Every finding on record at Mary Wade Home

Based on clinical record review, facility documentation review, and staff interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure a complete and thorough post-fall investigation was conducted and documented in accordance with accepted standards of nursing practice. The findings include:Resident #1's diagnoses included vascular dementia, hypertension, nonthrombocytopenic purpura, psychotic disorder, anxiety, restlessness, and agitation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS) and identified Resident #1 was severely cognitively impaired, and was dependent for ADL's (activities of daily living) and transfers. The Resident Care Plan dated 11/12/25 identified Resident #1 at risk for falls and had altered mobility. Interventions directed to reassess fall risk per policy and after each fall as needed, provide a busy blanket when at a table, encourage out of bed as tolerated and transfer per physician orders. Nursing note dated 12/24/2025 at 1:46 PM identified LPN #1 repositioned Resident #1 in the wheelchair as Resident #1 was leaning forward and refused to lean back. Resident #1 fell straight forward onto the floor, and the fall was also witnessed by NA #1. Resident #1 had a small laceration to the forehead and was transferred to the hospital for evaluation. Review of the facility reportable event form and investigation dated 12/24/25 at 12:38 PM identified that LPN #1 was repositioning Resident #1 in a wheelchair when Resident #1 leaned forward and fell to the floor, sustaining a small forehead laceration. Further review failed to identify staff interviews were conducted or additional investigative measures were completed to identify the root cause of the incident. Nursing note dated 12/24/2025 at 10:07 PM identified Resident #1 returned from the hospital with five (5) sutures on the middle of the forehead. Documentation review identified the facility failed to conduct a thorough investigation, including staff statements and an investigation to identify the root cause of the incident. Interview with the Director of Nursing (DON) on 4/10/26 at 12:00 PM identified the DON was unable to provide staff statements were obtained regarding the fall, and an investigation included an analysis of the cause of the fall. Further, the DON stated that RN #2 was the acting DON when the fall occurred, and stated her expectation was to complete a thorough investigation, including obtaining staff statements and a root cause analyses. Although attempted, an interview with RN #2 was unable to be conducted during the survey. Review of the facility Incidents and Accidents Policy dated 12/23/24 directed in part, if an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. The Policy further directed to conduct a root cause analysis to ascertain causative/contributing factors to avoid further occurrences.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for personal care, the facility failed to ensure the resident was not verbally abused by a nurse aide. The findings include:Resident #1's diagnoses included Alzheimer's Disease, depression, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, resisted care from staff at times, and was dependent on staff for dressing, toileting, personal hygiene and transfers in and out of bed. The Resident Care Plan dated 8/7/25 identified Resident #1 had a self-care deficit and altered cognition. Interventions directed staff to assist with activities of daily living, give simple explanations, use orientation guides, and reapproach if the resident refused care. The Facility Reported Incident form dated 8/27/25 identified on 8/27/25 at 7:45 PM the 3-11PM nursing supervisor, Registered Nurse (RN) #1, was called to Resident #1's room by the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, because LPN #1 had witnessed a nurse aide, Nurse Aide (NA) #1, screaming at Resident #1 while NA #1 was attempting to get the resident ready for bed. In a written statement dated 8/27/25, LPN #1 identified she observed NA #1 approach Resident #1 in the hallway, started to push Resident #1's wheelchair into the room, and she advised NA #1 to tell Resident #1 what she was doing because Resident #1 could get upset at times during care. LPN #1 explained approximately thirty (30) seconds later as she was in the hallway outside Resident #1's room, she visualized NA #1 aggressively gesturing and hovering over Resident #1 as NA #1 yelled what's up with you? Don't be putting your hands on me, and you're not going to put your hands on me. LPN #1 wrote she went into the room and told NA #1 that she could not yell at a resident even though NA #1 said Resident #1 was scratching her. LPN #1 informed NA #1 she should have ensured Resident #1 was safe and stepped away from the situation but never should have yelled at a resident. LPN #1 stated NA #1 was asked to leave Resident #1's room and the nursing supervisor was contacted. The Social Worker's note dated 8/29/25 at 12:25 PM identified the Social Worker met with Resident #1 on 8/29/25 in follow-up to an interaction with a staff member that occurred on 8/27/25, there were no signs of distress, and Resident #1 could not recall any negative interaction with a staff member. Interview with NA #1 on 9/15/25 at 12:45 PM identified she recalled working with Resident #1 from 3-11PM on 8/27/25. NA #1 identified after she pushed Resident #1 into his/her room she bent over to put the brakes on the wheelchair and Resident #1 began swinging and yelling at her NA #1 identified as she was backing away from Resident #1 she said to Resident #1, No, don't swing at me. The nurse told me to put you to bed. Interview with another 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2, on 9/15/25 at 1:00 PM identified on 8/27/25 she was in the hallway at her medication cart approximately three (3) doors away from Resident #1's room when she began to hear very loud yelling. LPN #2 stated heard NA #1 say, Stop doing that to me, I'm trying to help you. LPN #2 identified NA #1 was extremely loud and everyone could hear the altercation. LPN #2 identified she responded to Resident #1's room and when she arrived, she saw LPN #1 in the room. LPN #2explained Resident #1 would often resist care and could become combative while staff were trying to help him/her but if staff left Resident #1 and reapproached, Resident #1 would eventually allow staff to provide care. Interview with the Assistant Director of Nursing (ADON) on 9/15/25 at 1:40 PM identified she conducted the investigation for the alleged verbal abuse on 8/27/25 and LPN #1 and LPN #2 both identified they heard NA #1 screaming at Resident #1. The ADON indicated the nurses did not witness any physical altercation and were able to stop the altercation quickly. The ADON explained the nurse aide was removed from the building pending the facility's investigation. The ADON identified based on the investigation that the facility was able to substantiate the allegation of verbal abuse and the facility informed the staffing agency they would no longer employ NA #1 in the future. Review of the facility policy for Abuse, Neglect, and Exploitation, directed in part, the facility would implement policies and procedures that prohibit and prevent abuse and neglect. Review of the facility policy for Resident Rights, directed in part, the resident has a right to be treated with respect and dignity and be free from neglect.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for personal care, the facility failed to report an allegation of verbal abuse to law enforcement timely. The findings include:Resident #1's diagnoses included Alzheimer's Disease, depression, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, resisted care from staff at times, and was dependent on staff for dressing, toileting, personal hygiene and transfers in and out of bed. The Facility Reported Incident form dated 8/27/25 identified on 8/27/25 at 7:45 PM the 3-11PM nursing supervisor, Registered Nurse (RN) #1, was called to Resident #1's room by the 3PM to 11PM charge nurse, Licensed Practical Nurse (LPN) #1, because LPN #1 had witnessed a nurse aide, Nurse Aide (NA) #1, screaming at Resident #1 while NA #1 was attempting to get the resident ready for bed. In a written statement dated 8/27/25, the nursing supervisor, RN #1, identified she was called to Resident #1's room by LPN #1 due to alleged verbal abuse by a nurse aide against Resident #1. NA #1 denied yelling at Resident #1 and was told to leave the facility pending an investigation. Interview with the Assistant Director of Nursing (ADON) on 9/15/25 at 1:40 PM identified she conducted the investigation for the alleged verbal abuse on 8/27/25 and LPN #1 and LPN #2 both identified they heard NA #1 screaming at Resident #1. The ADON indicated the nurses did not witness any physical altercation and were able to stop the altercation quickly. The ADON explained the nurse aide was removed from the building pending the facility's investigation. The ADON identified based on the investigation that the facility was able to substantiate the allegation of verbal abuse and the facility informed the staffing agency they would no longer employ NA #1 in the future. The ADON identified the facility did not notify law enforcement of the allegation of verbal abuse because there was no evidence of the abuse being physical abuse. Review of the facility policy for Abuse, Neglect, and Exploitation, directed in part, the facility would notify law enforcement not later than two (2) hours after the allegation, if the events that cause the allegation involve abuse.

Based on review of the clinical record, facility documentation and facility policy, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to provide adequate supervision to ensure a resident identified at risk for wandering was not able to leave the facility without staff knowledge. The findings include:Based on review of the clinical record, facility documentation and facility policy, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to provide adequate supervision to ensure a resident identified at risk for wandering was not able to leave the facility without staff knowledge. The findings include: Resident #1 was admitted with diagnoses that included major depression and epilepsy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 (indicated was alert and oriented) and was independent for transfers and ambulation with a walker. The Resident Care Plan (RCP) dated 6/42025 identified required assistance with ADLs. Interventions directed independent ambulation with a rollator (walker). Record review identified Resident #1 had a voluntary court appointed Conservator of Person and Estate. A facility reportable event (RE) form dated 7/15/2025 at 1:30 PM identified a missing resident. Resident #1 left the building to take a walk. Staff followed Resident #1 out of the building, and due to a history of combativeness/resistive to care, staff followed Resident #1 until he/she returned to the facility. A facility RE summary dated 7/15/2025 identified Resident #1 had a BIMS of 14, was conserved, and was deemed to be an elopement risk. A wander guard was placed, a care plan was developed for elopement, and a picture was placed at nursing station and front desk as per facility policy. The Resident Care Plan (RCP) dated 7/16/2025 identified Resident #1 was an elopement risk, and had previously left the building and stated he/she was going for a walk. Interventions directed a wander guard placed on the left wrist and placed on the rollator (walker). A physician's order dated 7/15/2025 directed to check placement of wander guard to left wrist and rollator every shift. A facility RE form dated 8/2/2025 at 3 PM identified Resident #1 was alert, oriented, had mild cognitive impairment, and ambulated independently. Staff observed Resident #1 went to the library on campus and staff notified the front desk. Resident #1 stated he/she went to the library to get something good to read, and was escorted back to his unit without any incident. Observations during survey identified the campus library was located across the street from the facility. The street was a one (1) way street with sidewalks, parking on both sides of the street, and a traffic light at the corner with a pedestrian cross walk. The facility RE summary dated 8/5/2025 identified on 8/2/2025 at approximately 2:15 PM, Resident #1 exited through the front doors and went to the assisted living facility located across the street to use their library for a good book. At 3:00 PM, LPN #1 was parking her car and saw Resident #1 on the assisted living facility's property walking back towards the facility. She watched Resident #1 and called the security guard have someone get Resident #1. Resident #1 was escorted by security staff and a second staff member back into the building with no injuries identified. Resident #1 was last seen on the unit at 1:30 by Nurse Aide (NA) #1. Further, the investigation identified the security guard turned off the wander guard alarm when Resident #1 exited the facility about 2:15 PM. Interview and review of facility statement with the security guard (SG #1) identified if a resident with a wander guard comes close enough to the lobby wander guard system, it will activate the alarm, and the alarm noise sometimes causes a resident to turn around and move away from the door. On 8/2/2025 at approximately 2:15 PM he was at the front receptionist desk, and observed Resident #1 approach the front entrance of the building when the wander guard alarm sounded. SG #1 got up, entered the code to stop the alarm without speaking to Resident #1, and Resident #1 continued to walk out the front door of the facility. SG #1 stated that earlier in the shift the alarm had gone off and he did not observe any resident in the area, and he deactivated/reset the alarm. SG #1 stated although he had seen Resident #1's picture in the elopement book, he did not connect the observation to when the wander guard alarm was activated with Resident #1 nearby. When the alarm triggered with Resident #1 nearby, he did not realize it was triggered by Resident #1 because Resident #1 was previously in the residential care level and allowed to come and go freely. SG #1 was not aware Resident #1 was currently a resident in the nursing home section of the facility and although his/her photo was in the elopement book, he did not know Resident #1 had a wander guard. At approximately 3:00 PM, he was contacted by a nurse in the parking lot across the street and informed that she had observed Resident #1 coming out the assisted living building headed across the street back to the facility and was directed to go get Resident #1 as he/she should not leave the building alone. NA #2 was in the lobby, and she had already seen Resident #1 coming towards the facility and SG #1 and NA#2 went out to get Resident #1 and escorted him/her back to the facility. Interview and review of the facility investigation with the ADNS on 8/28/2025 at 2:00 PM identified SG #1 deactivated the wander guard alarm and allowed Resident #1 to leave the building. She would have expected once the wander guard alarm was activated that SG #1 would have prevented Resident #1 from leaving and notified the nursing staff. She did not know why SG#1 allowed Resident #1 to leave the building and deactivated the alarm after it was triggered. Although requested, interview with the ADNS identified the facility did not have a wander guard policy. The facility Elopements and Wandering Residents Policy dated 3/20/2025 directed in part, that adequate supervision will be provided to residents to help prevent accidents or elopements.

Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1and #2) who were incontinent of bowel and bladder and required staff assistance with personal hygiene, the facility failed to ensure the residents were provided with incontinent care as documented in the resident care plan. The findings include: 1. Resident #1's diagnoses included neuromuscular dysfunction of the bladder (loss of normal bladder control) and hemiplegia (weakness of left side extremities). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Basic Interview for Mental Status (BIMS) score of 12 out of 15 indicating some memory recall deficit and was dependent on staff for personal hygiene, had an indwelling catheter to drain the bladder of urine and was always incontinent of bowel. The Resident Care Plan revision dated 4/9/25 identified Resident #1 had actual skin breakdown to the coccyx. Interventions directed to provide incontinent care every two (2) hours and keep all areas of the skin clean and dry. Review of the nurse aide care flow sheets dated 4/9/25 through 4/15/25 identified Resident #1 as having been incontinent of bowels multiple times a day. On 4/14/25 the flow record identified documentation at 6:50 AM Resident #1 had a bowel movement on the 11PM-7AM shift and the flow record identified at 9:46 PM Resident #1 had a bowel movement. The flow record failed to reflect documentation for the 7AM-3PM shift. 2. Resident #2's diagnoses included benign prostatic hyperplasia (enlargement of the prostate gland). The quarterly Minimum Data Set, dated [DATE] identified a Basic Interview for Mental Status (BIMS) score of 12 out of 15 indicating some memory recall deficit, was dependent on staff for personal hygiene, and was always incontinent of the bladder and frequently incontinent of bowel. The Resident Care Plan dated 3/12/25 identified Resident #1 was always incontinent of urine and frequently incontinent of bowel. Interventions directed to provide incontinent care every two (2) hours and as needed, keep all areas of the skin clean and dry, and offer a bedpan every two (2) hours. Review of the nurse aide care flow sheets dated 4/9/25 through 4/15/25 identified Resident #2 was incontinent on each shift. On 4/14/25 the flow record identified documentation Resident #2 voided and had a bowel movement on the 11PM-7AM shift and the 3-11PM shift however the flow record failed to reflect documentation for the 7AM-3PM shift. The Violation of Work Standards Policy dated 4/15/25 identified the Director of Nursing (DON) initiated a written disciplinary action for a 7AM-3PM nurse aide, Nurse Aide (NA) #1, after Resident #1 was found soiled with feces and dirty linens and Resident #2 was found to have soaked pads and sheets with dried and wet urine on them, as well as a soaked brief with urine at the change of the 7AM-3PM to 3-11PM shifts on 4/14/25 Interview with the Director of Nursing (DON) on 6/6/25 at 10:50 AM identified on 4/14/25 a 3-11PM nurse aide, Nurse aide (NA) #2, had asked her to go to Resident #1 and Resident #2's rooms with her to assess how she found the residents who had been incontinent and were lying on soiled, both wet and dry, linens. The DON stated on 4/14/25 NA #1 was the assigned nurse aide for the 7AM-3PM shift, after her observations she had a conversation with NA #1, and a written disciplinary with education was issued regarding the importance of incontinent care. Interview with NA #1 on 6/6/25 at 11:35 AM identified that she checks the residents when she first arrives on shift, assists with breakfast, then begins to provide morning car, and begins the last rounds at 1:30 PM. Interview with NA #2 on 6/6/25 at 2:55 PM identified on 4/14/25 she reported to the DON that on first rounds she had found Residents #1 and #2 were lying on dried and wet soiled pads, sheets, and briefs. Review of the perineal care/incontinent care dated 4/7/25 policy directed all residents will receive incontinent care every two (2) hours.

Based on clinical record reviews, facility documentation, facility policies and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) who were dependent on staff for toileting and personal hygiene, the facility failed to ensure the residents were not neglected by a nurse aide and had been provided with the appropriate care. The findings include: 1. Resident #1's diagnoses included peripheral neuropathy, morbid obesity, and had a history of urinary tract infections. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was oriented to person, place, and time, was dependent on staff for toileting and personal hygiene, required partial assistance with bed mobility, and was occasionally incontinent of urine. The Resident Care Plan dated 1/17/25 identified Resident #1 was incontinent of bowel and bladder. Interventions directed to provide incontinent care every two (2) hours and as needed, keep resident clean and dry, monitor for signs and symptoms of urinary tract infections, offer and assist with the bedpan every two (2) hours when awake while in bed, toilet resident every two (2) hours and as needed, encourage resident to state need to void, and to keep the call bell in reach. The nurse's note dated 3/21/25 at 6:19 PM identified Resident #1 was noted to have concerns about the nurse aide, Nurse Aide (NA) #1, that cared for him/her last evening on 3/20/25. The note indicated Resident #1 stated NA #1 did not provide incontinent care after she put him/her to bed. The note identified Resident #1 was comfortable at that time and in no distress. Review of the point of care history report failed to reflect documentation that toileting hygiene had been provided on 3/21/25 from 11PM-7AM. The Facility Reported Incident form dated 3/21/25 identified Resident #1 had complained that the nurse aide assigned to him/her did not provide incontinent care from 6:00 PM on 3/20/25 to 7:00 AM on 3/21/25. The report indicated Resident #1 was provided incontinent care by the 7AM-3PM shift between 7-7:30AM. Interview with Resident #1 on 4/11/25 at 12:15 PM identified he/she recalled a recent incident with a nurse aide that he/she had not worked with in the past. Resident #1 reported the nurse aide had entered his/her room at approximately 6:30 PM, changed him/her and put him/her to bed, which was all part of his/her normal routine. Resident #1 identified a nurse aide usually came in before the end of the shift at about 10:30 PM, changed him/her if needed, and a nurse aide normally came to the room at 4:30 AM to change him/her but no one came in the room after 6:30 PM on 3/20/25. Resident #1 recalled waking up off and on during the night but was unable to reach the call bell to call for assistance. Resident #1 reported he/she was soaked in the morning when the 7AM-3PM nurse aide changed him/her. 2. Resident #2's diagnoses included osteoarthritis, rheumatoid arthritis, and had a history of recurrent urinary tract infections. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall deficits, was oriented to person, place, and time, was dependent on staff for toileting and personal hygiene, was always incontinent of bladder and frequently incontinent of bowel. The Resident Care Plan dated 1/9/25 identified Resident #2 was incontinent of bowel and bladder. Interventions directed to provide incontinent care every two (2) hours and as needed, keep resident clean and dry, monitor for signs and symptoms of urinary tract infections, offer and assist with the bedpan every two (2) hours when awake in bed, toilet resident every two (2) hours and as needed, encourage resident to state need to void, and to keep the call bell in reach. The nurse's note dated 3/21/25 at 6:13 PM identified Resident #2 had complaints about a nurse aide, NA #1, that took care of him/her last evening on 3/20/25. The note indicated Resident #2 reported NA #1 had a poor attitude and did not provide any care after 9:00 PM. The note indicated Resident #1 was comfortable at that time and in no distress. Review of the point of care history report failed to reflect documentation that toileting hygiene had been provided on 3/21/25 from 11PM-7AM. The Facility Reported Incident form dated 3/21/25 identified Resident #2 had complained that the nurse aide assigned to him/her refused to provide incontinent care and assistance. Resident #2 stated that he/she did not receive care from approximately 3/20/25 at 9:00 PM through 7:00 AM on 3/21/25. The report indicated Resident #2 was provided with incontinent care by the 7AM-3PM shift. In a written statement dated 3/21/25 the 7AM-3PM charge nurse identified Resident #2 made a complaint to her that the last time he/she received any care was on 3/20/25 at 9:00 PM and no one came into his/her room during the night to offer care and Resident #2 reported when he/she asked NA #1 to help boost him/her up in bed, NA #1 told Resident #2 you can do it yourself, use your feet. The Summary Report dated 3/27/25 identified at the conclusion of the investigation it was determined that NA #1 was neglectful in providing care to the residents and NA #1 had a pattern of refusing to provide care to residents. In an interview on 4/11/25 at 12:50 PM NA #1 denied all allegations. Interview with the Assistant Director of Nursing (ADON) on 4/11/25 at 1:30 PM identified on 3/21/25 the 7AM-3PM charge nurse informed her that Resident #1 and Resident #2 both reported NA #1 neglected to provide incontinent care to them overnight. The ADON interviewed both residents and their statements were the same as the initial statements they had made. The ADON identified NA #1 was suspended pending the facility's investigation and the facility terminated NA #1 as a result of the investigation. Resident #2 was out of the facility and not available for an interview. Review of the facility policy for Abuse, Neglect, and Exploitation, directed in part, the facility would implement policies and procedures that prohibit and prevent abuse and neglect. Review of the facility policy for Resident Rights, directed in part, the resident has a right to be treated with respect and dignity and be free from neglect.

Based on the tour of the Dietary Department, observations, staff interview, facility documentation and facility policy, the facility failed to ensure the Dietary Department served food at temperatures outside of the danger zone and failed to maintain dishwasher hot water temperatures at or above 160 degrees Fahrenheit. The findings included: 1. Observation of the tray line on 2/18/2025 at 12:49 PM identified a test tray was placed on the last meal delivery cart which was brought to the first floor. The meal delivery cart lacked doors and resembled a commercial sheet pan rack. The meal plates were covered with hard plastic covers and did not contain warming pellets. The test tray was the last tray served on the first floor. On 2/18/2025 at 1:00 PM the surveyor and [NAME] #1 obtained temperatures of the test tray food which identified the vegetable temperatures as follows: Surveyor temperature: 121.5 degrees Fahrenheit, [NAME] # 1 temperature:122.5 degrees Fahrenheit Interview on 2/18/2025 at 1:00 PM with [NAME] #1 identified that the meal delivery carts did not contain covers or doors and that a pellet system (heating system to keep plates warm to maintain food temperatures) was not used for food that is transported from the kitchen to resident rooms and dining rooms. Interview on 2/19/2025, at 9:47 AM with the Interim Dietary Director identified the meal delivery carts had always been uncovered and that a pellet system had never been used. Observation on 2/19/2025 at 12:21 PM identified a test tray was placed on the last meal delivery cart which was brought to the first floor. On 2/19/2025 at 12:25 PM the surveyor and [NAME] #1 obtained temperatures of the test tray food which identified the vegetable temperatures as follows: Surveyor temperature: 129.9 degrees Fahrenheit, [NAME] # 1 temperature:130.1 degrees Fahrenheit Interview on 2/19/2025 at 12:25 PM with [NAME] #1 identified that the food temperatures were low. Review of the policy Food Safety Handling identified danger zone food temperature are between 41 degrees Fahrenheit and 135 degrees Fahrenheit and allow for rapid growth of pathogenic microorganisms that can cause food borne illnesses. Holding hot food temperature to minimize the growth of microorganisms after food has been cooked to its proper temperature should be held at or above 135 degrees Fahrenheit until it is served. Appropriate food transport equipment is to be used to maintain safe temperatures for food while transporting the food in the facility to help minimize the risk of foodborne illness. 2. Observation on 2/24/2025 at 10:59 AM identified the dishwasher hot water temperatures were 149 to 150 degrees Fahrenheit and should have been 160 degrees Fahrenheit according to the label on the dishwasher temperature gauge. Interview on 2/24/2025 at 11:02 AM with the Dietary Manager identified that after several cycles of washing, the wash temperature did not rise above 150 degrees Fahrenheit which is below the standard of 160 degrees Fahrenheit. The Dietary Manager indicated he would notify the Maintenance Director and Ecolab (dishwasher servicer) of the low water temperatures. Subsequent to surveyor inquiry, the dishes were rewashed and sanitized in the 3 bay sink. Observation on 2/24/2025 at 1:20 PM identified that a Ecolab servicer was evaluating the dishwasher and identified a damaged terminal which he was replacing. The dishwasher temperatures were at 170 degrees Fahrenheit after the terminal was replaced. Review of food safety best practices from Ecolab identified, in part, a malfunctioning or improperly maintained machine that fails to clean tableware adequately can increase the risk of cross-contamination the next time it comes into contact with food or beverages. To help ensure that your machine functions as it should to effectively clean dishes and destroy harmful microorganisms, perform these steps: Inspect racks for damage and replace them when necessary. For conveyer-style machines: check the gauges and compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the data plate: High-temperature, or heat-sanitizing, machines will show a minimum rinse temperature of 180 F and minimum wash temperatures of 150 F, 155 F or 160 F, depending on machine type and make and model.

Based on observations, review of the clinical records, facility documentation, facility policy and interviews for 2 of 2 nursing units, the facility failed to ensure residents who did not meet clinical criteria to reside on a locked unit were provided with a method of opening doors independently. The findings include: Observations on 2/11/2025, 2/13/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025 and 2/25/2025 identified both nursing units: first floor (unit K1) and second floor (unit K2), had secured doors for entering and exiting the units to both stairwells and the elevator. A number code entered into a keypad was required to open the doors. Intermittent observation on all survey days identified only facility staff inputting the code for visitors and residents to enter and exit the units. Additionally, signage on the doors instructed to call a phone number if staff were not available to open the doors and to avoid knocking on the window/door to obtain staff members attention for opening the doors. Review of the Elopement Risk report dated 2/20/2025, for unit K1 identified 32 residents (Resident #12, Resident #15, Resident #17, Resident #21, Resident #24, Resident #26 , Resident #37, Resident #38, Resident #42, Resident #49, Resident #52, Resident #56, Resident #57, Resident #61, Resident #62, Resident #65, Resident #66, Resident # 67, Resident #73, Resident #81, Resident #84 , Resident #192 , Resident #193, Resident #194, Resident #195, Resident #196, Resident #197, Resident #198, Resident #199, Resident #200, Resident #201, and Resident #202) who were not at risk for elopement, Review of the Elopement Risk report dated 2/20/2025, for unit K2, which was equipped with a Wander Guard system (safety system that utilizes bracelets and door sensors to alert caregivers when a resident approaches the monitored area) identified 31 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #18, Resident #20, Resident #23, Resident #27, Resident #28, Resident #30, Resident #36, Resident #40, Resident #45, Resident #46, Resident #50, Resident #51, Resident #53, Resident #54, Resident #58, Resident #59, Resident #64, Resident #68, Resident #70, Resident #75, Resident #76, Resident #78, Resident #82, Resident #86, and Resident #203) who were not at risk for elopement. Although requested, the facility was unable to identify or provide a risk assessment for any residents residing on the secured/locked units or criteria for requiring a secured/locked unit. Interview on 2/19/2025 at 9:35 AM with LPN #1 identified that the unit doors were locked and residents needed to be accompanied by a staff member to different units or the lobby. LPN #1 indicated no residents were allowed off the unit without a staff member, independent/cognitively intact residents included. Interview with the Chief Operations Officer (COO) on 2/19/25 at 3:35 PM identified that both units were locked, unit K2 was equipped with a Wander Guard system and an Elopement Risk assessment was performed for all residents upon admission to the facility. Interview on 2/20/2025, at 3:35 PM with the Maintenance Director identified that the State Agency's Building Fire Safety Inspection on 2/6/2025 recommended the facility install delayed egress hardware because the existing keypad system prohibited anyone from leaving the units. Observation on 2/20/2025, at 3:55 PM, on the elevator from the first floor to the second floor, identified Resident #23 exited the elevator to the second floor and was unable to enter the unit because he/she did not have the code to the keypad. Resident #23 began to panic and stated to the surveyor let me in, please let me in. The surveyor entered the code and entered unit K2 with Resident #23. Observation of the unit identified that no staff were present near the door to the elevator and the closest staff identified were approximately 15 to 20 feet away, near the nurse's station, on the opposite side of the elevator. Interview on 2/20/2025, at 3:55 PM with NA #3 identified that Resident #23 was a resident on unit K2. NA #3 identified that a staff member should have accompanied Resident #23 from the first floor to the second floor and that Resident #23 should have knocked on the door to enter the unit if he/she was alone when he/she exited the elevator to obtain attention from a staff member to open the locked door. Interview on 2/25/25 at 9:41 AM with the DNS identified that independent residents residing on unit K1 were provided the keypad code to freely enter and exit the unit while independent residents residing on unit K2 (unit equipped with a Wander Guard system) were not provided with the keypad code. The DNS was unable to explain how the facility would ensure residents provided with the keypad code would know to secure the door behind them when entering or exiting the unit or how they would know what residents were not permitted to leave the units. The DNS further identified that the facility had no strategy to secure only the residents who were identified as elopement risks and identified all residents, whether or not an elopement risk, were scattered throughout both units indicating the need to secure both units in entirety. Although requested, a facility policy for secured/locked units was not provided. Although requested, a facility policy for assessment/criteria for placement on a secured/locked unit was not provided. A review of the Elopement and Wandering Resident policy identified, in part, that the facility ensures that residents that exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk. The policy further identified that the facility is equipped with door locks and alarms to help avoid elopement. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring effectiveness and modifying interventions when necessary.

Based on facility documentation, facility policy and interviews for 4 of 6 employee files, the facility failed to ensure the required annual performance evaluations were completed. The findings include: 1. NA #3's date of hire was 10/19/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #3. 2. NA #4's date of hire was 6/6/18. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #4. 3. NA #5's date of hire was 10/20/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #5. 4. NA #6's date of hire was 3/1/95. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #6. Interview and review of facility documentation with the Director of Nurses (DNS) on 2/13/25 at 1:19 PM identified that performance evaluations would be in the employee's personnel file and that she was not aware that the evaluations had not been completed. The DNS indicated that the prior DNS would have been responsible for completing the performance evaluations and that she (the current DNS) had only been the DNS since December of 2024. The DNS identified that it is facility policy that performance evaluations be completed annually and that she would work on getting them completed. Review of the facility policy, Performance Evaluations, dated 7/2012, directed that employees will receive an evaluation after completing 90 days of consecutive service and then be placed on an annual schedule. The policy further directed that evaluations will be prepared by Supervisors, submitted to the Administrator for review and the evaluation would be maintained in the employee's personnel file.

Surveyor: Green, [NAME] Based on facility policy and interviews for 8 residents (Resident #7, Resident #13, Resident #24, Resident #39, Resident #62, Resident #72, Resident #73, and Resident #76) reviewed for Resident Council, the facility failed to provide a selective menu for residents to make selections for meals. 1. Interview with Resident #72 on 2/11/2025 at 11:25 AM identified he/she did not receive a selective menu and would like to be able to choose what he/she is served at mealtime. Resident #72 indicated food was often overcooked and meats tough. Interview with Resident #76 on 2/11/2025 at 2:00 PM identified Resident #76 did not know what he/she would be served at mealtimes until the tray arrived. Resident #76 indicated he/she was not provided a selective menu and indicated he/she would like a menu to choose from because he/she was served the same foods repeatedly. During the Resident Council meeting on 2/13/2025 at 1:30 PM Resident #7, Resident #13, Resident #24, Resident #39, Resident #62, and Resident #73 identified they did not fill out selective menus, staff did not review menus with them, and they did not know what they were being served until they received their meal. The residents identified that if they sent their meal back to the kitchen because they did not like what they were served, an alternative meal would take up to 30 minutes to be delivered. The residents further identified they wanted selective menus to make their own menu selections and identified that the same request had been made at previous Resident Council meetings. During the Resident Council meeting on 2/13/2025 at 1:30 PM Resident #13 identified he/she had not had a staff member review a menu with him/her in over 2 years. Interview with the Interim Dietary Manager on 2/25/2025 at 10:20 AM identified that there were not enough staff in the dietary department to help residents fill out selective menus. Review of the Selective Menus policy identified residents may be offered the option of selecting his/her menus. Selective menus are available to those residents who choose to make their own menu selections. The dietary staff will label menus with the resident's name, room number, and diet and deliver the menus to the residents, menus are returned to the dietary department once they are filled in. 51183

Based on observations, review of the clinical record, facility policy and interviews for 4 of 4 residents (Resident #13, Resident #21, Resident #35, and Resident #57) reviewed for oxygen therapy, the facility failed to label, date and store oxygen tubing per facility policy. The findings include: 1. Resident #13 was admitted to the facility in July of 2022 and had diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), received oxygen therapy, was independent with eating, and required partial/moderate assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 2/5/2025 identified Resident #13 was at risk for altered cardiopulmonary status. Interventions included changing oxygen tubing weekly and monitor oxygen concentrator every shift. Observation on 2/13/2025 at 9:17 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #13. Observation on 2/19/2025 at 7:59 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #13. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/2025 at 12:25 PM identified it was the responsibility of the 11 PM to 7 AM shift nursing staff to label and date oxygen tubing weekly. Interview with Registered Nurse (RN) #4 on 2/19/2025 at 2:35 PM identified that she changed, labeled and dated all oxygen tubing on Sundays during the 11 PM to 7 AM shift. RN #4 further identified that if any resident's tubing was not labeled and dated she must have missed labeling that tubing. Review of the Physician Order Report dated 2/1/2025 through 2/20/2025 identified a provider order (order start date 2/19/2024) which directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift. Review of the Treatment Administration History report for February of 2025 identified RN #4 documented the order for the oxygen tubing change as administered on 2/9/2025 and 2/16/2025. 2. Resident #21 was admitted to the facility in August of 2024 and had diagnoses that included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, required substantial/maximal assistance for eating and bed mobility, and dependent for transfers. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #21 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify changing and labeling of the nasal cannula oxygen tubing per facility policy. A provider order dated 1/30/2025 directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift and included instructions which directed to place the tubing in a labeled bag and to not leave the tubing exposed. A provider order dated 2/1/2025 directed to administer oxygen continuously at 2 LPM via nasal cannula. Observation on 2/11/2025 at 11:12 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #21. A provider order dated 2/18/2025 directed to administer oxygen at 2 LPM via nasal cannula as needed for comfort. Observation on 2/19/2025 at 7:32 AM identified Resident #21's oxygen concentrator was turned off with a labeled oxygen nasal cannula oxygen disconnected from the oxygen concentrator and lying uncovered on a chair on top of a blanket. Observation on 2/19/2025 at 12:25 PM identified Resident #21's oxygen concentrator was off with two separate labeled oxygen nasal cannulas laying on top of the oxygen concentrator with one hanging approximately 2 inches from the top of a trash can. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/2025 at 12:25 PM identified it was the responsibility of the 11 PM to 7 AM shift to label and date oxygen tubing weekly. LPN #2 identified the two unbagged oxygen nasal cannulas on top of the oxygen concentrator should not have been exposed and she removed the tubes and discarded them. Interview with Registered Nurse (RN) #4 on 2/19/2025 at 2:35 PM identified that she changed, labeled and dated all oxygen tubing on Sundays during the 11 PM to 7 AM shift. RN #4 further identified that if any resident's tubing was not labeled and dated she must have missed labeling that tubing. Review of the Medication Administration Record for February of 2025 identified RN #4 documented the order for the oxygen tubing change as administered on 2/9/2025 and 2/16/2025. 3. Resident #35 was admitted to the facility in October of 2023 and had diagnoses that included congestive heart failure (CHF), chronic kidney disease, and obstructive sleep apnea. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10), received oxygen therapy, and was independent with eating, bed mobility, and transfers. The Resident Care Plan (RCP) dated 2/13/2025 identified Resident #35 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and change oxygen tubing weekly as scheduled. Observation on 2/13/2025 at 9:21 AM identified an oxygen nasal cannula connected to an oxygen concentrator, belonging to Resident #21, labeled with a date of 2/3/2025. Observation on 2/20/2025 at 10:30 AM identified an oxygen nasal cannula connected to an oxygen concentrator, belonging to Resident #21, labeled with a date of 2/3/2025. Interview with Licensed Practical Nurses (LPN) #5 on 2/24/2025 at 12:55 PM identified she changed oxygen tubing on Sundays during the 11 PM to 7 AM shift and did not know why Resident #35 ' s oxygen tubing was not labeled and dated. Review of the Physician Order Report dated 2/1/2025 through 2/25/2025 identified a provider order (order start date 3/22/2024) which directed to administer oxygen continuously via nasal cannula at 2 liters per minute (LPM). Review of the Physician Order Report dated 2/1/2025 through 2/25/2025 identified a provider order (order start date 3/22/2024) which directed to change oxygen tubing every weekly on Sundays during the 11 PM to 7 AM shift. Review of the Treatment Administration History report for February of 2025 identified LPN #5 documented the order for the oxygen tubing change as administered on 2/2/2025 and 2/16/2025. 4. Resident #57 was admitted to the facility in January of 2022 and had diagnoses that included pneumonia, dysphagia, and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. Observation on 2/11/2025 at 12:45 PM AM identified an unlabeled oxygen nasal cannula connected to a portable oxygen tank belonging to Resident #57. Observation on 2/13/2025 at 10:41 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #57. The Resident Care Plan (RCP) dated 2/17/2025 identified Resident #57 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify changing and labeling of the nasal cannula oxygen tubing per facility policy. Observation on 2/19/2025 at 7:40 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #57. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/2025 at 12:25 PM identified it was the responsibility of the 11 PM to 7 AM shift to label and date oxygen tubing each week. Review of the Physician Order Report dated 2/1/2025 through 2/20/2025 identified a provider order (order start date 2/9/2025) which directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift and included instructions which directed to place tubing in a labeled bag and not leave tubing exposed. Review of the Treatment Administration History report for February of 2025 identified RN #4 documented the order for the oxygen tubing change as administered on 2/9/2025 and 2/16/2025. Interview with Registered Nurse (RN) #4 on 2/19/2025 at 2:35 PM identified that she changed, labeled and dated all oxygen tubing on Sundays during the 11 PM to 7 AM shift. RN #4 further identified that if any resident's tubing was not labeled and dated she must have missed labeling that tubing. Review of the Oxygen Administration Policy directed that oxygen is administered under orders of the provider, the resident's care plan shall identify the interventions for oxygen therapy, to change oxygen tubing/nasal cannula weekly and as needed if soiled or contaminated, and keep oxygen delivery devices (tubing) in a plastic bag when not in use.

Based on observations, interviews, and facility policy for 2 of 2 medication rooms reviewed for medication storage and lebeling, the facility failed to date 3 of 3 multi dose Tuberculin PPD vials upon opening. The findings included: During a review of the facility medication storage rooms on 2/13/25 at 10:17 AM, the following was identified: a. On the K1 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, was half full, without the benefit of being dated. b. On the K1 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, and was slightly more than half full, without the benefit of being dated. c. On the K2 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, was half full, without the benefit of being dated. Observation and interview of the K1 medication room with Registered Nurse (RN) #1 on 2/13/25 at 10:07 AM identified it is facility policy that the nurse who opens a multi-use vial dates it upon opening. Observation and interview of the K2 medication room with Licensed Practical Nurse (LPN) #1 on 2/13/25 at 10:51 AM identified it is facility policy for multi-use vials to be dated when opened. Interview with Pharmacist #1 on 2/13/25 at 2:15 PM identified multi use vials are good for 28-30 days, and should be dated upon opening. If a multi-use vial of tuberculin PPD is not dated, but used after 30 days of opening the efficacy of the medication and the accuracy of the Mantoux test (a diagnostic procedure that uses tuberculin PPD to detect latent tuberculosis infection) can be impacted. Review of the Multi-Dose Vials Policy dated 12/23/24 directed, in part, that multi-dose vials will be re-labeled with a beyond use date, 28 days after the vial is opened or punctured. The beyond use date rule will begin on the first day the multi-use vial is opened or punctured and the medication label will also include the initials of the nurse who opened the vial. The unit manager will perform random checks of opened multi dose vials for appropriate dating.

Based on observations, review of the clinical record, facility policy and interviews for 2 of 4 residents (Resident #21 and Resident #57) reviewed for oxygen therapy the facility failed to revise the Resident Care Plan (RCP) for residents on oxygen therapy per facility policy. The findings include: 1. Resident #21 was admitted to the facility in August of 2024 and had diagnoses that included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, required substantial/maximal assistance for eating and bed mobility, and dependent for transfers. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #21 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify interventions for administration of continuous/intermittent oxygen with flow rate and type of oxygen delivery system, changing and labeling of the nasal cannula oxygen tubing, and monitoring for complications related to oxygen use. Review of the admission nursing assessment dated [DATE] identified Resident #21 required oxygen at 2 liters per minute (LPM) via nasal cannula. The Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, received continuous oxygen therapy, and was dependent for oral hygiene, bed mobility, and transfers. A provider order dated 1/30/2025 directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift and included instructions which directed to place tubing in a labeled bag and not leave tubing exposed. A provider order dated 2/18/2025 directed to administer oxygen at 2 LPM via nasal cannula as needed for comfort. Interview with Registered Nurse (RN) #5 on 2/19/2025 at 12:10 PM identified her (RN #5) and Licensed Practical Nurse (LPN) #4 updated the RCPs. RN #5 identified she completed RCPs for short term care residents and new admissions. RN #5 indicated she did not update RCPs for short term residents because they did not often remain in the facility for greater than a couple weeks. RN #5 identified she was not aware Resident #21 had an order for oxygen for comfort and that Resident #21 was transitioned to long term care. RN #5 further identified that LPN #4 completed the RCPs for long term care residents. Interview with LPN #4 on 2/19/2025 at 12:20 PM identified that she updated the RCPs for the long-term care residents. LPN #4 identified she added information to the focus section of the RCP as she received it, but the interventions were updated quarterly or if residents had a significant change. 2. Resident #57 was admitted to the facility in January of 2022 and had diagnoses that included pneumonia, dysphagia, and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. Observation on 2/11/2025 at 12:45 PM AM identified an unlabeled oxygen nasal cannula connected to a portable oxygen tank belonging to Resident #57. The Resident Care Plan (RCP) dated 2/17/2025 identified Resident #57 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify interventions for administration of continuous/intermittent oxygen with flow rate and type of oxygen delivery system, changing and of the nasal cannula oxygen tubing, and monitoring for complications related to oxygen use. Observation on 2/19/2025 at 7:40 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator, set at 3 LPM, belonging to Resident #57. Interview with LPN #4 on 2/19/2025 at 12:20 PM identified that she updated the RCPs for the long-term care residents. LPN #4 identified she added information to the focus section of the RCP as she received it, but the interventions were updated quarterly or if residents had a significant change. Review of the Oxygen Administration Policy directed that the resident's care plan shall identify interventions for oxygen therapy based upon resident assessments and provider orders and include but not be limited to: the type of oxygen delivery system; when to administer oxygen (continuous or intermittent) and/or when to discontinue oxygen; equipment setting for the ordered flow rate (LPM); monitoring of oxygen saturation levels (blood oxygen level) or vitals signs per provider order; and monitoring for the complications associated with oxygen use (vertigo, nausea, convulsions, slowed respiratory rate, medical device related pressure injury). The policy further directed to change oxygen tubing weekly and as needed if soiled or contaminated. Review of the Comprehensive Care Plans policy identified the comprehensive care plan includes measurable objectives and timeframes to meet the resident's needs and alternative interventions are documented as needed.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 4 residents (Resident #62) reviewed for dining the facility failed to provide supervision for a resident who required supervised feeding. The findings include: Resident #62 was admitted to the facility in November of 2020 and had diagnoses that included dementia, respiratory failure with hypoxia, and dysphagia. A Physician ' s Order dated 7/25/2024 directed an assist of 2 staff members for activities of daily living and assist of 1 staff member for supervision for feeding. A Physician Order dated 12/12/2024 directed for a dysphagia evaluation with treatment 3 times a week for 4 weeks. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #62 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), was on a mechanically altered diet, started speech therapy on 12/12/2024, required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. The MDS failed to accurately code Resident #62's eating functional ability per provider orders. A Physician Order dated 12/31/2024 directed to provide a carbohydrate controlled, no added salt, mildly thick diet which included instructions for a lidded sippy cup, extra sauce/gravy on the side, may have cheerios with thickened milk (let sit to get soft),thickened coffee and super oatmeal daily with breakfast. The Dysphagia Therapy note by Speech Therapist (ST) #1 dated 1/7/2025 at 2:46 PM identified Resident #62 was seen in the morning for dysphagia therapy, that nursing staff informed ST #1 that a chest X-RAY was performed for Resident #62 on 1/6/2025 which revealed aspiration pneumonia. ST #1 subsequently placed Resident #62 on aspiration precautions which included supervision with meals. The note further identified that nursing staff were informed of the new recommendations. A Physician's Order dated 1/7/2025 directed aspiration precautions: Supervision during meals, encourage Resident #62 to be out of bed for all meals, and if eating in bed, position Resident #62 upright with HOB at 90 degrees. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #62 was at risk for inadequate nutrition and required feeding assistance with meals but would refuse. Interventions included 1 to 1 feeding and that Resident #62 should be out of bed for all meals, but if in bed, the head of the bed (HOB) must be positioned at 90 degrees. The Resident Care Card (RCC) dated 1/15/2025 identified Resident #62 was on a limited concentrated sweets, no added salt, soft and bite sized diet, aspiration precautions, swallowing precautions, needed to sit upright with the HOB at 90 degrees during meals, and required 1 to 1 feeding assistance. A Dysphagia Therapy note by ST #2 dated 1/28/2025 at 5:51 PM identified Resident #62 was seen for dysphagia therapy and during the session Resident #62 verbalized that he/she had vomited earlier during the lunch meal because the meal was too dry and the food just wouldn't go down. The note further identified Resident #62 had emesis at the end of therapy treatment which was reported to the nurse. A Nutrition Assessment progress note by the Dietician dated 2/4/2025 at 10:58 AM identified Resident #62 had a history of dysphagia, was on a mechanically altered diet and was seen by ST #1. The note identified Resident #62 was observed at meals and ate well and identified a goal to have no symptoms of aspiration. Observation in the dining room on 2/11/2025 at 12:32 PM identified Resident #62 eating his/her meal without assistance or supervision from staff. No staff members were in the dining room while Resident #62 ate lunch. A Dysphagia Therapy note by ST #3 dated 2/20/2025 at 6:22 PM identified Resident #62 was seen for dysphagia therapy, and upon entry into the dining room, Resident #62 was observed red faced and coughing and reported, It just wouldn't go down for a second. The note further identified no additional swallowing difficulties observed with food and fluid intake during the therapy session and that safe swallowing strategies were reviewed with Resident #62. Observation on 2/25/2025 at 8:38 AM identified Resident #62 sitting upright (90 degrees) in bed, eating behind a privacy curtain, with no staff member in the room. Observation of the plate identified part of a muffin and some scrambled eggs were consumed. Resident #62 was observed drinking juice from a handled lidded sippy cup. Interview with RN #3 on 2/25/2025 at 8:40 AM identified there was a provider order for Resident #62 to have supervised feeding assistance, Resident #62 was not on the list of residents requiring feeding assistance, Resident #62 should have been on the list of residents requiring feeding assistance, and Resident #62 should not have been eating alone in his/her room without staff member supervision. Subsequent to surveyor inquiry, Resident #62 was added to the supervised feeding assistance list and RN #3 instructed a staff member to supervise Resident #62 with breakfast. Interview with NA #1 on 2/25/2025 at 9:05 AM identified she used the RCCs to determine the care residents needed. NA #1 identified that Resident #62 was not on the list of residents who required feeding assistance and she did not realize the RCC instructed to feed Resident #62 because she had not looked at it. Further identified by NA #1 was that if no one was in the dining room while Resident #62 was eating lunch, she would sit with Resident #62 until his/her meal was finished. Interview with ST #1 on 2/25/2025 at 11:08 AM identified Resident #62 was receiving speech therapy because he/she had a history of aspiration pneumonia and requested a diet upgrade to liberalize his/her diet. ST #1 identified Resident #62 had aspiration pneumonia again while on therapy services and he/she was subsequently placed on aspiration precautions. ST #1 indicated Resident #62 should have a staff member present while eating to help him/her during coughing episodes and to cue him/her to slow down and use proper swallowing techniques. ST #1 further identified it was beneficial for Resident #62 to have an extra set of eyes on him/her during meals to help prevent future episodes of aspiration. The Aspiration Precautions Protocol policy identified, in part, that for residents on aspiration precautions to follow these steps: encourage resident to maintain the HOB at 90 degrees if tolerated, offer small sips and bites at a feeding rate suitable for residents, and if a resident has trouble, notify the nurse immediately for: inability to chew food within diet consistency, increased coughing during feeding/after bites or sips, choking, and with pocketing of food (food getting trapped in cheek or mouth without swallowing).

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #46) reviewed for pressure ulcers, the facility failed to follow the plan of care for a resident with a pressure ulcer. The findings include: Resident #46 was admitted to the facility in October of 2023 with diagnoses that included abnormal weight gain, osteoarthritis of bilateral knees, neuromuscular dysfunction of bladder, generalized muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12), and was dependent on toileting hygiene, personal hygiene, bed mobility and transfers. The MDS identified that Resident #46 had an indwelling catheter, was always incontinent of bowel, was at risk of developing pressure ulcers and had a pressure reducing device for bed. The Resident Care Plan (RCP) dated 12/18/24 identified Resident #46 was a potential for skin breakdown. Interventions included an air mattress to the bed and to turn and reposition every 2 hours. A Physician ' s order dated 1/1/25 directed an air mattress with instructions to check functioning every shift. Review of the Weekly Ulcer Skin Assessment Flow Sheet dated 1/8/25 by the Infection Preventionist Nurse (LPN #3) identified a new stage II facility acquired pressure ulcer to the left buttock measuring 1.5 centimeters (cm) by 1.1 cm by 0 cm and was described as having a wound bed containing 55% red granulation tissue, 37% yellow and 8% black (discolored) tissue, was tender to touch with scant serosanguinous drainage noted. The flow sheet identified topical treatment with Medi-honey followed by a piece of calcium alginate (absorptive topical treatment) and border gauze dressing. The Resident Care Card dated 2/1/25 failed to direct turning and repositioning every 2 hours. Although the RCC contained a section to check off turning and repositioning, this intervention was not selected. Review of Weekly Ulcer Skin Assessment Flow Sheet dated 2/10/25 by LPN #3 identified a stage II pressure ulcer to the right and left buttock with treatments in progress. The wound on the left buttock measured 1.7 cm by 1.5 cm by 0 cm and the wound on the right buttock measured 0.6 cm by 0.5 cm by 0 cm. 1. Observation and interview with Resident #46 on 2/11/25 at 1:07 PM identified he/she was lying in bed with the head of the bed elevated. Resident #46 indicated he/she did not have the ability to re-position him/herself in bed and relied on staff for bed to chair transfers. Resident #46 identified that she had sores in his/her buttocks with ongoing treatments. An air mattress was observed in place but appeared mildly deflated. The indicator light on the power switch did not display any light. Interview and observation with Resident #46 on 2/11/25 at 2:54 PM identified Resident #46 lying in bed with head of bed elevated. The air mattress was observed in place but still appeared mildly deflated and the indicator light on the power switch did not display any light. Resident #46 indicated that he/she could not feel the air mattress fluctuate as it always did, and the bed felt uncomfortable. Interview and observation with LPN #1 on 2/11/25 at 2:56 PM identified that she disconnected the air mattress plug from the wall outlet when she performed incontinent care for Resident #46 before lunch. LPN #1 indicated she forgot to plug the air mattress back in and did not check for functioning before leaving Resident #46's bedside. LPN #1 identified that she should have checked the air mattress for functioning before leaving Resident #46's bedside. LPN #1 further identified that Resident #46 had a stage II pressure ulcer to the bilateral buttocks and was receiving daily wound treatments. Subsequent to surveyor inquiry, the air mattress was plugged into the wall outlet and placement and functioning was confirmed by LPN #1 prior to leaving the bedside. Interview with the DNS on 2/25/25 at 1:58 PM, identified that LPN #1 should have checked air mattress function and placement after performing incontinence care. 2. Observation and interview with Resident #46 on 2/20/25 at 10:00 AM, identified that he/she was lying on his/her back with head of bed slightly elevated. Resident #46 identified that he/she had been incontient of stool for approximately 1 hour and was waiting for staff to assist him/her with incontinence care. Resident #46 identified that, at times, it takes up to 4 hours for staff to assist him/her with incontinence care and indicated that waiting for staff to assist with washing him/her up caused him/her distress. Resident #46 identified that he/she turned on the call bell to request help at 10:30 AM and 1 of the NA's went into his/her room, switched the call bell off and informed him/her that his/her assigned NA was with a different resident and would assist him/her when finished. Observation on 2/20/25 at 11:20 AM identified Resident #46 had still not received incontinence care and Resident #46 again turned on the call bell. LPN #1 responded at 11:25AM, switched off the call bell, and informed Resident #46 that his/her assigned NA would be available shortly to assist him/her with incontinence care. Observation on 2/20/25 at 11:55 AM identified NA #8 arrived at Resident #46's bedside to assist Resident #46 with incontinence care. Observation of Resident #46 ' s skin identified a Stage II pressure ulcer to the right buttock and a stage II pressure ulcer to the left buttock. Resident #46 was observed lying on his/her back before the incontinence care was provided and was returned to his/her back after the incontinence care. Interview with NA #8 on 2/20/25 at 12:05 PM identified that Resident # 46 was not repositioned in bed after the incontinence care because he/she is not bed bound. NA #8 identified that turning and repositioning only occurs for residents who are bed bound. NA #8 indicated that Resident #46 is sometimes transferred to a recliner at the bedside, therefore he/she is not considered bed bound. NA #8 further identified that the RCC did not direct Resident #46 to be turned and repositioned every 2 hours. Interview with LPN #1 on 2/20/25 at 12:08 PM identified that she was the nurse assigned to care for Resident #46 and that Resident #46 repositioned him/herself in bed. Interview and record review with the Unit Manager (LPN #6) on 2/20/25 at 12:10 PM identified an RCP intervention to turn and reposition Resident #46 every 2 hours effective 9/24/24. LPN #6 indicated that the intervention of turning and repositioning every 2 hours should have been added the RCC and a Physician's order for turning and repositioning should have been obtained. LPN #6 indicated that since the RCC was not updated and there was no Physicians order, staff had not been turning and repositioning Resident #46 in bed, but only transferred him/her out of bed to the recliner. LPN #6 identified that Resident #46 was dependent for turning and repositioning in bed and currently had a stage II pressure ulcer to the right buttock and to the left buttock and needed to be turned and repositioned every 2 hours while in bed. Interview with the Rehabilitation Director on 2/24/25 at 11:35 AM identified that Resident #46 was dependent on staff for bed mobility and transfers and did not have the ability to turn or reposition him/herself in bed. Interview with the DNS on 2/25/25 at 1:58 PM identified Resident #46 had mobility issues and needed staff assistance with bed mobility and transfers. The DNS indicated that the RCC should have included interventions to turn and reposition Resident #46 every 2 hours as a pressure ulcer prevention strategy. Interview with PA #1 on 2/25/25 at 2:30 PM identified that Resident #46 did not have the ability to turn or reposition him/herself in bed. PA #1 identified that there were no contraindications to turning or repositioning Resident #46 in bed. PA #1 further identified that NAs were responsible for turning and repositioning residents in bed and indicated that they should have been turning and repositioning Resident #46. PA #1 indicated that if a resident is left in the same position and not moved, they would develop pressure ulcers, wounds or breakdown in skin. Review of facility policy titled, Turning and Repositioning Policy, identified that all residents at risk or with existing pressure injuries, will be turned and repositioned unless it is contraindicated due to a medical condition. In this case small shifts in repositioning will be employed. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. A resident's condition will warrant whether specialized turn schedule is warranted. The frequency of turning and repositioning will be documented in the resident's plan of care.

51183 Based on clinical record review, facility policy, and interviews for 2 of 3 residents (Resident #14 and Resident #80) reviewed for elopement, the facility failed to provide adequate supervision to prevent elopement. The findings include: 1. Resident #14 was admitted to the facility in September of 2024 with diagnoses that included alcohol and opiate use disorder, cognitive impairment, major depressive disorder and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), was independent with eating, required partial/moderate assistance with transfers and ambulated with a walker. An Elopement risk assessment performed on 11/4/24 identified Resident #14 as at risk for elopement. A Physician ' s order dated 12/23/25 by Physician Assistant (PA#1), directed to apply a wander guard (a wearable monitoring device to ensure resident safety and prevention of exiting the facility) to left ankle and check function and placement every shift. The Resident Care Plan (RCP) dated 12/24/24 Identified Resident #14 as at risk for elopement. Interventions included applying a wander guard for safety or 15 minutes checks for wander guard refusal, involving Resident #14 in recreation/diversional activities, maintaining safety and offering rest breaks, redirecting out of other residents rooms or staff areas, encouraging rest periods, providing emotional support, speaking in a calm and gentle tone and visitation by the social worker as needed. A Nursing progress note by RN #1 on 1/8/25 at 1:21 PM identified Resident #14 went to a medical appointment accompanied by NA #7. The note identified that upon return from the appointment with NA #7, Resident #14 refused to re-enter the facility. The note further identified that Resident #14 stepped out of the transport vehicle and began walking away from facility, refused redirection and was aggressive. Additionally, the note identified that NA #7 left Resident #14 unattended, outside on the sidewalk, and went inside the facility to request assistance. The note identified that the Director of Nursing (DNS), the Assistant Director of Nursing (ADNS) and NA #7 went outside to assist Resident #14 who was identified across the street at the stop sign of a 4-way intersection. The note further identified that Resident #14 continued walking to a liquor store despite being re-directed back to the facility and the DNS and ADNS remained with the Resident until he/she returned to the facility. A Nursing progress note by the ADNS on 1/9/25 at 12:31 PM, identified Resident #14 was accompanied by person #2 (a volunteer escort from an outside agency) to a medical appointment. Upon arrival back to the facility, Resident #14 was unresponsive in the transport van and subsequently transferred to the hospital. Physician's Evaluation/Conservatorship (PC-370) form dated 1/17/25 by MD #2 identified Resident #14 with alcohol dependance and associated cognitive impairments, major depression and multiple medical conditions. MD #2 further identified Resident #14 had poor insight and judgement, minimized risk and harm caused by his/her drinking, was vulnerable to abuse and became confused easily when ill. Interview with NA #7 on 2/19/25 at 2:22 PM identified that she escorted Resident #14 to a medical appointment on 1/8/25 in a medical transportation van. NA #7 indicated that Resident #14 was calm and cooperative throughout the trip but once they arrived back to the facility, Resident #14 told her he/she wanted to buy alcohol from a liquor store. NA #7 indicated that she tried to redirect Resident #14 but he/she became agitated and pushed her out his/her way. NA #7 identified that she ran back to the building and notified the DNS and the ADNS who responded to the incident and Resident #14 was located across the street at a stop sign of a 4-way intersection, approximately 150 feet from the facility's entrance. NA #7 indicated that they tried to redirect Resident #14, but he continued walking towards a liquor store. NA #7 identified that she was directed by the DNS to go back to the facility and notify the provider that Resident #14 eloped. NA #7 identified that she was not aware that Resident #14 was an elopement risk, and no education was provided to her prior to the appointment. She indicated that she worked on a different nursing unit and was pulled off her assignment to accompany Resident #14, who she had never previously cared for. She indicated she did not know how to respond to the incident and could not identify if she could have used her cell phone to alert the facility rather than leaving Resident #14 unattended outside the facility. Interview with the Unit Manager (LPN #6) on 2/19/25 at 3:56 PM identified that volunteer escorts do not receive resident healthcare information or education prior to escorting residents on medical appointments as that would be a Health Insurance Portability and Accountability Act (HIPAA) violation. LPN #6 further identified that Person #2 was not notified that Resident #14 was at risk of elopement. LPN #6 was unable to identify why NA #7 was not notified of Resident#14's elopement risk prior to the medical appointment on 1/8/25. Interview with the DNS on 2/20/25 at 2:00 PM identified that NA #7 accompanied Resident #14 to his/her medical appointment for safety due to his/her elopement risk. The DNS further identified that NA #7 should have been notified by the unit nurse that Resident #14 was an elopement risk and education should have been provided to NA #7 prior to accompanying Resident #14 to the medical appointment. Observation with the DNS on 2/20/25 at 2:15 PM, identified a one-way street in front of the facility's entrance, with cars parked on both sides of the street, causing low visibility, and a stop sign at a busy 4-way intersection, approximately 150 feet from the facility's entrance, on the opposite side of the street, was the location where Resident #14 was discovered during the elopement incident on 1/8/25. Interview with RN #1 on 2/20/25 at 3:36 PM identified that verbal education was provided to NA #7 after the elopement incident, but no education was provided to other facility staff. Interview with the DNS on 2/21/25 at 10:35 AM identified that the facility does not perform elopement drills for locating missing residents. Interview with Person #2 on 1/24/25 at 10:55 AM identified that no information, including Resident #14's elopement risk, was communicated to him by the facility, prior to accompanying Resident #14 to a medical appointment on 1/9/25. 2. Resident #80 was admitted to the facility in May of 2024 and had diagnoses that included dementia, hypertension and depression. The Elopement Risk assessment dated [DATE] identified Resident #80 was at risk for elopement and precautions must be initiated. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had fluctuating behaviors of inattention, fluctuating behaviors of disorganized thinking, was independent with eating, transfers and ambulating at least 150 feet without an assistive device. The Resident Care Plan (RCP) dated 9/18/2024 identified Resident #80 was alert and oriented to self with confusion and forgetfulness and walked around the unit. Interventions included to provide a daily routine that resembled Resident #80's prior lifestyle and provide a safe environment. The RCP further identified Resident #80 was at risk for altered cognition related to dementia and would get confused as to where his/her room was and enter other rooms and lay down in empty beds thinking they were his/hers. Interventions included to monitor cognitive changes and reorient as needed. The RCP failed to identify Resident #80 as an elopement risk. The Resident Care Card (RCC) dated 9/27/24 identified Resident #80 was oriented to self, confused at times, forgetful, independent with transfers, and independent with ambulation. Further identified was an entry dated 10/6/2024 which directed staff to take Resident #80 to a common area when awake. The RCC failed to identify Resident #80 was an elopement risk. A Provider progress note by PA #1 on 12/4/2024 at 1:15 PM identified Resident #80 was alert and disoriented, his/her mental status was at baseline and Resident #80 ambulated around the unit, was generally quiet and enjoyed sitting at the nurses station. Further identified was Resident #80 had poor safety awareness which was expected to progress. A Nursing progress note by Registered Nurse (RN) #2 on 12/8/2024 at 9:20 PM identified Resident #80 had dinner at 5:00 PM, had snacks at 6:00 PM, and was escorted to the unit at 6:40 PM by Security Guard #1. The note identified that the front desk cameras were reviewed and identified Resident #80 had exited the facility from a stair well door and walked toward the front door and re-entered the facility by the front door. The progress note further identified Resident #80's possible exit was by a wet floor sign inside the door, and that the Director of Nursing Services (DNS) and Resident #80's family member were notified of the incident. The RCP dated 12/11/2024 identified Resident #80 was at risk for elopement related to Resident #80 walking off the unit through the stair well door that was propped open and went down the stairs and out the door and walked back in through the front door. Interventions included to complete an elopement assessment per policy and as needed, redirect Resident #80 as needed, and provide an escort for off unit activities. A Psychiatric progress note dated 12/31/2024 at 1:50 PM identified Resident #80 received services in the context of behavioral assessment and medication management related to dementia, and Resident #80 was almost always confused. Interview with RN #2 on 2/24/2025 at 11:00 AM identified she had been notified by Licensed Practical Nurse (LPN) #8 on 12/8/24, that Resident #80 was brought back to the unit by Security Guard #1 at 6:40 PM after Resident #80 walked in the front door of the facility. RN #2 indicated that no staff members were aware Resident #80 was missing prior to Security Guard #1 bringing Resident #80 back to the unit and she did not know the last time Resident #80 was seen after Resident #80 received a snack at 6:00 PM. RN #2 identified she filled out an Accident and Incident (A&I) report which included statements from herself and Security Guard #1 and that she notified the DNS and Resident #80's family member of the incident. She indicated she recently destroyed the copy of the A&I report she filled out because she thought it was no longer needed. RN #2 further identified Resident #80 walked around the unit alone and she did not know if Resident #80's picture was in the elopement book at the nurses station. Interview with LPN #8 on 2/24/2025 at 12:32 PM identified Security Guard #1 brought Resident #80 back to the unit after Resident #80 walked in the front door. LPN #8 identified that none of the staff on the unit knew how Resident #80 exited the unit and did not know how long Resident #80 was off the unit. LPN #8 identified she was not aware of the elopement book on the unit, that exit seeking was passed on in report, and she had not received in report that Resident #80 was exit seeking. LPN #8 further identified she did not complete an elopement assessment for Resident #80 after the elopement, and she did not recall receiving education on elopement except during orientation to the facility. Interview with the DNS on 2/24/2025 at 1:35 PM identified she had been notified by RN #2 that Resident #80 had gone outside through the stairwell door next to the Chapel, walked left out the door, and then walked to the front door and re-entered the facility where he/she was discovered by Security Guard #1 and brought back to the unit. The DNS identified she had not reported the 12/8/2024 incident of Resident #80 exiting the building unattended by staff because she was new to her position and did not know the criteria for defining an elopement. The DNS identified she did not perform further investigation of the incident beyond the investigation conducted by RN #2 on 12/8/2024. The DNS did not know how long Resident #80 was off the unit and had not reviewed the A&I report filled out by RN #2 after the incident. The DNS identified the criteria for a resident being entered into the elopement book was a resident having the ability to ambulate in addition to exit seeking behaviors. The DNS was unable to identify why Resident #80 was not in the elopement book. Interview with LPN #6 on 2/24/2025 at 3:00 PM identified the unit managers are responsible for updating the elopement books and was unable to identify why the elopement book had not been updated to include Resident #80's picture. Interview with Security Guard #1 on 2/25/2025 at 12:54 PM identified he was at his post at the front desk on the ground floor on 12/8/2025 when Resident #80 walked into the building through the front door wearing a long sleeved shirt and pants. Security Guard #1 identified he asked Resident #80 if he could help him/her but did not receive a response, and after asking multiple questions without a response, Resident #80 finally responded yes to living at the facility. Security Guard #1 identified he immediately brought Resident #80 to the first floor unit and indicated the staff were surprised to see Resident #80 with him. Security Guard #1 further identified he reviewed the camera at the front desk and saw Resident #80 exit the building through the stairwell door and turn left and walk straight to the front door and re-enter. Review of the Incidents and Accidents policy dated 12/23/2024 identified it is the policy to use the CT Accident and Injury form to report, investigate, and review accidents or incidents that occur, and elopement is listed in the policy as an incident requiring a report be written. Review of the Elopements and Wandering Residents policy identified residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk. The policy defined elopement as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The policy identified the facility is equipped with door locks and alarms to help avoid elopements, a photo of each resident deemed to be at risk for elopement will be placed at the front desk and each nurse's station, and adequate supervision would be provided to help prevent accidents or elopements.

Based on review of facility documentation, facility policy and interviews for 3 of 5 employee files, the facility failed to ensure that the required Communication training/in-service was completed. The findings include: 1. NA #1's date of hire was 12/11/24. Review of the facility documentation for NA #1 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #1 failed to identify that required Communication training/in-service had been provided and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required Communication training had been completed for NA #1. 2. NA #2's date of hire was 12/23/24. Review of the facility documentation for NA #2 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #2 failed to identify that the required Communication training/in-service had been provided and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required Communication training had been completed for NA #2. 3. NA #3's date of hire was 10/19/21. Review of the facility documentation for NA #3 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #3 failed to identify that the required Communication in-service training had been provided and included in the files from 2023 until present. Although requested, the facility could not provide documentation that a current required Communication training had been completed for NA #3. Interview and review of facility documentation with the Staff Development RN (RN #1) on 2/13/25 at 3:48 PM identified that she was unable to provide current documentation for the required Communication in-service training for NA #1, NA #2, and NA #3 because the prior staff development nurse did not keep good records. RN #1 indicated that it would have been the responsibility of the prior Staff Development nurse to ensure the required in-service training was completed, documented, and placed in the employee file. Although RN #1 provided in-service documents for NA #3 from 2023 she indicated that she could not locate the current required in-service documentation for NA #1, NA #2 or NA #3 for 2024 or 2025. RN #1 indicated that it is facility policy to have staff complete the required Communication in-service training upon hire and annually, but she had only worked at the facility since December of 2024. Interview and review of facility documentation with the Director of Nurses (DNS) on 2/13/25 at 3:52 PM identified that she was unable to locate the required Communication in-service training documentation for NA #1, NA #2 and NA #3 and that it would have been the responsibility of the prior Staff Development nurse to ensure the required in-service trainings were completed, documented, and placed in the employee file. The DNS identified it is facility policy that staff complete the required Communication in-service training upon hire and annually and that she and RN #1 would work on getting it completed. Review of the facility policy, Training, dated 2/2010, directed that the facility maintains an effective training program for all employees and the required annual in-service training of employees would be offered at the discretion of the Administrator and/or Department Head.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #20) reviewed for abuse, the facility failed to keep Resident #20 free from physical restraint. The findings include: Resident #20 was admitted to the facility in June of 2022, with diagnoses that included Alzheimer ' s disease, dementia with other behavioral disturbance and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE], identified Resident #20 was cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was dependent for bed mobility, transfer and toileting, was non-ambulatory, and was independent with eating. A Resident Care Plan dated 10/12/2024 (start date of 7/12/23) identified increased combative behaviors and anxiety with medications and an intervention to start Trazadone 30 minutes prior to morning and evening care twice daily. The Accident and Incident report dated 10/31/2024, identified NA #10 alleged that LPN #9 hit Resident #20. A statement dated 10/31/2024 by NA #10 indicated that when she walked into Resident #20 ' s room to deliver a meal tray, she overheard LPN #9 speaking to Resident #20 in an aggressive tone, while attempting to administer medications. The statement identified NA #10 then saw LPN #9 hit Resident #20 on the arm. The statement indicated NA #10 delivered and set up the meal tray and encouraged Resident #20 to take his/her medication, then left the room. The statement identified LPN #9 returned to her medication cart and LPN #9 told staff nearby that Resident #20 scratched her. A statement dated 10/31/2024 by LPN #9 identified she was administering medications in applesauce to Resident #20 with a spoon and Resident #20 accepted the first bite then resisted taking another bite. The statement indicated Resident #20 scratched LPN #9 ' s arm and held onto LPN #9 ' s arm tightly. The statement indicated LPN #9 placed her hands on top of Resident #20 ' s hands and held Resident #20 ' s hands against his/her stomach. The statement identified that at that time, NA #10 entered the room with the meal tray. The statement indicated LPN #9 attempted to administer the rest of the medication to Resident #20, but Resident #20 refused. The statement identified that NA #10 approached LPN #9 about the incident and that LPN #9 called the Assistant Director of Nursing Services (ADNS) and that the Director of Nursing Services (DNS) initiated an investigation. A Progress note by Physician ' s Assistant (PA) #1 dated 11/1/2024 at 9:22 AM identified she was requested to assess Resident #20 for agitation and combativeness. The note identified that Resident #20 was reported to have had an episode involving nursing and was increasingly noncompliant with taking medications and becoming more agitated when reapproached by nursing to administer medications. The note further identified that Resident #20 was calm at the time seen and given the frequency of refusals, would attempt switching to liquid medications and/or discontinuing non-essential medications. Interview on 2/20/2025 at 10:30 AM with the DNS identified the facility conducted an investigation for the 10/31/24 allegation of abuse and the outcome of the investigation was unsubstantiated because NA #10 gave conflicting statements. The DNS was unable to produce documentation of the conflicting statements. The DNS identified that during the investigation no other residents on the unit were interviewed. She identified that statements were obtained from the alleged abuser, the alleged witness, the nursing supervisor and one other NA but failed to obtain statements from the remaining 4 staff members who were working on the unit. Interview on 2/21/2025, at 4:18 PM with NA #10 identified that on 10/31/2024 at approximately 5:00 PM, she entered Resident #20 ' s room to deliver a meal tray and witnessed LPN #9 standing on the door side of Resident #20 ' s bed, facing Resident #20 while Resident #20 was lying in bed, and she observed LPN #9 holding Resident #20 ' s hands down and LPN #9 hit Resident #20 ' s arm. Interview on 2/25/2025 at 12:37 PM with LPN #9 identified that on 10/31/2024 at around 5:00 PM she was trying to administer medications to Resident #20 and that Resident #20 grabbed her (LPN #9 ' s) hand. LPN #9 indicated that she did not call for help when Resident #20 became agitated/combative and did not attempt to step away from Resident #20 when he/she became agitated/combative. LPN # 9 indicated that the incident happened fast and grabbing Resident #20 ' s hands was a reaction. LPN #9 indicated that, at times, it was difficult to administer medications to Resident #20 and Resident #20 needed to be reapproached but had not attempted reapproaching Resident #20 during this incident. LPN #9 identified that she had not received training to restrain residents. Review of the Abuse, Neglect Exploitation and Misappropriation of Residents Property policy directed, in part, to provide protection for the health, welfare and rights of each resident by implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. The facility has developed and implemented these written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and establishes policies and procedures to investigate any such allegations and includes training for new and existing staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property, reporting procedures and dementia management and resident abuse prevention. Additionally, it establishes coordination with the facility QAPI program.

Based on review of the clinical record and facility policy for 1 of 3 residents (Resident #80) reviewed for elopement the facility failed to develop a comprehensive Resident Care Plan (RCP) for a resident at risk for elopement. The findings include: Resident #80 was admitted to the facility in May of 2024 and had diagnoses that included dementia, hypertension and depression. The Elopement Risk assessment dated [DATE] identified Resident #80 was at risk for elopement and precautions must be initiated. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had fluctuating behaviors of inattention, fluctuating behaviors of disorganized thinking, was independent with eating, transfers and ambulating at least 150 feet without an assistive device. The RCP dated 9/18/2024 identified Resident #80 was alert and oriented to self with confusion and forgetfulness and walked around the unit. Interventions included to provide a daily routine that resembled Resident #80's prior lifestyle and provide a safe environment. The RCP identified Resident #80 was at risk for altered cognition related to dementia and would become confused as to where his/her room was, would enter other rooms and would lay down in empty beds thinking they were his/her bed. Interventions included to monitor cognitive changes and reorient as needed. The RCP failed to identify Resident #80 was at risk for elopement. A Provider progress note by PA #1 on 12/4/2024 at 1:15 PM identified Resident #80 was alert and disoriented, his/her mental status was at baseline, he/she ambulated around the unit, was generally quiet, enjoyed sitting at the nurses station and had poor safety awareness which was expected to progress. Review of the Elopements and Wandering Residents policy identified residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan. The policy defines wandering as random or repetitive locomotion that may be goal-oriented or non-goal directed or aimless. The policy identified the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Review of the Comprehensive Care Plans policy directed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs including all services identified in the resident's comprehensive assessment. The process will include an assessment of the resident's strengths and needs.

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #46) reviewed for urinary catheters, the facility failed to maintain dignity for a resident with a urinary catheter drainage bag. The findings include: Resident #46 was admitted to the facility in October of 2023 with diagnoses that included osteoarthritis of bilateral knees, neuromuscular dysfunction of bladder, generalized muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12), and was dependent on toileting hygiene, personal hygiene, bed mobility and transfers. The MDS identified that Resident #46 had an indwelling catheter, and was always incontinent of bowel. The Resident Care Plan dated 1/1/24 identified Resident #46 had an indwelling catheter due to obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed either structurally or functionally) and neurogenic bladder (lack of bladder control due to medical issues). Interventions included enhanced barrier precautions, foley catheter care every shift, foley bag/leg bag to be changed weekly and foley to be changed monthly. Observations on 2/19/25 at 10:45 AM and on 2/20/25 at 9:30 AM and 11:04 AM identified Resident #46 lying in bed without the benefit of a privacy cover over the drainage bag. Urine was visible in the drainage bag from the hallway. A privacy cover was observed positioned above the drainage bag. Interview and observation with NA #8 on 2/20/25 at 11:55AM identified a privacy cover connected to a drainage bag but the privacy cover was positioned above the drainage bag and not covering the drainage bag. NA #8 identified that a privacy cover should cover the drainage bag and should not be positioned above the drainage bag. NA #8 could not explain why the privacy cover was positioned above the drainage bag. Subsequent to surveyor inquiry, Resident #46's privacy cover was pulled down to cover the drainage bag. Interview with the Unit Manager (LPN #6) on 2/20/25 at 12:10 PM, identified that privacy covers are used for dignity purposes and indicated that they should cover the drainage bag and should not be left pulled up or positioned above the drainage bag. LPN #6 was unable to explain why staff pulled the privacy cover above the drainage bag leaving urine visible from the hallway. Interview with the DNS on 2/20/25 at 1:55 PM identified that privacy covers should cover the drainage bag to conceal urine from public view. The DNS further identified that privacy covers provide dignity for residents with urinary catheters. Although requested, a policy for urinary catheter drainage bags or privacy covers was not provided.

Based on a review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for falls, the facility failed to protect the resident's safety during care resulting in a fall out of bed and the resident sustained a laceration to the head that required staples. The finding includes: Resident #2 was admitted to the facility with diagnoses that included dementia, anxiety and protein calorie malnutrition. A physician's order dated 6/10/21 directed two half side rails up to promote bed mobility. Review of the fall risk assessment dated [DATE] identified Resident #2 was a high risk for falls. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was always incontinent of bowel and bladder, required extensive assistance of one staff for bed mobility and transfers and used a wheelchair for mobility. The care plan dated 8/29/23 identified Resident #2 was nonambulatory, had altered mobility and required assist of one staff for ADL's and transfers utilizing a gait belt. A nursing note dated 9/18/23 at 3:25 PM identified the RN was called to Resident #2's room and observed Resident #2 lying on his/her back with a laceration to the left side of his/her head. Resident #2 was alert but could not explain what happened due to confusion. The APRN assessed Resident #2 and was sent to the hospital for an evaluation. Review of the Accident and Incident (A & I) form dated 9/18/23 identified Resident #2 fell on the floor from his/her bed resulting in a laceration to the left side of his/her head. NA #2's statement identified after giving care to Resident #2 she turned to get Resident #2's wheelchair and Resident #2 rolled off of the bed. The summary identified NA #2 had finished doing care and was going to get Resident #2 out of the bed, however, Resident #2's wheelchair was out of reach. When NA #2 turned to get the wheelchair, Resident #2 fell on to the floor. Resident #2's bed was raised and the side bars were down. A nursing note dated 9/20/23 at 9:04 PM identified Resident #2 was admitted back to the facility with intact staples on the Resident #2's left forehead. Review of the hospital discharge summary dated 9/20/23 identified Resident #2 had a witnessed fall from his/her bed and developed a left side skin laceration on his/her forehead that required staples. Interview with NA #2 on 10/30/23 at 12:35 PM identified Resident #2 required total care and on 9/18/23, during care, she raised the bed to a higher position and lowered the side rails to perform care. NA #2 identified she washed and dressed Resident #2 in the bed and while the resident remained lying down, she turned her back to walk over and get Resident #2's wheelchair (approximately three steps away). NA#2 identified she heard Resident #2 fall off the bed and called for help. NA #2 stated she could have lowered Resident #2's bed prior to retrieving wheelchair. Interview with the DNS on 10/30/23 at 2:00 PM identified she would expect the bed to be lowered while turning away to get a wheelchair. Follow up interview with the DNS on 11/15/23 at 3:00 PM identified she would expect the side rails to be raised back up while turning away to get a wheelchair. Review of the Safe resident handling/transfers policy directed that staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. It further directed that resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of five sampled residents (Resident # 6) reviewed for accidents, the facility failed to follow the resident's plan of care related to bed mobility to prevent an accident. The findings include: Resident #6's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident #6 was without cognitive impairment, had behaviors of rejection 1 to 3 days per week and required extensive assistance of two staff with bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on staff for transfers. The fall risk assessment dated [DATE] identified Resident #6 was at risk for falls. The care plan prior to the fall identified the Resident #6 was at risk for falls and interventions directed to place dycem in the chair, two side rails up in bed, and conduct a fall assessment quarterly. Interview with Resident #6 on 12/5/17 at 1:44 PM identified that he/she fell out of bed when the Nursing Assistant (NA) was rolling him/her over to the opposite side of the bed and that he/she broke his/her femur. The nurse's note dated 6/1/17 at 12:55 PM identified called to the room status [REDACTED].#6 was receiving morning care when he/she rolled off the bed onto the floor on his/her knees and complained of pain to the right leg. The resident was assisted to a lying position, 911 was called and the resident was sent to the hospital for evaluation. The Resident's Responsible party and APRN werenotified. The nurse's note dated 6/1/17 at 2:19 PM identified that Resident #6 was admitted to the hospital with [REDACTED]. Review of the Facility Reportable Event and investigation dated 6/1/17 identified Resident #6 rolled and fell from the bed during AM care, complained of leg pain, was sent to the emergency department and was admitted with a closed [MEDICAL CONDITION] femur. The quality assurance document identified that the resident assignment sheet indicated Resident #6 required assist of two staff for all care. The hospital discharge summary dated 6/2/17 identified a closed fracture of shaft of right femur, unspecified fracture morphology, non-displaced spiral [MEDICAL CONDITION] femur. Orthopedic deferred surgical interventions. Orthopedics placed locked hinge knee brace and follow up in 2 weeks. The nurse's notes dated 6/2/17 identified that Resident #6 was readmitted to the facility at 2:30 PM with a right immobilizer in place and was complaining of severe pain to the right leg 8 out of 10, the resident was medicated with [MEDICATION NAME] 15 mg and the resident continued to cry and was given emotional support. The nurse's notes dated 6/2/17 through 6/9/17 identified that Resident #6 was emotional, inconsolable at times, asking staff please don't hurt me, was anxious with care, was nervous and shaking with bed mobility and continued to complain of severe pain 8/10 to 10/10 needing to be medicated. The nurses note dated 6/9/17 at 4:14 PM identified that Resident #6 was crying and unable to be calmed, in severe pain to the right knee and that the MD was in to see the resident and that the immobilizer was not on properly and needed to be seen by orthopedics when an appointment was available to fix the immobilizer or possible cast. The pain medication [MEDICATION NAME] was increased to 7.5 mg every 4 hours around the clock. An interview with NA #1 on 12/11/17 at 1:53 PM identified that he/she had gone in to provide morning care for Resident #6 and when he/she turned the resident toward the door, he/she rolled out of bed and landed on his/her knees. Resident #6 was complaining of pain, NA #1 called for help and a NA and Registered Nurse (RN) responded. NA #1 identified that the staff laid Resident #6 on the floor and called 911. NA #1 identified that he/she had not known until after Resident #6 rolled out of bed, that the resident required two for care at all times for accusatory behavior. NA #1 identified that he/she had not looked at the care card prior to giving the resident care and was not aware that the resident also required assist of two for ADL's. Interview with the DNS on 12/11/17 at 12:15 PM identified that NA #1 failed to follow the care plan to provide the assistance of two staff for care and that staff are to follow the plan of care.

Based on review of the clinical record, review of facility documentation, and interviews for two of five residents reviewed for pressure ulcers, (Residents #73 and R #109), the facility failed to address the wound specialist's recommendations for limited sitting time in a timely manner. The findings include: 1. Resident #73 (R #73) had [DIAGNOSES REDACTED]. The admission nursing note dated 6/16/15 identified R #73 with an open area to the coccyx. The Braden assessment dated [DATE] identified that R #73 was at high risk for developing a pressure ulcer. The Admission Minimum (MDS) data set [DATE] identified R #73 with severe cognitive impairment. In addition, the assessment identified that R #73 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene and was at risk for pressure ulcers with one Stage II pressure ulcer present. The care plan dated 6/17/15 identified R #73 with a Stage II pressure ulcer on admission with interventions that included to encourage good nutrition, turn and reposition the resident every two hours, and to apply a pressure reducing mattress and chair pad. The Wound Specialist Note dated 6/17/15 identified Resident #73 with a stage II pressure ulcer to the coccyx measuring 2.0 cm by 3.0 cm with no depth reported. Recommendations included to provide the resident with a group 2 pressure reducing mattress and to limit R #73's sitting to thirty minutes to reduce pressure to the wound. Review of the clinical record lacked documentation to reflect that the wound specialist's recommendations were implemented at that time. The wound specialist evaluation dated 7/7/15 identified that R #73's coccyx pressure wound had deteriorated, was now a Stage III, and measured 1.5 cm by 1.5 cm by 0.3 cm with 70% yellow necrotic tissue and 30% granulation tissue. Recommendations again included to limit sitting to thirty minutes for the purpose of off-loading the wound. Review of the clinical record lacked documentation to reflect that the wound physician's recommendations were implemented at that time. Physician orders [REDACTED].#73's bed which was provided subsequent to the physician order. The wound specialist evaluation dated 7/15/15 identified the Stage III pressure ulcer to the coccyx now measured 2.0 cm by 2.0 cm by 0.3 cm with the peri-wound radius noted to be purple/maroon, suggestive of a deep tissue injury. Recommendation included to off-load the wound. The wound specialist evaluation dated 7/22/15 identified the Stage III area to the coccyx measured 2.0 cm by 2.0 cm by 0.3 cm with recommendations including to limit sitting to thirty minutes. Review of the clinical record lacked documentation to reflect that the wound specialist's recommendations were implemented at that time. The recommendation by the wound care specialist to limit R #73's sitting to thirty minutes was not addressed until 7/23/15 when a written physician's orders [REDACTED].#73's sitting to one hour for the lunch and dinner meals. Review of R #73's Medication Administration Record [REDACTED]. Review of the Nurse Aide assignment sheet failed to identify R #73 was to be limited to sitting for one hour for lunch and dinner meals. Subsequent to surveyor inquiry, the limited sitting for one hour for lunch and dinner was added to the nurse aide care card and added to the TAR for monitoring. Interview with the Director of Nursing Services (DNS) on 9/3/15 at 8:44 AM identified that the delay in providing Resident #73 with a group 2 pressure reducing mattress was related to the facility transitioning from renting to purchasing the mattresses, however he/she was unable to produce documentation to support the delay in following the recommendation and/or that the delay was discussed with the wound specialist and/or the attending physician. Although the DNS identified that the facility decided not to follow the recommendation for limited sitting time related to R #73's family preference for the resident be out of bed for meals and/or activities, the facility was unable to provide documentation to support this information, documentation to support that the resident s family was educated on the risks and benefits of prolonged sitting, and/or that the decision to not follow the recommendations was reviewed with the wound specialist and/or attending physician. The DNS indicated that although the facility had no specific policy and procedure for addressing the wound specialist's recommendations, his/her expectation was that there would be documentation to support that the facility had addressed the recommendations. 2. Resident #109 (R #109) had [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident with a Stage II pressure ulcer, present on admission, with granulation tissue with interventions that included a pressure reducing device for chair and bed. R #109 was first seen by the wound specialist on 07/29/15. Review of the documentation by the wound specialist identified that R #109 had a stage II coccyx pressure ulcer that measured 0.2 cm by 0.3 cm by 0.1 cm. Recommendations included to supply a Group 2 mattress and to limit sitting to thirty minutes to off-load the wound. Review of the clinical record lacked documentation to reflect that the recommendations for limited sitting were implemented based on the would specialist's recommendations. The thirty day Minimum Data Set assessment ((MDS) dated [DATE] identified that R #109 had a BIMS score of eight out of fifteen, indicative of moderate cognitive impairment, and required extensive assistance for most activities of daily living (ADLs), was frequently incontinent of bladder, and occasionally incontinent of bowel. In addition, the assessment identified that R #109 had a Stage III pressure ulcer that measured 1.5 cm by 0.4 cm stage III pressure ulcer, present on admission, with granulation tissue. Although review of the care plan revised on 8/6/15 identified that the resident had a Stage III pressure ulcer, present on admission, and that wound treatment orders were incorporated into the care plan, the care plan lacked documentation to reflect the wound specialist's recommendations to limit the resident's sitting to thirty minutes. The same recommendations for limited sitting were made by the wound specialist on visits of 8/12/15. On 8/12/15, the wound specialist surgically debrided R #109's wound to remove thick eschar and identified the wound was now at Stage III and measured 1.5 cm by 0.4 by 0.1cm. The recommendation for limited sitting was once again made by the wound specialist on the visit of 8/19/15. Review of the clinical record and subsequent interview with the Unit Manager, RN #1, on 09/02/15 at 12:15 PM identified that R #109's clinical record lacked documentation to reflect that the wound specialist's recommendations for limited seating were implemented. RN #1 identified that although a Group 2 mattress had been supplied to the resident on 8/24/15, the physician orders, care plan, and nurse aide assignment sheets were not updated to reflect the resident's need for limited seating Interview with NA #8 on 9/3/15 at 10:15 AM identified that R #109 usually got up into a chair for breakfast, went to physical therapy, and then would usually lay down for a short while before lunch. NA #8 stated that he/she was not aware that the resident was to be limited to no more than thirty minutes up in the chair. Interview with LPN #4 on 9/3/15 at 10:40AM identified that he/she was not aware of the recommendations dating from 7/29/15 from the wound specialist, to limit R #109's sitting to thirty minutes and to off-load the resident's wound. Although review of the clinical record dated 7/29/15 through 9/2/15 lacked documentation to reflect that the wound specialist recommendations for limited sitting was initiated and and/or communicated to direct care staff, review of the wound specialist evaluation dated 9/9/15 identified that R #109's wound was found to be clean and in the stages of healing.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to position a resident safely in a wheelchair to prevent a fall and injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified that Resident #1 had severe cognitive impairments, required extensive two person assistance with transfers in and out of the bed and/or chair, was non-ambulatory, functional limitation in range of motion of both lower extremities, height was 5'7", weight 69 pounds and the resident utilized a wheelchair for mobility. The resident care plan dated 11/20/13 identified the resident was at risk for falling related to difficulty with sitting balance and legs crossing. Interventions directed to utilize a dycem in the wheelchair and bed, personal alarm in the bed and chair at all times, padded side rails, and mats on both sides of the bed. A physician's orders [REDACTED]. The nurse's note dated 12/27/13 identified that Resident #1 was witnessed falling forward out of wheelchair during lunch. Bleeding from mouth and nose were note, a two centimeter laceration was observed to the left side of nose, and the anchor tooth and part of the upper bridgework were broken and fell out of the resident's mouth during the fall. Upper lip swelling was noted and the bleeding had stopped. The family and physician were notified and Resident #1 was transferred to the hospital for an evaluation. The Reportable Event Form dated 12/27/13 identified that Resident #1 fell out of the wheelchair. The investigation dated 1/2/14 identified that Registered Nurse (RN) #1 instructed staff to transfer Resident #1 into a different wheelchair than the resident normally utilized as a trial. RN #1 felt that the old wheelchair was no longer meeting his/her needs and RN #1 had discussed with the occupational therapist trialing Resident #1 in a different wheelchair. The new wheelchair did not have a positioning belt on it like the regular wheelchair. On 12/27/13 at approximately 10:00-10:30 AM Resident #1 was transferred to the wheelchair and the occupational therapist was called to come to the unit and evaluate the resident's positioning. At 12:00 PM when the therapist had not arrived on the unit, the staff moved Resident #1 to the dining area in the new wheelchair for lunch. After the meal the nurse aide reclined the resident slightly. Licensed Practical Nurse (LPN) #1 saw Resident #1 lean forward and fall out of the wheelchair. Review of hospital discharge summary dated 1/1/14 identified Resident #1 had sustained a fracture of the anterior maxillary alveolar ridge which appeared to extend through the root of the upper lateral incisor with overlying soft tissue swelling noted in the upper lip. There was also a depressed small nasal bone fracture of uncertain chronicity and a fracture of the mid bony nasal septum, also of uncertain chronicity. Resident #1 was evaluated in the Emergency Department by the dental and trauma surgeons. Dental felt a splint to teeth six and seven was indicated for airway protection; however they were unable to do this secondary to the resident's pain. Resident #1 was started on Morphine for pain and observed for airway protection overnight. Oral and plastic surgery determined the resident was a poor surgical candidate for any interventions. The goals of care were discussed with the family and the decision was to focus on quality of life. Resident #1 was made a Do Not Resuscitate, Do Not Intubate and discharged to inpatient hospice. Interview with the Director of Rehabilitation and Occupational Therapy (OT) #1 on 7/17/14 at 10:55 AM identified that she was asked in the morning by the charge nurse if Resident #1 could be trialed in a different chair. OT #1 responded for the staff to contact her when they were ready to transfer. The next call she received was to come up to the unit Resident #1 had fallen. The nursing staff had transferred to the chair without the OT #1's knowledge. OT #1 could not recall if Resident #1 required a dycem but stated that Resident #1 did require a pelvic positioning belt for safety which was not on the wheelchair. Interview with LPN #1 on 7/17/14 at 1:00 PM identified that she was sitting across from Resident #1 in dining room assisting another resident when she looked up and observed the table moving. Resident #1 had leaned forward and fell out of the chair and onto the ground. LPN #1 indicated that Resident #1 needed a seat belt for control while in the chair and was not aware that the wheelchair did not have the seat belt on until after the fall. Interview with Nurse Aide (NA) #1 on 7/17/2014 at 1:15 PM identified that it takes two nurse aides to transfer Resident #1 to the wheelchair. On 12/27/13 they transferred Resident #1 to a different wheelchair and therapy was supposed to assess the resident in the new chair. When it was determined that therapy was unavailable to come at that time, NA #1 asked RN #1 if Resident #1 should be transferred back into the original wheelchair because of the lack of a seat belt. RN #1 directed her to keep Resident #1 in the wheelchair and bring the resident into the fireside dining area for lunch. Attempts to contact RN #1 were unsuccessful. Review of the facility's inservice education directs that under no circumstances was nursing to trial any assistive device and/or wheelchair. Rehab will be responsible for trialing these items.

Based on clinical record review, review of facility documentation and interviews for one of four sampled residents (R#18) reviewed for accidents, the facility failed to provide adequate supervision to prevent an accident. The findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary dated 1/11/11 indicated the resident required maximum cues with the assist of one and a rolling walker for safety with transfers and ambulation. A physician's orders [REDACTED]. An admission nursing fall risk assessment dated [DATE] indicated a score of 16 (14 or above indicating a high risk). The care plan dated 1/11/11 indicated a risk for falls related to illness, dementia and a new environment. Interventions included to observe frequently when out of bed, place in a supervised area, the use of a personal bed/chair alarms and to toilet every two hours and as needed. The care plan further indicated not to leave the resident alone on the toilet. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment, one person assist for transfers and bed mobility, total assistance for toilet use and ambulation and a fall in the last month prior to admission. An initial Occupational Therapy (OT) note dated 1/15/11 indicated moderate assistance for toilet use with maximum voice cues for placement of hands and turn directions with resident presently unable to grasp the concept. A nurse ' s note dated 1/15/11 at 2:00 PM indicated staff responded to a bed alarm and found the resident on the floor with no injury. Resident #18 indicated that he/she was attempting to go to the bathroom and fell . A subsequent nurse ' s note dated 1/21/11 for the 11-7 AM shift indicated RN#2 was called to assess Resident #18 who was found on the floor in the bathroom at 6:20 AM. The note further indicated Resident #18 was at the usual level of consciousness, was able to move all extremities, was bleeding from a laceration 1.0 centimeters (cm) in diameter on the outer aspect of the left eye, sustained two skin tears on the left arm below the elbow and had a swollen right hand. A physician's order dated 1/21/11 directed an x-ray of the right hand and left facial bones. A radiology report dated 1/21/11 indicated no definite fracture of the right hand, but unable to diagnose the facial bones and a CT scan was advised. Subsequently R#18 was transported to theER on [DATE] for a CT scan. A radiology report from the acute care facility dated 1/22/11 indicated a [DIAGNOSES REDACTED]. Interview with NA #1 on 8/16/11 at 11:05 AM indicated she was assisting another resident to the shower at approximately 6:15 AM when she heard R#18 ' s bed alarm sounding. NA #1 indicated she went to the resident ' s room and LPN #1 was assisting the resident out of bed to the bathroom. NA #1 then took over for the nurse and assisted the resident to the bathroom. NA#1 indicated that she left the resident on the toilet to check on the resident in the shower chair and upon returning to the room, heard a thud and found the resident lying on the floor of the bathroom. NA #1 further indicated she was aware that R#18 was not to be left alone on the toilet and should have asked for assistance to check on the other resident.