Every finding on record at Masonicare at Bishop Wicke Health & Rehabilitation

Based on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for nutrition, the facility failed to ensure adequate nutritional status and timely identification and response to significant weight loss. This included failure to accurately monitor and evaluate weight changes, obtain a timely re-weight to confirm a significant weight loss, recognize and act upon poor oral intake, notify the physician and Registered Dietitian (RD), implement nutritional interventions, and respond to family concerns. These failures resulted in a significant, unaddressed weight loss and severe malnutrition requiring hospitalization and clinical intervention. The findings include:Resident #1's diagnoses included vascular dementia, history of falls, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disorder (GERD), and depression.The significant change in condition Minimum Data Set assessment dated [DATE] identified Resident #1 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 3) and required supervision when eating.The Resident Care Plan (RCP) dated 10/21/25 identified Resident #1 had a self-care deficit and nutritional risk. Interventions directed to supervise Resident #1 while eating, administer medications as ordered, diet as ordered, offer ice cream with lunch and supper, monitor and report signs of dysphagia, and report a significant weight loss of three (3 ) lbs. in one (1 ) week, greater than a five (5) % weight loss in one (1) month, over seven and a half (7.5 %) in 3 months or over ten (10) % in six (6) months, and Registered Dietician (RD) to evaluate and make diet changes as needed.Physician's orders dated 10/21/25 directed a regular diet, with a regular texture, and thin liquids.Review of the weight log from 5/29/25 to 12/3/25 identified the following weights: 5/29/25: 134 lbs., 6/11/25: 130.5 lbs., 7/13/25: 129 lbs., 8/28/25: 129 lbs., 9/19/25: 128.5 lbs., 10/15/25: 128 lbs., 11/6/25: 127.6 lbs., and 12/3/25: 105.6 lbs. (documented by LPN #1).Review of the food intake log from 11/6/25 to 12/3/25 identified that out of 84 meals, Resident #1 consumed less than 50% or had no meal consumption documented for 45% of meals (26 meals: 26-50% consumed, 9 meals: 0-25% consumed, 9 meals: no documentation).Review of the nurses' notes from 11/6/25 to 12/3/25 failed to identify a cause for the significant weight loss or notification to the RD or physician. The Reportable Event (RE) form dated 12/6/25 at 2:05 AM identified Resident #1 yelled help, staff responded and observed Resident #1 on the floor in his/her room lying parallel to the bed frame on top of the floor mat. Resident #1 had a large hematoma on the left side of the head and was complaining of head and back pain. Resident #1 was confused at baseline and identified he/she was getting up to go to the bathroom and fell. The hospital record dated 12/6/25 identified Resident #1 sustained a left hip fracture from a fall and underwent an open reduction and internal fixation (ORIF) of the left hip on 12/7/25. The hospital record identified a weight of 96.6 lbs. was obtained using a bed scale prior to administering anesthesia for surgery. Hospital records identified Resident #1 weighed 133.54 lbs on 5/23/25. The hospital record further identified Resident #1 was at high nutritional risk due to significant weight loss and was diagnosed with severe malnutrition based on a body mass index (BMI) of 17.1 combined with age and interventions were required. A nutritional assessment was performed on 12/8/25 and identified a 28% weight loss over one month. A speech evaluation and twice daily nutritional supplements were ordered. Resident #1 remained in the hospital until discharged to hospice care on 12/12/25 and expired on 12/18/25. Interview with Person #1 on 4/14/26 at 10:40 AM identified she reported concerns regarding Resident #1 losing weight to LPN #1 (the 7:00 AM to 3:00 PM charge nurse) in September and October 2025 and LPN #1 responded that Resident #1's weight was unchanged. Person #1 further identified she requested Resident #1 be given a dietary supplement and that was never started. Interview with the DON (Director of Nursing) on 4/14/26 at 12:46 PM identified the charge nurse was responsible for checking weights and if a significant weight change was noted, a re-weight should be obtained for accuracy and if the significant change still existed, the RD and physician should be notified. The DON identified that if a family member voiced a concern regarding a weight, a re-weight should be obtained to evaluate for a weight change and if a supplement was requested, the RD should be notified. The DON identified LPN #1 should have re-weighed Resident #1 on 12/3/25 and if the weight loss remained accurate, the LPN should have notified the RD and physician. The DON further identified the facility failed to follow its policy.Interview with RN #1 on 4/14/26 at 1:25 PM identified she did not recall anyone reporting a 22 lb. weight loss in one month and if LPN #1 had reported that to her she would have notified the physician. Interview with the dietician on 4/14/26 at 1:37 PM identified she did not recall staff informing her of the weight loss documented on 12/3/25 or concerns regarding weight loss, and if she were made aware, she would have requested a re-weight and reported to the physician regarding new interventions. Although attempted, an interview with LPN #1 was not obtained. Review of the facility policy for Weights identified, in part, that the nurse reviewed all weights for a weight loss or gain and signed off on the process. If the nurse were to identify a weight discrepancy of plus or minus five (5) lbs. they were to ask the nurse aide to re-weigh the resident and if the gain or loss was verified the nurse was to notify the RD, physician, and family member.

Based on clinical record review, facility documentation/policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for a change in condition, the facility failed to ensure timely notification of the physician, Registered Dietitian (RD) and resident's representative when the resident experienced a significant weight loss and decline in nutritional status, which delayed clinical assessment and intervention for a significant weight loss. The findings include:Resident #1's diagnoses included vascular dementia, history of falls, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disorder (GERD), and depression.The significant change in condition Minimum Data Set assessment dated [DATE] identified Resident #1 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 3) and required supervision when eating.The Resident Care Plan (RCP) dated 10/21/25 identified Resident #1 had a self-care deficit and nutritional risk. Interventions directed to supervise Resident #1 while eating, administer medications as ordered, diet as ordered, offer ice cream with lunch and supper, monitor and report signs of dysphagia, and report a significant weight loss of three (3 ) lbs. in one (1 ) week, greater than a five (5) % weight loss in one (1) month, over seven and a half (7.5 %) in 3 months or over ten (10) % in six (6) months, and Registered Dietician (RD) to evaluate and make diet changes as needed.Physician's orders dated 10/21/25 directed a regular diet, with a regular texture, and thin liquids.Review of the weight log from 5/29/25 to 12/3/25 identified the following weights: 5/29/25: 134 lbs., 6/11/25: 130.5 lbs., 7/13/25: 129 lbs., 8/28/25: 129 lbs., 9/19/25: 128.5 lbs., 10/15/25: 128 lbs., 11/6/25: 127.6 lbs., and 12/3/25: 105.6 lbs (documented by LPN #1).Review of the food intake log from 11/6/25 to 12/3/25 identified that out of 84 meals, Resident #1 consumed less than 50% or had no meal consumption documented for 45% of meals (26 meals: 26-50% consumed, 9 meals: 0-25% consumed, 9 meals: no documentation).Review of the nurses' notes from 11/6/25 to 12/3/25 failed to identify a cause for the significant weight loss or notification to the RD or physician. The Reportable Event (RE) form dated 12/6/25 at 2:05 AM identified Resident #1 yelled help, staff responded and observed Resident #1 on the floor in his/her room lying parallel to the bed frame on top of the floor mat. Resident #1 had a large hematoma on the left side of the head and was complaining of head and back pain. Resident #1 was confused at baseline and identified he/she was getting up to go to the bathroom and fell. The hospital record dated 12/6/25 identified Resident #1 sustained a left hip fracture from a fall and underwent an open reduction and internal fixation (ORIF) of the left hip on 12/7/25. The hospital record identified a weight of 96.6 lbs. was obtained using a bed scale prior to administering anesthesia for surgery. Hospital records identified Resident #1 weighed 133.54 lbs on 5/23/25. The hospital record further identified Resident #1 was at high nutritional risk due to significant weight loss and was diagnosed with severe malnutrition based on a body mass index (BMI) of 17.1 combined with age and interventions were required. A nutritional assessment was performed on 12/8/25 and identified a 28% weight loss over one month. A speech evaluation and twice daily nutritional supplements were ordered. Resident #1 remained in the hospital until discharged to hospice care on 12/12/25 and expired on 12/18/25. Interview with Person #1 on 4/14/26 at 10:40 AM identified she reported concerns regarding Resident #1 losing weight to LPN #1 (the 7:00 AM to 3:00 PM charge nurse) in September and October 2025 and LPN #1 responded that Resident #1's weight was unchanged. Person #1 further identified she requested Resident #1 be given a dietary supplement and that was never started. Interview with the DON (Director of Nursing) on 4/14/26 at 12:46 PM identified the charge nurse was responsible for checking weights and if a significant weight change was noted, a re-weight should be obtained for accuracy and if the significant change still existed, the RD and physician should be notified. The DON identified that if a family member voiced a concern regarding a weight, a re-weight should be obtained to evaluate for a weight change and if a supplement was requested, the RD should be notified. The DON identified LPN #1 should have re-weighed Resident #1 on 12/3/25 and if the weight loss remained accurate, the LPN should have notified the RD and physician. The DON further identified the facility failed to follow its policy.Interview with RN #1 on 4/14/26 at 1:25 PM identified she did not recall anyone reporting a 22 lb. weight loss in one month and if LPN #1 had reported that to her she would have notified the physician. Interview with the dietician on 4/14/26 at 1:37 PM identified she did not recall staff informing her of the weight loss documented on 12/3/25 or concerns regarding weight loss, and if she were made aware, she would have requested a re-weight and reported to the physician regarding new interventions. Although attempted, an interview with LPN #1 was not obtained.Review of the facility policy for Weights identified, in part, that the nurse reviewed all weights for a weight loss or gain and signed off on the process. If the nurse were to identify a weight discrepancy of plus or minus five (5) lbs. they were to ask the nurse aide to re-weigh the resident and if the gain or loss was verified the nurse was to notify the RD, physician, and family member.

Based on review of clinical records, interviews, and review of facility documents and policies for one (1) of three (3) residents (Resident #2) reviewed for falls, the facility failed to complete an evaluation and assessment following a resident's fall in accordance with facility policy. The findings included:Resident #2 was admitted to the facility in December of 2025 with diagnoses which included Alzheimer's, transient ischemic attack, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 7), required substantial assistance with personal hygiene, toileting, and bathing and was a partial to moderate assist of one (1) with transfers and ambulation with a walker. Review of the Resident Care Plan (RCP) dated 12/18/25 identified Resident #2 had impaired physical mobility due to Parkinson's Disease and was at risk for falls. Interventions directed to assist Resident #2 with ambulation and transfers, utilizing therapy recommendations. Review of a nursing note dated 12/26/25 at 7:03 AM identified Resident #2 was found on the floor in a prone position between his/her bed and closet and indicated he/she was trying to go to the bathroom and hit his/her head. The provider was informed and ordered Resident #2 be transferred to the emergency department for further evaluation. Review of the clinical record identified a Post Fall assessment was completed for the 12/26/25 fall event, however, failed to identify the Fall Risk assessment and the Post Fall evaluation were completed.Interview with the Assistant Director of Nurses (ADON) on 1/14/26 at 11:50 AM identified each fall incident event should be followed up with a Fall Risk assessment and Post Fall evaluation and that it was the responsibility of the nurse assigned to complete these documents.Review of the Fall Risk Evaluation policy directed a fall risk evaluation was to be performed on admission, change of condition, annually, quarterly or as needed.Review of the Documentation Procedure for Resident Falls directed it was the policy of the facility to assess all residents for a potential/actual injury sustained after a fall.

Based on observations, review of clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #87) reviewed for pressure ulcers, the facility failed to perform hand washing/sanitization during wound care. The findings include:Resident #87's diagnoses included peripheral vascular disease, dementia, and traumatic brain injury.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 had a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment, was dependent for personal hygiene, rolling left and right, and chair/bed-to-chair transfers, and had an unstageable pressure ulcer presenting as a deep tissue injury (DTI).The Resident Care Plan (RCP) dated 9/10/2025 identified Resident #87 had a DTI on his/her left inner heel related to immobility and peripheral vascular disease. Interventions included administer treatments as ordered and monitor for effectiveness, initiate Enhanced Barrier Precautions (EBP) per orders, and follow facility policies/protocols for the prevention/treatment of skin breakdown.A nursing note dated 9/10/2025 identified Resident #87 had a new facility acquired pressure ulcer on his/her left heel, measuring 5.3 centimeters (cm) x 5.5 cm with no depth and a base of deep red, maroon, or purple in color.A physician order dated 9/10/2025 directed to maintain EBP to the pressure area every shift, and to apply skin prep to the pressure area of the left inner heel every day for 14 days.Interview on 9/15/2025 at 10:58 AM with Registered Nurse (RN) #1 (infection prevention nurse) identified that hand hygiene should be performed by staff when entering or leaving a resident room, before applying gloves, and after glove removal.Observation and interview on 9/15/2025 at 11:16 AM with Licensed Practical Nurse (LPN) #3 during Resident #87's wound care identified that he failed to perform hand hygiene before wound care and failed to perform hand hygiene when changing his gloves during wound care. LPN #3 indicated the reason he did not perform hand hygiene was because he did not think of it. Further, LPN #3 indicated he had not received training on and was unaware of the facility's policy on hand hygiene.Interview on 9/15/2025 at 12:00 PM with the Director of Nursing Service (DNS) identified that during wound care, nurses should perform hand hygiene at the beginning and end of wound care and when changing gloves. Further she identified that staff receive education on hand hygiene, but LPN #3 would not be required to attend the in-service on hand hygiene as he is employed through an agency and not the facility.Review of the facility's Hand Hygiene Policy identified in part that hands should be washed with alcohol-based hand sanitizer after removing personal protective equipment (gloves) and before and after giving care to each resident. The Hand Hygiene Policy failed to identify that alcohol-based hand sanitizer should be used before donning personal protective equipment.

Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #58) reviewed for food choices, the facility failed to provide the correct diet. The findings include:Resident #58's diagnoses included hypertension, gastro-esophageal reflux disease (GERD), and gout.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status score of 14 indicating intact cognition, was dependent with personal hygiene, rolling left and right and with chair/bed-to-chair transfers, and required set-up assistance with eating. A signed Physician order dated 2/29/2024 identified Resident #58 had an allergy to garlic. The Resident Care Plan (RCP) dated 5/30/2024 and in effect at the time of survey identified Resident #58 had a nutritional problem or potential nutritional problem related to diagnoses of hypertension, GERD, morbid obesity, constipation, gout, and a food allergy to garlic. Interventions included educating the resident on the importance of maintaining the ordered diet and to encourage the resident to comply, provide/serve diet as ordered, and the Registered Dietician was to evaluate and make dietary change recommendations.Signed Physician orders dated 6/22/2024 and through 9/15/2025 directed Resident #58 to receive a regular diet of regular texture and consistency.Review of the Multidisciplinary Care Conference note dated 8/25/2025 identified that the Registered Dietician attended and that Resident #58 had an allergy to garlic.The Registered Dietician Quarterly Assessments dated 8/28/2024, 11/18/2024, and 8/19/2025 identified Resident #58 had an allergy to garlic.Interview with Resident #58 on 9/10/2025 at 10:55 AM identified that he/she had an allergy to garlic, the facility continued to serve him/her food with garlic against his/her request, and he/she stated that eating garlic resulted in a stomachache and gastrointestinal issues.Observation on 9/15/2025 at 1:18 PM identified Resident #58's lunch tray sitting on the bedside table and had been served spaghetti and meatballs with squash.Interview and record review on 9/15/2025 at 1:21 PM with the Director of Dietary Services identified she was aware Resident #58 had food allergies to melon, shellfish, and bananas but failed to identify a documented allergy to garlic. Further, she identified that both the spaghetti and meatballs and garlic vegetables contained garlic as an ingredient and Resident #58 had been served spaghetti and meatballs with a double portion of garlic vegetables for lunch.Interview on 9/15/2025 at 1:25 PM with the Dietary Aide #1 identified that she was responsible for entering food allergies into the kitchen's resident census and believed the garlic allergy was not included due to a cloud syncing problem with her computer.Interview on 9/15/2025 at 2:07 PM with the Director of Nursing Services identified that the Dietary Manager had notified her that Resident #58 was served food that contained ingredients for which he/she had a documented food allergy, that nursing had been directed to conduct an evaluation of him/her, and Medical Doctor (MD) #1 was called and was performing an evaluation. Further she indicated she would be calling Resident #58's family member and reporting the incident to the State Agency.Interview with Resident #58 on 9/15/2025 at 2:19 PM identified that she had taken a bite of the spaghetti and meatballs but did not eat the entire meal, and that staff removed her spaghetti and meatballs and garlic vegetables and provided him/her with chicken noodle soup. Resident #58 indicated that he/she had eaten 100% of the soup.Interview on 9/15/2025 at 2:25 PM with [NAME] #2 identified that the chicken noodle soup was prepared on 9/14/2025 and was made with a powdered soup stock base that did not contain garlic as a listed ingredient. [NAME] #2 stated garlic had been added to the soup, and cooks usually added garlic to their soups during the cooking process.Subsequent to surveyor inquiry, a new Resident Nutrition Interview was conducted on 9/15/2025 and identified Resident #58 had food allergies to shellfish, bananas, and melon. Further, it was identified that he/she had a food intolerance to garlic with no difference in symptoms between fresh or garlic powder as both cause him/her gas.Interview with MD #1 on 9/16/2025 at 11:51 AM identified that he had evaluated Resident #58 on 9/15/2025 and determined that he/she did not have a garlic allergy but preferred not to receive garlic in his/her meals. Further, he stated that he was unaware prior to 9/15/2025 that he/she had garlic documented as a food allergy and was unable to identify why garlic had been listed in the physician orders as a food allergy. Subsequent to surveyor inquiry, MD #1 directed nursing to remove garlic from his/her allergy list.Interview on 9/17/2025 at 11:10 AM with the Assistant Director of Nursing Services (ADNS) identified that she was the person who removed the spaghetti and meatballs from Resident #58's room and delivered him/her chicken noodle soup (a second meal containing garlic.) The ADNS stated she was unaware the soup contained garlic, failed to ask anyone in the kitchen if there was garlic in the soup, and should have asked but didn't think of it.Review of the facility's Menu Planning policy identified that a dining census shall be used to identify residents' diets, allergies, adaptive equipment, special needs and any other dietary concerns. Upon arriving at the facility, an interview will be conducted by the dining team to discuss with each resident what their special needs/requests are as well as ethnic background, likes/dislikes and how they can be best served while at the facility. Further, members of the dining team will attend quarterly resident care plan meetings to assess the residents' likes/dislikes with the food served and discuss whether or not the facility is meeting the dietary wishes of the residents.

Based on observations, interviews, and facility policy during a tour of the kitchen, the facility failed to ensure open food items were dated to include opened, expired, and used by dates, and failed to perform hand hygiene prior to placing gloves on during food preparation and food service. The findings include: 1. On 9/10/25 at 9:15 AM, during the initial brief kitchen tour and interview with the Food Service Director, identified in freezer #2, a previously opened and repackaged bag of raspberry turnovers with a handwritten best used by date of 6/7/25 and a previously opened and repackaged bag of apple turnovers, with a handwritten best used by date of 7/11/25. In the refrigerator on the second shelf was a thawed package of ground veal with a handwritten date of 9/2/25, indicating when it was thawed, along with a handwritten note for the veal to be used by 9/4/25. The Food Service Director stated that staff used the best used by date as the food's expiration date. Subsequent to the surveyor's inquiry, the Food Service Director noted she would dispose of the expired raspberry and apple turnover bags immediately and disposed of the expired ground veal. Further observations in the kitchen identified the following underneath the kitchen's prep counter: An unopened expired 16 oz Chili Powder container with a manufacturer's best buy date of 2/6/25 counter was observed. An opened 16 oz container of basil leaves, opened on 7/10/25 with no expiration date. Subsequent to this observation, the Food Service Director placed a best used date on the container for 7/10/26.An opened 16 oz container of cocoa powder, with no open date, and an expiration date of 8/29/25. Subsequent to observation, the Food Service Director discarded this container. An opened 16 oz container of granulated garlic without an opening date, and a manufacturer's expiration date of March 2029.An opened 16 oz container of granulated onion, without an opened date posted on the container, but did contain a handwritten received date of 7/30/25. The Food Service Director placed a best used date on the container for 7/30/26.An opened 16 oz container of Italian seasoning, dated to be opened on 6/5/25, without an expiration date, or used by date. The Food Service Director subsequently placed a best used by date of 6/5/26 on this container. In a large clear plastic covered storage bin was a 50 lb. bag of red velvet cake mix approximately 1/3 used, with a handwritten date opened January of 2025, along with a handwritten best used by date of March of 2025. The Food Service Director disposed of the Red Velvet Cake Mix. 2. On 9/15/2025 12:05 PM - During food service observation, with the Food Service Director in the kitchen, 5 staff members were noted to place and removed gloves without the benefit of sanitizing or washing their hands. [NAME] #1 failed to sanitize/wash 3 times, [NAME] #2 failed to sanitize/wash 2 times, Dietary Aides #4, #5 and #6 failed to wash/sanitize 2 times. Subsequent to surveyor inquiry, the Food Service Director immediately educated staff to the facility hand washing policy and the importance of hand washing or sanitizing prior to placing and following removal of gloves during food prep and food service. Review of the facility's Production Guidelines - Sanitation and Safety policy identified that hand contact with food shall be restricted. Proper hand hygiene shall be used. Plastic/vinyl, non-latex gloves should be used when contacting and preparing food.

Based on observations, interviews, clinical record review, and facility policy for 1 of 3 sampled residents (Resident #7) reviewed for pressure ulcers, the facility failed to set an alternating pressure mattress at the correct setting, per the physician order. The findings include: Resident #7's diagnoses included Alzheimer's disease, vascular dementia, and unspecified systolic (congestive) heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a short-term and long-term memory problem and was dependent on staff for toileting hygiene, rolling left and right in bed, lying to sitting on side of bed, and transfers. Additionally, the assessment identified 1 stage 3 pressure ulcer that was not present upon admission/entry or reentry into the facility and that there was a pressure reducing device for the bed. The Resident Care Plan (RCP) dated 8/12/2025 identified Resident #7 had a pressure ulcer to the coccyx related to immobility and bowel/bladder incontinence. Interventions included administer treatments as ordered and monitor for effectiveness, assist with position changes approximately every two (2) hours and as needed, and an alternating mattress set at 150 pounds (lbs.). Resident #7's Braden Scale (predicting pressure ulcer risk evaluation) dated 6/14/2025 identified that he/she was at high risk for pressure ulcer development.A physician's order dated 9/15/2025 for Resident #7 directed to set the alternating pressure mattress at 150 lbs. and to check the mattress function and setting every shift.Observations on 9/10/2025 at 10:28 AM, 9/10/2025 at 1:26 PM, 9/12/2025 at 9:11 AM, and 9/15/2025 at 9:56 AM, identified Resident #7 was in bed with the pressure-relieving mattress set at 200 lbs.Observation, interview, and review of physician orders with Licensed Practical Nurse (LPN) #1 on 9/15/2025 at 10:08 AM identified Resident #7 was sleeping in bed on his/her left side, covered by a blanket, with the head of the bed slightly elevated. The alternating pressure mattress was observed to be set at 200 lbs. and had been set to 200 lbs. during 4 previous observations. The current physician order directed the alternating pressure mattress to be set at 150 lbs. and to check the function and setting every shift. LPN #1 identified that the alternating air mattress was incorrectly set according to the physician's order. LPN #1 stated that the facility policy directed to set the alternating air mattress per the physician order and that it was her responsibility as the unit nurse to check and ensure the correct setting. LPN #1 indicated that she had not checked the setting on Resident #7's alternating air mattress that shift but should have. Subsequent to surveyor inquiry, LPN #1 changed the setting on Resident #7's alternating air mattress from 200 lbs. to 150 lbs. per the physician's order. Interview with the Director of Nursing (DNS) and Assistant Director of Nursing (ADNS) on 9/15/2025 at 10:25 AM indicated that the facility policy directed setting pressure relieving mattresses per the physician order. The unit nurse was responsible to check mattresses for the correct physician ordered setting every shift. The DNS and ADNS indicated Resident #7's mattress should have been set according to the physician's order, at 150 lbs., and not at 200 lbs. as observed. Review of specialty mattresses policy dated 11/2021 directed, in part, that residents who are at high risk for, are admitted with, or develop a pressure area will receive an appropriate specialty mattress. The policy failed to identify how the specialty mattress should be set.

Based on observation, interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #43) reviewed for communication difficulties, the facility failed to identify a change in communication ability had occurred and failed to provide appropriate services related to the change in status. The findings include:Resident #43's diagnoses included cerebral infarction, acquired deformity of head, left sided hemiplegia, and adjustment disorder with depressed mood.The annual Minimum Data Set assessment dated [DATE] identified Resident #43 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, was independent with eating, required moderate assistance with oral hygiene, was dependent on chair/bed-to-chair transfers, and had obvious or likely cavities or broken natural teeth and clear speech with distinct intelligible words.The Resident Care Plan (RCP) dated 7/11/2024 identified he/she had oral/dental health problems related to some broken teeth and multiple teeth extracted. Interventions included consulting with the dietician and change his/her diet if chewing/swallowing problems were noted. The RCP failed to address a change in his/her ability to communicate.A. The hospital Discharge summary dated [DATE] indicated that Resident #43 was hospitalized for aspiration pneumonia. A follow up Speech Therapy (ST) care plan note dated 8/21/2024 identified that the resident was seen post hospitalization and had intact motor speech skills and did not require further assessment.Dental consultation notes dated 10/15/2024, 11/26/2024, 1/3/2025, 1/22/2025, and 6/18/2025 identified that Resident #43 had multiple surgical dental extractions resulting in the resident becoming completely edentulous (no teeth) following the last visit on 6/18/2025.The annual Long Term Care Evaluation (performed yearly to identify changes in resident status) dated 7/7/2025 failed to identify Resident #43 had any changes in his/her ability to communicate verbally.Observation and interview on 9/10/2025 at 11:03 AM with Resident #43 identified he/she had unintelligible, unclear speech when responding to questions requiring more than a yes/no answer. No Augmentative and Alternative Communication (AAC) devices (specialized communication devices/aides) were present at his/her bedside or utilized by Resident #43.Interview on 9/15/2025 at 1:48 PM with the Director of Therapeutic Recreation identified Resident #43 communicated with facial expressions or yes/no answers. Further she indicated he/she does not have any AAC devices available to use and during observed family visits, Resident #43 was quiet and did not communicate much. Interview and review of ST documentation on 9/16/2025 at 1:28 PM with ST #1 identified that she had treated Resident #43 from 11/13/2024 through 12/10/2024 for dysphagia (swallowing difficulty) management after a hospitalization for aspiration pneumonia. At that time, the physician order directed treatment for dysphagia, so ST #1 did not evaluate Resident #43's ability to speak/communicate. From 11/13/2024 through 9/17/2025, ST #1 indicated that Resident #43 communicated his/her basic wants and needs through answering yes/no questions, could follow commands, had unclear and unintelligible speech, and had dental extractions leaving him/her edentulous. ST #1 was unaware of any changes in Resident #43's ability to communicate, so she did not further evaluate the resident for the change or for an AAC device. Interview on 9/17/2025 at 9:41 AM with Person #2 (Resident #43's family member) identified when Resident #43 was admitted to the facility he/she could speak in complete sentences and experienced a change in speech each time after his/her teeth were extracted. Person #2 notified ST #1 of Resident #43's speech difficulties in July or August of 2025 and had mentioned it several times to staff in RCP meetings. Person #2 indicated that while at the meetings, he/she requested assistance as to how family members could make him/her more comfortable and how he/she could learn to help Resident #43 or make things easier with communication. As of now, no one had assisted with his/her request for help. Further, Person #2 stated, you are on your own here. I'm getting used to that. You can't keep asking the same things over and over with no answers. It's not easy getting there (to the facility) and seeing him/her like that, it's hard. You want to do everything you can because he/she won't for themself. I really want help. He/she stated that the relationship between Resident #43 and family members had been negatively affected from Resident #43's change in speech. Resident #43 didn't speak to them anymore during visits and had to be forced to speak, which he/she found sad, and it bothered him/her. Interview on 9/17/2025 at 10:33 AM with the Director of Rehabilitation identified that Rehabilitation Services attended RCP meetings, but she was unaware of Resident #43's change in verbal communication. She indicated that the facility practice was for nursing to notify the Rehabilitation Department with any communication changes. Additionally, it was the responsibility of the speech therapist to review previous notes prior seeing a resident referred to speech therapy by the physician, and ST #1 should have done so in November 2024 post hospitalization. Once reviewed, if the notes indicated a change in speaking ability was noted from the previous information, ST #1 should have contacted nursing or the physician to make them aware of the change and to determine if further orders were required. The Rehabilitation Director stated that there was no policy for speech therapy to evaluate residents who have had tooth extractions as these are treated situationally.Interview on 9/17/2025 at 10:54 AM with Social Worker (SW) #1 identified that Person #2 regularly attended RCP meetings, visited the facility daily, and was happy with the care Resident #43 was receiving. SW #1 stated that Person #2 asked for help to make Resident #43's verbal communication easier, more comfortable during visits, and for methods that would help Resident #43's better. Although she had received the information, she failed to understand this was a request for assistance, failed to communicate the concern to nursing, and stated if she were aware that Person #2 was requesting assistance for Resident #43, she would have notified the Rehabilitation Department.Interview on 9/17/2025 at 12:01 PM with the Director of Nursing Services (DNS) identified that she was unaware that Resident #43 had a change in verbal communication following his/her dental extractions. Nursing staff on the unit attended Resident Care Plan meetings and the morning staff meetings. They were responsible to identify changes and act upon Person #2's concerns and changes in Resident #43's verbal communication ability, but no staff had made her aware. Further, Resident #43's tooth extractions should have been indicated in the Resident Care Plan, but the RCP was never revised.Review of the Facility's Communications Policy identified in part that upon admission, residents' ability to communicate with others is evaluated. Any resident with a suspected speech, language, or hearing problem will be referred to their physician for a referral to speech pathology for an evaluation as appropriate. The policy failed to identify the potential for resident evaluations after admission, including change in a resident's speech or a new edentulous status.

Based on review of the clinical record, facility documentation, facility policy, and interview for 2 of 2 sampled residents (Resident #49 and Resident #109) reviewed for skin issues, the facility failed to ensure neurological assessments were completed after falls. The findings include: 1. Resident #49 had diagnoses that included Alzheimer's disease, hypertension, and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 was severely cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for transfers. The Resident Care Plan (RCP) dated 11/7/24 identified Resident #49 was at risk for falls related to poor safety awareness and medical conditions. Interventions included to ensure Resident #49's call light was within reach, ensure prompt, and review information on past falls and attempt to determine possible root causes of falls, and alter or remove any potential causes if possible. a. A nursing note dated 1/3/25 at 7:13 AM identified at 6:15 AM Resident #49 was observed on the floor of his/her room stating he/she was putting clothes away, turned too fast, and fell. Resident #49 was noted to have had increased restlessness throughout the night. A Reportable Event Occurrence form with investigation documentation dated 1/3/25 at 6:15 AM identified Resident #49 had an unwitnessed fall without injury and neurological checks were initiated per the protocol. Review of the Head Injury Flow Sheet dated 1/3/25 indicated neurological checks began at 6:15 AM and were to be performed every 15 minutes 4 times, every 1 hour 4 times, every 4 hours 6 times, and every 8 hours 6 times for a total of 20 opportunities. Out of 20 opportunities 3 neurological checks failed to be completed. b. A nursing note dated 4/4/25 at 3:33 PM identified Resident #49 had an unwitnessed fall at 2:50 PM and was heard yelling for help. Resident #49 was subsequently found lying on the floor on his/her left side in a fetal position. Resident #49 complained of pain to the left hip and back of his/her head where a large hematoma (bruise) was noted. A Reportable Event Occurrence form with investigation dated 4/4/25 at 2:50 PM identified Resident #49 had an unwitnessed fall. Review of the Head Injury Flow Sheet dated 4/4/25 indicated neurological checks began at 2:55 PM and were to be performed every 15 minutes 4 times, every 1 hour 4 times, every 4 hours 6 times, and every 8 hours 6 times for a total of 20 opportunities. Out of 20 opportunities 3 neurological checks failed to be completed. 2. Resident #109's diagnoses included hypertension, overactive bladder, and unspecified falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #109 had a Brief Interview Mental Status (BIMS) score of 5 indicating severe cognitive impairment and was dependent on 1 staff for transfers to a wheelchair/bed and toileting. The Resident Care Plan (RCP) dated 7/29/25 identified Resident #109 was a fall risk. Interventions included monitoring for signs and symptoms of a urinary tract infection, follow the facility fall protocols, keep the bed in the lowest position, keep the resident in common areas as much as possible, anticipate needs, and provide physical therapy as needed. A physician's order dated 8/15/25 directed to ambulate Resident #109 with the assistance of 1 staff with a rolling walker and to transfer to a wheelchair with the assistance of 2 staff. a. A review of Resident #109's Reportable Event Occurrence form Report dated 9/4/25 at 9:00 AM identified Resident #109 had an unwitnessed fall attempting to ambulate to the bathroom. A physician's note dated 9/4/25 at 9:42 AM identified that Resident #109 had an unwitnessed fall in his/her room. Resident #109 complained of mild to moderate chest pain that worsened with palpation (touch) and deep breaths. The physician's assessment and plan indicated a contusion (bruise) to right front wall of his/her thorax (chest), to provide pain medications as needed and obtain a chest x-ray if the pain persisted. A nurse's note dated 9/4/25 at 11:27 AM identified that Resident #109 had an unwitnessed fall in his/her room attempting to self-toilet at 9:00 AM by getting out of bed unassisted. Resident #109 was incontinent of urine at the time of the fall, and no injuries were noted. Resident #109's RCP was updated on 9/4/25 to include a non-slip floor mat to the door side of the bed. A Fall Risk assessment dated [DATE] identified a fall risk score of 11 indicating Resident #109 was a high risk for falls. A Neurological Flow Sheet dated 9/4/25 indicated neurological checks began at 6:15 AM and were to be performed every 15 minutes 4 times, every 1 hour 4 times, every 4 hours 6 times, and every 8 hours 6 times for a total of 20 opportunities. Out of 20 opportunities 2 neurological checks failed to be completed. b. Resident #109's Reportable Event Occurrence form report dated 9/14/25 at 9:45 PM identified he/she attempted to get of bed, unattended, to use the bathroom and slipped onto the floor. The resident did not sustain any injuries. Resident #109's RCP was not updated with a new intervention for the fall on 9/14/25. The Neurological Flow Sheet dated 9/14/25 indicated neurological checks began at 9:45 PM and were to be performed every 15 minutes 4 times, every 1 hour 4 times, every 4 hours 6 times, and every 8 hours 6 times for a total of 20 opportunities. Out of 20 opportunities, 7 neurological checks failed to be completed. A Fall Risk assessment dated [DATE] identified a fall score of 14 indicating Resident #109 was a high risk for falls. Interview with Director of Nursing Services (DNS) on 9/17/25 at 10:56 AM and 12:35 PM identified that neurological checks should be completed for all residents who sustained an unwitnessed fall and hit their head and for cognitively impaired residents who had an unwitnessed fall. The DNS indicated that when neurological checks were initiated, the form must be filled out completely for all indicated times. She indicated that the neurological assessments were incomplete, and the charge nurses were responsible to ensure all neurological assessments were thoroughly completed on his/her shift. Further, the DNS stated that when nursing supervisors were performing rounds on their shift, they should be looking at the Head Injury Flow Sheets to ensure no missing entries. The DNS could not explain why staff were not thoroughly completing the neurological assessments. Review of the Head Injuries policy directed, in part, the Head Injury Flow Sheet is utilized if a fall is unwitnessed and the resident is cognitively unable to articulate the circumstances of the event. The policy directed the nurse observes for neurological responses and neurological assessments will be done immediately after the injury occurs, following the times designated on the Head Injury Flow Sheet. The policy directed if there was a change anytime during the assessment, the physician should be notified.

Based on interviews, review of the clinical record, facility documentation, and policy for 1 of 8 sampled residents (Resident #93), reviewed for accidents, the facility failed to revise the Resident Care Plan (RCP) following a fall. The findings include:Resident #93's diagnoses included osteoarthritis, gout, and adjustment disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition and required partial/moderate assistance for lower body dressing, and transfers. Additionally, the MDS identified Resident #93 had a fall in the month prior to admission.The Resident Care Plan dated 8/30/25 identified Resident #93 was at risk for falls related to weakness. Interventions included anticipating and meeting resident needs, appropriate footwear when ambulating, maintain a safe environment free of spills, clutter, adequate lighting, call light and personal items in reach, and keep the bed in low position.The Physician orders dated 8/20/25- 9/15/25 did not include fall prevention measures.A review of the Accident Occurrence form dated 8/30/25 at 9:52 PM identified Resident #93 had an unwitnessed fall and was found lying on the floor next to the bed. The RCP included a new intervention.A review of the Accident Occurrence form dated 9/1/25 at 7:10 AM identified Resident #93 had an unwitnessed fall and was found on the window side of the bed, sitting on the floor. The RCP included a new intervention.A review of the Accident Occurrence form dated 9/4/25 at 8:05 PM identified Resident #93 had an unwitnessed fall and was found on the bathroom floor, he/she hit his/her head which resulted in a transfer to the Emergency Room. A review of the RCP failed to identify the RCP had been revised to include a new intervention following the fall.An interview, clinical record review, and review of the Accident Occurrence with Registered Nurse Supervisor (RN) #3 on 9/16/25 at 1:45 PM identified the facility policy directed the supervisor to initiate a new intervention after a resident fell. RN #3 indicated RCP interventions were only to be placed in the RCP and not in physician's orders, nurses' notes, or on the Accident Occurrence form. RN #3 further stated although she had put a new intervention in place for a non-slip mat, the intervention never was placed on Resident #93's RCP but should have been. An interview and record review with the Director of Nurses (DNS) on 9/16/25 at 2:22 PM identified the facility policy directed nursing staff to update the RCP with a new intervention following a fall. The interdisciplinary team reviewed falls the next morning and, if needed, they would amend the intervention. Although a review of Resident #93's falls occurring on 8/30/25 and 9/1/25 had new interventions on the RCP, there was no new intervention put in place following Resident #93's fall that led to a hospitalization on 9/4/25. The DNS stated that a new RCP intervention should have been put in place to prevent further falls, however, she was unable to explain why Resident #93's RCP failed to include a new intervention following the resident's fall. The Resident Care Planning Guidelines directed, in part, that the care planning process assures all members of the interdisciplinary team are caring for the individual patient/resident based on their specific needs. Additionally, the nurse on the floor and members of the interdisciplinary team update care plans as needed. The Resident Care Team Policy directed in part that the care plan needs to be updated to reflect day-to-day changes in the resident.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 8 sampled residents (Resident #16 and Resident #49) reviewed for accidents, for Resident #16, the facility failed to transfer a resident according to the plan of care resulting in a fall, and for Resident #49, the facility failed to implement new Resident Care Plan (RCP) interventions following falls, and failed to utilize wheelchair equipment according to the Resident Care Plan. The findings include: 1. Resident #16's diagnoses included pain in left hip, abnormalities of gait and mobility, Parkinson's disease, psychotic disturbance, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 had a Brief Interview for Mental Status score of 14, indicating no cognitive impairment and required a wheelchair/walker for mobility and needed partial/moderate assistance for bed mobility, toileting, and bathing transfers. A Facility Reported Incident (FRI) form dated 8/13/25 at 12:45 PM identified Resident #16 had reported to the speech therapist that he/she was pushed down by NA #5 while being transferred to the toilet. According to the investigation, Resident #16 indicated he/she did not believe NA #5 was intentionally attempting to hurt him/her but felt like he/she was being rushed. NA #5's statement identified that Resident #16 needed to use the bathroom and during the transfer his/her feet became twisted and were close to the bar next to the toilet, so NA #5 used the resident's brief to guide him/her onto the toilet. Resident #16 used the restroom and offered no complaints. NA #5 indicated that she did not observe Resident #16 hit the bar during the transfer. Resident #16's undated NA Resident Care Card (used to direct care) indicated that Resident #16 required the assistance of 2 with ambulation and transfers. Interview with Physical Therapist (PT) #1 on 9/16/25 at 1:25 PM, identified that, at the time of Resident #16's fall, he/she required the assistance of 2 for transfers. Interview and review of facility documentation with PT #2 (Rehabilitation Director) on 9/26/25 at 1:35 PM identified that although she had written a note in the unit's communication log on 7/17/25, alerting nursing staff that Resident #16 was able to ambulate to the bathroom with the assistance of 1, the resident still required the assistance of 2 for transfers. Attempts to reach NA #5 were unsuccessful. 2. Resident #49 had diagnoses that included Alzheimer's disease, hypertension, and anxiety. A Fall Risk Evaluation dated 10/20/24 identified Resident #49 had a score of 13 indicating a high fall risk. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 had a Brief Interview of Mental Status score of 4 indicating severely impaired cognition, required setup or clean-up assistance with eating, supervision or touching assistance with wheelchair mobility 50 ft. and dependent for 150 ft., substantial/maximal assistance with bed mobility, and was dependent for transfers. The MDS assessment further identified Resident #49 had not fallen since a previous assessment dated [DATE]. The Resident Care Plan (RCP) dated 11/7/24 identified Resident #49 was at risk for falls related to poor safety awareness and medical conditions. Interventions included to ensure Resident #49's call light was in reach, encourage use, and respond promptly, on the falling star program (intervention not to leave Resident #49 alone unless nurse was aware), place Dycem above and below the wheelchair cushion, physical therapy to evaluate and treat as ordered/needed, and review information on past falls to determine the possible root cause, and alter or remove any potential causes if possible. A. Review of the Reportable Event Occurrence form dated 1/3/25 at 6:15 AM identified Resident #49 had an unwitnessed fall and was found in his/her room sitting upright on the floor behind the door. The recommendation/preventative measures initiated were to obtain a urine dip and implementation of the Urinary Tract Infection (UTI) protocol. Review of the Reportable Event Occurrence form dated 4/4/25 at 2:50 PM identified Resident #49 had an unwitnessed fall in his/her room and was found lying on the floor, on their left side, with their head facing the door, calling for help. Additionally, Resident #49's wheelchair was by the bed, and the wheels were unlocked. The recommendation/ preventative measure was to place the resident back to bed for a nap after lunch. Review of a Reportable Event Occurrence form dated 5/1/25 at 3:40 PM identified Resident #49 had an unwitnessed fall in his/her room and was found lying on his/her back on the floor facing the door calling for help. Review of the clinical record identified on 5/1/25 all Resident #49's RCP interventions were reviewed and appropriate. No new intervention was implemented. Review of a Reportable Event Occurrence form dated 5/30/25 at 9:15 AM identified Resident #49 was found on his/her knees facing the bed, arms on the bed, and the wheelchair behind him/her with the wheels unlocked. Resident #49 was last seen at 8:30 AM self-propelling on and off the unit in his/her wheelchair. The recommendation/ preventative measure was to continue the fall prevention measures already in place. Review of the clinical record identified on 5/30/25 all Resident #49's RCP interventions were reviewed and appropriate. No new intervention was implemented. Review of a Reportable Event Occurrence form dated 6/9/25 at 3:15 PM identified Resident #49 had an unwitnessed fall in his/her room and was found lying on the floor next to the bed on his/her back. The recommendation/preventative measures indicated all interventions were reviewed and appropriate. Review of the clinical record identified on 6/9/25 all Resident #49's RCP interventions were reviewed and appropriate. No new intervention was implemented. A Reportable Event Occurrence form dated 6/10/25 at 12:55 PM was requested but not provided. An Interim Nurses Notes Post Fall form dated 6/10/25 at 12:55 PM identified Resident #49 was found lying on the floor next to his/her bed wearing shoes and reporting that his/her head hurt. Potential alternative measures post fall were the initiation of the UTI protocol and placement of anti-rollback devices to Resident #49's wheelchair. Review of the clinical record identified a fall evaluation was completed on 6/10/25 with a score of 2 indicating a high fall risk. B. Observation on 9/17/25 at 11:40 AM identified Resident #49 in a wheelchair in the front lobby with a staff member and then at 11:50 AM was sitting at a table in the dining room. During both observations Resident #49 failed to have an anti-rollback device attached to the wheelchair. Interview, observation, and record review with Licensed Practical Nurse (LPN) #5 on 8/17/25 at 12:15 PM identified following a fall, 2 fall evaluations (Fall Risk and Post Fall) as well as a Reportable Occurrence form were completed by the charge nurse and the RN Supervisor. LPN #5 identified the process for initiating new interventions post fall was a bit of a mess. There were 2 RCP's, a fall risk and an actual fall RCP. LPN #5 indicated her RCP update would include the date, an explanation the fall, indicate if there were injuries, and a new intervention if appropriate. Upon the direction of the RN, she would update the RCP to indicate that all interventions were reviewed and appropriate if there was no new intervention being implemented. LPN #5 identified that unfortunately Resident #49 fell a lot and that Resident #49 was quick and quiet. On observation of Resident #49's wheelchair failed to have an anti-roll back device attached per the RCP intervention. LPN #5 identified that she hadn't actually observed that the anti-rollbacks were not in place, but she had thought something did not look right. LPN #5 stated if she had realized Resident #49 was in the wrong wheelchair earlier, she would have made the switch right away. Resident #49's wheelchair was subsequently found 2 rooms away in another resident's room. LPN #5 indicated that the NA may have put the resident in the wrong wheelchair and requested a NA to switch Resident #49 to the correct wheelchair. Interview and record review with the Director of Nursing Services (DNS) on 9/17/25 at 12:35 PM identified: A. After a resident fall the interventions should be reviewed and if there was an intervention already in place that met the circumstances of the fall it may not be necessary to initiate a new intervention. There were many interventions within the fall policy that nursing staff could use if they were having trouble thinking of a new intervention, however, if the resident fell doing the same type of activity then it was her expectation that a new intervention would be added, or the current intervention would be changed to prevent another fall with the same activity. The DNS identified that out of 6 falls, only 3 had new interventions. When Resident #49 had fallen 3 consecutive times while appearing to be trying to independently transfer to the bed, the nursing staff should have tried a new intervention, so she was unsure why nursing staff documented the fall interventions in place remained appropriate and did not add any new intervention. B. Review of the fall documentation dated 1/3/2025, 4/4/2025, 5/1/25, 5/30/25, 6/9/25, and 6/10/25 identified that of the 6 falls, only 1 had a post fall, Fall Risk assessment documented on 6/10/25. The DNS identified that it was facility policy to complete a fall risk assessment after every fall so Resident #49 should have had fall assessments completed on 1/3/2025, 4/4/2025, 5/1/25, 5/30/25, and 6/9/25. Review of the Resident Safety policy dated 8/2025 directed, in part, it is the policy of the facility to provide interventions that promote resident safety based on individual goals of care. The policy directed the following evaluations to be completed after a fall: Fall risk evaluation, Post Fall evaluation, and Registered Nurse post fall assessment (instituted 7/21/25). The policy directed after a fall the RCP is reviewed and new interventions added if deemed appropriate. The policy directed the Reportable Event Occurrence Form is given to the supervisor and/or the DNS for completion of the investigation and input regarding appropriate follow up intervention.

Based on observations, facility policy, and interviews, for the only sampled resident (Resident #68) reviewed for respiratory issues, the facility failed to change the resident's nebulizer mask and tubing per the facility policy. The findings include:Resident #68's diagnosis included: anemia, heart failure and chronic obstructive pulmonary disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 had a Brief Interview of Mental Status score of 13 indicating intact cognition and required substantial/maximal assistance with upper and lower body dressing, and transfers and partial/moderate assistance with bed mobility. A physician's order dated 8/25/25 directed to provide Ipratropium-Albuterol Inhalation Solution (0.5-2.5 MG/3ML) to be used with the resident's nebulizer as needed every 6 hours for complaints/feelings of shortness of breath while awakeObservations of Resident #68's nebulizer equipment identified that the tubing was dated 7/18/25 (indicating when first put into use) and stored uncovered, exposed to the environment on 9/10/25 at 11:15 AM on the bedside table, on 9/12/25 at 10:02 AM on the arm of the recliner chair, and on 9/15/25 on the seat of the recliner.Review of Resident 68's Medication Administration Record (MAR) identified that the resident last received a nebulizer treatment on Saturday 9/13/25 at 6:03 AM. Interview and observation with LPN #5 on 9/15/25 at 10:18 AM identified Resident #68's nebulizer mask and tubing was dated 7/18/25 and stored on the arm of the recliner. LPN #5 indicated that the policy directed nebulizer masks and tubing were to be replaced every Wednesday on the 11:00 PM to 7:00 AM shift. LPN #5 stated that she was responsible to replace the tubing it's my fault and that she should have checked the equipment to ensure a storage bag was present and that the tubing had been replaced per the facility policy. LPN #5 indicated that although the equipment should have been contained in a bag and there was no bag present, that Resident #68 was self-care and may have completely removed the bag from the room.Subsequent to surveyor inquiry, LPN #5 immediately removed Resident #68's old tubing and mask and replaced it with new equipment and dated it for 9/15/25.Review of the facility's policy statement in Department of Nursing Services - Cleaning of Respiratory Equipment, identifies oxygen cannulas and masks, and nebulizer masks are to be changed weekly.

Based on review of facility documentation, facility policy and interviews during a review of the infection control program, the facility failed to ensure documentation of a 48-to-72-hour review of antibiotic use and failed to ensure practitioners were documenting the rationale for continued antibiotic use when the antibiotic failed to meet the criteria. The findings include:Interview and review of the Antibiotic Stewardship Program on 9/14/25 from 11:00 AM through 12:30 PM with the Infection Control Nurse (ICN), Registered Nurse (RN) #1 and Assistant Director of Nursing Services (ADNS) identified that the facility used McGeer's criteria in determining if antibiotic use was appropriate for a suspected or diagnosed infection. Although the information was reviewed as a guide, the facility practice did not include documentation of the review. Additionally, it was identified that practitioners (physician/Advanced Practice Registered Nurse, APRN) were not consistently documenting the rationale for continuing the use of antibiotics when McGeer's criteria had not been met.A. RN #1 indicated that the facility followed the Centers for Disease Control (CDC) recommendations to determine the continued need for antibiotic use during the time out period (48 to 72 hours) after the initiation of antibiotic therapy. A review of the resident antibiotic use log failed to identify an area to document a 48 to 72 hour look back or any documentation that a look back had taken place to determine antibiotic necessity. RN #1 indicated that she did not conduct a 48 to 72-hour time out for resident antibiotic use stating the review was her responsibility, but she was unable to state why she had failed to conduct the review per the facility policy.B. RN #1 identified that the facility did not have any systems in place to ensure practitioners were documenting the rationale for the continued use of an antibiotic that was contraindicated. Any antibiotic use failing to meet the initial McGeers criteria or the criteria during the 48 to 72-hour look back period, or any antibiotic use based on the practitioner's judgement required documentation according to the facility policy. RN #1 was unable to identify how this was communicated to the practitioner or how the facility was ensuring compliance with practitioner documentation.Interview with APRN # 1 on 9/15/25 at 3:00 PM identified that the facility had never communicated an individual resident review of antibiotic use, or that there was a formal process in place at the facility since she started in March 2025. (6 months prior) APRN #1 indicated that she usually documented the rationale for continuing an antibiotic without direction from the facility. An interview with the Medical Director on 9/16/25 at 10:30 AM indicated that he prescribed antibiotics based on his assessment of the resident and did not determine the need for antibiotic use based solely on diagnostic testing. Although he indicated that he did not always document the rationale for continuing the use of an antibiotic. he stated that if it was the policy and recommended practice for antibiotic stewardship then the facility should be following the standard and policy.A review of the Antibiotic Stewardship Program Policy dated 1/25 directed, in part, the Stewardship Program is based on the CDC's core elements of Antibiotic Stewardship for nursing homes. The core elements are leadership, accountability, drug expertise, action, tracking, reporting and education. Nursing contacts providers for reassessment during the time out period for the ongoing need for and choice of antibiotics once more data is available including clinical response, additional diagnostic information, and alternate explanations for the status change which prompted the antibiotic start.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 sampled residents (Resident #86 and #88) for vaccinations, the facility failed to ensure the pneumococcal vaccine was offered. The findings included:1.Resident #86's was admitted to the facility in January 2020. Resident #86's diagnoses included heart disease and hypertension.The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #86 had a Brief Interview for Mental Status score of 15 indicating intact cognition and required moderate assistance with Activities of Daily Living (ADL).The Resident Care Plan dated 9/12/25 failed to address Resident #86's vaccination status. A review of Resident #86's clinical record for the pneumococcal conjugate vaccination (PCV) status identified that he/she received the PCV 13 in July of 2021. The Center for Disease Control (CDC) pneumococcal vaccination recommendation indicated that Resident #86 was to receive 1 dose of either the PVC20 or PCV21 one year after PCV13 was given. The clinical record failed to identify a consent to offer any further vaccinations, or that any further vaccinations had been administered. 2. Resident #88 was admitted to the facility March 2024. Resident #88's diagnoses included heart failure and type 2 diabetes.The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 88 had a Brief Interview for Mental Status score of 4 indicating extreme cognitive impairment and was totally dependent on staff for ADLS.The Resident Care Plan dated 9/5/25 failed to address Resident #88's vaccination status. A review of Resident # 88's clinical record failed to identify a signed consent or nursing documentation of pneumococcal vaccination status. An unsigned, undated vaccination worksheet indicated that the PVC 23 pneumococcal vaccination had been declined. The form directed that educational and consent forms should be given to all residents and/or resident representatives, whether the resident choose to receive a vaccine or wished to consult in the future with their attending physician. Additionally, there was no information in Resident #88's clinical record of a pneumococcal vaccination history.Interview with RN #1 on 9/16/25 at 1:00 PM identified that the facility should have offered the opportunity to provide vaccinations to Resident #86 and Resident #88. She believed that the vaccination was offered to Resident #86, but he/she may have declined. Additionally, RN #1 was unable to find a consent form accepting or declining the vaccinations or documentation for either resident in the clinical record. RN #1 indicated that it was her responsibility to ensure the facility had offered vaccinations to Resident #86 and Resident #88 indicating it may have been an oversight. A review of the Pneumococcal Vaccine Policy dated 4/25 directed, in part, it is the policy of [NAME] Health Center to vaccinate all eligible residents against pneumococcal disease. A consent form is signed by the resident or party responsible. Eligibility for vaccination is determined by guidelines established by the CDC which are based on individual's age, prior vaccination status, and medical condition.

Based on the clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was properly positioned prior to the provision of care resulting in a fall out of bed. The resident sustained a fractured ankle. The finding includes: Resident #1 was admitted with diagnoses that included Alzheimers disease, osteoarthritis, and abnormalities of mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition, height was 67 inches, weight 181 pounds, and required maximum staff assistance with bed mobility. The Resident Care Plan (RCP) dated 6/28/2024 identified Resident #1 had decreased mobility and was at risk for falls. Interventions included one (1) staff assist for bed mobility. Facility incident report dated 6/28/2024 at 10 PM identified a NA asked the resident to turn onto his/her side so that the NA could provide care. When Resident #1 went to turn onto his/her side, the resident rolled out of bed onto the floor before the NA could reach or stop the resident. Resident #1 reported pain to the left ankle. An RN assessment was completed and identified the left ankle was swollen. The physician was notified, and the resident was transferred to the hospital for further evaluation. Review of the incident summary dated 7/1/2024 identified the left ankle x-ray results identified Resident #1 had oblique transverse fractures of the distal tibial and fibular metaphyses (leg bones that connect with the ankle) with posteromedial (toward the middle) displacement of the distal fragments and the bones are osteopenic. Resident #1 returned to the facility with a diagnosis of a left ankle fracture and orders for no weight bearing to left lower extremity, splint with ace wrap to left ankle at all times, follow up with the orthopedic physician in one (1) week. Interview with NA #1 on 7/24/2024 at 12:46 PM identified she was repositioning Resident #1 in the bed alone and had directed Resident #1 to turn away from her (to the opposite side of the bed). NA #1 stated there were short (1/4 or 1/2 side rails) up at the head of the bed. NA #1 further stated Resident #1's legs were close to the edge of the bed (on the side opposite where NA #1 was standing) prior to turning Resident #1 onto his/her side. The NA stated when Resident #1 turned onto his/her side, Resident #1's legs slid off the mattress to the floor and then Resident #1's upper body slid off the bed onto the floor. NA #1 states she should have moved Resident #1's legs away from the edge of the mattress to the middle of the bed or closer to where she was standing. Interview with MD #1 on 7/24/24 at 11 AM identified that the type of fracture that Resident #1 sustained would be caused from trauma and stated it was highly likely that this type of fracture could be caused by falling out of bed. Interview with the ADNS on 7/24/24 at 1:30 PM identified Resident #1 used a standard size mattress, and was positioned too close to the edge prior to being turned in bed. The ADNS stated when Resident #1 turned, his/her legs slid off the bed and his/her body then slid off the bed onto the floor. The ADNS stated she would have expected NA #1 to reposition Resident #1's legs to the center of the mattress, or closer to the NA prior to turning the resident to prevent the resident from sliding or rolling out of the bed onto the floor.

Based on observation of the Dietary Department, staff interview, and facility policy, the facility failed to ensure food items were dated and labeled, the kitchen was in clean and sanitary condition, and adequately store a chemical solution. The findings include: Tour of the Dietary Department on 2/14/24 at 11:00 AM and 2/20/24 at 9:55 AM with the Operations Manager identified the following: a. The kitchen floor was observed throughout the entirety of the kitchen with debris and food on the floor (including under the storage racks). b. Dust and debris was observed on the ice machine vents with dried stains going down the side of the ice machine. Additionally, black grime was observed on a metal bar, located beneath the ice machine lid, adjacent to the front panel. c. The reach-in refrigerator was noted with stains running down the outside of the doors. d. The milk and orange juice cooler had stains and marks on the doors. e. The racks used for clean dishes to drip dry were dirty with debris and grime. One rack was observed to have clean dishes stored on it. f. The grease trap located next to the rack where clean dishes are stored was unkempt with stains and grime. g. A heavy accumulation of dust was observed on the scooper used for the flour and sugar bin. h. The flour and sugar bins were dirty with grime and stains with loose food particles on the floor around the bins. i. The stove had built up stains and grime on the back plate. j. A half full plastic container of opened grape jelly was located inside the reach-in refrigerator and lacked an expiration date, was not dated when it was opened, and had no use by date. k. A 25 pound (lb) bag that was approximately one quarter full of flour and a 50 lb bag approximately one quarter full of cornmeal was located inside a plastic bin but was not dated when it was opened. l. A 25 lb bag approximately one quarter full of sugar and a 50 lb bag approximately two thirds full of red velvet cake mix was located inside a bin labeled sugar but was not dated when opened and lacked an expiration date. m. A red container (approximately 1 gallon) containing a chemical solution (Quat sanitizer) was observed to be adjacent to crackers, the steam table entrees (chicken tetrazini) and cod. On 2/20/24 at 9:55 AM observation with the Operations Manager identified the following: a. Freezer number 3 had a two-pound bag of green beans which was half full and lacked an open date labeled on the bag. b. A five-pound bag of French fries was one third full with no open date labeled on the bag. c. A two-pound bag of gnocchi was half full with no open date labeled on the bag. d. A 6 ounce container of Chipotle cinnamon rub spice which was approximately half full was opened with no open or use by/expiration date located on spice container. On 2/14/24 at 11:20 AM, an interview with the Operations Manager stated the kitchen was supposed to be cleaned daily according to the cleaning schedule. The Operations Manager identified being unaware the kitchen was dirty and although the staff did clean the kitchen according to the cleaning schedule, did not know the reason the kitchen wasn't in clean condition. Additionally, she also identified that food items should be labeled with an open date when opened and all food items should have an expiration or use by date. Additionally, interview with the Operations Manager on 2/20/24 at 9:55 AM identified that the red container (approximately 1 gallon) with a chemical solution contained Quat sanitizing solution should not be stored adjacent to food and did not know reason it was placed there. She also identified that the container with sanitizer solution should be filled, used as needed and then discarded afterwards or stored under the chefs bench. Facility policy regarding storage of food identified placing chemicals in areas specifically designated for that purpose and away from food and food preparation areas. Dispose of items that are beyond the expiration or use by date. The Safety Data Sheet regarding Quat Sanitizer identified do not ingest, may be harmful if swallowed.

Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #60) reviewed for unnecessary medications, the facility failed to initiate a care plan for an anticoagulant (blood thinning) medication. The findings include: Resident #60's diagnoses included heart failure, atrial fibrillation, and edema. A physician's order dated 2/2/24 directed to administer Eliquis (an anticoagulation medication) 2.5 milligrams (mg) by mouth twice daily (BID). The Medication Administration Record dated 2/2/24 to 2/21/24 identified Resident #60 received Eliquis 2.5 mg by mouth BID at 8:30 AM and 8:30 PM. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was without cognitive impairment and required total assistance with transfers and substantial/maximal assistance with bathing. Additionally, the MDS had anticoagulation coded for consideration for care planning. Interview and review of the Resident Care Plan (RCP) with RN #3 on 2/21/24 at 9:56 AM identified the facility failed to initiate a care plan for the use of the anticoagulant medication (Eliquis). Further, RN #3 identified that all of nursing was responsible for initiating, changing, and updating the care plan and that she would be implementing an anticoagulant care plan. Subsequent to surveyor inquiry, on 2/21/24 a RCP was developed which indicated a potential for bleeding related to anticoagulation therapy. Interventions included to administer Eliquis as ordered, monitor for unanticipated bleeding (bruising, hematuria, nosebleeds, guiac positive stools, etc), and update family and physician as needed. Review of the facility Care Plan policy directed, in part, that the comprehensive care plan would be developed within 7 days after completion of the comprehensive MDS assessment. All care assessment areas triggered by the MDS would be considered in developing the plan of care. 50179

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #39) reviewed for bowel and bladder incontinence, the facility failed to assess a decline in continence status and failed to implement a plan to restore continence. The findings include: Resident #39 was admitted to the facility for short term rehabilitation on 12/28/23 with diagnoses that included a fall with bilateral shoulder dislocations, hilar mass with metastasis to the brain, and intracranial bleed. Inter-agency Patient Referral Report (W-10) from the hospital dated 12/28/23 identified Resident #39 was continent of bowel and bladder. An Interdisciplinary Admission assessment dated [DATE] identified Resident #39 was not incontinent of bladder with no history of incontinence and continent of bowel. The Resident Care Plan (RCP) dated 12/28/23 identified a potential for skin impairment secondary to decreased mobility, incontinence, pain, and compromised medical condition. Interventions included notifying the medical doctor (MD) of exacerbation of medical condition changes as needed and incontinent care per individual care plan. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 had intact cognition and required partial/moderate assistance for both toileting hygiene and personal hygiene. Additionally, the MDS identified Resident #39 was always continent of urine and bowel. Nurse Aide (NA) activities of daily living flow chart documentation (which was part of the clinical record) identified from 12/28/23 through 1/15/24, Resident #39 was continent of bladder. A re-admission Interdisciplinary Admission Assessment completed on 1/29/24 identified Resident #39 was incontinent of bladder and bowel (a decline from the 12/28/23 assessment). Furthermore, the Interdisciplinary Admission Assessment indicated: If No to continent of bladder/bowel or both, institute an incontinence record for 3 days followed by a bowel and bladder evaluation tool. Nurse Aide (NA) activities of daily living flow chart from 1/15/24 through 2/15/24 identified Resident #39 was incontinent of bladder (a decline from NA flow chart documentation from 12/28/23 through 1/15/24). a. On 2/16/24 at 11:00 AM, interview and record review with Registered Nurse (RN) #3 failed to provide documentation that a Bowel and Bladder Evaluation tool had been completed on admission (per facility policy) and/or with the identified decline in continence status on the 1/29/24 Interdisciplinary Admission Assessment and NA flow chart documentation. RN #3 also identified she was responsible for completing the Bowel and Bladder Evaluation tool and did not know the reason she did not complete the evaluation tool. Subsequent to surveyor inquiry, a Bowel and Bladder Evaluation tool was completed on 2/21/24 that identified Resident #39 was frequently incontinent, uses a brief, and recommended prompted/habit trained toileting program. The quarterly MDS assessment dated [DATE] identified Resident #39 was moderately cognitively impaired and dependent with both toileting hygiene and personal hygiene. Additionally, the quarterly MDS assessment identified Resident #39 was frequently incontinent of urinary and bowel (a decline from the MDS assessment from 1/3/24). b. Review of the RCP with RN #3 on 2/16/24 at 11:00 AM failed to provide documentation to reflect the RCP had been revised to include interventions for the decline in bladder and bowel function from the 2/4/24 quarterly MDS assessment. Interview with Resident #39 on 2/15/24 at 9:08 AM stated it can be quite a while before getting help and when using the call light not everyone will answer. Resident #39 further indicated he/she was continent of bowel and bladder but when he/she does not get help on time to get on the bedpan he/she was incontinent in the bed. Additional interview and review of the clinical record with RN #3 on 2/16/24 at 11:00 AM identified that although Resident #39 had a decline in continence status, he/she was not on a bowel and bladder program to restore bladder/bowel function. Interview and record review with RN #4 (MDS Consultant covering for the MDS Coordinator) 2/21/24 at 9:37 AM identified that on the admission MDS assessment dated [DATE], Resident #39 was coded as being always continent of bowel/bladder. On the quarterly MDS dated [DATE], Resident #39 was coded as frequently incontinent of bowel/bladder. RN #4 identified that although the MDS software does not flag when there was a change in continence status, she would bring the decline to someone's attention (Nursing Supervisor) but could not provide documentation that the MDS Coordinator had done that. Subsequent to surveyor inquiry, the RCP was updated on 2/21/24 to include Resident #39 was currently on a prompted or habit training program related to overflow/urge/functional/mixed incontinence. Interventions included placement on a prompted toilet plan, toilet approximately every 2 hours while awake and two times on the 11:00 PM to 7:00 AM shift until a plan is developed, encourage resident to void and assist/cue/remind as needed. Review of the Facility Bladder/Bowel Continence Evaluation Policy, revised 12/04, directed that a Bowel and Bladder Continence Evaluation Tool is to be done on admission, quarterly and when there is a significant change in status.

Based on observations, review of the clinical records, facility policy, and interviews for 2 of 3 residents (Resident #5 and #57) reviewed for Activities of Daily Living (ADL's), the facility failed to ensure personal hygiene services were provided to dependent residents. The findings include: 1. Resident #5's diagnoses included vascular dementia, Cerebral Vascular Accident (CVA) affecting the dominant side, and osteoporosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was severely cognitively impaired and required setup assistance for transfers, dressing, and personal hygiene. The Resident Care Plan dated 1/11/24 identified that Resident #5 was unable to perform ADL's independently due to impaired cognition, mixed dementia, and osteoporosis. Interventions included providing the assistance of 1 staff for transferring, toileting, and personal hygiene. An observation on 2/14/24 at 11:47 AM, identified Resident #5 in his/her room with long facial hair. Observation on 2/16/24 at 2:32 PM, identified Resident #5 in his/her doorway with long facial hair. Review of Nurse Aid (NA) flow sheets (amount of care required) from 2/1/24 through 2/20/24 identified that Resident #5 had ranged from requiring limited assistance to extensive staff assistance for personal hygiene. Review of Resident #5's nursing notes and APRN/MD notes from 2/1/24 through 2/16/24 failed to identify that Resident #5 had been refusing assistance with ADL's. 2. Resident #57's diagnoses included vascular dementia, glaucoma, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was severely cognitively impaired and required maximum assistance for transfers, dressing, and personal hygiene. The Resident Care Plan dated 2/1/24 identified that Resident #57 was unable to perform ADL's independently due to dementia, paranoia, and delusions. Interventions included providing the assistance of 1 staff for transferring, toileting, and personal hygiene. Observation on 2/14/24 at 12:15 PM, identified Resident #57 in his/her room with long facial hair. Observation on 2/16/24 at 2:34 PM, identified Resident #57 in his/her room with long facial hair. Review of Nurse Aid (NA) flow sheets (amount of care required) from 2/1/24 through 2/20/24 identified that Resident #57 had required limited assistance for personal hygiene. Review of nursing notes and APRN/MD notes from 2/1/24 through 2/16/24 failed to identify that Resident #57 had been refusing assistance with ADL's. Interview with LPN #1 on 2/16/24 at 2:39 PM, identified that NAs should be shaving residents with facial hair as needed with personal care, and that shaving should have been completed on Resident #5 as well as Resident #57. She was unable to locate a policy on shaving residents but indicated that staffing was not an issue in the past week and that supplies were available on the unit. Interview with NA #6 on 2/16/24 at 2:42 PM identified that Resident #5 and Resident #57 did require shaving but could not identify the last time either resident had been shaved. She indicated that the NA's would shave residents once per week on shower days and as needed, but stated she was not sure why Resident #5 and #57 remained unshaved. Subsequent to surveyor interview, NA #6 reported on 2/20/24 at 10:35 AM that all residents on the unit that required assistance with personal hygiene, had been shaved. Although requested, a policy on shaving was not provided.

Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #5) reviewed for positioning/mobility, the facility failed to ensure an AFO (Ankle Foot Orthotic) brace/splint was in place. The findings include: Resident #5's diagnoses included right footdrop, Cerebral Vascular Accident (CVA) affecting the right dominant side, and osteoporosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was severely cognitively impaired, had a right sided physical impairment requiring set-up assistance for lower body dressing and putting on and taking off footwear, and was independent for transfers. The Resident Care Plan dated 1/11/24 identified a history of a CVA with hemiparesis (partial paralysis on one side of the body) and foot drop. Interventions included Resident #5 to independently apply and remove right lower extremity AFO. Observations on 2/14/24 at 11:08 AM and 2/15/24 at 1:16 PM, identified an AFO on a bedside chair in Resident #5's room. Review of Physical Therapy notes dated 9/19/23 through 12/26/23 indicated that Resident #5 had an AFO in place to the right lower extremity. Interview and review of facility documentation with LPN #1 on 2/15/24 at 1:28 PM identified that Resident #5 should have been wearing an AFO splint since the admission physician's order dated 6/7/23. Although LPN #1 knew Resident #5 should have been wearing the AFO, she was unable to recall when the last time he/she had applied the brace. LPN #1 identified Resident #5 had independently applied the AFO previously but was no longer able to do so due to the resident's decline which occurred around October 2023. LPN #1 reported that per the facility policy, the application and removal of the AFO should have been noted on the Treatment Administration Record (TAR), the Nurse Aid (NA) Kardex, and the NA assignment sheet but when reviewed from 6/2023 through 2/2024 the documentation failed to reflect an indication for Resident #5 to wear the AFO. Further, a physician's order on the TAR directed nursing staff to monitor right lower extremity skin integrity due to the use of the AFO, and although there was no order for an AFO to be utilized, the skin check had been signed off as complete since 6/7/23. LPN #1 was unable to identify why an order for the AFO was not on the TAR per the facility policy, but that it was possibly dropped when the residents change in condition occurred. Additionally, Resident #5 had received new shoes around the holidays, but LPN #1 indicated she had not contacted the Rehabilitation Department to have the resident screened to ensure the brace would fit in the new shoes. Subsequent to surveyor inquiry, LPN #1 called therapy and submitted a therapy screen request dated 2/15/24. Review of physician's order dated 2/17/24 and 2/19/24 identified a physical therapy evaluation and subsequent order directing staff to assist Resident #5 with the application and removal of the AFO. Interview with OT #1 on 2/20/24 at 10:38 AM indicated that therapy was not aware that Resident #5 had not been wearing the AFO prior to the screen request dated 2/15/24. OT #1 indicated that Resident #5 had been seen for therapy services from 9/19/23 to 12/26/23 for difficulty standing and transferring and had been wearing the AFO at that time. She indicated that she would expect to have been notified to screen the resident if there was a pattern of refusals or if a resident received new shoes to ensure appropriate fit. Further, when a new therapy recommendation was made, therapy would communicate the information to the floor nurse, write the recommendation in the communication book and then nursing was responsible to obtain a physician's order and transcribe the order to the paper chart. Re-interview with OT #1 on 2/21/24 at 3:18 PM indicated that Resident #5 did not have a functional decline or increased foot drop as a result of not wearing the AFO daily. Review of the Care of the individuals with a splint, brace, and immobilizer policy dated 7/2012 directed, in part, admission nurses should make certain that the order for the application and use of the device is clear, has an appropriate time frame, and that all of these devices should be documented on the treatment Kardex and applied and removed by nurses only, and document that the device is in place on the NA Kardex.

Based on clinical record review and interview, for one of three sampled residents reviewed for accidents (R #18), the facility failed to ensure that the physician was notified that the resident struck their head during a fall, and/or when the resident experienced significant changes in mental and physical status. The findings include: Resident #18's [DIAGNOSES REDACTED]. The 14 day MDS assessment dated [DATE] identified that the resident was without cognitive impairment, required extensive assistance of two staff for transfers and ambulation, and was frequently incontinent of bladder. The care plan dated 10/24/15 identified the risk for falls and a fall with no injuries. Interventions included placing the call light in reach, appropriate footwear and safety education. Nurse's notes dated 10/24/15 at 10:15 AM indicated that the resident was found on the floor in the bathroom. The resident stated that he/she hit his/her head. No injuries were noted at that time. The nurse's notes identified that neuro checks were completed for 48 hours. On 10/25/15 at 8:00 AM the neuro check sheet identified that the resident had no changes in mental status and was alert and oriented times three. At 11:00 AM, the neuro check sheet identified a mental status change indicating that the resident was now alert, oriented and forgetful. Nurse's notes failed to reflect that the physician was notified of the change in mental status. NA flowsheets dated 10/26/15 identified that the resident consumed 75% of breakfast, refused lunch and took only 25% of supper. Physical Therapy notes dated 10/26/15 identified that the resident refused to participate in skilled Physical Therapy; resident with complaints of feeling very drained after therapy in the morning, resident with repetitive statements and keeping eyes closed while speaking. NA flowsheets dated 10/27/15 identified that the resident consumed 25% of breakfast, 25% of lunch, and 25% of supper. Occupational Therapy notes dated on 10/27/15 identified that the resident not seen for full session due to illness. Physical Therapy notes dated 10/27/15 identified that the resident withheld from skilled Physical Therapy as per nursing secondary to significant decline in function. NA flowsheet dated 10/27/15 identified that the resident did not ambulate on the 7-3 shift. The nurse's note dated 10/27/15 at 8 AM identified that the resident was fatigued, complained of being very tired, and was transferred with two assistants. The neuro checks noted that the pupils were equal, positive, reactive, and that the physician was notified. The nurse's note dated 10/27/15 at 8:15 AM identified that after much encouragement, the resident was able to get into the wheelchair and again complained about fatigue. An untimed addendum nurse's note dated 10/27/15 identified that the resident's overall mental status was not within normal limits and that the resident continued being cooperative but was very weak, needing more assistance and talking slow. A nurse's note dated 10/27/15 at 2 PM identified that the physician ordered a stat chest x-ray and a urine test was pending. A nurse's note at 4:00 PM identified that the resident's temperature was 100.5 degrees, and the blood pressure was 90/50. [MEDICATION NAME] (an antibiotic) and Tylenol were administered. The nurse's note at 5:00pm identified that the chest x-ray results identified a possible right lung base atelectasis no pneumonia, no infiltrate noted, and were reviewed by the physician with no new orders. The nurse's note dated 10/28/15 at 2:00 PM identified that the resident complained of pain to the back of the head, pupils were equal and reactive and hand grasps were equal. Vital Signs identified that the resident's temperature was 98.6 degrees, pulse 90, respirations 18, blood pressure 140/68, neuro checks within normal limit, family visiting and stated that the resident was hallucinating and the physician was notified. At 2:50 PM the charge nurse received a physician's orders [REDACTED]. During an interview with Physician #1 on 4/7/2016 at 8:55 AM, s/he stated that s/he had never been told that the resident had hit his/her head during the fall on 10/24/15 or on 10/27/15 when s/he assessed the resident. Physician #1 indicated that s/he was working the resident up for possible infection and had s/he been aware that the resident on anticoagulation had struck their head, s/he would have taken a different course of action. An interview and sworn statement by RN#1 on 4/7/16 identified that on 10/27/15 while making rounds with Physician #1, he/she discussed his/her concerns that the resident was on anticoagulation therapy and had hit his/her head. RN#1 identified that he/she had notified the physician that the resident had a decline in function, mental status change and respiratory symptoms. RN#1's sworn statement documented that the physician reassured me that we were monitoring (the resident) and felt that (the resident) was displaying issues for possible other issues. RN#1 indicated that the physician ordered a chest x-ray and laboratory tests and was started on antibiotics due to a high white blood cell count. When the resident complained of pain in the back of his/her head, the physician was called and ordered that the resident be sent to the hospital for evaluation. Further interview, clinical record review, 24 hour report review and other document review with RN#1 failed to provide any documentation that indicated that the physician was ever made aware that the resident struck his/her head during the fall. RN#1 indicated that the procedure was to fax changes in condition to the physician and although s/he stated that this was done, the fax was not part of the clinical record nor had it been saved as documentation to indicate the MD was made aware. Acute care hospital emergency department documentation dated 10/28/15 indicated that the resident had sustained a subdural hematoma that was not operable. The emergency department also documented that the resident had blood in the stool, and elevated BUN of 50, and dry mucous membranes.

Based on review of clinical records, review of facility policies, and interviews, the facility failed to implement protective measures to prevent a pressure ulcer for one resident, Resident #158, who entered the facility with a blanchable area on the right heel. The findings include: 3. Resident #158 (R#158) had [DIAGNOSES REDACTED]. Review of the nursing admission assessment dated [DATE] identified that upon admission, R #158 had multiple community acquired skin tears, a right hip incision with staples, and ecchymosis on the right ankle. In addition, the assessment identified that R #158 had a "blanchable area" on the right heel though lacked further description and/or measurement of the blanchable area. The nursing admission assessment further identified that R #158 had a decline in his/her current Activities of Daily Living (ADL) status related to decreased mobility. Interview with the Director of Nursing on 3/20/14 at 12:30 PM identified that R #158 had just lost his/her spouse the day prior to admission. The care plan dated 1/20/14 identified the resident's potential for skin impairment secondary to decreased mobility, pain, skin fragility and [MEDICAL CONDITION] with interventions that included to monitor the resident's skin every shift, and to provide resident/family education. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that R #158 had no cognitive impairment but required extensive assistance of two persons for bed mobility and transfer. Although a nursing note dated 1/20/14 identified that R #158 was educated to offload heels secondary to blanchable redness (right heel) and an unsigned entry on the resident education log dated 1/20/14 that the resident was educated to off load his/her heels, R #158 required extensive assistance for bed mobility at that time. Review of the clinical record that included the January 2014 TAR and nursing notes dated 1/20/14 through 2/1/14 lacked documentation to reflect that the blanchable area on R #158's heel, present on admission, was measured and/or monitored through 2/1/14. Although an entry dated 1/31/14 to R #158's care plan included an intervention for off-loading the resident's heels from the bed, review of the skin/wound flow record, dated one day later on 2/1/14, identified that R #158 had developed a 4.0 centimeter (cm) by 4.3 cm blue, purple area to right heel. The care plan was updated on 2/1/14 to address off-loading of the resident's heels when in bed and that the resident was not to wear a shoe on the right foot. In addition, the Treatment Administration Record (TAR) dated 2/1/14 identified that staff documented off-loading of R #158's heels beginning on the 3:00 PM to 11:00 PM shift on that date. Review of the skin/wound flow sheets dated 2/2/14 through 2/26/14 identified that on 2/3/14, R #158's right heel areas was suspected to be a Deep Tissue Injury (DTI) that now measured 3.1 cm by 3.9 cm, was intact and purple in color. On 2/17/14, physician orders [REDACTED]. On 2/26/14, R #158's right heel was assessed to be an unstageable pressure area that measured 3.0 cm by 3.8 cm that was intact dark purple area. Review of the clinical record that included the January 2014 TAR and nursing notes dated 1/20/14 through 2/1/14 lacked documentation to reflect that the blanchable area on R #158's heel, present on admission, was measured and/or monitored through 2/1/14 and/or that the resident's heels were off-loaded when in bed with the assistance of staff and/or that the resident was able to accomplish offloading of his/her heels on his/her own until 2/1/14, after identification of the resident's right heel pressure area. Interview with RN #9 on 3/20/14 at 2:40 PM identified that he/she was unable to provide documentation that R #158's heels were offloaded prior to 2/1/14. Review of facility policy and procedure identified that the skin integrity of residents would be maintained at the optimum level of wellness through interventions that included skin assessment, compliance with turning and repositioning, and pressure relieving interventions. In addition, the facility's policy for skin integrity directed in part, that residents at risk for skin impairment would be identified, that the facility would initiate care focused on prevention and appropriate interventions if deemed necessary, and that an interdisciplinary approach should be utilized in the endeavor.

Based on observation, clinical record review, and staff interview for one of four residents in the survey sample reviewed with falls (R #240), the facility failed to supervise the resident to prevent an accident and/or the facility failed to maintain the environment in a safe manner. The findings include: 1. Resident # 240's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident had severe cognitive impairment, displayed problem behaviors that included screaming, required extensive assistance from staff with transfers and walking, and had a history of [REDACTED]. A care plan dated 12/10/11 identified that R#240 was at risk for falls secondary to a history of falls and poor safety awareness. The care plan noted the resident sustained [REDACTED]. Interventions included call light within reach, chair pad alarm, safety education to the resident, and keep legs off the wheelchair. An observation of R#240 on 12/27/11 at 10:30 AM noted the resident sitting in a wheelchair. The resident was observed with a large bruised/ecchymotic area on the left side of his/her forehead, extending down into the check and over to the left nares. Nurse's notes from 12/10/11 through 12/18/11 identified the resident with multiple attempts to self transfer from the bed to the wheelchair or out of the wheelchair. A nurse's note dated 12/18/11 at 2:30 PM noted the resident had increased agitation, attempting to transfer self several times, redirected several times without effect, and placed in the small dining room with staff for close monitoring. Review of facility investigation documentation dated 12/18/11 at 8:05 PM identified that R#240's alarm sounded and the resident was found on the floor in the dayroom. The resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation. The investigation further documented that all staff were taking time staying with the resident prior to the fall. The investigation noted R#240 was given things to keep him/her busy and occupied, but the resident continued to throw the things on the floor. An interview with LPN # 2 on 1/3/2012 at 1:30 PM noted that at the beginning of the 3-11 shift on 12/18/11, she instructed the three nurse aides who were working on the unit that R#240 needed a staff member to sit with him/her due to the fact the resident was restless, and constantly trying to get out of the chair and that they could take turns sitting with him/her. LPN #2 stated that they gave R#240 things to do to try to occupy the resident's time, but the resident kept throwing the things on the ground. LPN # 2 stated that she became aware that R # 240 was on the floor when she heard the alarm sound. She indicated no staff member was with the resident at the time the resident was found on the floor. Interview with NA#3 on 1/3/2012 at 1:55 PM noted that LPN # 2 told her and the other 2 NA's in the beginning of the shift on 12/18/11 that someone needed to stay with R # 240 at all times. She indicated she was with R #240 when a call bell went off and she went to answer it. When asked if she let anyone know she was leaving R # 240 to answer the call bell, NA#3 changed her initial interview statement and stated that the resident was calm then and did not need to be watched continuously. 2. A tour of the facility on 12/27/11 at 9:17 AM noted damaged doors that had sharp edges and/or splinters on the Pavilion 4 bathing suite, and resident rooms 41, 50, 52 and 54. An interview with maintenance person #1 on 12/29/11 at 2:34 PM indicated that although there was a door replacement plan in place, the facility had not replaced a resident door in the past year. 3. The Pavilion 4 shower stall floor was noted to have an approximately 5 inch by 4 inch area of missing tiles and/or loose tiles.