Therapy PT Discharge Summary dated from 4/26/23 - 7/3/23, indicated the following: - Patient Progress: All functional goals met. - Discharge Recommendations and Status - Discharge Recommendations: FMP (Functional Maintenance Program) in place for walking program with one staff member assisting. -D/C (discharge) Reason: Maximum Potential Achieved, referred to FMP - Discharge Recommendations and Status: Prognosis to maintain CLOF (current level of function) = excellent with consistent staff support, Excellent with participation in FMP, Excellent with home exercise program. During an interview on 2/5/25 at 12:13 P.M., the Director of Rehab (DOR) of the facility said she is a PTA (physical therapy assistant) and has worked in the facility for less than one year. The DOR said the facility does quarterly screens for all residents in the building to see who has not been seen by therapy. The DOR said quarterly screens are typically done by occupational therapy and they will let PT know who needs to be seen. The DOR then reviewed Resident #40's PT Discharge Summary from 4/26/23 - 7/3/23 and said Resident #40 was discharged from PT using a rolling walker. The DOR said Resident #40 was discharged with a functional maintenance program (FMP) for walking using a walker with one staff member. The surveyor requested to see the FMP, but she was unable to provide it, so she was unsure if it was ever done. The DOR said once a resident is referred to a FMP she would expect nursing to be educated on it and follow through with it. The DOR said Resident #40 would benefit from seeing PT again as he/she has not been using his/her walker. During a follow up interview on 2/5/25 at 12:50 P.M., Resident #40 said he/she would like to do PT again so he/she could try using his/her walker again. He/she said the facility used to have someone walk down the hallway with him/her, but they stopped doing it and he/she does not know why. During an interview on 2/5/25 at 12:56 A.M., Certified Nursing Assistant (CNA) #1 said she has worked in the facility for [AGE] years. CNA #1 said Resident #40 used to walk with a walker, but he/she stopped because it was painful for him/her, and he/she has not seen therapy in a while. CNA #1 said ever since the Resident moved to this floor (long-term care unit) he/she has used a wheelchair while ambulating. During an interview on 2/6/25 at 8:23 A.M., Unit Manager #1 said she was not sure if Resident #40 was a part of a functional maintenance program. During a follow up interview on 2/6/25 at 7:13 A.M., the DOR said she spoke with Resident #40, and he/she said he/she would like to have physical therapy again so he/she will be starting again. During an interview on 2/6/25 at 8:42 A.M., the Director of Nursing said when Physical Therapy makes recommendations they should let nursing know and those recommendations should be followed.

Based on observations, record review and interviews, the facility failed to maintain professional standards in the management and care for urinary catheter devices for one Resident (#95) out of a total sample of 24 residents. Specifically, the facility failed to ensure that an indwelling catheter bag (a tube that enters the bladder to drain urine into a collection bag) was at the proper location below the Resident's bladder to allow urine to be drained into the bag for Resident #95. Findings include: Resident #95 was admitted to the facility in August 2023 with diagnoses including end stage renal disease, bipolar disorder, dementia, obstructive and reflux uropathy and peripheral vascular disease. Review of Resident #95's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment. Further review of the MDS indicated that the Resident did not reject care, was dependent on staff for all activities of daily living and had an indwelling catheter. The surveyor made the following observations: - On 2/5/25 at 6:43 A.M., Resident #95 was sleeping in his/her bed. The Resident's legs were exposed to reveal a urinary catheter bag strapped to his/her right leg above the knee. The catheter bag was not hanging below the level of the Resident's bladder. - On 2/5/25 at 9:50 A.M., Resident #95 was sleeping in his/her bed. The Resident's legs were exposed to reveal a urinary catheter bag strapped to his/her right leg above the knee. The catheter bag was not hanging below the level of the Resident's bladder. - On 2/6/25 at 6:46 A.M., Resident #95 was lying in his/her bed. The Resident's urinary catheter bag was not visibly hanging from his/her bed. Resident #95 told the surveyor that he/she always has his/her catheter bag strapped to his/her leg, even when sleeping. Review of Resident #95's physician's orders indicated the following: - Start date 7/1/24: Foley - site care provide foley catheter care - Start date 2/3/25: Foley Catheter Every Shift, 14 fr (French) Review of Resident #95's Kardex (a care card displaying the needs of the resident) indicated the Resident uses a catheter under the Bladder section. Review of Resident #95's urinary catheter care plan dated 2/3/25 indicated the Resident uses a urinary catheter due to urinary retention with the following intervention: Secure catheter to prevent tension on the tube and facilitate urine flow. Review of Resident #95's medical record failed to indicate any documentation that the Resident has refused to hang his/her catheter bag at the bedside when lying in bed. During an interview on 2/6/25 at 8:23 A.M., Unit Manager #1 said Resident #95's catheter bag should be hanging from his/her bed when he/she is laying down, so it is below his/her bladder level to prevent backflow and tube kinking. During an interview on 2/6/25 at 8:42 A.M., the Director of Nursing (DON) said Resident #95's foley catheter bag should be below his/her bladder level to prevent urinary backflow and tube issues, and the Resident should not be using a leg bag while in bed. The DON said staff should be encouraging Resident #95 to hang his/her catheter bag at the bedside and if the Resident refuses staff should be documenting this behavior.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of falls, was assessed by nursing as being at risk for falls and whose comprehensive plan of care included an intervention of a fall mat on the floor beside his/her bed when in bed, the Facility failed to ensure staff consistently implemented and followed the plan of care, when on 10/21/24, Resident #1 was found on the floor after a fall out of bed, and there was no fall mat in place beside his/her bed. Findings include: The Facility Policy, titled Care Planning, dated 10/28/22, indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. Resident #1 was admitted to the Facility in June 2024, diagnoses included dementia and history of falls. Review of Resident #1's Falls Risk Assessment, dated 09/25/24, indicated he/she was assessed as being at risk for falls. Review of Resident #1's Medical Record indicated he/she had a Physician's Order, dated 10/03/24 for the use of a fall mat at his/her bedside on the right side of his/her bed. Review of Resident #1's Falls Care Plan indicated he/she had an intervention, dated 10/03/24 for fall mat on the floor while in bed. Review of Resident #1's Nurse Progress Note, dated 10/21/24, indicated he/she was found lying on the floor in his/her room. Review of the Facility's Corrective Measures Narrative, dated 10/25/24, indicated the Facility identified that the fall mat was not in place when Resident #1 fell on [DATE]. During an interview on 11/20/24 at 08:40 A.M., the Director of Nurses (DON) said that on 10/21/24 at 07:00 A.M., he observed Resident #1 sleeping in his/her bed, but could not recall if he saw the floor mat in place at that time. The DON said that at 07:30 A.M., he was alerted by staff that Resident #1 was found on the floor in his/her room, and said that he (DON) observed that the floor mat was not in place next to Resident #1's bed, or in his/her room at all, but should have been in place per his/her plan of care. On 11/20/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 10/21/24, The Morning Meeting Resident At Risk Minutes indicated Resident #1's fall was reviewed by the Interdisciplinary Team. B. 10/21/24, The Ad-Hoc Quality Assurance Performance Improvement (QAPI) Plan indicated the Facility Leadership developed a plan to correct the deficient practice and ensure that residents were provided with fall devices as indicated in the plan of care. C. 10/21/24, an Audit Tool was initiated and completed by Unit Managers and the Facility's Regional Nurse, who conducted rounds on all units to ensure residents with falls devices identified in the plan of care, had the devices in place. D. Audit Tool indicated Unit Managers and the Facility's Regional Nurse will continue to conduct rounds to ensure residents with falls devices were in place daily, until substantial compliance is met. E. 11/13/24, The October Monthly QAPI Meeting Minutes indicated the Interdisciplinary Team reviewed compliance with falls device placement and staff education. F. 11/15/24, Staff Development Coordinator provided education to nursing staff to ensure any devices identified in the residents' care plans to prevent falls are in place, and with nursing staff required to sign and participate in the educational inservice. G. The DON/designee will continue audits to ensure placement of falls devices weekly through the end of November 2024, then monthly ongoing. H. The Facility will continue to monitor compliance at the monthly and quarterly QAPI meetings. I. The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she was at risk for falls due to impulsivity and decreased strength, required assistance from two staff members for toileting and transfers, with a staff member remaining outside the bathroom door while he/she was on the toilet, the Facility failed to ensure staff implemented and followed interventions identified in his/her care plan, when on 02/26/24, Resident #1 told the Director of Rehabilitation (DOR) that he/she had to use the bathroom, The DOR left him/her in his/her room to take him/herself to the bathroom, and did not tell any other staff that he/she was going to use the bathroom. Resident #1 transferred him/herself into the bathroom and as a result, fell . The next day, Resident #1 complained of left elbow pain and was diagnosed with a fractured elbow. Findings include: The Facility Policy, titled Care Planning, indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and psychological needs that are identified in the comprehensive assessment. Resident #1 was admitted to the Facility in January 2024, diagnoses included spinal stenosis, left sided hemiplegia, left foot drop, history of falls, and anxiety. Review of Resident #1's Falls Care Plan, dated as revised on 01/31/24, indicated he/she was at risk for falls, was impulsive, and had multiple falls while at the Facility. The Care Plan indicated staff would remind Resident #1 to use the call bell to ask for assistance and when assisting him/her to the bathroom, staff were to stand outside the door (later clarified by the Director of Nurses to mean that once Resident #1 was on the toilet, a staff member would stay outside of and next to the bathroom door to allow for privacy and provide supervision). Review of Resident #1's Activities of Daily Living (ADL) care plan, dated 01/19/24, indicated he/she required assistance by two staff members for toileting and transfers. Review of Resident #1's Physical Therapy Evaluation, for certification period 02/06/24 through 03/06/24, indicated Resident #1 required standby assistance and close supervision for safety for toilet transfers. Review of Resident #1's Occupational Therapy Evaluation, for certification period 02/07/24 through 03/07/24 indicated Resident #1 required contact guard level of assistance for toilet transfers. Review of the Nurse Progress Note, dated 02/26/24, indicated that at 01:45 P.M., Resident #1 fell while attempting to transfer him/herself into the bathroom, and as a result had a new skin tear on his/her elbow. Review of the Nurse Progress Note, dated 02/27/24, indicated Resident #1 complained of increased pain in his/her left elbow, and a Physician's order for an X-ray of his/her elbow was obtained. Review of the Radiology Report, dated 02/28/24, indicated Resident #1 had an acute proximal ulna (lower arm bone) nondisplaced fracture and moderate joint effusion (fluid buildup) of his/her left elbow. Review of the Facility's Investigation Report, dated 02/28/24, indicated Resident #1 was known to be impulsive, had poor safety awareness, required assistance with all transfers, and staff were to stay outside his/her bathroom door when he/she was on the toilet. The Report indicated that on 02/26/24, Resident #1 told the Director of Rehabilitation (DOR) that he/she needed to use the bathroom, and the DOR asked him/her if he/she could do it on his/her own, Resident #1 said yes, and the DOR left him/her to toilet his/herself. The Report indicated Resident #1 then attempted to transfer his/herself to the bathroom, fell , the next day complained of pain in his/her elbow, and was diagnosed with a left elbow fracture. During an interview on 04/16/24 at 9:54 A.M., the Director of Rehabilitation said he was familiar with Resident #1 since he had worked with him/her for a few weeks. The DOR said that he knew Resident #1 was known to be impulsive, had a history of falls, and that he/she required standby assistance by rehabilitation staff for transfers. The DOR said that on 02/26/24 he went to Resident #1's room to bring him/her to therapy, he/she was seated in his/her wheelchair next to the bed, and Resident #1 said he/she needed to use the bathroom. The DOR said he asked him/her if he/she could go to the bathroom by him/herself to which Resident #1 said yes, so he then left Resident #1's room, and did not assist Resident #1 to the bathroom. The DOR said he did not tell anyone else that Resident #1 said he/she needed to use the bathroom. The DOR said he should have stayed with Resident #1 or told another staff member that he/she had to use the bathroom, but did not. The Director of Rehabilitation said when he returned to get Resident #1 a little while later, he was told he/she had fallen while taking him/herself to the bathroom. During a telephone interview on 04/16/24 at 11:48 A.M., the Director of Nurses (DON) said the Rehabilitation Department staff had helped develop Resident #1's Care Plan and said the DOR should have helped Resident #1 or asked another staff member to help him/her to the bathroom but did not. On 04/16/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 02/26/24, Resident #1's Care Plan was revised to include staff are to remind him/her with each encounter to call for assistance, and when rehabilitation staff work with him/her they are to assist him/her with toileting. B. 02/26/24, The Audit Sheet, completed by the Director of Rehabilitation, indicated all residents who were receiving rehabilitation services were audited to ensure the nursing and rehabilitation plans of care were up to date. C. 02/28/24, The Hospital Visit Summary indicated Resident #1 was assessed and treated at the Emergency Department for a closed fracture of the left ulna, and a follow up appointment was scheduled. D. 02/2024, The Education Sign in Sheet indicated nursing staff were educated by the Staff Development Coordinator (SDC) that all residents identified as being at risk for falls have a care plan in place and staff are to implement the interventions as per the resident's care plan and kardex. E. 03/01/24, The Education Sign in Sheet indicated rehabilitation staff were educated by the SDC that rehabilitation staff are responsible for checking with nursing staff prior to resident treatment sessions to determine the required level of assistance with toileting. F. 03/08/24, The Weekly Risk Meeting Fall Review minutes indicated the interdisciplinary team reviewed Resident #1's fall that occurred on 02/26/24, and other falls that occurred that week. G. 03/20/24, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents were provided with the appropriate level of supervision and assistance as determined by assessments and identified in their plans of care. H. The Facility will continue to review all falls at Weekly Risk Meetings. I. The Director of Nurses and/or designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was known to be impulsive, required two staff member assistance for toilet transfers, with one staff member remaining outside the bathroom door while he/she was on the toilet to provide standby assistance, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety, when on 02/26/24, Resident #1 told the Director of Rehabilitation (DOR) that he/she had to use the bathroom, the DOR left him/her in his/her room to take him/herself to the bathroom, and did not inform any other staff that he/she was going to use the bathroom. Resident #1 attempted to transfer him/herself in the bathroom, fell , sustained a skin tear to his/her left arm, and the next day he/she complained of left elbow pain and was diagnosed with a fractured elbow. Findings include: The Facility Policy, titled Falls Risk Reduction, dated 11/02/23, indicated residents determined to have risk factors for falls would receive individualized interventions based on the risk factors in order to reduce risk for and minimize falls, and that each resident would receive adequate supervision and assistance devices to prevent accidents. The Facility Policy, titled Care Planning, indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and psychological needs that are identified in the comprehensive assessment. Review of the Facility's Investigation Report, dated 02/28/24, indicated Resident #1 was known to be impulsive, had poor safety awareness, required assistance with all transfers, and staff were to stay outside his/her bathroom door when he/she was on the toilet. The Report indicated that on 02/26/24, Resident #1 told the Director of Rehabilitation (DOR) that he/she needed to use the bathroom, and the DOR asked him/her if he/she could do it on his/her own, Resident #1 said yes, and the DOR left him/her to toilet him/herself. The Report indicated Resident #1 then attempted to transfer him/herself to the bathroom, fell , the next day complained of pain in his/her elbow, and was diagnosed with a left elbow fracture. Resident #1 was admitted to the Facility in January 2024, diagnoses included spinal stenosis, left sided hemiplegia, left foot drop, history of falls, and anxiety. Review of Resident #1's Falls Care Plan, dated as revised on 01/31/24, indicated he/she was at risk for falls, was impulsive, and had multiple falls while at the Facility. The Care Plan indicated staff would remind Resident #1 to use the call bell to ask for assistance and when assisting him/her in the bathroom, staff were to stand outside the door (later clarified by the Director of Nurses to mean that once Resident #1 was in the toilet, staff would stay outside of and next to the bathroom door, to provide supervision and privacy). Review of Resident #1's Activities of Daily Living (ADL) care plan, dated 01/19/24, indicated he/she required assistance by two staff members for toileting and transfers. Review of the Facility's Incident Reports indicated Resident #1 fell while attempting to toilet him/herself on the following dates: -01/26/24 -02/04/24 -02/11/24 Review of Resident #1's Physical Therapy Evaluation, for certification period 02/06/24 through 03/06/24, indicated Resident #1 required standby assistance and close supervision for safety for toilet transfers. Review of Resident #1's Occupational Therapy Evaluation, for certification period 02/07/24 through 03/07/24 indicated Resident #1 required contact guard level of assistance for toilet transfers. Review of the Nurse Progress Note, dated 02/26/24, indicated that at 01:45 P.M., Resident #1 fell while attempting to transfer him/herself in the bathroom, and as a result had a new skin tear on his/her elbow. Review of the Nurse Progress Note, dated 02/27/24, indicated Resident #1 complained of increased pain in his/her left elbow, and a Physician's order for an X-ray of his/her elbow was obtained. Review of the Radiology Report, dated 02/28/24, indicated Resident #1 had an acute proximal ulna (lower arm bone) nondisplaced fracture and moderate joint effusion (fluid buildup) of his/her left elbow. During an interview on 04/16/24 at 9:54 A.M., the Director of Rehabilitation said he was familiar with Resident #1 since he had worked with him/her for a few weeks. The DOR said that he knew Resident #1 was known to be impulsive, had a history of falls, and that he/she required standby assistance by rehabilitation staff for transfers. The DOR said that on 02/26/24 he went to Resident #1's room to bring him/her to therapy, he/she was seated in his/her wheelchair next to the bed, and Resident #1 said he/she needed to use the bathroom. The DOR said he asked him/her if he/she could go to the bathroom by him/herself to which Resident #1 said yes, so he then left Resident #1's room, and did not assist Resident #1 to the bathroom. The DOR said he did not tell anyone else that Resident #1 said he/she needed to use the bathroom. The DOR said he should have stayed with Resident #1 or told another staff member that he/she had to use the bathroom, but did not. The Director of Rehabilitation said when he returned to get Resident #1 a little while later, he was told he/she had fallen while attempting to take him/herself to the bathroom. The DOR said the next day Resident #1 complained of increased pain in his/her left elbow, and was found to have a left elbow fracture. During a telephone interview on 04/16/24 at 11:48 A.M., the Director of Nurses (DON) said the Rehabilitation Department staff had helped develop Resident #1's Care Plan and said the DOR should have helped Resident #1 or asked another staff member to help him/her to the bathroom but did not. On 04/16/24, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 02/26/24, Resident #1's Care Plan was revised to include staff are to remind him/her with each encounter to call for assistance, and when rehabilitation staff work with him/her they are to assist him/her with toileting. B. 02/26/24, The Audit Sheet, completed by the Director of Rehabilitation, indicated all residents who were receiving rehabilitation services were audited to ensure the nursing and rehabilitation plans of care were up to date. C. 02/28/24, The Hospital Visit Summary indicated Resident #1 was assessed and treated at the Emergency Department for a closed fracture of the left ulna, and a follow up appointment was scheduled. D. 02/2024, The Education Sign in Sheet indicated nursing staff were educated by the Staff Development Coordinator (SDC) that all residents identified as being at risk for falls have a care plan in place and staff are to implement the interventions as per the resident's care plan and kardex. E. 03/01/24, The Education Sign in Sheet indicated rehabilitation staff were educated by the SDC that rehabilitation staff are responsible for checking with nursing staff prior to resident treatment sessions to determine the required level of assistance with toileting. F. 03/08/24, The Weekly Risk Meeting Fall Review minutes indicated the interdisciplinary team reviewed Resident #1's fall that occurred on 02/26/24, and other falls that occurred that week. G. 03/20/24, The Quality Assessment Performance Improvement (QAPI) Plan indicated Facility leadership developed a plan to correct the deficient practice and ensure that residents were provided with the appropriate level of supervision and assistance as determined by assessments and identified in their plans of care. H. The Facility will continue to review all falls at Weekly Risk Meetings. I. The Director of Nurses and/or designee are responsible for overall compliance.

Based on staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels, as defined by the facility assessment, were maintained to meet each resident's personal and cognitive care needs safely and adequately. Findings include: Review of the facility policy, titled Staffing in the Department of Nursing, revised 05/02/05, indicated, but was not limited to, the following: -It is the policy of this facility to have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and consider the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. A system is in place to determine daily staffing needs, using a staffing pattern established by comparing policies and standards and reviewed by the Administrator and the Director of Nursing Services. -Procedure: Determine staffing needs based upon daily census, resident acuity, and facility assessment. Review of the facility assessment, last reviewed by the Administrator, Director of Nursing (DON), Infection Control Nurse, and Medical Director on 1/26/23, indicated the following staffing plan needed to ensure sufficient staff to meet the needs of the residents at any given time: -Five CNA's on the 7-3 shift on each unit. -Four CNA's on the 3-11 shift on each unit. -Two CNA's on the 11-7 shift on each unit. During the resident group meeting on 2/1/24 at 10:33 A.M., residents voiced the following concerns: -Six out of Seven attending residents said the facility is short staffed all shifts, every day. -Five out of Seven residents said that staffing is not getting better despite residents addressing it all the time. -The food tastes good but is often not hot due to the lack of staff passing trays. -Showers are scheduled twice a week but will typically not get showers twice a week because the facility is short-staffed. During an interview on 2/6/24 at 7:38 A.M., Certified Nursing Aide (CNA) #13 said they often do not have enough CNA's working, CNA #13 said there should be five CNA's on the 7-3 shift in order to properly care for the residents. During an interview on 2/6/24 at 7:55 A.M., CNA #14 said there should be five CNA's working on the 7-3 shift in order to properly care for the resident, and that sometimes there are not enough CNA's. During an interview on 2/6/24 at 8:02 A.M., Nurse #10 said there are not always enough CNA's working. Nurse #10 said five is an adequate number of CNA's for the 7-3 shift, but that three to four times a week there are less than four CNA's working on the unit. During an interview on 2/6/24 at 8:23 A.M., Nurse #3 said they are often short of CNA's, and that there is often less than four CNA's working on the unit during the 7-3 shift. During an interview on 2/6/24 at 8:25 A.M., Nurse #9 said there are not always enough CNA's working, and that this is a persisting problem at the facility. Nurse #9 said there are often less than four CNA's working on the unit during the 7-3 shift. Review of the actual working schedules for January and February indicated that the facility had less than the required amount of nursing staff needed, as determined by the facility assessment, for 30 of the 37 days reviewed. During an interview on 2/6/24 at 8:54 A.M., the scheduler said the 7-3 shift is the most challenging to adequately staff with CNA's. The scheduler said in order to meet the residents needs there needs to be five CNA's on the 7-3 shift on each unit, four CNA's on the 3-11 shift on each unit, and two CNA's on the 11-7 shift on each unit. The scheduler said staffing has been a little rough since October of last year, and that there are less than four CNA's working on the 7-3 shift on average three days a week. During an interview on 2/6/24 at 9:36 A.M., the Administrator said that staffing has been a challenge. The administrator said there should be five CNA's on the 7-3 shift on each unit, four CNA's on the 3-11 shift on each unit, and two CNA's on the 3-11 shift on each unit and that this is not always achieved. The Administrator said PPD (per patient day) is calculated by dividing the total amount of hours worked by direct care staff by the daily census. The Administrator said the facility has budgeted 3.35 PPD for direct care nursing staff consisting of CNA's, floor nurses, and unit managers and that this does not include administrative staff. Review of the actual working schedules for January and February of 2024, cross referenced with the daily census reports, indicated that the facility had less than 3.35 PPD on 35 of the 37 days reviewed.

Based on observations, record review and interviews, the facility failed to ensure they provided a clean, sanitary, and homelike environment. Specifically: - For one of three resident units (second floor unit), the facility failed to ensure the varnish on bedroom doors was in good, home-like condition - For Resident #113, the facility failed to ensure it emptied a filled urine hat (used for urine sample collection, or to collect and/or measure urine output) observed on his/her dresser for three days. Findings include: 1. On 2/1/24 at 1:54 P.M., the surveyor observed the second floor unit's bedroom closet and entry doors. Patches of varnish on the exterior door surfaces had been stripped off and exposed the undersurface, measuring approximately 2' x 2' and located on the top third of the doors. The following bedrooms were affected: #208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 222, and 223. On 2/2/24 at 9:00 A.M., the Maintenance Director and surveyor toured the second floor. The Maintenance Director and surveyor observed that many of the resident closet doors and bedroom entry doors were missing patches of varnish on the top third of the doors. The Maintenance Director said he was aware of the missing varnish, but had not repaired the doors yet. The Maintenance Director said the varnish was stripped off the doors because of staff taping notices on the doors, and when the notices were removed the backing tape pulled off the varnish. The Maintenance Director said the doors were not home-like. 44095 2. Resident #113 was admitted to the facility in January 2024 with diagnoses including hearing loss, chronic pain and dementia without behaviors. Review of the Minimum Data Set (MDS) assessment, dated 1/13/24, indicated Resident #113 had a Brief Interview of Mental Status (BIMS) score of 5 out of a possible 15 which indicated he/she had a cognitive impairment. The MDS indicated he/she required partial/moderate assistance with toilet transfer and toilet hygiene. The MDS indicated he/she was frequently incontinent of urine. Review of Resident #113's plan of care related to incontinence, dated 1/22/24, indicated: - toilet resident during their individual morning and evening care, before and after meals, before going back to bed. - provide incontinence as needed. - Resident #113 wears: large brief for management of urinary incontinence. Review of Resident #113's plan of care related to behaviors, dated 1/22/24, indicated: - provide well lit, uncluttered environment. Review of Resident #113's plan of care related to activities of daily living, dated 1/11/24, indicated: - toileting one assistance. - transfers one assistance. On 1/31/24 at 8:23 A.M. and at 2:20 P.M., on 2/1/24 at 6:54 A.M. and at 2:01 P.M., and on 2/2/24 at 6:55 A.M., and on 2/2/24 at 9:16 A.M., the surveyor observed a urine hat filled with approximately 250 millimeters (mls) of yellow concentrated urine on Resident #113's dresser immediately next to his/her hearing aids. On 2/2/24 at 9:16 A.M., Resident #113 was in his/her bed, the surveyor asked Resident #113 about the urine hat on his/her dresser. Resident #113 stated that's gross pee, I don't want that there, I want it gone. Resident #113 was not sure why the urine was there. On 2/2/24 at 10:04 A.M., Certified Nurse Assistant (CNA) #4 observed the urine with the surveyor. CNA #4 said the urine should not be left on the dresser. During an interview on 2/2/24 at 10:05 A.M., Nurse #3 said she was assigned to Resident #113 on 2/1/24 and 2/2/24 said she did not notice the urine in the hat left on Resident #113's dresser and Nurse #3 said it should not have been there. During an interview on 2/2/24 at 10:38 A.M., Unit Manager #1 said nursing and CNAs are in and out of Resident #113's room and staff should have noticed the urine and removed it. During an interview on 2/2/24 at 1:48 P.M., the Director of Nursing said the urine on Resident #113's dresser should have been emptied and not left in the room.

Based on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for five Residents (#113, #70, #10, #60 and #22 ), in a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #113, to ensure the MDS accurately reflected his/her cognitive status; and 2. For Resident #70, to ensure the MDS accurately reflected his/her cognitive status. 3. For Resident #10, to ensure the MDS accurately reflected his/her cognitive status. 4. For Resident #60, to ensure the MDS accurately reflected his/her cognitive status. 5. For Resident #22, to ensure the MDS accurately reflected his/her cognitive status. Findings include: 1.) For Resident #113 the facility failed to ensure they coded the Brief Interview of Mental Status (BIMS) accurately on the Minimum Data Set (MDS) assessment. Resident #113 was admitted to the facility in January 2024 with diagnoses including hearing loss, chronic pain and dementia without behaviors. Review of the Minimum Data Set (MDS) assessment, dated 1/13/24, indicated Resident #113 had a Brief Interview of Mental Status (BIMS) score of 99 out of a possible 15. Further review of the BIMS assessment indicated Resident #113 had a summary score of 5 out of a possible 15 points (word repetition three points, recall two points). During an interview on 2/2/24 at 12:53 P.M., the Director of Social Services said Resident #113 scored a 5 on the BIMS assessment. During an interview on 2/2/24 at 12:55 P.M., the MDS Coordinator said Resident #113 scored a 5 on the BIMS assessment. During an interview on 2/2/24 at 1:46 P.M., the Director of Nursing said the BIMS on the MDS should have been coded correctly. 15016 2.) For Resident #70, the facility failed to ensure it coded the Brief Interview of Mental Status (BIMS) examination accurately on the Minimum Data Set (MDS) assessment. Resident #70 was admitted to the facility in January 2024 with diagnoses including cerebral vascular accident and coronary artery disease. Review of the Minimum Data Set (MDS) assessment, dated 1/11/24, indicated Resident #70 had a BIMS score of 99 out of a possible 15. Further review of the BIMS assessment indicated Resident #70 had a summary score of 4 out of a possible 15 points (word repetition one point, temporal orientation three points) During an interview on 2/2/24 at 12:53 P.M., the Director of Social Services said scores are based on a summary of the BIMS points. During an interview on 2/2/24 at 12:55 P.M., the MDS Coordinator said the BIMS score is based on the total number of BIMS points. During an interview on 2/2/24 at 1:46 P.M., the Director of Nursing said the BIMS score is based on the total number of BIMS points. 43807 3. For Resident #10, the facility failed to ensure it coded the Brief Interview of Mental Status (BIMS) examination accurately on the Minimum Data Set (MDS) assessment. Resident #10 was admitted to the facility in September 2021 with diagnoses including Alzheimer's Disease. Review of the Minimum Data Set (MDS) assessment, dated 1/2/24, indicated Resident #10 had a BIMS score of 99 out of a possible 15. Further review of the BIMS assessment indicated Resident #10 had a summary score of 2 out of a possible 15 points. He/she scored 2 points in the repetition of 3 words. During an interview on 2/2/24 at 12:53 P.M., the Director of Social Services said scores are based on a summary of the BIMS points. During an interview on 2/2/24 at 12:55 P.M., the MDS Coordinator said the BIMS score is based on the total number of BIMS points. During an interview on 2/2/24 at 1:46 P.M., the Director of Nursing said the BIMS score is based on the total number of BIMS points. 4. For Resident #60, the facility failed to ensure it coded the Brief Interview of Mental Status (BIMS) examination accurately on the Minimum Data Set (MDS) assessment. Resident #60 was admitted to the facility in March 2019 with diagnoses including renal failure. Review of the Minimum Data Set (MDS) assessment, dated 11/21/23, indicated Resident #60 had a BIMS score of 99 out of a possible 15. Further review of the BIMS assessment indicated Resident #60 had a summary score of 3 out of a possible 15 points. He/she scored 3 points in the repetition of 3 words. During an interview on 2/2/24 at 12:53 P.M., the Director of Social Services said scores are based on a summary of the BIMS points. During an interview on 2/2/24 at 12:55 P.M., the MDS Coordinator said the BIMS score is based on the total number of BIMS points. During an interview on 2/2/24 at 1:46 P.M., the Director of Nursing said the BIMS score is based on the total number of BIMS points. 5. For Resident #22, the facility failed to ensure it coded the Brief Interview of Mental Status (BIMS) examination accurately on the Minimum Data Set (MDS) assessment. Resident #22 was admitted to the facility in November 2016 with diagnoses including stroke with right sided hemiparesis. Review of the Minimum Data Set (MDS) assessment, dated 12/19/23, indicated Resident #22 had a BIMS score of 99 out of a possible 15. Further review of the BIMS assessment indicated Resident #22 had a summary score of 4 out of a possible 15 points. He/she scored 3 points in the repetition of 3 words and 1 point for reporting the correct day of the week. During an interview on 2/2/24 at 12:53 P.M., the Director of Social Services said scores are based on a summary of the BIMS points. During an interview on 2/2/24 at 12:55 P.M., the MDS Coordinator said the BIMS score is based on the total number of BIMS points. During an interview on 2/2/24 at 1:46 P.M., the Director of Nursing said the BIMS score is based on the total number of BIMS points.

Based on observations, interviews and record review, the facility failed to implement physician's orders and care plans for 5 Residents (#10, #36, #46, #60 and #53) out of a sample of 26 residents. Specifically, 1. For Resident #10, the facility failed to implement a wheelchair wanderguard per the physician's order. 2. For Resident #36, the facility failed to implement a smoking care plan. 3. For Resident #46, the facility failed to implement a Prevalon boots physician's order. 4. For Resident #60, the facility failed to implement a Geri leg sleeves physician's order. 5. For Resident #53, the facility failed to implement interventions on the fall's care plan. Findings include: 1. For Resident #10, the facility failed to implement a wheelchair wanderguard per the physician's order. A review of the facility policy titled 'Elopement Prevention and Responses' with a revision date of April 2024 indicated the following: -It is the policy of this facility to provide a secure environment for residents identified at risk for elopement. -It is the policy of this facility to identify residents at risk for elopement Resident #10 was admitted to the facility in September 2021 with diagnoses including Alzheimer's Disease. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident is rarely/never understood. Further review of the MDS assessment indicated that the Resident uses a wheelchair to ambulate. On 2/1/24 at 9:37 A.M., the surveyor observed the Resident sitting in a wheelchair in the hallway next to the nurse's station, the wheelchair did not have a wander guard attached to it. On 2/1/24 at 10:08 A.M., 10:12 A.M., and 10:20 A.M., the surveyor observed the Resident in the wheelchair, ambulating on his/her own up and down the hallway, the wheelchair did not have a wander guard attached to it. On 2/1/24 at 10:47 A.M., and 10:58 A.M., the surveyor observed the Resident sitting in his/her wheelchair in front of the main exit door, the wheelchair did not have a wander guard attached to it. A review of the active physician's orders indicated the following: -Wander guard bracelet every shift, wheelchair check placement A review of the elopement care plan dated 8/18/23 indicated the following: -Apply wander guard detection bracelet to wheelchair A review of the most recent wandering/elopement risk assessment dated [DATE] indicated the following: -Resident is self-mobile in the wheelchair. -History of opening doors to outside or elopement. -Implement care plan for high risk elopement During an interview and observation on 2/2/24 at 9:42 A.M., Unit Manager #2 and the surveyor observed the Resident in the dining area in his/her wheelchair, the wheelchair did not have a wander guard attached to it. Unit Manager #2 said that staff should follow the physician's orders and make sure the wander guard is attached to the wheelchair at all times, she also said that the Resident was sitting in another resident's wheelchair. During an interview on 2/2/24 at 11:01 A.M., the Director of Nurses said that Resident #10's wheelchair should have a wander guard attached to it as indicated in the physician's orders. 2. For Resident #36, the facility failed to implement a smoking care plan. Specifically, the facility failed to make sure the Resident did not have possession of cigarettes and a lighter. A review of the facility policy titled 'Resident's Smoking Policy' with a revision date of 7/15/22 indicated the following: -Smoking is never allowed inside the facility and is allowed only in designated locations to be determined in collaboration with the facility leadership and the local fire chief. -All smoking ignition materials, including matches and lighters, will be held and secured by facility staff in designated locations. -Assign staff to supervise residents who require supervision/assist with smoking in the designated smoking location at the scheduled times. -Residents have the responsibility to comply with the smoking policy. Non-compliance with the policy may result in the development of a smoking contract to serve as an agreement generated between the resident and the facility. Such a contract will be developed when a resident has a history of non-compliant smoking behaviors or behavior problems related to smoking arise. Resident #36 was admitted to the facility in April 2018 with diagnoses including a history of substance abuse and bipolar disorder. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. A review of Social Services progress notes dated 1/6/24 indicated the following: -Resident was picked up by his/her brother to attend his/her son's wake. Further review of the Social Services notes dated 1/7/24 indicated the following: -On call nurse found the Resident out in the front of the building with a lighter and a cigarette, he/she stated to the nurse that he/she was waiting for his/her brother. When the nurse took the cigarette and lighter away, the Resident went to his/her room. When the social worker arrived to take the smokers out, the Resident was waiting, social worker informed the Resident that due to the incident that happened earlier in the day, he/she would have to skip this smoke break. The resident became verbally abusive towards the social worker. The social worker left the common area to take the other smokers out. A review of the Resident's smoking care plan dated 2/5/24 indicated the following: -All lighters and cigarettes are to be stored in a secured area. Further review of the Resident's behavior care plan dated 12/18/23 indicated the following: -History of substance abuse disorder, med seeking behaviors and bringing contraband/unapproved substances into the facility. A review of the Resident's smoking contract signed and dated on 4/19/22 indicated the following: -Resident level of assistance needed: supervision. -Residents are permitted to smoke during scheduled smoking times only. -Residents are to be supervised by staff during smoking times in designated smoking area only. -Residents are not permitted to keep/store their own cigarettes and lighters, all smoking materials must be kept locked in a secured area and retrieved by staff only. -When returning from an outing/appointment, the resident must turn over any smoking materials directly to the nurse to put in the designated storage area. -The facility reserves the right to institute a room search to remove from a resident's room any potentially dangerous or unsafe items, including but not limited to cigarettes, lighters, matches and other flammable materials. A room search will be conducted if there is a strong reason to suspect that a resident has any of these smoking materials or other items in his/her possession. Resident will be informed of the room search and the resident has the right to be present during the room search if he/she chooses. During an interview on 2/5/24 at 10:07 A.M., the Resident said he/she left the facility for a leave of absence twice in the month of January, the first time to attend his/her son's wake and the second time to attend the funeral, both times, he/she was allowed to sign out his/her cigarettes and lighter because he/she was with a responsible party. Resident #36 said he/she signed back the cigarettes and lighters in after returning from both leaves of absence. The Resident said he/she could not recall being found by a nurse outside the facility with cigarettes and a lighter. During a telephone interview on 2/7/24 at 10:57 A.M., Social Worker #1 said she was the manager on duty on 1/7/24, she was informed by the on call nurse who was physically in the building that she found the Resident out in the front of the building with a lighter and cigarettes. The on call nurse told the Social Worker that the Resident told her he/she was waiting outside to be picked up by his/her brother. The Social Worker said the Resident was not getting picked up by his/her brother on that day, he/she told the staff on the unit that his/her brother was picking him/her up to gain access to the front of the building. The Social Worker said as per his/her smoking contract, the Resident lost his/her smoking privileges for the next smoke break. The Social Worker said the Resident left the faciity on [DATE] with his/her brother to attend a wake, the Resident returned later that day. She said the Resident should not have smoking materials in his/her possession, these materials should always be locked in a secure room by staff. During an interview on 2/5/24 at 11:37 A.M., Nurse #6 said she was the on-call nurse on 1/7/24. She said she saw the Resident in the lobby area with cigarettes and a lighter, she asked the Resident for the smoking materials, the Resident handed them back to her, she then reported the concern to the Social Worker. During an interview on 2/5/24 at 12:24 P.M., the Director of Nurses said the Resident did lose his/her son recently, he/she did leave the facility with a responsible party to attend the wake and funeral the day before staff found him/her with smoking materials in front of the building. She said they did not have any reason to believe that the Resident had possession of smoking materials, if they did, a room search would have been completed, they have completed room searches in the past because Residents are not allowed to have possession of smoking materials, she said smoking paraphernalia should be locked in a secure room. 3. For Resident # 46, the facility failed to implement a physician's order. Specifically, the facility failed to apply Prevalon boots as ordered. Resident #46 was admitted to the facility in March 2023 with diagnoses including alcoholic polyneuropathy. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an interview and observation on 1/31/24 at 8:21 A.M., the Resident was lying in bed, he/she told the surveyor that staff do forget to help him/her with the Prevalon boots. The boots were on the dresser. On 1/31/24 at 10:07 A.M., and 2:21 P.M., the surveyor observed the Resident in bed without his/her Prevalon boots on. The boots were on the dresser. On 2/1/24 at 8:15 A.M., and 8:52 A.M., the surveyor observed the Resident in bed without his/her Prevalon boots on. The boots were on the dresser. A review of the active physician's orders indicated the following: -Prevalon boots every shift, apply to bilateral feet while in bed, remove for care. A review of the Nursing progress notes did not indicate documented refusal of care on 1/31/24 and 2/1/24 during the first shift. A review of the electronic medication record behavior sheet dated 1/31/24 and 2/1/24 first shift did not indicate any documented behavior or refusal of care. During an interview and observation on 2/2/24 at 9:31 A.M., the Certified Nurse's Assistant (CNA) #8 and surveyor observed the Resident in bed without Prevalon boots, CNA #8 said both Prevalon boots should be on the Resident's feet while he/she is in bed, the CNA #8 said the Resident requires help to put them on. During an interview on 2/2/24 at 9:33 A.M., Unit Manager #2 said staff should follow physician's orders. During an interview on 2/2/24 at 10:55 A.M., the Director of Nurses said Resident #46's Prevalon boots should be on while he/she is in bed as ordered by the physician, if the Resident refuses, the refusal should be documented in the behavior sheet in the electronic medication record or documented in a Nursing progress note. 4. For Resident #60, the facility failed to apply Geri leg sleeves as ordered. Resident #60 was admitted to the facility in March 2019 with diagnoses including renal failure. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident is rarely/never understood. A review of the active physician's orders indicted the following: -Geri sleeves bilateral lower legs every shift, apply daily, check placement every shift. On 1/31/24 at 8:29 A.M., the surveyor observed the Resident in bed eating breakfast, he/she was not wearing Geri leg sleeves. On 1/31/24 at 2:23 P.M., the surveyor observed Resident #60 in the activity room playing bingo. He/she was not wearing Geri leg sleeves, he/she was wearing white socks and sneakers. On 2/1/24 at 8:15 A.M., the surveyor observed the Resident in bed eating breakfast, he/she was not wearing any Geri leg sleeves. On 2/1/24 at 10:47 A.M., the surveyor observed the Resident in the activity room wearing white socks and sneakers. He/she was not wearing Geri leg sleeves. During an interview on 2/2/24 at 9:30 A.M., Certified Nurse Assistant (CNA) #7 said the Resident should be wearing Geri leg sleeves but there are none in the room. During an interview on 2/2/24 at 9:35 A.M., Unit Manager #2 said the Resident was not wearing any Geri sleeves because he/she needed a new pair, she showed the surveyor a pair of Geri leg sleeves at the nurse's station, she said the Resident could not wear them because they were too small, they needed to order a larger size. During an interview on 2/2/24 at 10:54 A.M., the Director of Nurses said staff should follow the physician's orders, if the Resident needs a new device, it should be replaced promptly so that the Resident's plan of care is not affected. 48671 5. For Resident #53, the facility failed to implement interventions on the fall's care plan. Findings include: The facility policy titled Falls Risk Reduction, date as revised 11/2/23, indicated but is not limited to the following: -Develop individualized plan of care. -Include fall interventions on Kardex and Care plan. -Review and revise care plan/Kardex regularly to ensure individualized interventions are effective. Resident #53 was admitted to the facility in September 2023 with diagnoses which included right femur fracture, dementia, repeated falls and orthostatic hypotension. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/8/23, indicated that on the Brief Interview for Mental Status exam Resident #53 scored a 4 out of 15, indicating severely impaired cognition. The MDS further indicated that Resident #53 required substantial/maximal assistance for toileting and was dependent on staff for transferring and ambulation. Review of the current Physician's orders indicated: -An order, dated 1/8/24, Floor bed, keep bed in lowest position when resident in bed. Mattresses on both sides of bed to be aligned with the floor bed to create an equal plane minimizing risk of serious injury. Review of the current fall's care plan for Resident #53 indicated the following interventions: -Bed in the lowest locked position when in bed. -Supervised area for mealtimes. -Out of bed into a wheelchair at the beginning of the 7:00 A.M.- 3:00 P.M., shift at the nurse's station for breakfast. -Floor bed: keep bed in lowest position when Resident #53 is in bed. Mattresses on both sides of bed to be aligned with the floor bed to create an even plan, minimizing the risk of serious injury. Review of the current Kardex (resident specific care instructions), included the following instructions: -Encourage Resident #53 to be in supervised area when awake to monitor safety & redirect when unsafe behaviors occur. -Supervision for all meals. -Resident #53 prefers to get up at the beginning of 7-3 shift-bring to area of supervision. -Keep bed in the lowest position when resident in bed. Mattresses on both sides of bed to be aligned with the floor bed to create an equal plane minimizing the risk of serious injury. During an initial tour of the unit on 1/31/24 at 8:12 A.M., the surveyor observed Resident #53 in bed. A staff person walked in the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision with the meal, with the bed at a regular height and no right side fall mat in place. The surveyor continued to make the following observations: -At 8:15 A.M., the surveyor observed that Resident #53 remained without supervision or a fall mat beside the regular height bed. The fall mat was placed across the room. On 2/01/24 at 8:26 A.M., the surveyor observed Resident #53 in bed. A staff person walked in the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision with the meal, with the bed at a regular height and no right side fall mat in place. The surveyor continued to make the following observation: -By 8:37 A.M., Resident #53 remained without supervision or a fall mat beside the regular height bed. The fall mat was placed across the room. On 2/2/24 at 8:17 A.M., the surveyor observed Resident #53 in bed. A staff person walked in the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision, with the bed at a regular height and no right side fall mat in place. The surveyor continued to make the following observation: -By 8:23 A.M., Resident #53 remained without supervision or a fall mat beside the regular height bed. The fall mat was placed across the room. On 2/5/24 at 8:11 A.M., the surveyor observed Resident #53 in bed. A staff person walked in the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision, with the bed at a regular height and no right side fall mat in place. The surveyor continued to make the following observation: -By 8:16 A.M., Resident #53 remained without supervision or a fall mat beside the regular height bed. The fall mat was placed across the room. During an interview on 2/5/24 at 10:38 A.M., with Resident #53's Certified Nursing Assistant (CNA) #9 she said that Resident #53 is weak and has had many falls. CNA #9 said Resident #53 eats alone in his/her room and that she was not aware that the Resident was supposed to be in a supervised area for meals. CNA #9 said that she has access to Resident #53's Kardex. During an interview on 2/5/24 at 10:36 A.M., with Resident #53's Nurse (#9) she said that Resident #53 eats breakfast alone in his/her room and is unable to use the call light. During an interview on 2/5/24 at 12:28 P.M., with the Director of Nurses (DON) she said the following: -Resident #53 does not need supervision when eating in his/her room alone. -Both CNAs and Nurses should follow the care plan interventions and Kardex instructions. -The fall mats are to be in place at all times when Resident #53 is in bed and the bed should not be left in the high position.

Based on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#53 and #102) out of a total sample of 26 residents. Specifically, 1. For Resident #53, the facility failed to provide adequate supervision and implement effective interventions to prevent falls, resulting in ten unwitnessed falls in 80 days. Additionally, on all days of survey the facility failed to implement falls interventions indicated on Resident #53's plan of care and physician orders. 2. For Resident #102, who has sustained 7 unwitnessed falls at the facility, the facility failed to supervise and provide Darco boots while he/she transferred from the toilet and ambulated, as indicated in his/her plan of care. Findings include: The facility policy titled Falls Risk Reduction, dated as revised 11/2/23, indicated the following: -All residents will be assessed for fall risk factors. Those determined to have risk factors will receive individualized interventions based on the risk factors in order to reduce the risk for falls and minimize the actual occurrence of falls. -To ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. -Develop individualized plan of care. -Include fall interventions on Kardex and Care plan. 1. For Resident #53, the facility failed to provide adequate supervision and implement effective interventions to prevent falls, resulting in ten unwitnessed falls in 80 days. Additionally, on all days of survey the facility failed to implement falls interventions indicated on Resident #53's plan of care and physician orders. Resident #53 was admitted to the facility in September 2023 and had diagnoses that included a right femur fracture, dementia, repeated falls and orthostatic hypotension. Review of the Physician's admission note indicated that Resident #53 had advanced dementia, likely Alzheimer's and recurrent falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/8/23, indicated that on the Brief Interview for Mental Status exam Resident #53 scored a 4 out of 15, indicating severely impaired cognition. The MDS further indicated that Resident #53 required substantial/maximal assistance for toileting and was dependent on staff for transferring and ambulation. Review of the current Physician's orders included the following order: -An order, dated 1/8/24, Floor bed, keep bed in lowest position when resident in bed. Mattresses on both sides of bed to be aligned with the floor bed to create an equal plane minimizing risk of serious injury. Review of the current Falls care plan for Resident #53 indicated the following: -The concern identified, was dated as last revised 10/2/23: Resident #53 is at risk for major injury from falls. The following risk factors have been identified: Confused/forgetful, Resident #53 is impulsive at times and had multiple falls recently and in hospital pta (prior to admission). Interventions on the care plan included: -9/21/23 Bed in the lowest locked position when in bed. -9/24/23 Encourage Resident #53 to be in a supervised area when awake to monitor safety and redirect when unsafe behaviors occur. -10/23/23 Supervised area for mealtimes. -10/30/23 Out of bed into a wheelchair at the beginning of the 7:00 A.M.- 3:00 P.M., shift at the nurse's station for breakfast. -1/8/24 Floor bed: keep bed in lowest position when Resident #53 is in bed. Mattresses on both sides of bed to be aligned with the floor bed to create an even plane, minimizing the risk of serious injury. Review of the current behavior care plan failed to indicate that Resident #53 refused to be in supervised areas when awake or out of bed in a wheelchair at the nurse's station at the start of the 7-3 shift and failed to indicate Resident #53 refused to be in a supervised area at mealtimes. Review of the clinical progress notes failed to indicate that Resident #53 refused to be in supervised areas when awake or out of bed in a wheelchair at the nurse's station at the start of the 7:00 A.M. - 3:00 P.M. shift and failed to indicate Resident #53 refused to be in a supervised area at mealtimes. Review of the current Kardex (resident specific care instructions), included the following instructions: -Encourage Resident #53 to be in supervised area when awake to monitor safety & redirect when unsafe behaviors occur. -Supervision for all meals. -Resident #53 prefers to get up at the beginning of 7:00 A.M. - 3:00 P.M. shift-bring to area of supervision. -Keep bed in the lowest position when resident in bed. Mattresses on both sides of bed to be aligned with the floor bed to create an equal plane minimizing the risk of serious injury. Review of the Fall Risk assessment completed for Resident #53, dated 11/19/23, indicated Resident #53 scored a two. According to the assessment a score of a 2 indicates that Resident #53 is at No Risk for falls. Review of the record indicated that Resident #53 had falls on 9/21/23, 9/23/23, 9/24/23, 10/6/23, 10/22/23, 10/24/23, 10/30/23, 11/19/23, 11/30/23, and 12/10/23. Review of the fall's investigations provided by the facility indicated that 10 of the 10 falls were unwitnessed. Review of the facility incident report, dated 11/30/23, indicated an unwitnessed fall on 11/30/23 at 9:30 P.M., Resident was found on the floor in the bedroom by an aide, required transfer to ER (emergency room ) d/t (due to) bump on head and c/o (complained of) dizzy. Review of falls care plan interventions on 11/30/23 included: -9/21/23 Bed in the lowest locked position when in bed. -9/24/23 Encourage Resident #53 to be in a supervised area when awake to monitor safety and redirect when unsafe behaviors occur. -10/19/23 Offer diversional activities: resident enjoys coloring, coloring books, conversation. -10/23/23 Supervised area for mealtimes. -10/24/23 When Resident #53 is agitated and continually trying to stand staff is to sit next to him/her. -10/30/23 Out of bed into a wheelchair at the beginning of the 7-3 shift at the nurse's station for breakfast. Further review of Resident #53's care plan dated 10/2/23 indicated that Resident #53 is at risk for major injury from falls. The following risk factors have been identified: Confused, forgetful. Impulsive at times and had multiple falls recently and in hospital. Review of a nursing note dated 12/1/23, indicated: Resident #53 was found lying on the floor, on assessment has a bump on L (left) side of head, complaint of generalized body pain, vitals, and neuros abnormal, resident states that he/she is dizzy, on call notified and order to transfer patient to ER for eval. Review of nursing note dated 12/6/23, indicated: Resident was readmitted to the facility that day with a right femur fracture. Resident had surgery while in the hospital for fixation and screw implantation. Resident #53 had an unwitnessed fall in his/her room on 12/10/23 at 7:00 A.M. As well, the following observations were made during the survey process: During an initial tour of the unit on 1/31/24 at 8:12 A.M., the surveyor observed a staff person enter Resident #53's room to deliver breakfast. The staff person pulled the fall mat away from the right side of Resident #53's bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision, with the bed at a regular height and no right-side fall mat in place. -At 8:15 A.M., the surveyor observed that Resident #53 remained alone in the room, without supervision or a fall mat beside the regular height bed. The fall mat was placed across the room. On 2/01/24 at 8:26 A.M., the surveyor observed Resident #53 in bed. A staff person walked into the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision, with the bed at a regular height and no right-side fall mat in place. The surveyor observed that Resident #53 remained without supervision or a right-side fall mat in place, beside the regular height bed, until 8:37 A. M. The fall mat was placed across the room. On 2/2/24 at 8:17 A.M., the surveyor observed Resident #53 in bed. A staff person walked into the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision, with the bed at a regular height and no right-side fall mat in place. The surveyor observed 2/2/24 at 8:23 A.M., Resident #53 remained without supervision or a fall mat in place, beside the regular height bed. The fall mat was placed across the room. On 2/5/24 at 8:11 A.M., the surveyor observed Resident #53 in bed. A staff person walked into the room to deliver Resident #53 breakfast. The staff person pulled the fall mat away from the right side of the bed, raised the bed to a regular height and exited the room, leaving Resident #53 alone in the room, without supervision, with the bed at a regular height and no right-side fall mat in place. On 2/5/24 at 8:16 A.M., Resident #53 remained without supervision or a fall mat beside the regular height bed. The fall mat was placed across the room. During an interview on 2/5/24 at 10:38 A.M., with Resident #53's Certified Nursing Assistant (CNA) #9 she said that Resident #53 is weak and has had many falls. CNA #9 said Resident #53 eats alone in his/her room and that she was not aware that the Resident was supposed to be in a supervised area for meals. CNA #9 said that she has access to Resident #53's Kardex. During an interview on 2/5/24 at 10:36 A.M., with Resident #53's Nurse (#9) she said that Resident #53 eats breakfast alone in his/her room and is unable to use the call light. During an interview on 2/5/24 at 12:28 P.M., with the Director of Nurses (DON) she said the following: -Staff can't provide constant 1 to 1 supervision to Residents #53 and therefore he/she now uses an alarm. -Resident #53 does not need supervision when eating in his/her room alone. -Both CNAs and Nurses should follow the care plan interventions and Kardex instructions. -The fall mats are to be in place at all times when Resident #53 is in bed and the bed should not 15016 2. For Resident #102, who has sustained 7 unwitnessed falls at the facility, the facility failed to supervise and provide Darco boots (medical boots designed for diabetic patients) while he/she transferred from the toilet and ambulated, as indicated in his/her plan of care. Resident #102 was admitted to the facility in August 2023, and had diagnoses which included unsteadiness on feet, diabetes, peripheral vascular disease and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/21/23, indicated Resident #102 scored a 15 of 15 points on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that Resident #102 required partial to moderate staff assistance with sit-to-stand and toilet transfers. Review of Resident #102's current physician orders, dated 12/6/23, indicated: -Monitoring of noncompliance with weightbearing status. Review of the current plan of nursing care dated February 2024 indicated Resident #102 was at risk for major injury from falls. Risk factors included a fall in the past year, medication which affects gait and balance, recent toe amputation, confusion, and unwillingness to follow therapeutic plan of care for safety with weight bearing status. The care plan indicated the Resident sometimes attempts to transfer without assistance as well as ambulates in his/her room and bathroom despite education. Fall risk interventions included: -Staff are not to leave Resident unsupervised while toileting, stay close while maintaining privacy. -Resident should wear Darco boots when ambulated or transferred from bed to chair Darco boots help to stabilize unsteadiness on feet] -Encourage and remind Resident to ask for assistance with transfers when needed. -Encourage Resident to be in a supervised setting. Review of fall incident reports for 2023, indicated Resident #102 had seven unwitnessed falls. These included: 1) 1/18/23 unwitnessed fall in bathroom, bruise to head. 2) 6/3/23 unwitnessed fall reported on this date, in bedroom. Actual date of fall unknown. No injury. 3) 7/16/23 unwitnessed fall in bedroom. No injury. 4) 9/18/23 unwitnessed fall in bedroom. No injury. 5) 10/18/23 unwitnessed fall in bathroom after staff transferred him/her onto the toilet. No injury. 6) 11/29/23 unwitnessed fall in bedroom, cervical neck fracture and skin tear on hand. 7) 1/23/24 unwitnessed fall in bathroom. No injury. On 2/5/24 at 8:30 A.M. the surveyor observed Resident #102 in the bathroom on the toilet, and not wearing Darco boots. The bathroom door was half open and no staff were present in the bathroom, bedroom or vicinity. During an interview on 2/5/24 at 8:33 A.M. with the MDS Nurse she said Resident #102 required staff supervision for transfers in his/her bedroom. During an interview on 2/5/24 at 8:54 A.M., with Resident #102's Certified Nurse Aide (CNA) #6 she said Resident #102 requires supervision for transfers, walking and while in the bathroom. She said that earlier in the morning she entered Resident #102's bedroom to pass out the breakfast meal tray and saw Resident #102 walking toward the bathroom. CNA #6 said she intervened and helped the Resident to transfer to the toilet however, she then left Resident #102 unsupervised and returned to the hallway to continue passing out trays to other residents. CNA #6 said she was unaware that Resident #102 required Darco boots for walking and transfers. During an interview on 2/5/24 at 9:10 A.M., Nurse (#5) said Resident #102 was at a high risk for falls and fell many times over the past year. Nurse #5 said the Resident required supervision during transfers, ambulation, and close supervision while in the bathroom and was required to wear Darco boots while ambulating, such as walking to the bathroom. Nurse #5 said CNA #6 should have remained with Resident #102 while he/she was in the bathroom and should have placed Darco boots on his/her feet.

Based on observation, record review and interview, the facility failed to accurately document in the medical record for 5 Residents (#8, #10, #22, #46 and #60) out of a total sample of 26 Residents. Specifically: 1. For Resident #8 the facility failed to maintain his/her advanced directives accurately and consistently in the medical record. 2. For Resident # 10, the facility failed to document accurately that a wheelchair wanderguard was not placed on the wheelchair. 3. For Resident #22, the facility failed to document accurately that a handroll was not applied. 4. For Resident #46, the facility failed to document accurately that Prevalon boots were not applied. 5. For Resident #60, the facility failed to document accurately that Geri leg sleeves were not applied. Findings include: 1.) For Resident #8 the facility failed to maintain his/her advanced directives accurately and consistently in the medical record. Review of the facility policy titled, Advanced Directives/ Do Not Resuscitate Orders, dated as revised 7/11/18, indicated advanced directives will be reviewed quarterly during care plan meeting. 6. Documentation in the clinical record of an advanced directive is found on the Minimum Data Set (MDS). 7. Whenever possible the MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment) form should be used to document advanced directives. Resident #8 was admitted to the facility in November 2021 with diagnoses including schizophrenia, osteoarthritis and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 12/5/23, indicated Resident #9 had a Brief Interview of Mental Status (BIMS) score of 8 out of a possible 15 which indicated he/she had a cognitive impairment. The MDS indicated he/she had a diagnosis of schizophrenia. The MDS indicated do not resuscitate (DNR) and he/she had a health care proxy which was not invoked. Review of the MOLST form, dated 11/14/22, indicated: - Attempt Resuscitation. (FULL CODE) - Do not Intubate (DNI) and Ventilate. Review of the plan of care related to advanced directives, dated 6/28/23, indicated: - Resident #9 has an advanced directive in place: DO RESUSCITATE DO NOT INTUBATE. Review of the physician's order, dated 2/8/23, indicated: - Do Resuscitate DNI, see MOLST. Review of the clinical directives snapshot, dated 2/1/24, indicated: - DNR (Do Not Resuscitate). Not documented as attempt resuscitation (Full Code). Review of the social service note, dated 12/5/23, indicated: -Advanced Directives in place with MOLST in file for DNR code status. Not documented as attempt resuscitation (Full Code). Review of the physician note, dated 1/13/24, indicated: -code status is DNR and DNI. Not documented as attempt resuscitation (Full Code). During an interview on 2/2/24 at 9:18 A.M., Resident #8 said he/she wants to be resuscitated and does not wish to be intubated. During an interview on 2/2/24 at 9:34 A.M., Unit Manager #1 said Resident #8 is a full code. Unit Manager #1 said the snapshot is a way for nursing to see the code status of a resident. During an interview on 2/2/24 at 12:58 P.M., the Director of Social Services (DSS) and the surveyor reviewed Resident #8's medical record. The DSS said that she coded the MDS incorrectly and documented in his/her note Resident #8 was a DNR but after reviewing the MOLST she said Resident #8 is a full code. The DSS said there is conflicting documentation in the medical record. During an interview on 2/2/24 at 1:40 P.M., the Director of Nursing said Resident #8's code status should be consistently documented in the medical record. During a follow up interview on 2/2/24 at 1:59 P.M., Unit Manager #1 said Resident #8 is a full code and the snapshot was not coded correctly in his/her medical record. Unit Manager #1 said Resident #8 was coded as a DNR. Unit Manager #1 said she was not sure how long or when Resident #8's snap shot indicated DNR, but she said it would be confusing because it read DNR- see MOLST and the Unit Manager #1 said the MOLST indicated attempt resuscitation. Unit Manager #1 and the surveyor reviewed the clinical directives snapshot and observed that on 2/8/23 the snapshot was changed to DNR from Full Code. Unit Manager #1 said that the conflicting information from the snap shot, the physician and DSS notes needed to clarified and should reflect the MOLST. 43807 2. For Resident #10, the facility failed to accurately document in the medical record that the wheelchair wanderguard was not placed on the wheelchair. Resident #10 was admitted to the facility in September 2021 with diagnoses including Alzheimer's Disease. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating that the Resident is rarely/never understood. Further review of the MDS assessment indicated that the Resident uses a wheelchair for mobility. On 2/1/24 at 9:37 A.M., the surveyor observed the Resident sitting in a wheelchair in the hallway next to the nurse's station, the wheelchair did not have a wander guard attached to it. On 2/1/24 at 10:08 A.M., 10:12 A,M., and 10:20 A.M., the surveyor observed the Resident in the wheelchair, self-propelling on his/her own up and down the hallway, the wheelchair did not have a wander guard attached to it. On 2/1/24 at 10:47 A.M., and 10:58 A.M., the surveyor observed the Resident sitting in his/her wheelchair in front of the main exit door, the wheelchair did not have a wander guard attached to it. A review of the electronic treatment record with an order to check placement of the wander guard each shift dated 2/1/24 indicated the following: -The first shift signed off by staff indicating a wanderguard was attached to the wheelchair. During an interview and observation on 2/2/24 at 9:42 A.M., Unit Manager #2 said staff should document accurately in the medical record. During an interview on 2/2/24 at 11:01 A.M., the Director of Nurses said the medical record which includes the electronic medical record should be documented accurately by staff. 3. For Resident #22, the facility failed to accurately document in the medical record that a handroll was not applied. Resident #22 was admitted to the facility in November 2016 with diagnoses including stroke with right-sided hemiparesis and right-hand contracture. A review of the Minimum Data Assessment (MDS) dated [DATE] indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 99 indicating the Resident is rarely/never understood. During an interview and observation on 1/31/24 at 8:59 A.M., the Resident was sitting on his/her bed, his/her right hand appeared contracted, a [NAME] cloth hand roll was observed on the dresser. The Resident told the surveyor the staff are supposed to assist with placing the hand roll, but they forget most days. A review of the Resident's active physician's orders indicated the following: -Wash right hand/palm with soap and water rinse then dry completely place hand roll day and evening. On 1/31/24 at 2:18 P.M., the surveyor observed a nurse pushing the Resident's wheelchair back to his/her room, no handroll was observed in the right hand. The rolled [NAME] cloth was on the Resident's dresser. On 2/1/24 at 8:15 A.M., 8:57 A.M., and 10:58 A.M., the surveyor observed the Resident in bed with no hand roll in the right hand, the rolled [NAME] cloth was on the dresser. A review of the electronic medication record dated 1/31/24 and 2/1/24 indicated staff had signed off that the Resident was wearing the hand roll during the first shift. During an interview on 2/2/24 at 9:40 A.M., Unit Manager #2 said staff should document accurately in the medical record. During an interview on 2/2/24 at 10:59 A.M., the Director of Nurses said staff are expected to document accurately in the clinical medical record. 4. For Resident #46, the facility failed to document accurately that the Resident was not wearing Prevalon boots. Resident #46 was admitted to the facility in March 2023 with diagnoses including alcoholic polyneuropathy. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an interview and observation on 1/31/24 at 8:21 A.M., the Resident was lying in bed, he/she told the surveyor that staff do forget to help him/her with the Prevalon boots. The boots were on the dresser. On 1/31/24 at 10:07 A.M., and 2:21 P.M., the surveyor observed the Resident in bed without his/her Prevalon boots on. The boots were on the dresser. On 2/1/24 at 8:15 A.M., and 8:52 A.M., the surveyor observed the Resident in bed without his/her Prevalon boots on. The boots were on the dresser. A review of the active physician's orders indicated the following: -Prevalon boots every shift, apply to bilateral feet while in bed, remove for care. A review of the electronic treatment record dated 1/31/24 and 2/1/24 indicated that staff had signed off that the Resident was wearing Prevalon boots during the first shift. During an interview on 2/2/24 at 9:33 A.M., Unit Manager #2 said that staff should not document incorrectly in the medical record. During an interview on 2/2/24 at 10:55 A.M., the Director of Nurses said that staff should document accurately in the medical record. 5. For Resident #60, the facility failed to document accurately that Geri leg sleeves were not applied. Resident #60 was admitted to the facility in March 2019 with diagnoses including renal failure. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident is rarely/never understood. A review of the active physician's orders indicted the following: -Geri sleeves bilateral lower legs every shift, apply daily check placement every shift. On 1/31/24 at 8:29 A.M., the surveyor observed the Resident in bed eating breakfast, he/she was not wearing Geri leg Sleeves. On 1/31/24 at 2:23 P.M., the surveyor observed Resident #60 was observed in the activity room playing bingo. He/she was not wearing Geri leg sleeves, he/she was wearing white socks and sneakers. On 2/1/24 at 8:15 A.M., the surveyor observed the Resident in bed eating breakfast, he/she was not wearing any Geri leg sleeves. On 2/1/24 at 10:47 A.M., the surveyor observed the Resident in the activity room wearing white socks and sneakers. He/she was not wearing Geri leg sleeves. A review of the electronic treatment record dated 1//31/24 and 2/1/24 indicated that staff had signed off that they applied the Resident's Geri Sleeves during the first shift. During an interview on 2/2/24 at 9:30 A.M., Certified Nurse's Assistant (CNA) #7 and said the Resident should be wearing Geri leg sleeves but there were none in the room. During an interview on 2/2/24 at 9:35 A.M., Unit Manager #2 said the Resident was not wearing any Geri sleeves because he/she needed a new pair, she showed the surveyor a pair of Geri leg sleeves at the nurse's station, she said the Resident could not wear them because they were too small, they needed to order a larger size. The unit manager said that staff should document the medical record accurately. During an interview on 2/2/24 at 10:54 A.M., the Director of Nurses said staff should accurately document the clinical record.

Based on observations, interviews and record review, the facility failed to maintain professional standards of practice for two Residents (#22 and #8) out of a sample of 26 residents. Specifically: 1. For Resident #22, the facility failed to apply a handroll as ordered. 2. For Resident #8, the facility failed to implement physician's orders for air mattress settings. Findings include: A review of the facility policy titled 'Activities of Daily Living' with no revision date indicated the following: -Assistive and adaptive equipment are provided as needed 1. Resident #22 was admitted to the facility in November 2016 with diagnoses including stroke with right-sided hemiparesis and right-hand contracture. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 99 indicating the Resident is rarely/never understood. During an interview and observation on 1/31/24 at 8:59 A.M., the Resident was sitting on his/her bed. His/her right hand appeared contracted. A [NAME] cloth hand roll was observed on the dresser. The Resident said staff are supposed to assist with placing the hand roll in the right hand, but they forget most days. A review of the Resident's active physician's orders indicated the following: -Wash right hand/palm with soap and water rinse then dry completely place hand roll day and evening. A review of the Resident's Activities of Daily Living (ADL) care plan indicated the following: -Bathing, grooming and dressing-dependent/assist x1 On 1/31/24 at 2:18 P.M., the surveyor observed a nurse pushing the Resident's wheelchair back to his/her room, no handroll was observed in the right hand. The rolled [NAME] cloth was on the Resident's dresser. On 2/1/24 at 8:15 A.M., 8:57 A.M., and 10:58 A.M., the surveyor observed the Resident in bed with no hand roll in the right hand, the rolled [NAME] cloth was on the dresser. A review of the Nursing progress notes did not indicate documented refusal of care on 1/31/24 and 2/1/24 during the first shift. A review of the electronic medication record dated 1/31/24 and 2/1/24 first shift failed to indicate any behaviors or refusal of care documented during the first shift. During an interview and observation on 2/2/24 at 9:30 A.M., Certified Nurses Assistant (CNA) #7 and the surveyor observed the Resident without a handroll in the right hand, CNA #7 said a hand roll should be applied in the Resident's right hand after cleaning the right hand with soap and water. During an interview on 2/2/24 at 9:40 A.M., Unit Manager #2 said Resident #22's handroll should be applied during the day and evening as the order states. She said any refusals should be documented in the behavior sheets in the electronic medication record or in the Nursing progress notes. During an interview on 2/2/24 at 10:59 A.M., the Director of Nurses said Resident #22's hand roll should be applied in the right hand as ordered and if the Resident refuses care, staff should document in the behavior sheets in the electronic medication record. 44095 2.) For Resident #8 the facility failed to implement physician's orders for air mattress settings. Review of the facility policy titled, Support Surfaces, dated as 12/3/23, indicated: 5. Setting for specialty mattress use specifically for comfort and pain management will be based on the resident's assessment and preference. Mattress setting will be documented in the resident's physician order, eTAR (treatment sheet), plan of care and kardex. Resident #8 was admitted to the facility in November 2021 with diagnoses including schizophrenia, osteoarthritis and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 12/5/23, indicated Resident #9 had a Brief Interview of Mental Status (BIMS) score of 8 out of a possible 15 which indicated he/she had a cognitive impairment. Review of the physician's order, dated 3/22/22, indicated: - alternating pressure mattress for comfort, set at #4-15 min alternating, monitor for functioning every shift. Review of therapy note, dated 10/1/23, indicated: - Resident #8 said my bed has a big hole in the middle of it, makes it hard for me to move my bowels. Review of the Treatment Record, dated 1/31/24-2/2/24, indicated nursing set the air mattress to: - Coded M on 1/31/24 during shift 1. - Set to 4 on 2/1/24 during shift 1. - Set to 4 on 1/31/24 and 2/1/24 during shift 2. - Set to 0 on 1/31/24 and 2/1/24 during shift 3. - Set to 4 on 2/2/24 during shift 3. On 1/31/24 at 8:16 A.M., Resident #8 was in bed on his/her air mattress that was set to 5, 20 alternating pressure. During an interview on 1/31/24 at 9:00 A.M., Resident #8 said he/she was in a divot, and sunk in the air mattress and Resident #8 continued to say, the divot interferes with my comfort. On 2/1/24 at 6:52 A.M., Resident #8 was in bed on his/her air mattress that was set to 5, 20 alternating pressure. On 2/1/24 at 9:49 A.M., Resident #8 was in bed on his/her air mattress that was set to 5, 20 alternating pressure. On 2/1/24 at 12:11 P.M., Resident #8 was in bed on his/her air mattress that was set to 5, 20 alternating pressure. On 2/2/24 at 6:53 A.M., Resident #8 was in bed on his/her air mattress that was set to 5, 20 alternating pressure. On 2/2/24 at 9:32 A.M., Resident #8 was in bed on his/her air mattress that was set to 5, 20 alternating pressure. During an interview on 1/31/24 at 2:16 P.M., Certified Nurse Assistant (CNA) #2 said CNAs do not adjust air mattress settings, even during care. During an interview on 2/2/24 at 7:01 A.M., CNA #1 said CNAs do not adjust air mattress settings, even during care. During an interview on 2/2/24 at 2:03 P.M., CNA #5 said CNAs do not adjust air mattress settings, even during care. During an interview on 2/2/24 at 6:57 A.M., Nurse #1 said air mattress use requires a physician's order and nurses are supposed to verify settings every shift. During an interview on 2/2/24 at 6:58 A.M., Nurse #2 said air mattress use requires a physician's order and nurses are supposed to verify settings every shift. On 2/2/24 at 9:32 A.M., Unit Manger #1 and the surveyor observed Resident #8 in bed and his/her air mattress was set to 5, 20 alternating pressure. Unit Manager #1 said the air mattress was not set to the correct setting. During an interview on 2/2/24 at 1:36 P.M., the Director of Nursing said around January 18th, Resident #8 requested a change to his/her air mattress. The DON said that nursing should have updated the physician's order.

Based on observations, interviews and record review, the facility failed to provide Activities for two Residents (#26 and #46) out of a sample of 26 residents. Specifically, for Residents #26 and #46, the facility failed to provide one to one Activity visits as indicated in the care plan. Findings include: A review of the facility policy titled 'Activities Programs' with no revision date indicated the following: -The facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities. -The assessment of resident preferences for activities will be included in the care plan. 1. Resident #26 was admitted to the facility in April 2019 with diagnoses including severe morbid obesity. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an interview and observation on 1/31/24 at 8:40 A.M., Resident #26 was in bed, he/she told the surveyor he/she does not like to get out of bed, he/she would like to have activities in the room, he/she has not had any one-to-one visits from Activities offering in room activities. A review of Resident #26's Activities of Daily Living (ADL) care plan dated 3/11/22 indicated the following: -Residents prefers to stay in bed, staff will dress for dignity, does not like to get out of bed for dignity. Further review of Resident #26's Activities care plan dated 10/20/23 indicated the following: -Residents prefers to stay in bed, does enjoy staff visits. An intervention dated 3/11/22 indicated to provide 1:1 visits 3-4 times per week. A review of the medical record failed to indicate documented 1:1 Activity visits with the Resident 3-4 times a week. During an interview on 2/5/24 at 8:19 A.M., the Activities Director said she did not have any documented 1:1 visits 3-4 times a week with the Resident. She said the Resident is bed bound and should be offered activities in the room [ROOM NUMBER]-4 times a week as his/ her care plan states, she said she just created participation sheets for January and February after the surveyor requested to see them, she said the participation sheets will be used going forward to document the Resident's 1:1 activities and any refusals. 2. Resident #46 was admitted to the facility in March 2023 with diagnoses including alcoholic polyneuropathy. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an observation and interview on 1/31/24 at 8:21 A.M., Resident #46 was lying in bed, he/she told the surveyor he stays in bed most days because of the pain in his/her feet, he/she would like to get offered activities in the room. A review of Resident #46's Activities care plan dated 9/13/23 indicated the following: -Resident does enjoy brief room visits from staff, an intervention dated 4/13/23 indicated to provide 1:1 visits 3-4 times a week. A review of the medical record failed to indicate documented 1:1 Activity visits with the Resident 3-4 times a week . During an interview on 2/5/24 at 8:19 A.M., the Activities Director said she did not have any documented 1:1 visits 3-4 times a week with the Resident. She said the Resident is bed bound and should be offered activities in the room [ROOM NUMBER]-4 times a week as his/her care plan states, she said she just created participation sheets for January and February after the surveyor requested to see them,she said the participation sheets will be used going forward to document the Resident's 1:1 activities and any refusals.

Based on observations, policy review, record review and interviews the facility failed to ensure a resident who required respiratory care (continuous oxygen) received care consistent with professional standard of practice for one (Resident #317) out of a total sample of 26 Residents. Specifically, for Resident #317, nursing administered continuous oxygen without a physician's order. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised 11/3/16, indicated oxygen is administered as ordered by the physician. 1. Verify physician's order for oxygen administration or weaning. Physician's orders for weaning will include parameters for the amount of time oxygen is decreased and include oxygen saturation parameters. Resident #317 was admitted to the facility in January 2024 with diagnoses including anxiety, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Review of the Minimum Data Set (MDS) assessment, dated 1/22/24, indicated Resident #317 had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. The MDS indicated Resident #317 required continuous oxygen therapy. Review of the plan of care related to alteration in respiratory function, dated 1/19/24, indicated: - administer oxygen as ordered by the physician, if applicable Review of the physician progress note, dated 1/31/23, indicated: - Currently on 2 liters of oxygen which is his/her baseline. -Continue to wean down oxygen to keep oxygen saturation below 92% and above 88%. Review of the physician's orders, dated 2/2/24, failed to include an order to administer continuous oxygen. On 1/31/24 at 8:17 A.M., Resident #317 was in his/her bed. He/she was receiving oxygen via nasal cannula at 2 liters per minute. Resident #317 said he/she wears oxygen at his/her home and oxygen is not new. On 1/31/24 at 2:18 P.M., 2/1/24 at 6:51 A.M., 2/1/24 at 9:39 A.M., 2/1/24 at 12:10 P.M., 2/2/24 at 6:53 A.M., and on 2/2/24 at 9:38 A.M., Resident #317 was observed being administered oxygen via nasal cannula. During an interview on 2/2/24 at 10:54 A.M., Certified Nurse Assistant (CNA) #3 said Resident #317 uses oxygen. CNA #3 said that CNAs do not adjust oxygen. During an interview on 2/2/24 at 6:59 A.M., Nurse #1 said Resident #317 uses oxygen and that oxygen use requires a physician's order. During an interview on 2/2/24 at 7:00 A.M., Nurse #2 said Resident #317 uses oxygen and that oxygen use requires a physician's order. On 2/2/24 at 9:38 A.M., Unit Manager #1 and the surveyor went into Resident #317's room. Unit Manager said Resident #317 was being administered oxygen and oxygen use requires a physician's order. During an interview on 2/2/24 at 1:35 P.M., the Director of Nursing said oxygen use requires an order.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that he/she was free from physical abuse by staff when, on 12/11/19, Nurse #1 was observed physically dragging Resident #1 out from another resident's room into the hall and hitting him/her twice in the face, as a result Resident #1 sustained multiple bruises and abrasions. Findings Include: Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), indicated that on 12/11/19, Certified Nurse Aide (CNA) #1 reported that she witnessed Nurse #1 pulling Resident #1 by his/her wrist along a carpeted floor when he removed him/her (Resident #1) from Resident #2's room. The Facility's Final Investigation Report indicated that CNA #1 had also witnessed Nurse #1 hitting Resident #1 twice in the face with an open hand. The Report indicated that the Facility concluded that physical abuse was confirmed and that Resident #1's injuries appeared to be consistent with being dragged on a carpeted floor by the wrist. The Report indicated that Nurse #1's approach for removing Resident #1 from Resident #2's room was overly aggressive and unnecessary. The Facility Policy titled Resident Abuse Prevention, Investigation, and Reporting, last revised 2/27/17, indicated that it was the responsibility of all staff to ensure an environment free of abuse. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], indicated that he/she was severely cognitively impaired. A Nurse Progress Note, dated 12/11/19, indicated that a skin assessment was conducted and Resident #1 was noted to have six new skin issues which included the following: - 10.0 centimeter (cm) by 2.5 cm abrasion to right side of face, - 8.8 cm by 6.4 cm bruise to lower back, - 5.8 cm by 4.6 cm hematoma (collection of blood under skin) to right shin, - 4.4 cm by 3.2 cm bruise under right arm, - 2.4 cm by 1.7 cm abrasion to top of coccyx area, - 2.0 cm by 2.0 cm skin tear to right hand. The Nurse Progress note indicated that Resident #1 complained of right shin pain when touched, the Physician was notified, and treatment orders were obtained. During an interview on 1/2/20 at 8:57 [NAME]M., CNA #1 said that, on 12/11/19 at around 2:30 [NAME]M., while she was seated in the hall, she observed Resident #2 approaching the nurse's station saying that another resident hit him/her. CNA #1 said Nurse #1, who was seated at the nurse's station, immediately got up and went into Resident #2's room. CNA #1 said, after Nurse #1 went into Resident #2's room, she heard a commotion that sounded like fighting and someone being hit. CNA #1 said as she walked toward Resident #2's room she observed Resident #1 laying on his/her back on the floor with Nurse #1 holding his/her (Resident #1's) wrist and said Nurse #1 was pulling him/her (Resident #1) out of the room by his/her arm. CNA #1 said Nurse #1 twisted Resident #1's wrist while he pulled him/her into the hall, that Resident #1 swung his/her hand at Nurse #1, and said Nurse #1, with an open hand, hit Resident #1 hard in the face two times. CNA #1 said she asked Nurse #1 if they could help Resident #1 get off the floor and said she called CNA #2, who was at the nurse's station, to come help. CNA #1 said she held on to the back of Resident #1's pants as Nurse #1 and CNA #2 lifted Resident #1 up into the wheelchair. CNA #1 said the right side of Resident #1's face was beet red, he/she had a skin tear on his/her right hand, and what looked like a scratch on his/her back. CNA #1 said Nurse #1 brought Resident #1 into his/her room, left him/her there, closed the door and walked back to the Nurse's station. CNA #1 said she left the unit to tell Nurse #2 what she had witnessed. During an interview on 12/31/19 at 9:08 [NAME]M., Nurse #2 said that, at around 3:00 [NAME]M. on 12/11/19, CNA #1 informed her that she had witnessed Nurse #1 abusing Resident #1. Nurse #2 said she went to check on Resident #1 and said she observed Resident #1 sitting at the foot of his/her bed with his/her head hung down. Nurse #2 said Resident #1's right hand was bloody, there was a skin tear on it, there was blood on his/her bed and said there were drops of blood on the floor. Nurse #2 said after assessing Resident #1, she asked Nurse #1 to leave the Facility. During an interview on 12/20/19 at 1:45 P.M., the Unit Manager said she arrived at the Facility at around 6:00 [NAME]M. on 12/11/19 and said when she arrived and initially checked on Resident #1 he/she was in bed asleep and said when she later brought him/her breakfast, she observed blood on his/her sheets and his/her hand was bleeding. The Unit Manager said Resident #1 had multiple bruises and abrasions which included a purplish red area that went from the side of his/her forehead down to his/her chin, with bruises on his/her lower back and under his/her right arm. The Unit Manager said Resident #1 had an area on his/her coccyx that appeared to be from shearing (occurs when forces moving in opposite directions are applied to body tissues which damages the skin), an abrasion on his/her upper back between his/her shoulder blades and said it appeared to her that Resident #1 had been dragged. During an interview on 12/20/19 at 8:45 [NAME]M., the Administrator said she conducted the investigation and it appeared that the skin tear and bruises that Resident #1 sustained were consistent with CNA #1's description of what had occurred. Although Resident #1's impaired cognition limited his/her ability to recall the experience of being physically dragged on the floor, hit in the face, and sustaining multiple injuries, an unimpaired individual would experience both physical and emotional distress from being treated in this manner by a caregiver.

Based on observation, record review, and interview, the facility failed to: 1. ensure care was provided in a manner to prevent the development of pressure ulcers for 1 Resident (#19) and 2. implement the plan of care for the prevention of pressure ulcers for 1 Resident (#81) from a total sample of 25 Residents. Findings include: 1. For Resident #19 the facility failed to prevent the development of pressure ulcers. On 12/2/19 at 8:43 A.M., the surveyor observed a prevalon boot (a boot used to keep the heel off the mattress to relieve pressure) in Resident #19's room on his/her dresser. Resident #19 was in bed with his/her heels lying on the mattress. On 12/2/19 at 3:21 P.M., the surveyor observed a prevalon boot in Resident #19's room on his/her dresser. Resident #19 was in bed with his/her heels lying on the mattress. On 12/3/19 at 10:30 A.M., the surveyor observed a prevalon boot in Resident #19's room in the same position as the previous day on his/her dresser. On 12/4/19 at 7:10 A.M., the surveyor observed a prevalon boot in Resident #19's room in the same position as the previous day on his/her dresser. Resident #19 was in bed with his/her heels lying on the mattress. On 12/4/19 at 8:37 A.M., the surveyor observed Certified Nursing Assistant (CNA) #6 in Resident #19's room assisting him/her with breakfast. CNA #6 did not apply the prevalon boot nor did she offload Resident #19's heels. Review of Resident #19's medical record indicated Resident #19 was admitted to the facility in May 2019 with [DIAGNOSES REDACTED]. Review of Resident #19's Minimum (MDS) data set [DATE] indicated the resident was at risk for the development of pressure ulcers. It further indicated Resident #19 did not have unstageable pressure ulcers. Review of Resident #19's baseline careplan assessment dated [DATE] indicated no skin issues on admission to the facility. Review of Resident 19's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 scored a 0 out of a possible 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The MDS dated [DATE] also indicated the resident was at risk for developing pressure ulcers. Review of Resident #19's weekly skin checks indicated a weekly skin check dated 10/21/19 identified a necrotic area on Resident #19's left heel. There is no evidence in the medical record to indicate that weekly skin checks were completed between 10/21/19 and 11/21/19. Review of the Nurse Practitioner's note, dated 11/13/19, indicated Resident #19's bilateral heels had unstageable ulcers (unstageable wounds have dead tissue on the base of the wound, rendering the wounds unstageable). Review of Resident #19's physician's orders [REDACTED]. -An order dated 9/24/19 for weekly skin checks. -An order dated 10/25/19 for a prevalon boot to the left heel every shift. -An order dated 11/29/19 to apply skin prep to bilateral heels eschar (black, necrotic tissue) twice daily and as needed. -An order dated 11/29/19 to cover bilateral heels with [MEDICATION NAME] (a dressing) and change the dressing daily. Review of Resident #19's risk for skin breakdown care plan, dated 11/12/19, indicated the following: -Resident #19's Norton plus score was a 9, putting him/her at high risk for pressure ulcer development. -An intervention dated 11/12/19 to use devices that eliminate pressure on the heels: pillows as needed, and if the resident allows. -An intervention dated 11/12/19 to use pillows or foam wedges to keep bony prominence's from direct contact with each other. Review of Resident #19's nursing progress notes from November 2019 and December 2019 failed to indicate that Resident #19 refused to have his/her boot applied or heels offloaded. Review of Resident #19's Medication Administration Record [REDACTED]. During an interview on 12/4/19 at 4:34 P.M., the Director of Nursing (DON) said Resident #19's care plan and orders should have been followed for managing his/her skin. The DON said facility staff should have attempted to offload the resident's heels. During an interview on 12/4/19 at 4:48 P.M., Nurse #1 said Resident #19 needs to have his/her heels offloaded in bed because of the pressure ulcers to his/her heels. Nurse #1 said Resident #19 does not refuse his/her boots or offloading when in bed. During an interview on 12/5/19 at 10:16 A.M., Unit Manager #3 said the facility staff should attempt to put boots on Resident #19 or attempt to offload his/her heels while in bed to reduce pressure to his/her heels. 2. For Resident #81 the facility failed to ensure interventions to prevent pressure ulcers were implemented in accordance with the medical plan of care. Resident #81 was admitted to the facility in February 2018 with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #81 was dependent for bed mobility, transfers, dressing and locomotion. On 12/3/19 at 11:06 A.M., the surveyor observed Resident #81 in his/her Broda chair (reclining wheelchair); the resident was not wearing offloading boots and his/her heels were on the chair's footrest. On 12/4/19 at 10:41 A.M., the surveyor observed Resident #81 in his/her Broda chair. Resident #81 was not wearing offloading boots and his/her heels were on the chair's footrest. On 12/4/19 at 3:36 P.M., the surveyor observed Resident #81 in his/her Broda chair. Resident #81 was not wearing offloading boots and his/her heels were on the chair's footrest. Review of Resident #81's physician's orders [REDACTED]. Review of Resident #81's care plans indicated an intervention dated 12/13/18 for a prevalon boot to the left foot. During an interview on 12/5/19 at 10:12 A.M., Unit Manager (UM) #3 said Resident #81 needs boots to offload heels when up and in the chair. UM #3 said the boots sometimes go to the laundry to be cleaned. The prevalon boots were found in Resident #81's closet by Unit Manager #3.