Every finding on record at Lanessa Extended Care

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included parameters for blood pressure readings related to the administration of Lisinopril (antihypertensive, reduces blood pressure) medication, and who sustained two unwitnessed falls which resulted in head injuries, the facility failed to ensure professional standards of practice were provided and maintained when the nursing staff 1) administered the Lisinopril despite his/her blood pressure readings being outside of the physician ordered parameters, and 2) failed to monitor him/her for neurological changes following two unwitnessed falls, in accordance with nursing best practice and facility policy.Findings include:1) Review of the facility's policy titled, Specific Medication Administration Procedures, dated 2017, indicated the following:-Review the five rights [patient, medication, dose, route, time] (3) times.-Prior to removing the medication from the container, check the label against the order on the Medication Administration Record (MAR).-Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration.-Document administration in the MAR.Resident #1 was admitted to the facility in January 2025 diagnoses included Hypertension (elevated blood pressure) and dementia with agitation.Review of Resident #1's Medication Administration Record (MAR) for the month of May 2026 indicated he/she had an order for Lisinopril (for hypertension) 10 milligram (mg) - give one tablet by mouth once a day, hold for systolic blood pressure (top number, maximum pressure in the arteries when the heart contracts and pumps blood to the circulatory system) less than 110 and diastolic blood pressure (bottom number, minimum pressure in the arteries when the heart is at rest between beats) less than 70.Further review of the MAR indicated nursing signed off as having administered Resident #1's Lisinopril on the following dates with the following blood pressure readings (which were below the acceptable parameters set by the provider):-05/13/26- Blood pressure (BP) 104/62-05/14/26- BP 101/62-05/15/26- BP 108/64-05/26/26- BP 104/65-05/27/26- BP 106/62-05/29/26- BP 105/65During an interview on 07/07/26 at 2:06 P.M., Nurse #1 said she administered the Lisinopril 10 mg to Resident #1 on 05/13/26, 05/14/26, 05/15/26, 05/26/26, 05/27/26, and 05/29/26. Nurse #1 said she didn't know how it happened that she administered Resident #1's medication when she should have held it based on the physician ordered blood pressure parameters.During an interview on 07/07/26 at 3:51 P.M., the Director of Nurses (DON) said that nursing should not have administered Resident #1's Lisinopril when his/her blood pressure readings were outside of the physician's ordered parameters. The DON said it was her expectation that nursing followed the physician's orders.2) Review of the facility's policy, titled Neurological Signs, undated, indicated the following:-Any resident who sustains a head injury or when a head injury is questioned or suspected will have neurological signs monitored as follows:*Every 15 minutes for one hour*Every 30 minutes for one hour*Every hour for four hours*Every four hours for 16 hours*Every eight hours for 48 hours.-Neurological signs to be evaluated and inclusive of:*Pupils reaction to light*Level of consciousness*Change in mental status*Change in speech*Change in strength in extremities*Vital signs- blood pressure, pulse, respirations*Head pain*Nausea/vomitingThe findings of each evaluation are compared, analyzed and documented in the medical record. The physician is promptly notified of any abnormal findings.Review of Resident #1's Fall Incident Report, dated 05/16/26 at 5:20 A.M., indicated he/she sustained an unwitnessed fall and was found by nursing on his/her bathroom floor.Further review of the Report indicated Resident #1 had a bruise and swelling on the back of his/her head and he/she was transferred to the Hospital Emergency Department (ED) for evaluation and treatment.Review of Resident #1's After [Hospital] Visit Summary, dated 05/16/26, indicated he/she was evaluated and CT scan (provides detailed images of the inside of the body) of his/her head and cervical spine showed no intracranial bleeding or fractures.Review of Resident #1's Fall Incident Report, dated 05/16/26 at 12:45 P.M., indicated Resident #1 sustained an unwitnessed fall in his/her room.Further review of the Report indicated Resident #1 was bleeding from the back of his/her head and he/she was transferred to the Hospital ED for evaluation and treatment.Review of Resident #1's After [Hospital] Visit Summary, dated 05/16/26, indicated he/she was evaluated for the second time that day, and there were no acute fracture or post traumatic malalignment of the cervical spine, and head CT scan was negative for bleeding.Review of Resident #1's medical record indicated there was no documentation to support that Resident #1's neurological checks were initiated or completed by nursing after either of his/her falls, per facility policy. During an interview on 07/07/26 at 2:06 P.M., Nurse #1 said neurological checks should have been initiated for Resident #1 after his/her falls. During an interview on 07/07/26 at 3:51 P.M., the Director of Nurses (DON) said that neurological checks were to be initiated by nursing following every unwitnessed fall or a fall with a head injury. The DON said neurological checks should have been completed for Resident #1 following his/her falls.

Based on observations, interview, and record review, the facility failed to notify the Provider as to whether treatment needed to be altered when a change in condition occurred for two Residents (#1 and# 53) out of total sample of 18 Residents. 1) Specifically for Resident #1, the facility failed to notify the Provider when the Resident experienced unanticipated weight loss, resulting in a significant weight loss (16.52% in 73 days) and malnutrition. 2) Specifically for Resident #53, the facility failed to notify the Provider and Occupational Therapist (OT) when the Resident was unable to tolerate the application of a left-hand palm guard as ordered by the Provider, and when therapy goals to tolerate the device were not being met. Findings include: Review of the Condition: Significant Change Policy and Procedure, dated April 2015, indicated: -professional staff will communicate with the physician. Regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management. -The Physician, Resident/patient and or responsible party will be notified by the nurse in the event of a change in condition. -This notification shall be documented in the clinical record. 1) Resident #1 was admitted to the facility in October 2025 with diagnoses including Vascular Dementia with agitation and mood disturbance, history of Transient Ischemic Attack (TIA) and Cerebral Infarction (CI) without residual deficits, Dysphagia. Review of the Minimum Data Set (MDS) Assessment dated 4/24/26, indicated Resident #1: -was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview of Mental Status (BIMS). -required setup from staff for eating. -had no weight loss or weight gain Review of Resident #1's Weights and Vitals Summary indicated the following weights: -2/1/26: 181.6 pounds (lbs.) -3/1/26: 161.4 lbs. (weight loss of 20.2 lbs. [11.12 % in 30 days]) -4/15/26: 151.6 lbs. (weight loss of 9.8 lbs. in 45 days; loss of 30 lbs. [16.52% in 73 days]) Review of Resident #1's March 2026 Progress Notes, failed to indicate that the Provider had been notified of the Resident's 20.2 lb. (11.12 %) weight loss that was identified by the facility on 3/1/26. Review of the Registered Dietician (RD) Progress Note dated 3/6/26 indicated: -Resident #1 had a significant weight loss in 30 days. -Resident #1 had a significant weight loss in 180 days. Review of the RD Progress note dated 3/27/26 indicated Resident #1: -Current weight on 3/1/26 was 161 lbs. [161.4] with significant gain [loss] in 30 days. -Weight 30 days ago was 181 [181.6]. During an interview on 5/6/26 at 11:10 A.M., the RD said she evaluated Resident #1 on 3/6/26 and identified a weight obtained on 3/1/26 (161.4), which was a 20 lbs. weight loss and felt it was significant. The RD said she was unsure if the Provider had been notified about the 20 lb. weight loss that occurred and said that the Nurses would be responsible for contacting the Provider. The RD said the nursing department did not notify the RD of Resident #1's weight loss, that the weight loss was identified when she reviewed the weekly weight report in the EMR (Electronic Medical Record) on 3/6/26. During an interview on 5/6/26 at 2:17 P.M., Unit Manager (UM) # 2 said it was the Nurse's responsibility to input the completed weights into the EMR and notify the Provider and RD of any weight loss or weight gain. UM # 2 said the Provider and RD should have been notified right away on 3/1/26 when the weight loss was identified but they were not. UM #2 said that staff did not notify the Provider of the Resident's significant weight loss and did not implement interventions to address the Resident's weight loss until 4/17/26 (47 days after the facility identified the weight loss on 3/1/26). During an interview on 5/6/26 at 2:50 P.M., the Director of Nursing (DON) said Resident #1's weight loss was not reported to the Provider until 4/17/26 but should have been reported by the nursing department on 3/1/26. During an interview on 5/7/26 at 12:21 P.M., the Physician said if he or the NP had been updated regarding Resident #1's weight loss, they would have documented in their progress note and re-evaluated the Resident's food intake, need for supplements, and medical evaluation would have been completed at that time. 2) Review of the Splints/Orthotics/Prosthetics Policy and Procedure, dated April 2015, indicated: -Residents will receive splint/orthotics/ prosthetic devices as deemed appropriate by the physician and rehabilitation services. -Nursing staff should notify the rehabilitation department of any worn, ill-fitting and/or misplaced splint / orthotic/ prosthetic device. -If the resident refuses to wear the device, notify the rehab department, physician and responsible party. Resident #53 was admitted to the facility in January 2026 with diagnoses including Adult Failure to Thrive, altered mental status, and left-hand contractures. Review of the MDS assessment dated [DATE], indicated Resident #53: -was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview of Mental Status (BIMS). -had impairment of Range of Motion (ROM) on one side. -required maximum assistance from staff for completion of Activities of Daily Living (ADLs). Review of the Occupational Therapy Evaluation and Plan of Treatment dated 2/4/26, indicated a new goal that Resident #53 would be able to tolerate a left-hand orthotic (flat palm guard) for 8 hours without redness/irritation/discomfort to allow for skin integrity/ bathing/ nail care. Review of Resident #1's Alteration in Skin integrity Care Plan, initiated 2/19/26, indicated: -Resident has potential alteration in skin integrity related to incontinence, left hand contracture. -Goal: Splint: apply left palm guard to left hand at A.M. care and off at P.M. care, as tolerated. Check skin integrity every shift. Review of Resident #1's April 2026 and May 2026 TAR (Treatment Administration Record) indicated: -Apply left palm guard to left hand at A.M. care and off at P.M. care as tolerated. Remove palm guard for skin hygiene. Check skin integrity every shift, initiated 2/18/26. On 5/5/26 at 10:22 A.M., the surveyor observed Resident #53 lying in bed with no left-hand palm guard visible in use and his/her left hand was closed in a fist. During an interview on 5/5/26 at 3:51 P.M., Nurse #6 said Resident #53 did not like to have his/her hand opened and showed the surveyor that the Resident's fist was currently closed tightly. Nurse #6 attempted to slowly open Resident #53's left hand and he/she became agitated. When the surveyor asked about Resident #53's hand palm guard, Nurse #6 said he was unsure about the hand palm guard being applied and was unsure when it had last been used by the Resident. During an interview on 5/5/26 at 4:01 P.M., Nurse #3 said that Resident #53's left hand palm guard was difficult to apply because he/she did not open the left hand easily. Nurse #3 said that the therapy department had issued Resident #53 a left-hand palm guard, but this morning Nurse #3 was unable to get the palm guard on because the Resident could not tolerate it. Nurse #3 said that it now required two staff members to apply the hand palm guard, so Nurse #3 preferred to apply a towel folded into the left hand because the Resident tolerated the towel better. Nurse #3 said she had not alerted physical therapy or the Physician that she was unable to apply the hand splint but should have. On 5/6/26 at 7:47 A.M., the surveyor observed Resident #53 out of bed, fully dressed and sitting in a recliner chair and the left-hand splint was sitting on Resident #53's lap and his/her left hand was closed in a fist. On 5/6/26 at 9:46 A.M., the surveyor observed Nurse #3 attempting to apply a hand splint to Resident #53's left hand. Nurse #3 was unable to apply the hand splint because Resident #53 became agitated. Nurse #3 said that the hand splint was a Physician order to be applied in the morning and removed at night and if they were unable apply the splint for any reason, then the therapy department and the Provider should be updated. Nurse #3 said that she had been unable to apply the hand splint for about two weeks and had taken care of Resident #53 several times in the past few weeks. During an interview on 5/6/26 at 10:09 A.M., the Occupational Therapist (OT)/ Rehab Manager said Resident #53 was admitted to the facility with a left-hand contracture and had a history of being resistant. The OT said that Resident #53's left hand was tight upon admission and was he/she ordered a flat foam hand splint with a goal of keeping his/her hand open enough so that the hand and nail care could be performed. The OT said that the therapy department had not been notified that Resident #53 was unable to tolerate the application of the hand splint. The OT also said nursing should have alerted them right away to avoid worsening of the left-hand contracture. During an interview on 5/6/26 at 12:07 P.M., the Regional Clinical Specialist said that when the Nurses were unable to apply the hand splint, they should have notified the Provider and therapy department right away instead of waiting two weeks. During an interview on 5/6/26 at 1:00 P.M., Nurse #3 said that she had not applied Resident #53's left hand splint in a few weeks and should have alerted the Provider but did not. During an interview on 5/6/26 at 2:38 P.M., UM #2 said the Provider and therapy department should have been updated right away when the Nurses noticed Resident #53 was not tolerating the hand-splint application. During a follow-up interview on 5/6/26 at 4:55 P.M., the OT said that she was not aware staff were having difficulty with applying Resident #53's palm guard until today when she spoke with the surveyor. The OT said she did not know that nursing staff had had not applied the palm guard for about two weeks. During an interview on 5/8/26 at 11:22 A.M., Physician #1 said he did not recall having been notified that facility staff were unable to perform the left-hand treatment over the last two weeks until a couple of days ago when staff called him (during the survey period). Physician #1 said there was no evidence the on-call service had been contacted during off hours in relation to the left-hand treatment/ splint. During an interview on 5/8/26 at 12:35 P.M. the Nurse Practitioner (NP) said no one from the facility had called to alert her that Resident #53 had been unable to tolerate the left-hand splint being applied. The NP said she would have expected to be alerted so further instruction could have been given. See F688 and F692

Based on observations, interviews, and record review, the facility failed to ensure that one Resident (#13) out of a total sample of 18 residents received foot care and treatment in accordance with professional standards of practice, increasing the Resident's risk for medical complications. Specifically, the facility failed to ensure that Resident #13 received podiatry toenail care when the Resident's invoked Health Care Proxy (HCP) consented for the Resident to receive podiatry care, and the Resident's toenails were growing out to the length where the toenails curled against the ends of the Resident's toes, placing the Resident at risk for pressure injury, and infection. Findings include:Review of the facility policy titled Consultant Services, dated April 2015, indicated:-The facility will identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident through consultant services.-For podiatry, ., all families will sign a release form upon admission indicating whether they do or do not want the facility to make these arrangements.-The facility routinely uses their own consultants in . podiatry.-Once the consultant is identified by the physician and after the family has been notified and given the permission for the consult, the staff will call the consultant to notify him/her of the request and document response in medical record. Resident #13 was admitted to the facility in February 2025 with diagnoses including Dementia, Right Foot Drop, and abnormalities of gait and mobility. Review of Resident #13's Nursing Progress Note dated 2/26/25, indicated the Resident's family came in to visit and signed the Resident's consents. Review of Resident #13's [Consultant Name] Request for Service form, undated, indicated the Resident's HCP consented for the Resident to receive podiatry services. Review of Resident #13's Skin Integrity Care Plan, initiated 2/26/25, indicated:-The Resident has potential alteration in skin integrity related to decreased mobility, . friction site to right lower lateral leg related to brace (resolved June 2025).-Assess skin under splint devices, orthotics, braces, . (2/26/25)-Follow physician orders for skin care and treatments.-Inspect feet daily with care . Review of Resident #13's Minimum Data Set (MDS) Assessment, dated 4/17/26, indicated:-has a diagnosis of Dementia.-has severely impaired cognitive skills for daily living.-was dependent upon staff for bathing, dressing, and personal hygiene.-was at risk for pressure injuries. Review of Resident #13's May 2026 Physician orders indicated:-Podiatry care as needed (9/3/25).-Skin protocol: Weekly skin checks on bath/shower day . (9/30/25).-Skin protocol: Remove right leg brace in the evening for skin check (10/28/25).-Right ankle-foot orthosis on when out of bed. Off when in bed. Check for skin irritation and breakdown after removal (11/3/25).-Apply ankle-foot orthosis to right foot when out of bed, off when in bed . Remove splint for skin hygiene. Check skin integrity Q (every) shift (1/20/26). On 5/6/26 at 8:55 A.M., the surveyor observed Resident #13 walking into the hallway from the Dining Room on the Elmwood Unit, wearing a brace on his/her right lower leg. The Resident stopped walking when he/she reached the surveyor who was in the hallway, stood in one place, bent his/her right knee and repetitively lifted his/her right foot off the floor. Resident #13 was observed to touch his/her right foot back on the floor and place most of his/her weight through the left leg briefly, then walked away from the surveyor. During an interview at the time, Certified Nurse Aide (CNA) #2 said Resident #13 always wore a brace on his/her right leg because he/she needs it to be able to walk safely. On 5/6/26 at 9:27 A.M., the surveyor observed Resident #13's right lower extremity (from mid-calf to the toes) with Nurse #4 and Unit Manager (UM) #2 as follows:-The Resident's great toenail was grown out approximately one inch beyond the tip of the toe. The toenail was yellowish in color and thick.-The Resident's other four toenails were grown out past the tips of the toes, yellowish in color and thick, and angled toward the great toe. One toenail was curled under toward the tip of the toe. During an interview on 5/6/26 at 10:00 A.M., UM #2 said Resident #13's toenails on the right foot were long and that she would provide Resident #13's podiatry visit notes for the surveyor's review. During an interview on 5/6/26 at 12:15 P.M., the Regional Clinical Specialist (RCS) said she could not locate any evidence Resident #13 had been seen by the Consultant Podiatry Provider since the Resident was admitted to the facility in February 2025. The RCS said she called the Consultant Podiatry Service Provider following the surveyor's observation of Resident #13's right foot with Nurse #4 and UM #2, and that the Consultant Podiatry Service Provider had no record of Resident #13 being enrolled for podiatry services. During a telephone interview on 5/6/26 at 1:02 P.M., the Podiatry Service Provider Representative said there was no record of Resident #13 ever being provided podiatry services and that there was no record the Resident was enrolled to receive podiatry services. On 5/6/26 at 2:06 P.M., the surveyor observed Resident #13's right and left feet with the Director of Nursing (DON) as follows:-The Resident had four toes on the left foot, and the left great toe was absent.-All four toes had thick, yellowish colored nails, grown out approximately three-quarters of an inch to one inch from the tips of the toes.-The toenail on the small toe was angled toward the adjacent toe (to the right of the small toe) on the Resident's left foot.-The surveyor's observation of the toenails on the Resident's right foot was unchanged from the previous observation on 5/6/26 at 9:27 A.M.During an interview immediately following this observation, the DON said the Resident's toenails were overgrown, growing toward the great toe sides of the feet and the nails were curling under. The DON said Resident #13 has a Physician ordered treatment to inspect the Resident's skin when applying and removing the Resident's leg brace and that there is also a Physician order for weekly skin checks. The DON said the Nurses are required to inspect the Resident's whole body during weekly skin checks. The DON said the Nurses assigned to care for Resident #13 should have observed that the Resident's toenails were not properly cared for and that the Resident should have been enrolled in the consultant podiatry service as indicated by the HCP's consent. The DON said the condition of Resident #13's toenails placed the Resident at increased risk for pressure injury and infection. Review of Resident #13's Nursing Progress Note, dated 5/7/26, indicated the Resident was seen by the Physician that morning and that the Physician trimmed the Resident's toenails. During an interview on 5/7/26 at 11:00 A.M., the Physician said he was alerted on 5/6/26 that Resident #13 needed his/her toenails trimmed and that he trimmed the Resident's toenails that morning (5/7/26). The Physician said the Resident's toenails were long, grown out, and ingrown toward the Resident's skin. The Physician said facility staff should have noticed that the Resident's toenails needed to be cared for and that facility staff should have either communicated with the Consultant Podiatry Service or with him (Physician) that the Resident required toenail care. The Physician said the condition of the Resident's toenails prior to being trimmed that morning placed the Resident at increased risk for infection.

Based on observations, interviews, and record review, the facility failed to ensure that appropriate services to maintain or improve range of motion were implemented for one Resident (#53) out of a total sample of 18 residents. Specifically, for Resident #53, the facility failed to ensure the Physician's orders were followed relative to the use of the left-hand palm guard, resulting in a worsening contracture and increased pain when applying the left-hand palm guard. Findings include: Review of the facility policy titled Splints/Orthotics/Prosthetics Policy and Procedure, dated April 2015, indicated: -Residents will receive splint/orthotic/ prosthetic devices as deemed appropriate by the Physician and rehabilitation services. -Nursing staff will apply/remove the designated splint/ orthotic/ prosthetic device during scheduled wearing times. Review of the facility policy titled Activities of Daily Living (ADL) Policy and Procedure, dated April 2015, indicated: -A program of ADLs is provided to residents to maintain or restore maximum functional independence. -A program of assistance and instruction in ADL skills is developed and implemented based on the individual evaluation to encourage the highest level of functioning. Resident #53 was admitted to the Facility in January 2026 with diagnoses including left-hand contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #53: -was severely cognitively impaired as indicated by a score of 0 out of 15 on the Brief Interview of Mental Status (BIMS) exam. -had impairment of Range of Motion (ROM) on one upper side. -required maximum assistance from staff for completion of ADLs. Review of the Comprehensive Care Plan, initiated on 1/29/26, indicated Resident #53: -had impaired functional mobility related to Dementia, Arthritis, history of fracture, Osteoporosis and Pain. -Goal: functional mobility, positioning and transfers will be achieved daily with use of appropriate device. -was totally dependent on staff for completion of ADLs. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 2/4/26, indicated a goal that Resident #53 would be able to tolerate a left-hand orthotic (flat palm guard) for eight hours without redness/irritation/discomfort to allow for skin integrity/bathing/nail care. Review of Resident #53's Alteration in Skin Integrity Care plan, initiated 2/19/26, indicated: -The Resident has potential alteration in skin integrity related to incontinence and left-hand contracture. -Goal: Splint: apply left palm guard to left hand at A.M. Care and off at P.M. Care, as tolerated. Check skin integrity every shift. -Follow Provider orders for skin care and treatments. Review of Resident #53's Order Summary Report, dated 5/6/26, indicated: -Splint: Apply Left palm guard to left hand at A.M. care and off at P.M. care, as tolerated. Remove palm guard for skin hygiene. Check skin integrity every shift. start date 2/18/26. On 5/5/26 at 10:22 A.M., the surveyor observed Resident #53 lying in a recliner chair with the left hand closed in a fist without a left-hand palm guard in his/her left hand. During an interview and observation on 5/5/26 at 3:51 P.M., Nurse #6 said Resident #53 did not like to have his/her hand opened and showed the surveyor that the Resident's fist was currently closed tightly. Nurse #6 attempted to slowly open Resident #53's left hand and he/she shouted and stopped shouting immediately when Nurse #6 released his/her hand. When asked about Resident #53's palm guard, Nurse #6 said he was unsure why the palm guard was not on the Resident's left hand because it gets applied with morning care. During an interview on 5/5/26 at 4:01 P.M., Nurse #3 said Resident #53's left hand palm guard was difficult to apply because he/she did not open the left hand very easily. Nurse #3 said that the therapy department had issued Resident #53 a left-hand splint, but this morning Nurse #3 was unable to get the palm guard on because the Resident could not tolerate it. Nurse #3 said that two staff members were now required to apply the palm guard because the Resident becomes agitated and aggressive. Nurse #3 said she preferred to apply a folded facecloth into the Resident's left hand because it was better tolerated by the Resident. On 5/6/26 at 7:47 A.M., the surveyor observed Resident #53 out of bed, fully dressed and sitting in a recliner chair. The left-hand palm guard was observed on Resident #53's lap and the Resident's left hand was closed in a fist. On 5/6/26 at 9:46 A.M., the surveyor observed Resident #53 sitting in a recliner chair with his/her left hand in a fist. Nurse #3 gently opened Resident #53's left hand by lifting the fingers away from his/her palm. Resident #53 said Ow that hurts, that's awful and then started hitting Nurse #3 with his/her right hand. Nurse #3 was unable to apply the palm guard to the Resident's left hand at that time. Nurse #3 said she had been unable to apply the Resident's palm guard for about two weeks and had taken care of Resident #53 several times during that time period. During an interview on 5/6/26 at 10:09 A.M., the Occupational Therapist (OT)/ Rehabilitation Services Manager said Resident #53 was admitted to the facility with a left-hand contracture. The OT said that Resident #53's left hand was very tight upon admission, and the Resident was ordered a flat foam palm guard with a goal of keeping his/her hand open enough so that hand and nail care could be performed. The OT said when the palm guard was ordered in February 2026, staff was able to open the Resident's left-hand half to three-quarters of an inch but now was unable to open the Resident's left hand as much. The OT said Resident #53's left hand was tighter. The OT said that if staff had applied the left-hand palm guard as ordered during the last few weeks, the left-hand contracture would not have worsened. The OT said that the therapy department had not been notified that Resident #53 was unable to tolerate the application of the palm guard and nursing should have alerted them right away to avoid worsening of the contracture. During an interview on 5/6/26 at 1:00 P.M., Nurse #3 said she had not applied the left-hand palm guard to Resident #53's left hand for a few weeks and should have. Nurse #3 said Resident #53 showed symptoms of increased pain during the attempt to apply the left-hand palm guard today. During an interview on 5/6/26 at 4:55 P.M., the surveyor and the OT reviewed the updated evaluation dated 5/6/36. The OT said she was not aware staff were having difficulty with applying the palm guard to Resident #53's left hand until today when she spoke with the surveyor. The OT said she did not know that nursing staff had not applied the palm guard for about two weeks and further said that the contracture was a little bit worse today than it was when the OT did her initial evaluation. The OT said that it is just enough worse that the palm guard would not fit like it did when it was ordered in February 2026 and the Resident now expressed pain.

Based on interviews, and record reviews, the facility failed to adequately provide nutritional services for one Resident (#1) out of total sample of 18 residents. Specifically, the facility failed to implement timely interventions to maintain nutritional needs when the Resident had a severe weight loss of 16.52% (30 pounds) (lbs.) between 2/1/26 and 4/15/26, resulting in Protein Calorie Malnutrition. Findings include:Review of the facility policy titled Food First Nutrition Policy and Procedure, dated August 2015, indicated: -It is the policy of this facility to assess all residents/ patients and identify those residents/patients at risk for weight loss and provide appropriate interventions according to the physical and mental abilities of his/her wishes. -The following residents/patients are weighed weekly x4: >Residents/patients with an unanticipated, unplanned weight loss of > five percent (%) in one month. >All residents with a significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party, and interventions are implemented as appropriate and are monitored weekly. Review of the facility policy titled Weights Policy and Procedure, dated August 2015, indicated: -The following residents/patients are weighed weekly x4:>Residents/ patients with an unanticipated, unplanned weight loss >five % in one month. >All residents with a significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party, and interventions are implemented as appropriate and are monitored weekly. -Residents will be weighed monthly, unless clinically indicated. Resident #1 was admitted to the facility in October 2025 with diagnoses including Vascular Dementia with agitation and mood disturbance, history of Transient Ischemic Attack (TIA) and Cerebral Infarction (stroke) without residual deficits, and Dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) Assessment dated 4/24/26, indicated Resident #1: -was severely cognitively impaired with a score of 0 out of 15 on the Brief Interview of Mental Status (BIMS) exam. -required setup from staff for eating. -had a significant weight loss. Review of the Nutritional Care plan, initiated 10/27/25, indicated: -Resident #1 is at risk for nutritional issues related to dementia and past medical history. -Goals of care include food intake of 75-100% and weight maintenance, target date 6/22/26. -Provide regular diet as ordered and encourage intake of at least 75% Review of Resident #1's Weights and Vitals Summary included the following weights: -2/1/26: 181.6 lbs. -3/1/26: 161.4 lbs. (loss of 20.2 lbs. in 30 days) -4/15/26: 151.6 lbs. (loss of 30 lbs. in 73 days from 2/1/26) Review of the Registered Dietician (RD) Progress Note dated 3/6/26 indicated: -Resident #1 had a significant weight loss in 30 days. -Resident #1 had a significant weight loss in 180 days. -Resident #1 had variable by mouth (PO) intake. -The Dietician had recommended Ensure (nutritional supplement) and indicated that Resident #1 refused a cup of Ensure that she had offered. -RD to monitor. Review of the RD Progress note dated 3/27/26 indicated Resident #1: -Current weight on 3/1/26 was 161 lbs. [161.4] with significant gain [sic] in 30 days. -Weight 30 days ago was 181 lbs. [181.6]. Review of Resident #1's clinical record failed to indicate: -new interventions for identified weight loss on 3/1/26. -weekly weights were not ordered for identified weight loss on 3/1/26 per the facility policy Review of the MAR for April 2026 indicated: -Ensure Plus 237 ml. (milliliters) container two times a day, initiated 4/17/26 (46 days later). -Prosource 30 ml. three times a day, initiated 4/17/26 (46 days later) -Evening snack related to weight loss [sic] at bedtime for weight loss, initiated 4/17/26 (46 days later). Review of Resident #1's Weight loss Care Plan, initiated 4/17/26 indicated: -The Resident had a weight loss. -Goal: to maintain his/her body weight (avoid significant changes) through next review. -Interventions: Offer the Resident bedtime snacks nightly and provide the Resident with double portions each meal. Review of Resident #1's Malnutrition Care Plan, initiated 4/24/26, indicated: -The Resident has protein calorie malnutrition related to inadequate calorie/protein intake as evidenced by the Nutrition Focused Physical Exam (NFPE) with findings of Protein Calorie malnutrition (PCM). -Goal of care includes food intake 75-100% and weight maintenance. -Interventions: Provide diet as ordered and Prosource and Ensure as ordered. Review of the Nursing Progress Note dated 4/17/26, indicated the Nurse Practitioner (NP) was updated on Resident #1's weight loss and a new order was implemented for double portions every meal. Review of the NP Progress Note dated 4/17/26, indicated Resident #1: -weighed 151.6 lbs. on 4/15/26. -Staff reported the Resident had a 30 lb. weight loss. -Staff reported the Resident's appetite had been appropriate. Review of the RD Progress Note dated 4/17/26, indicated Resident #1: -was being seen for weight loss. -had a weight of 161.4 lbs. on 3/1/26. -had a weight of 151.6 lbs. on 4/15/26. -had a physical exam and was found to have mild to moderate malnutrition. -was started on Ensure Plus twice a day. -was started on Prosource 30 ml three times a day. During an interview on 5/6/26 at 11:10 A.M., the RD said she evaluated Resident #1 on 3/6/26 and identified a 20 lbs. weight loss in 30 days and felt it was significant. The RD assessed Resident #1 on 3/6/26 and tried to give him/her a cup of Ensure but he/she refused to drink it at that time. The RD said she did not implement Ensure or any other new intervention but should have implemented Prosource and Ensure (even though Resident #1 had refused a cup), in the hopes that staff could get him/her to start taking it, but these interventions did not get implemented until 4/17/26. The RD said Resident #1 should have had weekly weights implemented when she identified the weight loss on 3/6/26 but he/she remained a monthly weight and then staff did not obtain Resident #1's monthly weight on 4/1/26 and did not obtain another weight until 4/15/26. The RD said Resident #1 did not have a weight obtained for 45 days resulting in an additional 10 lbs. weight loss from 3/1/26 to 4/15/26. The RD said Resident #1's weight had stabilized from the Ensure and Prosource that was started on 4/17/26 but was unsure if the weight loss could have been avoided if started earlier because Resident #1 had a period of sickness and medical leave at the end of March (3/19/26 - 3/23/26). During an interview on 5/6/26 at 2:17 P.M., Unit Manager (UM) #2 said nursing staff was responsible for completing monthly weights on every patient on the 1st of the month, and weekly weights on Residents that had a Physician order. UM #2 said Nurses should input the weights into the Electronic Medical Record (EMR) and notify the Provider and RD of any weight loss or gain. UM #2 said the Provider and RD should have been notified right away on 3/1/26 when the weight loss was identified and weekly weights and other interventions such as Ensure should have been implemented but were not. UM #2 said she had not been notified that the RD had attempted to try a cup of Ensure on 3/6/26 but had she been made aware, she would have suggested nursing try again or something else. UM #2 said that the Provider was notified on 4/17/26 that Resident #1 had a significant weight loss and new interventions were implemented at that time. UM #2 said she was not aware of Resident #1 having a weight loss prior to 4/17/26. UM #2 said she was unsure why staff had not obtained Resident #1's monthly weight on 4/1/26 but it was completed on 4/15/26 (2 weeks later). During an interview on 5/6/26 at 2:50 P.M., the Director of Nursing (DON) said nursing staff should have been completing weights for Resident #1 according to the Physician orders. The DON said she did not know why Resident #1's identified weight loss was not reported to the Provider and said the RD should have implemented interventions such as weekly weights and supplements right away when she saw the Resident on 3/6/26. The DON said Resident #1's weight loss was not reported to the Provider until 4/17/26. During an interview on 5/7/26 at 12:21 P.M., the Physician said if Resident #1 was losing weight and the intake of food was not adequate, then supplements should have been attempted. The Physician said if the supplements did not help, then the Resident should be evaluated medically to rule out malignancy or something else that may be going on medically. The Physician said all those factors would prompt a conversation with the family to determine course of treatment, but he was unsure if this had occurred.

Based on observations, and interviews, the facility failed to maintain proper sanitation, food handling, and food storage practices to prevent the outbreak of foodborne illness in the main facility kitchen. Specifically, the facility failed to: 1) ensure that the minimum wash temperature necessary was maintained per manufacturer's guidelines for the dish machine utilized for cleaning and sanitizing dishware for resident use in the main facility kitchen, when the high temperature dish machine was operating at registered temperatures below acceptable ranges of 150 degrees Fahrenheit (F) for the wash cycle. 2) properly label and date prepared food items before storing them in the refrigerator and also failed to discard expired bread products that were being stored in the dry storage area. Findings include: Review of the Dishwashing Instructions Guide provided by the facility, dated October 2000, indicated: -Minimum water temperatures is: >Hot Water Wash 150 degrees Fahrenheit. Review of The Food Safe Pal, Dishwashing Temperature Guidelines, dated 10/29/24, retrieved from https://foodsafepal.com/dishwashing-temperature-guidelines/ indicated the following: Review of the Dietary Department Guidelines, dated May 2015, indicated: -The Dietary Department will be maintained in a clean and sanitary manner to prevent food borne illness. -All items stored in the refrigerator will be covered, labeled with the contents and the date. All potentially hazardous food must be discarded within 3 calendar days after the date prepared. -All food items should be labeled and dated to allow for rotation of supplies. -Dishwashing must reach certain temperatures to effectively kill bacteria and other disease-causing organisms called pathogens that can lead to foodborne illnesses. -Ensuring that the wash and rinse water of your dishwasher reaches a certain minimum temperature is just as important as cooking food to the proper minimum internal temperature. -Just as bacteria and other pathogens can survive on food that's not cooked to its minimum internal temperature, they can also survive on dishes and utensils that aren't washed and rinsed at the proper temperatures. -The minimum wash and rinse temperature depends on the type and whether it uses heat or chemicals to sanitize. -High-temperature dishwashers should operate at a minimum temperature of 150ºF to 165ºF (66ºC to 74ºC) during the wash cycle and at 165ºF to 180ºF (74ºC to 82ºC) during the rinse cycle. 1) On 5/7/26 from 10:05 A.M. through 10:30 A.M., the surveyor observed the following during a walkthrough of the main facility kitchen: -Dish machine was in operation and running. -Dietary Aide (DA) #1 was pre-rinsing and loading dirty dish ware and meal trays into the dish racks to be washed. -Dish machine wash temperatures fluctuated and did not reach above 150 degrees F. -Dish machine wash temperatures were observed at 130 to 132 degrees F. During an interview at the time, DA #1 said she was not able to get the dish machine temperature to rise above 140 degrees F. DA #1 said she only worked in the facility one day every week. DA #1 said when the dish machine temperature does not rise above 150 degrees, she would finish washing the dishes and then notify the Administrator. DA #1 said the facility would usually reach out to a vendor when this happened. On 5/7/26 at 11:31 A.M., the surveyor and the Food Service Director (FSD) observed the lunch tray line in the main kitchen. During an interview at the time, the FSD said that washing and rinsing dishes at 132 degrees F was an acceptable temperature because the dish machine rinse cycle was not affected by the low temperature of the dish wash and that because the rinse temperature was normal, there was no concern about the low dish wash temperature. The FSD further said washing dishes at temperatures below 150 degrees F, the dishes may not be as clean as they should be. During an interview on 5/7/26 at 11:41 A.M., the Administrator said the plates should not be used to serve Resident meals as the dish machine did not reach the manufacturer recommended temperature. The Administrator said there was a risk for foodborne illness if the residents are served food on a plate that had not been adequately cleaned. The Administrator said the residents needed to receive their meals in a Styrofoam/disposable plate until the dish machine was either repaired or the plates had been re-washed by hand. 2) During the initial kitchen walk through on 5/5/26 at 7:08 A.M., the surveyor observed: -the following items that were undated and unlabeled in the refrigerator: sliced ham, two seafood sandwiches, tortilla wraps, lettuce, container of scrambled eggs. -container of hard-boiled eggs, dated 4/28/26. -A cooked ham in the walk-in refrigerator dated 4/30/26. -the following items were on the bread shelf: 1 Package of Tortillas (use by date 12/30/25), 1 Package of tortillas (use by date 2/1/26), 1 Package of tortillas (use by date 4/13/26), three packages of rolls - undated. -bag of green split peas on the shelf in the dry storage area, open and undated. -bag of pasta on the shelf in the dry storage area, open and undated. During an interview at the time, the Regional Food Service Director (RFSD) said he was unsure of how long the undated food items (sliced ham, seafood sandwiches, tortilla wraps, lettuce and scrambled eggs) had been in the refrigerator and that all food items in the refrigerator should be dated when put into the refrigerator and discarded within three days if not used. The RFSD said he was unsure if the tortillas had been previously frozen but said that they should have been labeled and dated if defrosted but were not. The RFSD was unsure when the split peas and pasta had been opened but said they should have been labeled accordingly.

Based on observations, record reviews, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for one Resident (#61) out of a total sample of 18 residents. Specifically for Resident #61, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required for the Resident on Enhanced Barrier Precautions (EBP) placing the Resident at increased risk of contamination and the spread of infections. Findings include:Review of Centers for Disease Control and Prevention (CDC) Guideline for Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revised 6/28/24, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html indicated: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. -Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Enhanced Barrier Precautions expand the use of gowns and gloves beyond anticipated blood and body fluid exposures. They focus on use of gowns and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. -Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Review of facility policy titled, Enhanced Barrier Precaution Policy, undated, indicated: -The policy is to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Novel or targeted MDROs (Multidrug Resistant Organisms) are organisms that are resistant to all or most antibiotics tested, are uncommon in a geographic area, or have special genes that allow them to spread their resistance to other germs. -Enhanced barrier precautions (EBP) require the use of gown and gloves for certain residents during specific high-contact resident care activities in which there is an increased risk for transmission of multidrug-resistant organisms. High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care. Resident #61 was admitted to the facility in July 2024 with diagnoses including Extended-Spectrum Beta-Lactamases (ESBL) in urine, Basal Cell Carcinoma of Overlapping Sites of Skin, Adult Failure to Thrive and Dementia. Review of Resident #61's May 2026 Physician's orders indicated: -Enhanced Barrier Precaution related to history of ESBL, start 10/27/25. On 5/5/26 at 3:34 P.M., the surveyor observed the following: -Signage at Resident #61's door indicated that the Resident #61 was on EBP. -EBP signage indicated that anyone entering the room should wash their hands when entering or exiting the room and staff must wear gloves and a gown for high-contact care activities. -CNA #1 was observed providing incontinent care to the Resident, the Resident's door was wide open, and the curtain was partially pulled. -CNA #1 was not observed donning a gown prior to providing personal care to the Resident. -CNA #1 changed and dressed Resident #61. -CNA #1 exited Resident #61's room with used linen in her gloved hands and placed them in a hamper in the hallway and sanitized her hands. During an interview on 5/5/26 at 3:40 P.M., CNA #1 said Resident #61 was not on any form of precaution and that the EBP sign at the door should not be there. CNA #1 walked to the nurse's station and was observed talking to Nurse #1. CNA #1 returned to Resident #61's door and removed the EBP sign and told the surveyor that the sign was a mistake and was not supposed to be there. During an interview on 5/5/26 at 3:42 P.M., Nurse #1 said the Resident was not on precautions and the EBP sign was not supposed to be posted at Resident #61's door. During an interview on 5/5/26 at 3:44 P.M., Nurse #2 said Resident #61 had a history of ESBL in the urine and required to be on EBP. Nurse #2 obtained an EBP sign and replaced the sign at the Resident's door. Nurse #2 said Nurse #1 and CNA #1 should have checked before removing the sign at the Resident's door. During an interview on 5/5/26 at 3:59 P.M., the Infection Prevention Nurse (IP) said Resident #61 was on EBP for ESBL in his/her urine. The IP said CNA #1 should have worn a gown while changing the Resident and should not have removed the sign from the Resident's door. The IP said Nurse #1 should have checked before informing CNA #1 to remove the EBP sign from the Resident's door.

Based on observation, and interview, the facility failed to ensure the safe and secure storage of medications as required to meet the needs of the facility residents and for one medication storage room (Windsor Unit) out of a total of two medication storage rooms. Specifically, the facility failed to: 1. ensure medications kits are replaced by the pharmacy after being opened with medications removed and not accounted for. 2. ensure the refrigerator that stored medications in the medication room was within the required temperature range of 36 to 46 degrees. 3. ensure medications were securely stored and only accessible by authorized staff on the Windsor Unit medication storage room. Findings include: Review of the facility policy titled Medication Storage Room, revised April 2015, indicated: -All licensed personnel are responsible for always ensuring the cleanliness of the medication room and at the end of the shift. -Drugs requiring refrigeration are stored separately in a refrigerator that is used exclusively for medication and medication adjuncts. -If anything needs to be repaired, please notify maintenance immediately. Review of the facility policy titled Storage of Medications, dated 2017, indicated: -Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. -Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. -Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit). -Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. -The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day per CDC Guidelines. 1.On 5/6/26 at 10:02 A.M., the surveyor and Unit Manager (UM) #1 observed the following in Windsor Unit Medication Storage Room: a. Intravenous (IV) kit was opened with no paper documentation indicating what was removed from the kit and for which resident. b. An emergency kit Super Kit (a kit that had most of the facility's used medications for the residents) was laying on the floor in the Medication Storage Room. The Super Kit contained a paper that itemized all the medications that should have been available in the kit. The surveyor further observed: >No documentation of which resident a medication had been removed for. >No documentation of the date the medication was removed. >No documentation of which Nurse opened the kit. >No evidence that the Super Kit had been re-ordered from the Pharmacy. c. An antibiotic had been opened, and there was no evidence that the kit had been re-ordered from the Pharmacy. 2. The surveyor and UM#1 reviewed of the refrigerator temperature log in the Windsor unit medication room indicated: >Temperature checks must be done twice per day. >Temperatures should be 36 to 46 degrees Fahrenheit. Review of the refrigerator temperature log documentation in the Windsor Unit medication room indicated the following:a) 2/1/26 – 2/28/26: the refrigerator temps were out of range 16 times in the month of February 2026. -47 degrees was documented one time -48 degrees was documented seven times -49 degrees was documented five times -50 degrees was documented three timesb) 3/1/26 - 3/31/26: the refrigerator temps were out of range 31 times for March 2026. -47 degrees was documented four times -48 degrees was documented nine times -49 degrees was documented 13 times -50 degrees was documented five timesc) 4/1/26 - 4/30/26, the refrigerator temps were out of range 30 times for April 2026. -48 degrees was documented one time -49 degrees was documented 20 times -50 degrees was documented nine timesd) 5/1/26 - 5/7/26, the refrigerator temps were out of range seven times. -49 degrees was documented five times -50 degrees was documented one time -51 degrees was documented one timeAt the time, UM #1 opened the refrigerator, and the surveyor and UM #1 observed the thermometer gauge at 50 degrees F. During an interview at the time, UM #1 said the refrigerator felt warm. The surveyor and UM #1 observed the following medications in the refrigerator with the temperature at 50 degrees F:a) One bottle of Acidophilus (probiotic medication used to maintain digestive health) required to be refrigerated for freshness and potency within a temperature range of 36 to 46 degrees F for long-term viability. b) One bottle of Omeprazole liquid (works by reducing the production of stomach acid, relieving the symptoms associated with acid-related gastrointestinal conditions) - Refrigerated storage: 2– 8 degrees C (36–46 degrees F). c) Five vials of unopened Humalog (insulin lispro for Diabetes) should be stored between 36 degrees F and 46 degrees F (2 degrees C and 8 degrees C) to maintain stability and effectiveness. d) Three Trulicity (for Diabetes) pens. e) One Tresiba (insulin degludec pen) should be stored between 36 degrees F and 46 degrees F (2 degrees C to 8 degrees C) until it is ready to be used. f) Seven vials of Lantus (for Diabetes). g) Three vials of Munjaro (for weight loss and diabetes management). h) One vial of Insulin Lispro (for Diabetes). i) One Xalatan (eye drop for Glaucoma). During an interview at the time, UM #1 said the refrigerator appeared to have been broken for a while and that the medications observed in the refrigerator needed to be discarded and re-ordered and that the medications were not good to be administered to the Residents. Review of the refrigerator medications listed above and retrieved from: https://www.drugs.com › medical-answers, indicated that medications requiring refrigeration should be kept in the refrigerator at 36 degrees F to 46 degrees F (2 degrees C to 8 degrees C) until ready to use. This ensures the medications remain stable and effective. During an interview on 5/6/26 at 12:05 P.M., the Assistant Director of Nursing (ADON) said he was not aware the emergency kits had been opened and not re-ordered. The ADON said he was not aware that the facility staff had documented the refrigerator temperatures above the required temperature. The ADON further said that the medications in the refrigerator needed to be discarded and new medications re-ordered for the residents. During an interview on 5/6/26 at 12:25 P.M., the Director of Nursing (DON) said she was not aware the Windsor Unit medication room refrigerator had not been working at the required temperature range. The DON said the medications would be discarded and re-ordered. The DON further said anytime an emergency kit is opened, facility staff are required to document the date the medication was removed, the resident's name, and the staff removing the medication. The DON further said the emergency medication kits should have been re-ordered but they were not. 3. Review of the facility policy titled Medication Storage Room/Medication Cart Policy, reviewed in January 2025 indicated: -Storage for other medications will be limited to a locked medication room. On 5/6/26 at 8:09 A.M., the surveyor observed the door of the Windsor Unit medication storage room (located behind the nurse's station and accessible to anyone) was slightly ajar and able to be opened by the surveyor. The surveyor also observed several residents ambulating in the hallway in the vicinity of the medication storage room. During an interview immediately following the observation, the ADON said the medication storage room door was supposed to be closed and always locked. The ADON said only the Nurses had a key to open the medication storage room. On 5/6/26 at 4:15 P.M., the Windsor Unit medication storage room door was slightly ajar and able to be opened by the surveyor. The surveyor observed several residents ambulating in the hallway in the vicinity of the medication storage room. During an interview immediately following the observation, the ADON said the door to the medicating storage room was supposed to be closed and locked. On 5/7/26 at 8:05 A.M., the Windsor Unit medication storage room door was slightly ajar and able to be opened by the surveyor. The surveyor further observed several residents ambulating in the hallway in the vicinity of the medication storage room. During an interview immediately following the observation, Nurse #5 said the medication storage room should always be locked and only the Nurses on the unit had access. The surveyor opened the door that was slightly ajar and Nurse #5 said the door should not be open and that the surveyor should not have been able to open the door. Nurse #5 said the medications in the medication storage room could be accessed by anyone when the door was not closed completely and locked, and that it was not safe. Nurse #5 said the door should be closed and always locked and not accessible to anyone else other than the Nurses on the unit. During an interview on 5/7/26 at 11:27 A.M., the DON said the medication storage rooms should always be locked and only accessible to the nursing staff on that unit. The DON said if the door was not completely closed, anyone, including unauthorized staff, residents or visitors would be able to walk into the medication storage rooms. The DON said she was not aware that the medication storage room door was not completely closing all the way.

Based on observations, interviews, and record review, the facility failed to serve food that was palatable, attractive, and appetizing on one resident Unit (Elmwood) and the facility Main Dining Room, placing residents at risk for reduced meal consumption. Specifically, the facility failed to: -For the Elmwood Unit: >serve chicken that was attractive and easy to chew.>serve banana slices that could be identified as banana by taste. -For the facility's Main Dining Room: -serve chicken that was easy to cut and chew. Findings include:Review of the facility's Food Committee Minutes indicated: -3/11/26: Residents said food was served cold. -4/15/26: Residents stated that the food is cold mostly on weekends and nights and the portions are too small. During a screening interview on 5/5/26 at 7:52 A.M., Resident #68 said his/her main concern at the facility was the food. Resident #68 said the food was [expletive]. During the Resident Council Meeting on 5/6/26 at 10:26 A.M., residents in attendance reported the following relative to food:-Four of six residents said they do not receive food items they request.-one of six residents said the meatloaf is like a hockey puck.-A second resident said the food was not good and that he/she attended monthly Food Committee meetings, and that there is never any change. -A third resident said the food is not edible, that it's terrible and most meals are cold. On 5/7/26, from 12:29 P.M. through 12:58 P.M., lunch meal test trays were conducted as follows on the Elmwood Unit and in the facility's Main Dining Room: >The surveyor completed the test tray observation on the Elmwood Unit after the last resident meal tray was passed at 12:29 P.M. -The test tray included but was not limited to boneless chicken breast and fruit cocktail containing banana slices. -The boneless chicken breast was discolored on one side with grey and pink patches on the outside of the chicken breast. -The boneless chicken breast was difficult to cut and chew and had a rubbery texture. -The banana slices in the fruit cocktail did not taste like bananas, were stringy and tasted like fruit cocktail syrup. >The surveyor completed the test tray observation in the facility's Main Dining Room after the last resident meal was delivered at 12:58 P.M. -The test tray included but was not limited to boneless chicken breast. -The boneless chicken breast was difficult to cut and hard to chew. During an interview at the time, the Minimum Data Set (MDS) Nurse, who also tasted the food, said the chicken was hard to cut and chew. During an interview on 5/8/26 at 10:02 A.M., the Administrator said that she had been made aware of the Resident complaints about food. The Administrator said food being served to residents should look appetizing and should not be difficult to cut and chew.

Based on observation, interviews, and record review, the facility failed to ensure staff served food that accommodated resident allergies, intolerances, and/or food preferences for three Residents (#49, #57 and #70) out of a total sample of 18 residents.Specifically, the facility failed to ensure that the meal preferences requested were provided for Resident's #49, #57 and #70 as requested. Findings include:Review of the facility policy, dated August 2015, indicated the following in part:-Residents/patients will receive nourishing, attractive meals to meet individual nutritional and special needs.-.this will be done while providing a positive dining experience to enhance the residents/patient's quality of life and respect his/her rights. Review of the resident council meeting minutes dated 2/20/26, the following was stated in part:-The biggest issue in the facility is the kitchen. The kitchen was short help for dietary aides and cooks.Review of food committee minutes dated 4/15/26 the following was stated in part:-Multiple issues with the kitchen. the kitchen department was short staffed. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. Review of the MDS assessment dated [DATE] indicated Resident #57 was cognitively intact as evidenced by a BIMS score of 13 out of a possible 15. Review of the MDS assessment dated [DATE] indicated Resident #70 was cognitively intact as evidenced by a BIMS score of 14 out of a possible 15. During an interview 5/5/26 at 10:55 A.M., Resident #70 said the food was not edible. Resident #70 further said he/she would eat whatever they brought in because he/she did not want to deal with having to wait. During an interview on 5/5/26 at 11:09 A.M., Resident #49 said he/she often did not receive the requested meals during mealtime. Resident #49 said that dinnertime seemed to be the most challenging for the kitchen staff and that dinner time was the meal he/she most often did not receive the items he/she requested. During a resident council meeting held on 5/6/26, the following was stated relative to food concerns:-At 10:26 A.M., one resident said they did not receive what they ordered often.-By a show of hands, four out of six residents in attendance indicated they often did not receive what they ordered for a meal.-Resident #57 said he/she believed that the staff in the kitchen simply did not read what was on the ticket because he/she rarely received the food he/she requested, on their meal tray. On 5/7/26 at 12:46 P.M., the surveyor was observing the lunch meal tray pass near the meal cart located at the nurse's station and Resident #57 could be heard yelling from his/her room. Resident #57 was yelling profanities and asking what is wrong with these people? How stupid can they be? During an interview on 5/7/26 at 12:48 P.M., Resident #57 said the kitchen staff put pork on his/her tray even though he/she requested chicken. Resident #57 said he/she did not like pork and would never choose pork over chicken and that was not what he/she ordered. Resident #57 was upset as he/she was slamming the silverware onto the tray and pushed the tray table away from him/her. The surveyor observed pork on the Resident's tray. During an interview on 5/7/26 at 1:04 P.M., with the Administrator, the Regional Clinical Specialist, and Resident #57, the Resident said he/she was happy that the staff brought him/her chicken. Resident #57 said he/she was initially supposed to get soup and crackers with the chicken, however only received the crackers with no soup. Resident #57 said he/she was satisfied with the meal that was brought to him/her, that it was good, he/she wished that his/her meal would come as ordered. Resident #57 said he/she understood the staff were trying to do their jobs but felt discouraged, and that it appeared like things were never going to get better. When the surveyor requested to see the meal ticket that was on the tray, Resident #57 said when the staff brought him/her a new tray, there was no new ticket, and the staff removed the old tray with the original meal ticket on it. During an interview on 5/7/26 at 1:36 P.M., the Food Service Director (FSD) said there were two soup options available for lunch today that the residents could have. The FSD said he did not know why Resident #57 did not receive soup if he/she requested it. The FSD could not provide additional information as to the Resident's food requests for lunch on 5/7/26. The FSD said chicken was the main meal and pork was the alternate meal for lunch service. The FSD reviewed the alternate meal list for residents dated 5/7/26 and said Resident #57's name was not on the list, so he/she should have initially received the main meal of chicken.

Based on interviews, and record review, the facility failed to afford the opportunity to formulate an advance directive relative to orders for life sustaining treatment, for one Resident (#5) out of a total sample of 18 residents, increasing the Resident's risk for undesired care in the event of a medical emergency.Specifically, the facility failed to review life sustaining treatment options with Resident #5's healthcare proxy (HCP) when:-the Resident was incapacitated at the time of admission.-the Resident's HCP was invoked.-the Resident's Medical Orders for Life Sustaining Treatment (MOLST), indicating Do Not Resuscitate (DNR) and Do Not Intubate (DNI), was not signed by the Resident's invoked HCP. Findings include: Review of the facility's MOLST policy, dated [DATE], indicated:-Purposes of the policy were to: -provide an outline for the process to follow when a resident is admitted with a MOLST form. -outline procedures regarding the completion of a MOLST form by a resident and the steps necessary when reviewing or revising a MOLST form.-The MOLST form should be executed as part of the health care planning process and preliminary advance care planning conversations.-The MOLST is designed to be a portable, valid and immediately actionable medical order consistent with the individual's wishes and current medical condition, which shall be honored across treatment settings.-Once the MOLST is completed, it must be signed by the resident, or if the resident lacks decision-making capacity the resident's legally recognized health care agent, AND the attending health care provider.-The MOLST will be reviewed by the facility interdisciplinary team (IDT) during the quarterly care planning conference, . Resident #5 was admitted to the facility in [DATE] with diagnoses including Atrial Fibrillation (A-fib) and Dementia. Review of Resident #5's Social Service Summary, dated [DATE], indicated:-The Resident's HCP was invoked.-The Resident was full code (resuscitation and intubation in event of cardiac or respiratory arrest) status. Review of Resident #5's Minimum Data Set (MDS) Assessment, dated [DATE], indicated:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of zero out of 15 total possible points.-HCP was invoked. -advanced directives included DNR and DNI. Review of Resident #5's IDT Care Plan Meeting Notes, dated [DATE] and [DATE], indicated:-advance directives were reviewed at the meeting.-The Resident or Representative were invited and declined to attend the meeting. Review of Resident #5's clinical record indicated:-The Resident was determined permanently incapacitated by his/her Nurse Practitioner (NP) on [DATE] (prior to admission to the facility).-A MOLST, dated and signed by NP #1 on [DATE] (prior to admission to the facility) for DNR and DNI.-The MOLST Form was not signed and was not dated by the Resident's HCP.-The signature line for the Resident's Representative indicated: verbal consent via telephone.Further review of Resident #5's clinical record failed to include evidence that the Resident's wishes relative to life sustaining treatment had been reviewed with the Resident's HCP between the Resident's admission to the facility and the survey period. During an interview on [DATE] at 9:30 A.M., the surveyor and Nurse #3 reviewed Resident #5's MOLST Form and Nurse #3 said Resident #5's MOLST Form was not valid because the MOLST Form was not signed by the Resident's HCP. Nurse #3 said in the event Resident #5 experienced cardiac or respiratory arrest, because the MOLST Form indicating DNR and DNI was not valid, the facility would be required to treat the Resident as full code status and provide cardiopulmonary resuscitation (CPR). Nurse #3 said the invalid MOLST Form would result in the Resident receiving CPR and that receiving CPR may not be upholding the wishes of the Resident/Representative. During an interview on [DATE] at 10:00 A.M., the Director of Nursing (DON) said she spoke to Resident #5's HCP following the surveyor's inquiry and that the Resident's HCP said he/she elected DNR and DNI for the Resident. The DON said she emailed a new MOLST Form to Resident #5's HCP so that the HCP could complete, including sign and date, the MOLST Form and return it to the facility. During an interview on [DATE] at 10:39 A.M., the Regional Clinical Specialist (RCS) said Resident #5's MOLST form required Resident #5's representative's signature to be considered valid. The RCS said that the facility should have provided Resident #5's HCP with information relative for MOLST. The RCS said the Resident's HCP could either sign the [DATE] MOLST form, or a new MOLST form could have been completed relative to life sustaining treatment with the required HCP signature.

Based on interviews, and record review, the facility failed to administer the pneumococcal immunization to one Resident (#11) out of five applicable residents for immunizations, out of a total sample of 18 residents, placing the Resident at increased risk for pneumococcal infection.Specifically, the facility failed to administer the pneumococcal immunization to Resident #11 when the Resident:-was eligible to receive the pneumococcal immunization.-Consented for the pneumococcal immunization to be administered. Findings include:Review of the facility's policy titled Immunization of Residents, dated April 2017 and revised January 2026 indicated the following:-All eligible residents will be offered the . pneumococcal vaccine unless medically contraindicated.-Adults 50 years and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV15, PCV20, or PCV21). Resident #11 was admitted to the facility in March 2026 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung, and Dementia. Review of Resident #11's clinical record indicated the Resident was aged 50 years or older. Review of Resident #11's admission Vaccination Education Form, signed by the Resident's health care proxy and dated 3/25/26, indicated:-The PCV20 or PCV21 vaccine is recommended for persons greater than or equal to [AGE] years of age .-The Resident/Representative had been given a copy of the Vaccine Information Statement (VIS) and had the opportunity to ask questions.-The Resident/Representative agreed to receive the pneumococcal conjugate vaccine. Review of Resident #11's Immunization Record on 5/7/26 failed to indicate any evidence the pneumococcal conjugate vaccine had been administered to the Resident. Review of the facility's Resident Immunization Log, undated, indicated Resident #11 was not up to date with his/her pneumococcal conjugate vaccine. During an interview on 5/7/26 at 11:19 A.M., the Infection Preventionist (IP) said the facility did not have a record of Resident #11 ever having a pneumococcal vaccine. The IP said the facility obtained consent to administer the pneumococcal conjugate vaccine to Resident #11 on 3/25/26, and he was unsure whether the pneumococcal vaccine had already been administered to the Resident. During an interview on 5/7/26 at 2:45 P.M., the Director of Nursing (DON) said when a resident consents to receive a pneumococcal conjugate vaccine, the facility will order the vaccine from the pharmacy, and the vaccine will be delivered to the facility on the overnight after the vaccine is ordered. The DON said the facility should have ordered the pneumococcal conjugate vaccine for Resident #11 to be administered when the Resident's Representative consented to the vaccine so that the vaccine could have been administered to the Resident. The DON said the pneumococcal conjugate vaccine was not ordered to be administered to the Resident until after the surveyor's inquiry relative to the Resident's pneumococcal vaccination status.

Based on interviews, and record review, the facility failed to offer and administer the 2025/2026 COVID-19 vaccine to one Resident (#11) out of five applicable residents for vaccinations, out of a total sample of 18 residents, in accordance with Centers for Disease Control and Prevention (CDC) recommendations, placing the Resident at increased risk for COVID-19 infection and COVID-19 infection complications.Specifically, the facility failed to offer and administer the 2025/2026 COVID-19 vaccine to Resident #11 in a timely manner when Resident #11 was eligible to receive the vaccine. Findings include:Review of the Centers for Disease Control and Prevention (CDC) guidance titled 2025/2026 COVID-19 Vaccine Guidance, dated 11/4/25 and located at 2025-2026 COVID-19 Vaccination Guidance | Covid | CDC indicated the following:- . some people may be at increased risk for SARS-CoV-2 infection including . residents . in long-term care facilities.-vaccination is recommended based on individual-based decision-making with an emphasis that the risk-benefit of vaccination is most favorable for individuals who are at an increased risk for severe COVID-19 disease and lowest for individuals who are not at an increased risk, according to the CDC list of COVID-19 risk factors (including COPD and Diabetes).-For individuals aged 12-64 years previously vaccinated before the 2025/2026 vaccine, administer one dose of 2025/2026 vaccine. Review of the facility's COVID-19 Vaccination Policy, undated, indicated:-It is the facility's policy to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by offering residents immunization to COVID-19.-COVID-19 vaccines will be offered as per Centers for Disease Control and Prevention (CDC) and/or Food and Drug Administration (FDA) guidelines unless such immunization is medically contraindicated, the resident has already been immunized during this time period, or resident/responsible party refuses to receive the vaccine. -COVID-19 vaccines may be administered in the facility by the Infection Preventionist (IP) or licensed staff member. -Resident's receiving the COVID-19 vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine . The completed, signed, and dated record will be filed in the resident's medical record. -Documentation will . include if the resident received or did not receive the immunization due to medical contraindication or refusal, . Resident #11 was admitted to the facility in March 2026 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung, and Dementia. Review of Resident #11's clinical record indicated:-The Resident was between the ages of 12- [AGE] years of age.-The Resident had diagnoses including COPD and Diabetes.-The Resident's most recent COVID-19 vaccine was administered on 4/12/21.-The facility offered, and the Resident's Representative agreed to receive the 2024/2025 COVID-19 vaccine on 3/25/26.Further review of Resident #11's clinical record did not indicate any evidence the facility offered the 2025/2026 COVID-19 vaccine to Resident #11 and/or his/her Representative and whether the Resident received or did not receive the COVID-19 immunization due to medical contraindication or refusal. Review of the facility's Resident Immunization Log, undated, indicated Resident #11's most recent COVID-19 vaccine was administered on 4/21/21. During an interview on 5/7/26 at 11:19 A.M., the IP said Resident #11's most recent COVID-19 vaccine was administered on 4/21/21. The IP said Resident #11's Representative consented for a COVID-19 immunization to be administered to the Resident on 3/25/26 and he was unsure whether an updated COVID-19 vaccine had been administered to the Resident after his/her Representative gave consent. During an interview on 5/7/26 at 2:45 P.M., the Director of Nursing (DON) said the facility offers updated COVID-19 vaccines when residents are admitted to the facility. The DON said if a resident is not up to date with the COVID-19 vaccine and consent is obtained to administer the vaccine, facility staff will order the vaccine from the pharmacy, and the pharmacy will deliver the vaccine on the overnight after it is ordered. The DON said the 2025/2026 COVID-19 vaccine was not offered and administered to Resident #11 until 5/7/26, after the surveyor's inquiry about the Resident's COVID-19 vaccination status.

Based on record review, and interview, the facility failed to resolve grievances timely for two Residents (#57 and #68) out of a total sample of 18 residents. Specifically, a) for Resident #57, the facility failed to ensure that the Resident's grievance for missing money was reviewed and followed through the grievance process when nursing staff filed the grievance on the Resident's behalf. b) for Resident #68, the facility failed to appropriately investigate the Resident's grievance related to missing clothing before documenting that the grievance was resolved. Findings include: Review of the facility's policy titled Grievance, undated, indicated: -The facility will make prompt efforts to resolve any grievances in accordance with the policy. -Upon receiving the grievance, the staff person receiving the grievance shall immediately notify the grievance officer. -The grievance officer shall begin the grievance process by logging a summary of the grievance (if oral), the date the grievance was received and by initiating an investigation. -Review of any grievance filed should be completed within seven days. If the review cannot be completed within this timeframe, the grievance officer should communicate the status of the review and an updated time in which it is expected the review will be completed. -Upon completion of the review, the grievance officer should document the following: a) The date the grievance was received. b) A summary of the residents' grievance. c) Steps taken to investigate grievance. d) A summary of the pertinent findings or conclusions regarding the grievance. e) A statement as to whether the grievances were confirmed or not; and f) Any corrective action taken or to be taken in response. 1. Resident #57 was admitted to the facility in February 2025 with diagnoses including Heart Failure, Hypertension and Dysphagia oropharyngeal phase. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #57 was cognitively intact as evidenced by a BIMS score of 13 out of 15 total possible points. During an interview on 5/5/26 at 8:04 A.M., Resident #57 said he/she reported his/her missing money to one of the evening Nurses over a week prior but had not received any feedback from his/her report. Review of Resident #57's Nursing Progress Note dated 4/26/26 at 10:56 P.M., indicated the Resident had reported his/her missing money to Nurse #5. During an interview on 5/6/26 at 4:04 P.M., Nurse #5 said Resident #57 reported the missing money to her and she had filed a grievance on his/her behalf. Nurse #5 said the facility's policy indicates when a Resident reports any concern, the staff would file a grievance on the Residents behalf, leave it in the Social Worker's (SW) mailbox and write a progress note. 2. Resident #68 was admitted to the facility in March 2026 with diagnoses including Dementia with Mild Behavioral Disturbance and Psychoactive Substance Dependence. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #68 was cognitively intact as evidenced by a BIMS score of 14 out of 15 total possible points. During an interview on 5/5/26 at 7:52 A.M., Resident #68 said he/she had reported and filed grievances about his/her missing clothes that were sent to the laundry a few weeks back but never received responses. Resident #68 said the clothes were brought to him by his/her sibling after he/she was admitted to the facility. Review of the Grievance Binder provided by the facility indicated that on 4/30/26, Resident #68 filed a grievance with a statement they have repeated [sic] failed to return any of the clothes I turned in to them. Further review of the grievance indicated that the SW had attached Resident #68's clothing inventory sheet and signed off that the grievance was complete. During an interview on 5/6/26 at 4:17 P.M., the Social Worker (SW) said she was the grievance officer for the facility. The SW said when she receives grievance she would follow through with investigation and notify the resident of the findings and conclusion. The SW said she found Resident #57's grievance in a pile of paperwork on her desk but has not had the time to review, investigate, or follow through with findings. The SW said she should have reviewed, investigated and communicated the investigative findings with the Resident, but she had not. The SW also said she received Resident #68's grievance but after she reviewed the Resident's inventory sheet on admission, she thought the Resident was not admitted with any clothing, so she never followed through with the investigation and filed the grievance as complete. The SW said she should have performed an investigation to find out when Resident #68 received his/her clothing, who brought them in for him/her and followed through with resolution, but she did not. During an interview on 5/6/26 at 4:54 P.M., the Administrator said she was not aware of Resident #57's missing money. The Administrator said the SW should have followed through the grievance process for Resident #57, but she had not. The Administrator further said there was no evidence that Resident #68's grievance was investigated before it was resolved.

Based on observation, interview, and record review, the facility failed to ensure the daily required nurse staffing information was posted as required.Specifically, the facility failed to:-ensure the total hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift (Registered Nurses (RN), Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), and Certified Nurses' Aides (CNA) were posted as required.-maintain a copy of the staffing records for 18 months. Findings include:On 5/5/26 at 7:18 A.M., the surveyor observed that the nurse staffing information was handwritten with an erasable marker on a wipe off board posted at the entrance of the reception area. The handwritten information on the wipe off board did not include the following required information:-the total hours worked by staff directly responsible for resident care per shift (RN's, LPN's, LVN's and CNA's). During an interview on 5/5/26 at 9:26 A.M., the Scheduler said she would leave the information for the Receptionist the day before and the Receptionist would write the information on the wipe off board with an erasable marker daily. The Scheduler said she did not have a record of the daily staff posting for 18 months as required.During an interview on 5/5/26 at 10:28 A.M., the Receptionist said she was responsible for updating the daily staff posting. The Receptionist said she would write the staffing information provided to her by the Scheduler on a wipe off board with an erasable marker.During an interview on 5/6/26 at 7:51 A.M., the Administrator said she was unaware that total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift needed to be on the nursing staff posting. The Administrator also said the facility has not maintained the posted daily staffing for 18 months as required.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, resided on a secured unit, was known by staff to exhibit exit seeking behaviors and was assessed at being at risk for elopement, the Facility failed to ensure that Resident #1 was provided with an adequate level of staff supervision to prevent an incident of elopement when on 01/05/26, Resident #1 exited the secured unit, through an alarmed door unbeknownst to staff and was found outside at the end of the block by the police.Findings include:Review of the Facility's policy titled Elopement, dated July 2015, indicated the Facility would maintain a process to screen all residents for risk of elopement, implement preventative strategies for those identified at risk, and institute measures for resident identification at the time of admission. Elopement is defined as the ability of a resident who is not capable of protecting him/herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter harm's way.Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 01/05/26, indicated Resident #1 exited the secured unit around 2:10 A.M., [through an alarmed door] the staff heard the alarm but assumed the Nurse set it off when she left the unit to obtain supplies. The Report indicated the alarm had sounded for five minutes when staff discovered footsteps outside one of the exit doors. The Report indicated staff implemented Dr. Hunt protocol (a Facility wide code to alert staff of a missing resident and to implement their search policy) and Resident #1 was found by the police at the end of the block.Further review of the Report indicated Resident #1 was transferred to the Hospital Emergency Department (ED) where he/she was evaluated and it was determined he/she did not have hypothermia. Resident #1 returned to the facility later that morning, around 7:00 A.M.Resident #1 was admitted to the secured unit (alarms on all exit doors) of the facility in April 2025, diagnoses included vascular dementia and generalized anxiety disorder.Review of Resident #1's Elopement and Wandering Risk Assessments, dated 11/03/25, indicated Resident #1 was at risk for elopement and wandering.Review of Resident #1's Minimum Data Set (MDS) assessment, dated 11/04/25, indicated he/she was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9, (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, and 13-15 indicates cognitively intact). The MDS also indicated that Resident #1 had a behavior of wandering four to six days during the seven day look back period.Review of Resident #1's Behavior Care Plan, dated 05/05/25, indicated Resident #1 had behaviors of wandering, exit seeking and was sometimes resistive to care.Review of Resident #1's Nursing Progress Note, dated 01/05/26 and written by Nurse #1, indicated that at 2:10 A.M. an alarm was sounding on the secured unit, staff began a unit wide search and at 2:18 A.M. a Dr. Hunt was called. The Note indicated Nurse #1 called 911 as other staff drove around the premises and Resident #1 was located by the police and a facility staff member. The Police transferred Resident #1 to the Hospital Emergency Department (ED) for an evaluation and the Hospital ED reported to Nurse #1 that Resident #1 had no signs of hypothermia or low body temperature and was discharged back to the facility.The Surveyor was unable to interview Nurse #1, as she did not respond to the Department of Public Health's telephone or letter requests for an interview. During a telephone interview (which included review of his written statement) on 01/22/26 at 8:15 A.M., Certified Nurse Aide (CNA) #1 said he was on duty the night shift (11:00 P.M. to 7:00 A.M.) on 01/05/26, when Resident #1 eloped from the facility. CNA #1 said Resident #1 often wandered the halls throughout the night, sometimes pushed on the exit doors, and required redirection by staff.CNA #1 said he was completing his documentation at the opposite end of the hallway to the door Resident #1 exited out of, when Nurse #1 approached him and asked if he could hear the alarm sounding on the exit door. CNA #1 said he could not hear it because there was a loud TV on in a resident room close to him, and said once he walked closer to the Nurses Station, he could hear the alarm sounding on the exit door.CNA #1 said the staff began searching the entire unit and discovered Resident #1 was missing. CNA #1 said he looked outside and in the parking lot for Resident #1 and was later told that he/she had been located by the police, not far from the facility.During a telephone interview (which included review of her written statement) on 01/22/26 at 7:37 A.M., Certified Nurse Aide (CNA) #2 said she was on duty the night shift of 01/05/26. CNA #2 said Resident #1 was well known to her and often wandered the unit during the night. CNA #2 said she was providing care in a resident's room when she heard an alarm sounding sometime around 2:10 A.M., and said she thought it was the alarm to the door that was between the unit and the lobby. CNA #2 said Nurse #1 had just told her that she was going to the other unit [through the doors to the lobby] to get supplies, and when she heard the alarm, she assumed it was because Nurse #1 had not entered the code when she left the unit. CNA #2 said she then came out of the resident's room and looked around to see which door was sounding and that's when she saw it was the exit door to the outside.CNA #2 said Nurse #1 came back to the unit, they all began searching the unit and identified that Resident #1 was missing. CNA #2 said when they could not find him/her inside the facility, she drove down the street and located Resident #1 who was a block away with the police. CNA #1 said she called Nurse #1 at 2:33 A.M. to tell her that she was with Resident #1 and the police.During an interview on 01/21/26 at 2:56 P.M., the Director of Nurses (DON) said the secured unit is for residents who have exit seeking behaviors. The DON said the staff mistakenly thought the alarm they heard on the morning of 01/05/26 was due to Nurse #1 leaving the unit.The DON said their investigation concluded that the exit door to the lobby and the exit door to the outside have the same sounding alarms, and the alarm on the exit door to the outside is not loud enough to be heard throughout the unit. The DON said she expected all staff to respond to all alarms in a timely manner.On 01/21/26, the Facility presented the Surveyor with a plan of correction with an effective date of 01/12/26, that addressed areas of concern identified in this survey, the Plan of Correction is as follows:A) Resident #1 returned to the facility, he/she sustained no injuries during the elopement, and is monitored/supervised by unit staff.B) On 01/05/26 the Director of Nurses and Administrator educated all facility staff of door alarm response time and Dr. Hunt Protocol.C) On 01/05/26 the Facility initiated random of audits of staff response times to alarms set off (by management staff) on the unit with response times recorded. They will continue to monitor and conduct random tests to ensure appropriate staff response times to alarms.D) Door Alarm Audits for staff response time will continue to be conducted weekly for three months.E) The Facility determined the door alarms should have different sounding alarms, and this change was tasked to the Maintenance Department. F) Ad-hoc QAPI was conducted, and new QAPI project for Elopement was implemented, with targeted completion date 03/20/26.G) The Administrator and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident # 1), who developed a pressure related injury on his/her right wrist area and required wound care, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals and outcomes that addressed his/her wound care needs. Findings include: Review of the Facility's Policy titled, Comprehensive Care Plans, dated November 2017, indicated that: - the Facility provides individualized, person-centered care which is reflected in each resident's care plan. To facilitate the creation of such plans, the Facility performs a comprehensive assessment on all residents. - the care plan will include an assessment of residents' strengths and needs. - the care plans are oriented toward preventing avoidable decline in clinical and functional levels. Review of the Facility's Policy titled, Condition: Significant Change, dated April 2015 indicated that: -In the event of a significant status change, the resident will be re-evaluated to amend the Care Plan. Resident #1 was admitted to the Facility in September 2021 diagnoses included dementia, chronic kidney disease, anemia, and a recent fractured right humerus. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 sustained a closed right distal humerus ( long bone in upper arm) fracture from a fall and his/her right arm was placed in an immobilizer (splint) and sling and he/she had a follow up with the orthopedic surgeon scheduled in one week to assess candidacy for possible open reduction surgery. Review of Resident #1's Pressure Injury Evaluation, dated 5/28/25, indicated he/she had a new stage 3 pressure injury measuring 0.2 centimeters (cm) x 0.2 cm x 0.1 cm on his/her right wrist and treatment orders were obtained. Review of the Orthopedic Surgeons Consult Note dated 6/03/25, indicated Resident#1 had a pressure injury over the right ulnar styloid (wrist) area with 1-to-2-millimeter depth, no bone or tendon was exposed, and recommended a splint above the wrist area, pressure injury treatment, with follow-up in one week. Further review of the Consult Note indicated surgery was not recommended. Review of Resident #1's Medical Record from 05/28/25 through 06/10/25, indicated there was no documentation to support a Care Plan related to his/her new Pressure Injury with interventions, treatment, goals and outcomes, had been developed and implemented by nursing to meet his/her wound care needs by nursing. During an interview on 06/10/25 at 1:04 P.M., the Unit Manager said she discovered the pressure injury on Resident #1's right wrist on 5/28/25 and obtained treatment orders. The Unit Manager said she did not update Resident #1's Care plan and said she should have. During an interview on 06/10/25 at 1:47 P.M., the Director of Nurses (DON) said Resident #1 did not have a Pressure Injury Care Plan in place and said it is the Facility's expectation that the Nursing ensure all care plans are updated, including when there is a change in condition.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who sustained a right distal humerus (long bone in upper arm ) fracture that would potentially need surgical intervention to treat, and who required a one week follow up appointment with his/her Orthopedic Surgeon, the Facility failed to ensure he/she was provided with quality care and services when transportation services were not properly arranged for several of his/her follow up appointments, which resulted in more than a months delay in him/her being seen and evaluated by an Orthopedic Surgeon. Findings include: Review of Resident #1's medical record indicated that he/she was admitted to the Facility during September 2021 and his/her diagnoses included dementia, chronic kidney disease, anemia, and a recent fractured right humerus. Review of the Hospital Discharge summary, dated [DATE], indicated that Resident #1 was hospitalized for a right distal humerus fracture, had an immobilizer splint placed on the right arm and a sling and was to be seen for follow up by the Orthopedic Surgeon in one week. The Discharge Summary indicated the Orthopedic Surgeon would evaluate candidacy for an open reduction surgery on Resident #1 at the follow up appointment. During an interview on 6/09/25 at 2:40 P.M., the Reporter said Resident #1's Orthopedic Surgeons' one week follow-up appointment was scheduled for 4/29/25, but the facility had to cancel it due to transportation issues, that it was rescheduled for 5/21/25, then canceled again by the facility and rebooked for 5/27/25. The Reporter said the 5/27/25 appointment was also canceled due to transportation issues. The Reporter said Resident #1 was finally seen by the Orthopedic Surgeon on 6/3/25, almost six weeks later. During an interview on 6/10/25 at 11:02 A.M., the Transportation Scheduler said Resident #1 required a wheelchair van and the transportation company sent a car for the initial follow up visit to the Orthopedic Surgeon on 4/29/25 and for the second appointment on 5/21/25 the van was late. The Scheduler said transportation issues occurred again for the 5/27/25 appointment, resulting in cancellation of that appointment. Review of the Regional Transit Authority Provider Request for Transportation (PT-1) Forms for Resident #1, dated 4/24/25, 4/29/25, and 5/21/25, indicated that the transportation request form did not include that a wheelchair van was specifically requested by the facility on the form. During an interview on 6/10/25 at 1:30 P.M., the Director of Social Services said the facility has had transportation issues involving Resident #1 and his/her appointments, and said that they have since changed their transportation services/process. During an interview on 6/10/25 at 1:47 P.M., the Director of Nursing (DON) said Resident #1 required a follow up appointment with the Orthopedic Surgeon in one week after admission and required a wheelchair van to be transported to the clinic for his/her follow-up appointment. The DON said staff had not been able to arrange for Resident #1 to be transported to the clinic for the follow up with the Orthopedic Surgeon in a vehicle equipped for a wheelchair resulting in there being a delay in his/her follow up appointment. The DON said that the Facility had been having transportation issues with their previous provider and has since changed to using another process/provider service to book necessary transportation. During an interview on 6/10/25 at 1:40 P.M., the Administrator said the facility implemented a new process to book transportation for the residents, it has been in place for one month due to the previous transportation concerns.

Based on record review, and interview, the facility failed to maintain accurate records of controlled substance medications management and reconciliation for four locked medication carts on two Units (Elmwood Unit and Windsor Unit). Specifically, the facility failed to: -maintain accurate records of controlled substance medications that had been removed from locked medication carts and stored in the DON's office while awaiting disposal/ destruction. -maintain accurate records of controlled substance medications that were awaiting disposal/destruction for a period of six months. Findings include: Review of the facility policy titled, Disposal of Medications and Medication Related Supplies, revised December 2019, indicated: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. -All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of in the facility by the administrator, director of nursing and/or consultant pharmacist. -Accountability records for controlled substances that are disposed of or destroyed are maintained with the unused supply until it is destroyed or disposed of and then stored for five years or per applicable law or regulation. On 1/28/25 at 10:15 A.M., during a medication administration observation of the Elmwood Unit medication cart one, the surveyor reviewed the controlled substance medication documentation labeled Book #1 with Unit Manager (UM) #2. The surveyor observed that narcotic medications had been removed from the controlled substance medication book and had been signed by two staff members as removed from count since 8/16/24. Further review of the controlled substance documentation in Book #1 did not indicate that the controlled substance medications had been destroyed. On 1/28/25 at 11:00 A.M., on the Elmwood Unit on the medication cart two, the surveyor and UM #2 observed the controlled substance medication documentation Book #2, which indicated twenty (20) entries of controlled substance medications that had been removed from medication cart two by two Nurses from 8/16/24 - 11/24/24. Further review of the controlled substance documentation in Book #2 did not indicate that the controlled substance medications had been destroyed. On 1/28/25 at 12:15 P.M., on the Windsor Unit, the surveyor and UM #1 reviewed a medication cart and the controlled substance medication documentation labeled Book #3. UM #1 said the documentation in the controlled substance medication book indicated that controlled substance medications had been released from the medication cart by the Nurse on duty to the Director of Nursing (DON) for destruction. Further review of the controlled substance medication documentation in Book #3 did not indicate when the controlled substance medications had been destroyed. On 1/28/25 at 12:19 P.M., the surveyor and UM #1 reviewed the second medication cart on the Windsor unit where the controlled substance medication documentation book was labeled Book #4. The controlled substance medication book was worn in appearance and the book reference number was unable to be identified. The surveyor observed there were four pages in the controlled substance medication documentation book that indicated the controlled substance medications had been released from the medication cart and signed off by the DON on 11/26/24. Further review of the controlled substance medication documentation in Book #4 did not indicate that the controlled substance medications had been documented as being destroyed. During an interview on 1/28/25 at 12:38 P.M., the DON said the controlled substance medications had been removed from the medication carts for destruction and remained under double lock and key in her office. The DON further said she was unsure how long the controlled substance medications in her office had been waiting for destruction. During an interview on 1/28/25 at 1:05 P.M., the Clinical Nurse Specialist (CNS) said the controlled substance medications had been removed from the medication carts for destruction and that the controlled substance medications were under double lock and key but had not been destroyed for six months. The CNS said the last time controlled substance medications were destroyed by the facility was 5/31/24. During an interview on 1/29/25 at 10:00 A.M., with the CNS, the DON, and the Administrator, the CNS said the controlled substance medications were in bags but there was no record of the controlled substance medications that had been removed from the Nurse's controlled substance medication carts. The CNS said the controlled substance medications that were removed from the Nurses' medication carts had not been recorded on a controlled substance disposal record. During an observation at the time, the surveyor observed five large bags containing controlled substance medications in the DON's office. The surveyor observed the following total of 80 different controlled substance medications in the five large bags in the DON's office: -multiple cards of Tramadol (opioid pain medication) for multiple residents -multiple vials of Lorazepam (antianxiety medication) for multiple residents -multiple cards of Oxycodone (opioid pain medication) for multiple residents -multiple vials of Morphine Sulfate liquid (opiate narcotic pain medication) for multiple residents -multiple cards of Lorazepam tablets for multiple residents -multiple tablets of Hydromorphone (opioid pain medication) for multiple residents -multiple cards of Phenobarbital (barbiturate medication) for multiple residents -multiple doses of Lyrica (used to treat nerve pain) for multiple residents -multiple doses of Clonazepam (antianxiety) for multiple residents -Fentanyl patches (opiod pain medication) for multiple residents -multiple doses of Ambien medication (sedative medication) for multiple residents -multiple doses of Dilaudid medications (opioid medication) for multiple residents During a follow-up interview on 1/29/25 at 3:15 P.M., the CNS said the controlled substance medications that were removed from the medication carts should have been recorded on the controlled substance medication disposal record with the dates of removal from the medication cart, the amount of medication removed per resident, the resident's name, and the type of medication removed. The CNS said the facility did not have a controlled substance medication disposal record in place.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests on one Unit (Windsor) and the facility's Main Dining Room. Specifically, the facility failed to: -obtain routine pest control services. -obtain pest control services when staff and residents at the facility identified fruit flies in the facility's Main Dining Room and on the Windsor Unit. Findings include: Review of the facility's Pest Control Services Agreement with [Contracted Pest Control Company], dated 1/15/20, indicated the following: -Inspection and treatment for pests would be provided at least 12 times per year. -Areas of service included the exterior perimeter of the facility, common areas, kitchen and food preparation areas, dining areas, storage areas, restrooms, laundry, and resident rooms upon request. -The technician was to check in on each visit and maintain the pest control log book. Review of the facility's Pest Control Service Reports indicated: -Pest control services were provided to the facility 11 times during 2024 (not 12 times as indicated in the Pest Control Services Agreement). -The last pest control service visit to the facility was on 10/29/24 to re-treat the kitchen and dishwasher areas for fruit fly prevention. Review of the facility's Pest Control Log indicated: -the Administrator had observed fruit flies in the facility's Main Dining Room and Main Kitchen on 11/19/24. -no evidence that pest control services were obtained relative to fruit flies in the facility's Main Dining Room and Main Kitchen. On 1/27/25, between 9:45 A.M. and 9:51 A.M., surveyor #5 observed a few small, winged insects, lying dead on towels on the windowsill in Resident #25's room. During an interview at the time, Resident #25 said he/she had noticed small flies in the room and that the small flies would come and go. On 1/28/25, between 11:20 A.M. and 11:47 A.M., surveyor #1 observed the following in the facility's Main Kitchen: -a small, winged fly flying in front of the stand-up freezer. -a small, winged fly flying in the hallway between the food preparation area and the dry storage room. -a small, winged fly flying over egg salad sandwiches being made by the Cook. -The [NAME] waved her hand at the small, winged fly and said, Get out of here!. During an interview at the time with the Food Service Director (FSD) and the Cook, the FSD said that the facility had a problem with fruit flies a few months prior, and he didn't notice any problems with fruit flies currently in the Main Kitchen. The [NAME] then said that she did not see fruit flies often in the Main Kitchen. On 1/28/25 at 2:20 P.M., surveyor #1 observed a small, winged fly flying in the FSD's office, located in the facility's Main Kitchen and one small, winged fly flying in the hallway, just outside of the FSD's office (in the hallway between the food preparation area and the dry storage room). During an interview on 1/28/25 at 3:29 P.M., the Administrator said that the facility did not have a policy for pest control and that the facility did have a pest control agreement with a pest control company. The Administrator said that routine pest control services were supposed to be provided monthly and that the facility could call the pest control company for additional visits as needed, if pests were observed in the facility. The Administrator said that the last date the pest control company had been to the facility was on 10/29/24 and that the pest control company had provided treatment for fruit flies on that date. The Administrator said that she observed fruit flies in the facility's Main Kitchen and Main Dining Room in November 2024 and that she entered the observations into the Pest Control Log. The Administrator further said that no one at the facility followed up with the pest control company relative to the sightings of fruit flies and that no pest control services had been obtained by the facility since 10/29/24.

Based on observations, interviews, record and policy reviews, the facility failed to ensure that one Resident (#79) of one applicable resident, in a total sample of 19 residents, who received enteral nutrition (method of delivering nutrition through the stomach or the small intestine) via a gastrostomy tube (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) received care and services to prevent complications. Specifically, the facility failed to ensure that all pertinent Physician's orders were implemented relative to the G-tube, that fluids were administered and monitored to maintain acceptable parameters of hydration, resulting in clinical signs of dehydration and need for the administration of intravenous fluids (IV fluids: specially formulated liquids that are injected into a vein to prevent or treat dehydration) for the Resident. Findings include: Review of the facility policy titled Enteral Feeding, dated April 2015, indicated enteral feeding provides an alterative method of nutritional support via a G-tube . and is used to enhance and maintain nutritional status when there is an inability to take adequate nutrients orally. The policy also included the following: - Check the Physician's order for formula, rate of administration, and water flushes. - Aspirate (medical procedure that removes something from the area of the body) stomach contents to check for residual (amount of liquid drained from the stomach following the administration of enteral feed). - Hold the feeding for residual amount as designated by Physician's orders. - Set desired flow rate on the pump and start feeding. - Record intake, flush, and free water volume administered. Review of the facility policy titled Intake and Output (I&O) Monitoring, dated April 2015, indicated I&O will be monitored, as indicated by the resident's hydration status, risk of dehydration, and/or per Physician's order. The policy also included the following: - I&O will be monitored initially for 72 hours after a resident is admitted or readmitted . Continued monitoring may be required based on the resident's risk factors for dehydration, as outlined in the Hydration policy, or based on the results of the Dehydration Evaluation, if conducted. - I&O is documented for each shift, beginning with the 11:00 P.M. to 7:00 A.M. shift - I&O is totaled daily by the 3:00 P.M. to 11:00 P.M. shift Nurse and the 24 hour totals are transcribed to the Medication Administration Record (MAR). Review of the facility policy titled Hydration, dated April 2015, indicated at risk residents will be reviewed and will be provided with interventions to promote hydration based on the resident's physical and mental abilities, resident/responsible party's wishes pertaining to hydration and quality of life. The policy also included: - Residents identified for a potential at risk for dehydration will be placed on I&O monitoring until adequate hydration status is achieved or until I&O monitoring is no longer clinically indicated. - Registered Dietitian (RD)/Physician/Licensed Nurse will determine the minimum fluid needs range. - Implement interventions to promote hydration based on the resident's needs. - If the resident has consumed less than their estimated needs for three consecutive days, complete a dehydration evaluation. - Notify the Physician and resident/responsible party of abnormal dehydration evaluation findings. - Establish, implement, and revise, as necessary, a plan of care for any resident at risk for dehydration. Review of https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/hypernatremia-high-level-of-sodium-in-the-blood article, included the following: -In hypernatremia, the level of sodium in blood is too high -Hypernatremia involves dehydration, which can have many causes, including not drinking enough fluids . -Blood tests are done to measure the sodium level -Usually, fluids are given intravenously to slowly reduce the sodium level in the blood Resident #79 was admitted to the facility in October 2023 with diagnoses including Traumatic Brain Injury (TBI: brain dysfunction resulting from a sudden, external, physical injury to the head), Gastrostomy tube status, and Dysphagia (difficulty swallowing). Review of the Baseline Care Plan, initiated on 10/6/23, indicated Resident #79 had a decline in activities of daily living (ADLs: fundamental skills to care for oneself which includes bathing, mobility, eating) and had a feeding tube. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #79: -had moderate cognitive impairment as obtained through staff interview. -was dependent on staff for eating and oral hygiene. -had significant weight loss (5 percent (%) or more in a month or 10% or more in six months) that was not prescribed by the Physician. -was receiving tube feeding that provided greater than (>) 51% needs and > 501 milliliters (mls) or more of fluids during the reference period. Review of the Physician/Telephone orders for the following dates and times included the following: -10/5/23 Osmolite 1.5 (type of enteral feeding) 55 mls per hour with 150 mls water every 6 hours, obtain admission labs which included: Basic Metabolic Panel (BMP) -10/6/23 Diet: NPO (nothing by mouth), bed upright 30 degrees at all times, aspiration precautions, strict oral care every shift and as needed (PRN) -10/17/23 Osmolite 1.5 at 55 mls per hour for 24 hours, document mls infused every shift -10/19/23 Water flushes 245 mls (increased from 150 mls) water every six hours via G-tube -10/26/23 Osmolite 1.5 at 70 mls/hour for 20 hours via G-tube, up at 2:00 P.M. and down at 10:00 A.M., 60 mls water before initiating enteral feeding and after completion. - 11/6/23 Check G-tube placement prior to medication administration - 11/6/23 Check residuals [not legible] 15 - 11/6/23 Flush 30 mls water before and after medications - 11/6/23 Elevate the Resident's bed 30-45 degrees at all times - 11/7/23 One liter of IV fluids at 80 mls/hour - 11/7/23 Repeat BMP lab work STAT (immediately) after fluid administration - 11/7/23 Increase water flushes to 175 mls/hour (decreased from the previous 250 mls) Review of the November 2023 Physician's orders included the following: - NPO - Strict oral care every shift and as needed - Treatment to G-tube site: monitor for signs/symptoms of infection every shift - Bed upright, 30 degrees at all times - Aspiration precautions Review of the clinical record included the following lab work obtained on the following dates: - 10/10/23 Blood Urea Nitrogen (BUN: waste product that kidneys remove from blood; normal levels = 10-24): 26 H (high) - 10/10/23 Creatinine (efficiency of kidneys; normal levels = 0.7 - 1.5): 1.0 - 10/10/23 Sodium (Na: measures amount of sodium in the blood; normal levels = 133 - 145): 140 - 10/24/23 BUN: 22 (within normal range) - 10/24/23 Creatinine: 0.9 (within normal range) - 10/24/23 Sodium: 137 (within normal range) - 11/4/23 BUN: 36 (high) - 11/4/23 Creatinine: 1.1 (within normal limits) - 11/4/23 Sodium: 152 (high) - 11/7/23 BUN: 44 (high) - 11/7/23 Creatinine 1.1 (within normal limits) - 11/7/23 Sodium: 159 (high) Review of the October 2023 Medication Administration Records (MARs) and Treatment Administration Records (TARs) did not include instructions for fluid flushes when administering medications, nor I&O information. Review of the November 2023 MAR and TAR included the following orders: - NPO, Tube feed 70 mls/hour over 20 hours (did not indicate the type of enteral formula) - Strict oral care every shift and as needed - Treatment to G-tube site: monitor for signs/symptoms of infection every shift - Aspiration precautions - Bed upright, 30 degrees at all times Review of the RD Progress Note dated 10/19/23, indicated Resident #79 was sent to the hospital on 10/17/23 after he/she had a syncopal episode (loss of consciousness) while being weighed and was noted to be dry (another term to indicate dehydrated) while in the Emergency Department. The RD recommended increasing the water flushes from 150 mls to 245 mls every six hours to provide a total of 1,985 mls of water (including water present in the enteral feeding and the water flushes). Review of the RD Progress Note dated 10/26/23, indicated Resident #79 had a significant weight loss of 5.2% over a three-week period. Recommendation was made to change the enteral feeding to Osmolite 1.5 at 70 mls per hour over 20 hours, up at 2:00 P.M. and down at 10:00 A.M., with 60 mls water before initiating and after discontinuing feeding. The RD also recommended to continue the 245 mls water flushes every 6 hours to provide 100% estimated nutritional needs. Review of the Tube Feeding Care Plan, initiated 10/17/23 and revised 11/2/23, indicated Resident #79 was dependent on tube feeding as a nutrition source, and included the following interventions: - Check placement of the G-tube site every shift and as needed, as ordered - Ensure the Resident's head of the bed is greater than 30 degrees while tube feeding is infusing - Provide water flushes as ordered - Monitor tolerance to tube feeding, may check residuals as needed, if the residual is less than 500 mls, may re-instill, if residual is greater than 500 mls, hold tube feeding and contact the Physician . - Provide Osmolite 1.5 at 70 mls/hour over 20 hours - Monitor the Resident's weights and labs as needed On 11/5/23 at 10:31 A.M., the surveyor observed Resident #79 lying in bed with eyes open, with both knees bent and legs exposed. The Resident was very thin in appearance and the skin on his/her legs/feet were dry. A tube feeding machine was observed to the right of the Resident's bed and was not running. An unlabeled bag containing brown liquid was hanging from the tube feeding pole and was dated 11/5/23: 6:00 A.M. Another clear bag containing clear fluid was also hanging from the tube feeding pole and was dated 11/5/23: 6:00 A.M. On the following dates and times, the surveyor observed Resident #79 lying in bed, the head of the bed elevated, and the tube feeding was infusing (running) at 70 mls/hour with 250 mls flush every 0 hours (not 6 hours as recommended). -11/5/23 at 4:50 P.M., (the tube feed bag was dated 11/5/23: 6:00 A.M., and the water flush bag was dated 11/5/23: 6:00 A.M). -11/6/23 at 8:19 A.M., (the tube feed bag was dated 11/6/23: 6:00 A.M [with 800 mls observed], and the water flush bag was dated 11/5/23: 6:00 A.M). -11/6/23 at 3:19 P.M., (the tube feed bag was dated 11/6/23: 6:00 A.M.[with 600 mls observed], and the water flush bag was dated 11/5/23: 6:00 A.M). -11/7/23 at 7:36 A.M., (the tube feed bag was dated 11/6/23: 7:00 A.M., to 3:00 P.M.[with 700 mls observed], and the water flush bag was dated 11/6/23: 7:00 A.M. to 3:00 P.M). On 11/6/23 at 10:58 A.M., the surveyor observed Nurse #2 provide oral care to the Resident with Certified Nurses Aide (CNA) #3. The Resident's mouth was observed to have numerous discolored teeth, his/her tongue was patchy and his/her lips had pieces of dry skin present. During the oral care procedure, Resident #79 was observed to close his/her mouth and suck on the toothette (disposable oral care swabs). During an interview at the time, Nurse #2 said Resident #79 was trying to drink the liquid on the toothette. When the surveyor asked her to assess the condition of the Resident's mouth, Nurse #2 said his/her lips and mouth were dry and that his/her tongue was patchy. Nurse #2 further said there were dry patches on the roof of the Resident's mouth and that he/she did not take anything by mouth and was tube fed. On 11/7/23 at 8:09 A.M., the surveyor with Nurse #2 observed Resident #79. Nurse #2 said the Resident was receiving G-tube feedings of Osmolite 1.5 at 70 mls/hour. She said the tube feeding was started at 2:00 P.M. and runs until 10:00 A.M. the next day. She said that anytime medications are given, 30 mls of water are administered before and after the medication administration and that residuals are checked on the day shift when the tube feeding was taken down. Nurse #2 said that residuals should be checked every shift. When the surveyor asked where the residuals were documented, Nurse #2 said she thought it was documented in the MAR. When the surveyor asked about the tube feeding pump set up, Nurse #2 said that the tube feeding and flushes are programmed by the night shift when the bag was replaced with a new bag. She further said that everything was programmed into the machine so the tube feeding formula and water flushes were automatically administered. During an interview on 11/7/23 at 2:52 P.M., the Physician said hydration has been an issue for Resident #79. He said that the Resident's water flushes were increased, he/she had poor skin turgor (elasticity of the skin, ability for it to change shape and return back to normal) and dry skin. When the Physician reviewed the Resident's lab work from 11/4/23, he said that the Resident was not receiving enough fluids and he would increase his/her water flushes. On 11/8/23 at 7:27 A.M., the surveyor and Nurse #10, who worked the 11:00 P.M. to 7:00 A.M. shift, observed Resident #79. Nurse #10 said she hung the Resident's bag of water and tube feeding at 2:30 A.M., and that the tube feeding pump flushes the water by itself. The surveyor observed the Resident lying in bed with eyes closed. Both the clear bags containing the tube feeding and the water flushes were dated 11/8/23, had approximately 1000 mls of fluid, and did not have a time or any other label noted. The tube feeding pump was set to infuse at 70 mls/hour with 175 water flush every 0 hours. The surveyor observed IV fluids were being infused via a peripheral line (a small catheter that is placed through the skin and into the vein to provide fluids) set at 80 mls/hour and was dated 11/7/23: 3:00 P.M. to 11:00 P.M. On 11/8/23 at 9:55 A.M., the surveyor and Nurse #2 observed Resident #79. Nurse #2 said the tube feeding pump was set to flush fluids every six hours and it was recently increased from 150 mls to 175 mls. The surveyor reviewed the pump settings with Nurse #2, and asked why the pump indicated the flushes were set to 175 mls every 0 hours. Nurse #2 said it should be set to administer fluids every 6 hours. The surveyor observed that the clear bag the water flushes still had approximately 1000 mls of fluid (same amount as previously observed). The surveyor reviewed the November 2023 MAR with Nurse #2 who said the Resident's water flushes were not transcribed into the MAR and they should be. During a subsequent interview on 11/8/23 at 11:19 A.M., Nurse #2 said that Resident #79 was not receiving his/her water flushes as ordered and the tube feeding pump was not programmed correctly. She said the Resident's tube feeding orders and water flushes should be transcribed into the MAR but they were not. She also said that residual amounts should also be recorded in the MAR, but they were not. Nurse #2 said the Resident's mouth was very dry and that he/she had crusty dried material on the upper roof of his/her mouth. Nurse #2 reviewed Resident #79's Physician's orders with the surveyor at this time and said the water flushes should have been programmed at 175 mls/hour, but were not. She said prior to this new order, the Resident should have been receiving 245 mls of water flushes every 6 hours, and that all of the Resident's orders should be a part of the MAR, but they are not. She further said that intake and output should be monitored for this Resident, in the I&O book, and that the Nurses should be checking and reviewing this information. Review of Resident #79's Intake and Output Documentation indicated the following: -10/5/23 - 10/9/23, 10/13/23, 10/16/23- 10/20/23, 10/23/23- 10/25/23, 10/28/23 and 10/30/23- 11/5/23: no documented evidence that intake was monitored. -10/10/23 -10/12/23: intake monitored on the 7:00 A.M. to 3:00 P.M. shift, no other shifts had intakes documented. -10/14/23 - 10/15/23: intake monitored on the 11:00 P.M. to 7:00 A.M. and the 7:00 A.M. to 3:00 P.M. shifts, no tube feeding amounts documented on the 3:00 to 11:00 shift, nor did any shift indicate amount of water administered during the shifts. -10/21/23 - 10/22/23, 10/26/23 - 10/27/23, 10/29/23: intake monitored on the 11:00 P.M. to 7:00 A.M. shift, no other shifts had intakes documented, nor did any shift indicate amount of water administered during the shifts. During an interview on 11/8/23 at 11:51 A.M., the Director of Nurses (DON) said that Nurse #2 spoke with her about Resident #79 and indicated that he/she was not receiving the water flushes as ordered by the Physician. The DON said the Resident could be dehydrated if not receiving the fluids that were ordered by the Physician and further said that the Resident's labs indicated he/she was dehydrated. On 11/8/23 at 12:23 P.M., the surveyor reviewed Resident #79's chart with the Registered Dietitian. The RD said that any resident receiving tube feeding would be assessed on admission. She said that there should be Physician's orders that include the type of formula, the rate of infusion, the water flushes, and a standing order to obtain residuals with information on what amount would need to be obtained to hold the tube feeding and to contact the Physician. The RD reviewed the I&O documentation, and said that the Resident's intakes were not being documented, and that she would expect to see the amount of the tube feeding formula and water flushes documented for each shift. She further said this information was important so that she could assess to see if the Resident was getting the amount of tube feeding and water flushes as indicated in the orders and if these amounts needed to be adjusted. On 11/8/23 at 1:22 P.M., the surveyor and the DON reviewed the Resident's chart. The DON said that the Physician's orders should be in place relative to the enteral feeding, including the type of tube utilized, orders indicating the tube feeding formula, rate of the feeding, whether it was continuous or intermittent, care of the G-tube, monitoring the insertion site, and amount and frequency of water flushes. The DON further said that residents who are on enteral feeding should have Physician's orders for intake and output monitoring and orders for the frequency of oral care. The DON said the orders for the amount and frequency of water flushes, instructions on residuals and checking the placement of the G-tube should be in the MAR, but they were not. The DON said I&O's would be monitored to assess the amount of tube feeding and water administered and compared to the resident's output to ensure adequate hydration status. She said that lab work would also be assessed as well as urine output, and an assessment of the resident's oral cavity to ensure it was not dry. The DON reviewed the I&O documentation for Resident #79 and said the intakes were not consistently being documented, and she was unable to assess how much nutrition and hydration the Resident received based on the I&O documentation, and she should be able to. She reviewed the November 2023 MAR for Resident #79 and said the orders in place for the tube feeding were not complete and did not include the type of formula, the rate of infusion and the water flushes as required.

Based on observation, interview, record review and policy review, the facility failed to ensure that its staff maintained a hazard free environment for five Residents (#5, #55, #136, #19, and #25) out of a total of 19 sampled residents and in one out of two medication rooms, resulting in an injury for one Resident (#5). Specifically, For Resident #5 the facility failed to ensure that its staff performed neurological checks, completed a comprehensive fall investigation, and developed and implemented new fall interventions after an unwitnessed fall, resulting in a subsequent fall, a hospital admission and a diagnosed impacted proximal humerus (arm) fracture. 2) For Resident #55 and #136 the facility failed to ensure that its staff provided the required supervision with eating. 3) For Residents #19 and #25 the facility failed to ensure its staff completed an assessment and care plan for smoking safety. 4) The facility staff also failed to ensure that medications were a) secured for one Resident (#136) and b) for one out of two medication storage rooms. Findings include: 1. For Resident #5 the facility failed to ensure that its staff performed neurological checks, developed and implemented immediate interventions and revised a fall care plan with interventions after an unwitnessed fall from bed on 8/29/22, where the Resident said he/she hit their head. The Resident had a second fall on 8/31/22 under similar circumstances resulting in an impacted proximal humerus fracture. Review of the facility policy titled, Falls Management, revised August 2018, indicated the following: - The interdisciplinary team will develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score. -Neurological checks (to assess for any medical or cognitive changes) to be documented on the neurological flow sheet for 72 hours in the following circumstances, resident/patient states that he/she hit head, physical evidence resident hit head and an unwitnessed fall if the resident is an unreliable historian. Resident #5 was admitted to the facility in November 2015, with diagnoses including Dementia without behavioral disturbance, anxiety, Alzheimer's Disease, mild cognitive impairment, and moderate intellectual disability. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #5 had a severe cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS assessment also indicated that the Resident required supervision with one assist for toileting and transfers. Review of the Nursing Note dated, 8/29/22, indicated Resident #5 had a fall at the bedside and that he/she hit their head a little. Review of the 8/29/2022 Fall Incident Report & Investigation indicated that at 10:45 P.M., Resident #5 had an unwitnessed fall and was found lying on the floor bedside, close to the wall and that he/she just slipped off the bed. The Incident Report was incomplete with the following blank areas: -Was MD notified? -Was therapy department notified? -Was the care plan/care card updated? -What was the intervention to prevent further occurrence? Review of the medical record indicated there was no evidence of falls, pain, skin or neurological assessments that were completed in response to the fall that occurred 8/29/22. Review of the care plan for fall prevention indicated no new interventions were added after the fall on 8/29/2022. Further review indicated no new interventions since 11/23/2018. During an interview on 9/2/22 at 2:33 P.M., the Director of Nursing (DON) said that on 8/29/22 staff reported finding Resident #5 on the floor after an unwitnessed fall. She further said that for an unwitnessed fall, neurological assessments should be initiated, as well as assessments for pain, skin and falls risk and there was no evidence that any of those were done. She further said the expectation was for the incident reports to be completed without blanks; neurological assessments to be completed; the care plan should be updated with new interventions and the Physician should be notified. She further said that there was no evidence that the care plan had been updated with new interventions or that the Physician had been notified of the fall or that the assessments for neurological pain, skin and risk for fall assessments were completed. On 8/31/22 at 9:33 A.M., the surveyor observed Resident #5 in bed with a bruise to the right side of his/her head. During an interview on 8/31/22 at 9:36 A.M., Resident #5 said he/she fell out of bed last night. Review of a Progress Note, dated 8/31/22 at 7:52 A.M., indicated, that Resident #5 sustained a fall and was found lying on the floor in a supine position at the end of the bed. A lump was noted on upper right forehead and positive range of motion to all extremities except his/her right arm. Resident stating it hurt and guarding the extremity (arm). Review of a Progress Note, dated 8/31/22 at 12:53 P.M., indicated that the Resident was sent to the emergency room (ER) for evaluation after having two falls, noting his/her right forehead was bruised and with swelling. Review of a Progress Note, dated 8/31/22 at 3:25 P.M., indicated the Resident returned from the ER with a new diagnosis of a right proximal humerus (arm) fracture. During an interview on 9/02/22 at 2:33 P.M., The surveyor and the DON discussed how the unwitnessed falls on 8/29/22 and on 8/31/22 occurred under similar circumstances. When the surveyor asked the DON what interventions were put in place after the fall on 8/29/22 to prevent a further fall, the DON said that no new interventions or care plan revisions were initiated after the first fall. She said following the fall on 8/31/22 the Resident was sent to the ER where a diagnosis of a right proximal humerus fracture was given. 2. For Resident #55 the facility failed to ensure that its staff provided the required supervision during meals. Resident #55 was admitted to the facility in March 2018 with diagnoses including unspecified severe protein calorie malnutrition, unspecified Dementia without behavioral disturbance, legally blind, and dysphagia oropharyngeal phase (difficulty swallowing). Review of a Speech Language Pathology (SLP) Discharge Summary, dated 5/31/22, indicated the following discharge recommendations: -Diet recommendations: Dysphagia ll diet, ground textures (no bread), ground solids, pureed fruits and vegetables. -Recommend continual supervision and assistance in the carry over of the recommended swallowing guidelines to decrease the risks associated aspiration and to improve mealtime intake percentages. -Intake protocol: sit upright at 90 degrees and remain upright for at least 30 minutes after mealtime. Allow increased time between bites and sips and use a second swallow. Take turns with liquids and solids. No straws. Encourage no talking while food is in the mouth. Bring attention to mealtime activity. -Swallowing: provide 1:8 continual supervision -Self feeding: 1:8 continual Supervision. Review of an MDS assessment, dated 7/13/22, indicated Resident #55 was severely cognitively impaired as evidence by a score of 5 out of 15 on the Brief interview for Mental Status (BIMS). Review of a Physician's interim order, dated 7/15/22, indicated a change from independent with eating to supervised. Review of a Nurses note, dated 7/18/22, indicated the Dietician was in to see Resident #55 due to new orders for supervision at meals. Review of the Resident Care Card, dated 7/19/22, indicated the Resident required continual supervision 1:8 with meals. On 8/31/22 at 8:50 A.M., the surveyor observed Resident #55 in bed, sitting up with breakfast prepped on the bedside table. The Resident (and roommate) were alone in the room eating breakfast. Resident #55 had eaten less than 25 percent of the meal and was playing with the eggs on his/her tray. The Resident's roommate went down the hall and told Certified Nurse Aide (CNA) #4 that the Resident was playing with his/her food. CNA #4 went to the room and removed the breakfast tray. On 9/2/22 at 8:20 A.M., the surveyor observed Resident #55 sitting up in bed eating breakfast. There were no staff in the room. The nearest staff was at the other end of the hall assisting another Resident in their room. 09/2/22 at 9:02 A.M., the surveyor observed a staff member come to collect the breakfast tray from Resident #55. The Resident indicated he/she no longer wanted to eat and did not like the food. The surveyor observed that staff had not entered the Resident's room since prior to 8:20 A.M and provided no supervision with the breakfast meal. During an interview on 9/2/22 at 9:05 A.M., CNA #3 said that Resident #55 required extensive assistance to total care with most Activities of Daily Living (ADLs). He further said the Resident usually ate on his/her own and often refused help. CNA #3 said he set up the tray for breakfast and tried to help but the Resident wouldn't allow it, so he left. During an interview on 9/6/22 at 11:15 A.M., Speech and Language Pathologist (SLP) #1 said she reviewed the SLP Discharge Summary, dated 5/31/22, and said it showed that Resident #55 required a dysphagia diet with continual supervision for swallowing strategies to decrease the risk of aspiration (when food or fluids are inhaled into the lungs). When the surveyor asked SLP #1 how she would define 1:8 supervision she said it meant that the resident should eat in a supervised area and there should be no more than a 1 staff member to 8 resident ratio. When the surveyor asked if someone requiring 1:8 continual supervision was safe to eat alone in their room, she said no, that would not meet the definition of continual supervision. 3. For Resident #136 the facility failed to ensure its staff provided supervision with eating. Resident #136 was admitted to the facility in August 2022. Review of the SLP Evaluation and Plan of Treatment, with certification date 8/23/22 through 9/21/22, indicated the following: -Goal: To decrease the risks associated with aspiration -Reason for Referral: difficulty swallowing -Dentician: edentulous (no teeth) -Analysis: Behaviors impacting safety: decreased insight regarding concerns related to dysphagia. -Diet recommendations: Dysphagia 2-ground textures -Intake Protocol: Swallowing: 1:8 (staff to resident ratio) continual supervision. Self Feeding: 1:8 continual supervision. -Impressions: Moderate oropharyngeal dysphagia, with decreased oral phase breakdown of solids, resulting in episodes of throat clearing and coughing during intake. Review of the care plan indicated the Resident had swallowing difficulty related to edentulous status and the goal was to be free from aspiration. The interventions included the following: -During meals and after each meal check for signs of pocketing food in oral cavity. -During meals and after each meal: observe for signs and symptoms of aspiration. -Provide safe swallow strategies per SLP: feed slowly, alternate solids and liquids, offer small bites and sips, provide verbal/tactile cues when necessary to encourage the Resident to chew and swallow each bite. -Resident requires close supervision at meals. Review of the CNA care card indicated the Resident required continual supervision 1:8 for eating and was to eat in the dining room. Review of the August 2022 CNA Documentation Report indicated the Resident was coded as eating independently with set up from staff (no supervision) from 8/22/22 through 8/31/22. On 8/31/22 at 8:34 A.M., the surveyor observed Resident #136 eating a piece of toast alone in his/her room. The breakfast tray had another piece of plain toast, hot cereal, milk, and juice. On 9/01/22 at 12:38 P.M., the surveyor observed the Resident eating lunch alone in his/her room. On 9/02/22 9:10 A.M., the surveyor observed the Resident eating breakfast alone in his/her room. During an interview on 9/02/22 at 9:30 A.M., CNA #1 said she took care of the Resident. She said the Resident ate alone in his/her room for meals, and was independent. CNA #1 reviewed the care card and said that it indicated the Resident needed 1:8 supervision for eating. She said no one told her the Resident needed supervision for eating and the communication in the building was awful. CNA #1 said if the Resident needed supervision then he/she should have been having his/her meals in the large dining room on the unit because that's where they put the residents who needed supervision or assistance at meals. 4. For Resident #19 the facility failed to ensure that its staff did a smoking assessment and developed an individualized care plan related to smoking. Review of the facility's policy for Smoking, dated November 2020, indicated it was the policy of the facility to provide a healthy and safe environment for residents, staff and visitors. The purpose of the policy was to afford residents the opportunity to smoke while maintaining a safe and clean environment. Further review indicated the procedure included the following: -The facility will review the smoking policy with residents and/or the responsible parties upon admission. -Residents who smoke will be evaluated for their ability to smoke safely upon admission, quarterly and as dictated by any significant change in condition, to ensure that they continue to be capable of smoking and use smoking materials without presenting a danger to themselves or others. The need for assistive and/or safety devices will be identified and noted in the residents individualized care plan. Resident #19 was admitted to the facility in June 2022. Review of an MDS assessment, dated 6/14/22, indicated the Resident had moderate cognitive impairment as evidenced by a score of 10 out of 15 on the BIMS. Review of a Nursing Progress Note, dated 7/10/22, indicated the Resident was found with a cigarette lighter in his/her pocket when he/she requested to go outside to smoke. The Resident said he/she had the lighter for a while and the Resident also had a cigarette in his/her pocket. The Nurse documented that she took the items away and would leave a message for the Resident's family to not give these items directly to the Resident as they could be a fire hazard. During an interview on 8/31/22 at 9:18 A.M., Resident #19 said he/she went out to smoke four times per day and the staff held onto the cigarettes and lighter. Review of the clinical record indicated the Smoking Evaluation and Safety Screen was completed on 8/31/22 (survey start date). Review of the clinical record indicated a care plan for smoking was developed on 8/31/22. On 9/01/22 at 9:49 A.M., the surveyor observed the Resident smoking in the supervised smoke group. During an interview on 9/01/22 at 10:57 A.M., Nurse #1 said the Resident had been smoking since shortly after admission (end of June 2022). She said she had caught him/her several times with cigarettes or a lighter and had to provide education to the Resident and the Resident's family. During an interview on 9/01/22 at 1:49 P.M., the Regional Clinical Specialist said the smoking assessment and care plan for smoking weren't done until yesterday (8/31/22) and should have been done when the Resident began smoking. 5. For Resident #25 the facility failed to ensure that its staff performed a smoking safety evaluation and developed a smoking care plan on admission, when the Resident actively smoked. Resident #25 was admitted to the facility in March 2022 with diagnoses including Chronic Obstructive Pulmonary Disease ([CONDITION(S)]) and dependence on Oxygen. Review of the Physician's orders indicated an order, initiated 3/16/22, for Oxygen as needed at 2 liters/minute via nasal cannula to maintain oxygen above 90 percent for a diagnosis of [CONDITION(S)] (absence of oxygen to sustain bodily functions). Review of the Nursing progress notes indicated the following: -3/19/22 The Resident asked several staff to allow him/her to make his/her own cigarettes. The Resident was taken out to smoke at smoking times. -3/24/22 The Resident was rolling his/her cigarettes. -5/10/22 The Resident was constantly looking for someone to take him/her out to smoke and needed education on the smoking times. -5/11/22 The Resident was constantly looking for someone to take him/her outside to smoke and was educated about smoking times. -5/14/22 The Resident was anxious at times, wanting to go out and smoke. Review of the record indicated smoking evaluations were completed on 5/13/22 and 9/2/22. Further review indicated the Resident had been smoking since admission, but the record showed no evidence that a smoking safety evaluation was completed prior to 5/13/22. Review of the smoking care plan showed it was not initiated until 6/24/22 and indicated the Resident required supervision with smoking. During an interview on 9/7/22 at 4:14 P.M., the DON reviewed the assessments and care plan with the surveyor and said smoking assessments should be done on admission and then quarterly. She said the Resident had been an active smoker since admission in March 2022 but she was unable to find evidence that a smoking evaluation was completed prior to 5/13/22. She also said the care plan was not initiated until 6/24/22 but should have been initiated in March 2022. She said she could not speak to why the evaluation and care plan were not done on admission because she was not working at the facility at that time. 6. The facility failed to ensure that its staff safely secured medications on the Elmwood Unit (secured unit). Specifically, a) Medication was left unsecured at the bedside for one Resident (#136) and b) Leaving the medication room unlocked. Review of the Facility Assessment indicated the facility had two units and the Elmwood Unit houses more advanced cognitively impaired individuals. Review of the facility's Medication Storage Room/Medication Cart Policy, dated February 2018, indicated the following: -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -Storage for other medications will be limited to a locked medication room. a. For Resident #136 the facility failed to ensure its staff kept the environment free from hazards, regarding an inhaler that was not stored safely and securely, observed at the bedside of the Resident. Resident #136 was admitted to the facility in August 2022 with diagnoses including Interstitial Pulmonary/Lung Disease (ILD - groups of conditions that cause scarring of the lungs). On 8/31/22 at 8:36 A.M., the surveyor observed a [MEDICATION(S)] inhaler on the Resident's over the bed table. The Resident told the surveyor it was new and that he/she used it twice a day. On 9/01/22 at 8:26 A.M., the surveyor observed the Resident asleep in bed and the [MEDICATION(S)] inhaler on the over the bed table. On 9/01/22 at 9:40 A.M., Nurse #1 and the surveyor observed the [MEDICATION(S)] inhaler on the Resident's over the bed table. Nurse #1 said the Resident should not have the inhaler and she took it out of the Resident's room. Review of the August 2022 Physician's orders did not indicate an order to self-administer medications. b. On 9/01/22 at 9:45 A.M., the surveyor observed Activities Assistant (AA) #1 exit the medication room holding two cigarettes. The surveyor asked how she got into the medication room and AA #1 said the medication room was unlocked so she just went in to get the Resident's cigarettes for the smoking group. AA #1 said they often left the medication room unlocked because the Nurses knew they had to go in and out throughout the day to get the cigarettes. On 9/01/22 at 10:36 A.M., the surveyor observed the medication room was unlocked. On 9/01/22 at 1:21 P.M., the surveyor observed Nurse #1 enter the medication room without using a key. During an interview on 9/01/22 at 1:38 P.M., Nurse #1 said the medication room should always be locked.

Based on record review, observation and interview, the facility failed to ensure that its staff revised the care plan for one Resident (#5) out of 19 sampled residents after he/she sustained an unwitnessed fall on 8/29/22 and had a subsequent unwitnessed fall of similar circumstances on 8/31/22 that resulted in an impacted proximal humerus fracture [A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus)]. Findings include: Resident #5 was admitted to the facility in November 2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, dated 8/17/22, indicated Resident #5 had severe cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS assessment also indicated the Resident required supervision with one assist for toileting and transfers. Review of the Nursing Note, dated 8/29/22, indicated Resident #5 had a fall in his/her room next to the bed. He/she stated that he/she was not going anywhere. He/she also said they, hit their head a little. Review of the Fall Incident Report & Investigation, dated 8/29/22, indicated that at 10:45 P.M., Resident #5 was observed lying on the floor beside the bed, close to the wall and said he/she was not going anywhere, he/she just slipped off the bed. The Incident Report was incomplete with blank areas. There was no documentation of immediate interventions or that the care plan was updated. Review of the current comprehensive care plan for falls, indicated that no new interventions were subsequently added after the first fall on 8/29/2022. On 8/31/22 at 9:33 A.M., the surveyor observed Resident #5 in bed with a bruise to the right side of his/her head. During an interview on 8/31/22 at 9:36 A.M., Resident #5 said he/she fell out of bed last night. Review of the Progress Note, dated 8/31/22, indicated that the Resident was found around 2:20 A.M. in his/her room on the floor laying in a supine position at the end of the bed. The Nurse documented that a lump was noted on the upper right forehead and the Resident was guarding the right upper extremity (arm) and saying that it hurt. The Resident was sent to the emergency room (ER) for evaluation. Review of a subsequent Progress Note, dated 8/31/22, indicated the Resident had returned from the ER with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/02/22 at 2:33 P.M., The surveyor and the Director of Nurses (DON) discussed how the unwitnessed falls on 8/29/22 and on 8/31/22 occurred under similar circumstances. When the surveyor asked the DON what interventions were put in place after the fall on 8/29/22 to prevent any further falls, the DON said that no new interventions or care plan revisions were initiated after the first fall. She said following the fall on 8/31/22 the Resident was sent to the ER where a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ***Refer to F689

Based on observations, records reviewed, and interviews, for one of five sampled residents (Resident #5), the Facility failed to ensure nursing staff implemented and followed interventions indicated in his/her comprehensive plan of care when nursing staff failed to apply his/her Juzo wrap compression stockings (leg wraps used to treat swelling), which resulted in him/her experiencing pain in his/her legs that effected his/her ability to stand and walk. Findings include: The Facility's Policy, titled, Resident Assessment and Care Plan, dated, 4/2015, indicated, the Interdisciplinary Team would develop a comprehensive Care Plan for each resident that included measurable objectives and timelines to accommodate preferences, and special need identified in the resident assessment. Resident #5 was admitted to the Facility in August 2019, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's medical record indicated there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Care Plan, dated as revised 3/22/22, indicated he/she had [CONDITION(S)] in both lower extremities, and interventions included Juzo wraps compression stockings as ordered and as allowed. Review of the Grievance Sheet, dated, 4/07/22, indicated Resident #5 said his/her legs were not being wrapped by nursing staff every day, and the follow up plan of action was for the therapy department to wrap his/her legs every morning. Review of Resident #5's Treatment Administration Record (TAR), dated April 1st through 13 th, 2022, indicated eight out of 13 mornings, the Treatment Sheet for Resident #5's Juzo wraps was left blank (indicating treatment not completed), and five out of 13 mornings, the nurse's initials were circled to indicate the treatment was not administered. Further review of the TAR indicated there was no documentation to support the reason the treatment was not done. For 11 out of 12 night shifts, the Treatment Sheet to remove his/her Juzo wraps was left blank, and one night shift, the nurse's initials were circled to indicate the treatment was not administered, however there was no documentation to support the reason the treatment was not done. During an interview on 4/14/22 at 10:30 A.M., Resident #5 said he/she had complained several times to nursing staff and the Administrator that his/her Juzo wraps were not applied daily, and said it had been well over a week since his/her legs were last wrapped. Resident #5 said his/her legs were very painful, and the swelling effected his/her ability to stand and walk. The Surveyor observed, during the interview, Resident #5's legs did not have the Juzo wraps on them, and his/her legs appeared swollen with the skin taught and shiny. During interview on 4/14/22 at 3:00 P.M., Nurse #2 said she was told Resident #5's Juzo wraps were going to be done by therapy, said she had noticed the wraps were not on his/her legs every day. Nurse #2 said she did not have the time needed to apply the wraps due to short staffing. During interview on 4/14/22 at 2:24 P.M., The Director of Rehabilitation Services said Resident #5 had not received rehabilitation services since October 2021, said his/her application of his/her leg wraps were not a therapy intervention. During interview on 4/14/22 at 3:32 P.M., the Administrator said she had personally spoken with and asked one of the therapists to apply Resident #5's Juzo wraps every morning, but said that therapist had been on vacation, and had not communicated to his peers to apply Resident #5's Juzo wraps in his absence.

Based on observations, records reviewed, and interviews, for four of five sampled residents, (Resident #1, #2, #3 and #5), the Facility failed to ensure treatments and services provided by nursing were conducted in accordance with professional standards of practice. 1) Resident #1, staff failed to notify his/her physician or nurse practitioner of blood laboratory work results, specifically International Ratio (INR), which is used to determine effectiveness of [MEDICATION(S)] (blood thinner) dosages, resulting in missed [MEDICATION(S)] doses and INR levels that were not within therapeutic range. 2) Resident #2, nursing staff failed to obtain and document daily weights as ordered by Nurse Practitioner #1, when he/she had a 13.2 pound weight gain over a four month period 3) Resident #3, nursing staff failed to reconcile his/her medications with the physician upon readmission from the Hospital, resulting in physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4) Resident #5, during the dates of 4/01/22 through 4/14/22, staff failed to ensure his/her Juzo wraps (for swelling) were applied to his/her legs, which resulted in Resident #5 experiencing pain in his/her legs and difficulty ambulating. Findings include: 1) The Facility's Policy, titled, Anticoagulation ([MEDICATION(S)]) Therapy, dated 01/2016, indicated the administration of [MEDICATION(S)] therapy would be done by Physician order, and dosing would be done by monitoring INR values, the therapeutic range would be determined by the physician and/or nurse practitioner, the nurse would obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In the event that the INR is 4 or greater, the test should be repeated immediately, and the physician should be contacted for orders. The Facility's Policy, titled, Physician Notification (Laboratory, X-Rays, and Other Diagnostic Services), dated, 11/2016, indicated staff would provide or obtain laboratory and other diagnostic services ordered by the physician or nurse practitioner and report results to the physician or nurse practitioner. Resident #1 was admitted to the Facility in March of 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record indicated a he/she had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record indicated there was no documentation to support that the INR laboratory level result from 3/13/22 was reported to his/her provider until 3/14/22. -Review of Resident #1's Medication Administration Records (MARs) for the months of March 2022 and April 2022 indicated there were dedicated spaces for the target INR per MD, all of which were left blank. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - 3/14/22, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - 3/15/22, lab report of an INR level of 0.96. There was no documentation to support that the INR was reported to his/her provider. - 3/17/22, lab report of an INR level of 0.97. There was no documentation to support that the INR was reported to his/her provider. - 3/18/22, an INR level of 0.92, and [MEDICATION(S)] 5 mg daily, obtain INR level on 3/21/22. -There was no documentation to support that there was an INR level drawn on 3/21/22. -There was no documentation to support that Resident #1 received [MEDICATION(S)] on 3/21/22 or 3/22/22. - 3/23/22 [MEDICATION(S)] 5 mg x 1 dose, and obtain INR level on 3/24/22. - 3/24/22, an INR level of 1.07, administer [MEDICATION(S)] 7 mg and repeat INR level on 3/25/22. - 3/25/22, an INR level of 1.21. There was no documentation to support that the INR was reported to his/her provider until 3/26/22, There was also no documentation to support an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - 3/26/22, administer [MEDICATION(S)] 7 mg for two days, and obtain INR level on 3/28/22. - 3/28/22, an INR level of 1.03, and administer [MEDICATION(S)] 10 mg, repeat INR level on 3/29/22. -There was no documentation to support an INR level was obtained on 3/29/22, or that Resident #1 received [MEDICATION(S)] on 3/29/22. - 3/30/22, a STAT physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -There was no documentation to support that the INR level was done on 3/31/22, and no documentation to support Resident #1 was administered, or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - 4/01/22, an INR level of 1.83, administer [MEDICATION(S)] 7 mg on 4/01/22, repeat INR level on 4/02/22 and 4/03/22. - 4/02/22, an INR level of 1.62, administer [MEDICATION(S)] 10 mg. - 4/03/22, an INR level of 3.31, hold [MEDICATION(S)] on 4/03/22, and repeat INR level on 4/04/22. - 4/04/22, an INR level of 4.30. There was no documentation to support that the INR was reported to his/her provider, and no documentation to support a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated there was no documentation to support the INR was repeated. - 4/05/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - 4/06/22, an INR level of 1.49, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 4/14/22 at 3:00 P.M., Nurse #2 said there were several times she would come in after being off for a day or two and noticed there was no [MEDICATION(S)] dose order on Resident #1's [MEDICATION(S)] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 said she would report the INR and obtain [MEDICATION(S)] orders, but said they were not obtained on the date the INR was drawn, and Resident #1 was not administered [MEDICATION(S)] daily. During interview on 4/13/22, Nurse Practitioner (NP) #1 said Resident #1's INRs were not reported to her by nursing staff in a timely manner, and as a result, his/her INR was subtherapeutic (low) due to missed [MEDICATION(S)] doses, and said INR results should be reported as soon as they are available. NP #1 said the therapeutic range for for Resident #1's INR levels was 2.0 to 3.0 (between those levels). NP #1 said the risks involved with missed [MEDICATION(S)] doses and a subtherapeutic INR level include blood clots and stroke, and the risks of a supratherapeutic (elevated) INR level included uncontrolled bleeding. 2) The Facility policy, titled, Weights, dated, 8/2015, indicated, residents would be weighed monthly, unless clinically indicated, and documented in the resident's medical record and/or weight book. Resident #2 was admitted to the Facility in November 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Nutritional Care Plan, dated, 3/09/22, indicated, staff would monitor and evaluate Resident #2's weight and weight changes. Review of Resident #2's medical record indicated, his/her body weight was measured on 01/01/22 at 161.6 pounds, and on 4/01/22 his/her body weight was measured at 174.8 pounds, a weight gain of 13.2 pounds, or 7.5%. Further review of Resident #2's medical record indicated there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to support that Resident #2's weights were obtained for the dates of 4/02/22 through 4/04/22, or at all after 4/01/22. During interview on 4/14/22 at 1:10 P.M., the Director of Nurses said Resident #2's weights were not done as ordered, and said the weights should be documented. 3) The Facility Policy, titled, Admission of a Resident, dated, 4/2015, indicated staff would perform a medication reconciliation, and confirm medication and treatment orders with the resident's attending physician and/or covering MD or Nurse Practitioner. Resident #3 was admitted to the Facility in April, 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note, titled Nursing Admission Note, dated 3/31/22, that indicated, Resident #3 returned to the Facility at 7:00 P.M., following a Hospital admission. Review of Resident #3's Hospital Discharge Summary, dated 3/31/22, that indicated he/she was admitted to the Hospital due to [CONDITION(S)], urinary tract infection, and [CONDITION(S)] infarction (heart attack). Further review of the Discharge Summary indicated Resident #3 had new MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)], 1 Gram via IV every 24 hours for three days, (last administered at the Hospital on 3/31/22 at 11:11 A.M.) -[MEDICATION(S)], 7.5 milligrams (mg), by mouth, every evening, (last administered at the Hospital on 3/30/22 at 11:43 P.M.) -[MEDICATION(S)] 12.5 mg, by mouth, every 12 hours, (last administered at the Hospital on 3/31/22 at 8:29 A.M.) -[MEDICATION(S)] 7 units subcutaneous, every bedtime, (last administered at the Hospital on 3/30/22 at 11:43 P.M.) However, review of Resident #3's Medical Record, indicated he/she had Nurse Practitioner's orders, dated, 4/01/22, timed, 5:00 P.M., therefore, orders were not obtained until 22 hours after he/she was readmitted to the Facility. Further review of the MARs indicated there was no documentation to support that for two of the medications, which Resident #3 had exiting physicians orders for ([MEDICATION(S)] and [MEDICATION(S)]) that nursing obtained new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MARs indicated there was no documentation to support Resident #3 was administered [MEDICATION(S)] 12.5 mg, or [MEDICATION(S)] 7 units, as indicated in the Hospital Discharge Summary. During interview on 4/15/22 at 11:05 A.M., Nurse Practitioner (NP) #1 said that on 4/01/22, she happened to be rounding on the unit, and noticed that Resident #3 had returned form the Hospital. NP #1 said she had not been notified on 3/31/22 of Resident #3's return from the Hospital. NP #1 said she then reviewed the Hospital Discharge Summary, noticed the Discharge orders for [MEDICATION(S)], [MEDICATION(S)], and change of doses for [MEDICATION(S)] and [MEDICATION(S)], and said she wrote orders for those medications at that time. During interview on 4/14/22 at 4:10 P.M., the Director of Nurses said Resident #3's Hospital Discharge orders should have been reviewed and reconciled upon readmission on 3/31/22, and said nursing should have obtained new physician orders. 4) Resident #5 was admitted to the Facility in August 2019, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Treatment Administration Record (TAR) indicated he/she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Care Plan, dated as revised 3/22/22, indicated he/she had [CONDITION(S)] in both lower extremities, and interventions included to apply Juzo wraps compression stockings as ordered and as allowed. Review of the Grievance Sheet, dated, 4/07/22, indicated Resident #5 said his/her legs were not being wrapped by nursing staff every day, and the follow up plan of action was for the therapy department to wrap his/her legs every morning. Review of Resident #5's TAR, dated April 1st-13th, 2022, indicated eight out of 13 mornings, the TAR for Resident #5's Juzo wraps were left blank, and five out of 13 mornings, the nurse's initials were circled to indicate the treatment was not administered. However there was no documentation to support the reason the treatment was not done. For 11 out of 12 night shifts, the TAR to remove his/her Juzo wraps was left blank, and one night shift, the nurse's initials were circled to indicate the treatment was not administered, however there was no documentation to support the reason the treatment was not done. During an interview on 4/14/22 at 10:30 A.M., Resident #5 said he/she had complained several times to nursing staff and the Administrator that his/her Juzo wraps were not applied daily, and said it had been well over a week since his/her legs were last wrapped. Resident #5 said his/her legs were very painful, and the swelling effected his/her ability to stand and walk. The Surveyor observed, during the interview, Resident #5's legs did not have the Juzo wraps on them, and his/her legs appeared swollen with the skin taught and shiny. During interview on 4/14/22 at 3:00 P.M., Nurse #2 said she was told Resident #5's Juzo wraps were going to be done by therapy, said she had noticed the wraps were not on every day, and said she did not have the time needed to apply the wraps due to short staffing. During interview on 4/14/22 at 2:24 P.M., The Director of Rehabilitation Services said Resident #5 had not received rehabilitation services since October 2021, said application of Resident #5's leg wraps were not a therapy intervention. During interview on 4/14/22 at 3:32 P.M., the Administrator said she had personally spoken to and asked one of the therapists to apply Resident #5's Juzo wraps every morning, but that therapist had been on vacation, and had not communicated to his peers to apply Resident #5's Juzo wraps in his absence.

Based on records reviewed and interviews, for the Facility failed to ensure there was sufficient nursing staff to meet the care needs of every resident, when, for at least a two week period of time in April 2022, there were not enough licensed nurses scheduled to meet the nursing to resident ratios, as required. As a result of the Facility's significant nursing staff shortage, for four of five sampled residents (Resident #1, Resident #2, Resident #4, and Resident #5), nursing staff were unable to provide care and services necessary for their medical well being. 1) Resident #1, blood laboratory work results, specifically International Ratio (INR) timely, which is used to determine effectiveness of [MEDICATION(S)] (blood thinner) dosages, where not communicate to timely his/her provided resulting in missed [MEDICATION(S)] doses and INR levels that were not within therapeutic range. 2) Resident #2, nursing staff failed to obtain and document daily weights as ordered by Nurse Practitioner #1, when he/she had a 13.2 pound weight gain over a four month period 3) Resident #3, his/her medications were not reconciled with the physician upon readmission from the Hospital, resulting in physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4) Resident #5, during the dates of 4/01/22 through 4/14/22, staff failed to ensure his/her Juzo wraps (for swelling) were applied to his/her legs, which resulted in Resident #5 experiencing pain in his/her legs and difficulty ambulating. Findings include: Review of Facility's (as worked) Staffing Schedules, dated 3/31/22 through 4/13/22, indicated the staffing patterns for nurse to resident ratios during the referenced time period were the following: - 3/31/22, 86 residents, 6.7 nurses scheduled for 24 hours, average 38.5 residents per nurse. - 4/01/22, 89 residents, 8 nurses scheduled for 24 hours, average 33.4 residents per nurse. - 4/02/22, 89 residents, 5.5 nurses scheduled for 24 hours, average 48.5 residents per nurse. - 4/03/22, 89 residents, 6 nurses scheduled for 24 hours, average 44.5 residents per nurse. - 4/04/22, 87 residents, 5.5 nurses scheduled for 24 hours, average 47.5 residents per nurse. - 4/05/22, 88 residents, 6.3 nurses scheduled for 24 hours, average 42 residents per nurse. - 4/06/22, 89 residents, 7.5 nurses scheduled for 24 hours, average 35.6 residents per nurse. - 4/07/22, 89 residents, 6.8 nurses scheduled for 24 hours, average 39.3 residents per nurse. - 4/08/22, 89 residents, 5 nurses scheduled for 24 hours, average 53.5 residents per nurse. - 4/09/22, 89 residents, 5 nurses scheduled for 24 hours, average 53.5 residents per nurse. - 4/10/22, 89 residents, 6 nurses scheduled for 24 hours, average 44.5 residents per nurse. - 4/11/22, 87 residents, 5.5 nurse scheduled for 24 hours, average 47.5 residents per nurse. - 4/12/22, 85 residents, 5 nurses scheduled for 24 hours, average 51 residents per nurse. - 4/13/22, 86 residents, 6 nurses scheduled for 24 hours, average 43 residents per nurse. 1) The Facility's Policy, titled, Anticoagulation ([MEDICATION(S)]) Therapy, dated 01/2016, indicated the administration of [MEDICATION(S)] therapy would be done by Physician order, and dosing would be done by monitoring INR values, the therapeutic range would be determined by the physician and/or nurse practitioner, the nurse would obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In the event that the INR is 4 or greater, the test should be repeated immediately, and the physician should be contacted for orders. The Facility's Policy, titled, Physician Notification (Laboratory, X-Rays, and Other Diagnostic Services), dated, 11/2016, indicated staff would provide or obtain laboratory and other diagnostic services ordered by the physician or nurse practitioner and report results to the physician or nurse practitioner. Resident #1 was admitted to the Facility in March of 2022, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record indicated a he/she had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record indicated there was no documentation to support that the INR laboratory level result from 3/13/22 was reported to his/her provider until 3/14/22. Further review of Resident #1's medical record indicated: -Review of Resident #1's Medication Administration Records (MARs) for the months of March 2022 and April 2022 indicated there were dedicated spaces for the target INR range per MD, all of which were left blank. Review of Resident #1's MAR and lab reports for his/her INR's, indicated nursing documentation was as follows: - 3/14/22, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - 3/15/22, an INR level of 0.96. There was no documentation to support that the INR was reported to his/her provider. - 3/17/22, an INR level of 0.97. There was no documentation to support that the INR was reported to his/her provider. - 3/18/22, an INR level of 0.92, and [MEDICATION(S)] 5 mg daily, obtain INR level on 3/21/22. -There was no documentation to support that there was an INR level drawn on 3/21/22. -There was no documentation to support that Resident #1 received [MEDICATION(S)] on 3/21/22 or 3/22/22. - 3/23/22 [MEDICATION(S)] 5 mg x 1 dose, and obtain INR level on 3/24/22. - 3/24/22, an INR level of 1.07, administer [MEDICATION(S)] 7 mg and repeat INR level on 3/25/22. - 3/25/22, an INR level of 1.21. There was no documentation to support that the INR was reported to his/her provider until 3/26/22, and no documentation to support an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - 3/26/22, administer [MEDICATION(S)] 7 mg for two days, and obtain INR level on 3/28/22. - 3/28/22, an INR level of 1.03, and administer [MEDICATION(S)] 10 mg, repeat INR level on 3/29/22. -There was no documentation to support an INR level was obtained on 3/29/22, or that Resident #1 received any [MEDICATION(S)] on 3/29/22. - 3/30/22, a STAT physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -There was no documentation to support that the INR level was done on 3/31/22, and no documentation to support Resident #1 was administered, or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - 4/01/22, an INR level of 1.83, administer [MEDICATION(S)] 7 mg on 4/01/22, repeat INR level on 4/02/22 and 4/03/22. - 4/02/22, an INR level of 1.62, administer [MEDICATION(S)] 10 mg. - 4/03/22, an INR level of 3.31, hold [MEDICATION(S)] on 4/03/22, and repeat INR level on 4/04/22. - 4/04/22, an INR level of 4.30. There was no documentation to support that the INR was reported to his/her provider, and no documentation to support a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated there was no documentation to support the INR was repeated. - 4/05/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - 4/06/22, an INR level of 1.49, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 4/14/22 at 3:00 P.M., Nurse #2 said there were several times she would come in after being off for a day or two and notice there was no [MEDICATION(S)] dose on Resident #1's [MEDICATION(S)] Medication Administration Record (MAR), and that the INR labs reports had not been reported to Nurse Practitioner #1 or Resident #1's physician. Nurse #1 said she would report the INR and obtain [MEDICATION(S)] orders, but said they were not obtained on the date the INR was drawn, and Resident #1's [MEDICATION(S)] doses were missing on several occasions. Nurse #2 said nursing staff were so busy with the medication pass and treatments for close to 40 residents that they would miss reporting the INRs and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 4/13/22, Nurse Practitioner (NP) #1 said Resident #1's INRs were not reported to her by nursing staff in a timely manner, and as a result, his/her INR was subtherapeutic (low) due to missed [MEDICATION(S)] doses, and said INR results should be reported as soon as they are available. NP #1 said the risks involved with missed [MEDICATION(S)] doses and a subtherapeutic (low) INR level include blood clots and stroke, and the risks of a supratherapeutic (elevated) INR level included uncontrolled bleeding. NP #1 said the therapeutic range for INR levels was 2.0 to 3.0. 2) The Facility policy, titled, Weights, dated, 8/2015, indicated, residents would be weighed monthly, unless clinically indicated, and documented in the resident's medical record and/or weight book. Resident #2 was admitted to the Facility in November 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Nutritional Care Plan, dated, 3/09/22, indicated, staff would monitor and evaluate Resident #2's weight and weight changes. Review of Resident #2's medical record indicated, his/her body weight was measured on 01/01/22 at 161.6 pounds, and on 4/01/22 his/her body weight was measured at 174.8 pounds, a weight gain of 13.2 pounds, or 7.5%. Further review of Resident #2's medical record indicated there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to support that Resident #2's weights were obtained for the dates of 4/02/22 through 4/04/22, or at all after 4/01/22. During interview on 4/14/22 at 1:10 P.M., the Director of Nurses said Resident #2's weights were not done as ordered, and said the weights should have been obtained and documented. 3) The Facility's Policy, titled, Admission of a Resident, indicated, staff would obtain sufficient, accurate information that would be required to properly care for the resident, including an admission evaluation. The Facility's Job Description for the Director of Nurses, signed and dated by the Director of Nurses on 11/08/21, indicated the Director of Nurses would audit newly admitted /readmitted residents by bringing the medical record to the next morning report. The record would be reviewed and audited through the assessments, care plan, and admission nurses notes. Resident #4 was admitted to the facility on [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's medical record indicated there was no documentation to support that a nursing admissions assessment, including skin assessment, had been done as of 4/13/22, 13 days after he/she was admitted to the Facility. Further review of Resident #4's medical record indicated there was no documentation to support that any skin assessment had been done, and no documentation to support any nurses' notes of any kind. During interview on 4/13/22 at 1:42 P.M., the Director of Nurses (DON) said the admissions assessment was not done for Resident #4, and said there were no nurse progress notes for Resident #4, The DON said the admissions assessment should have been done within 48 hours of admission, and there should have been an admission note completed. The DON said she was unable to complete the audits of new admissions because she was assigned to work as a charge nurse on the units. 4) Resident #5 was admitted to the Facility in August 2019, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Treatment Administration Record (TAR) indicated he/she had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Care Plan, dated as revised 3/22/22, indicated he/she had [CONDITION(S)] in both lower extremities, and interventions included to apply Juzo wraps compression stockings as ordered and as allowed. Review of the Grievance Sheet, dated, 4/07/22, indicated Resident #5 said his/her legs were not being wrapped by nursing staff every day, and the follow up plan of action was for the therapy department to wrap his/her legs every morning. Review of Resident #5's TAR, dated April 1st-13th, 2022, indicated eight out of 13 mornings, the TAR for Resident #5's Juzo wraps were left blank, and five out of 13 mornings, the nurse's initials were circled to indicate the treatment was not administered. However there was no documentation to support the reason the treatment was not done. For 11 out of 12 night shifts, the TAR to remove his/her Juzo wraps was left blank, and one night shift, the nurse's initials were circled to indicate the treatment was not administered, however there was no documentation to support the reason the treatment was not done. During an interview on 4/14/22 at 10:30 A.M., Resident #5 said he/she had complained several times to nursing staff and the Administrator that his/her Juzo wraps were not applied daily, and said it had been well over a week since his/her legs were last wrapped. Resident #5 said his/her legs were very painful, and the swelling effected his/her ability to stand and walk. The Surveyor observed, during the interview, Resident #5's legs did not have the Juzo wraps on them, and his/her legs appeared swollen with the skin taught and shiny. During interview on 4/14/22 at 3:00 P.M., Nurse #2 said she was told Resident #5's Juzo wraps were going to be done by therapy, said she had noticed the wraps were not on every day, and said she did not have the time needed to apply the wraps due to short staffing. During interview on 4/14/22 at 2:24 P.M., The Director of Rehabilitation Services said Resident #5 had not received rehabilitation services since October 2021, said application of Resident #5's leg wraps were not a therapy intervention. During interview on 4/14/22 at 3:32 P.M., the Administrator said she had personally spoken to and asked one of the therapists to apply Resident #5's Juzo wraps every morning, but said that therapist had been on vacation, and had not communicated to his peers to apply Resident #5's Juzo wraps in his absence.

Based on observations, record review and staff interview, the facility staff failed to implement effective interventions to prevent hazards and risks, and to ensure the environment was free from accident hazards for one sampled resident (#46) out of a total sample of 18 residents. Findings include: Resident #46 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/5/17 indicated that the resident had modified independence for cognitive skills for daily decision making. The resident required extensive assist of two for transfers and bed mobility. Further review of the MDS indicated the resident had two or more falls with injury since the previous MDS. Review of the medical record indicated the resident had 8 falls between 5/25/17 thru 1/13/18. Review of the 6/4/17 1:45 P.M., unwitnessed fall report indicated the resident slid out of his/her wheelchair in the hallway. No injuries noted from this fall. The intervention was to encourage rest periods in wheelchair and to redirect/provide activities when husband/family not in to visit. Review of the 10/18/17 9:00 A.M. witnessed fall report indicated the resident had a witnessed fall in the Welcome Room on the unit. The resident was sent to the hospital for evaluation and treatment. The resident sustained [REDACTED]. The intervention put in place after this fall was to offer frequent rest periods. Review of the 11/16/17 6:15 P.M. witnessed fall report indicated the resident was ambulating independently in the hallway and tripped over a mechanical lift protruding out of a resident's room into the hallway that was left by staff. The resident sustained [REDACTED]. The intervention put in place after the fall was to educate staff on hallways to remain clutter free. Review of the 11/25/17 4:55 P.M. witnessed fall report indicated the resident was ambulating in the hallway and lost his/her balance and fell on to right side. The fall investigation indicated the hallway lights were dimmed to night time. He/she was sent to the hospital for evaluation and treatment of [REDACTED]. During an observation on 2/1/18 at 8:09 A.M., the Surveyor observed a mechanical lift jutting out into the hallway from room [ROOM NUMBER] on the Elmwood Unit. In addition, the linen delivery cart was on the left side of the hall and two linen carts were on the right side of the hall. The mechanical lift was there approximately 5 minutes resulting in a fall/trip hazard. The Surveyor observed a resident ambulating in the hallway and the resident needed to negotiate around the carts and the lift. During an observation on 2/1/18 at 8:15 A.M., the Surveyor observed two staff members remove the 3 compartment linen cart from the tub room (to ambulate a resident with assist of 2 ) into the tub room and left the linen cart in the middle of the 4 hall intersection in front of the nurses station. In addition, the Surveyor observed a resident ambulating independently and turned sideways to negotiate around the linen cart. During an interview on 2/2/18 at 12:45 P.M., the Director of Nurses (DON) said the intervention put in place after the 10/18/17 was the same as after the 6/4/17 fall and when questioned about the similarity, she said the repeat intervention was a reinforced intervention since the resident did not have a fall within a 4 month span. In addition, when questioned as to why hall lights were dimmed at 4:55 P.M. when resident fell on [DATE], DON was unable to provide a reason. During an interview on 2/1/18 at 8:17 A.M., the Staff Development Coordinator could not provide any documentation to support that staff education was provided after the 11/16/17 and 11/25/17 falls. She said the education was most likely given to staff that was present at the time of the falls but she was unable to provide any inservice/education sign in sheets to the surveyor.

Based on records reviewed and interviews, for 1 of 4 sampled residents (Resident #2), the Facility failed to notify the Physician of Resident #2's weight loss, progressive decline in food intake after 03/15/16, signs and symptoms of insufficient fluid intake and decreased fluid intake on 03/18/16. Findings include: 1. The Admission Nursing assessment dated [DATE] indicated that Resident #2 weighed 115 lbs (pounds). The Medication Administration Records for February and March 2016 indicated that Resident #2 was to be weighed daily. Resident #2's recorded weights included: - 112.4 lbs. (pounds) on 02/20/16, - 100.6 lbs on 02/21/16, - 111.2 lbs on 02/22/16 and 02/23/16, - 109.6 lbs on 02/25/16, - 109 lbs on 02/27/16, - 106.9 lbs on 02/28/16, - 106.4 lbs on 02/29/16, - 103 lbs on 03/01/16, - 103.6 lbs on 03/04/16, - 97.8 lbs on 03/07/16, - 98.6 lbs on 03/09/16, - 98.7 lbs on 03/10/16, - 95 lbs on 03/12/16, - 94.8 lbs on 03/13/16 through 03/15/16, - 94.6 lbs on 03/17/16, - 94 lbs on 03/18/16 and 03/19/16, and - 91 lbs on 03/20/16. The Minimum Data Set ((MDS) dated [DATE] indicated that Resident #2 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 60 days. The MDS indicated that Resident #2 was not on a physician-prescribed weight loss program. The Nutrition Note dated 02/29/16 indicated that Resident #2 had a 5.4% weight loss in a week. The Nurses Progress Note dated 03/01/16 at 3:00 P.M. indicated that the Physician was updated on Resident #2's weights via written notation on the communication board, and nursing was awaiting review by the Physician. The Surveyor interviewed the Dietician at 2:30 P.M. on 03/25/16. The Dietician said she was not notified of the 9 lbs weight loss between 02/19/16 and 02/21/16. There was no documentation at the time of survey that the Physician was notified of Resident #2's weight loss until 03/15/16. 2. The Resident Daily Flow Sheet dated March 2016 indicated a decline in Resident #2's breakfast and dinner meal intake. The Flow Sheet indicated that Resident #2's breakfast intake declined from 75% to 50%; and for dinner, declined from 75% to 50%. The Flow Sheet indicated that between 03/15/16 and 03/17/16, Resident #2's breakfast and lunch intake declined to 25%. The Flow Sheet indicated that on 03/15/16, Resident #2's dinner intake declined to 25%. The Physician's Note dated 03/15/16 at 3:41 P.M. indicated Resident #2 had some decrease in oral intake. The Nurse Practitioner (NP) Note dated 03/21/16 at 3:03 P.M. indicated that Resident #2 was being see due to failure to thrive (a term used to indicate insufficient weight gain or inappropriate weight loss), poor appetite and lack of motivation, and a weight loss of 12 lbs since admission. The Dietician said she was not notified of Resident #2's decline in oral intake. There was no documentation at the time of survey that the Physician was notified of Resident #2's decline in oral intake prior to the Physician's Progress Note dated 03/15/16, or of the continued decline in oral intake prior to the NP Note dated 03/21/16. The Facility Transfer Form dated 03/21/16 indicated that Resident #2 was transferred to Hospital #2 on 03/21/16 at Family Member #1's request for further evaluation and treatment of [REDACTED]. 3. The Dehydration Evaluation dated 02/19/16 indicated that Resident #2 was at risk for dehydration. The Evaluation indicated that Resident #2 had the following: dry mucous membrane, cracked lips/mouth/tongue, and a new finding of a pulse over 100. The Evaluation also indicated that the Physician and Resident #2's responsible party were notified. The Nutrition assessment dated [DATE] indicated that there was an alteration in nutrition related to bilateral lower extremity [MEDICAL CONDITION] (swelling) and diuretic use (a medication to decrease the amount of fluid in the body). The Assessment indicated that Resident #2's daily fluid requirements were 1270 cubic centimeters (cc). The Intake and Output (I&O) Records indicated that Resident #2's fluid intake was 1800 cc on 03/16/16, 1560 cc on 03/17/16, 980 cc on 03/18/16, and on 03/19/16 was incomplete for 2 of 3 shifts and indicated that Resident #2's fluid intake was 120 cc on the 3:00 P.M. to 11:00 P.M. shift. The Dietician said that the I&O records dated 03/18/16 and 03/19/16 indicated that Resident #2 had not reached his/her adequate hydration needs. Hospital #2's documentation indicated that Resident #2 was admitted on [DATE]. There was no documentation at the time of survey that the Physician was notified of Resident #2's decline in fluid intake, and Resident #2 continued to receive his/her diuretic.

Based on records reviewed and interviews, for one of 4 sampled residents (Resident #2), the Facility failed to ensure that Resident #2 maintained acceptable parameters of nutritional status, and to provide adequate interventions and evaluate their effectiveness to prevent further significant weight loss. Resident #2 sustained a 24 lb (pound) weight loss in a 30-day period, and was admitted to Hospital #2 with a [DIAGNOSES REDACTED]. Findings include: Resident #2's [DIAGNOSES REDACTED]. The Primary Physician's Note dated 07/17/15 indicated that Resident #2 had a history of [REDACTED]. The Admission Nursing assessment dated [DATE] indicated Resident #2 had a history of [REDACTED]. The Facility's Food First - Nutrition Policy dated April 2015 indicated that: .facility to assess all residents/patients and identify those residents/patients at risk for weight loss and provide appropriate interventions according to the physical and mental abilities and his/her wishes. The Policy's Practice Guidelines indicated that all weight loss or gain of 3 lbs or more required a reweigh for verification; If a significant weight loss or gain, defined as greater than 5% in 30 days or greater than 10% in 6 months, is identified, the interdisciplinary team (IDT), dietician, physician, and family were to be notified; and, all residents with a significant weight loss were to be reviewed by the IDT and the resident/responsible party and interventions implemented as appropriate and were monitored weekly. 1. The Medication Administration Records (MARs) for February and March 2016 indicated that Resident #2's weight decreased or increased by 3 or more pounds from the prior weight on 02/21/16, 02/22/16, 03/01/16, 03/07/16, 03/12/16, and 03/20/16. The Surveyor interviewed the Dietician at 2:30 P.M. on 03/25/16. The Dietician said that Resident #2 was not reweighed in accordance with the Facility's policy. There was no documentation at the time of survey that Resident #2 was reweighed in accordance with Facility policy after documented weight losses or gains of 3 lbs or more. 2. The physician's orders [REDACTED].#2 was to be weighed daily, received a regular diet and a snack at bedtime, and was administered [MEDICATION NAME] (a medication used to decrease the amount of fluid in the body). The Nutrition and Hydration care plan dated 2/16 indicated that Resident #2 was prescribed a house diet, and staff were to monitor daily weights. The Nutritional assessment dated [DATE] indicated that the goals for Resident #2 included to promote a weight between 105 and 115 lbs. The Assessment indicated that Resident #2's admission weight was 115 lbs, and the Dietician questioned such a large weight loss in one day (from 112.4 lbs on 02/20/16 to 100.6 lbs on 02/21/16). The Dietician said she was not notified of Resident #2's weight loss between 02/19/16 and 02/21/16. The Minimum Data Set ((MDS) dated [DATE] indicated that Resident #2 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 60 days. The MDS indicated that Resident #2 was not on a physician-prescribed weight loss program. The Nutrition Note dated 02/29/16 indicated that Resident #2 had a 5.4% weight loss in a week. The Note indicated that recommendations for Super cereal (cereal with added nutrients and calories to prevent or treat undernutrition) to be added at breakfast and a 7 gram Protein Supplement twice a day were made. The Nurses Progress Note dated 03/01/16 at 3:00 P.M. indicated that the Physician was updated on Resident #2's weights via written notation on the communication board, and nursing was awaiting review by the Physician. The Update Order dated 03/02/16 indicated that Super cereal and protein supplement were added to Resident #2's diet. There was no documentation at the time of survey that daily weights were done as ordered on [DATE], 03/03/16, 03/05/16, 3/6/16, 03/08/16, 03/11/16, 03/16/16, or 03/21/16. The MAR for March 2016 indicated that on 03/20/16, Resident #2 weighed 91 lbs (a loss of 12lbs (11.7%) in 20 days, 24 lbs (20.9%) in 30 days). The Facility Transfer Form dated 03/21/16 indicated that Resident #2 was transferred to Hospital #2 on 03/21/16 at Family Member #1's request. Hospital #2's records indicated that Resident #2's admission [DIAGNOSES REDACTED]. There was no documentation at the time of survey that the Physician was notified of Resident #2's weight loss prior to, or continued weight loss after, 03/01/16. 3. The Nutritional assessment dated [DATE] indicated that the goals for Resident #2 included a greater than 75% meal intake, that a meal intake of 50% was needed to maintain Resident #2's weight. The Resident Daily Flow Sheet for February 2016 indicated that Resident #2 had a decline in meal intake: on 02/28/16 and 02/29/16, breakfast intake was 50% (intake from 02/19/16 to 02/27/16 was 100%); and, on 02/28/16 and 02/29/16, lunch intake was 25% (intake from 02/19/16 to 02/27/16 was 100%). The Resident Daily Flow Sheet dated March 2016 indicated a decline in Resident #2's breakfast and dinner meal intake. The Flow Sheet indicated that Resident #2's oral intake for breakfast declined from 75% to 50%; and for dinner, declined from 75% to 50%. The Flow Sheet indicated that between 03/15/16 and 03/17/16, Resident #2's breakfast and lunch intake declined to 25%. The Flow Sheet indicated that on 03/15/16, Resident #2's dinner intake declined to 25% The Physician's Note dated 03/15/16 at 3:41 P.M. indicated that Resident #2 had some decrease in oral intake. The Dietician said that she was not notified of Resident #2's decline in oral intake. There was no documentation at the time of survey that the decline in Resident #2's intake was communicated to the Physician prior to 03/15/16, or of Resident #2's continued decline in intake after 03/15/16. 4. Resident #2's laboratory blood test results dated 03/21/16 indicated that his/her pre-[MEDICATION NAME] level (which shows protein depletion before the [MEDICATION NAME], and is a 2-week look back at the adequacy of protein intake) was low 11.7 g/dl (normal 20-40 g/dl). The Dietician said that Resident #2's low pre-[MEDICATION NAME] level was an indication of protein depletion. The Dietician said that with such a low pre-[MEDICATION NAME], Resident #2's 7 gram protein supplement needed to be changed to another type of supplement containing 15 grams of protein.

Based on records reviewed, interviews and observations, for 1 of 4 sampled residents (Resident #2), the Facility failed to ensure sufficient staffing to meet the care needs and supervision of residents to prevent accidents. Findings include: The Surveyor interviewed the Director of Nurses (DON) at 4:39 P.M. on 03/25/16. The DON said that the Facility was low on staffing for the 3:00 P.M. to 11:00 P.M shift, and were having a hard time filling the open positions. The DON said that the Facility's staffing levels should be: 6 Certified Nursing Assistants (CNAs) and 2 nurses on each of the 2 units for the 7:00 A.M. to 3:00 P.M. shift; 5 CNAs and 2 nurses on each of the 2 units for the 3:00 P.M. to 11:00 P.M. shift; and, 4 CNAs and one nurse on each of the 2 units for the 11:00 P.M. to 7:00 A.M. shift. The DON said that during the 3:00 P.M. to 11:00 P.M. shift from Monday to Friday, there was also a nursing supervisor on duty. The DON said the staffing levels were the same on weekends, with the exception of the nursing supervisor, who worked from 7:00 A.M. to 7:00 P.M. The Facility's As-Worked Daily Guidelines (schedule of staff who were present and working in the Facility) dated 09/22/15 through 10/03/15, 02/15/16, and 03/16/16 through 03/23/16 were provided to the Surveyor by the DON. The Daily Guidelines indicated that, according to the Facility's staffing levels provided to the Surveyor by the DON: The Elmwood Unit was understaffed on the following dates and shifts: - 7:00 A.M. to 3:00 P.M. shift on: 09/28/15 (one CNA), 09/29/15 (one CNA), 09/30/15 (one CNA), 10/02/15 (one CNA), 03/16/16 (one CNA), 03/19/16 (2 CNAs), 03/20/16 (two CNAs and one nurse), 03/21/16 (one CNA), 03/23/16 (one CNA), and 03/25/16 (one CNA). - 3:00 P.M. to 11:00 P.M. shift on: 09/23/15 (one CNA), 09/27/15 (one CNA), 02/15/16 (one CNA), 03/16/16 (one CNA), 03/17/16 (one CNA and one nurse), 03/19/16 (3 CNAs and one nurse), 03/20/16 (3 CNAs and one nurse), 03/21/16 (3 CNAs), and 03/25/16 (one CNA). The Windsor Unit was understaffed on the following dates and shifts: - 7:00 A.M. to 3:00 P.M. shift on: 09/22/15 (one CNA), 09/24/15 (one CNA), 09/27/15 (one CNA), 09/29/15 (one CNA), 10/01/15 (one CNA), 02/15/16 (one CNA), 03/19/16 (one CNA), 03/20/16 (3 CNAs), 03/21/16 (2 CNAs), and 03/22/16 (one CNA). - 3:00 P.M. to 11:00 P.M. shift on: 09/26/15 (one CNA), 09/28/15 (one CNA), 10/02/15 (one CNA), 03/16/16 (2 CNAs), 03/17/16 (2 CNAs), 03/18/16 (one CNA and one nurse), 03/19/16 (one CNA), 03/20/16 (one CNA and one nurse), 03/21/16 (2 CNAs), 03/22/16 (one CNA), 03/23/16 (one CNA), and 03/25/16 (one CNA). The Surveyor interviewed the Scheduler at 11:32 A.M. on 03/23/16. The Scheduler said that the schedules provided to the Surveyor reflected the staff that were present and working in the Facility on those dates. The Surveyor interviewed the Ombudsman at 11:57 A.M. on 03/22/16. The Ombudsman said that she had received multiple complaints about the Facility being short of staff. The Ombudsman said she had also received a complaint that Resident #2 was not receiving adequate assistance with his/her care needs. The Surveyor interviewed the Director of Nurses (DON) at 12:17 P.M. on 03/23/16. The DON said that she had worked as a floor nurse to cover open positions on the schedule. The Surveyor interviewed the Staff Development Coordinator (SDC) at 10:31 A.M. on 03/25/16. The SDC said she was working 28 hours a week as the SDC, and 12 hours a week as the interim Assistant Director of Nurses (ADON). The SDC said she also regularly worked shifts as a nurse and a Certified Nursing Assistant (CNA). The Surveyor interviewed CNA #5 at 2:23 P.M. on 03/25/16. CNA #5 said that residents were suffering because there were not enough staff to meet residents' needs. CNA #5 said that staff did not have time to interact with residents on a personal level, do perform tasks like styling hair. CNA #5 said that several of the nurses often assisted the CNAs to make sure residents' basic care needs were met because there were not enough CNAs on duty. CNA #5 said that CNAs were asked on almost a daily basis to work additional shifts to cover open positions. The Surveyor interviewed CNA #6 at 2:41 P.M. on 03/25/16. CNA #6 said that staffing levels were usually the lowest during the 3:00 P.M. to 11:00 P.M. shifts. CNA #6 said that the residents suffer because of the low staffing levels, that only basic care needs were being met. CNA #6 said that CNAs were asked on a regular basis to work additional shifts to cover open positions. The Surveyor interviewed CNA #7 at 2:53 P.M. on 03/25/16. CNA #7 said that staff were only doing the basics to get by in terms of providing care to residents. CNA #7 said that if the Facility was short-staffed, residents received bed baths instead of showers, because the bed baths were quicker. CNA #7 said that staff were not able to provide thorough care because there weren't enough staff available. CNA #7 said that on a daily basis, CNAs were asked to work additional shifts to cover open positions. The Surveyor interviewed Nurse #4 at 3:04 P.M. on 03/25/16. Nurse #4 said that she regularly worked as a CNA because there were not enough CNAs scheduled to ensure that the residents received adequate care. Nurse #4 said that some residents were not receiving showers because there were not enough staff on hand. Nurse #4 said that she had observed residents in their pajamas at 3:30 P.M. because there weren't enough staff scheduled for later in the shift to accommodate residents' needs. Nurse #4 said that nurses were frequently told to ask CNAs to work additional shifts to cover open positions. The Surveyor interviewed the Social Worker (SW) at 9:43 A.M. on 03/28/16. The SW said that the Facility was often short staffed. The SW said residents were not being toileted in a timely manner, because there were not enough staff to assist in the process. The SW said that she had observed nurses, including the SDC, performing CNA duties because there were not enough CNAs working. The SW said that she had also observed a lack of documentation in resident charts by nursing, missing care plans, and erroneous charting, due to the lack of sufficient staff. The Surveyor interviewed Nurse #6 at 9:53 A.M. on 04/04/16. Nurse #6 said the Facility consistently operated short staffed. Nurse #6 said that nurses regularly worked shifts as a nurse, and then stayed for the next shift to work as a CNA as there were not enough CNAs scheduled to work. Nurse #6 said that she had observed residents receiving bed baths instead of showers and residents not being weighed or reweighed because there were not sufficient staff on duty. Nurse #6 said it was just a matter of time before a resident was seriously injured due to the lack of staff. The Surveyor interviewed Nurse #7 at 12:02 P.M. on 04/04/16. Nurse #7 said that the Facility had staffing issues, primarily during the 3:00 P.M. to 11:00 P.M. shift. Nurse #7 said that staffing issues had started to impact other shifts due to staff burnout. Nurse #7 said that the staffing shortage was impacting the residents, that residents were not receiving as thorough care as they should and staff struggled to get residents' basic needs met. Nurse #7 said that some nurses would stay after their shifts to assist the CNAs and just to ensure that there were enough staff in the building. The Surveyor interviewed CNA #3 at 12:04 P.M. on 04/11/16. CNA #3 said that the Facility was very short on staff. CNA #3 said that typical staffing during the 3:00 P.M. to 11 P.M. shift was 3 CNAs per unit, not 5 CNAs, which meant each CNA's assignment could consist of 15 or more residents. CNA #3 said because there were only 3 CNAs on the unit for more than 45 residents, they didn't even have time to offer residents showers, let alone give one. CNA #3 said that male residents sometimes were not shaved and residents were not walked because they did not have enough staff. CNA #3 said that staff did the best they could just to make sure that residents were in bed by 11:00 P.M. - The Facility's Food First - Nutrition Policy dated April 2015 included Practice Guidelines which indicated that all weight loss or gain of 3 pounds (lbs) or more required a reweigh for verification. The Medication Administration Records (MARs) for February and March 2016 indicated that Resident #2's weight decreased or increased by 3 or more pounds from the prior weight on 02/21/16, 02/22/16, 03/01/16, 03/07/16, 03/12/16, and 03/20/16. The Surveyor interviewed the Dietician at 2:30 P.M. on 03/25/16. The Dietician said that Resident #2 was not reweighed in accordance with the Facility's policy. There was no documentation at the time of survey that Resident #2 was reweighed in accordance with Facility policy after documented weight losses or gains of 3 lbs or more. There was no documentation to indicate at the time of survey that daily weights were done as ordered on [DATE], 02/26/16, 03/02/16, 03/03/16, 03/05/16, 3/6/16, 03/08/16, 03/11/16, 03/16/16, or 03/21/16. The Resident Daily Flow Sheet for February 2016 indicated that Resident #2's intake was less than 75% at breakfast and lunch on 02/28/16 and 02/29/16. The Resident Daily Flow Sheet dated March 2016 indicated that Resident #2's intake declined from 75% to 50% for breakfast and dinner. The Flow Sheet indicated that on 03/15/16, Resident #2's intake was 25% for all three meals, and remained at 25% for breakfast and lunch on 03/16/16 and 03/17/16. - The Dehydration Evaluation dated 02/19/16 indicated that Resident #2 was at risk for dehydration. - The Intake and Output (I&O) Record dated 03/18/16 & 03/19/16 indicated that Resident #2's intake was below the calculated daily fluid requirements of 1270 cc. The I&O Record dated 03/19/16 was incomplete: there was no documented intake or output for the 7:00 A.M. to 3:00 P.M. or 11:00 P.M. to 7:00 A.M. shifts, and Resident #2's intake was documented as 120 cc on the 3:00 P.M. to 11:00 P.M. shift. The Dietician said that the I&O records indicated that Resident #2 had not reached his/her adequate hydration needs. Resident #2's medical record indicated that on 02/22/16, Resident #2's BUN (blood urea nitrogen; an indicator of kidney function) was 32 mg/dl (milligrams per deciliter; normal range is 9-23 mg/dl). The medical record indicated that on 03/21/16, Resident #2's BUN had increased to 42 mg/dl on 03/21/16. There was no documentation at the time of survey to indicate that I&O monitoring was started prior to 03/16/16.

Based on observation, record review, and staff interviews, the facility failed to ensure that 1 (#6) resident of 13 applicable residents in a total sample of 20 residents, who developed urinary incontinence, received appropriate treatment and services to restore as much normal bladder function as possible. Findings include: Review of the facility's policy for Continence Management, revised 2/1/2010, indicated the facility would complete a Urinary Incontinence Assessment if the resident became incontinent (change in condition) and the continence status would be reviewed quarterly with the Minimum Data Set (MDS) assessment and with changes in continence. The assessment would be completed and transient causes addressed before initiating a Three Day Continence Diary. A plan of care would be developed based on information from assessments and the diary. A 14 Day plan would be developed using bladder retraining, Kegel exercises, prompted voiding or scheduled toileting as interventions. The facility would review the assessment and complete the Program Evaluation section at the next care plan or Weekly At Risk meeting. For Resident #6, the facility failed to conduct a bladder evaluation and assess for voiding patterns when the resident had a decline in bladder continence, and failed to promote or improve bladder functioning when the resident developed increased bladder incontinence. Resident #6 was admitted to the facility in 10/2010 with [DIAGNOSES REDACTED]. The resident's plan of care for maintaining skin integrity, dated 8/2013 to 5/12/14, indicated the resident remained continent and wore pull-up briefs. The resident's 10/29/13 Annual MDS assessment indicated the resident had impaired hearing and vision, was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9/15, was depressed, had no behaviors, was independent for transfers, eating and toilet use, required supervision for ambulation, limited assistance for hygiene, extensive assistance for dressing and bathing, was continent of bowel and bladder, and received antipsychotic and antidepressant medication daily. The current Certified Nursing Assistant (CNA) Care Card, last updated 1/13/14, indicated the resident was independent for toileting and continent of bowel. The resident's 1/28/14 Quarterly MDS assessment indicated the resident had an improved BIMS score of 14/15, walked independently in room, and was continent of bowel and bladder. Monthly Resident Daily Flowsheets of 3/2014 indicated the resident was incontinent of bladder during the day (from 3/5/14 to 3/31/14) with occasional continent episodes. Monthly Resident Daily Flowsheets of 4/2014 indicated the resident was daily incontinent of bladder during the evening shift and incontinent on the day shift from 4/5/14 to 4/26/14. The resident's 4/29/14 Quarterly MDS assessment indicated the resident was frequently incontinent of bowel and bladder. Record review indicated no evidence that the resident was assessed for the causes, and subsequent care planning, of the resident's incontinence in 4/2014, per the facility's policy. Monthly Resident Daily Flowsheets of 5/2014 indicated the resident had daily incontinent episodes during the day and evening shifts, from 5/1/14 to 5/31/14. The facility's plan of care indicated that, on 5/13/14, the resident had episodes of incontinence and a 3 day bladder patterning was initiated. The Three Day Continence Diary, dated 5/14/14 to 5/16/14, indicated episodes of bladder incontinence, but the pattern or results were not assessed or summarized. The resident's plan of care was updated to include a 14 day bladder plan to be initiated 7/2/14. Additional interventions included: -Incontinence care as needed, -Toilet as needed. Record review indicated no evidence that a Urinary Incontinence Assessment was ever initiated, nor was a 14 Day bladder plan initiated on 7/2/14, as planned. Monthly Resident Daily Flowsheets of 7/2014 indicated the resident was still experiencing day and evening bladder incontinence. Monthly Resident Daily Flowsheets of 8/2014 indicated the resident was incontinent daily, from 8/1 to 8/5/14, on the day and evening shifts. During the initial unit tour and observation of the resident on 8/5/14 at 8:30 A.M. with Unit Manager (UM) #2, she said the resident was continent of bladder and walked to the bathroom independently. The resident was observed in bed from 8:40 A.M. to 12:15 P.M., and on 8/6/14, from 7:50 A.M. to 8:25 A.M. A rolling walker was next to the resident's bed. The surveyor attempted to interview the resident at 8:20 A.M. on 8/6/14, but the resident had poor hearing and diminished vocalizations. During interview on 8/6/14 at 3:35 P.M., CNA #4, the resident's primary evening CNA, said the resident was alert and confused, had blocked ears, ambulated with a rolling walker, toileted self, was incontinent of bladder at times and asked for staff assistance when incontinent of bowel. During interview on 8/5/14 at 2:00 P.M., UM #2 said there was no evidence to support that the facility had completed a Urinary Incontinence Assessment or assessed for voiding patterns when the resident had a decline in continence, or provide the resident treatment and services to restore or improve, as much as possible, the resident's bladder functioning.

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to initiate a plan of care for a change in condition to Resident #1's right great toe. On 4/17/14, Resident #1 had a callous with dried blood on the bottom of the right great toe. Certified nurse aide (CNA) #1 said some time between 4/17/14 and 4/28/14, she notified the nurse Resident #1 had a dime sized excoriated area on the right great toe. There was no indication the nurses assessed or monitored the area until 4/29/14, when Resident #1's right great toe, foot, and ankle were swollen and there was yellow drainage from the toe and an anti-infective was prescribed. On 5/6/14, Resident #1 was hospitalized and had a right great toe amputation. Findings include: The Hospital Discharge summary, dated 1/22/14, indicated that Resident #1's [DIAGNOSES REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 1:25 P.M. on 5/28/14. CNA #1 said on 4/18/14, Resident #1 had dried blood on the sock on his/her right foot. CNA #1 said when she removed the sock, Resident #1 had a black scab underneath the right great toe. CNA #1 said she notified Nurse #1. The Report Book, dated 4/17/14, indicated that the bottom of Resident #1's right great toe had a calloused area with old blood. The Report Book indicated that Resident #1 may have picked or peeled the calloused area on the right great toe. The Surveyor interviewed Nurse #1 at 6:00 A.M. on 5/30/14. Nurse #1 said on 4/17/14, she evaluated Resident #1's right great toe. Nurse #1 said Resident #1 had no scab on the right great toe and had a calloused area. The Surveyor interviewed Unit Manager #1 at 8:40 A.M. on 5/28/14. Unit Manager #1 said on 4/17/14, she was not aware Resident #1 had an issue with the right great toe and did not assess Resident #1's right toe or initiate a plan of care. The Surveyor interviewed CNA #2 at 4:00 P.M. on 5/29/14. CNA #2 said after 4/17/14 and prior to 4/28/14, during the evening shift, Resident #1 had a dime sized excoriated area on the right great toe. CNA #2 said she notified Nurse #2. Interview with Unit Manager #1 and the nursing schedules indicated that between 4/18/14 and 4/28/14, Nurse #2 and Nurse #3 were assigned Resident #1 during the evening shift. The Surveyor interviewed Nurse #2 at 3:05 P.M. on 5/28/14. The Surveyor interviewed Nurse #3 at 4:15 P.M. on 5/28/14. Nurse #2 and Nurse #3 said between 4/18/14 and 4/28/14, the CNAs did not report issues regarding Resident #1's right great toe or feet and they did not evaluate Resident #1's feet. There was no indication nursing staff assessed Resident #1's right great toe between 4/18/14 and 4/28/14. Unit Manager #1 said she was not aware Resident #1 had an issue with the right great toe prior to 4/29/14, and did not initiate a plan of care in response to the area. The nurse's note, dated 4/29/14, indicated that Resident #1's right great toe, the top of his/her right foot, and above the right ankle was swollen and red. The nurse's note indicated that there was yellow drainage from the right great toe. Unit Manager #1 said on 4/29/14, she initiated a plan of care regarding Resident #1's right foot and right toe. See F 309

Based on record review and interview, for one of three sampled residents (Resident #1), the Facility failed to assess and treat Resident #1's right toe issue timely; and Resident #1 developed a right great toe infection, and required an amputation of the toe. On 4/17/14, Resident #1 had a callous with dried blood on the bottom of the right great toe and the certified nurse aide (CNA) #1 said she notified Nurse #1 Resident #1 had a dime sized excoriated area on the right great toe. There was no indication the staff assessed Resident #1's right great toe between 4/18/14 and 4/28/14 or notified a physician of the area until 4/29/14, when Resident #1's right great toe, foot, and ankle were swollen and red, and there was yellow drainage from the toe. On 5/6/14, the Podiatrist evaluated Resident #1's right foot and transferred Resident #1 to the Emergency Department (ED). Resident #1 had a right great toe amputation at the Hospital. Findings include: The Hospital Discharge summary, dated 1/22/14, indicated that Resident #1's [DIAGNOSES REDACTED]. The January 2014 plan of care related to Resident #1's self care deficit, included: assist with personal care. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 1:25 P.M. on 5/28/14. CNA #1 said on 4/18/14, Resident #1 had dried blood on the sock of his/her right foot. CNA #1 said when she removed the sock, Resident #1 had a black scab underneath the right great toe. CNA #1 said she notified Nurse #1. The Report Book, dated 4/17/14, indicated that the bottom of Resident #1's right great toe had a calloused area with old blood. The Report Book indicated that Resident #1 may have picked or peeled the calloused area on the right great toe. The Surveyor interviewed Nurse #1 at 6:00 A.M. on 5/30/14. Nurse #1 said on 4/17/14, she evaluated Resident #1's right great toe. Nurse #1 said Resident #1 had no scab on the right great toe and had a calloused area. The Surveyor interviewed Unit Manager #1 at 8:40 A.M. on 5/28/14. Unit Manager #1 said on 4/17/14, she was not aware Resident #1 had any issue with the right great toe and did not assess the right toe or initiate a plan of care. The weekly skin assessment forms and the treatment record entries, dated 4/18/14, 4/25/14, and 5/2/14, did not indicate the nurses completed the weekly skin check assessment in accordance with the plan of care. The treatment record entry, dated 4/25/14, indicated that Resident #1 refused the skin assessment. The Surveyor interviewed Nurse #2 at 3:05 P.M. on 5/28/14. Nurse #2 said on 4/18/14, she did not complete a skin assessment on Resident #1. Nurse #2 said on 4/25/14, Resident #1 refused the skin assessment. Nurse #2 said she could not recall if she reapproached Resident #1 on 4/25/14 or notified the oncoming nurse to have the skin assessment completed on 4/26/14. There was no indication a nurse completed the weekly skin assessment on 4/26/14. The Surveyor interviewed CNA #2 at 4:00 P.M. on 5/29/14. CNA #2 said after 4/17/14 and prior to 4/28/14, during the evening shift, Resident #1 had a dime sized excoriated area on the right great toe. CNA #2 said she notified Nurse #2. Interview with Unit Manager #1 and the nursing schedules indicated that between 4/18/14 and 4/28/14, Nurse #2 and Nurse #3 were assigned Resident #1 during the evening shift. The Surveyor interviewed Nurse #2 at 3:05 P.M. on 5/28/14. The Surveyor interviewed Nurse #3 at 4:15 P.M. on 5/28/14. Nurse #2 and Nurse #3 said between 4/18/14 and 4/28/14, the CNAs did not report issues regarding Resident #1's right great toe or foot and they did not evaluate Resident #1's feet. There was no indication the staff assessed Resident #1's right great toe between 4/18/14 and 4/28/14. The nurse's note, dated 4/29/14, indicated that Resident #1's right great toe, the top of his/her right foot, and above the right ankle was swollen and red. The nurse's note indicated that there was yellow drainage from the right great toe. Unit Manager #1 said she was not aware Resident #1 had an issue with the right great toe prior to 4/29/14 and did not assess Resident #1's right great toe and foot, or initiate a plan of care until 4/29/14. The Surveyor interviewed the Director of Nurses (DON) at 10:15 A.M. on 6/2/14. The DON said the CNAs were to report all new skin issues to the nurses. The DON said the nurses were to assess the skin issue and report concerns to the Unit Managers. The DON said the Unit Managers completed weekly assessments of skin issues and reported their findings to her. The DON said no one reported skin concerns regarding Resident #1 to her until 4/29/14. The Surveyor interviewed the Nurse Practitioner (NP) at 9:30 A.M. on 5/28/14. The NP said on 4/29/14, the nurse told her Resident #1 could have an ingrown toenail that became infected and she treated Resident #1 for [MEDICAL CONDITION] (inflammation/infection of the skin) of the right great toe. The physician order, dated 4/29/14, included: the anti-infective medication, Keflex 500 milligrams every 6 hours for 7 days; Polymem dressing (cleansing agent dressing) to the open areas on the right great toe, change every 7 days and/or when dressing had drainage; monitor for redness and swelling, and report changes to Physician/NP. The NP progress note, dated 5/5/14, indicated Resident #1 had no improvement in his/her toe infection. The NP note indicated Resident #1 had maceration of the plantar surface (sole) of the right great toe. The NP note indicated the plan was for the Podiatrist to evaluate Resident #1's right great toe for a possible incision and drainage of the area. The NP said on 5/5/14, Resident #1's right great toe was significantly worsened from the nurse's report to her on 4/29/14. The NP said she and the Physician evaluated Resident #1's right foot. The NP said the staff scheduled an outside Podiatry visit for Resident #1 on 5/6/14. The nurse's note, dated 5/6/14, indicated that at the the office staff transferred Resident #1 from the Podiatry office to the Hospital for an amputation of Resident #1's right great toe. See F 279