Every finding on record at Jefferson House

Based on interviews, observations, and review of facility policy during the Resident Council meeting, the facility failed to ensure that Grievance forms policy was in accessible to residents and failed to ensure residents had knowledge of the grievance process. The findings include:Resident #9's diagnoses included arthritis, weakness, anxiety, and high blood pressure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition.Resident #15's diagnoses included difficulty in walking, weakness, depression, anxiety, and depression. The significant change MDS assessment dated [DATE] identified Resident #15 had a BIMS score of 4 indicating severe cognitive impairment. Resident #21's diagnoses included congestive heart failure, chronic obstructive pulmonary disease, weakness, and difficulty in walking. The quarterly MDS assessment dated [DATE] identified Resident # had a BIMS score of 15 indicating intact cognition. Resident #35's diagnoses included weakness, difficulty in walking, anxiety, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #35 had a BIMS score of 7 indicating severe cognitive impairment.Resident #36's diagnoses included chronic obstructive pulmonary disease, anxiety, depression, high blood pressure, and bipolar disorder. The quarterly MDS assessment dated [DATE] identified Resident #36 had a BIMS score of 15 indicating intact cognition. Resident #45's diagnoses included weakness, difficulty in walking, high blood pressure, depression, anxiety and dementia. The annual MDS assessment dated [DATE] identified Resident #45 had a BIMS score of 15 indicating intact cognition. Resident #46's diagnoses included weakness, difficulty in walking and high blood pressure. The quarterly MDS assessment dated [DATE] identified Resident # had a BIMS score of 15 indicating intact cognition. Resident #53's diagnoses included weakness, difficulty in walking, dementia, high blood pressure, anxiety and depression. The quarterly MDS assessment dated [DATE] identified Resident #53 had a BIMS score of 13 indicating intact cognition. Resident #54's diagnoses included high blood pressure, CHF, type 2 diabetes, and weakness. The admission MDS assessment dated [DATE] identified Resident #54 had a BIMS score of 15 indicating intact cognition. Resident #61's diagnoses included arthritis, chronic pain, weakness, and difficulty in walking. The quarterly MDS assessment dated [DATE] identified Resident #61 had a BIMS score of 15 indicating intact cognition. Resident #67's diagnoses included dementia, type 2 diabetes, difficulty in walking and weakness. The quarterly MDS dated [DATE] identified Resident #67 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #68's diagnoses included weakness, difficulty in walking, type 2 diabetes, and high blood pressure. The quarterly MDS assessment dated [DATE] identified Resident #68 had a BIMS score of 15 indicating intact cognition. Resident #71's diagnoses included congestive heart failure, high blood pressure, weakness and difficulty in walking. The quarterly MDS assessment dated [DATE] identified Resident #71 had a BIMS score of 15 indicating intact cognition. Resident #84's diagnoses included weakness, difficulty in walking, high blood pressure, type 2 diabetes and depression. The quarterly MDS assessment dated [DATE] identified Resident #84 had a BIMS score of 15 indicating intact cognition. Resident #90's diagnoses included dementia, weakness, difficulty in walking, and type 2 diabetes. The quarterly MDS assessment dated [DATE] identified Resident #90 had a BIMS score of 15 indicating intact cognition. Resident #93's diagnoses included weakness, difficulty in walking, CHF, COPD, type 2 diabetes, depression and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #93 had a BIMS score of 13 indicating intact cognition. A Resident Council meeting was held on 8/28/26 at 1:30 PM with Resident #9, Resident #15, Resident #21, Resident #35, Resident #36, Resident #45, Resident #46, Resident #53, Resident #54, Resident #61, Resident #67, Resident #68, Resident #71, Resident #84, Resident #90, Resident #93 were attendance. None of the residents in attendance were able to identify the location of the Grievance forms, nor were they aware that they were able to fill out Grievance forms on their own, or with the assistance of a staff member. Resident #9, Resident #21, and Resident #68 identified they would notify a staff member, like a nurse or social worker and they believed that the staff member would follow up with their concerns but were unaware their concern was put in writing. Observations throughout the facility on 8/28/26 at 2:45 PM identified there was only one location to obtain Grievance forms on either the first or second floors of the facility, this was located off the units in the main lobby. The area was heavily obstructed by a large black welcome sign, a hand sanitizer pump on a stand with a plastic 11 x 8 sign on top of it directly in front of the Grievance form holder, and another two-piece cardboard sign attached to a stand to the left of the hand sanitizer station. The Administrator shared the observation of the obstructed Grievance form holder. An observation on 8/31/26 at 10:00 AM identified the obstructed view of the Grievance form holder in the main lobby had been cleared. The large signs and hand sanitizer station had been relocated and were no longer blocking the view of the Grievance form holder. An interview with Nurse Aid (NA) #1 on the 1st floor on 9/1/26 at 9:58 AM identified that if a resident or a family member stated they had a complaint and wanted to file a Grievance she'd refer them to her nursing supervisor. NA #1 was unable to indicate where the Grievance forms were located and stated that she would check with her supervisor and follow the chain of command.An interview with Licensed Practical Nurse (LPN) #4 on the first floor on 9/1/26 at 10:01 AM identified that if a resident or a family member stated they had a complaint and wanted to file a Grievance she'd gather information regarding the complaint and immediately notify the supervisor. LPN #4 stated that she knew where the Grievance forms were located but was unable to identify the location upon request. LPN #4 also indicated that she would follow up with the nursing supervisor, and that we don't have those papers on the unit.An interview with Registered Nurse/Unit Supervisor (RN) #12 on the 1st floor on 9/1/26 at 10:03 AM identified that if a resident or a family member stated they had a complaint and wanted to file a Grievance she'd take the information down, and that there's a formal grievance process, but if they want to fill out a Grievance form, she would get a form from the front office, or the Social Worker's office, and she would direct the complaint to the Social Worker or Director of Nurses (DON). During the interview with RN #12, LPN #4 interrupted stating that the Grievance forms were readily available for all residents and their families, and are available in the lobby as soon as you walk in. LPN #4 stated she had received the information from a powerful source. An interview with NA #3 on the second floor on 9/1/26 at 10:21 AM identified that if a resident or a family member stated they had a complaint and wanted to file a Grievance she'd refer to a supervisor or immediate nurse. NA #3 also identified that she did not know where the Grievance forms were located. An interview with RN #13 on the second floor on 9/1/26 at 10:23 AM identified that if a resident or a family member stated they had a complaint and wanted to file a Grievance she'd find out what the issue was but would then report it to her nursing supervisor. RN #13 also identified she did not know the location of the Grievance forms, but would reach out to her nursing supervisor, and they would be able to get her the document. Interview and observation with the Administrator on 9/1/26 at 10:48 AM identified that she was also the facility's Grievance Officer. The Administrator indicated that she believed one component of resident's rights were discussed each month, or resident's rights were discussed once a year by Social Worker #1. The Administrator stated that she decided to remove the clutter and objects blocking the site of the Grievance form folder following the Resident Council meeting on the afternoon of 8/28/26 because she was assuming it was a concern. The Administrator further identified that about 6 months ago, they decided to have Grievance forms in the main lobby, as well as on all the units in the facility. During a walking tour with the Administrator, it was identified there were 3 papers labeled at the top stating Communication Form and were placed at the bottom of the first-floor [NAME] Unit's bulletin board with a push pin. The location of the papers was unlabeled. The Administrator identified that the residents and family members would not be able to identify the papers hanging at the bottom of the bulletin board to file a grievance. There were no Grievance forms located on the second-floor unit ([NAME]) and the Administrator stated that the second floor did not have its bulletin board back up yet, as they were finishing up renovations on that floor. Observation of the previous location of the bulletin board identified a large hanging picture in its place. The Administrator further indicated that she was responsible for replenishing Grievance forms, and she wasn't sure why the forms weren't replenished, and stated, I guess my process needs to be updated. Interview with Social Worker (SW) #1 on 9/1/26 at 11:38 AM identified that the Administrator traditionally had been the staff member responsible for refilling the Grievance forms when they ran out. Review of the Resident's [NAME] of Rights Policy directs in part that residents have the right to have the facility must make information available on how to file a grievance or complaint.

Based on observations, interviews, clinical record review, and facility policy for 1 of 3 sampled residents (Resident #16) reviewed for position/mobility, the facility failed to set an alternating pressure mattress at the correct setting per the physician order, and for 1 of 2 sampled residents (Resident #40) reviewed for edema, the facility failed to obtain weights per the physician's order for a resident with a diagnosis of Congestive Heart Failure (CHF). The findings include: 1. Resident #16's diagnoses included unspecified dementia, chronic pain, anxiety and weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 had Brief Interview of Mental Status score of 4 indicating severe cognitive impairment and was dependent on staff for toileting hygiene, rolling left and right in bed, and transfers. Additionally, the assessment identified Resident #16 was at risk for pressure ulcer development and that there was a pressure reducing device for the bed. The Resident Care Plan dated 6/19/25 and in effect through 8/26/26 identified Resident #16 was at risk for impaired skin integrity related to chronic pain and anxiety. Interventions included a pressure-relieving mattress in bed. Resident #16's Braden Scale (predicting pressure ulcer risk evaluation) dated 6/10/26 identified that he/she was at moderate risk for pressure ulcer development. Review of Resident #16's clinical record identified that on 8/5/26 he/she weighed 104 pounds (lbs.). A physician's order dated 8/24/26 for Resident #16 directed a low air loss/alternating mattress, check for proper function and monitor that the setting was appropriate for the resident's weight every shift. Observations on 8/26/26 at 11:04 AM, 8/28/26 at 9:43 AM, and 9/1/26 at 8:48 AM, identified Resident #16 was in bed with the pressure-relieving mattress set at 200 lbs. Observation, interview, and review of clinical record with Registered Nurse (RN) #11 on 9/1/26 at 9:19 AM identified Resident #16 was awake in bed on his/her back, covered by a blanket, with the head of the bed slightly elevated. The alternating pressure mattress was observed to be set at 200 lbs. The current physician order directed the alternating pressure mattress to be set at resident weight and to check the function and setting every shift. RN #11 identified that the alternating air mattress was incorrectly set according to the physician's order. RN #11 stated that the facility policy directed to set the alternating air mattress per the physician order and that it was her responsibility as the unit nurse to check and ensure the correct setting. RN #11 indicated that she had not checked the setting on Resident #16's alternating air mattress that shift because she was conduction medication administration and would have checked when she went to administer Resident #16's medication. Subsequent to surveyor inquiry, RN #11 changed the setting on Resident #16's alternating air mattress from 200 lbs. to 100 lbs. per the physician's order. Interview with the Director of Nursing (DON) 9/1/26 at 9:39 AM indicated that the facility policy directed setting pressure relieving mattresses per the physician order. The unit nurse was responsible for checking pressure-relieving mattresses for proper function and the correct physician ordered setting every shift. The DON indicated that residents on hospice had their pressure-relieving mattress set by weight or comfort per physician's order. The DON identified that Resident #16's mattress should have been set according to the physician's order, at 100 lbs., and not at 200 lbs. as observed because the order did not direct to set per resident weight or comfort. Review of Air Mattress Policy and Procedure undated directed in part to obtain a physician order for law air loss, alternating pressure mattress and to select patient comfort setting based on average patient weight. 2. Resident #40 diagnoses included chronic diastolic heart failure, hypertensive heart disease, orthostatic hypotension and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had a Brief Interview of Mental Status of 15 indicating intact cognition and was independent for transfers and dressing. Additionally, the MDS failed to identify Resident #40 exhibited rejection of care that is necessary to achieve the resident's goals for health and well-being. The Resident Care Plan dated 7/6/26 identified Resident #40 was at risk for alteration in cardiac status related to hypertension, CHF, syncope, and bradycardia. Interventions included ace wraps and weights as ordered; notify medical staff if weight fluctuates within 2 pounds (lbs.) in a day or 5 lbs. in a week. A physician's order dated 8/6/26 directed to obtain daily weights per the cardiologist. Additional Lasix 20 mg to be given as needed for weight gain greater than 3 lbs. in a day or 5 lbs. in a week. Review of Resident #40's weights from 8/1/26 through 8/31/26 identified that the facility failed to obtain on 8/6/26, 8/8/26, 8/24/26, 8/28/26, or 8/29/26. Interview and facility documentation review with Nurse Aid (NA) #2 on 8/31/26 at 9:43 AM identified it was the facility's policy for Nurse Aids (NA) to obtain resident weights on shower day and more often per the nurse's verbal instructions and the assignment card posted in the resident room. Review of Resident #40's care card (directs nurse aid care) located in the resident's bathroom identified Resident #40 was a daily weight. Interview and clinical record review with Registered Nurse (RN) #6 on 8/31/26 at 9:50 AM identified it was the facility's policy to obtain weights per the physician's order, which were obtained by the NA and entered by the nurse. Review of Resident #40's weights identified that weights were not obtained daily per physician's order. Interview with the Assistant Director of Nurses (ADNS) on 8/31/26 at 10:50 AM identified resident weights were obtained once a week and more often per physician's order. Review of Resident #40's clinical record identified he/she should have a daily weight obtained but failed to identify weights that were recorded on 8/6/26, 8/8/26, 8/24/26, 8/28/26, or 8/29/26. Although the ADNS could not identify why those weights were missing, and that she was not familiar with the resident, she stated they should have been per physician's order. The undated Weight Loss/Gain Policy directed in part that all residents will be weighed at least monthly unless otherwise ordered by the physician. Additionally, if the Resident is on CHF protocol, nursing will notify the physician if there is weight gain of 2-3 pounds in one day or 5 lbs. in one week.

Based on interviews, review of the clinical record, facility documentation and facility policy for 2 of 3 sampled residents (Resident #9 and Resident #12) reviewed for abuse, the facility failed to report an allegation of abuse/neglect to the State Agency within the allotted reporting time frame. The findings include: 1. Resident #9's diagnoses included paraplegia, neuromuscular dysfunction of bladder, congestive heart failure and adjustment disorder with mixed anxiety/depressed mood. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 had a Brief Interview of Mental Status score of 15 indicating intact cognition and required substantial/maximal assistance for personal hygiene and was dependent for toileting, showering/bathing and dressing and was always incontinent of bladder and bowel. The Resident Care Plan dated 1/8/26 identified Resident #9 was at risk of incontinence of bladder and at risk for impaired skin integrity. Interventions included toileting plan to check for incontinence and change every 2-3 hours every shift, provide incontinent care after each incontinent episode, out of bed schedule to be up at 10:30AM, changed at 1:30 PM, 4:30 PM and 7:30 PM, to keep clean and dry as possible, minimize exposure to moisture, assist with turning/repositioning every 2 hours when in bed and toilet resident as ordered/indicated. A physician's order dated 3/16/26 directed to provide assist of 2 for toileting at bed level. Review of the Reportable Event sent to the Department of Health (DPH) dated 3/23/26 at 4:30 PM identified an allegation of neglect that Resident #9 had not received incontinent care as outlined in the care plan and further indicated that the resident complained to a social worker that her aid did not provide care for her the morning of 3/22/26. The report indicated that the facility became aware of the allegation of neglect on 3/23/26 at 12:00 PM and the event occurred on 3/22/26 at 12:30 PM. The report indicated that the physician was notified on 3/23/26 at 3:00 PM and law enforcement was notified on 3/23/26 at 3:00 PM. Nursing staff failed to write a note or Situation, Background, Assessment, Recommendation note (SBAR) regarding the allegation of neglect on 3/22/26. A police report dated 3/24/26 indicated police were dispatched to the facility on 3/23/26 at 4:10 PM to investigate an allegation of abuse/neglect involving Resident #9. The police report identified that Nursing Aide (NA) #4 did not promptly report that Resident #9 did not receive incontinent care, however she did inform her supervisor within the appropriate timeline at approximately 12:00 PM on 3/22/26. The police report concluded that based on investigation the officer did not believe that probable cause existed or that any criminal acts/behavior had occurred. Interview with Resident #9 on 8/27/26 at 9:35 AM failed to identify that he/she had a recollection of the allegation. Interview and review of a statement dated 3/22/26 written by NA #4 on 8/31/26 at 10:18 AM with NA #4 identified that on 3/22/26 she was late providing care to residents due to having back pain and spasms and she had let RN #7 know. NA #4 indicated she had not provided any care to Resident #9 until lunchtime and apologized to Resident #9 about being late. She further indicated that Resident #9 was upset while care was being provided and NA #4 indicated she updated RN #7 about 20-30 minutes later that Resident #9 was upset about the care and later provided a written statement to RN #8. Interview with RN #7 on 8/31/26 at 12:45 PM indicated she could not fully remember the specific incident on 3/22/26 but that she believed Resident #9 complained that s/he did not get care. RN #7 also stated she thought the assigned NA #4 was unable to provide care for Resident #9, but she couldn't recall why. She noted other NAs were in Resident #9's room during the shift but she was not sure what care was provided. RN #7 identified that Resident #9 did not report any care issues to her directly, and she thought she became aware of a delay in care later in her shift after someone else had already reported the lack of care to the supervisor, RN #8. RN #7 indicated that she was aware of the facility policy on abuse and neglect and that she believed a delay in incontinent care would be considered neglect. She further identified that if she was made aware of an allegation of neglect she would talk to the NA's and residents involved to get more information and then report it to the Nursing Supervisor so it could be investigated. Interview and review of a statement dated 3/30/26 written by RN #6 with RN #6 on 8/31/26 at 1:20 PM indicated that she answered the call bell for Resident #9 at 12:10 PM on 3/22/26 and Resident #9 was in bed, not washed or dressed and Resident #9 reported to her that she hadn't seen her aid all day. RN #6 indicated that she let Resident #9's primary nurse, RN #7 know and reported to the supervisor RN #8 that the resident was upset that NA #4 had not been in the room to provide incontinent care. RN #6 indicated that she was aware of the facility policy on Abuse and Neglect and believed a delay in incontinent care would be an allegation of abuse and that she was Interview and review of a statement dated 3/22/26 written by RN #8 on 8/31/26 at 2:53 PM with RN #8 indicated that she became aware sometime around 12:00 PM on 3/22/26 of staff complaining about Resident #9's behavior but that it wasn't clear what the issue was, so she interviewed Resident #9. Resident #9 indicated to her that NA #4 was mean and doesn't help him/her in a timely manner and Resident #9 no longer wanted to have NA #4 assigned to him/her. RN #8 indicated she wrote a statement, obtained statements from the NAs and left the statements in the Director of Nursing's (DON's) mailbox. RN #8 indicated that she did not report the incident to the DON or Administrator on 3/22/26 because she felt the issue was a customer service problem and not an allegation of abuse. RN# 8 identified that she was aware that the facility policy regarding abuse and neglect and identified that she was responsible for reporting any allegation of abuse or neglect immediately to the DON or Administrator. RN #8 indicated that even though Resident #9 felt safe and was ok, she should have reported to the DON immediately. RN #8 indicated that she received education from the DON and Administrator following the incident about reporting allegations of neglect/abuse including the difference between customer service issues and abuse allegations. Interview and review of facility policy with the DON on 8/31/26 at 3:20 PM identified that the facility practice for reporting allegations of abuse/neglect was that staff must immediately tell the supervisor and then the supervisor needed to notify the DON or Administrator. She stated that she expected them to call her right away even on the weekends. The DON further identified that any allegation of abuse or neglect must be reported to the State Agency, Department of Public Health (DPH) within 2 hours. The DON indicated that she became aware of the issue that had occurred with Resident #9 on 3/22/26 when she found statements from RN #8 in her mailbox on 3/23/26. The DON explained that the incident should have been reported to the State Agency per the requirement, within 2 hours on 3/22/26. She identified that RN #8 felt it was a customer service issue, but she wished RN #8 would have contacted her immediately to avoid a delay in reporting. Re-interview and facility documentation review with DON on 9/1/26 at 10:28 AM identified that RN #8 should have called her to discuss the incident on 3/22/26. The DON indicated that RN #8 received education following the investigation and the education included calling the DON immediately to discuss a potential allegation to ensure timely reporting. Interview and facility documentation review with the Administrator on 9/1/26 at 10:28 AM indicated that she reported the allegation of neglect to DPH on 3/23/26 after viewing video footage from 3/22/26 showing staff did not enter Resident #9's room with proper equipment for incontinent care until approximately 12:30 PM on 3/22/26. The facility investigation determined that a delay in incontinent care occurred. The Administrator explained that the facility was not aware of a delay in care until the video footage was reviewed on 3/23/26. She stated that RN #8 felt confident that it was a customer service issue after investigating. The Administrator identified that she would have expected RN #8 to coach the staff to be able to provide care and she expected that RN #8 would have called the DON to discuss and receive coaching regarding investigating and reporting allegations of abuse/neglect. 2. Resident #12's diagnoses included spinal stenosis, obesity, Post Traumatic Stress Disorder (PTSD), and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had a Brief Interview of Mental Status of 15 indicating intact cognition and was dependent on staff for toileting and personal hygiene. Additionally, the MDS identified Resident #12 was always incontinent of urine and frequently incontinent of bowels, was not on a bowel toileting program to manage bowel continence. The Resident Care Plan dated 7/14/26 identified Resident #12 was at risk for incontinence of bladder due to decreased mobility and use of diuretics. Interventions included a toileting plan, prompted and as needed, toileting upon rising, before and after meals, at hour of sleep and two times during the night. The Resident Care Plan dated 7/14/26 identified Resident #12 had decreased ability to perform self-care due to pain, weakness/decreased strength. Interventions included no male aids when changing and providing care and the preference of a female Nurse Aid (NA). A physician order dated 6/22/26 and in place through 8/26/26 directed to have Nurse Aids (NA) be only female and directed a toileting plan, prompted and as needed to toilet upon rising, before and after meals, at hour of sleep, and 2 times during the night. Review of the Patient/Resident Care Card (directs NA resident care) dated 3/14/26 and in place through 8/26/26, located in Resident #12's bathroom identified he/she preferred female care givers and needed prompted toileting before and after meals with toileting before breakfast and after lunch. A nurses' progress note dated 8/19/26 at 12:40 PM identified Registered Nurse (RN) #3 was administering Resident #12's insulin prior to lunch, indicating that 40 minutes ago he/she requested to use the bed pan but already went and no one answered his/her call bell. RN #3 observed staff working and getting residents set up and served for lunch, however neither she nor staff observed that the resident had utilized his/her call bell for assistance. Assigned NA #5 was approached and stated she observed the resident's call bell earlier but was literally escorting another resident into the shower room to give that patient a shower and asked a male colleague, NA #2, to assist her by answering the resident's call light. NA #2 told her (RN #3) that Resident #12 asked him to cover his/her feet because they were cold and made no request that would require a female aid to address at that time. NA #5 stated she would soon check on the resident needs when her break had completed. Resident #12 was provided with a shower earlier that morning by the assigned NA #5 per plan of care. Interview with Resident #12 on 8/26/26 at 11:25 AM identified that he/she sometimes waited a long time for up to approximately 2 hours for staff to respond to the call bell. Resident #12 stated this occurred on all shifts and that he/she had informed social work, though he/she could not recall specific dates. Resident #12 added that staff response time had improved recently since speaking with the social worker. Additionally, Resident #12 also shared his/her personal history of physical abuse by his/her parents, which resulted in the loss of vision in one eye. Review of the facility grievance log failed to identify any grievance filed by Resident #12 relating to call bell response time. Interview and clinical record review with the Director of Nursing (DNS) on 8/27/26 at 9:12 AM identified that the facility's policy required all staff to immediately report any allegation of abuse to the nursing supervisor who would then clarify the allegation and notify the DNS or the Quality Assurance (QA) nurse. The DNS stated that Resident #12 reported waiting 40 minutes for a bedpan and subsequent soiling of him/herself constituted an allegation of neglect, a form or abuse per the facility policy, and RN #3 should have followed the chain of command so the allegation could have been reported to the State Agency (SA) within the required 2-hour time frame. Review of the Nurse's progress note for Resident #12 dated 8/19/26 at 12:40 PM identified that she (the DNS) was not notified of the incident and was not aware it had occurred, adding that it did not appear the supervisor had been notified. Additionally, although NA #5 had asked fellow NA #2, to assist Resident #12, NA #2 was a male, and it was care planned and well-known by staff that the resident was not to be provided peri-care assistance by male NAs due to an extensive history of abuse. Interview and clinical record review with RN #3 on 8/28/26 at 10:20 AM identified that the facility's policy required all abuse allegations to be reported immediately to the nursing supervisor and then up the chain of command. She identified abuse as physical, mental, or emotional mistreatment, misappropriation of property, and neglect such as failing to provide a resident with necessities like timely incontinent care or meals. RN #3 identified that on 8/19/26, around lunch time, she entered the Resident #12's room to administer medications when the resident reported he/she was wet and had been waiting 40 minutes to be changed. RN #3 stated she had not heard the resident's call bell ringing. NA #5, who was assigned to the resident, had explained to RN #3 that she had given Resident #12 a shower earlier that morning around 8:00 to 9:00 AM and was then transporting another resident when Resident #12 requested assistance. At the time, NA #5 stated due to being with another resident, she requested NA #2, the male NA, to assist with the request. NA #2 reported to RN #3 that when he entered Resident #12's room, the resident commented that his/her feet were cold but did not mention needing help with a bedpan or toileting. RN #3 added that Resident #12 made the allegation around lunchtime and had not informed anyone else that he/she had been waiting that long. She further stated staff were aware that Resident #12 preferred female aides and was supposed to be toileted before and after meals. Despite the requirement that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediate but no later than 2 hours after the allegation was made, RN #3 did not report the incident to the supervisor stating she did not feel it was an issue because Resident #12 did not explicitly ask NA #2 (a male) for incontinent care assistance. Subsequent to surveyor inquiry the facility submitted a Reportable Event form to the state agency on 8/27/26 at 9:30 AM for the 8/19/26 incident which identified the lack response to a request for assistance with toileting and resultant incontinent episode. Attempts to reach NA #5 on 8/28/26 at 1:56 PM were successful, however NA #5 refused to be interviewed stating she was out to lunch and did not want to be taking time out of her personal life for work. Review of the Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Resident Property policy dated 8/24/22 directed, in part, that all staff must report any allegation of abuse or neglect immediately to the nursing supervisor, Administrator or Director of Nursing. It further directed that investigations of all alleged violations involving abuse or neglect be reported immediately, but not later than two hours after the allegation is made including reporting to DPH. It further directed that after an allegation of abuse in which a Resident may be the victim, but serious bodily injury is not involved, a report to local police department must occur no later than twenty-four hours after the allegation is made.

Based on interviews, review of the clinical record, facility documentation and facility policy for 1 of 3 sampled residents (Resident #9) reviewed for abuse, the facility failed to implement their abuse and neglect policy to remove the alleged perpetrator from the facility pending the investigation. The findings include:Resident #9's diagnoses included paraplegia, neuromuscular dysfunction of bladder, congestive heart failure, and adjustment disorder with mixed anxiety and depressed mood. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 had a Brief Interview of Mental Status score of 15 indicating intact cognition, required substantial/maximal assistance for personal hygiene, was dependent for toileting, bathing and dressing, and was always incontinent of bladder and bowel. The Resident Care Plan dated 1/8/26 identified Resident #9 was at risk of incontinence of bladder and at risk for impaired skin integrity. Interventions included toileting plan to check for incontinence and change every 2-3 hours every shift, provide incontinent care after each incontinent episode, out of bed schedule to be up at 10:30 AM, changed at 1:30 PM, 4:30 PM and 7:30 PM, to keep clean and dry as possible, minimize exposure to moisture, assist with turning/repositioning every 2 hours when in bed and toilet resident as ordered/indicated.A physician's order dated 3/16/26 directed to provide assist of 2 for toileting at bed level.Review of the Reportable Event form dated 3/23/26 at 4:30 PM identified an allegation of failure to provide incontinent care as outlined in the care plan and further indicated that the resident complained to a social worker that her aid did not provide care for her the morning of 3/22/26.Review of the clinical record failed to write a note or Situation, Background, Assessment and Recommendation (SBAR) regarding the allegation of neglect on 3/22/26.Interview and review of Nurses Aid (NA) #4's statement dated 3/22/26 with NA #4 on 8/31/26 at 10:18 AM identified that on 3/22/26 she was late in providing care to residents due to having back pain and spasms and she had let Registered Nurse (RN) #7 know. NA #4 indicated she had not provided any care to Resident #9 until lunchtime and apologized to Resident #9 about being late. She further indicated that Resident #9 was upset while care was being provided and NA #4 indicated she updated RN #7 about 20-30 minutes later that Resident #9 was upset. NA #4 then provided a written statement to RN #8.Interview with RN #7 on 8/31/26 at 12:45 PM indicated she could not fully remember the specific incident on 3/22/26 but that she believed Resident #9 complained that s/he did not get care. RN #7 also indicated that she thought the assigned NA #4 was unable to provide care for Resident #9, but she couldn't recall why. She further indicated that other NAs were in Resident #9's room during the shift but she was not sure what or if care had been provided. RN #7 indicated that Resident #9 did not report any care issues to her directly, and she thinks she became aware of a delay in care later in her shift after someone else had already reported the lack of care to the supervisor. RN #7 indicated that she was aware of the facility policy on abuse and neglect and that she believed a delay in incontinent care would be considered neglect. She further identified that if she was made aware of an allegation of neglect she would talk to the NA's and residents involved to get more information and then report the incident to the nursing supervisor.Interview and review of a statement dated 3/30/26 written by RN with RN #6 on 8/31/26 at 1:20 PM indicated that she answered the call bell for Resident #9 at 12:10 PM on 3/22/26 and Resident #9 was in bed, not washed or dressed reporting that she hadn't seen her aid. RN #6 indicated she let Resident #9's primary nurse, RN #7 know and reported to the supervisor RN #8 that the resident was upset NA #4 had not been in the room or provided incontinent care all day. RN #6 indicated that she was aware of the facility policy on abuse and neglect and believed a delay in incontinent care would be an allegation of abuse and she was responsible for immediately reporting the allegation to her supervisor. Interview and review of a statement dated 3/22/26 written by RN #8 on 8/31/26 at 2:53 PM with RN #8 indicated that she became aware sometime around 12:00 PM on 3/22/26 of staff complaining about Resident #9's accusatory behaviors but that it wasn't clear what the issue was so she interviewed Resident #9 who stated that NA #4 was mean and doesn't help him/her in a timely manner and no longer wanted to have NA #4 assigned to him/her. RN #8 identified that she was aware of the facility policy regarding abuse and that any allegation of abuse or neglect must be reported immediately and further indicated that it was her understanding that the Director of Nursing (DON) and Administrator were responsible. She indicated that she did not report the incident to the DON or Administrator on 3/22/26 because she felt the issue was a customer service problem rather than an allegation of abuse. RN #8 indicated that she wrote a statement and she obtained statements from NA's which she left in the DON's mailbox. RN #8 stated that she removed NA #4 from the care of Resident #9 however NA #4 was not removed from the facility. RN #8 identified she received education from the DON and Administrator following the incident about reporting allegations of neglect/abuse including the difference between customer service issues and abuse. RN #8 indicated that even though Resident #9 felt safe and was ok, she thinks she should have reported the allegation to the DON immediately. Interview and review of facility policy with the DON on 8/31/26 at 3:20 PM identified that all staff were responsible to immediately report any allegation of abuse/neglect to the supervisor and then the supervisor needed to notify the DON or Administrator and stated that she expected them to call her immediately even on the weekends. She indicated that she (DON), the Quality Nurse and Administrator were responsible for determining abuse and that the alleged perpetrator was to be sent home immediately following the allegation. The DON stated that she had only become aware of an issue that occurred on 3/22/26 when she found statements from RN #8 in her mailbox on 3/23/26. The DON identified that the incident should have been reported to the State Agency within 2 hours on 3/22/26 but RN #8 felt it was a customer service issue, so she had not called her. The DON indicated that she wished RN #8 had contacted her immediately, and had she, then NA#4 would have been removed from the schedule and sent home.Review of the Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Resident Property policy dated 8/24/22 directed, in part, that all staff must report any allegation of abuse or neglect immediately to the nursing supervisor, Administrator or Director of Nursing and following the allegation, actions are taken to protect the resident from further abuse, neglect, mistreatment, exploitation and misappropriation of resident property. Action must include the immediate removal from patient care area of the alleged employee pending collection of statements, followed by removal from the building and from the schedule pending the outcome of the investigation.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 4 sampled residents (Resident #7) reviewed for pressure ulcers, and 1 of 2 sampled residents (Resident #83) reviewed for dental, the facility failed to update the Resident Care Plan to reflect the resident's current status. The findings include:1. Resident #7 's diagnoses included dementia with psychotic disturbance, pressure ulcer stage 4 sacral region and acquired absence of the right leg above the knee.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment and required total staff assistance with bed mobility, dressing, personal hygiene, and toileting, remained in bed and had functional limitation in range of motion on one side for both upper and lower extremities. Resident #7 additionally, had a stage 4 pressure ulcer, not present on admission identified, moisture associated skin damage, pressure reducing device on the bed, application of nonsurgical dressings and application of ointments/medications other than feet.A modification of the quarterly Minimum Data Set assessment dated [DATE] was completed on 8/31/26 indicating the resolution of the stage 4 pressure ulcer.The Resident Care Plans dated 8/11/26 identified Resident #7 with impaired skin integrity due to decreased functional mobility and moisture due to recurring moisture associated skin damage (MASD), healing stage 4 pressure ulcer to coccyx (related to impaired mobility), left heel reopened stage 4, fissures noted to buttocks/sacrum, MASD to left lower quadrant of abdomen and under left breast and middle abdominal fold, under right and left breast. A review of the wound management documentation dated 7/14/26 identified Resident #7's left heel area was resolved and failed to identify the status of the coccyx area.A review of the nutritional assessment dated [DATE] identified pressure ulcer has been healed for several weeks now; skin was very fragile and Resident #7 had other skin issues such as MASD to the groin.A quarterly Resident Care Plan meeting (held to review and revise the Resident Care Plan) note dated 8/14/26 identified the facility had held the meeting and that the Interdisciplinary team as well as the family attended. Although Resident #7's skin was noted to be intact, the care plan still contained information identifying multiple skin issues that had healed were still present as well as the treatments.A physician's order dated 6/5/26 and in effect on 8/26/26 directed to clean the coccyx/divot, clean cavity with a Q tip or rolled wipes after each bowel movement (to ensure the area was kept clean). A physician's order dated 7/14/26 in effect on 8/26/26 directed to apply skin prep twice a day to left heel for protection, monitor left heel for redness every shift, MASD bilateral buttocks, peri rectal, and groin, apply zinc oxide every shift and as needed.Observations on 8/26/26 at 1:39 PM, identified RN #1 performed a treatment to coccyx divot and left heel, both areas were observed to be healed.A review of the wound management documentation dated 8/28/26 identified a divot in the coccyx in the previous wound spot, the wound base was not visible, surrounding skin was intact, pink in color, and barrier cream was applied.2. Resident #83's diagnosis included dementia with psychotic disturbance, dysphagia and schizoaffective disorder.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #83's Brief Interview for Mental Status score was 11, indicating moderate cognitive impairment and required set up assistance with oral hygiene and supervision with eating.Review of the Resident Care Plan failed to include any dental issues. A review of a dental referral form dated 7/2/26 identified tooth #2 was extracted with recommendations of soft food diet for 1-week, saltwater rinses for 7 days, Tylenol every 6 hours for 2 days for pain management and follow up as needed. Review of the physician orders from 7/2/26 through 7/9/26 failed to identify the information from the dental form was entered as a physician order.A review of the Health Drive Dental Group record dated 8/18/26 identified upper tooth #2 was extracted and initiated prior authorization for an upper partial plate was done with a follow up for denture scheduled for 8/26/26.Interview and record review with the Care Plan Coordinator, Registered Nurse (RN) #15 on 9/1/26 at 11:39 AM identified Resident #7 's wound documentation identified the coccyx and left heel wound were healed as of 7/28/26. RN #15 indicated that she was the staff who usually updated the Resident Care Plan but did not always update the care plan to reflect healed pressure ulcers and was not aware of what the facility policy directed. She indicated that Resident Care Plans were updated every 3 months to reflect the current status of the resident. Additionally, RN #15 identified she was unaware that Resident #83 had a tooth extracted or that she/he was to have a partial dental plate made. RN #15 further indicated that the dental changes should have been included in the Resident Care Plan, however, she was on vacation when this occurred and another MDS Coordinator had been covering.Interview and record review with LPN #1 (MDS Coordinator) on 9/1/26 at 11:42 AM identified that she did cover for RN #15 and she would only have included a tooth extraction if there was a problem. She further indicated that Resident Care Plans should reflect the current status of the residents. LPN # 1 additionally indicated that she was unaware of what was happening with Resident #83's teeth.Interview with the Director of Nursing (DON) on 9/1/26 at 11:48 AM indicated that the Care Plan Coordinator or MDS Coordinator, RN # 15, were responsible for updating the Resident Care Plans. She identified that she would expect Resident #7's current Resident Care Plan to reflect the resolved pressure ulcers however suggested because the areas had historically opened and closed may have been the reason why it had not been discontinued. The DON stated that any changes in condition, changes in the plan of care, or physician's orders should be reflected in the Resident Care Plan further stating for Resident #83, the dental extraction and partial plate process should have had a Resident Care Plan initiated. The DON was unsure why the Resident Care Plan had not been updated.Review of the Care Plan revisions upon status change policy dated revised 6/2023 directed, in part, the purpose was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change, upon identification of a change in status the nurse will notify the MDS Coordinator, the physician and the resident representative if applicable. The care plan will be updated with the new or modified interventions; care plans will be modified as needed by the MDS Coordinator or other designated staff member. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status was identified to ensure care plans had been updated to reflect current resident needs.

Based on staff interview and review of Payroll Based Journal (PBJ) submissions for Quarter 1 (October 1, 2024 through December 31, 2024) and Quarter 2 (January 1, 2024 through March 31, 2024) the facility failed to ensure the PBJ data was submitted on time. The findings include: PBJ submissions for Quarter 1 of 2024 and Quarter 2 of 2024 identified the facility as a 1-star rating and excessively low weekend staffing metric was suppressed for the facility for Quarter 1 and Quarter 2 of 2024. On 1/28/25 at 2:21 PM an interview with Administrator identified that the staff member who was responsible for submitting the PBJ reports had left and then came back per diem, she did not submit the PBJ on time for Quarter 1 and therefore Quarter 2 was also triggered. The Administrator further identified that she was responsible at this time for reporting the PBJ and no further issues have been identified. Review of the Mandatory submission of staffing information based on payroll data in a uniform format. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.

Based on observations, review of the clinical record, facility policy, and staff interviews for 5 of 5 residents (Resident #10, #32, #66, #73, and #83) reviewed for blood glucose testing, the facility failed to clean and disinfect a glucometer device per the manufacturer's instructions for use. 1. Resident #10's diagnoses included Type 2 Diabetes, Alzheimer's disease, and chronic obstructive pulmonary disease (COPD). A physician's order dated [DATE] directed to obtain a blood glucose level every Tuesday at 6:00 AM. A chart review identified that Resident #10 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 had moderately impaired cognition, required maximal assistance with his/her personal hygiene, and was dependent with chair/bed-to-chair transfers and rolling left and right. The Resident Care Plan (RCP) dated [DATE] identified Resident #10 was at risk for episodes of hyperglycemia and hypoglycemia from diabetes and included interventions of monitoring his/her glucose, obtaining blood glucose levels three times a day and as needed, and monitoring for signs and symptoms of hyperglycemia and hypoglycemia. 2. Resident #32's diagnoses included Type 2 Diabetes, Alzheimer's disease, and Stage 3 chronic kidney disease. A physician's order dated [DATE] and currently in effect directed to obtain a blood glucose level every Thursday at 6:00 AM. The significant change MDS assessment dated [DATE] identified Resident #32 had severely impaired cognition, required moderate assistance with eating, and was independent with chair/bed-to-chair transfers and rolling left and right. The RCP dated [DATE] identified Resident #32 was at risk for episodes of hyperglycemia and hypoglycemia from diabetes and included interventions of monitoring blood glucose as ordered, and monitoring for signs and symptoms of hyperglycemia and hypoglycemia. A chart review identified that Resident #32 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 3. Resident #66's diagnoses included Type 2 Diabetes, Stage 3 chronic kidney disease, and hemiplegia and hemiparesis. A RCP dated [DATE] failed to identify a risk for episodes of hyperglycemia and hypoglycemia from diabetes or implement any interventions. The quarterly MDS assessment dated [DATE] identified Resident #66 was cognitively intact, required maximal assistance with upper body dressing and rolling left and right, and was dependent with a change in position from sitting to lying. A physician's order dated [DATE] directed to obtain a blood glucose level one time a day on Monday, Wednesday, and Friday at 6:00 AM. A chart review identified that Resident #66 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 4. Resident #73's diagnoses included Type 2 Diabetes, dementia, and heart failure. The MDS assessment dated [DATE] identified Resident #73 had moderately impaired cognition, and required maximal assistance for personal hygiene, chair/bed-to-chair transfers, and rolling left and right. A chart review identified that Resident #66 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The RCP dated [DATE] identified Resident #73 was at risk for episodes of hyperglycemia and hypoglycemia from diabetes and included interventions of monitoring blood glucose as ordered, and monitoring for signs and symptoms of hyperglycemia and hypoglycemia. A physician's order dated [DATE] directed to obtain a blood glucose level one time a day on Monday, Wednesday, and Friday at 6:00 AM. 5. Resident #83's diagnoses included Type 2 Diabetes, atrial fibrillation, and hyperlipidemia. A physician's order dated [DATE] directed to obtain a blood glucose level once a day every three days at 6:00 AM. The quarterly MDS assessment dated [DATE] identified Resident #83 was cognitively intact, required maximal assistance for personal hygiene, and required moderate assistance for chair/bed-to-chair transfers and achieving a sit to stand position. The RCP dated [DATE] identified Resident #83 was at risk for episodes of hyperglycemia and hypoglycemia from diabetes and included interventions of monitoring blood glucose as ordered, and monitoring for signs and symptoms of hyperglycemia and hypoglycemia. A chart review identified that Resident #83 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. An observation of the glucometer's usage on [DATE] at 5:20 AM identified that Registered Nurse (RN) #1 was cleaning a glucometer with disinfectant wipes that expired on [DATE] (4 months ago). An interview with RN #1 on [DATE] at 5:20 AM identified that the glucometer was used to take blood glucose measurements for multiple residents on the facility's unit. RN #1 further identified the expired wipes were used for disinfection purposes daily and the responsibility to ensure the wipes used were not expired was the responsibility of the nurse using them. RN #1 failed to identify why the disinfectant wipes had not been removed from the medication cart when they expired and why she did not check the expiration date before using the wipes. RN #1 further stated the policy of the facility was to remove expired disinfection products from use and dispose of them. An interview on [DATE] at 5:37 AM with the Nursing Supervisor (RN #13) identified the disinfectant wipes used to clean the facility's glucometer expired on September of 2024. RN #13 identified it was the responsibility of the nurse using the wipes to ensure the wipes were not expired. RN #13 failed to identify why the disinfectant wipes had continued to stay in circulation for use for over 4 months after their expiration. Subsequent to surveyor inquiry, the disinfectant wipes were removed from the medication cart for disposal and a new container of disinfectant wipes was placed in the medication cart to be used for glucometer cleaning. An interview with the Disinfectant's Professional Customer Care Center on [DATE] at 9:11 AM identified the disinfectant wipes should be disposed of no later than the expiration date listed on the packaging. The Care Center indicated the greater the time that passes after the expiration date of the product, the less effective the product will be. The Care Center could not guarantee the expired product was providing proper disinfection and sanitizing of equipment and recommended its immediate disposal. An interview with the Nurse Manager (RN #4) on [DATE] at 8:59 AM identified 5 residents (Resident #10, #32, #66, #73 and #83) had received blood glucose testing using the glucometer from the cart with the expired disinfectant. Review of the Glucometer Disinfection Policy identified that glucometers should be disinfected according to manufacturer instructions before and after each use to prevent the transmission of Hepatitis A, Hepatitis B, and the Human Immunodeficiency Virus (HIV). Review of the Expired Cleaning Supply Disposal Policy identified that nurses are responsible for monitoring cleaning supplies on their carts and products should be removed before or at their expiration date.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #29) reviewed for pressure ulcers, the facility failed to properly document a change in skin condition and notify the provider and for 1 of 4 sampled residents, (Resident #57) reviewed for accidents, the facility failed to implement a physician's order for the application of padded side rails. Additionally, for 1 of 1 sampled resident (Resident #63) reviewed for choices, the facility failed to schedule an appointment with a specialist per provider recommendations and resident request, and for 1 of 3 residents (Resident #87) reviewed for general concerns, the facility failed to schedule a hematology consult per physician's order. The findings include: 1. Resident #29's diagnoses include pressure ulcer of sacral region, Type 2 Diabetes, and heart failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 was cognitively intact, and was dependent with personal hygiene and rolling left and right. A Resident Care Plan (RCP) dated 1/1/25 identified Resident #29 had a Stage 4 pressure injury at the coccyx level with an intervention to turn and reposition every two hours, conduct systematic skin inspections, and report any signs of further skin breakdown. An Advanced Practice Registered Nurse (APRN) order dated 1/2/24 directed wound care and a dressing change be performed once a day on the Stage 4 coccyx pressure ulcer. A Wound Assessment completed by Registered Nurse (RN) #11 and dated 1/25/25 at 2:58 PM identified a new pressure ulcer to Resident #29's gluteal crease. RN #11 failed to document the size of the wound, document the condition of the skin, indicate that a provider was notified to order a treatment, or document a progress note about the new wound. An interview with RN #9 (the nurse entering Resident #29's room to complete a wound treatment) on 1/27/25 at 10:58 AM identified she was unaware of the newly documented pressure ulcer to Resident #29's gluteal crease. An interview with the Nurse Manager (RN #4) on 1/27/25 at 11:11 AM identified that per policy, new skin integrity problem areas should be measured, documented, and the provider contacted for treatment. RN #4 failed to identify the wound was documented in a progress note, wound book, or APRN communication book. Further, she failed to identify the reason the wound was not assessed/documented on. Subsequent to surveyor inquiry, a wound care evaluation was completed on 1/27/25 at 11:42 AM by APRN #1. The area was determined not to be a pressure ulcer due to the area being blanchable, and APRN verbal orders were obtained on 1/27/25 at 11:42 AM directing Triad Cream to the gluteal fold (no frequency identified). Review of the Skin Integrity Policy identified that if there is a change in skin integrity, a Medical Doctor (MD) should be notified. Documentation should include a description of the wound and surrounding tissue, a description of the surrounding skin, drainage, and APRN notification of worsening condition if applicable. 2. Resident #57's diagnoses included cognitive decline, osteoarthritis, and acute embolism and thrombosis (blood flow blockage) of the deep veins in the lower extremities. The annual Minimum Data Set assessment dated [DATE] identified Resident #57 was cognitively intact, had limited range of motion on both sides of the lower extremities, and was totally dependent on staff for bed mobility and transfers. The Resident Care Plan dated 12/26/24 identified Resident # 57 was at risk for bruising and bleeding related to anticoagulant therapy and was also at risk for impaired skin integrity. Interventions included staff to provide a safe environment with no sharp edges, to monitor for active signs of bleeding, apply side ride pads, and to check for placement of rail pads each shift (3 times a day). The physician's orders in effect from 1/21/25 through 1/28/25 directed the application of side rail pads and staff were to check for placement each shift. Observation on 1/21/25 at 10:31 AM identified Resident #57 was awake, sitting upright in a chair. There were 2 blue side rail pads leaning against the wall, in the corner of the room, behind Resident #57's chair. Observation on 1/22/25 at 9:01 AM identified Resident #57 was awake and sitting upright in bed with a tray table across the bed. Resident #57 stated he/she just woke up. There were 2 side rails in the up position without the benefits of side rail pads. There were 2 blue side rails pads in the corner of the room, propped up against the wall. Observations on 1/24/25 at 5:58 AM and 7:58 AM identified Resident #57 in bed without the benefit of padded side rails on the 2 bed rails that were in the up position. Two blue side rail pads were noted in the corner of the room propped up against the wall. Observation and interview with RN #9 and NA #2 on 1/27/25 at 11:02 AM identified Resident #57 was sitting upright in a chair near the window in the corner of the room. RN #9 indicated that the blue pads in the corner of the room were side rail pads. NA #2 indicated that Resident #57 required the bed rail pads placed only when he/she was in bed because he/she bruised very easily. RN #9 took the blue pads and indicated she would have to reach out to the Maintenance Department to get new side rail pads because the blue side rail pads that were in Resident #57's room did not fit the new beds which had been obtained by the facility. RN #9 did not know what the policy was, but indicated it was the NA's responsibility to ensure the side rail rail pads were applied to the bed. Interview with the ADNS on 1/28/25 at 10:30 AM indicated the facility changed Resident #57's bed sometime over the summer. The ADNS was not aware the side rail pads did not fit the bed and would need to follow-up with maintenance. The ADNS indicated Resident #57 was at risk for bruising and bleeding if the side rail pads were not applied. Review of the Resident Safety Policy directed, in part, that bed rail protection is implemented for residents with seizure activity and any others requiring such intervention as designated in the care plan. 3. Resident #63 was admitted to the facilities Short-Term Care Unit on 9/19/24 with diagnoses that included chronic congestive heart failure (CHF), presence of an implanted defibrillator, left bundle branch block, and cardiomyopathy. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively intact, required maximal assistance with personal hygiene, and was dependent on chair/bed-to-chair transfers. The Resident Care Plan (RCP) dated 10/10/24 identified Resident #63 was at risk for decreased activity tolerance and shortness of breath related to CHF, cardiomyopathy, cardiac defibrillator, and atrial fibrillation. Interventions included adjusting the intensity of activities, monitoring of weight, and Cardiology follow-up as needed. An In-House Cardiology APRN note dated 10/14/24 at 9:54 AM directed follow-up with Resident #63's Cardiologist within 7 to 10 days of his/her transfer from the Short-Term Rehabilitation Unit to the Long Term Care Unit and recommended telemonitoring for CHF. The APRN note further stated that In-House Cardiology was signing off from Resident #63's care and his/her care should be managed with the CHF Protocol. Resident #63 was transferred to the facilities Long Term Care Unit on 11/29/24. A physician's order (from the facilities physician) dated 12/12/24 directed the Automatic Implanted Cardioverter Defibrillator (AICD) monitor to be plugged in at the bedside at all times. An interview with Resident #63 on 1/22/25 at 10:07 AM identified that he/she had requested to see his/her own Cardiologist and had not seen them as requested. Resident #63 expressed concern that he/she was told he/she could only see In-House providers and that did not include his/her own Cardiologist. An interview with Registered Nurse (RN) #2 on 1/27/25 at 12:40 PM identified that the facility physician was the person responsible for placing an order for a resident to see a specialist and nurses were responsible for tracking resident's appointments on a unit calendar. RN #2 failed to locate documentation that Resident #63 had been evaluated by his/her Cardiologist after Cardiologist APRN recommendations and admission to Long Term Care from the Short-Term Care Unit. An interview with the Nursing Supervisor (RN #4) on 1/27/25 at 12:56 PM identified that a follow-up visit with Resident #63's Cardiologist should have been scheduled (per APRN recommendations) after the resident's discharge from the Short-Term Care Unit but could not identify the reason the appointment was not made. An interview with the Unit Secretary/Scheduler on 1/28/25 at 9:40 AM identified she was not aware Resident #63 requested to see his/her Cardiologist and thus did not schedule an appointment. She further identified that she was usually notified in writing by a nurse manager when an appointment needed to be scheduled. An interview with Nurse Supervisor (RN #8) on 1/28/25 at 9:48 AM identified she was unaware that Resident #63 requested and needed to see a cardiologist (per APRN note from 10/14/24) and did not direct the Unit Secretary/Scheduler to make an appointment. RN #8 indicated that Resident #63 was planned to be discharged home but instead was transferred to the Long-Term Care Unit. She further noted that when a resident was transferred from Short Term Care to Long Term Care, they were no longer able to receive services from the In-House Cardiologist and that information should have been relayed between nurses during hand-off. An interview with the Unit Secretary on 1/28/25 at 9:48 AM identified that Resident #63 had attempted to schedule his/her own Cardiology appointment on 1/7/25 but canceled the appointment his/herself due to lack of transportation. The Unit Secretary stated she was unaware Resident #63 tried to independently schedule a Cardiology appointment until this morning when she called the Cardiology office and was given that information. She further noted the Cardiology office stated Resident #63's pacemaker and AICD had not been interrogated (a standard procedure performed by a Cardiologist to ensure a pacemaker is functioning properly and to retrieve stored usage data from the pacemaker itself, ensuring optimal pacing therapy is provided to a patient) since 1/2/24. An interview with Person #4 from Resident #63's Cardiology Office on 1/28/25 at 11:41 AM identified that Resident #63 should have been evaluated by his/her Cardiologist after his/her last facility In-House Cardiology visit on 10/14/24. She further noted that lack of timely follow-up by Resident #63 could result in potential heart failure exacerbation. Subsequent to surveyor inquiry a physician's order dated 1/28/25 directed staff to contact Resident #63's Cardiologist to schedule an appointment for his/her AICD. Review of the Physician Order Monitoring Policy identified that all resident medical records will be reviewed on a daily basis. The nurse will review each record and ensure that all orders have been implemented. 4. Resident #87's diagnoses included protein deficiency anemia, iron deficiency anemia and folate deficiency anemia. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 was cognitively intact and was independent with eating. Additionally, the MDS identified Resident #87 required supervision with toileting and personal hygiene and was independent with eating. The Resident Care Plan dated July 2024 identified Resident #87 was at risk for impaired nutritional status related to a diagnosis of protein deficiency anemia. Interventions included to monitor and report labs as ordered. A lab result collected on 9/3/24 and reported on 9/11/24, indicated a low albumin level and an abnormal protein band. The blood work results further identified a significantly elevated lambda light chain and a low [NAME]/lambda ratio. A physician's progress note dated 9/11/24 noted a review of recent blood work with abnormal results which needed further investigation and a hematology consult was to be scheduled. A physician's order dated 9/11/24 directed to schedule a hematology consult to evaluate Resident #87's abnormal blood work results. Interview and record review with the Unit Secretary/Scheduler on 1/27/25 at 10:37 AM identified that she was not aware that a hematology consult had been ordered by the physician on 9/11/24 and was unable to locate a record that the physician ordered hematology consult had been scheduled for Resident #87. Additionally, the Unit Secretary/Scheduler indicated that the nurse should have seen the order in the electronic system and when it was transcribed by the nurse it should have been written in the appointment book. The Unit Secretary/Scheduler identified that although she checks the appointment book regularly, she would not have known Resident #87 needed a hematology consult because it was not written in the appointment book. Subsequent to surveyor inquiry on 1/27/25 at 10:40 AM, the Unit Secretary/Scheduler indicated that she had contacted the hematology office and left a message with the office to schedule a new patient appointment for Resident #87. Interview and record review with the Registered Nurse Supervisor (RN #8) on 1/27/25 at 10:45 AM, identified that the physician order dated 9/11/24 for a hematology consult was placed under general orders in the electronic record, nursing should have seen it and transcribed it from there. Additionally, RN #8 indicated when the 11:00 PM to 7:00 AM nurse completed an audit of the orders for 9/11/24, the previously untranscribed order for the hematology consult should have been picked up, transcribed and put into the appointment book at that time. RN #8 indicated that nursing should have written the request for the hematology consult in the appointment book and without doing so, the Unit Secretary would not have known about or scheduled the needed appointment for Resident #87. Interview with MD #1 (the ordering physician) on 1/27/25 at 1:00 PM identified that he ordered the hematology consult on 9/11/24 after he reviewed abnormal blood work results for the resident. MD #1 indicated that he wrote the order for the hematology consult as a physician's order and in his progress note and that the order should have been transcribed and followed through by nursing. MD #1 identified that, although Resident #87 appeared relatively asymptomatic, the abnormal blood work results indicated he/she should have been seen by a hematologist to determine if he/she needed additional testing or treatment, especially because of the resident's various anemia diagnoses. MD #1 further indicated that failure to schedule the hematology consult could have led to a potential worsening of Resident #87's condition. Review of the facility's, Physician Order Monitor policy, undated, directed to ensure that all physician orders are noted and implemented as ordered. The policy further directed that all resident medical records will be reviewed daily and all audits will be completed by the 11:00 PM to 7:00 AM licensed staff on each nursing unit. The nurse should review each record and note that all orders have been implemented. 51182 52073

Based on the tour of the Dietary Department, interviews, review of facility policy and facility documentation, the facility failed to ensure that beard restraints were worn appropriately, perform hand hygiene when appropriate, ensure open food items were properly closed/dated and not near debris on the floor and failed to discard expired food items. The findings include: During observations of meal service on [DATE] at 11:45 AM with the Director of Food Services, the following was identified: 1a. Dietary Aide #1 (DA) was observed at the tray line placing plated food on residents' trays wearing a beard restraint that covered only the lower half of his facial hair with the sides of his beard exposed. Subsequent to surveyor inquiry, the Director of Food Services (who was also observing the meal service) informed DA #1 that his beard was exposed around the beard restraint and that his beard restraint needed to be readjusted. DA #1 proceeded to walk away from the plating area, removed his gloves, removed his beard restraint and reapplied it attempting to readjust the beard restraint. DA #1 then washed his hands, applied new gloves, and then returned to the serving area and resumed placing the plated food on the trays. DA #1's beard restraint still did not fully cover his beard with facial hair half exposed on the sides. DA # 1 stated to the Director of Food Services that he was not able to fully cover the beard as the beard restraint would not cover the sides of his face. DA #1 continued with plating food on the residents' trays with his facial hair exposed. b. The Executive Chef was observed to be plating food items from the steam table (chicken or hamburger on a bun with lettuce and tomato, rosemary potatoes and green beans) wearing a beard restraint that only covered half of his facial hair, with the sides of his beard exposed. Subsequent to surveyor inquiry, the Director of Food Services informed the Executive Chef at 11:54 AM that his beard restraint did not fully cover his facial hair. The Executive Chef proceeded to go to the sink area, removed his gloves, readjusted his beard restraint, washed his hands, and applied new gloves. He then returned to his station of plating food but the beard restraint still did not cover his facial hair with the sides and lower cheek facial hair being exposed. The Director of Food Services informed him that his beard was still not fully covered. The Executive Chef proceeded to attempt to readjust his beard restraint while at the steam table without the benefit of walking away from the area or performing appropriate hand hygiene including washing his hands and changing his gloves after touching his face. The Executive Chef continued to plate food with facial hair exposed and with the same gloves. c. At 11:57 AM, observation of the Executive Chef noted he walked away from the steam table and proceeded to the grill area. Hamburgers were cooking on the grill that were partially cooked and still raw on one side. The Executive Chef was observed to touch a raw hamburger with his gloved hands and flipped another hamburger with a spatula. He then proceeded and turned around to the preparation station and removed a hamburger bun from the package without the benefit of removing his gloves and washing his hands after touching the raw meat and before touching the hamburger bun. An interview with the Executive Chef on [DATE] at 10:20 AM indicated that he was aware that his beard restraint was not properly covering his facial hair on [DATE] when serving. He indicated that before serving he sometimes adjusts the beard restraint as it can be uncomfortable and forgets to put it back in place when he starts to serve meals. He also indicated that he should have changed gloves and washed his hands after he touched his face and after touching the raw hamburger. Additionally, he stated that he immediately was aware that he cross contaminated when he touched the raw hamburger and then touched the hamburger roll. The Executive Chef indicated he has been educated on the proper use of beard restraints, hand hygiene, glove use and cross contamination after handling raw meat. He stated that there was a lot going on and it just slipped his mind when these incidents occurred. 2. A tour of the large dry goods storage area (located in the basement) at 12:30 PM with the Director of Food Services, the following was identified: a. A bag of 50-pound flour that was ,d+[DATE] full, was partially opened without the benefit of a label of the date opened or discard/expiration date. On the floor next below the bag of flour there was a pile of swept debris. The floor had been swept without the benefit of discarding the debris on the floor. Interview with the Director of Food Services at the time of observation identified that the bag of flour should have been secured and dated and the debris on floor should have been discarded in the trash. In addition, a 20-pound bag of corn meal with less than one third used was on a shelf that was left partially opened without the benefit of a label of the date opened or discard/expiration date. The Director of Food Services indicated that the bag was not properly closed, and he would secure it or put it in a plastic container and label and date the corn meal. b. Metal shelves contained a ,d+[DATE] full, 21 ounce container of Everything Bagel spice with an expiration of [DATE] (14 months old), a Japanese Seven spice container with an expiration date of [DATE] (21 months old) that was two thirds filled and a Harissa Spice with expiration date of [DATE] (21 months old) that was two thirds full. There were (8) 32-ounce containers of plant-based coconut milk that expired February 2024 (11 months old). The Director of Food Services indicated that these products had not been in use and should have been removed from the shelves and discarded. A review of Uniform Dress Code policy dated ,d+[DATE] directed, in part, associates working with food wear approved restraints and refrain all facial hair with a beard net restraint. A review of Food Handling Guidelines policy dated ,d+[DATE] directed, in part, food shall be protected against cross-contamination by appropriately separating types of raw animal products from other foods and hands should be scrubbed following appropriate hand washing techniques according to facility policy between food preparation tasks, between tasks and before putting on clean gloves. A review of Disposable Glove use policy dated ,d+[DATE] directed, in part, that disposable gloves must be changed, and hands washed when the gloves are dirty or ripped and when moving from one task to another. A review of posted sign titled, Main Storage Room Standard Expectation, posted on the inside door of the in the main dry storage area, directed, in part, clean up all spills and trash from the floor. This task is to be conducted by each staff member who enters and uses the Main storage room. A review of Food and Storage Supply policy dated ,d+[DATE] directed, in part, to date and rotate items, first in and first out. Discard food past the used-by date or expiration date. Cover, label and date unused portions and open packages. Use the Medadvantage/Freshdale labeling system or complete all section on a [NAME] orange label.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #87 and Resident #353) reviewed for transmission-based precautions, the facility failed to ensure privacy related to having the posted isolation sign identify the type of infection/reason for the resident's isolation. The findings include: 1. Resident #87's diagnoses included current herpes zoster/shingles, chronic obstructive pulmonary disease and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #87 was cognitively intact and required partial to moderate assistance with toileting, transfers, and bed mobility. The Resident Care Plan dated 1/3/25 indicated a rash related to herpes zoster and antiviral medication for a diagnosis of shingles. Interventions included treatments and medications as ordered and to inform medical staff as needed. A physician's order dated 1/23/25 directed contact precautions, place a contact precaution sign on the door, highly transmissible active infection that cannot be contained, and Resident #87 must be in room alone and without a roommate. An observation on 1/27/25 at 10:00 AM identified Resident #87's room had a sign with a large red circle, a white hand inside the circle and text that indicated NO ENTRY to persons who HAVE NOT HAD: the varicella/chicken pox vaccine or chicken pox. Please visit the Nurses Station. Resident #87 was observed inside of the room and seated in the bedside recliner. Interview with Resident #87 on 1/27/25 at 1:15 PM identified that although he/she understood why the isolation sign was on the door, he/she did not like it and thought the sign should be removed. Resident #87 indicated he/she was going to speak to the nurse about removing the sign from the door. Interview with Person #2 on 1/27/25 at 1:17 PM identified that he/she did not like that there was an isolation sign on the door and that it made it look like the room was quarantined. Person #2 indicated she was going to speak to the nurse about having the isolation sign removed. An observation on 1/28/25 at 10:00 AM identified that the door to Resident #87's room had an isolation sign on the door with a large red circle, a white hand inside the circle and text that indicated NO ENTRY to persons who HAVE NOT HAD: the varicella/chicken pox vaccine or chicken pox. Please visit the Nurses Station. Resident #87 was observed inside of the room and seated in the bedside recliner. 2. Resident #353's diagnoses included current herpes zoster/shingles, pancytopenia and thrombocytopenia. The admission Minimum Data Set assessment dated [DATE] identified Resident #353 was cognitively intact and required substantial/maximal assistance with bed mobility and was dependent with transfers and toileting. The Resident Care Plan dated 1/13/25 indicated Resident #353 was at risk for impaired skin integrity related to severe protein malnutrition. Interventions included conduct a systemic skin inspection on shower day and provide treatment to impaired skin integrity and rashes as ordered. A physician's progress note dated 1/17/25 at 1:51 PM identified a unilateral left upper back/posterior left shoulder area with erythematous, blotchy rash with tiny vesicles noted in a dermatomal pattern, highly suspect for herpes zoster. The progress note indicated isolation precautions and antiviral medication were ordered. Observations on 1/22/25 at 11:15 AM and 1/23/25 at 1:30 PM identified the door to Resident #353's room had an isolation sign with a large red circle, a white hand inside the circle and text that indicated NO ENTRY to persons who HAVE NOT HAD: the varicella/chicken pox vaccine or chicken pox. Please visit the Nurses Station. Resident #353 was observed inside of the room and seated in the bedside recliner. Interview with the Infection Preventionist (RN #7), on 1/27/25 at 12:17 PM identified the isolation signs observed on the door of Resident #87 and Resident #353's rooms indicating NO ENTRY to persons who HAVE NOT HAD: the varicella/chicken pox vaccine or chicken pox were placed there according to the facility policy and that the same signage is utilized at all of the company's locations. RN #7 identified that, although the isolation sign indicated varicella/chicken pox in the text, the isolation sign did not divulge Resident #87 and Resident #353's actual diagnoses of shingles. Futher, RN #7 was unable to explain how a visitor with a medical background would remain unaware of the resident diagnosis since specific infections were posted on the isolation sign. RN #7 was unable to identify conditions/diagnoses other than varicella/chicken pox to which these particular precautions would apply, therefore not maintaining Resident #87 and Resident #353's privacy. Interview with Resident #353 on 1/28/25 at 9:49 AM identified that although he/she knew why the isolation sign was on his door, he/she had to explain to his many visitors what his/her condition was and why the sign was there. Resident #353 indicated he preferred the sign was no longer on his door. Review of the facility policy, Contact/Airborne Precautions for Herpes Zoster (Shingles), undated, directed that a patient with localized shingles (lesions confined to one area and can be covered) would be placed on Standard Precautions with No Entry signage on the door. Non-immune staff should not enter the room if possible. The policy further directed that ideally the patient with shingles should be placed in a single room if available. Review of the facility policy, Enhanced Barrier Precautions, undated, directed that Standard Precautions were a set of infection control practices used for all residents regardless of their diagnosis and infection status. Review of the facility policy, Precautions for Shingles, dated 6/1/24, directed when Standard Precautions are required, ideally the patient with shingles should be placed in a single room if available and a No Entry shingles sign shall be posted.

Based on observations, review of clinical records, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #9 and Resident #64) reviewed for unnecessary medications, the facility failed to follow professional standards for medication administration. The findings include: 1. Resident #9 was admitted to the facility in August of 2022 with diagnoses that included infection and inflammatory reaction due to internal right knee prosthesis (chronic infection of knee replacement), peripheral vascular disease, and Factor VIII disorder (increase bleeding disorder). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 as being cognitively intact and required maximum assistance with personal hygiene, dressing, showering and totally dependent for toileting and independent with eating. The Resident Care Plan dated 1/2/25 identified behavioral symptoms with interventions to administer medications per physician orders and monitor for any side effects or adverse reactions and may have artificial tears and Ayr saline nasal spray at bedside to self-administer. Physician's orders dated August 2022 through 1/3/25 identified Resident #9 was not on Insulin (had no physician orders for Insulin). A nurse's note dated 1/22/25 at 5:33 PM and written by Registered Nurse (RN) #6 identified Person #1 phoned the facility to inform nursing staff that Resident #9 reported that Licensed Practical Nurse (LPN #2/an agency nurse) entered Resident #9's room to administer an Insulin injection into his/her abdomen. Additionally, the nursing note identified LPN #2 prepared Resident #9's abdomen with an alcohol wipe for injection and then asked Resident #9 his/her name. Resident #9 asked LPN #2 what he/she was doing, and then LPN #2 proceeded to leave the room. RN #6 explained to Person #1 that LPN #2 was sent home, and the staffing agency was contacted. Facility documentation titled Near Miss Report Form and completed by RN #6 identified that on 1/22/25, LPN #2 attempted to administer Insulin subcutaneously (beneath the skin) to Resident #9's abdomen until Resident #9 questioned what he/she was doing. LPN #2 proceeded to leave the room. RN #6 updated the staffing agency of the incident, and that LPN #2 could no longer return to the facility. An interview with Resident #9 on 1/27/25 at 11:00 AM indicated that LPN #2 walked into Resident #9's room, pulled up his/her shirt, started to wipe down his/her stomach and took a cap off a pen containing medication (Insulin). Resident #9 stated he did not recognize LPN #2 and did not think he/she had ever seen LPN #2. Resident #9 proceeded to ask LPN #2 what he/she was doing and what was LPN #2 going to give him/her. LPN #2 responded that he/she was going to give Resident #9 Insulin and Resident #9 stated he/she informed LPN #2 that he/she did not take Insulin. LPN #2 responded by asking Resident # 9 his/her name at that time (but not before attempting to inject Insulin to Resident #9). Resident #9 informed LPN #2 that his/her name was on the door and asked LPN #2 if he/she checked the door prior to coming in the room. Resident # 9 indicated that LPN #2 responded that he/she had to leave. Resident #9 verbalized that if he/she received the Insulin could have had a bad reaction. Resident #9 indicated that he/she proceeded to call Person #1 to update on what had transpired and Person #1 contacted the facility. Resident #9 indicated that LPN #2 never asked his/her name when entering the room nor did LPN #2 check Resident #9's name bracelet on his/her wrist. On observation during interview, Resident #9's name bracelet was on his/her right wrist and appeared to be slightly worn, indicating he/she had been wearing it awhile. Resident #9 indicated that the name bracelet had been on since he/she was admitted to the facility in 2022 and he/she has never removed the name bracelet (yet LPN #2 had not verified his/her name bracelet to ensure the right resident was receiving an injectable medication). Interview with LPN #2 on 1/27/25 at 1:15 PM via the telephone indicated that he/she went into Resident #9's room and placed all medications on Resident #9's over bed table. LPN #2 stated that Resident #9 was not wearing a name bracelet, so he/she proceeded to ask Resident #9 his/her name. According to LPN #2, instead of providing his/her name, Resident #9 asked what the injection pen was for. LPN #2 informed Resident #9 that the pen contained Insulin and indicated that just because he/she entered the room with the Insulin pen did not mean Resident # 9 was going to receive it. LPN #2 stated that he/she informed Resident #9 that he/she needed to know his/her name and indicated to Resident #9 that the Insulin was not for him/her. LPN #2 denied raising Resident #9's shirt and wiping his/her abdomen with alcohol. LPN #2 indicated that Insulin was for another male resident that was eating in the dining room (yet LPN #2 was in Resident #9's room). LPN #2 indicated that many residents were not wearing name bracelets (all residents had name bracelets on during survey). LPN #2 stated he/she was feeling ill and shortly after RN #6 informed LPN #2 around 5:30 PM that he/she needed to leave the facility related to the Insulin incident and due to feeling ill. Interview with RN #6 on 1/27/25 at 2:30 PM indicated that Person #1 phoned the facility on 1/22/25 and spoke to her to report that LPN #2 attempted to administer Insulin to Resident #9 prior to supper without properly identifying Resident #9. RN #6 stated she was already going to assess LPN #2 since she had been sick (vomiting) in the bathroom and was planning to send LPN # 2 home. RN #6 stated after the Insulin incident, LPN #2 needed to leave and not return. RN #6 indicated that she contacted the ADNS and the staffing agency to inform them of the incident and that LPN #2 had left the facility around 5:30 PM. RN #6 indicated that she was informed that there was a medication error with another resident who did not receive the correct dose of medication from LPN #2 on 1/22/25. 2. Resident #64 was admitted to the facility in August 2024 with diagnoses that included dementia with behavioral disturbances, anxiety, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #64 as being cognitively impaired with inattention and disorganized thinking and required moderate assist for personal hygiene, dressing, showering, toileting and eating. The Resident Care Plan dated 12/3/24 identified behavioral symptoms as a focus issue and to administer medications as ordered, monitor effectiveness, avoid over stimulation, provide 1 to 1 as needed and provide and follow consistent and familiar routines. A physician's order dated 1/22/25 directed to administer Klonopin (a medication for anxiety) 0.5 mg (milligrams) at 5:00 PM and Klonopin 0.5 mg every 12 hours as needed for restlessness or agitation. A Reportable Event Form dated 1/22/24 at 4:06 PM indicated that LPN #2 administered Klonopin 0.25 mg instead of Klonopin 0.5 mg to Resident #64 as ordered at 5:00 PM. A nursing note dated 1/23/25 at 8:30 AM identified that Person #2 was notified of a medication error. An interview with LPN #2 on 1/27/25 at 1:15 PM revealed that she was not aware of making any type of medication errors and that she had no idea what the facility was referring to. Interview with the ADNS on 1/28/25 at 9:30 AM identified that LPN #2 had made a medication error regarding Resident #64's Klonopin on 1/22/25, that the appropriate documentation for medication errors had been completed and the staffing agency had been notified by the ADNS on 1/23/25 regarding LPN # 2's medication error. A review of Medication Administration Policy directed, in part, to bring medication cart to an area adjacent to resident room, read order entirely, remove medications from the drawer and read label 3 times (when removing from drawer, before pouring and after pouring). Identify resident by reading the wristband. A review of Medication Error policy date 7/1/24 directed, in part to prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration. b. Right resident and right documentation. If a medication error occurs the nurse assess and examines the resident's condition and notifies the health care practitioner. The nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report.

Based on observations, interviews and record review for 1 of 1 sampled residents (Resident #39), reviewed for positioning, the facility failed to offload heels for a resident at risk for pressure ulcers and for 1 of 3 sampled residents (Resident #8) reviewed for pressure ulcer injury, the facility failed to provide the necessary treatment to prevent the redevelopment of a pressure ulcer. The findings include: 1. Resident #8's diagnoses included rheumatoid arthritis, contracture of both knees, contracture of right thigh muscle, spinal stenosis, and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #8 was cognitively intact, had limited range of motion on both sides of the lower extremities, and was totally dependent on staff for turning and transferring. The Resident Care Plan dated 12/20/24 identified Resident #8 was at risk for impaired skin integrity related to limited bed mobility, weakness and a history of right heel redness and skin tears. Interventions included treatment to areas of impaired skin integrity as ordered. A nursing note dated 1/10/25 indicated a Stage 2, fluid filled blister, to the right heel measuring 5.5 centimeters (cm) by 6 cm which was tender to touch (a Stage 2 pressure injury is a partial-thickness skin loss that appears as an open wound, blister, or scrape). A pressure ulcer risk assessment dated [DATE] identified that Resident #8 had a Braden Score of 13 which indicated Resident #8 had a moderate risk for developing a pressure ulcer. A nursing note dated 1/25/25 indicated Resident #8's right heel blister had healed. A physician's order in effect on 1/27/25 directed the application of skin prep to both heels and reddened areas, twice a day at 9:00 AM and 9:00 PM. Observation, interview, and review of the clinical record with RN #2 and RN #9 on 1/27/25 at 9:44 AM identified both RN's turned Resident #8 in preparation for his/her treatment. RN #2 washed Resident #8's feet with soap and water then patted them dry. RN #2 was observed to apply a small amount of [NAME] healing dry skin moisturizer to Resident #8's right and left feet. RN #2 indicated that Resident #8's prescribed wound care treatment consisted of cleaning his/her right heel with soap and water and then applying the Resident's personal cream. During a clinical record review of the physician's orders with RN #2, she noted that she had failed to provide the physician directed appropriate treatment. RN #2 indicated that she would try to find skin prep and would return to provide the correct physician prescribed treatment to Resident #8. Interview on 1/27/25 at 10:02 AM with Register Nurse Supervisor (RN) #4 indicated that she would have expected the nurse to use skin prep as directed by the physician's order. RN #4 identified that Resident #8's personal dry skin moisturizer was not the same as what was ordered (skin prep) and would not provide the same protection against the redevelopment of the pressure injury. RN #4 stated that she would have expected a nurse would know to follow the physician's orders. Review of the Skin Integrity: Protocol, Promotion and Maintenance of Skin Integrity Policy, directed, in part, that residents having pressure ulcers receive the necessary treatment and services to promote healing, prevent infections, and prevent new ulcers from developing. Treatment modalities should be chosen according to the wound stage and drainage. Treatment choice is either preventative or the stage of the wound. Treatment requires orders from NP/PA or MD. 2. Resident #39's diagnoses included osteoarthritis, osteoporosis and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 had moderate cognitive impairment, and required substantial/maximal assistance from staff for upper body dressing, rolling from left to right and moving from sitting to lying in bed. Additionally, the MDS identified Resident #39 was at risk for developing pressure ulcers and pressure injuries. The Resident Care Plan dated 12/24/24 identified Resident #39 was at risk for skin breakdown and pressure ulcers due to non-ambulatory status related to osteoarthritis, valgus deformity of the knees, gait abnormality and osteoporosis. Interventions included in part, to perform systematic skin inspections every shower day and as needed, report any signs of skin breakdown, and to keep heels elevated while in bed. A physician's order dated 12/20/24 directed to off load heels every shift while lying in bed, and document if refused. The Patient/Resident Care Card located in Resident #39's bathroom directed to off load heels in bed. Observations on 1/21/25 at 10:52 AM, 1/21/25 at 1:12 PM and 1/22/25 at 9:09 AM identified Resident #39 lying in bed, legs outstretched with a flat pillow placed under the calves which did not afford his/her heels to be off of the bed (heels were lying directly on the bed). An interview and observation with Registered Nurse (RN) #3 on 1/23/25 at 8:59 AM identified the facility policy on off-loading heels was that heels should not be touching the bed, and Nurse Aides were responsible for elevating the heels by utilizing a pillow, green boots or a positioning wedge. Additionally, observation of Resident #39 with RN #3 identified that the positioning of the heels was not considered offloaded because the pillow was too flat, and the heels were touching the bed. Subsequent to surveyor inquiry RN #3 off loaded Resident #39's heels by placing a thicker pillow under her/his calves so that the heels were not lying on the bed. An interview and care card review with Nurse Aid (NA) #1 on 1/23/25 at 9:08 AM identified she did not know what off-load heels meant, but instructions on care were identified on care cards located in resident bathrooms. Review of the care card in Resident #39's bathroom directed to offload heels in bed under positioning, however NA #1 could not identify what that meant or what was expected to carry out that care. Subsequent to surveyor inquiry RN #3 educated NA #1 about off-loading heels. Review of the Skin Integrity: Protocol for prevention and maintenance of skin integrity promotion/maintenance; prevention and treatment of pressure ulcers and wounds Policy directed in part that a resident without a pressure ulcer does not develop a new pressure ulcers, and that preventative measures will be instituted to relieve heel pressure by rising heels off the bed by using multiple pillows. 52073

Based on clinical record reviews, review of the Resident Assessment Instrument (RAI) Manual, facility policy, and interviews for 2 of 4 sampled residents (Resident #49 and Resident #89) reviewed for resident assessment, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner. The findings include: 1. Resident #49's diagnoses included dementia and spinal stenosis. On 1/27/25 at 10:43 AM review of MDS submissions with MDS Coordinator #2 (LPN #1) identified a quarterly MDS assessment was completed on 8/16/24, but failed to complete further MDS assessments. Additionally, MDS Coordinator #2 identified a quarterly MDS assessment should have been completed in November 2024 (72 days past due). 2. Resident #89's diagnoses included chronic systolic heart failure and type 2 diabetes mellitus. On 1/27/25 at 10:43 AM review of MDS submissions with MDS Coordinator #2 (LPN #1) identified a quarterly MDS assessment was completed on 8/28/24, but failed to complete further MDS assessments. Additionally, MDS Coordinator #2 identified a quarterly MDS assessment should have been completed in November 2024 (60 days past due). Further interview with MDS Coordinator #2 (LPN #1) identified that although Resident #49 and #89 appeared on the November 2024 MDS calendar as being due for assessment completion, she did not know the reason they were not completed. As per the RAI OBRA required assessment summary the facility has 3 months to complete a Quarterly MDS assessment.

Based on record review, staff interview and Resident Assessment Instrument (RAI) policy for 4 of 4 sampled residents (Resident's #49, #52, #89, and #96) reviewed for late Minimum Data Set (MDS) transmittals, the facility failed to ensure MDS' were transmitted timely. The findings include: Interview and transmittal review of MDS' on 1/27/25 at 10:23 AM with MDS Coordinator #1 (RN #5) identified the following: 1. Resident #49 was admitted to the facility in February 2023. a. An annual MDS assessment was completed on 2/20/24, but not transmitted until 3/11/24 (5 days past due). b. A quarterly MDS assessment was completed on 8/16/24, but not transmitted until 9/19/24 (19 days past due). 2. Resident #52 was admitted to the facility in October 2021. a. A quarterly MDS assessment was completed on 6/20/24, but not transmitted until 8/15/24 (42 days past due). b. A quarterly MDS assessment was completed on 12/17/24, but not transmitted until 1/23/25 (23 days past due). 3. Resident #89 was admitted to the facility in September 2023. a. A quarterly MDS assessment was completed on 5/30/24, but not transmitted until 6/25/24 (12 days past due). b. An annual MDS assessment was completed on 8/28/24, but not transmitted until 9/16/24 (6 days past due). 4. Resident #96 was admitted to the facility in September 2024. a. An admission MDS assessment was completed on 9/10/24, but not transmitted until 9/30/24 (6 days past due). b. A quarterly MDS assessment was completed on 12/10/24, but not transmitted until 1/23/25 (30 days past due). Additional, MDS Coordinator #1 identified she was a newer employee and was catching up when she was hired. Additionally, she stated they were behind in transmitting MDS' due to other MDS Coordinators having time off. According to the Resident Assessment Instrument (RAI) manual, a quarterly assessment must be electronically submitted within 14 days of the MDS completion date.

Based on tour of the nourishment rooms and interviews, the facility failed to ensure that 3 sinks in 4 nourishment rooms were maintained in a clean and sanitary manner. The findings included: Observations and interviews on 1/23/25 at 10:35 AM with Director of Environmental Services and Administrator revealed the following: a. The first floor [NAME] nourishment room cabinet under the sink was locked with a zip tie and a green substance was noted on the bottom of the cabinet. Interview with the Director of Environmental Services at that time indicated that it should not have a green substance on the bottom and the green substance must be coming from the pipes. b. The first floor [NAME] North nourishment room door was unlocked, the sink was noted with a container under the pipe that was collecting water with small black particles on the bottom of the cabinet. The Director of Environmental Services turned on the faucet which revealed a slow leak coming from the pipe under the cabinet. He indicated that the particles on the bottom were most likely debris and rust. He stated the leak would be fixed and area under the sink cleaned. Interview with the Administrator at time of discovery indicated that nothing should be under the sink and items were removed. The small kitchenette area adjacent to the large kitchen had a small sink that was unlocked with small black spots on the bottom of the cabinet. The Director of Environmental Services indicated that the area would be cleaned and locked. c. The second floor [NAME] nourishment room cabinet under the sink had some black debris, rust and a mouse trap. The Director of Environmental Services indicated on interview during observation that the area needed to be cleaned, could not identify the last time the sink was checked and it should not be maintained in this manner. Interview with Environmental Services Assistant on 1/23/25 at 11:30 AM revealed that he was not doing any repairs under the sinks in the nourishment rooms at this time and that he did not receive a verbal request for work or a ticket issued for work requests. Interview with the Administrator on 1/23/25 at 11:40 AM indicated that there was no preventive maintenance in place for under the sinks, but she would be initiating a preventive maintenance plan. The Administrator indicated that staff was able to put in a work request with computerized system called Workhub which produces a work request ticket. She was unable to provide any work tickets related to repairs needed under the sinks. Interview with RN #7 on 1/28/25 at 10:00 AM revealed Environmental Rounds are done monthly with the Director of Environmental Services and the Assistant. She indicated that they do not check under the sinks as they are usually zip tied closed. She stated that she does not remove the zip ties to check under the sink as she does not have spares to replace them. Although requested, a facility policy for maintenance and care for under the sinks was not provided as the Administrator stated there was no policy available.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Record review identified Resident #1 was admitted to the skilled nursing facility during 5/2024 and had an emergency contact listed as a Durable Power of Attorney (POA). Resident #1's diagnoses included depression, anxiety and cerebral infarction (stroke). The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, and required assistance with ADLs. The Resident Care Plan (RCP) dated 8/27/2024 identified a risk for loneliness due adjustment to change in living situation related to placement for long term care. Interventions directed to allow to express feelings, and visits with social services. Review of facility Reportable Event form dated 11/18/2024 at 2:00 PM identified that the DNS was contacted by an officer from the local police department regarding misappropriation of Resident #1's funds by NA #1. The form indicated NA #1 was suspended and a locked drawer was provided for Resident #1's valuables storage. The facility summary dated 11/20/2024 identified the POA reported suspected larceny to the local police. The local police notified the facility that Resident #1's banking information (routing number and account number) was used to pay debt in the name of NA #1; between $1400 and 1500 was misappropriated. Review of the Administrator timeline summary of investigation identified the following: On 11/18/2024 the local police notified the facility of fraudulent use of Resident #1's bank account for NA #1's bills totaling around $1,900.00 during the end of September/early October 2024. The police indicated family had left a blank check with Resident #1 for approximately four (4) days. NA #1 did not work on Resident #1's unit, denied the allegation when staff questioned her, and was suspended. NA #1 informed the facility she had documentation to show she paid the bills in question. The police informed the facility, NA #1 had documentation to show she paid the bills in question after the bills were paid using Resident #1's account and they were flagged by the bank fraud department. Interview, clinical record review and facility documentation review on 12/4/2024 at 2:17 PM with the Administrator and ADNS identified that Resident #1's family member brought in a blank check that was in Resident #1's drawer for four (4) days before another family member came to collect it. NA #1 knew Resident #1 from another area of the campus prior to admission to the skilled nursing section (SNF), and although NA #1 worked in the SNF part of the campus, she did not work on Resident #1's unit and had never floated to that unit to work. Interview identified Resident #1's responsible party had indicated Resident #1 had a history of leaving his/her checkbook out at the other area of campus prior to admission to the SNF, where NA #1 worked in another role. Interview on 12/5/2024 at 9:30 AM with Police Officer (PO #1) identified although NA #1 denied the accusation, PO #1 stated Resident #1's account was used to pay bills for NA #1. Further PO #1 stated the case was pending court and prosecutor review regarding any arrest warrant. Although several attempts were made, an interview with NA #1 not obtained during the survey. Review of facility Resident [NAME] of Rights directed in part, the facility must take reasonable care in protecting your property from loss or theft and the right to be from misappropriation of property. Review of facility Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Resident Property directed in part, to prohibit misappropriation of property. Additional information provided by the Administrator on 12/16/2024 identified NA #1 did work two (2) of the days when the blank check was alleged to be in the facility, although NA #1 was not scheduled on Resident #1's unit on either of the days she worked.

Based on a tour of the kitchen and staff interview, the facility failed to ensure that kitchen equipment was maintained in a sanitary manner. The findings include: A tour of the kitchen on 9/25/23 at 10:27 AM with the Food Service Director identified the following: The ice machine in the kitchen was observed to have a black and pink substance on the inside of the ice machine. Subsequent to inquiry, the ice machine was emptied and cleaned. Interview on 9/25/23 at 10:30 AM with the Food Service Director identified the ice machine should be cleaned by kitchen staff in the evening at the end of meal service. Interview on 9/26/23 at 8:10 AM with System Director identified there is no specific cleaning schedule other than the expectation that the ice machine is cleaned at the end of the day.

Based on clinical record reviews, observations, facility policy review and interviews for for four residents (Resident #19, #29, #52 and #77) requiring assistance to eat in 2 of 4 dining rooms, the facility failed to provide a dignified dining experience. The findings included: 1. Resident #19's diagnoses included Alzheimer's disease, anxiety, schizoaffective disorder, anemia, dysphagia, and cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had severe cognitive impairment, had no signs and symptoms of possible swallowing disorder, and required extensive assistance with eating. The Resident Care Plan (RCP) dated 7/28/23 identified Resident #19 at risk for loneliness. Interventions directed staff to allow the resident to express feelings, offer emotional support, keep topics of conversation light and cheerful, and allow the resident to participate in daily care and decision-making or in establishing goals. Further review identified the resident was at risk for aspiration. Interventions directed to check oral cavity for pocketing, assist of one with feeding and observe for signs and symptoms of aspiration during meals. A physician's order dated 9/22/23 directed regular, nectar thick and pureed (NDD1) diet. Special instructions directed adaptive equipment; scoop dish, liquids by cup or spoon, no straws, small bites/sips and assist of one with feeding. Observations of the lunch meal on 9/25/23 at 12:50 PM identified Resident #19 shared a table with Resident #18 in the first-floor dining room. Nurse Aide (NA) #1 was observed standing over Resident #19 while assisting him/her to eat and interacting/conversing with Resident #18 rather than with Resident #19 while feeding the resident. Interview with NA #1 on 9/25/23 at 1:10 PM identified due to Resident #19 's height she wanted to make sure that she was feeding him/her at the correct angle, so he/she would not choke. NA #1 further identified I did not know that sitting down was a requirement. If I had known, I would have sat down of course. Interview with the Administrator on 9/26/23 at 11:05 AM identified the expectation was for staff to sit down while feeding a resident and to include the resident in the conversation as appropriate. The Administrator further identified she was not aware NA #1 was concerned with sitting down because of the resident's height therefore, rehabilitation department will assess the resident for need of any additional equipment and for safety during feeding. Interview with the Director of Nursing Services (DNS) 9/28/23 at 11:03 AM identified NA #1 received education on 9/26/23 which directed for staff to sit down while feeding the resident and to involve the resident in as many decisions as possible, to include the resident in the conversation and not to talk about the resident as he/she was not there. The resident should be treated with consideration, respect, and dignity. Speech therapy note dated 9/29/23 identified Resident #19 safely tolerated current diet texture without sign and symptoms of aspiration. The resident was upright for all by mouth intake and noted the resident was safe and appropriate for staff to sit while feeding. Review of facility Residents Rights directed in part the resident has the right to be treated with consideration, respect and full recognition of his/her dignity and individuality in an environment that promotes maintenance or enhancement of his/her quality of life and privacy in treatment and in care for his/her personal needs. 2. Resident #29's diagnosis included chronic congestive heart failure, asthma, weight loss and hypertension. A physician's order dated 7/2/2023 directed to provide a regular diet with thin liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated cognitive status was intact and required supervision and set up for eating. The care plan dated 8/31/2023 indicated Resident #29 was at nutritional risk and has a decreased ability to perform self-care activities related to weight loss and medical conditions. The interventions included in part to determine likes and dislikes, provide diet as ordered to assist with meals as needed. An observation on 9/26/23 at 12:28 PM Resident #29 (1 of 10) residents dining in the [NAME] dining room were all served meals on trays. On 9/26/2023 at 1:09 PM an interview with NA #5 identified they served meals on trays because it is easier to keep all the resident food items together. NA #5 further indicated that prior to the start of Covid the food items may have been removed from the dietary trays and placed on the dining table. On 9/26/2023 at 1:11 PM an interview with Registered Nurse (RN#4) indicated meals have been served on dietary trays in the dining room. On 9/25/2023 an interview with the DNS who was made aware residents in the dining room were served meals on dietary trays during the lunch meal. The DNS indicated s/he would talk to the staff regarding the incident. An interview on 9/28/2023 at 10:54 AM with the DNS identified s/he would expect when meals are served, food items would be transferred from the dietary trays and placed on the dining table. The facility policy dated 1/2023 labeled Resident Food Services, Resident Dining Preferences, indicated in part during meal service food will be provided on trays in the dining room only by resident request and or per the plan of care. 3. Resident #52's diagnoses included dementia, chronic kidney disease, and hypertension. The quarterly nutritional assessment completed on 8/6/23 by dietary indicated Resident #52 was on a regular, thin liquid diet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had moderately impaired cognition, required extensive assistance of 1 for bed mobility, transferring, dressing, toilet use, and personal hygiene. Resident #52 required supervision with set up help only for eating. Observation on 9/27/23 at 7:55 AM identified Resident #52 was served breakfast on the dietary tray in the [NAME] dining room. Resident #52 was observed sitting alone at a table with a breakfast tray in front of him/her. Interview on 9/27/23 at 7:57 AM with NA#1 identified meals are served on dietary trays in the dining room and s/he has never removed food item from trays when serving residents in dining rooms. Interview with DNS on 9/29/23 at 8:35 AM identified meals served in a dining room should be removed from the dietary tray prior to serving the resident unless a resident requests his/her meal on the tray. Additionally, the DNS identified meals served in resident rooms can be served on trays unless a resident requests the tray be removed. Facility policy reviewed for resident dining preferences which identified trays are only to be provided in the dining room by resident requests and/or per care plan. 4. Resident #77's diagnoses included cerebral infarction, hypertension, and depression. The quarterly nutritional assessment completed on 8/19/23 by dietary identified the resident was on a regular, thin liquid diet. The annual MDS assessment dated [DATE] identified Resident #77 as severely cognitively impaired, required extensive assistance of 1 for bed mobility, transferring, dressing, toilet use, and personal hygiene. Resident #77 required extensive one person assistance for eating. The physician's order dated 9/15/23 directed Resident #77 requires assistance of one with feeding. Observation on 9/27/23 at 7:55 AM identified Resident #77 was served breakfast on the dietary tray in the [NAME] dining room without the benefit of the food items being removed. Interview with DNS on 9/29/23 at 8:35 AM identified meals served in a dining room should be removed from the dietary tray prior to serving the resident unless a resident requests his/her meal on the tray. Additionally, the DNS identified meals served in resident rooms can be served on trays unless a resident requests the tray be removed. Facility policy reviewed for resident dining preferences which identified trays are only to be provided in the dining room by resident requests and/or per care plan. 46046 48336

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 sampled residents (Resident #1 and Resident #22), the facility failed to ensure advanced directives in the paper clinical record matched advanced directives in the electronic health record (EHR). The findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease, coronary artery disease with angina pectoris, and cognitive impairment. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition and required extensive assistance of 2 for bed mobility, was totally dependent on 2 for transferring, dressing and toilet use, and dependent on 1 for personal hygiene. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 needed assistance and guidance in management of disease/illness. Interventions included the resident's code status was do not resuscitate (DNR), do not Intubate (DNI), Registered Nurse (RN) may pronounce, no tube feeding, okay to hospitalize and okay with intravenous (IV) fluids. A review of the clinical record identified a Resident Expression of Treatment Preferences document signed by Resident #1's Health Care Administrator on [DATE]. The document indicated Resident #1's code status was DNR, do not hospitalize, no tube feedings and no IV fluids. Additionally, there is no documentation of Resident #1's preference for intubation. Provider progress notes dated [DATE] identified that Resident #1's code status is comfort measures only (CMO), DNR, DNR, RN may pronounce death, no IV fluid, no tube feed, and do not hospitalize. Interview with APRN #1 on [DATE] at 1:55 PM identified that providers are responsible for reviewing and updating advanced directives. APRN #1 indicated that if a resident chooses to be DNI, it is noted on the Resident Expression of Treatment document with a notation indicating the resident is a DNI, and also documented in a provider order and in a provider progress note. Additionally, APRN #1 noted that advanced directives are reviewed every 120 days. Interview with RN #4 on [DATE] at 2:30 PM identified that advanced directives in the paper clinical records should match advanced directives in the EHR. RN #4 indicated that in the event he/she needed to review a resident's advanced directive he/she would look in the paper clinical record and/or the EHR. He/she further identified that if advanced directives in the paper clinical record and EHR do not match, he/she would contact the nursing supervisor and the provider. Interview with RN #6 on [DATE] at 8:34 AM identified that staff receive annual education about advanced directives including intubation status, resident rights, and review of advanced directives. Additionally, RN #6 indicated that staff are educated that advanced directives in the paper clinical record and EHR must match and if they do not match staff is to discuss with the resident and the provider. Interview with the DNS on [DATE] at 8:25 AM identified that all residents of the facility should have a signed advance directive in the clinical record, which should be obtained on admission to the facility. The DNS further identified advanced directives should be reviewed at the quarterly RCP meetings. Additionally, the DNS identified that the advanced directives in the paper clinical record should match the advanced directives in the resident's EHR. 2. Resident #22 was admitted to the facility on [DATE]. The resident's diagnoses included. cerebral infarction, vascular dementia, and atrial fibrillation. The physician's progress note dated [DATE] identified Resident #22's advanced directives included DNR, DNI and no hospitalization . The Resident Care Plan (RCP) dated [DATE] identified Resident #22 needed assistance and guidance in management of illness/disease conditions. Interventions included the resident had an established advance directive of full code (full code means that if a person's heart stopped beating and/or they stopped breathing, resuscitation procedures will be provided to keep them alive). A review of the clinical record identified a Resident Expression of Treatment Preferences document signed by Resident #22's Health Care Administrator on [DATE]. The document indicated Resident #22's code status was DNR, do not hospitalize, no tube feedings but wishes to receive IV fluids. Additionally, there is no documentation of Resident #1's preference for intubation. The physician's progress note dated [DATE] identified Resident #22's advanced directives included DNR, DNI, RN may pronounce death, do not hospitalize, no feeding tubes and CMO. The quarterly MDS assessment dated [DATE] identified Resident #22 had intact cognition and required extensive assistance of 1 for bed mobility, transfers, dressing, toilet use and personal hygiene. The physician's orders dated [DATE] directed Resident #22's advanced directives included DNR, DNI, RN may pronounce, do not hospitalize, no tube feedings but noted the resident wishes to receive IV fluids. Interview with APRN #1 on [DATE] at 1:55 PM identified providers are responsible for reviewing and updating advanced directives. APRN #1 indicated that if a resident chooses to be DNI, it is noted on the Resident Expression of Treatment document with a notation indicating the resident is a DNI. APRN #1 also indicated the information is documented in a physician's order and in a physician's progress note. Additionally, APRN #1 noted advanced directives are reviewed every 120 days. Interview with RN #4 on [DATE] at 2:30 PM identified advanced directives in the paper clinical records should match advanced directives in the EHR. RN #4 indicated that in the event s/he needed to review a resident's advanced directive s/he would look in the paper clinical record and/or the EHR. She/he further identified that if advanced directives in the paper clinical record and EHR do not match, s/he would contact the nursing supervisor and the provider. Interview with RN #6 on [DATE] at 8:34 AM identified staff receive annual education about advanced directives including intubation status, resident rights, and review of advanced directives. Additionally, RN #6 indicated staff are educated that advanced directives in the paper clinical record and EHR must match and if they do not match staff is directed to discuss with the resident and the provider. Interview with the DNS on [DATE] at 8:25 AM identified all residents of the facility should have a signed advance directive in the clinical record, which should be obtained on admission to the facility. The DNS further identified advanced directives should be reviewed at the quarterly RCP meetings. Additionally, the DNS identified that the advanced directives in the paper clinical record should match the advanced directives in the resident's EHR. The facility policy on advanced care code status directed that every resident of the facility had the right to accept or decline CPR in the event of a cardiac or respiratory arrest, and the facility would ensure that the resident's wishes were followed. Additionally, the policy directed that DNR orders are reviewed every 60 days.

Based on observation, review of facility documentation, staff interviews, and facility policy, the facility failed to ensure the environment was maintained in good repair and a homelike manner. The findings include: Tour of the facility 9/25/23 at 11:50 AM identified the following: Room A 209 was observed with a black substance noted in the vents of the window unit air conditioner. Observation with Manager of Facilities on 9/25/23 at 12:00 PM identified the air conditioner in room A 209 had a black substance noted in the vents of the window unit air conditioner. Subsequent to surveyor's inquiry, the window unit air conditioner in room A 209 was replaced with a brand-new window unit air conditioner. Interview with the Manager of Facilities on 9/28/23 at 1:10 PM indicated that window unit air conditioners are cleaned, and filters changed in April when window unit air conditioners are put in and cleaned again in October when window unit air conditioners are removed and stored. Additionally, the Manager of Facilities indicated there was no documentation of cleaning of window air condition units. Review of facility policy Equipment Safety identified that all equipment will be maintained in good working order to ensure safe, efficient performance and prevention of injury to the user.

Based on clinical record review, interviews and review of facility documentation for one sampled resident (Resident #159) reviewed for accidents; the facility failed to ensure the resident received adequate supervision to prevent an accident resulting in an injury. The findings include: Resident #159 [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified severely impaired cognition, required extensive assistance of one for bed mobility, transfers and toilet use and is not steady with surface to surface transfers. The fall risk assessment dated [DATE] identified a score of 13 which represents a high risk for falls. The care plan dated 10/9/15 identified a risk for falls with interventions which included non-skid socks on at bedtime, a dycem to the wheelchair, and toilet transfer with assist of one.The accident incident report dated 12/18/15 at 12:15 AM identified Resident #159 was being transferred from the bed to the wheelchair for toileting and fell on the floor in a sitting position. The resident was transferred to the emergency department for an evaluation and diagnosed with [REDACTED]. The nurse's note dated 12/18/15 at 7:00AM for the 11:00PM-7:00 AM shift identified RN#2 was called by NA#1 to assess the resident who was observed sitting on the floor between the bed and the bedside chair. RN #2 assessed the resident and observed a skin tear to the right arm, abrasion to the back, positive range of motion and complaints of slight pain to the right leg. Resident #159 was assisted off the floor with three staff members, transferred to the toilet and then returned to bed. The nurse's note further identified that later in the shift, Resident #159 complained of increasing pain from the right hip to the right knee upon movement and palpation. The APRN was updated by RN #1 (nursing supervisor) and directed to transfer the resident to the emergency room for an evaluation. The acute care record dated 12/18/15 identified a right intertrochanteric hip fracture with a plan for surgical fixation. Interview with RN #1(nursing supervisor) on 2/4/16 at 7:20AM identified NA #1 did not follow the facility policy on 12/18/15 for the use of a gait belt during transfer of a resident who requires assistance. Interview with NA#1 on 2/4/16 at 8:20AM identified on 12/18/15 at 12:45AM Resident #159 requested to use the bathroom. NA#1 positioned the wheelchair close to the bed at which time the resident leaned forward to get out of bed. NA #1 was behind the wheelchair at the time and not positioned next to the resident when the resident leaned forward. Resident #159 was facing the wheelchair and placed each hand on the arms of the wheelchair. The resident's right arm slid off the wheelchair and the resident fell to the floor. NA#1 further identified at the time of the transfer he/she did not utilize a gait belt per facility policy because she placed the gait belt on the linen cart in the hallway. NA #1 indicated she removed the gait belt from her waist because it was making a loud clanking noise. NA #1 did not instruct the resident to remain seated or sit back down until she could use the gait belt or be positioned closer to the resident during the transfer. NA#1 further identified she was provided re-education on the gait belt policy and safety following the incident with Resident #159. The facility gait belt policy identifies gait belts are used for all residents requiring assistance of 1 or 2 for ambulation or transfer. Stand as close to the resident as possible, maintaining a broad base of support. Assist the resident to a standing position by grasping the belt at the waist from underneath. Pivot the resident into chair or bed.

Based on review of the clinical record, facility documentation and interviews for one sampled resident (Resident #225) reviewed for significant medication error, the facility failed to ensure the resident was free from a significant medication error. The findings include: Resident #225 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission nurse's note dated 3/19/15 at 1:19AM identified intact cognition. The physician's orders [REDACTED]. Blood sugar between 181-200 give 1 unit Blood sugar between 201-250 give 2 units Blood sugar between 251-300 give 4 units Blood sugar between 301-350 give 6 units Blood sugar between 351-400 give 8 units The accident/incident report dated 3/19/15 at 12:55PM identified Resident #225 received 100 units of [MEDICATION NAME] Flex pen Insulin at 12:55PM for a blood sugar of 434 mg/dl. The APRN was notified and assessed the resident. Intravenous fluids were initiated at the facility and the resident was transferred to the emergency room for an evaluation and returned to the facility on [DATE] at 7:30PM. Blood sugars monitored following the incident were identified as 427mg/dl at 1:20PM and 484 g/dl at 1:45PM. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Interview with the DNS on 2/2/16 at 10:40AM identified the electronic medical record documentation did not reflect the correct [MEDICATION NAME] Flex pen Insulin order prescribed by the physician. The electronic documentation indicated to administer 100 units not ____ (blank) units subcutaneous three times a day for a sliding scale blood sugar result as follows: Blood sugar between 181-200 give 1 unit Blood sugar between 201-250 give 2 units Blood sugar between 251-300 give 4 units Blood sugar between 301-350 give 6 units Blood sugar between 351-400 give 8 units The DNS identified Resident #225 was admitted on [DATE] during the 3:00PM-11:00PM shift and the11:00PM-7:00AM Supervisor incorrectly wrote the order for the sliding scale insulin coverage and a double check was not completed by the next shift as requested by the 11:00PM-7:00AM Supervisor. Interview with LPN#1 on 2/3/16 at 11:10AM identified he/she did not read the entire physician order [REDACTED]. LPN #1 further identified the physician normally would be notified if a resident's blood sugar is 434 mg/dl because the insulin sliding coverage stops for a blood sugar of 400. Interview with the Director of Staff Development on 2/3/16 at 12:00PM identified LPN #1 received re-education regarding the importance of reading the entire order prior to medication administration. The Director of Staff Development further identified the facility has revised the insulin administration practice to include a second verification of orders prior to administering greater than 20 units of insulin.

Based on review of the clinical record review, facility documentation and interviews for one sampled resident (Resident #184) with a history of smoking, the facility failed to ensure adequate supervision was provided to maintain a safe environment. The findings include: Resident #184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The admission nursing assessment dated [DATE] identified intact cognition. The physical therapy evaluation dated 2/17/11 identified R #184 was able to follow commands but exhibited decreased safety awareness. The nurse's note dated 2/17/11 at 11:30 PM identified the resident was found with cigarettes and matches underneath his/her pillow. The resident was identified to be agitated, irritable, and restless and had removed the Nicotine patch. Education was provided regarding the facility no smoking policy and the smoking materials were removed. The interim care plan dated 2/18/11 identified smoking cessation with interventions that included providing social service visits, medications as ordered, monitor, assess and document the resident's mood, provide smoking cessation support and to remove cigarettes and matches from room. The nurse's note dated 2/21/11 at 7:17 AM identified R #184 exhibited mild to moderate body tremors and was seeking cigarettes versus medication. The nurse's note dated 2/24/11 identified that at 2:30 AM Nurse Aide (NA) #1 identified an odor of smoke when assisting the resident back to bed. Registered Nurse #1 was notified and the resident was reeducated on the facility non smoking policy and a pack of cigarettes (with three missing) was removed from the resident's room. A subsequent nurse's note dated 2/24/11 at 12:37 PM identified a book of matches was found by Registered Nurse (RN) #2 and was removed from the resident's room. Review of the clinical record and interview with the Director of Nurse's on 2/24/11 at 11:55 AM failed to reflect that new interventions were implemented and/or assessments were conducted after the resident was found on 2/17/11, 2/21/11 and 2/24/11 with smoking materials, and/or smoking in the facility and/or expressed a desire to smoke. Additionally, the clinical record failed to reflect interventions were implemented after the resident was identified to be non compliant with the facility smoking policy. Although the facility was aware the resident had smoking materials in her/his possession, the clinical record failed to identify that a investigation was initiated and/or monitoring was completed to determine the source of the resident's smoking materials.