Every finding on record at Larsen Health Center

Based on observation, record review, facility policy review, resident and staff interviews, the facility failed to provide care and services in accordance with the resident's individualized care plan to minimize the risk of avoidable accidents for 1 (Resident #1) of 3 dependent residents reviewed for transfers.The findings included:Review of the facility Transfer of Resident Using Support Devices policy (last revised on 11/2017) noted The Therapy Department will screen residents and determine a level of assistance. This determination will be incorporated into the plan of care for the resident and communicated to the staff by the means of the care plan.Review of the facility Care Plan- Interdisciplinary Resident policy (last revised on 1/2025) noted A comprehensive care plan will be developed for each resident that include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. All personnel who provide care to the resident, including private duty, shall have access to and be knowledgeable of the resident's care plan.On 6/24/26 at 8:28 a.m., Resident #1 was observed in bed with a stabilizing boot to her right lower leg. In an interview, Resident #1 said that at times she has pain in her right foot, and that wearing the boot was very uncomfortable. Resident #1 said that she did not know how she sustained the injury to her foot, she just woke up one day and the boot was on.Review of the facility provided investigation related to Resident #1's right foot injury revealed that on 6/15/26, the resident was diagnosed with a right ankle fracture. Resident #1 first complained of pain to her ankle to Certified Nursing Assistant (CNA) Staff A on 6/11/26. CNA Staff A provided a statement that as she was transferring Resident #1 from her recliner back to her bed, the resident began to complain of her foot hurting.I heard her yelp my foot I gently sat her down onto the bed laid her down and took off her gripper socks to examine her foot for blood scratches or anything else to indicate that she was hurt. I did not see anything immediately, so I continued with changing her brief and changing her clothes. occasionally, she would say her right foot hurt and she needed it to be looked at.I left her room when I was done and looked over at the nurses station. to notify her of the situation. Review of Registered Nurse (RN) Staff B's statement revealed, Upon helping (resident) back to bed, resident complained that her right foot was hurting, (CNA Staff A) finished transferring the resident and then came to get me. Resident's foot/ankle had some swelling and was warm to touch. Unit Manager and ARNP (Advanced Registered Nurse Practitioner) notified.Review of the results of Resident #1's right ankle X-ray completed on 6/12/26 revealed, Impression: Nondisplaced posterior right calcaneus (heel bone) fracture.The facility investigation noted It is stated that the CNA was alone while transferring from the recliner to the bed.Review of Resident #1's medical record noted an admission date of 10/27/23. Diagnoses included Dementia (date diagnosed: 11/2/23), Muscle Weakness (date diagnosed: 10/30/23), Unspecified Lack of Coordination (date diagnosed: 11/2/23), Other Abnormalities of Gait and Mobility (date diagnosed: 11/2/23), Pain in Right Ankle and Joints of Right Foot (date diagnosed: 6/12/26) and Nondisplaced Fracture of Right Calcaneus Initial Encounter for Closed Fracture (date diagnosed: 6/12/26).Review of the Brief Interview for Mental Status completed on 6/16/26 revealed Resident #1 scored 08 of 15, indicating moderately impaired cognition.Review of Resident #1's orders with a start date of 2/16/26 noted ADL (Activities of Daily LivingK)- Transfer Assist x 2.Review of Resident #1's Plan of Care on 6/11/26 noted, Resident requires assistance with ADLs due to weakness, low endurance and decreased mobility as a result of chronic conditions, dementia, falls history of pelvic fracture. The interventions included assist x 2 for transfers (start date: 12/16/25).Review of Resident #1's Minimum Data Set (a standardized assessment tool that measures health status in nursing home residents) completed on 3/16/26 noted Resident #1 was dependent (helper does ALL of the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to chair transfer.Review of Resident #1's most recent PT (Physical Therapy) Evaluation & Plan of Treatment completed on 9/4/25 noted, Pt (patient) spends significant amount of time in bed which has resulting in increased weakness and fear of falling. Pt reportedly had a fall in recent past during a transfer warranting PT assessment, but given pt unwillingness to participate, I would recommend (full body mechanical lift) lift for bed -chair transfers moving forward for safety.On 6/24/26 at 9:48 a.m., in an interview, the ARNP taking care of Resident #1 said that on the day of the incident, the staff told her the resident was complaining of pain to her ankle after a transfer. She immediately went up to see the resident. She said when she initially saw her ankle, it was barely swollen. She said she had Tylenol ordered and waited to see how she was. She said the next day, an X-ray was ordered since the resident was having more pain. The X-ray showed a nondisplaced posterior right calcaneus fracture. She said since she has known Resident #1, she has always been in bed and barely gets out of bed. She said that if there is an order for two person assist with transfers, her expectation is that 2 people assist with transfers.On 6/24/26 at 10:19 a.m., in an interview, the Medical Director said that it was reported to her that Resident #1 complained of foot pain after being transferred. She said Resident #1's injury is suspected of compression fracture but, We cannot say, with 100 percent certainty that is what caused the fracture. The Medical Director said that if there is an order for two-person staff assistance with transfers, her expectation is that 2 staff members assist the resident with transfers.On 6/24/26 at 11:21 a.m., in an interview, the Director of Rehab said and confirmed that the last Physical Therapy Assessment prior to the incident for Resident #1 was completed in September 2025. She said this was the prior company and her company took over on 10/1/25. The Director of Rehab reviewed Resident #1's Physical Therapy Assessments and said it looks like a full body mechanical lift was recommended for Resident #1 based on the evaluation completed. She said staff can always add interventions for safety but cannot take away interventions that physical therapy recommends without therapy intervention.On 6/24/26 at 12:51 p.m., in a telephone interview, CNA Staff A said she transferred Resident #1 to the recliner. CNA Staff A said when she transferred Resident #1 back to bed, she complained of her foot hurting. She said at that point she got the nurse and it was escalated to the manager. She said that she would refer to the assignment sheet given to her to find a resident's transfer status. She said if she was not familiar with a resident assigned to her, she would ask the CNA who was leaving. She said if the leaving CNA was not available, she would ask a CNA familiar with the resident or the nurses. When asked if there is a way to look up resident transfer status, she said, I'm sure there is a way to look them up. She said she can see what previous CNAs have put in their documentation and go from there. When asked what if the previous CNAs charted wrong, she said, That is a good question. She said she would look for more than 1 response. She said she would look up 3 responses or someone's response with seniority who knows the resident. CNA Staff A said that she was not aware that Resident #1 required two person assistance with transfers. She said she did not know how to look up the transfer status for Resident #1, she went off what she remembered for the resident. She confirmed that she transferred Resident #1 alone. Review of CNA Staff A's signed job description (signed on 5/1/24) noted under job functions to assists residents in transfers, ambulation, uses a gait belt per policy and assistive devices when appropriate including: transfer board, walker, cane, another staff member etc. per plan of care.On 6/24/26 at 1:35 p.m., in an interview, CNA Staff C said residents' transfer status can be found in their electronic chart. CNA Staff C said since Resident #1 has never walked and has always been a two-person assist with transfers since she's been at the facility.On 6/24/26 at 1:38 p.m., in an interview, CNA Staff D said they can look up residents' transfer status in the electronic chart. CNA Staff D said Resident #1 has always been a two-person assist with transfers.On 6/24/26 at 2:14 p.m., in an interview, the Director of Nursing (DON) said when CNA Staff A transferred Resident #1, she had some discomfort to her ankle. When Resident #1 voiced a second time that her ankle was hurting, the CNA notified RN Staff B. The DON said that the provider was notified, an X-ray was ordered and they went from there. The DON confirmed that the therapy note from September 2025 documented that Resident #1 required the use of a full body mechanical lift for transfers, for her safety. The DON confirmed that they cannot change the use of a full body mechanical lift to a 2 person assist with transfers without therapy seeing them. She said that the manager and MDS (Minimum Data Set) coordinator can enter the therapy recommendations in the resident's medical record. She said she would have to look back to see if she ever got an order for a full body mechanical lift. She said that the report sheets given to the CNAs at the beginning of their shift include residents transfer status. She said she reviewed CNA Staff A's report sheet for that day, it noted that Resident #1 was a two-person assist with transfers. She said CNAs can also look up resident transfer status in the electronic medical record. She said from her knowledge, CNA Staff A was alone during the transfer. She said CNA Staff A should not have transferred the resident alone. She confirmed that Resident #1 had an order for a two-person assist with transfers and that the resident's care plan and MDS specified a two-person assist with transfers. She said her expectation is that staff follow the current orders.On 6/24/26 at 3:20 p.m., in an interview, the Nursing Home Administrator (NHA) said if there is an order for a two-person assist with transfers for a resident, that is how they should be transferred. The NHA said that the order should have reflected the change of transfer status to a full body mechanical lift as noted in the Physical Therapy note for Resident #1.On 6/24/26 at 3:51 p.m., in an interview, the DON said that she was not able to locate an order for the full body mechanical lift at this time.

Based on records review, observation and staff interviews the facility failed to accurately document physician ordered treatments for 2 (Residents #82 and Resident #93) of 2 resident's reviewed with feeding tubes. The findings included: Review of the facility's Charting and Documentation Policy revealed the facility, is committed to ensuring that all services provided to the resident, progress towards the care plan goals . is documented in the resident's medical record . The following information is to be documented in the resident medical record: . Treatments or services performed . Documentation in the medical record will be objective . complete, and accurate . documentation of procedures and treatments will include care-specific details, including: . The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care . The signature and title of the individual documenting . Review of the facility's Gastrostomy Enteral Nutrition Via Gravity policy (last revised 9/2022) revealed states under the steps in the procedure section to check the order to verify the type, amount, method, and rate of administration. This section also notes to flush tubing with at least 30 mL warm water (or prescribed amount). Under the Initiate Feeding section, the policy states unless otherwise ordered, follow the feeding with 30-60 mL (milliliters) of warm water. Under the Documentation section, the policy states the person performing the procedure should document amount of feeding and amount of water administered in the resident's medical record. 1. Record review of Resident #82 showed a diagnosis of dysphagia (difficulty swallowing), nutritional anemia and iron deficiency anemia. Resident #82's orders dated April 4, 2025, revealed the resident's diet as nothing by mouth NPO. Resident #82's Care Plan (4/7/2025) noted resident is at potential risk for dehydration d/t (due to) dysphagia with PEG tube feeding and hydration. The Care Plan also noted resident will not show any sign/symptoms of dehydration: i.e. dry skin, cracked concentrated urine, noted or increased confusion, abnormal lab values that may indicate dehydration. The Care Plan also listed to give tube feeding and flushes as ordered. Resident #82's orders dated April 24, 2025, revealed Feeding tube (tube inserted directly into the stomach through the abdominal wall) flushes - 60 milliliters (ml) Feeding tube 3 times a day before and after medications. Total volume 360 ml. Resident #82's medications were scheduled at 6:30 a.m., 9:00 a.m., and 9:00 p.m. Review of the Medication Administration Record (MAR) tube feeding flushes before and after medications during May 2025 revealed: On 18 occasions at 6:30 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 60 mL of water (5/1/2025 through 5/14/2025, 5/17/2025 through 5/19/2025 and 5/21/2025). On 19 occasions at 9:00 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 60 mL of water (5/1/2025 through 5/16/2025, 5/19/2025 through 5/21/2025). On 17 occasions at 9:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 60 mL of water (5/1/2025 through 5/13/2025, 5/16/2025 through 5/18/2025, 5/20/2025). Resident #82's orders dated April 23, 2025, revealed Feeding tube flushes - 30 mL Feeding tube 4 times per day before and after bolus (single, large dose) feedings, total volume 240 mL. Resident #82's bolus tube feedings were scheduled for 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Review of the MAR for tube feeding flushes before and after bolus feedings during May 2025 revealed: On 21 occasions at 9:00 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/15/2025, 5/17/2025 through 5/21/2025). On 19 occasions at 1:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/17/2025, 5/19/2025, 5/20/2025). On 19 occasions at 5:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/17/2025, 5/19/2025, 5/20/2025). On 18 occasions at 9:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (5/1/2025 through 5/13/2025, 5/16/2025 through 5/20/2025). On 5/21/2025 at 1:36 p.m., Registered Nurse (RN) Staff B was observed providing tube feeding for Resident #82. RN Staff B followed physician orders by flushing 30 mL of water before and after tube feed administration. RN Staff B said Resident #82 receives hydration through water flushes because they cannot have anything by mouth. Resident #82's MAR was reviewed and noted the resident received only 30 mL of water when they actually received 60 mL of water. RN Staff B was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the error was explained. RN Staff B said the documentation was not correct and it makes it look like water flushes are not being given per physician orders. On 5/21/2025 at 1:58 p.m., RN Staff A said when a resident is NPO they will have water flushes to maintain proper hydration. RN Staff A was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the errors were explained. RN Staff A said the documentation was not correct and it looks like water flushes are not being given per physician orders. On 5/21/2025 at 2:12 p.m., the Director of Nursing (DON) said when a resident is NPO and has tube feeds, the dietitian will evaluate and put in for hydration. The DON said water flushes would be hydration. The DON was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the errors were explained. The DON said the documentation is incorrect and it looks like the resident in not receiving proper hydration per the physician orders. On 5/22/2025 at 10:08 a.m., the Nursing Home Administrator said when a physician puts in orders, staff are expected to follow those orders. The Nursing Home Administrator was unable to identify the incorrect documentation in the MAR for Resident #82's water flushes until the errors were explained. The Nursing Home Administrator said the documentation makes it look like the resident is not receiving enough water flushes per physician orders. Records review of Resident #93 showed a diagnosis of dysphagia, unspecified protein-calorie malnutrition and Vitamin B-12 deficiency. 2, Resident #93's Care Plan listed Resident is at potential risk for dehydration. The resident's care plan also noted to administer tube feed flushes as ordered. Resident #93's orders dated September 6, 2024, revealed 30 mL H2O (water) via feeding tube 3 times a day before and after bolus feedings, total volume: 180 mL. Resident #93's bolus tube feeds were scheduled for 8:00 a.m., 1:00 p.m., and 6:00 p.m. Review of the MAR for tube feeding flushes before and after bolus feedings during April 2025 revealed: On 28 occasions at 8:00 a.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (4/1/2025 through 4/21/2025, 4/23/2025 through 4/26/2025, 4/28/2025 through 4/30/2025). On 28 occasions at 1:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (4/1/2025 through 4/21/2025, 4/23/2025 through 4/26/2025, 4/28/2025 through 4/30/2025) On 29 occasions at 6:00 p.m., the MAR showed documentation that the resident's feeding tube was flushed with 30 mL of water (4/1/2025 through 4/26/2025, 4/28/2025 through 4/30/2025).

Based on observations, interviews, and record reviews, the facility failed to follow physician's orders and provided skilled therapy services for 1 (Residents #89) of 4 residents reviewed for following physician's orders. The findings included: Review of the clinical record for Resident #89 revealed an admitted [DATE]. Diagnoses included debility and sarcopenia (age related loss of muscle mass and strength). Review of the Minimum Data Set (MDS) Admission assessment with a target date of 4/6/25 revealed Resident #89 scored 14 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Resident #89 required supervision or touching assistance to stand from sitting in a chair or on the side of the bed. The resident required supervision or touching assistance to walk 10 feet and partial to moderate assistance to walk at least 50 feet and make two turns. Review of the care plan initiated on 4/1/25 revealed Resident #89 was at risk for falls due to recent fall with pelvic fracture, Alzheimer's, weakness, low endurance, and decreased mobility as a result of acute and/or chronic health conditions requiring admission for care. The goal was for the resident to have decreased risk of falls utilizing assessment of the interdisciplinary team and appropriate interventions. The interventions included Physical Therapy (PT) and Occupational Therapy (OT) screen/evaluation. Review of the progress notes revealed Resident #89 sustained multiple falls since admission to the facility, on 4/8/25, 4/10/25, 4/26/25, and 4/28/25. Review of the Therapy notes revealed Resident #89 received Physical and Occupational Therapy. Resident #89 was discharged from Physical Therapy on 5/7/25 and was discharged from Occupational Therapy on 4/27/25. Further review of the clinical record revealed on 5/14/25 the Advanced Practice Registered Nurse (APRN) wrote a new order for PT, OT and Speech Therapy (ST) evaluation and treatment for weakness and sarcopenia. On 5/19/25 at 5:17 p.m., observed Resident #89 in a chair in his room. In an interview, Resident #89 said he sits in the chair all day. He said he thought he should be getting more therapy. He said, My legs buckle sometimes when I walk and I lower myself to the ground. The facility calls them falls. On 5/21/25 review of the clinical record, and therapy progress notes failed to reveal documentation Resident #89 received PT, OT and ST as per the APRN order dated 5/14/25. On 5/21/25 at 10:40 a.m., in an interview the Director of Rehabilitation (DOR) said he did not know Resident #89 had new orders for a therapy evaluation and treatment on 5/14/25. The DOR said he did not know the fracture follow-up included orders to continue PT. The DOR said the orders were not executed and Resident #89 did not receive PT, OT or ST services as ordered. On 5/21/25 at 1:40 p.m., in an interview the Director of Nursing (DON) said the therapy orders from the APRN dated 5/14/25 should have been carried out. On 5/21/25 at 1:48 p.m., in an interview Registered Nurse (RN) Staff E said on 5/14/25 she added the order for therapy services to the resident's orders. Staff E said the order for therapy was discussed in the morning meeting, and the DOR should have known about it. She said she did not know why Resident #89 was not receiving therapy services. On 5/21/25 at 3:48 p.m., in an interview the Nursing Home Administrator (NHA) said there should have been a follow-up from the therapy orders dated 5/14/25 before 5/21/25.

Based on record review, facility staff, resident and resident's representative interviews, the facility failed to develop and implement a comprehensive care plan to meet the needs of 1 (Resident #123) of 2 residents reviewed with a cardiac pacemaker (implanted device to treat irregular heart rhythm). The findings included: Review of the Resident #123's clinical record revealed a hospital surgical history of a cardiac pacemaker. The facility's physician admission progress note dated 4/9/25 revealed Resident #123 had a past medical history of a pacemaker. On 4/21/25, the Advanced Practice Registered Nurse (APRN) documented in a progress note that Resident #89's surgical history included a pacemaker. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #123 scored 12 on the Brief Interview for Mental Status (BIMS) indicative of moderate cognitive impairment. The diagnoses listed on the MDS did not include the presence of a cardiac pacemaker. Review of the care plan for Resident #123 noted the resident had alteration in cardiac function. The care plan did not document the presence of the cardiac pacemaker with goals and interventions related to the pacemaker. On 5/21/25 at 8:50 a.m., in an interview Resident #123 said he used a home monitoring device for the pacemaker. The monitoring device was not brought to the facility. The resident said the nurses did not ask about the pacemaker, and no one asked how it was monitored. On 5/22/25 11:01 a.m., during an interview the resident's spouse said the facility did not inquire about the pacemaker. She verified Resident #123 still had the cardiac pacemaker and the monitoring device was at home. The spouse said no one at the facility asked about the cardiac pacemaker or how it was being monitored. On 5/22/25 at 11:09 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said residents with a pacemaker should have regular appointments with the cardiologist. She said she would look to see if Resident #123's pacemaker was being monitored. On 5/22/25 at 11:13 a.m., RN Staff E said she was responsible for the comprehensive assessment data and resident care planning. She said if a resident has a pacemaker, they send them to the cardiologist for regular follow ups to ensure proper functioning and battery life. RN Staff E said the facility monitors for dizziness, shortness of breath, and vital signs. She said there should be a care plan in the record with that information. She verified there was no care plan for pacemaker in the record. On 5/22/25 at 11:39 a.m., RN Staff D said the pacemaker was not on the hospital transfer form (Agency for Health Care Administration form 3008), and it was not listed in the diagnoses. She said they have limited information from the hospital.

Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from abuse by failing to honor the residents' right to refuse care for 1 (Resident #999) of 3 sampled residents when the resident displayed agitated and aggressive behaviors during care. The findings included: The facility policy Abuse Policy and Procedure Manual with a review date of 3/24/23 noted, Each person served has the right to be free from abuse and mistreatment . Some examples, rough handling a resident. Prevention. Appropriate supervision of staff to maintain the mission of caring for, serving and satisfying all residents is provided .Signs and Symptoms Dementia residents in distress may exhibit the following: Aggressiveness, agitation, yelling out, delusions, wandering etc. Be aware of risk factors (age, cognitive and or physician limitations, etc.) . Listen to residents . If they say stop, stop! The facility Employee Agreements signed upon hire specified, If a resident refuses care at any time, I will inform the nurse and or supervisor of the refusal of care. I will respect the residents wishes and reapproach with the nurses' help to offer care at a later time. Review of the clinical record revealed Resident #999 had an admitted [DATE]. Diagnoses included dementia, and major depressive disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with a reference date of 11/27/24 documented Resident #999 required substantial/maximum assistance with toileting. The MDS noted Resident #999's brief interview for mental status score was 03, indicating her skills for daily decision making were severely impaired. The care plan initiated 11/26/24 noted Resident #999 had a behavior problem and, exhibits periods of anxious behavior and physical aggression toward staff due to a diagnosis of Dementia. Resident can become combative, spitting on staff/throwing feces. The care plan also noted Resident #999 at times, resists/refuses care The interventions for Resident #999 included: Approach in a calm manner, make eye contact and reassure the resident. Use a pleasant voice and identify self when approaching resident. Offer friendly nonverbal cues by smiling and using friendly tone of voice when speaking to resident. If resident refuses/resists care, reapproach and reintroduce care or task to be performed at a later time. Further review of the clinical record revealed an initial psychiatric note dated 9/3/24 documented new patient with dementia and depression. Patient has been confused and combative with care, impulsive. Arrived on Paxil and Trazadone (antidepressants). Per sitter gets fearful with care and agitated. Will decrease Paxil to 10 milligrams (mg) and add Depakote 125 mg twice a day for impulse control. Review of the Psychiatric note dated 12/20/24 documented [AGE] year-old lady with a history of dementia has been smearing feces, combative and throwing things . I am going to substitute current medications with Seroquel (an antipsychotic) 25 mg twice a day and re-evaluate. Review of the facility's incident investigation revealed on 12/19/24 the facility initiated an investigation of abuse related to observation of bruising , redness and swelling of Resident #999's left hand. Resident #999 had voiced pain in the thumb and finger. The resident was unable to describe how the injury occurred. The resident was assessed and sent to the emergency room for evaluation. An x-ray of the left hand revealed no fracture or acute process. The investigation findings revealed Licensed Practical Nurse (LPN) Staff D in the shift -to -shift reported the incident occurred on 12/18/24 on the evening shift. The nursing progress dated 12/19/24 at 7:09 a.m., by Staff D documented, Resident #999 was fighting, biting, kicking with her legs and hands. The resident required three staff members to change her. The facility investigative findings noted statements were obtained from the staff. The Interviews Conducted revealed the following: LPN Staff D indicated Resident #999 had two episodes of combativeness during the evening shift. During the second episode at approximately 9:00 p.m., Certified Nursing Assistant (CNA) Staff E called him to come to Resident #999's room because they were trying to clean her up and she was combative. LPN Staff D said he walked into the room and the resident was kicking, swinging her arms in the air. LPN Staff D said he held Resident #999's legs down while CNA Staff E changed. He said CNA Staff C was trying to hold Resident #999's arms. LPN Staff D said when they were done, CNA Staff E had asked him to do a skin check on Resident #999 because she did not want anyone to say the resident had an injury. CNA Staff E said Resident #999 was combative when trying to clean her, so she asked CNA Staff C and CNA Staff B to assist her. Staff E said they were not able to clean Resident #999 and she asked one of the CNA's to get LPN Staff D to help. CNA Staff E said she cleaned the resident but did not remember where the other staff were. CNA Staff E asked LPN Staff D to check the resident's skin because she didn't want anyone saying the resident had bruising. CNA Staff C revealed that she went with another staff member to assist CNA Staff E to clean Resident #999. CNA Staff C said when CNA Staff E was trying to clean Resident #999 was kicking and swinging her arms in the air. CNA Staff C said she observed Resident #999 hitting the bed with her hand. CNA Staff B said on 12/18/24 at approximately 9:00 p.m., LPN Staff D asked her to assist CNA Staff E to change Resident #999's bed linen because she was combative. CNA Staff B said when she walked into the room CNA Staff E and CNA Staff C had already cleaned the resident. CNA Staff B said she assisted with changing the bed linens but did not touch Resident #999. On 1/16/25 at 11:15 a.m., during an interview with Resident #999 said she was fine and had no problems with the staff. She said everyone was good to her and she had no recall of the event of 12/18/24. On 1/16/25 at 10:55 a.m., in an interview LPN Staff A said, I was here the next day on 12/19/24. I sent her (Resident #999) out to the emergency room , and I was the one who noticed her hands when I helped to toilet her. Her left hand was not like that the day before. The left hand was just different, swollen and bruised. I spoke with my supervisor and had her assess her (Resident #999) as well. I did not know how it occurred. I don't know how it happened. The night before I worked with her and she was ok, her hand was not like that when I had her. I notified her family. I notified the physician. LPN Staff A said If the resident refuses care, we re-approach, redirect and speak with the resident. We try to make them as comfortable as we can. They have a right to refuse, but most of the residents on this unit do not understand. We just try and take care of them as they allow us. I speak with the family and the provider to see what we can do. On 1/16/25 at 12:15 p.m., in a telephone interview CNA Staff B said she was working on 12/18/24 on the secured unit. She said, I was on my break when the nurse (LPN Staff D) called me into the room to help them. He told me to change the sheet, so I pulled the sheets off the bed. The resident was in the bed and I put new sheets on. I did not see anything. I did not observe anyone holding the resident, that is the only thing I can tell you. I was called to change the sheets, and I did it and left the room. That is it. I did not see anything. The resident was in bed on her side, and I took the dirty sheets off the bed and I left the room. I never saw anyone holding the resident or touching her. I did not see anything. On 1/16/25 at 5:18 p.m., in a telephone interview CNA Staff E said on 12/18/24 Resident #999 was in the dining room about 8:00 or 8:30 p.m., and she was playing in feces. Resident #999 had all of her clothes off and they were on the floor. She took the resident to her room, o the bed to clean her up. Resident #999 started fighting me and I tried to speak to her very nicely and explained to her that she had feces all over her and I needed to change her. That night she was agitated, so I left her in bed for 30 minutes and I came back, and she was still agitated with me. I explained to her what I needed to do but she tried to hit me. She was yelling and tried to hit me. I put the call light on, and I asked CNA Staff C and LPN Staff D to help me because we are told to always use two people. I asked them to stand there and make sure Resident #999 did not roll onto the floor, and I cleaned her. She was fine when I left that night, there was nothing on her hands. I never told anyone to hold her. I just asked them to stay on either side of the bed, so she does not fall out of the bed. I never saw them holding Resident #999 by her arms or her hands. I work with Alzheimer's residents, and I know you have to be patient. Resident #999 always wants to fight you. She could have hit her hand in the dining room before I found her. On 1/17/25 at 2:30 p.m., in a phone interview LPN Staff D said on 12/18/24 I had just received the change of shift report. It was approximately 7:30 p.m., and Resident #999 was in the dining room, and she had blood running from her ankle. She had scratched her ankle, and she had no clothes on. Everything was off and on the floor. She had her hand in her brief, and she had feces all over her. It was everywhere and on both of her hands. The other nurse was still there, LPN Staff A. I asked her what happened, and she did not know. I told her to go, I would take care of it. I cleaned the wound and put a dressing on it. I asked CNA Staff E to come and get Resident #999, to take her to her room and take care of her and she did. Staff E came to me and said the resident was combative, hitting and throwing feces, so I told her to wait a bit and go back. At approximately 8:00 p.m., Staff E went back to the room to help Resident #999, and she asked CNA Staff C to help her. The resident accepted the care. Staff C came to get me approximately 8:30 p.m., to tell me the dressing to the ankle needed to be changed because there was feces on it. I went into the room and changed the dressing. The resident had already been cleaned by CNA Staff E. I put the dressing on the wound, I never held her legs down. I did not say that in my witness statement. CNA Staff B came into the room and took the dirty linen out, she never touched the resident. No one did that, no one was holding her. She had nothing, no bruising or nothing that I saw on her all night. On 1/16/25 at 12:00 p.m., in an interview the Chief Nursing Officer (CNO) said CNA (Staff E) felt the resident required changing because she had soiled herself and she wanted to clean her. In the end her decision to ask someone to hold her down was not appropriate and the staff were terminated. It may not be in the best interest of the residents to leave them soiled, but sometimes you have to do it and you keep trying. Resident #999 can be combative, but she has the right to refuse if she wants to, all we can do is to continue to try to provide her care. The CNO said the root cause of the event was the staff did not respect the resident's rights. On 12/24/24 the facility completed the investigation of abuse and documented The facility verifies that the injuries to Resident #999's hand was a result of physical abuse committed jointly by CNA Staff E, CNA Staff C and LPN Staff D. Their actions of holding Resident #999 down to provide care was a physical restraint of resident #999 as well as violated her right to refuse care.

Based on record review, and interview, the facility, after identifying an adverse incident, failed to initiate actions aimed at performance improvement, implement action, measure success and track performance to ensure that improvements are realized and sustained for 1 (Resident #4) of 1 resident identified with a medication error and 3 (Residents #1,# 2 and #3) of 3 residents reviewed for improper transfer. The findings included: 1. On 8/9/24, the facility reported to the Agency for Healthcare Administration (Agency) an incident in which a Staff D Registered Nurse (RN) had falsified Resident #4's medical administration record (MAR) signing off that a controlled substance was given on 8/8/24 at 9 a.m. and 12 p.m. and controlled drug sign out sheet, when it had not been given. This was discovered by Staff E (RN) when she retrieved the medication to give the 4 p.m. dose and discovered the actual count of 24 capsules reflected the last dose removed was on 8/7/24 at 4 p.m. and the dose for 9 a.m. and 12 p.m. had not been removed from the punch card on 8/8/24. On 12/11/24 at 10:18 a.m., Staff E said she had been pulled to the med cart about 11:30 a.m. or so after Staff D had to leave. She said Staff D was an as needed employee and only slotted to work a few hours. Staff E said they didn't know Staff D was leaving, that she had given the keys to someone and just left. Staff E said its possible a narcotic count may not have been done as she'd already left. Staff E said she personally didn't notice the count was off until she went to pull the 4 p.m. dose and then noticed the 2 earlier in the day had been signed off on the MAR but were still in the pack. On 12/11/24 at 10:51 a.m., the Director of Nursing (DON) said when there is a change of staff on the med cart, there is supposed to be a count, by both nurses, of the narcotics. There is a sign off sheet they both will sign off on that it was done and the count is correct. At 11:25 a.m., the DON said she was not able to provide the narcotic sign off sheet for 8/8/24. She said Medical Records said they had been told in the past to hold it for a month and then to shred them. On 12/10/24 a review of the facility file for investigation revealed no documentation of presenting to Quality Assurance Performance Improvement (QAPI) committee, identifying a root cause, no improvements implemented and no auditing to measure success and track performance. 2. On 10/26/24, the facility reported to the Agency an incident whereby Resident # 1 sustained lacerations to both shins requiring transfer to the emergency room where they placed sutures to both shins. Facility investigation found Resident #1 had been evaluated as a 2 person assist for transfers and Staff A (CNA) had improperly transferred her alone resulting in skin tears to Resident #1's shins and an emergency room visit in which she received 7 stitches to her right leg and 6 stitches to her left leg. On 12/10/24 a review of the facility file for investigation revealed no documentation of presenting to Quality Assurance Performance Improvement (QAPI) committee, identifying a root cause, no improvements implemented and no auditing to measure success and track performance. 3. On 11/8/24, the facility reported to the Agency an incident whereby Resident #2 slipped off the edge of the bed onto the floor sustaining a laceration to his forehead resulting in a trip to the emergency room where CT scan and lab work were found to be negative and a 3 cm superficial laceration to the forehead. Resident #2 had been evaluated to be dependent on staff for Hoyer transfer from the bed to his wheelchair. Facility investigation found Staff B (CNA) failed to follow the plan of care of a 2 person assist with hoyer resulting in Resident #2 sustaining a fall while unattended at the edge of his bed while Staff B left the room to get the hoyer lift. On 12/10/24 a review of the facility file for investigation revealed no documentation of presenting to Quality Assurance Performance Improvement (QAPI) committee, identifying a root cause, no improvements implemented and no auditing to measure success and track performance. 4. On 12/5/24 the facility reported to the Agency an incident where on 12/4/24 Resident #3 complained to Staff F (RN) that the aide the previous night was rough and hurt her hand resulting in a small bruise on the resident's left pinky finger. Facility investigation found Staff C (CNA) had been assigned to Resident #3 on 12/3/24 and the injuries were a result of Staff C improperly transferring Resident #3 using the hoyer lift without the assistance of another staff member. On 12/10/24 at 12/10/24 1:09 p.m., the Administrator said the incidents with Residents #1, #2 and #4 were with the prior Administration and she personally had recently reported the incident with Resident #3. She said she had recognized follow up had been lacking and she was in the process of basic education with QAPI and what it should be. She said she could not provide any documentation of any follow through by the previous Administration, but was aware some of the employees involved had been terminated. On 12/11/24 at 10:55 a.m., the Administrator said upon discovering an incident there should be an investigation done, determine the cause, develop a performance improvement plan, monitor to track success/improvement and discuss in QAPI ad hoc, don't wait until the next month. She said she has identified this as an area that needs improvement and has begun QAPI education.

Based on record review, and interview, the facility failed to ensure staff followed the individualized care plan to ensure the safe transfer of 3 (Residents #1, #2 and #3) of 3 residents reviewed, resulting in residents injury and transfer to a higher level of care. The findings included: The Facility Policy titled Transfer of Resident using support devices, revision date 11/17 indicated Under Procedure: The Therapy Department will screen residents and determine a level of assistance needed for transfers and movement. This determination will be incorporated into the plan of care for the resident and communicated to the staff by means of the care plan. Under bullet 2 (d) Total Assistance - resident is non-weight bearing and requires mechanical devices for lifting. The resident requires two (2) persons and a mechanical lift to facilitate resident movement and/or transfer. 1. Review of Resident #1's clinical record revealed the Resident Care Guide for Certified Nurse Assistants (CNA) indicated Resident #1 required two staff assistance for transfers. Resident #1's care plan with a start date of 10/21/24 indicated Transfer with 2 assist, weight bearing as tolerated. Review of progress notes revealed on 10/27/24 Resident #1 had been found the previous evening with blood coming from her left shin. The resident stated she didn't know what happened. Resident #1 was transferred to the local emergency room and returned with sutures in place to the left and right shin. Review of the incident investigation revealed Certified Nursing Assistant (CNA) Staff A transferred the resident from her recliner to her wheelchair and from the wheelchair to the bed with a one person transfer. The facility's investigation included direct care staff interviews. The incident investigation noted Resident #1 sustained the skin tears during the improper transfer with one staff assist. On 12/10/24 at 2:07 p.m., in a telephone interview, Staff A said the skin tears happened before she came on shift. Staff A said Resident #1 was a physical transfer and mostly everybody transferred her by themselves. Staff A said she told the former Administrator on paper Resident #1 is a two person assist, but she had never seen two staff transfer the resident, everyone transferred her by themselves. Staff A said sometimes the paper does not get updated and her transfer was perfect. 2. Review of Resident #2's clinical record revealed the Resident Care Guide for CNAs indicated Resident #2 required the use of a mechanical lift with two staff assistance for transfers. The care plan noted the resident used a sit to stand lift with two person assist for all transfers. Review of progress notes for Resident #2 revealed a note dated 11/8/24 indicating resident had slipped out of the bed and was found sitting on a hoyer pad on the floor. Resident #2 had a laceration on his forehead and was sent out to the hospital. Returned to facility same day with no acute findings other than small 3 cm superficial laceration to the forehead, vertical midline. Review of the facility investigation revealed Staff B (CNA) was preparing to transfer Resident #2 from bed using they hoyer lift and had left him alone seated at the edge of the bed. Staff A then left the room to obtain the hoyer lift and Resident #2 fell off the edge of the bed. 3. On 12/10/24 at 1:09 p.m., during an interview, the Administrator said on 12/3/24 there was another reportable incident involving an improper transfer with Resident #3 and provided the investigation. Investigation indicated on 12/4/24 Resident #3 reported to her nurse the CNA who worked with her the previous day 12/3/24 was rough with her, grabbed her hand and it was painful. Resident #4 had 2 small bruises on her left hand. Administrator said through the course of the investigation she determined Staff C had improperly transferred Resident #3 in the bed using the hoyer lift alone. She said Staff C had told her the private duty had assisted but when she interviewed the private duty they said they had left that day at 5 pm. Administrator said she terminated Staff C's employment due to improper transfer and false information in her interview Record review of Resident #3's chart revealed the Resident Care Guide for CNA's indicated Resident #2 was total dependence hoyer with 2 staff needed for transfer. Resident #3's care plan indicated hoyer lift for transfers with 2 person assist. On 12/10/24 at 2:48 p.m., during an interview, Resident #3's private duty aide said she did not not help with a transfer and said she had left the facility that day around 5 p.m. and resident was still out of bed when she left. On 12/10/24 at 1:09 p.m., during an interview, the Administrator said the first two incidents happened under the prior administration, and she and the Director of Nursing were new. She said she had recognized follow through had been lacking and was in the process of basic education with Quality Assurance Performance Improvement (QAPI) and what it should be. She said Staff B and C had been terminated in regards to these incidents, but she does not have anything that will show any type of performance improvement or audits were documented or even done.

Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement necessary interventions to prevent avoidable accidents for 1 (Resident #143) of 4 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, and a fracture requiring a transfer to a higher level of care. The findings included: The facility policy Fall Management Program origination 3/8/17 (revised 11/22) documented, The Falls Management Program is an interdisciplinary quality improvement program that provides resident fall processes and outcomes. The program utilizes a systemic approach to assessment, individualized intervention and monitoring that will result in injury reduction and minimizing fall risk to our residents . The IDT [interdisciplinary team] will complete a thorough investigation as well as a root cause analysis of all falls by completing a Post Fall Review form. The care plan, and staff assignment sheets will be adjusted as needed to reflect current and appropriate fall interventions. The nursing staff will observe, interview as appropriate and document resident's post fall status as well as effectiveness of identified fall interventions in place on each shift for the next 3 days in the resident record. It is important to recognize that on size does not fit all when considering interventions for residents fall management. Review of the clinical record revealed Resident #143 had an admitted [DATE] with readmissions on 1/20/23 and 2/18/23 with diagnoses including Alzheimer's, dementia, left hip fracture, frequent falls, and aphasia (loss of ability to express or understand speech). The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 1/26/23 documented Resident #143 required limited assistance of one person with bed mobility, transfers, and ambulation. Resident #143 was frequently incontinent of urine, and bowel. A urinary and bowel toileting program was not being used to manage the resident's incontinence. The MDS noted a Brief Interview for Mental Status (assessment of a resident's cognitive function) was 99 indicating the resident was unable to complete the interview. The facility initiated a care plan on 12/26/22 indicating Resident #143 was at risk for falls due to weakness, low endurance and decreased mobility as a result of acute or chronic health conditions and aphasia. The care plan interventions on 12/28/22 included to orient resident to room, call light, and need to call for, and wait for assistance, maintain adequate lighting in resident's room, keep bed in lowest position possible, attempt to keep resident as active in activities during the day as resident will allow. The facility fall assessment dated [DATE] determined the resident was a moderate risk for falls. Review of the incident reports revealed: On 1/20/23 at 6:30 a.m., Resident #143 was found on the floor in her room and was unable to state what she was doing at the time of the fall. Resident #143 sustained a skin tear to the right side of her abdomen. On 1/21/23 at 3:31 p.m., Unit Manager, Licensed Practical Nurse (LPN) Staff F completed the investigation follow up and documented Resident #143 was agitated, had dementia and restlessness. LPN Staff F documented, IDT (interdisciplinary team) meeting regarding found on floor next to bed. Regular mattress in place. Work for grab bars placed. Intervention: Staff to ensure wheelchair to be placed at bedside. The facility lacked documentation of an investigation to determine the root cause of the fall and implement appropriate interventions to prevent further avoidable falls. On 1/24/23 at 1:00 a.m., Resident #143 was found on the floor in her room. After assessment, a bump noted on the back of the head. Resident complained of pain. Tylenol given as ordered and ice pack applied. On 1/25/23 at 4:48 p.m., LPN Staff F completed the investigation follow up and documented Visual reminder to use call bell for assistance. There was no documentation of an investigation to determine the root cause of the fall and implement appropriate interventions to prevent further avoidable falls. On 1/29/23 at 6:25 p.m., Resident #143 was found sitting on the floor. The incident report documented this nurse was notified by neighboring resident family that she heard a big bang. Upon arrival resident was observed sitting, guarding LLE (left lower extremity) and being in distress/teary. Three wheeled walker next to her. The nurse documented the resident reported pain pointing to the left knee. The nurse assessed Resident #143 and documented the left lower extremity appeared shorter and rotated with substantial bruising. The resident was sent to the local hospital emergency room (ER). Review of the ER nursing documentation revealed Resident #143 had left knee swelling and laceration to the left forehead. A left knee x-ray was obtained. The x-ray report documented no acute fracture or dislocation. The clinical impressions were closed head injury, contusion, acute pain of the left knee. Resident #143 was transferred back to the facility. On 2/27/23 at 1:03 p.m., (29 days after the fall), LPN Staff F completed the investigation follow up and documented, IDT meeting regarding fall 1/29/23. Resident returned from ER (emergency room ) continue B&B (bowel and bladder) observation and set up B&B schedule for resident. The clinical record lacked documentation a bowel and bladder schedule was initiated for the resident. The Admission MDS with a target date of 2/23/23 noted a toileting program was not being used to manage the resident's urinary and bowel continence. On 3/16/23 at 11:40 a.m., Unit Manager LPN Staff F said the root cause of the fall on 1/29/23 was Resident #143 got up to go the bathroom because she does not get up unless she has to go to the bathroom. The resident is nonverbal and took herself to the bathroom. She was found next to the bed with the walker so, I figured she was going to the bathroom. The investigation as to why she fell was she was getting up to go to the bathroom it is what she always does. LPN Staff F confirmed there was no documentation the bowel and bladder schedule was initiated. On 2/10/23 at 9:00 p.m., a facility incident report documented 2/9/23 resident complained of left hip pain, primary nurse notified, some bruising and edema on left hip. Resident #143 was sent to the local hospital emergency room where an x-ray result documented an acute left hip fracture. The resident was admitted to the hospital and had a surgical repair of the left hip fracture on 2/12/23. On 3/14/23 at 12:57 p.m., an observation showed Resident #143's room door was closed and no staff were observed in the hallway. The resident was in her room alone and the call light was on the floor out of her reach. On 3/15/23 at 9:37 a.m., Certified Nursing Assistant (CNA) Staff G said Resident #143 will yell, no words just screams when she wants assistance. She is able to use the call light, but she does not. The CNA said Resident #143 was able to use the toilet and ambulates with the rolling walker and assistance. Staff G said the resident will go to a few activity programs a week and she has family and friends who come to visit her. She does not speak but she understands you. I was not here when she fell and hurt her hip. She could walk with the walker but not by herself, she always needed help. The CNA said, Resident #143 did not like to get out of bed, and she will yell out. On 3/16/23 at 9:40 a.m., the Administrator confirmed the incident report did not specify if the care plan interventions were in place at the time of the fall on 1/29/23. The Administrator confirmed Resident #143 had multiple falls and said, we review the falls and update the care plan. Review of Resident #143's care plan showed the care plan interventions were not updated after the falls on 1/20/23, 1/24/23 and 1/29/23. On 3/16/23 at 1:53 p.m., the Rehab Director said prior to Resident #143 sustaining the left hip fracture she required supervision with bed mobility and stand by assistance. She was ambulating with supervision walking household distance of 100 feet with a three wheeled walker and contact guard. She was not able to toilet herself and was not able to dress her lower body. The Rehab Director said as long as someone was in the general area with eyes on her, she was safe to ambulate. The Rehab Director confirmed Resident #143 had a decline in ambulation and activities of daily living since she sustained the left hip fracture.

Based on observations, interviews, records review and facility policy review the facility failed to review the risks and benefits of bed rails with the resident/representative or attempt alternative interventions prior to bed rail installation for 5 residents, (#28, #97, #110, #143 and #554) of 5 residents reviewed for bed rails. The findings included: Review of facility policy titled, Grab Bars, revised 1/2023 stated, This program will promote resident mobility with the highest quality of care while maintaining resident safety. These guidelines are to ensure the safe use of grab bars as restraints unless necessary to treat a resident's medical symptoms. 1. Clinical records review for Resident #97 documented an admitted to the facility of11/14/22. A Grab bar data collection form was completed on 11/15/22 at 2:36 p.m. An order was entered on 11/15/22 at 2:34 p.m. for patient to have bilateral grab bars. A verbal consent for side rail device was signed by the Health Care Surrogate on11/15/22. On 3/13/23 at 945 a.m., observed bilateral grab bar / side rails elevated on both sides of Resident #97's bed. Certified Nursing Assistant (CNA) Staff BB said resident had the grab bars for as long as she has worked with her. On 3/14/23 at 10:42 a.m., observed bilateral grab / side rails on both sides of Resident #97 bed. CNA Staff Q said she has had them as long as she has worked with her. 2. Clinical record review for Resident #110 documented an initial admission to the facility of 7/7/22 and current admission of 7/12/22. A Grab bar data collection form was completed on 7/8/22 at 12:24 a.m. An order was entered on 7/13/22 at 5:51 p.m. for the resident to have bilateral grab bars. A consent for side rail device was signed by resident 7/8/22. On 3/13/23 at 1:30 p.m., observed Resident #110 in bed with bilateral grab bar side rails elevated on both sides of bed. On 3/14/23 at 10:07 a.m., Resident #110 observed in bed with bilateral grab bar side rails elevated. Resident said she did not recall signing a consent or having risks reviewed with her before they were installed. On 3/15/23 at 12:00 p.m., CNA Staff CC said resident #110 has had the side rails as long as she has been on their floor. The CNA said, Most of our residents have the grab bars so they can hold on to them when we are doing care. I don't know what is done to decide who gets grab rails or not. That is up to the nurses. On 3/15/23 at 1:15 p.m., interviewed Registered Nurse (RN) Staff DD about Resident #97 and Resident #110 having grab bars on their bed. RN Staff DD said, we have a grab bar assessment that is done, we get an order and consent. RN Staff DD did not know of any interventions attempted prior to installation of the grab bars side rails. On 3/15/23 at 4:00 p.m., the DON confirmed Resident #97 and Resident #110 had grab bars in place. She said, they are for bed mobility. The DON said she would have to look into interventions attempted prior to the installation of the grab bars. She said she was not sure what was meant by interventions attempted. The DON said, They are screened by therapy and nursing. I will need to look into that. On 3/16/23 at 9:32 a.m., the DON confirmed there were no documented interventions attempted prior to installing the grab bar on residents' beds. She confirmed the grabs bar were started on the day of admission for Resident #97 and #110. 41155 3. Review of the clinical record revealed Resident #28 had a readmitted [DATE] with diagnoses including hypertension, fracture of the right femur and morbid obesity. A Grab Bar Data Collection form dated 2/10/23 documented intervention lower bed to the floor or provide a low bed. There was no documentation in the clinical record of alternate interventions were attempted before the grab bars were applied to the bed. Random observations on 3/14/23 at 12:39 p.m., and 3/15/23 at 8:56 a.m., noted Resident #28 in a regular bed at regular height, with grab bars on both sides in the raised position. 4. Review of the clinical record revealed Resident #143 had a readmitted [DATE] with diagnoses including muscle weakness, fracture of the left femur/left hip and repeated falls. A Grab Bar Data Collection form dated 2/18/23 documented grab bars were not recommended. On 3/14/23 at 12:57 p.m., Resident #143 was observed in a low bed with grab bars in the raised position on both sides of the bed. 5. Review of the clinical record revealed Resident #554 had an admitted [DATE] with diagnoses including muscle weakness and sever protein calorie malnutrition. A Grab Bar Data Collection form dated 2/8/23 documented lower bed to the floor or provide a low bed. There was no documentation in the clinical record of alternate interventions were attempted before the grab bars were applied to the bed. On 3/14/23 at 2:55 p.m., Resident #554 was observed in a regular bed with grabs on both side of the bed in the raised position. On 3/16/23 at 9:03 a.m., in an interview the Administrator confirmed there was no documentation of alternate interventions attempted before the grab bars were applied for Residents #28, #143 and #554.

Based on review of facility policy and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility. The findings included: The facility policy, Activity Programs - Staffing (revised June 2018) documented, Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. Our activity programs are under the direct supervision of a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable by the state in which practicing. On 3/15/23 at 3:14 p.m., Activity Aide Staff H said the facility did not have an Activity Director to oversee the activity programs. Staff H said there were five activity aides to cover six floors of the facility. She said they are each assigned a floor and there are two units on each floor. Staff H said she bounced around a bit to cover her assigned floor and assist with coverage on other floors. On 3/15/23 at 4:21 p.m., the Administrator, said the Activity Director resigned on 10/21/22 and she had tried to replace her. The Administrator said she was overseeing the activity department and was meeting with the activity staff each week. The Administrator confirmed she did not have the credentials to oversee the activity program.

Based on observation, record review, and staff interview, the facility failed to conduct regular inspection of all bed frames, mattresses, and grab bars, as part of a regular maintenance program to ensure they remain safe, in good operating condition and to identify areas of possible entrapment for residents with grab bars. This had the potential to cause serious injury to the residents. The findings included: On 3/14/23 random observations on all six floors of the facility revealed multiple residents with grab bars on the beds in the raised position. Review of the facility's list of residents with grab bars revealed 117 residents had grab bars installed on their bed. On 3/16/23 at 10:44 a.m., in an interview the Maintenance Manager said the grab bars are on the beds prior to a resident's admission. He said we order them from the manufacturer and we put them on, that is all we do. We do not assess the grab bars or beds for areas of entrapment. The Maintenance Manager said he receives a work ticket from the staff requesting grab bars and they are placed on the beds. He said the mattress had two positions, wide and narrow but he did not measure for gaps between the mattress and the grab bars. He said a bed check was done quarterly and every movable component is checked. Grab bars are already on the beds and are either up or down, they are called pivoting plastic grab bars. The Maintenance Manager said routine maintenance of 20 beds was conducted monthly. The Maintenance Manager was not able to locate documentation of the routine bed checks for safety of the grab bars. He said he had no policy for use of the grab bars and said he did not check the grab bars and the mattress for entrapment areas. He confirmed he did not measure for gaps that might be present between the mattress and the grab bars. On 3/16/23 at 12:00 p.m., in an interview the Administrator confirmed the maintenance team was not measuring the beds and grab bars for areas of potential entrapment.

Based on observation, clinical record review, review of the facility's policy and procedure, resident and staff interviews, the facility failed to provide care and services in accordance to professional standards of practice to meet the needs of 2 (Resident #148, and #67) of 5 sampled residents reviewed for skin condition. The findings included: 1. Clinical record review revealed Resident #148 was admitted to the facility on [DATE]. Diagnoses included fracture of the right femur. Resident #148 was non-weight bearing on the right leg. The physician's orders dated 1/27/23 included to apply thigh high TED hose (compression stockings) every morning before rising and remove at bedtime. On shower days, staff was to apply the TED hose after the shower and remove at bedtime. The Admission Minimum data set (MDS) assessment dated [DATE] revealed resident #148 was cognitively intact. The resident required limited physical assistance of one person for dressing (including donning/removing a prosthesis or TED hose), and bathing. Review of the Treatment Administration Record for 3/1/23 through 3/15/23 revealed documentation the TED hose was applied daily at 6:00 a.m., and removed at 9:00 p.m., including on 3/13/23 and 3/14/23. On 3/13/23 at 9:38 a.m., and 3:12 p.m., Resident #148 was observed sitting in a recliner. She was not wearing the TED hose. On 3/13/23 at 3:12 p.m., Resident #148 said she had never had the TED hose put on. On 3/14/23 at 1:31 p.m., Resident #148 was observed in her room. She stated she was just returning from the salon. Resident was not wearing the TED hose. She stated staff had never applied the TED hose to her legs. She said no one asked if she wanted to wear them, and she had never refused to wear them. On 3/15/23 at 2:51 p.m., in a telephone interview Licensed Practical Nurse (LPN) Staff X, stated she works the night shift and took care of Resident #148. She said, I don't have any knowledge of her [Resident #148] wearing the TED hose or refusing them. I do not recall putting them on her. On 3/15/23 at 3:08 p.m., Certified Nursing Assistant (CNA), Staff S said Resident #148 required one person assistance for dressing and transferring. She said, I didn't put the TED hose on her myself. I do not recall seeing them on her. On 3/15/23 at 3:28 p.m., LPN Staff O said she knew Resident #148 had an order to wear TED hose during the day but she could not recall Resident #148 wearing them. On 3/15/23 at 3:35 p.m., the Physical Therapist assigned to resident #148 stated she never saw the resident with TED hose on. On 3/16/23 at 3:41 p.m., Registered Nurse Staff Z stated she did not recall Resident #148 wearing TED hose, the resident may have refused on occasion. She said the flow sheet showing documentation of the TED hose being put on and taken off may have been documented incorrectly, and she would have to investigate it further. 2. The facility's policy and procedure titled Skin tear protocol with a policy revision date of 1/23 noted skin tears will be treated immediately to expedite rapid healing. The procedure noted to write the order as described. Cleanse with (brand name) wound cleanser . Apply silicone foam dressing. Change every seven days and as needed. The protocol specified, in the presence of a skin tear, the procedure will be written as an order and transcribed to the Treatment Administration Record. The Licensed Nurse will document the procedure and the progress. Review of the clinical record for Resident #67 revealed an admitted [DATE]. The Admission Minimum Data Set (MDS) assessment (tool to measure health status of nursing home residents) with an assessment reference date of 2/12/23 noted the resident's skin was intact. On 3/13/23 at 11:15 a.m., Resident #67 was observed sitting on the edge of her bed. Resident #67 said she had multiple skin tears. A dressing dated 3/2/23 was observed to the right shoulder, and a dressing to the right leg, and left upper arm dated 3/7/23. On 3/15/23 at 8:14 a.m., Resident #67 was observed with the same dressing to the right shoulder dated 3/2/23, the right leg dated, and left upper arm dated 3/7/23. Review of the skin evaluation forms completed on 2/18/23, 2/25/23, 3/3/23, and 3/12/23 did not note skin tears to the right shoulder, the right leg and left upper arm. Review of the Treatment Administration Record (TAR) for 3/23 for Resident #67 failed to reveal treatment orders for the right shoulder the right leg and left upper arm. The TAR had a weekly treatment order for a skin tear starting on 3/3/23 and ending on 3/15/23. The TAR did not specify the location of the skin tear. On 3/15/23 at 8:16 a.m., a joint observation of the dressings to Resident #67's right shoulder, right leg and left upper arm was made with Licensed Practical Nurse (LPN) Staff AA, and the 3rd-floor Unit Manager. Both nurses verified the dressing to the right shoulder was dated 3/2/23 and the dressings to the right leg and left upper arm were dated 3/7/23. LPN Staff AA said the skin tear protocol was to change the dressing every seven days. She confirmed the dressing to the right shoulder was dated 3/2/23 and had not been changed in 13 days. She also confirmed the dressing to the right leg and left upper arm were dated 3/7/23 and had not been changed in eight days. On 3/16/23 at 1:04 p.m., the Unit Manager said she would investigate why the treatment to the right shoulder, the right leg and the left upper arm were not done.

Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to have documentation of a thorough investigation related to alleged violations, including injuries of unknown origin for 2 (Resident #143 and #140) of 3 sampled residents reviewed for accidents. The findings included: 1. The facility policy Fall Management Program origination 3/8/17 (revised 11/22) documented, The Falls Management Program is an interdisciplinary quality improvement program that provides resident fall processes and outcomes. The program utilizes a systemic approach to assessment, individualized intervention and monitoring that will result in injury reduction and minimizing fall risk to our residents. An incident report will be completed for every resident fall within 24 hours. The interdisciplinary team (IDT) will complete a thorough investigation as well as a root cause analysis of all falls by completing the Post Fall Review Form. Review of the clinical record revealed Resident #143 had an admitted [DATE] and a readmitted [DATE] with diagnoses including Alzheimer's, dementia, left hip fracture, frequent falls, and aphasia (loss of ability to express or understand speech). The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 1/26/23 documented Resident #143 required limited assistance of one person with bed mobility, transfers, and ambulation. The MDS noted a Brief Interview for Mental Status (assessment of a resident's cognitive function) was 99 indicating the resident was unable to complete the interview. The facility fall assessment dated [DATE] determined the resident was a moderate risk for falls. The facility initiated a care plan on 12/26/22 indicating Resident #143 was at risk for falls due to weakness, low endurance and decreased mobility as a result of acute or chronic health conditions and aphasia. The care plan interventions on 12/28/22 included to orient resident to room, call light, and need to call for, and wait for assistance, maintain adequate lighting in resident's room, keep bed in lowest position possible, attempt to keep resident as active in activities during the day as resident will allow. On 1/20/23 at 6:30 a.m., Resident #143 was found on the floor in her room and was unable to state what she was doing at the time of the fall. On 1/21/23 at 3:31 p.m., Unit Manager, Licensed Practical Nurse (LPN) Staff F completed the investigation follow up and documented IDT (interdisciplinary team) meeting regarding found on floor next to bed. Regular mattress in place. Work for grab bars placed. Intervention: Staff to ensure wheelchair to be placed at bedside. On 1/24/23 at 1:00 a.m., Resident #143 was found on the floor in her room. On 1/25/23 at 4:48 p.m., LPN Staff F completed the investigation follow up and documented Visual reminder to use call bell for assistance. On 1/29/23 at 6:25 p.m., Resident #143 was found sitting on the floor. The incident report documented This nurse was notified by neighboring resident family that she heard a big bang. Upon arrival resident was observed sitting, guarding LLE (left lower extremity) and being in distress/teary. Three wheeled walker next to her. The nurse documented the resident reported pain pointing to the left knee. The nurse assessed Resident #143 and documented the left lower extremity appeared shorter and rotated with substantial bruising. The resident was sent to the local hospital emergency room where a left knee x-ray was obtained. The x-ray report documented no acute fracture or dislocation. The resident was transferred back to the facility. On 2/27/23 at 1:03 p.m., LPN Staff F completed the investigation follow up and documented, IDT meeting regarding fall 1/29/23. Resident returned from ER (emergency room ) continue B&B (bowel and bladder) observation and set up B&B schedule for resident. On 2/10/23 at 9:00 p.m., a facility incident report documented 2/9/23 resident complained of left hip pain, primary nurse notified, some bruising and edema on left hip. Resident #143 was sent to the local hospital emergency room where an x-ray confirmed acute left hip fracture. The resident was admitted to the hospital and had a surgical repair of the left hip fracture on 2/12/23. On 3/6/23 at 4:16 p.m., LPN Staff F completed the investigation follow up and documented, Left hip fx (fracture). Provider notified supervisor to send to ER for left hip fx, pain management and ortho consult. On 3/16/23 at 11:40 a.m., LPN Staff F said she completed the incident form on 1/29/23 at 6:25 p.m., when Resident #143 was found on the floor. She said she did not find her. The Registered Nurse completed the incident report but did not sign it and, I signed it after I reviewed it. The initial investigation process is the manager or supervisor is notified. The process is to ensure we did contact the house supervisor. In this situation, the supervisor sent her out. Normally we review the incident and if it was a witnessed fall, we interview staff to see what they observed. If the fall was unwitnessed we do not do interviews but we will now. The root cause of the fall on 1/29/23 was Resident #143 got up to go the bathroom because she does not get up unless she has to go to the bathroom. The resident is nonverbal and took herself to the bathroom. She was found next to the bed with the walker so I figured she was going to the bathroom, it does not say that on the form. The investigation as to why she fell was she was getting up to go to the bathroom it is what she always does. LPN Staff F confirmed she did not have documentation of witness statements, and no documentation of an interview with the family member who reported on 1/29/23 hearing a loud bang from the resident's room. LPN Staff F said there was no documentation of additional falls between 1/29/23 and 2/10/23 when the left hip fracture was identified. The LPN said, the resident was sent to the emergency roiagnom on [DATE] and returned with no fracture, she was propelling herself in the wheelchair with no pain. On 2/9/23 she had pain and we sent her for an x-ray, it showed a fracture, and she was sent to the emergency room . LPN Staff F said I can't say for certain if Resident #143 was ambulating after the fall on 1/29/23 because there was no documentation. I can't say for sure the left hip fracture was related to the fall on 1/29/23 because there was no investigation. On 3/15/23 at 1:38 p.m., the Administrator who is the Risk Manager said she did not investigate or file a report to the required State Agency once the hospital identified an acute left hip fracture with Resident #143, because we did not know what happened to her. On 3/16/23 at 9:40 a.m., in an interview the Administrator said she did an informal investigation with staff but had no documentation of an investigation for the acute left hip fracture. The Administrator confirmed Resident #143 had multiple falls before the left hip fracture was identified on 2/10/23. The Administrator confirmed the follow up and investigation section of the incident reports were completed several weeks after the incident and did not show a complete investigation. On 3/16/23 at 1:31 p.m., the Director of Nursing said they felt the fracture of the left hip was a result of the fall on 1/29/23 but confirmed no investigation was completed. 25618 2. On 3/14/23 at 1:50 p.m., Resident #140 was observed with a purplish-blue bruise under his right eye. On 3/14/23 at 1:52 p.m. , Resident #140's wife said the bruise around her husband's right eye appeared one-day several weeks ago. When she asked what happened they told her they did not know. On 3/15/23 review of Resident #140's medical record revealed he was admitted on [DATE] with a diagnosis of muscle weakness and Parkinson's disease. A nursing progress note dated 2/24/23 at 7:24 a.m. said at 7:15 a.m. they found a new small open area to Resident #140's right temple. They applied pressure to the area and then left it open to the air. The cause of the open area was unknown, and the incident was unwitnessed. Neuro checks were initiated. The daughter was notified, and staff would continue to monitor. Resident #140's medical record revealed a fall care plan stating Resident #140 was at risk for falls due to weakness, and poor safety awareness related to dementia diagnosis. Some of the approaches listed to keep Resident #140 from falling were to keep the call light within reach, the bed in a low position, reduce stimulus in the room at night, maintain adequate light when the resident was awake and keep personal items within reach. On 3/15/23 at 12:10 p.m., Certified Nursing Assistant (CNA) Staff K, she said when she came to work several weeks ago, she found Resident #140 sitting in a chair. There was a large bruise around his right eye and temple area but due to his dementia, he was unable to tell her what happened. She believed he hit his head on something but did not know what caused the bruise on Resident #140's right temple and eye area. She said no one from the administration interviewed her about the bruise on Resident #140's right temple area. On 3/16/23 at 10:57 a.m., the Director of Nursing (DON), she said Resident #140 was admitted to the facility on [DATE]. She said due to Resident #140's increased confusion and safety concerns he was moved to a secured unit. The DON reviewed Resident #140's medical record and confirmed the nurse wrote a progress note on 2/23/23 at 7:43 a.m. which stated they found a new small open area to Resident #140 right temple. She said when an injury of unknown origin was found an incident report should be created and a full investigation should be started to include resident and staff interviews to assist in determining what could have caused the injury. The DON said after reviewing the 2/24/23 incident report, Resident #140 was found by Staff K in the living area with a bruise on his right temple. She said there was no documentation they had interviewed any of the residents or staff to determine how the injury might have occurred and/or put into place interventions to ensure it didn't happen again. She said the Nurse Manager was responsible to conduct the investigation. On 3/16/23 at 12:55 p.m., Nurse Manager Staff F and Clinical Coordinator Staff L, said they oversee the memory care units. They said on 2/24/23 during the morning meeting they saw the incident report about a bruise of unknown origin on Resident #140's right temple. After the morning meeting, they did an assessment of the bruise of unknown origin on Resident #140's right temple. They said since it was not bleeding, they did not have to get a treatment order. Staff F said they did not document their assessment of the bruise on Resident #140's right temple area and did not investigate to determine how the bruise of unknown origin might have occurred and/or put interventions in place to ensure it did not occur again. On 3/16/23 at 4:26 p.m., the DON said after a full review of Resident #140's medical record, the incident report, and the morning Stand Up meeting notes, she was unable to find the documentation they had completed a full investigation into the bruise of unknown origin to Resident #140's right temple as required.

Based on observation, record review, review of facility's policy and procedure, resident representative and staff interviews, the facility failed to assist with necessary podiatry follow up appointments for 1 (Resident #81) of 5 sampled residents reviewed. The findings included: The facility's policy and procedure for care of the fingernails and toenails reviewed February 2018 noted the purpose included to keep nails trimmed, and to prevent infections. The general guidelines specified unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairment; stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. Review of the clinical record for Resident #81 revealed an admitted [DATE]. Diagnoses included generalized muscle weakness, dementia, and high blood pressure. Resident #81 resided in the Memory Care Unit of the facility. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 2/20/23 noted the resident was cognitively impaired and dependent on staff for activities of daily living. Resident #81 did not reject care. Review of the physician's progress notes revealed on 9/8/22 Resident #81 saw the podiatrist. The podiatrist documented a diagnosis of atherosclerosis of the arteries of the extremities (thickening of the arteries, causing reduced blood flow to extremities). The podiatrist documented Resident #81 had a painful corn to the left foot; ten mycotic (nail fungus) painful incurvated, inflamed toenails; ingrown toenails; pain in left foot; pain in right toes; pain in left toes. The podiatrist performed a sharp debridement (removal of dead tissue) of the keratotic lesion (corn). The podiatrist documented Resident #81 needed to be seen again in two months. Review of the Social Work Progress Note dated 2/22/23 revealed a care plan meeting was held with the resident's healthcare surrogate (HCS). The HCS said she was worried about Resident #81's toenails. The HCS stated she would check Resident #81's toes and let them know if she needs to be seen. On 3/15/23 at 12:55 p.m., during a telephone interview, Resident #81's Health Care Surrogate (HCS) said the facility was not taking care of Resident #81's toenails. On 3/16/23 at 10:35 a.m., observation of Resident #81's toenails with Clinical Coordinator Registered Nurse (RN) Staff L revealed long, thick, yellow toenails on both feet. RN Staff L said toenail clippers would not be effective for trimming the toenails, and Resident #81 should be seen by the podiatrist. On 3/16/23 at 12:29 p.m., RN Staff L verified on 9/8/22 the podiatrist requested a two month follow up appointment for Resident #81. She said the facility failed to arrange the two month podiatry follow up appointment, and Resident #81 did not receive the necessary foot care. On 3/16/23 at 2:58 p.m., the Administrator said it has been a problem arranging and transporting Memory Care Residents to and from the podiatrist for a few months.

Based on record review, review of facility's policy and procedure, and staff interviews the facility failed to follow the physician's orders and administer medications according to professional standards of practice resulting in a significant medication error for 1 (Resident #5) of 3 residents sampled for accuracy of medication administration. The findings included: The facility policy titled, Medications- Administration Of with a policy revision date of 1/27/22 documented, Medication will be received, processed and administered in a safe manner that complies with State and Federal Regulations and Professional Standards of Care. In administering medications, medication administration records, physician orders and labels on drug containers are used as reference points.When administering medications, each dose of the drug is given according to the directions on the medication sheet. Clinical record review showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes showed on 10/7/22 at 3:58 a.m., Resident #5's reported chest pressure and chest pain. Oxygen was administered to the resident and the physician was notified. Resident #5 was transferred to the emergency room and required intravenous diuretic medication for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/27/22 at 11:29 a.m., the Director of Nursing (DON) said the nurse identified on her second day of work the order was to give three tablets of [MEDICATION(S)] 20 mg, and only one tablet was given. She said the resident received the wrong dose of [MEDICATION(S)] three days in a row. Review of the facility's incident report submitted to the Agency for Health Care Administration on 10/24/22 showed the facility utilizes a medication dispensing machine that houses and dispenses medications into totes for the medication pass. The [MEDICATION(S)] was not packaging and dispensing as part of the routine process. This resulted in the nurse having to individually pull the [MEDICATION(S)] each day from the machine. On 10/6/22 the floor nurse reported to the nurse manager the [MEDICATION(S)] was not packaging. Upon pulling a report from the machine, the facility realized that likely Resident #5 was not getting the correct amount of [MEDICATION(S)]. The report noted the nurse manager corrected the order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/18/22 the Director of Nursing became aware of the incident, conducted further investigation and verified Resident #5 received one tablet of [MEDICATION(S)] 20 mg on 10/3/22, 10/4/22 and 10/5/22 instead of three tablets of [MEDICATION(S)] 20 mg for a total of 60 mg as per the physician's order. The decision was made to submit an adverse incident report to the Agency for Health Care Administration since the failure to administer the prescribed amount of [MEDICATION(S)] could have been the result of the resident's hospitalization . The facility concluded the following contributed to the medication error: The machine was not packaging the medication. The nurses did not follow the five rights of Medication Administration. There are three different views on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses were using the monthly view and the number of pills is displayed towards the bottom of the screen. The facility does not require nurses to use a certain view. It was determined education was needed on the different views available and where to look for key information. On 10/27/22 at 5:20 p.m., Registered Nurse (RN) Staff E said she was familiar with the medication dispensing system used by the facility. RN Staff E confirmed she removed one [MEDICATION(S)] 20 mg tablet from the system on 10/3/22 and 10/4/22 for Resident #5. RN Staff E said she did not see the portion of the physician order to give the 3 tablets. The RN Staff E confirmed the medication error. Review of the education provided to the nurses revealed on 10/18/22 the facility individually in-serviced the staff nurse and the agency nurse who administered the wrong dose of [MEDICATION(S)] to Resident #5. On 10/26/22 seven staff nurses were educated and on 10/27/22 five staff nurses were educated. The facility educated 13 of the 53 nurses listed on their employed at the facility. On 10/27/22 at 3:24 p.m., the DON said the pharmacy was investigating why Resident #5's [MEDICATION(S)] was not packaged but she has not yet received an answer.

Based on record review, observations, and interviews, the facility failed to ensure food was served in a sanitary manner by not taking the temperatures of food prior to serving and by wet nesting pots on the self with clean pots. The findings included: Review of the documented Trayline Taste & Temperature Log from 9/1/22 to 9/21/22 showed: The food temperature was not documented for breakfast on 9/1/22, 9/2/22, 9/3/22, 9/4/22, 9/5/22, 9/6/22, 9/7/22, 9/8/22, 9/11/22, 9/14/22, 9/15/22, 9/16/22 and 9/21/22. The food temperature was not documented for lunch on 9/6/22, 9/8/22, 9/11/22, 9/15/22, and 9/16/22. The food temperature was not documented for the supper meal on 9/3/22, 9/5/22, 9/6/22, 9/7/22, 9/11/22, 9/12/22, 9/15/22, and 9/16/22. On 9/21/22 at 1:25 p.m., dietary Staff H verified hot food is served daily at breakfast. Staff H said she was not aware she was supposed to take the temperature of all hot food items being served to residents on the tray table. Staff H said she had just started plating food about a month ago for residents. On 9/21/22 at 1:53 p.m., dietary Staff I said he documents the food temperature. Staff I said he forgot to fill out the form in some areas. He got mixed up as to where to put the different items because the facility was using a new form to document the food temperature. On 9/21/22 at 1:15 p.m., dietary Staff J was observed placing several small pots in the rack holding clean pots. He was taking them as they were still wet from the sink and wet nesting them on a large rack with clean pots. On 9/21/22 at 1:20 p.m., Staff J verified he had wet nested pots next to clean dry pots.

Based on observation, review of facility policy and procedure, record review, and staff and resident interview, the facility failed to follow Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding included: The facility policy titled, Restorative Nursing Services, revised 09/2020, states, The purpose is to provide services that will increase or maintain functional performance in activities of daily living, diminish the risk of psychological and physiological complications of inactivity and enhance the resident's dignity and quality of life in the skilled car setting. Procedure #3 states, After receiving and reviewing the forms, the Restorative Nurse will enter the new information into the AOD [Answers on Demand] charting system. The facility policy titled Point of Care Documentation, revised 09/2020, states, Minimum daily charting by nursing assistants on every shift for every resident shall include the following a. ADLS [Activities of Daily Living], b. Toileting, c. Meals/ Eating, d. Bed Mobility, e. Transfers, f. Locomotion, g. Restorative Nursing. On 6/28/21 at 10:57 a.m., Resident #3 said, I am not getting therapy right now, they switched me to restorative care, but I don't get it every day since there is only one person to do it. Resident #3 raised concerns that he would not continue to improve without more consistent restorative care or therapy. On 7/1/21 at 9:17 a.m., Resident #3's records reviewed, which showed referral to restorative care program since discharge from therapy dated 6/7/2021. Referral included instructions for restorative care 5 times a week for 90 days and recommendations for implementations of goals. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's current care plan was reviewed. No documentation or interventions for restorative care was in current care plan. On 7/1/21 at 10:00 a.m., interviewed clinical coordinator Minimum Data Set (MDS) Registered Nurse (RN) Staff D, who was unable to find any documentation in clinical record for restorative care for Resident #3. RN Staff D, said, The restorative Certified Nursing Assistant (CNA) is off today. The other one quit, so she is the only one who does restorative care. On 7/1/21 at 12:44 p.m., interviewed Unit Manager RN Staff C, who said she did not track which residents received restorative care on her unit. On 7/1/21 at 1:05 p.m., interviewed Director of Nursing (DON) confirmed Resident #3 did not have any documentation in the Electronic Medical Record (EMR) in point of care documentation or in his care plan addressing his restorative care since it was ordered on 6/7/21.

Based on observation, interview, policy and record review, the facility failed to ensure proper weight management for a high-risk resident by not properly assessment and following facility policy for weight monitoring. The finding include: A review of facility policy and procedure on Resident Weight Management, last revision on 8/20, records: 1. Each resident's weight is obtained upon admission or readmission within 24 hours, by the nursing staff. 2. Each admission/re-admission is then weighed weekly for 4 weeks by designated nursing staff 6. Residents who are identified at risk for weight loss/gain will be reviewed with appropriate intervention and a plan of care at the weekly Risk Management committee meeting. On 6/28/21 at 12:12 p.m., Resident #480 was observed sitting in her chair at the bedside. Resident appeared significantly underweight and cachectic (extreme weight loss and muscle wasting). Her face was thin and her collar bones, wrist bone and hip bone were markedly visible even through her loose-fitting clothing. Her temples were sunk in. The resident room was observed to have 2 bags of multiple snacks of various kinds and several bottles of nutritional drinks. On 6/28/21 at 12:15 p.m., Resident #480 stated that she had lost a large amount of weight and weighed 76 pounds while in the hospital. She said that she felt she was trying to eat but the some of the food she liked had been taken from her because of her potassium level being slightly elevated. A review of Resident #480's medical record revealed she was admitted to the facility on [DATE], with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission weight was done on 6/21/20 at 2:56 p.m., (3 days after admission) and was 83.80 pounds. Resident #480 next weight was on 6/22/21 and was 84.40 pounds. On 6/30/21, Resident #480's weight was 81.2 pounds. This was 8 days after the last weight and a 3.2 pound weight loss. On 6/30/21 at 12:33 p.m., in an interview, the Director of Nursing (DON) said that the resident was weighed, and she was 81 pounds. (a loss of 3 pounds in 8 days). The DON said that the residents were to be weighed within the first 24 hours after admission, per policy, and weekly thereafter for 4 weeks. She acknowledged that the resident was not weighed according to policy. On 6/30/21 at 2:24 p.m., in an interview, the Dietitian said Resident #480 was first seen by her on 6/21/21, 3 days after her admission. She said when she did her first assessment, she did not have an admission weight and went on what the resident had stated to her which was 71 pounds. She said because the resident's potassium level was elevated on admission, she took some of the food that the resident liked, and she felt that was why she lost the 3 pounds over the 8 days. She said she did not do a calorie count or personally review what resident was taking for meals. The Dietitian said resident was eating 50-100% of her meals and 50-100% of supplements. The Dietitian could not explain how resident lost 3.2 pounds over the 8 days with eating the above amounts. On 7/1/21 at 11:30 a.m., in an interview, RN Staff M said that all residents were supposed to be weighed within 24 hours of admission and then weekly after that. She said that Resident #480 should have been weighed on admission because she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she also did not know why she was not weighed within the week. She said the policy was not followed.

Based on medical record review, interview, and observation, the facility failed to develop and implement an activity program consistent with resident preferences choices for 1 (Resident #73) of 28 residents sampled for activities. The findings include: Resident's #73 medical record revealed an admitted [DATE], with the following active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/29/21 at 9:41 a.m., during Resident #73 observation, the resident was sitting in the chair, completing his breakfast, and stated the meals were ok. The television was on. The resident was asked about activities. He said, I don't think I can leave this room; my wife comes and visits. When asked about the picture in his room of him and his wife, the resident said, I can't see the picture of me and my wife. When asked about audio books, the resident said, How does that work? Review of the Activity Care Plan revealed, Resident's length of stay is expected to be of short duration to complete rehabilitation program. Resident was admitted for skilled nursing and rehabilitation service. Resident is participating with therapy regime, PT/OT (Physical Therapy/Occupational Therapy). Review of the Comprehensive Assessment, dated 5/18/21, noted the resident's Activity Preferences. It noted the importance of books, newspapers, and magazines to read were rated very important to the resident. On 6/29/21 at 9:57 a.m., in an interview, Activity Supervisor stated, when they are first admitted just for rehabilitation, we put that first. She continued to say, He can't see?, I don't recall discussing audio books with him. On 6/29/21 at 3:49 p.m., in another interview, the Activity Supervisor stated the resident refused non-preferred activities. She said, I spoke with him today and we will get audio books. On 6/29/21 at 4:39 p.m., during an interview with SW and Resident and Family Counselor Staff L. The Resident and Family Counselor Staff L said, I just found out about this, I am going to talk to the resident now .

Based on observation, resident interview, and staff interview, the facility failed to provide sufficient and consistent nursing staff to meet the needs of 6 residents (Resident #25, #34, #60, # 65, #111, and #482) of 6 residents sampled. The failure to maintain sufficient and consistent staffing, resulted in the inability of nursing staff to respond to call lights and provide nursing related services to the residents in order to maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: On 6/28/21 at 11:48 a.m. Observation of Resident #482's room revealed the call light was illuminated from 11:48 a.m. to 12:13 p.m. when a Certified Nursing Assistant (CNA) Staff N from another hall came to answer the light, she then turned off the light and left the room, she came back 4 minutes later (12:17 p.m.). On 6/28/21 at 12:17 p.m., in an interview, CNA Staff N said she did not know how to transfer the resident so she could not get her up. CNA Staff N said she would just get her up because she did not have time to look at the Kardex because the resident had been waiting long already. On 6/29/21 at 2:15 p.m., in an interview, Director of Nursing (DON) said the facility was staffed based on PAR numbers, meaning they set a number they would like to meet each day and on resident census and acuity of residents. DON said occasionally if the facility was short staffed, they would pull a Certified Nursing Assistant (CNA) from activities or restorative program and give them an assignment on the nursing unit. On 6/29/21 at 2:30 p.m., in an interview with Activities Assistant CNA, said she very rarely got pulled form activities to work an assignment on the floor, but said it did happen. On 6/29/21 at 10:00 a.m., in an interview, Licensed Practical Nurse (LPN) Staff I, said the 3rd floor nursing unit was short 1 nurse that day. LPN Staff I said there were usually 3 nurses assigned to the unit daily, but there were only 2 nurses assigned that day. LPN Staff I said she was responsible for 2 halls on the unit and was required to administer medications, answer call lights and do wound care. On 6/30/21 at 3:00 p.m., in an interview, Restorative CNA Staff B said she got pulled from her restorative duties to cover a floor shift approximately 2 times a week. Restorative CNA Staff B said when this occurred there would be no one to provide restorative nursing programs for the residents. Restorative CNA Staff B said the CNA's working on the units were not trained to provide the restorative nursing programs for the residents. Restorative CNA Staff B said there were currently 24 residents in the facility who were on restorative nursing programs. On 6/29/21 at 10:00 a.m., in an interview, Resident #34 said she was upset that it took so long for the call light to be answered when she needed assistance. Resident #34 said she could not wait very long for the staff to assist her to the toilet when she put the call light on. Resident #34 said when she had to wait for staff, she would often have incontinent episodes. On 6/29/21 at 11:00 a.m., in an interview, Resident #25 said it sometimes took longer than 15 minutes for the call light to be answered and said, sometimes it takes so long to answer the light I forget why I rang it. Resident #25 said there was no continuity with the staff and the resident care provided. On 6/29/21 at 11:00 a.m., in an interview, Resident #60 said he resided on the 4th floor but always went to the 3rd floor dining room for his noon meal. Resident #60 said it took a long time for anyone to help him back to his room after he was finished with the meal. Resident #60 said he put in a request to the nurse and CNAs for transportation back to his room for 12:30 to 1:00 p.m., but he often waited up to an hour for assistance. Resident #60 said the staff would arrive between 1:30 p.m. to 2:00 p.m. He stated he wanted to get back to his room because he enjoyed watching television and when staff were late, he would miss his favorite television programs. On 6/29/21 at 3:20 p.m., in an interview, Resident #111 said it took 15-20 minutes for staff to respond when she put on her call light. She said she had had accidents with her bowel and bladder when she waited for staff assistance and said it made her feel humiliated. On 6/29/21 at 3:25 p.m., in an interview, Resident #65 said it took 20 minutes or longer for staff to come answer the call light and assist her. Resident #65 said she was bedbound and called for staff assistance when she needed changed. On 6/30/21 at 3:30 p.m., in an interview, DON said the facility did not have a policy to direct staff on answering resident call lights in a timely manner. DON said the expectation was for staff to answer the resident call lights in 2-5 minutes.