Every finding on record at Meadow Green Nursing and Rehabilitation Center

Based on observations and interviews, the facility failed to ensure Resident protected health information (PHI) was secure and not visible to others on two of three nursing units.Findings include:Review of the facility policy titled Electronic Medical Records dated revised 8/1/23, indicated that the facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure. On 2/4/26 at 5:00 P.M. the surveyor and the Director of Nursing (DON) observed a medication cart to have the computer screen displaying a resident's personal medical information in the hallway. The surveyor and DON also observed other residents in the hallway with access to the information. The surveyor and DON also observed the nurse not to be within eyesight of the computer screen. On 2/5/26 at 2:21 P.M. the surveyor and the DON observed a medication cart to have the computer screen displaying a resident's personal medical information in the hallway. The surveyor and DON also observed other residents in the hallway with access to the information. The surveyor and DON also observed the nurse not to be within eyesight of the computer screen. During an interview on 2/5/26 at 2:21 P.M. the DON said that the computer screen should not be displaying a resident's medical information for other residents and staff to see. During an interview on 2/5/26 at 2:21 P.M. Nurse #3 said that the computer screen should not be displaying a resident's medical information for other residents and staff to see.

Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for six Residents (#61, #15, #71, #74, #51, #105) out of a total sample of 30 residents.Specifically:For Resident #61 the facility failed to float both heels at all times as indicated in the Resident's plan of care.For Resident #15 the facility a). failed to place floor mats on each side of the bed and b). failed to obtain weights as ordered.For Resident #71 the facility failed to develop an activities of daily living (ADLs) care plan.For Resident #74 the facility failed to develop a comprehensive person-centered care plan for a pacemaker.For Resident #51 the facility failed to develop a comprehensive person-centered care plan for a pacemaker.For Resident #105 the facility failed to develop a comprehensive person-centered care plan for a pacemaker. Findings include:Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated revised 8/1/23, indicated that the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 1. Resident #61 was admitted to the facility in December 2025 with diagnoses including Parkinson's disease, altered mental status and deep tissue injury of the left heel. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #61 is severely cognitively impaired. Further review indicated that Resident #61 is totally dependent on staff for all activities of daily living. Review of the current care plan indicated a focus of: Actual skin breakdown. Resident has actual skin breakdown - L -heel DTI (deep tissue injury). Further review indicated an intervention of: Pillow to float heels. Review of the physician orders dated February 2025 indicated the following order: use pillow to float heels while in bed and in Geri-chairevery shift for wound care/protection On 2/5/26 at 7:03 A.M., the surveyor observed Resident #61 sitting across from the nurse's station, in a Geri-chair (recliner), with both heels directly on the footrest. On 2/5/26 at 8:13 A.M., the surveyor observed Resident #61 sitting across from the nurse's station, in a Geri-chair, with both heels directly on the footrest. Resident #61 was being fed by staff. On 12/5/26 at 10:05 A.M., and 12:12 P.M., the surveyor observed Resident #61 in the dining room sitting in a Geri-chair with both heels directly on the footrest. During an interview on 2/5/26 at 1:55 P.M., Certified Nurse's Aide (CNA) #3 said that she was responsible for Resident #61's care today. When asked about off-loading Resident #61's heels, she was not able to respond. When asked if the Resident was supposed to have a pillow placed under the calves to float the heels, she was unable to respond. On 2/5/26 1:59 P.M. the surveyor and Nurse #3 observed Resident #61 reclined in a Geri- chair in the hallway without both heels being offloaded. Nurse #3 then said that if the physician orders and or care plan guide the staff to off-load the Resident's heels then they should be off-loaded. 2/6/26 at 8:43 A.M. and 9:42 A.M., the surveyor observed Resident #61 reclined in a Geri- chair in the hallway without both heels being offloaded. On 2/9/26 at 8:23 A.M., the surveyor and Nurse #3 observed Resident #61 sitting in a Geri-chair with both feet directly on the floor. During an interview on 2/9/26 at 8:25 A.M, Nurse #3 said that Resident #61 was just fed, and the staff member must have forgotten to float Resident #61's heels. 2a. Resident #15 was admitted to the facility in July 2025 with diagnoses including dementia, bipolar disorder and kidney disease. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #15 is severely cognitively impaired, scoring a 6 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #15 requires assistance with all activities of daily living. Further review indicated Resident #15 has a history of falls. Review of the care plan indicated a focus for falls with an intervention for floor mats on the floor next to the bed. On 2/4/26 at 10:45 A.M. and 2:30 P.M., the surveyor observed Resident #15 in bed with a floor mat on one side of the bed, in between bed A and bed B. On 2/5/26 at 7:08 and 8:49 A.M. the surveyor observed Resident #15 in bed with a floor mat on one side of the bed. On 2/9/25 at 8:20 A.M. the surveyor and Nurse #3 observed Resident #15 in bed with two floor mats leaning against the wall on the far side of the room and no mats on the floor next to the Resident's bed. On 2/9/26 at 8:20 A.M., Nurse #3 said that the mats should be on the floor on both sides of the bed. 2b. Review of the facility policy titled Weight Assessment and Intervention dated revised 8/1/23 indicated that weights are recorded in each unit's weight record chart and in the individual's medical record. Review of the weight record for Resident #15 indicated that the last weight was obtained 10/31/25. Review of the physician's orders dated December 2025 indicated the following order: Monthly weights to be completed on the 10th of every month. Review of the Treatment Administration Record (TAR) dated December 2025 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the TAR Dated January 2026 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the progress notes dated 1/8/26, 1/9/26 and 1/10/26 failed to indicate that Resident #15 refused to be weighed. During an interview on 2/5/26 at 9:33 A.M., Nurse #3 said that when a weight is obtained it is put in the weights section of the electronic medical record on the date it was obtained. Nurse #3 then said that there is no separate weight book that weights are alternately entered into on the unit. Nurse #3 also said that if a nurse documents that a weight has been obtained then the weight should be also documented in the medical record. During an interview on 2/9/26 at 10:54 A.M., the Dietician said she reviews weights weekly. The Dietician said that if she can't find a weight, she lets nursing know. The Dietician said that she doesn't know why the Resident hasn't had a weight since October 2025. 3. Resident #71 was admitted to the facility in May 2025 with diagnoses that included cerebral infarction, hemiplegia affecting the right dominant side, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. The MDS further indicated that the Resident required supervision or touching assistance for meals. On 2/5/26 at 8:10 A.M., and 8:20 A.M., the surveyor observed Resident #71 eating breakfast alone in his/her room. The privacy curtain was pulled around the Resident's bed, and the Resident was not visible from the hallway. Review of the Resident Kardex (a document that indicates the level of assistance needed for various tasks and activities of daily living) failed to indicate the level of assistance required by Resident #71 for eating. Review of Resident #71's care plan failed to indicate an activity of daily living (ADL) care plan indicating the assistance required for assistance with meals and other ADLs. During an interview on 2/6/26 at 8:19 A.M. Certified Nurse's Aide #2 said they utilize the Kardex (a document that indicates the level of assistance a resident requires for care) that triggers from the care plan to determine the level of assistance a resident requires. During an interview on 2/9/26 at 9:41 A.M., Unit Manager #2 said that everyone should have an ADL care plan so that staff are aware of the level assistance required by a resident. He reviewed Resident #71's medical record and said that he/she did not have a care plan indicating the level of assistance needed for ADLs, but they should have. During an interview on 2/9/2026 at 10:10 A.M., the Director of Nurses said that everyone in the facility should have an ADL care plan in place, which triggers onto the Kardex for staff, indicating the level of assistance required by the resident for various tasks. 4. Review of facility policy titled Pacemaker, Care of a Resident with, dated as updated 8/1/23, indicated the following: -The purpose of this procedure is to provide information about the guidance for the care of a resident with a pacemaker. -Documentation: For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: -a. The name, address, and telephone number of the cardiologist; -b. Type of pacemaker; -c. Type of Leads; -d. Manufacturer and model; -e. Serial number; -f. Date of implant; and -g. Paced rate. -When the resident's pacemaker is monitored by a Physician, document the date and results of the pacemaker surveillance. Resident #74 was admitted to the facility in December 2021 with diagnoses that included syncope and collapse and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15, indicating moderate cognitive impairment. On 2/4/26 at 10:57 A.M., the surveyor observed the Resident in his/her room. There was a pacemaker monitor on the bureau in the room. Review of the physician's progress note, dated 1/15/26, indicated in part: -Afib (atrial fibrillation) s/p (status post) pacemaker. Review of the active care plan failed to indicate a plan of care around the management of a pacemaker Review of Resident #74's active physician's orders failed to indicate monitoring orders for pacemaker. During an interview on 2/9/26 at 8:07 A.M., Nurse #2 said that when a resident has a pacemaker there should be a plan of care in place documenting any information about the pacemaker that is relevant to the resident's care. She said they should know who the cardiologist is and when the next appointment is. During an interview on 2/9/26 at 9:18 A.M., Unit Manager #2 said that residents with pacemakers either follow up in the cardiologist's office, or wirelessly for pacemaker checks. He said that there should be a comprehensive care plan in place indicating the type of pacemaker, the serial number, paced rate and cardiologist. He said the plan of care should also include the type of pacemaker checks the resident has. During an interview on 2/9/26 at 10:07 A.M., the Director of Nurses said that residents with a pacemaker have all pertinent information available in a care plan including the serial number, cardiologist and paced rate. 5. Resident #51 was admitted to the facility in March 2024 with diagnoses that included hypertension and atherosclerotic heart disease. Review of the most recent Minimum Data Set assessment, dated 12/12/25, indicated a Brief Interview for Mental Status score (BIMS) of 11 out of a possible 15, indicating moderate cognitive impairment. On 2/4/26 at 10:49 A.M., the surveyor observed the resident sitting up in a wheelchair in his/her room. There was a cardiac pacemaker monitor at the bedside. Review of 1/26/26 physician's progress note indicated, in part: -Surgical History: pacemaker, coronary stents Surgical History Verified. Review of active resident care plans failed to indicate a plan of care around a pacemaker. Review of physician's orders failed to indicate orders around the pacemaker and the care of the pacemaker. Review of active diagnoses failed to indicate the presence of a pacemaker. Review of the medical record failed to indicate pacemaker information regarding serial # device type or paced rate of the pacemaker. During an interview on 2/9/26 at 8:07 A.M., Nurse #2 said that when a resident has a pacemaker there should be a plan of care in place documenting any information about the pacemaker that is relevant to the resident's care. She said they should know who the cardiologist is and when the next appointment is. During an interview on 2/9/26 at 9:18 A.M., Unit Manager #2 said that residents with pacemakers either follow up in the cardiologist's office, or wirelessly for pacemaker checks. He said that there should be a comprehensive care plan in place indicating the type of pacemaker, the serial number, paced rate and cardiologist. He said the plan of care should also include the type of pacemaker checks the resident has. During an interview on 2/9/26 at 10:07 A.M., the Director of Nurses said that residents with a pacemaker have all pertinent information available in a care plan including the serial number, cardiologist and paced rate. 6. Resident #105 was admitted to the facility in March 2022 with diagnoses including Atrial Fibrillation and presence of a cardiac pacemaker. Resident #105 does not have any Minimum Data Set (MDS) information. A review of Resident #105's February physician's orders indicated the following: -Pacemaker. Order date 3/4/22. Further review of the Pacemaker care plan indicated the following: -Focus-I have a pacemaker in place r/t (related to) Atrial fibrillation, SSS (Sick, Sinus,Syndrome), hx (history) of syncope. [Sic] Date Initiated: 03/12/2022, Revision on: 04/25/2025. -Goal-I will remain free of complications r/t altered cardiac output through review date. [Sic] Date Initiated: 03/12/2022, Revision on: 01/14/2024, Target Date: 05/07/2026. Interventions/Tasks-Monitor/document/report PRN any s/sx, (signs and symptoms) of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P (blood pressure). [Sic} Date Initiated: 03/12/2022. During an interview and record review on 2/6/26 at 9:03 A.M., Unit Manager #1 reviewed the medical record and said the resident is currently on hospice, and his/her pacemaker is being monitored externally therefore the care plan does not need to be person centered with the pacemaker's serial number. During an interview and record review on 2/9/26 at 8:39 A.M., the Director of Nurses said Resident #105's care plan and physicians orders should include the pacemaker's serial number even if the pacemaker is being monitored externally. The DON said he could not locate the pacemaker's serial number in the medical record; he said this information should have been obtained from the Resident's cardiologist and added to the care plan when the Resident was admitted but wasn't.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for three Residents (#9, #51 and #71) out of a total sample of 30 residents. Specifically:1. For Residents #9, who has a history of difficulty swallowing, the facility failed to provide supervision during meals.2. For Resident #51 the facility failed to provide supervision with meals as indicated in the plan of care.3. for Resident #71 the facility failed to provide supervision with meals as indicated in speech therapy notes. Findings include:1. Resident #9 was admitted to the facility in October 2025 with diagnoses including dysphagia (difficulty swallowing), dementia and heart disease. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #9 is moderately cognitively impaired, scoring a 12 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #9 complained of having difficulty swallowing and is observed to be holding food in his/her mouth/cheeks or residual food in his/her mouth after meals. Review of the care plan indicated a focus for ADL (activities of daily living) with an intervention of supervision while eating, related to a diagnosis of dysphagia. On 2/4/26 at approximately 12:10 P.M., the surveyor observed Resident #9 alone in his/her room, eating lunch. The surveyor also observed that the privacy curtain was partially pulled closed and Resident #9 was not visible from the hallway. The surveyor also observed Resident #9 to be coughing after swallowing. On 2/5/26 at 8:09 A.M., the surveyor observed Resident #9 alone in his/her room, eating breakfast. The surveyor also observed that the privacy curtain was partially pulled closed and Resident #9 was not visible from the hallway. The surveyor also observed Resident #9 to be coughing after swallowing. On 2/9/26 at 8:15 A.M., the surveyor observed Resident #9 alone in his/her room, eating breakfast. The surveyor also observed that the privacy curtain was partially pulled closed and Resident #9 was not visible from the hallway. The surveyor also observed Resident #9 to be coughing after swallowing. During an interview on 2/9/26 at 8:31 A.M., Nurse #3 said that staff should follow the care plan and if the care plan is not accurate then it should be changed. 2. Resident #51 was admitted to the facility in March 2024 with diagnoses that included hypertension and atherosclerotic heart disease. Review of the most recent Minimum Data Set assessment, dated 12/12/25, indicated a Brief Interview for Mental Status score (BIMS) of 11 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated that the Resident required supervision or touching assistance for meals. On 2/5/26 at 8:18 A.M., the surveyor observed Resident #51 eating alone in his/her room. The privacy curtain was partially pulled, and the Resident was not visible from the hallway. The surveyor entered the room and observed the Resident in bed with the head of the bed elevated to approximately a 45-degree angle. The over bed table was on the right side of the bed, and the Resident was leaning to the right eating from his/her tray that was placed off to the side. On 2/6/26 at 8:14 A.M., the surveyor observed the Resident sitting on the side of the bed eating breakfast alone. The curtain was pulled around the Resident, and he/she was not visible from the hallway Review of Resident 51's active activities of daily living (ADL) care plan indicated to assist/supervise resident with meals, dated as revised 8/29/24. Review of Resident #51's Kardex (a document that indicate the level of assistance required to care for the resident) indicated to assist/ supervise resident with meals. During an interview on 2/6/26 at 8:19 A.M., Certified Nurse Aide (CNA) #1 said that the staff utilize the kardex for each resident to determine the level of assistance required and said that staff follow what the kardex says when providing care. During an interview on 2/6/26 at 10:46 A.M., Nurse #2 said that if a resident's care plan says to assist or supervise with meals, then staff should be in the room with the resident. During an interview on 2/6/26 at 11:12 A.M., Unit Manager #2 said that CNAs and nurses should be following what is indicated in the care plan or kardex when providing assistance to residents. 2/6/26 at 10:49 A.M., the Director of Nurses said that if a resident's care plan or kardex indicates supervision or assistance with meals then the resident should not be outside of the line of vision for staff. He further said staff should be following the active care plan and kardex. 3. Resident #71 was admitted to the facility in May 2025 with diagnoses that included cerebral infarction, hemiplegia affecting the right dominant side, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 11/21/25 indicated a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. The MDS further indicated that the Resident required supervision or touching assistance for meals. On 2/5/26 at 8:10 A.M., and 8:20 A.M., the surveyor observed Resident #71 eating breakfast alone in his/her room. The privacy curtain was pulled around the Resident's bed, and the Resident was not visible from the hallway. On 2/6/26 from 8:16 A.M. to 8:23 A.M., the surveyor observed Resident #71 eating breakfast alone in his/her room. The privacy curtain was pulled around the Resident's bed, and the Resident was not visible from the hallway. Review of the Speech Therapy Discharge summary, dated [DATE], indicated the following: -Patient was seen for 6 days for a swallowing evaluation for dysphagia (difficulty swallowing). -Comments: Patient continues to aspirate on thin liquids. -Results of a Modified Barium Swallow Study indicated that the patient continues to aspirate on thin liquids and is judged to be at moderate risk for developing aspiration pneumonia. Patient noted to have inefficient cough reflex with thin liquids. -Discharge status and recommendations: Supervision for oral intake= close supervision. Review of the Resident Kardex (a document that indicates the level of assistance needed for various tasks and activities of daily living) failed to indicate the level of assistance required by Resident #71 for eating. Review of Resident #71's care plan failed to indicate an activity of daily living care plan indicating the assistance required for meals and other ADLs. During an interview on 2/6/26 at 11:12 A.M., Unit Manager #2 said that CNAs and nurses should be providing supervision to the residents who require it. During an interview on 2/6/26 at 10:49 A.M., the Director of Nurses said that if a resident requires supervision with meals, staff should be providing supervision and a resident in their room with the curtain pulled is not being supervised.

Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#71, #66, and #1) out of sample of 30 residents. Specifically, For Resident #71 the facility failed to obtain orders for suctioning and failed to store suction equipment consistent with professional and infection control standards of practice.For Resident #66 the facility failed to maintain a clean filter on the oxygen concentrator.For Resident #1, the facility failed to provide oxygen as indicated in physician's orders, obtain a physician's order for CPAP (Continuous Positive Airway Pressure), and label and date the CPAP supplies.Findings include: 1. Resident #71 was admitted to the facility in May 2025 with diagnoses that included cerebral infarction, hemiplegia affecting the right dominant side, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 11/21/25, indicated a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. On 2/4/26 at 10:06 A.M., the surveyor observed Resident #71 sleeping in bed. On the bedside table was a suction set up. There was no date on any of the equipment. There was a liquid in the suction canister and a yankauer (a ridged plastic suction catheter used for oral suctioning) catheter was stored in a plastic cup wrapped in a napkin. On 2/05/26 at 8:11 A.M., the surveyor observed a suction set up on the bedside table. There was no date on any of the equipment. There was a liquid in the suction canister and a yankauer suction catheter on the table, with the tip resting on the cover to a plastic bottle. On 2/6/26 at 7:21 A.M., the surveyor observed a suction set up on the bedside table. There was no date on any of the equipment. There was a liquid in the suction canister and a yankauer suction catheter on the table, with the tip resting on the cover to a plastic bottle. On 2/9/26 at 8:15 A.M., the surveyor observed a suction set up on the bedside table. There was no date on any of the equipment. There was a liquid in the suction canister and a yankauer suction catheter on the table, with the tip resting on the cover to a plastic bottle. Review of physician's orders failed to indicate orders around suctioning the Resident or the maintenance of the suction equipment. During an interview on 2/6/26 at 10:36 A.M., Unit Manager #2 said that the staff do not use the suction equipment, but the family does when they help the Resident brush his/her teeth. Unit Manager #2 said there should still be orders for the suctioning and the facility should be maintaining the equipment. He said without maintaining the equipment appropriately there is a potential for bacteria growth within the equipment. He did not know when the equipment was last changed out. During an interview on 2/9/26 at 10:11 A.M., the Director of Nurses said that the storage of Resident #71's suction equipment was not okay. He said there is a risk for bacteria growth when not changed out or stored correctly. The Director of Nurses further said that regardless of who is performing the suctioning procedure there should be physician's orders for suctioning. 2. Review of facility policy titled Oxygen Concentrators, dated as updated 8/1/23, indicated the following: -The facility will maintain oxygen concentrators functioning correctly at all times. -Nursing should ensure concentrator has not visible soilage on it. [sic] -Filters for concentrators need to be cleaned weekly. Resident #66 was admitted to the facility in December 2025 with diagnoses that included COPD (chronic obstructive pulmonary disease) and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/14/26, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident received continuous oxygen therapy. On 2/4/26 at 11:08 A.M., the surveyor observed the Resident receiving oxygen via nasal cannula from an oxygen concentrator. The filter on the concentrator was covered with a thick layer of dust. On 2/5/26 at 8:16 A.M., the surveyor observed the Resident receiving oxygen via nasal cannula from an oxygen concentrator. The filter on the concentrator was covered with a thick layer of dust. On 2/6/26 at 7:05 A.M., the surveyor observed the Resident receiving oxygen via nasal cannula from an oxygen concentrator. The filter on the concentrator was covered with a thick layer of dust. Review of physician's orders indicated the following: -Administer Oxygen continuously at 2L/LPM via nasal cannula to maintain O2 sats >88%, dated 12/19/25. Review of physician's orders failed to indicate orders for management of or cleaning of the filter in the concentrator. Review of Resident #66's active care plan, dated 12/19/25, indicated the following: -COPD: Resident is at risk for complications due to COPD with interventions that included apply O2 (oxygen) via nasal cannula as needed. During an interview on 2/6/26 at 7:06 A.M., Nurse #2 said that the night shift nurses check the filters for the oxygen concentrators daily. The surveyor and Nurse #2 observed the filter on the concentrator to be covered in a thick layer of dust. Nurse #2 said she is not sure who is responsible for cleaning or changing the filter, but that it should not be covered in a thick layer of dust. During an interview on 2/6/26 at 10:35 A.M., Unit Manager #2 said that he was under the impression that the oxygen company was managing the filters in the oxygen concentrators. He observed the layer of dust on the filter and said it should not be like that. During an interview on 2/6/26 at 10:49 A.M., The Director of Nurses said that oxygen filters should be cleaned and maintained on a weekly basis. He said that there was not a process in place currently to do this. He said that filters covered in a layer of dust places the Resident at risk for not receiving the ordered liter flow of oxygen. 3. Review of the facility policy titled 'Oxygen Administration', updated 8/1/23, indicated the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility policy titled 'CPAP/BiPAP support', updated 8/1/23, indicated the following: -To promote the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. -CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea or restrictive/obstructive lung disease. -There are general guidelines for cleaning, specific cleaning instructions are obtained from the manufacturer's guidelines. Resident #1 was admitted to the facility in November 2025 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease) and obstructive sleep apnea. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/4/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating intact cognition. Review of Resident #1's February 2026 physician's orders indicated the following: -Administer Oxygen continuously at 3L/LPM (liters per minute) via nasal cannula to maintain O2 (oxygen) sats >88% every shift, dated as an active order from 8/2/25 through 2/6/26. Further review of the physician's failed to indicate an order for the use of CPAP. On 2/4/26 at 11:28 A.M., the Surveyor observed Resident #1 in bed wearing a nasal cannula, his/her oxygen was set at 2 Liters, the CPAP was not labeled or dated. On 2/5/26 at 8:15 A.M., the Surveyor observed Resident #1 in bed wearing a nasal cannula, his/her oxygen was set at 2 Liters, the CPAP was not labeled or dated. During an interview on 2/5/26 at 8:16 A.M., Resident #1 said he/she wears the CPAP every night to help him/her sleep. He/she said he/she cannot sleep without the CPAP. During an interview and observation on 2/6/26 at 7:35 A.M., the Surveyor and Nurse #1 observed the Resident in bed wearing a nasal cannula, the oxygen was set at 2 Liters. Nurse #1 said the oxygen should be set at 3 Liters as indicated in the physician's orders. Nurse #1 observed the CPAP in the Resident's drawer unlabeled and undated. Nurse #1 said the CPAP should have a label with a date on it to indicate when it was last cleaned. During an interview and observation on 2/6/26 at 7:37 A.M., the Unit Manager #1 said the Resident's oxygen should be set at 3 Liters per the physician's orders, the Unit manager said the CPAP is not the responsibility of the facility since it belongs to the Resident. The Unit Manager said the Resident's family is responsible for its maintenance. During an interview on 2/6/26 at 8:04 A.M., the Nurse Practitioner said she had just changed the Resident's oxygen orders from 3 Liters to 2 Liters and wrote an order for the use of CPAP since there was not one in place previously. During an interview on 2/9/26 at 8:55 A.M., the Director of Nurses (DON) said CPAP orders should be in place and that the facility is responsible for the CPAP maintenance even though the CPAP belongs to the Resident. The DON said the CPAP should be cleaned per the manufacturer's guidelines, and the CPAP should be labeled and dated so staff can track when it was last cleaned. The DON said oxygen should be provided to the Resident as indicated in physician's orders. The CPAP manufacturers' guidelines were requested during the survey. The guidelines were not provided. 4. Resident #86 was admitted to the facility in March 2024 with diagnoses including chronic obstructive pulmonary disease, obstructive sleep apnea and major depression. Review of the Minimum Data Set assessment, dated 11/14/25, indicated that Resident #86 had moderate cognitive impairment, scoring an 8 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #86 is dependent on staff for most activities of daily living and also receives oxygen therapy. Review of the physician orders dated February 2026 indicated the following order for oxygen: 02 at 2 liters via NC (nasal cannula) on at HS (hour of sleep) and off in AM (morning), two times a day for On at Bedtime and off in AM. On 2/4/26 at 10:20 A.M., the surveyor observed Resident #86 to be sitting in a wheelchair. The surveyor also observed an oxygen concentrator next to the bed with the tubing and nasal cannula, dated 2/2/26, on the floor. The surveyor also observed that there was no container present to store the cannula when not in use to help prevent contamination. On 2/5/26 at 8:24 A.M., the surveyor observed Resident #86 to be sitting in a wheelchair. The surveyor also observed an oxygen concentrator next to the bed with the tubing and nasal cannula, dated 2/2/26, on the floor. The surveyor also observed that there was no container present to store the cannula when not in use to help prevent contamination. Review of the Medication Administration Record (MAR) dated February 2026 indicated that on 2/4/26 and 2/5/26 Resident #86 received oxygen via NC. Further review indicated that the oxygen tubing and cannula was not changed until 2/6/26. During an interview on 2/9/26 at 8:30 A.M. Nurse #3 said that oxygen tubing should be stored in a plastic bag tied to the concentrator for infection control.

Based on observation, record review and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#85) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of one applicable Resident. Specifically, the facility failed toObtain orders to monitor and assess the Resident's dialysis access site; and Maintain communication with the dialysis center.Findings include:Review of facility policy, titled End-Stage Renal Disease, Care of a Resident with, dated as updated 8/1/23, indicated the following:-Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.-Education and training of staff includes, specifically: the care of grafts and fistulas.-Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: communication on labs, weights and other potential medical issues between facilities. Best practice is to have a communication binder that staff can review.-The resident's comprehensive care plan will reflect the resident's needs related to ESRD/ dialysis care. 1. Resident #85 was admitted to the facility in May 2025 with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/7/25, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the Resident was cognitively intact. The MDS further indicated that the Resident received dialysis treatment. Review of Resident #85's active physician's orders indicated the following:-Nurse to give resident [his/her] Monday, Wednesday and Friday morning meds to take with him/her to dialysis, dated 5/10/25.-Resident goes to dialysis on Monday, Wednesday and Friday at 10AM. Asks not to be given meds on those days., dated 5/4/25. Review of physician's orders failed to indicate the location and type of dialysis access the Resident has and monitoring orders for the access. Review of the medical record failed to indicate where the Resident goes outside of the facility to receive dialysis. Review of the Resident's care plan for dialysis, dated as created 5/13/25 indicated the following:-DIALYSIS: Resident is at risk for complication due to hemodialysis treatment. -goal: Resident will have positive bruit and thrill x 90 days.-interventions: Provide dialysis communication book as needed and assess resident's dialysis access site for signs of bruit and thrill every shift and notify MD/NP if absent. Review of care plan fails to indicate the location of the dialysis access. Review of progress notes from 9/1/25 through 2/5/26 failed to indicate an assessment of the dialysis site to indicate positive bruit or thrill were present. During an interview on 2/6/26 at 7:26 A.M., Nurse #4 said that Resident #85 has a fistula, but she is not sure what side it is on. She said that nursing should be assessing the fistula for bruit and thrill and that the assessment of the fistula should be documented in the medical record. During an interview on 2/6/26 at 8:06 A.M., Unit Manager #2 said that there should be an order for assessing the dialysis access and documenting the findings in the medical record, but there was not. He said that the medical record did not hold any evidence that assessment of the dialysis site was happening. During an interview on 2/9/26 at 10:16 A.M., the Director of Nurses said that any resident on dialysis should have orders to monitor their dialysis access site in order to intervene on any complications related to the access. 2. On 2/6/25 at 7:35 A.M., the surveyor asked staff if there was a dialysis communication book to review for Resident #85. Unit Manager #2 said there was no communication book. He further said that he has not had any communication with the dialysis facility in regard to Resident #85's dialysis treatment. He said he has not received communication regarding lab results, weights or vital signs. He said the facility has also not communicated with the dialysis facility. During an interview on 2/6/26 7:36 A.M., Nurse #2 said that she cares for Resident #85 and that there is no communication book that goes back and forth between the facility and the dialysis facility. During an interview on 2/9/26 at 10:16 A.M., the Director of Nurses said that all residents on dialysis should have a communication book to ensure proper communication with the dialysis center regarding any changes in the plan of care for the resident.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for three Residents (#22, #35 and #71) out of 30 sampled residents, the facility failed to implement Enhanced Barrier Precautions (EBP) as indicated. Specifically,For Resident #22, who has a PICC (Peripherally Inserted Central Catheter) line, the facility did not implement EBP.For Resident #35 who has wounds, the facility did not implement EBP.For Resident #71 who has a gastrostomy tube (a surgically placed tube that delivers nutrition, fluids, or medication directly into the stomach for individuals who cannot eat enough by mouth), the facility did not implement EBP.Findings include:Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Resident #22 was admitted to the facility in January 2026 with diagnoses that included infection following a procedure and fracture of the upper end of the left humerus. Review of the most recent Minimum Data Set (MDS) Assessment, dated 2/1/26, indicted a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate cognitive impairment. Review of physician's orders indicated the following:-Meropenem Solution (an antibiotic), 1 gram intravenously every 12 hours for a bacterial infection for 36 days, dated as started 1/16/26.-Change PICC Dressing and document measurement evert shift every Friday. Notify MD NP (Doctor or Nurse Practitioner) with any discrepancies and as needed for soiled/ loose/ missing dressing, dated 1/16/26. On 2/4/26 at 10:30 A.M., the surveyor observed Resident #22 awake in bed. Resident #22 had a PICC line in his/her right arm. There was no signage on the doorway to indicate that the Resident was on Enhanced Barrier Precautions (EBP). There was no Personal Protective Equipment (PPE) readily available for use surrounding the Resident room. On 2/5/26 at 10:00 A.M., the surveyor observed a staff member providing activities of daily living (ADL) care to the Resident. The staff member was wearing gloves but was not utilizing a gown. On 2/6/26 at 9:34 A.M., the surveyor observed a staff member enter Resident #22's room and tell the Resident that she was going to get him/her washed and dressed for the day. The staff member entered the room and applied gloves but did not apply a gown to assist the Resident with ADL care. During an interview on 2/6/26 at 9:44 A.M., Certified Nurse Aide (CNA) #2 said she was familiar with enhanced barrier precautions and only one resident on the unit is on enhanced barrier precautions, who has a foley catheter. She said no one else requires them on the unit. During an interview on 2/6/26 at 10:30 A.M., Unit Manager #2 said that any resident with a urinary catheter requires enhanced barrier precautions. He said there is only one Resident on his unit that requires enhanced barrier precautions. He said Resident #22 has a PICC line and is not on enhanced barrier precautions. During an interview on 2/6/26 at 10:49 A.M. the Director of Nurses said that any resident with open areas or indwelling medical devices such as urinary catheters, PICC lines or gastrostomy tubes, should be on enhanced barrier precautions in order to decrease the risk of spreading infection to these higher risk residents. 2. Resident #35 was admitted to the facility in November 2025 with diagnoses that included altered mental status and reduced mobility. Review of the Minimum Data Set (MDS) assessment, dated 12/9/25, indicated a Brief Interview for Mental Status score of 15 out of a possible 15, indicating that the Resident was cognitively intact. Further review of the MDS indicated that the Resident had one or more unhealed pressure injury. The MDS indicated one unstageable pressure injury presenting as a deep tissue injury that was present on admission. On 2/05/26 at 8:13 A.M., the surveyor observed Resident #35 sleeping in bed. There was no signage on the Resident's doorway to indicate the need for EBP, and there was no readily available PPE outside the Resident's room. On 2/6/26 at 9:30 A.M., the surveyor observed two staff members in the room providing ADL care to the resident. Both staff members were wearing only gloves, neither of the staff members were wearing gowns while providing care to the Resident. Review of Resident #35's physician's orders indicated the following:-For R.(right) heel wound, Wash with NS (normal saline), pat dry, xeroform and apply foam dressing till healed, one time a day, dated 12/20/25-2/5/26.-For R. heel wound, Wash with NS, pat dry, gauze soaked in silver gel into wound and cover w/ foam dressing, dated 2/5/26.-NS, pat dry, silver hydrogel, xeroform and foam dressing daily to R butt cheek Stage 3 wound, dated 11/27/25. Review of the most recent weekly skin assessment, dated 2/2/26 indicated the following:-right heel: DTI (deep tissue injury) treatment in place-coccyx: wound treatment in place During an interview on 2/6/26 at 9:44 A.M., Certified Nurse Aide (CNA) #2 said she was familiar with enhanced barrier precautions and only one resident on the unit is on enhanced barrier precautions, who has a foley catheter. She said no one else requires them on the unit. She further said that she had just provided ADL care to Resident #35 and did not utilize enhanced barrier precautions with the use of a gown. During an interview on 2/6/26 at 10:30 A.M., Unit Manager #2 said that any resident with a urinary catheter requires enhanced barrier precautions. He said there is only one Resident on his unit that requires enhanced barrier precautions. He said Resident #35 has wounds and is not on enhanced barrier precautions. During an interview on 2/6/26 at 10:49 A.M. the Director of Nurses said that any resident with open areas or indwelling medical devices such as urinary catheters, PICC lines or gastrostomy tubes, should be on enhanced barrier precautions in order to decrease the risk of spreading infection to these higher risk residents. 3. Resident #71 was admitted to the facility in May 2025 with diagnoses that included cerebral infarction, hemiplegia affecting the right dominant side, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 11/21/25 indicated a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. The MDS further indicated that the Resident utilized a feeding tube. On 2/4/26 at 10:06 A.M., the surveyor observed the Resident sleeping in bed. There was no signage on the Resident's doorway to indicate the need for EBP, and there was no readily available PPE outside the Resident's room. Review of physician's orders indicated the following:-G-tube (gastrostomy) site- wash with NS (normal saline), pat dry, change dressing daily and PRN, dated 7/24/25.-Monitor G tube site for signs and symptoms of infection every shift, dated 5/21/25.During an interview on 2/6/26 at 10:30 A.M., Unit Manager #2 said that any resident with a urinary catheter requires enhanced barrier precautions. He said there is only one Resident on his unit that requires enhanced barrier precautions. He said Resident #71 has a gastrostomy tube and is not on enhanced barrier precautions. During an interview on 2/6/26 at 10:49 A.M. the Director of Nurses said that any resident with open areas or indwelling medical devices such as urinary catheters, PICC lines or gastrostomy tubes, should be on enhanced barrier precautions in order to decrease the risk of spreading infection to these higher risk residents.

Based on record review, policy review and interview, the facility failed to provide education regarding vaccine refusals, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four out of five resident records reviewed. Findings include: Review of four out of five resident immunization records failed to indicate pneumococcal immunizations were offered and/or administered. During an interview on 2/9/26 at 10:35 A.M., the Director of Nursing (DON) said that he could not locate documentation in four out of the five resident's medical records reviewed that the pneumococcal immunization was offered or administered. The DON also said that he could not find any documentation that the residents were educated on the risks and benefits of receiving the vaccine or that the residents refused the vaccine.

Based on record review and interview, the facility failed to ensure that recommendations made by the Consultant Pharmacist during the Monthly Medication Review (MMR) were addressed for two Residents (#2 and #65) out of a total sample of 30 residents. Specifically, the facility failed to review and implement recommendations from the Consultant Pharmacist in regard to a stop date for as needed (PRN) psychotropic medications. Findings include:Review of facility policy titled Consults: Pharmacy, [named facilities consulting provider], wound MD and other outside consultants, dated as updated 8/1/23, indicated the following: -Residents who have consultants will have recommendations reviewed by attending MD/NP/PA/LIP (physician/ nurse practitioner, physician's assistant, licensed independent practitioner).-Staff will review consultation report and or recommendations with prescriber.-Prescriber will make decision on if recommendations are followed and orders obtained.-Nursing will document new orders and. will order supplies if necessary.-Nursing will document per house protocol. 1a. Resident #2 was admitted to the facility in November 2025 with diagnoses that included depression and muscle weakness. Review of Resident #2's most recent Minimum Data Set (MDS) assessment, dated 12/24/25 indicated a Brief Interview for Mental Status (BIMS) score of 121 out of 15, indicating moderate cognitive impairment. The MDS further indicated the use of antidepressant medications. Review of active physician's orders indicated the following:Trazodone (an antidepressant medication) 50 mg, give 0.5 tablet every 24 hours as needed for insomnia, give at bedtime, dated 11/6/25. Review of Monthly Medication Reviews completed for Resident #2 indicated the following:-A Note to Attending Physician/ Prescriber, dated 11/20/25, that indicated the following: The Resident has an order for a psychoactive PRN (as needed) Trazodone which has been in place without a STOP date recorded. If this medication is continued as a PRN, a stop date or evaluation date must be added to this PRN order.-A Note to Attending Physician/ Prescriber, dated 12/17/25, that indicated the following: The Resident has an order for a psychoactive PRN (as needed) Trazodone which has been in place without a STOP date recorded. If this medication is continued as a PRN, a stop date or evaluation date must be added to this PRN order.-A Note to Attending Physician/ Prescriber dated, 1/23/26, that indicated the following: The Resident has an order for a psychoactive PRN (as needed) Trazodone which has been in place without a STOP date recorded. If this medication is continued as a PRN, a stop date or evaluation date must be added to this PRN order. The Note to Attending Physician/ Prescriber dated 11/20/25 was signed as reviewed by the physician on 12/3/25 and indicated to add a stop date of 12/3/25 and an evaluation date of 12/17/25 for the Trazodone. Review of the Note to Attending Physician/ Prescriber dated 12/17/25 and 1/23/26 failed to indicate it had been reviewed by the physician or prescriber. Review of a Pharmacist progress note, dated 1/22/26, indicated, in part, the following:-MD rec (Medical Doctor recommendation): stop date PRN (as needed) Trazodone Review of the medical record failed to indicate a stop date or evaluation date was added to the PRN Trazodone order and the order had been an active, ongoing order since 11/6/25. During an interview on 2/9/26 at 9:20 A.M., Unit Manager #2 said that monthly pharmacy recommendations get printed out and put into each Unit Manager's mailbox to address. He said sometimes there are nursing recommendations that are addressed immediately and sometimes there are recommendations for physicians. He said that those recommendations are placed in communication books for the physician to review. He said that the physician will sign to agree or disagree with the recommendations and orders will be update by nursing as indicated. He said that pharmacy recommendations should be addressed within 7-10 days. During an interview on 2/6/26 at 11:00 A.M., The Director of Nursing said that the pharmacy brings the recommendations to the facility and nursing notifies the physician of any recommendations which should be addressed as soon as practically able, and it should be documented in the medical record. He said that the most recent recommendations from 1/23/26 should have been addressed by now. 1b. Resident #65 was admitted to the facility in February 2022 with diagnoses that included Alzheimer's disease and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15, indicating severe cognitive impairment. Further review of the MDS indicated the use of antidepressant medications. Review of active physician's orders indicated the following:-Trazodone (an antidepressant medication), give 50 mg by mouth every 24 hours as needed for agitation 50mg PO daily as needed for agitation, dated 1/6/26. Review of a pharmacist progress note, dated 1/23/26 indicated in part, the following:-MD rec (medical doctor recommendation): stop date PRN (as needed) Trazodone Review of the Summary of Recommendations for DNS (Director of Nursing)/ Medical Director indicated the following recommendation, indicated as created between 1/1/26 and 1/23/26:This resident has an order for a psychoactive PRN (as needed) Trazodone which has been in place without a STOP date recorded. If this medication is continued as a PRN, a stop or evaluation date must be added to the PRN order. Review of the recommendation failed to indicate that it had been reviewed by a physician. Review of the medical record failed to indicate this recommendation had been reviewed with the physician or prescribing provider. During an interview on 2/9/26 at 9:20 A.M., Unit Manager #2 said that monthly pharmacy recommendations get printed out and put into each unit managers mailbox to address. He said sometimes there are nursing recommendations that are addressed immediately and sometimes there are recommendations for physicians. He said that those recommendations are placed in communication books for the physician to review. He said that the physician will sign to agree or disagree with the recommendations and orders will be update by nursing as indicated. He said that pharmacy recommendations should be addressed within 7-10 days. During an interview on 2/6/26 at 11:00 A.M., The Director of Nursing said that the pharmacy brings the recommendations to the facility and nursing notifies the physician of any recommendations which should be addressed as soon as practically able, and it should be documented in the medical record. He said that the most recent recommendations from 1/23/26 should have been addressed by now.

Based on record review and interviews, the facility failed to ensure that medications were accurately reconciled by nursing for one Resident (#104), out of a total sample of 30 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to ensure Cefadroxil (an antibiotic medication) was accurately transcribed in the medical record upon admission to the facility, resulting in the Resident not receiving the complete course of antibiotics. Findings include: Review of facility policy titled Administering Medications dated as updated 8/1/23, indicated the following:-Medications are administered in accordance with prescriber orders, including any required time frame. Resident #104 was admitted to the facility in January 2026 with diagnoses that included fracture of the shaft of the left tibia and encounter for orthopedic aftercare. There is no MDS information available for Resident #104. Review of admission paperwork from the referring acute care hospital indicated the following:-Start cefadroxil 500 mg (milligrams) capsule, 1 capsule by mouth every 12 hours for 7 days. [sic] Review of active physician's orders failed to indicate an order for cefadroxil. Review of completed orders indicated an order for the following:-Cefadroxil 500 mg 1 capsule twice a day for 7 administrations, dated 2/1/26. [sic] Review of the February Medication Administration Record (MAR) indicated that the medication stopped after seven administrations. Review of progress notes since admission failed to indicate that the recommendation was to change the order from seven days (and 14 administrations) to seven administrations. During an interview on 2/5/26 at 2:20 P.M., Unit Manager #2 said that the Resident was admitted after orthopedic surgery and was on antibiotics prophylactically to prevent infection. Unit Manager #2 reviewed the medical record and said that there was no active order for the medication but that it was ordered for seven administrations instead of seven days and had dropped off the administration record at this time. He said he would look into it. During a follow up interview on 2/5/26 at 3:00 P.M., Unit Manager said that the medication was transcribed incorrectly, and a medication error had occurred. During an interview on 2/6/26 at 10:55 A.M., the Director of Nurses said that a medication error had occurred for Resident #104. He further said that a transcription error had occurred on admission. He said that not receiving the full course of antibiotics places the resident at risk of developing a post-operative infection.

Based on observations, interviews, and record review, the facility to ensure that services provided met professional standards of practice for three Residents (#15, #61 and #71) out of a total sample of 30 Residents. Specifically,For Resident #15 the facility failed to ensure that monthly weights were obtained as indicated in physician's orders.For Resident #61 the facility failed to ensure that monthly weights were obtained as indicated in physician's orders.For Resident #71 the facility failed to ensure that weekly skin checks were completed as indicated in physician's orders. Findings include: 1. Resident #15 was admitted to the facility in July 2025 with diagnoses including dementia, bipolar disorder and kidney disease. Review of the Minimum Data Set assessment dated [DATE], indicated Resident #15 is severely cognitively impaired, scoring a 6 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #15 requires assistance with all activities of daily living. Review of the weight record for Resident #15 indicated that the last weight was obtained 10/31/25. Review of the physician's orders dated December 2025 indicated the following order: Monthly weights to be completed on the 10th of every month. Review of the Treatment Administration Record (TAR) dated December 2025 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the TAR Dated January 2026 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the progress notes dated 1/8/26, 1/9/26 and 1/10/26 failed to indicate that Resident #15 refused to be weighed. During an interview on 2/9/26 at 10:54 A.M., the Dietician said she reviews weights weekly. The Dietician said that if she can't find a weight, she lets nursing know. The Dietician said that she doesn't know why the Resident hasn't had a weight since October 2025. 2. Resident #61 was admitted to the facility in December 2025 with diagnoses including Parkinson's disease, altered mental status and deep tissue injury of the left heel. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #61 is severely cognitively impaired. Further review indicated that Resident #61 is totally dependent on staff for all activities of daily living. Review of the physician's orders dated January 2026 indicated the following order: Monthly weights to be completed on the 10th of every month. Review of the weight record failed to indicate a weight was obtained in January 2026. Further review indicated that the last weight was obtained 12/17/25. Review of the Treatment Administration Record Dated January 2026 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the progress notes dated 1/8/26, 1/9/26 and 1/10/26 failed to indicate that Resident #61 refused to be weighed. During an interview on 2/5/26 at 9:33 A.M., Nurse #3 said that when a weight is obtained it is put in the weights section of the electronic medical record on the date it was obtained. Nurse #3 then said that there is no separate weight book that weights are alternately entered into on the unit. Nurse #3 also said that if a nurse documents that a weight has been obtained then the weight should be also documented in the medical record. 3. Resident #71 was admitted to the facility in May 2025 with diagnoses that included cerebral infarction, hemiplegia affecting the right dominant side, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 11/21/25 indicated a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. The MDS further indicated that the Resident required supervision or touching assistance for meals. Review of active physician's orders indicated the following: -Weekly skin assessment by licensed staff to be completed every Wednesday on 3-11p shift, dated 5/21/25. Review of the Norton Assessment (an assessment to determine a resident's risk for skin breakdown and the development of pressure ulcers), completed 1/8/26, indicated a risk score of 10, indicating high risk for skin breakdown. Review of the medical record indicated that between 9/30/25 and 1/8/26, no skin assessments were completed. Review of the medical record indicated that the most recent skin assessments were completed on the following dates: -9/30/25, 1/8/26, 1/15/26, 1/25/26, 2/7/26. Review of the medical record indicated that five weekly skin assessments were completed in a 19-week time period. During an interview on 2/9/26 at 8:08 A.M., Nurse #2 said that skin checks are done weekly. She said there are orders to complete it that get signed off, and an assessment in the electronic medical record is also completed with the results of the skin check. During an interview on 2/9/26 at 9:37 A.M., Unit Manager #2 said that skin checks are completed weekly, usually on the 3:00-11:00 P.M. shift or on a resident's shower day. He said that an assessment in the electronic medical record should be completed weekly as indicated in the physician's orders. During an interview on 2/9/26 at 10:15 A.M., The Director of Nurses said that his expectation is that weekly skin checks are completed as indicated in the physician's orders and documented in the medical record with the findings.

Based on observation, record review and interview, the facility failed to ensure one Resident (#72) with a history of pressure ulcers, and assessed as being at high-risk for the development of pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 30 Residents. Specifically, the facility failed ensure the air mattress turned on while the Resident was in bed.Findings include: Review of the facility policy titled 'Support Surface Guidelines', updated 8/1/23, indicated the following:-The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.-Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air loss or gel while lying in bed.-Use a pressure ulcer risk scale such as the Braden Scale to help determine need for and appropriate type of pressure relieving devices. Resident #72 was admitted to the facility in July 2023 with diagnoses including Dementia with agitation.Review of the Minimum Data Set (MDS) assessment, dated 1/9/26, did not indicate a Brief Interview Mental Status (BIMS) score because the Resident is rarely/never understood.Review of the [NAME] Skin Assessment (an assessment to determine a resident's risk for the development of pressure ulcers), dated 1/23/26, indicated a score of 8, indicating the Resident is at high risk for the development of pressure ulcers.Review of the February 2026 physician's orders indicated the following:-Monitor air mattress for placement and function, order date 12/10/25.-Apply an air mattress, set proper settings, monitor proper settings adjust accordingly. Report adverse findings of the heel DTI (Deep Tissue Injury) to the MD (Medical Doctor) related to pressure ulcer of right heel, stage 4. Start date 11/6/25.Further review of the wound doctor's progress notes dated 1/14/26 indicated that the stage 4 pressure wound to the right heel had resolved.On 2/4/26 at 10:46 A.M., 11:47 A.M., and 12:21 P.M., the Surveyor observed the Resident in bed, sleeping on an air mattress that was not turned on.On 2/4/26 at 12:44 P.M., the Surveyor observed a Certified Nurse's Aide deliver the Resident's lunch tray, the Resident was in bed, and the air mattress was off. The CNA delivered the lunch tray and left the room.During an observation and interview on 2/4/26 at 12:46 P.M., the Surveyor and Unit Manager #1 observed the Resident in bed on an air mattress that was turned off. The Unit Manager said the air mattress was not on because it was unplugged. The Unit Manager plugged it back in and set the air mattress as ordered per the Resident's weight. The Unit Manager said the Resident's right heel wound had resolved but the air mattress should be turned on for wound prevention purposes. During an interview on 2/9/26 at 8:53 A.M., the Director of Nurses (DON) said physician's orders should be followed at all times. The Director of Nurses said the Resident's air mattress should always be plugged in, and on, while he/she is in bed and set according to his/her weight. The DON said the Resident's heel had resolved and the air mattress is being used for wound prevention purposes because the Resident is at a high risk for developing pressure ulcers.The air mattress manufacturer's guidelines were requested during the survey. The guidelines were not provided.

Based on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#71) out of a total sample of 30 residents, after each assessment, including the quarterly review assessment. Specifically, the facility failed to review and revise the care plan after a quarterly assessment was completed to reflect the current status of the Resident.Findings include:Resident #71 was admitted to the facility in May 2025 with diagnoses that included cerebral infarction, hemiplegia affecting the right dominant side, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 11/21/25 indicated a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Review of the Resident's active care plan indicated that the Resident is positive for Covid- 19, dated as 11/7/25. The active care plan indicated the following focus statements:-PRECAUTIONS: Resident on isolation/contact precautions for covid-19.-COVID-19: Resident is at risk for complication due to positive COVID-19 or COVID-19 likely status. On 2/5/26 at 9:47 A.M., the surveyor observed the Resident room. There is no indication that the Resident is on precautions or is positive for Covid-19. Review of a Physician's progress note, dated 11/14/25 indicated the following:-He/she tested positive for COVID-19 on 11-7, he/she was treated and tested negative on 11-12. [sic] During an interview on 2/9/26 at 10:10 A.M., the Director of Nurses said that care plans should be revised and updated with quarterly assessments to reflect the accurate and current status of the residents. The Director of Nurses said the Covid-19 care plans for Resident #71's should have been resolved following the quarterly assessment in November 2025, and upon testing negative for Covid-19.

Based on record review and interview the facility failed to maintain accurate medical records for two Residents (#15 and #61) out of a total sample of 30 residents. Specifically:For Resident #15 the facility documented that weights were obtained when they were not.For Resident #61 the facility documented that weights were obtained when they were not.Findings include: Review of the facility policy titled Charting and Documentation, dated revised 8/1/23, indicated that documentation in the medical record will be objective, complete and accurate. 1. Resident #15 was admitted to the facility in July 2025 with diagnoses including dementia, bipolar disorder and kidney disease. Review of the Minimum Data Set assessment, dated 10/31/25, indicated Resident #15 was severely cognitively impaired, scoring a 6 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #15 requires assistance with all activities of daily living. Review of the weight record for Resident #15 indicated that the last weight was obtained on 10/31/25. Review of the physician's orders dated December 2025 indicated the following order: Monthly weights to be completed on the 10th of every month. Review of the Treatment Administration Record (TAR) dated December 2025 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the TAR Dated January 2026 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the progress notes dated 1/8/26, 1/9/26 and 1/10/26 failed to indicate that a weight was obtained or that Resident #15 refused to be weighed. 2. Resident #61 was admitted to the facility in December 2025 with diagnoses including Parkinson's disease, altered mental status and deep tissue injury of the left heel. Review of the Minimum Data Set assessment, dated 12/5/25, indicated Resident #61 had severe cognitive impairment. Further review indicated that Resident #61 is totally dependent on staff for all activities of daily living. Review of the physician's orders dated January 2026 indicated the following order: Monthly weights to be completed on the 10th of every month. Review of the weight record failed to indicate a weight was obtained in January 2026. Further review indicated that the last weight was obtained 12/17/25. Review of the Treatment Administration Record Dated January 2026 indicated that a weight was obtained on the 8th, 9th and 10th. Review of the progress notes dated 1/8/26, 1/9/26 and 1/10/26 failed to indicate that a weight was obtained or that Resident #61 refused to be weighed. During an interview on 2/5/26 at 9:33 A.M., Nurse #3 said that when a weight is obtained it is put in the weights section of the electronic medical record on the date it was obtained. Nurse #3 then said that there is no separate weight book that weights are alternately entered into on the unit. Nurse #3 also said that if a nurse documents that a weight has been obtained then the weight should be also documented in the medical record. Nurse #3 also said that nurses should not be documenting that a weight was obtained if it was not.

Based on record reviews and interviews, the facility failed to ensure two Residents (#2 and #65) out of 30 sampled residents were free from unnecessary psychotropic medications by ensuring a stop date on a PRN (as needed) psychotropic medication. Specifically, for Resident #2 and Resident #65 the facility failed to ensure that as needed orders for Trazodone (an antidepressant medication) had a stop date.Findings include:Review of facility policy titled Psychotropic Medication Use, dated as updated 8/1/23, indicated the following:-Residents will not receive medications that are not clinically indicated to treat a specific condition.-Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:-b. anti-depressants-13. Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.-a. PRN orders for psychotropic medications are limited to 14 days.-(1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond the 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1a. Resident #2 was admitted to the facility in November 2025 with diagnoses that included depression and muscle weakness. Review of Resident #2's most recent Minimum Data Set (MDS) assessment, dated 12/24/25 indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated the use of antidepressant medications. Review of Resident #2's active physician's orders indicated the following:Trazodone (an antidepressant medication) 50 mg, give 0.5 tablet every 24 hours as needed for insomnia, give at bedtime, dated 11/6/25. Further review of physician's orders failed to indicate a stop date for as needed Trazodone and indicated it had been an active order since 11/6/25. During an interview on 2/9/26 at 9:20 A.M., Unit Manager #2 said that initially the PRN order for Trazodone should have had a 14 day stop date, then could have been extended by the provider, but it should have a stop date, and it does not. During an interview on 2/6/26 at 11:00 A.M., the Director of Nurses said that all as needed psychotropic medications require an initial 14- day stop date and then an evaluation in person by the provider to determine if the medication should be extended, but it would still require a stop date. 1b. Resident #65 was admitted to the facility in February 2022 with diagnoses that included Alzheimer's disease and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/2/26, indicated a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15, indicating severe cognitive impairment. Further review of the MDS indicated the use of antidepressant medications. Review of active physician's orders indicated the following:-Trazodone (an antidepressant medication), give 50 mg by mouth every 24 hours as needed for agitation 50mg PO daily as needed for agitation, dated 1/6/26 Review of the January Treatment Administration Record indicated that the Resident received PRN trazodone on the following dates:-1/9, 1/12, 1/21, 1/25, 1/29. Review of nursing progress notes, dated 1/6/26 indicated the following:-Resident is alert and confused. Did not sleep last night once more and refused to stay in room this morning. ADL's (activities of daily living) done and brought to the nursing station where he/she dosed (sic) off throughout the shift. He/She ate breakfast and lunch at 60-70% of each meal. This writer updated NP (Nurse Practitioner) on resident status. New order to increase bedtime Trazodone from 75M and 50mg PO (by mouth) daily as needed for 14 days, melatonin changed to 6 mg PO at bedtime. Will continue to monitor. [sic] Review of the medical record failed to indicate that the 14 day stop date was implemented, and the active order had been in place for 30 days at the time of review by the surveyor. During an interview on 2/9/26 at 9:20 A.M., Unit Manager #2 said that initially the PRN order for Trazodone should have had a 14 day stop date, then could have been extended by the provider, but it should have a stop date, and it does not. During an interview on 2/6/26 at 11:00 A.M., the Director of Nurses said that all as needed psychotropic medications require an initial 14- day stop date and then an evaluation in person by the provider to determine if the medication should be extended, but it would still require a stop date. Refer to 756

Based on interview, and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued with the required information for two out of two applicable residents reviewed. Specifically, the facility failed to issue a complete SNF ABN notice, so the Resident/Resident Representative could decide if they wished to continue receiving skilled services that may not be paid for by Medicare and were aware of the financial responsibility they may have to assume. Findings include: The SNF ABN (CMS-10055) notice is administered to a Medicare recipient when the facility determines that the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all of the Medicare benefit days for that episode. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility.Review of two out of two applicable Advance Beneficiary Notices of Non-Coverage failed to indicate the cost of services received while the residents were covered by Medicare part A. During an interview on 2/5/26 at 2:17 P.M., the Social Service Director said that the ABN's were incomplete and should include the cost of the room as well as the cost of therapies that the resident received while on their Medicare part A benefit. During an interview on 2/5/26 at 2:25 P.M., the Director of Nursing said that the ABN's were incomplete and should include the cost of the room as well as the cost of therapies that the resident received while on their Medicare part A benefit.

Based on record review and interview the facility failed to inform each resident of services available in the facility and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF/ABNs) to two out of two applicable records reviewed. During an interview on 2/26/25 at 2:00 P.M., Social Worker #2 said she had never issued an ABN before. She said that it was the business office that issued the ABNs. During an interview on 2/27/25 at 10:54 A.M., the Administrator said the facility is not issuing the ABNs, but they should be.

Based on observations, interviews, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for four Residents (#27, #21, #13 and #93) out of sample of 25 residents. Specifically, 1. For Resident # 27, the facility failed to include an oxygen physician's order in the medical record and have oxygen set at the right flow rate. 2. For Resident #21, the facility failed to routinely change and date oxygen tubing for one Residents. 3. For Resident #13, the facility failed to properly store the nebulizer tubing and mask. 4. For Resident #94, the facility failed to properly store and label the nebulizer tubing and mask. Findings include: A review of the policy titled 'Oxygen Administration' with a revision date of 8/1/23 indicated the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. -Turn on the oxygen, unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. A review of the facility policy titled Maintenance of O2 (Oxygen) Tubing/Nebulizer Tubing and Supplies, dated 8/23, indicated the following: Purpose: The purpose of the policy is to address infection prevention with regards to O2/Nebulizer tubing. Preparation: -Review MD orders for accuracy of use of oxygen/nebulizer General Guidelines: -All oxygen use should have orders to change tubing weekly and as needed for being soiled or dirty. -Nursing will be responsible for ensuring weekly O2 tubing is labeled with the appropriate date of being changed. -O2 tubing/nebulizer tubing when not in use should be stored in a plastic bag or other non-permeable material to keep from infection. 1. Resident #27 was admitted to the facility in November 2019 with diagnoses including adult failure to thrive. A review of the most recent Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. On 2/25/25 at 9:17 A.M., the surveyor observed the Resident in bed wearing a nasal cannula and oxygen set at 1.5 liters. On 2/26/25 at 7:30 A.M., the surveyor observed the Resident in bed wearing a nasal cannula and oxygen set at 1.5 liters. During an interview, medical record review and observation on 2/26/25 at 10:43 A.M.,, Nurse #2 and the surveyor observed the Resident in bed wearing the nasal cannula with oxygen set at 1.5 liters. Nurse #1 said the Resident is on continuous oxygen. She said the oxygen should be set at 2 liters. Nurse #1 reviewed the medical record and said there were no current physician's orders in place for how many liters of oxygen the Resident should be on and how often the Resident should be on oxygen. She said a physician's order for oxygen should be in place. During an interview on 2/27/25 at 8:52 A.M., the Director of Nurses said, for safe oxygen administration, a physician's order should be in place. She said Resident #27 started using oxygen continuously on 10/14/24. She said his/her oxygen should be set at 2 liters. 45343 2. Resident #21 was admitted to the facility in October 2023 with diagnoses including acute and chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD), and hypertensive heart disease without heart failure. Review of Resident #21's most recent Minimum Data Set (MDS), dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) exam score of 12 out of a possible 15, indicating he/she has intact cognition. Further review of the MDS indicated Resident #21 requires partial/moderate to dependent assistance for daily self-care activities and is on oxygen therapy. Review of Resident #21's physician orders indicated the following: -Replace and date O2 (Oxygen) tubing on Sundays 11:00 P.M. to 7:00 A.M. shift, every night shift, every Sunday, initiated 10/23/24. On 2/25/25 at 8:53 A.M., 12:05 P.M., and 2:40 P.M., Resident #21 was observed lying in bed wearing oxygen at 2 liters per minute (L/min) via nasal cannula. The oxygen tubing was labeled 1/27/25. Review of the Treatment Administration Record (TAR) for February 2025 indicated that the oxygen tubing was changed on 2/2/25, 2/9/25, 2/16/25, and 2/23/25. During an interview on 2/26/25 at 4:43 P.M., Nurse #1 said the oxygen tubing should be changed weekly and stored in a plastic bag when not in use. Nurse #1 said nurses should follow the physician's orders for changing and labeling oxygen tubing. During an interview on 2/27/25 at 9:17 A.M., the Director of Nursing said any resident on oxygen or nebulizer should have the tubing changed and labeled weekly on Sundays 11:00 P.M. to 7:00 A.M. shift and stored in a plastic bag. 3. Resident #13 was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease (COPD), and influenza due to identified novel influenza A virus with other respiratory manifestations, other forms of dyspnea (difficulty breathing or shortness of breath). Review of Resident #13's most recent Minimum Data Set (MDS) Assessment, dated 12/20/24, indicated a Brief Interview for Mental Status (BIMS) exam score of 11 out of 15, indicating he/she has moderate cognitive impairment. Further review of the MDS indicated Resident #13 requires partial/moderate assistance to supervision/touching assistance for self-care activities. Review of physician's orders indicated the following order, dated 2/23/25: - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3 ml (milliliter)-inhale orally every 6 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. On 2/25/25 at 8:31 A.M., the surveyor observed a nebulizer machine with tubing and a mask on the Resident's nightstand. The nebulizer tubing was not labeled with a date, and the mask and tubing was not stored in a bag and no bag was present. On 2/25/25 at 10:31 A.M., the surveyor observed a nebulizer machine with tubing and a mask on the Resident's nightstand. The nebulizer tubing was not labeled with a date, and the mask and tubing was not stored in a bag and no bag was present. On 2/26/25 at 7:27 A.M., the surveyor observed a nebulizer machine with tubing and a mask on the Resident's nightstand. The nebulizer tubing was not labeled with a date, and the mask and tubing was not stored in the bag now attached to the nightstand drawer. During an interview on 2/16/25 at 4:43 P.M., Nurse #1 said that the nebulizer mask and tubing should be changed weekly, labeled with the date, and stored in a plastic bag when not in use. During an interview on 2/27/25 at 9:17 A.M., the Director of Nursing (DON) said any resident on oxygen or nebulizer should have the tubing changed weekly on Sundays on 11:00 P.M. to 7:00 A.M. shift and stored in a plastic bag. 50338 4. Resident #93 was admitted to the facility in June 2024 with diagnoses including neurocognitive disorder with Lewy bodies (a form of dementia) and Parkinson's Disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/27/24, indicated that Resident #93 had severe cognitive impairment as evidenced by rarely/never understood and a staff assessment for Brief Interview for Mental Status (BIMS). Review of Resident #93's physician's order, dated 1/28/25, indicated Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters (ml). 3 ml inhale orally every 6 hours as needed for shortness of breath/wheezing via nebulizer. Review of Resident #93's physician's order, dated 2/4/25, indicated Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters (ml). 1 vial inhale orally two times a day for cough/congestion. (Nebulizer). Review of Resident #93's physician's active orders as of 2/25/25, failed to indicate any orders to change nebulizer tubing and mask. Review of Resident #93's Medication Administration Record (MAR) and Treatment Administration Record (TAR) as of 2/27/25, failed to indicate any orders to change nebulizer tubing and mask. Review of Resident #93's physician's progress note, dated 1/29/25, indicated Patient has auditory inspiratory wheezing, staff nurse at bedside, staff reported today that [he/she] does that sometimes, I had a telephone conversation with patient's daughter today and she stated that it happens when it is cold and [he/she] went outside yesterday for a doctor's appointment, she stated that DuoNebs (combination medication of ipratropium and albuterol) as needed helps, added DuoNeb every 6 hours as needed, patient is in no acute distress. [sic] Review of Resident #93's physician's progress note, dated 2/8/25, indicated Added DuoNeb twice daily scheduled as requested by [his/her] daughter, continue as needed, [sic] On 2/25/25 at 7:58 A.M., the surveyor observed nebulizer on Resident #93's nightstand, the tubing was attached and undated and the mask was laying in the drawer of the nightstand, not in a bag. On 2/26/25 at 8:03 A.M., the surveyor observed nebulizer on Resident #93's nightstand, the tubing was attached and undated and the mask was laying in the drawer of the nightstand, not in a bag, On 2/26/25 at 12:18 P.M., the surveyor observed nebulizer on Resident #93's nightstand, the tubing was attached and undated and the mask was laying in the drawer of the nightstand, not in a bag. On 2/27/25 at 7:08 A.M., the surveyor observed nebulizer on Resident #93's nightstand, the tubing was attached and undated and the mask was laying in the drawer of the nightstand, not in a bag. During an interview on 2/27/25 at 7:10 A.M., Nurse #3 said nebulizer tubing and masks are changed every seven days and should be dated when changed. During an interview on 2/27/25 at 8:41 A.M., Nurse #4 said nebulizer tubing and masks get changed weekly and they should be labeled when changed and stored in bag when not in use. During an interview on 2/27/25 9:18 A.M., the Director of Nursing (DON) said nebulizer tubing and mask should be stored in a bag when not in use. Tubing should be changed weekly and there should be a physician's order to change tubing on oxygen and nebulizers weekly.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment that prevents the development and transmission of communicable diseases and infections when the facility failed to implement Enhanced Barrier Precautions for three Residents (#306, #95, and #40) out of a total sample of 25 residents and staff wore gloves in the hallways and failed to perform hand hygiene following glove removal. Findings include: 1. Review of facility policy titled Enhanced Barrier Precautions, dated as updated 8/1/23, indicated the following: -Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. -EBPs are targeted gown and glove use during high contact resident care activities when contract precautions do not otherwise apply. -Gloves and gown are applied prior to performing the high contact resident care activity. -Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: -dressing; -bathing/ showering; -transferring; -providing hygiene; -changing linens; -changing briefs or assisting with toileting; -device care or use (central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.); and -wound care (any open skin requiring a dressing). -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. -PPE (personal protective equipment) is available outside of the resident's rooms. 1 a. Resident #306 was admitted to the facility in February 2025 with diagnoses that include acute respiratory failure with hypoxia and retention of urine Review of Resident #306's most recent Minimum Data Set (MDS) Assessment, dated 2/14/25 was an Entry MDS, therefore did not indicate a Brief Interview for Mental Status Score. -On 2/25/25 at 8:06 A.M., Resident #306 was observed in his/her room with a urinary catheter in place. There was no signage outside of the room to indicate the need for Enhanced Barrier Precautions (EBPs). There was no personal protective equipment (PPE) outside of the room for use. -On 2/26/25 at 9:05 A.M., staff were observed providing activities of daily living care to Resident #306. Staff were not utilizing EBPs during care. There was no signage outside of the room to indicate the need for EBPs. There was no PPE outside of the room for use. 1 b. Resident #95 was admitted to the facility in January 2025 with diagnoses that included sepsis and acute respiratory failure with hypoxia. Review of Resident #95's most recent Minimum Data Set (MDS) Assessment, dated 1/31/25 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the Resident had intact cognition. -On 2/25/25 at 7:56 A.M., the surveyor observed Resident #95 in bed. He/she had a cholecystostomy tube (a tube that goes into the gallbladder) in place. There was no signage outside of the room to indicate the need for EBPs. There was no PPE outside of the room for use. -On 2/26/25 at 7:01 A.M., the surveyor observed Resident #95 in his/ her room. There was no signage outside of the room to indicate the need for EBPs. There was no PPE outside of the room for use. 1 c. Resident #40 was admitted to the facility in September 2020 with diagnoses including acute kidney failure. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident has an indwelling catheter (including suprapubic catheter and nephrostomy tube). On 2/25/25 at 9:11 A.M., the surveyor observed the Resident awake in bed, he/she had a nephrostomy tube in place (a thin, flexible tube inserted into the kidney to drain urine directly from the organ). There was no signage outside of the room to indicate the need for EBPs. There was no PPE outside of the room for use. On 2/26/25 at 7:39 A.M., the surveyor observed the Resident in the room sleeping. He/she had a nephrostomy tube in place. There was no signage outside of the room to indicate the need for EBPs. There was no PPE outside of the room for use. On 2/26/25 at 8:38 A.M., the surveyor observed the Resident in the room, sitting on his/her bed. He/she had a nephrostomy tube in place. There was no signage outside of the room to indicate the need for EBPs. There was no PPE outside of the room for use. During an interview on 2/26/25 at 2:08 P.M., the Corporate Director of Nurses said that anyone with an open area or who is susceptible to infection, such as residents who have urinary catheters, gastrostomy tubes or drains should be on EBPs. During an interview on 2/27/25 at 9:41 A.M., the Director of Nurses said that she would expect that EBPs be in place as appropriate and followed in the facility. 2. Review of facility policy titled Personal Protective Equipment- Using Gloves, dated as updated 8/1/23, indicated the following: -Objectives -1. To prevent the spread of infection -3. To protect hands from potentially infectious material -Miscellaneous -5. Wash hands after removing gloves (Note: gloves do not replace hand washing.) Review of facility policy titled Handwashing/ Hand hygiene, dated as updated 8/1/23, indicated the following: -Use alcohol- based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: -After removing gloves. -On 2/25/25 at 9:17 A.M., the surveyor observed a housekeeping staff member pulling a barrel of trash in the hallway on the first-floor unit. The housekeeping staff member had one glove on one of his hands. He got onto the elevator and using his gloved hand, held open the elevator door for the surveyor to get on. -On 2/26/25 at 9:03 A.M., the surveyor observed a housekeeping staff member in the hallway of the first-floor unit with gloves on bilateral hands. Another staff member stopped him and said that he needed to take his gloves off in the hallway. The housekeeping staff member removed the gloves and threw them away. He did not perform hand hygiene upon removing the gloves. He walked down the hallway to the linen closet, opened the door, potentially contaminating the handle, and got supplies from the closet. During an interview on 2/26/25 at 2:14 P.M., the Corporate Director of Nurses and Infection Preventionist said that staff should be removing gloves before entering the hallways and should perform hand hygiene after removing gloves. During an interview on 2/27/25 at 9:43 A.M., the Director of Nurses said that staff should not be wearing gloves in the hallways and should be sanitizing their hands after glove removal.

Based on observations, interviews and record review, the facility failed to provide a dignified environment for two Residents (#33 and #27) out of a sample of 25 residents. Specifically, 1. For Resident #33, the facility staff referred to the Resident by their level of assistance. 2. For Resident #27, the facility staff assisted the Resident with a meal while standing and referred to the Resident by their level of assistance. Findings include: A review of the facility policy titled 'Dignity' with a revision date of 8/1/23 indicated the following: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. 1. Resident # 33 was admitted to the facility in August 2019 with diagnoses including dementia. A review of the most recent Minimum Data Set (MDS), dated [DATE], did not indicate a Brief Interview for Mental Status (BIMS) score because the Resident is rarely/never understood. During an interview on 2/25/25 at 8:59 A.M., Certified Nurse's Assistant (CNA #1) was in the dining room with residents. The surveyor asked her if Resident #33 was done eating. She said Resident #33 was done eating, he/she is a feeder. During an interview on 2/27/25 at 8:22 A.M., CNA #1 said residents should not be referred to by their level of assistance. During an interview on 2/27/25 at 8:50 A.M., the Director of Nurses said staff should not be addressing residents by their care level needs. 2. Resident #27 was admitted to the facility in November 2019 with diagnoses including adult failure to thrive. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. On 2/26/25 at 8:38 A.M., the surveyor observed a hospice staff member assisting the Resident with breakfast while standing. During an interview on 2/27/25 at 8:27 A.M., CNA #1 was in the hallway assisting with breakfast trays. CNA #1 was in the earshot of other residents. She said all staff, including hospice staff, should not assist residents with meals while standing. CNA #1 said Resident #27 is a feeder and staff should assist with meals while seated. CNA #1 said she should not be referring to Resident #27 based on his/her care needs. During an interview on 2/27/25 at 8:50 A.M., the Director of Nurses said all staff, including hospice staff, should not assist residents with meals while standing. She said they should be seated at eye level. She said staff should not refer to residents based on their level of care.

Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for two Residents (#11 and #95), out of a total sample of 25 residents were consistently documented in the medical record. Findings include: Review of facility policy titled Advance Directives, dated as updated [DATE], indicated the following: -The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. -Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. -If the resident does not have an advance directive: -1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline the assistance. 1 a. Resident #11 was admitted to the facility in [DATE] with diagnoses that include chronic kidney disease stage 3, dysphagia, gout and muscle weakness. Review of Resident #11's most recent Minimum Data Set (MDS) Assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 2 out of a possible 15 indicating severe cognitive impairment. The MDS further indicated that the Resident does not have a pressure ulcer but is at risk for developing one. The MDS indicated that the Resident is a full code. Review of the paper record indicated a MOLST (Massachusetts Medical Orders for Life Sustaining Treatment) form, signed and dated [DATE], indicating Do Not Resuscitate and Do Not Intubate signed by both the Health Care Proxy (HCP) and the physician. Review of Resident #11's physician's orders, dated [DATE], indicated the following: -Do not Intubate. -Do not resuscitate . Review of Resident #11's active advanced directives care plan, dated as revised [DATE], indicated Advanced Directives: MOLST reads as full code with an intervention that indicates to uphold and respect my wishes and healthcare proxy wishes. [sic] Review of a social services progress note, dated [DATE], indicated in part, we honor [his/her] MOLST and HCP (healthcare proxy) is invoked. During an interview on [DATE] at 8:26 A.M., Unit Manager #1 said that once a MOLST form is filled out and signed, then an order is entered into the medical record. He further said that advanced directives and code status are discussed at care plan and quarterly meetings with the resident and or their HCP. He said that advanced directives should be consistently documented throughout the medical record including physician's orders, care plan and MDS assessment. During an interview on [DATE] at 9:29 A.M., the Director of Nurses said that she would expect that advanced directives are documented consistently throughout the medical record. She said she would expect that advanced directives are discussed at care plan meetings and that changes in resident status are updated in the moment. 1 b. Resident #95 was admitted to the facility in [DATE] with diagnoses that included sepsis and acute respiratory failure with hypoxia. Review of Resident #95's most recent Minimum Data Set (MDS) Assessment, dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the Resident had intact cognition. The MDS further indicated that the Resident was a full code. Review of Resident #95's care plan failed to indicate a plan of care regarding advanced directives. Review of Resident #95's physician orders failed to indicate an order for advanced directives. Review of uploaded documents into the Electronic Medical Record (EMR) failed to indicate a MOLST (Massachusetts Medical Orders for Life Sustaining Treatment) form was uploaded. Review of the paper medical record indicated a blank MOLST form, not filled out or signed by the Resident or physician. Review of Resident #95's Progress notes indicated the following: -a social services progress note, dated [DATE], indicated a 48-hour care plan meeting was held. The progress note failed to indicate that advanced directives were discussed at this time. -A social Services progress note, dated [DATE], indicated a 48-hour care plan meeting was held. The progress note failed to indicate that advanced directives were discussed at this time. -A review of all progress notes since admission failed to indicate a discussion around advanced directives. During an interview on [DATE] at 10:33 A.M., Resident #95 said that no one at the facility had discussed advanced directives or his code status with him/her. Resident #95 said that if he/she were to pass naturally, they would not want to receive CPR (Cardiopulmonary Resuscitation) and would want to be a do not resuscitate. During an interview on [DATE] at 8:26 A.M., Unit Manager #1 said that if a resident is admitted without a valid MOLST form then the staff will complete one with the resident and or the healthcare proxy. If the Resident or healthcare proxy do not complete one, then the resident is a full code and that is communicated to the resident or healthcare proxy. He said once the code status is determined it is entered into the medical record as a physician's order. During an interview on [DATE] at 9:29 A.M., the Director of Nurses said that a MOLST form should be completed or attempted to be completed on every resident. She said that if a resident or their designee decline to fill out the form she would expect documentation of that in the medical record and education provided to the resident or designee that a full code would be implemented.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, when on 09/28/24 Certified Nurse Aide #1 transferred him/her without assistance from another staff member, and as a result Resident #1 sustained a fractured right ankle, which required surgical intervention to repair. Findings include: The Facility's Policy, titled Safe Lifting and Movement of Residents, dated 08/01/23, indicated resident safety, dignity, comfort, and medical condition would be incorporated into goals and decisions regarding the safe lifting and movement of residents. Review of the Report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS), dated 10/03/24, indicated that on 09/29/24, Resident #1's right ankle was assessed to be swollen and bruised, X-Ray results indicated his/her right ankle was fractured, and through the Facility's internal investigation, it was determined that on 9/28/24, Certified Nurse Aide #1 transferred Resident #1 without assistance from another staff member, which was identified as the source of his/her injury. Resident #1 was admitted to the Facility in September 2023, diagnoses included history of falls, dementia, rheumatoid arthritis, and osteoarthritis. Review of Resident #1's Hospital Physical Therapy Discharge Assessment Note, dated 09/11/23, indicated Resident #1 required two staff members to assist with transfers. Review of Resident #1's Post Admission Care Plan Meeting Note, dated 09/26/23, indicated he/she required maximum assistance of two staff for transfers. Review of Resident #1's Certified Nurse Aide Activities of Daily Living Flowsheet for September 2024 indicated he/she was dependent on staff for all transfers (that resident does none of the effort to complete the task, and/or requires the assistance of two or more staff to complete the activity). Review of Resident #1's Annual Minimum Data Set (MDS) assessment (a comprehensive assessment of each resident's functional capabilities), dated 09/07/24, indicated he/she was dependent for transfers. Review of Resident #1's Nurse Progress Note, dated 09/29/24, indicated Resident #1's right foot was bruised and swollen, and a physician's order for an x-ray was obtained. Review of Resident #1's Radiology Report, dated 09/29/24, indicated he/she had an acute fracture of the right distal fibular shaft (long bone on the outside of the lower leg). Review of Resident #1's Hospital Admission History and Physical, dated 10/02/24, indicated he/she was diagnosed with a displaced fracture of the right distal fibular shaft with valgus angulation (type of fracture where the distal part (part furthest away from the center of the body) of the bone points away from the body's midline), and required surgical intervention of a closed reduction percutaneous pinning. During a telephone interview on 10/16/24 at 01:10 P.M., Nurse #2 said she was Resident #1's nurse on 09/28/24 and 09/29/24. Nurse #2 said CNA #1, who was familiar with Resident #1 and had provided care for him/her many times, was assigned to Resident #1 during the 07:00 A.M., to 03:00 P.M., shift on 09/28/24. Nurse #2 said that on the morning on 09/29/24 Resident #1's right ankle was observed to be bruised and swollen. During a telephone interview on 10/16/24 at 01:59 P.M., Nurse Supervisor #1 said that on 09/29/24 she was called to Resident #1's room by Nurse #2 because his/her foot was bruised and swollen. Nurse Supervisor #1 said she interviewed Certified Nurse Aide (CNA) #1, who had provided care for Resident #1 on 09/28/24, and said CNA #1 told her that she had transferred Resident #1 from his/her bed to his/her chair without any help from another staff member. Nurse Supervisor #1 said CNA #1 should have gotten and had assistance from another staff member to transfer Resident #1, but did not. Review of Certified Nurse Aide (CNA) #1's signed written statement, dated 09/29/24, indicated that on 09/28/24 at 10:30 A.M., she provided ADL care to Resident #1, and that she transferred him/her from his/her bed to his/her wheelchair without assistance from another staff member. CNA #1 did not respond to the Department of Public Health telephone or letter request for an interview. During an interview on 10/15/24 at 12:25 P.M., the Director of Nurses (DON) said CNA #1 should have had another staff member present to assist her with transferring Resident #1 on 09/28/24, but did not, and as a result Resident #1 sustained a right ankle fracture.

Based on record reviews and interviews, the facility failed to protect seven Residents (#5, #100, #19 #108, #26, #62 and #90) from abuse and neglect by staff out of a total sample of 41 residents. Specifically, the facility failed to prevent abuse 1a) after one Resident (#5) alleged that Certified Nursing Assistant (CNA) #16 forced him/her to take a shower and sprayed water in his/her face, causing emotional distress and 2) by neglecting to complete incontinence care for Residents #100, #19, #108, #26, #62 and #90. Findings include: Review of the Facility policy titled, Resident Rights/Abuse, undated, indicated the following: -Federal requirements state that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; And that we may not mistreat, neglect, abuse, or misappropriate the resident's property. -Emotional abuse happens when a resident is humiliated, harassed or feels threatened. -Psychological abuse - causing emotional pain or distress to a resident. Psychological abuse includes but is not limited to: humiliation. -Signs of psychological abuse may include the resident suddenly becoming fearful, withdrawn, refuses to eat, sleeps poorly at night, ringing the bell more frequently because the resident is afraid. -Neglect - the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect includes but is not limited to: failing to provide medical, dental, nursing, physical therapy, pharmacy, psychological, speech or other treatments or services; failing to carry out medical or nursing care plans or specific treatments; failing to provide for the dietary requirements of a resident; and failing to provide safety measures. Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, dated 8/1/23, indicated the following: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -The staff, with the physicians input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of the Facility policy titled Abuse and Neglect-Clinical Protocol, dated as updated 8/1/23, indicated the following: -Neglect as defines at 483.5, means the failure of the facility, its employer or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 1a. Resident #5 was admitted to the facility in May 2023 with diagnoses including legal blindness, cerebral infarction, anxiety, and depression. Review of Resident #5's most recent Minimum Data Set Assessment (MDS) assessment, dated 12/17/23, indicated Resident #5 had a Brief Interview for Mental Status score of 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #5 required substantial-maximal assistance with bathing. During an interview on 3/07/24 at 12:30 P.M., with Resident #5 and Resident #5's Family Member (#2), Resident #5 reported that staff ignored his/her requests to not take a shower and not have his/hair washed and that he/she feels ignored. Resident #5 said Certified Nursing Assistant (CNA) #16 forced him/her to take a shower on 2/28/24. Resident #5 said he/she goes to the hair salon on Tuesdays and told CNA #16 he/she did not want a shower or to have his/her hair washed the following day. Resident #5 said She picked me up and made me take a shower, sprayed water in my face and used a whole bottle of shampoo. She scrubbed my nose and was a big, awful person and scared me even after I kept telling her no, she would not stop spraying me and scrubbing my hair. Resident #5 said CNA (#16) shouldn't be working and that he/she told his/her privately paid helper what had happened that afternoon. Resident #5 said, I was overpowered, and no one could help. I was frightened and I was afraid. Family Member #2 said she received a call from the privately paid aide and was notified of the incident and went to visit Resident #5 that evening and was told the same information by Resident #5. The Resident's Family Member #2 said a formal complaint was made to Unit Manager #1, and to the Director of Nurses (DON) on 2/28/24 by Resident #5's Health Care Proxy. During an interview on 3/08/24 at 2:57 P.M., with Resident #5, and Family Member (#3), the family member said the Resident and family are upset and concerned about this incident. Family Member #3 said he spoke with Nurse Unit Manager #1 a few days after the incident again because Resident #5 was still afraid and scared and had been refusing showers for 9 days. Resident #5 said I don't want a shower because I am afraid and scared still. Family Member #3 said he was very upset because this has put fear into Resident #5 and the Resident does not want family to leave him/her alone since this incident. During an interview on 3/08/24 at 3:14 P.M., Family Member (#1) said Resident #5 was very upset and crying during a phone call and said he/she felt overpowered, frightened, and afraid of this staff member. Family Member #1 said Resident #5 told CNA #16 he/she did not want a shower and that he/she had a shower on Monday. Family member #1 said Resident #5 said CNA #16 said he/she must take a shower because her family told him/her to and brought him/her into the shower very upset and proceeded to shower him/her. Resident #5 reported that CNA #16 continued to spray water on the Resident after repeat attempts at telling the CNA to stop. Resident #5 said please don't do my hair, I just paid to have it done, and the CNA took the hose and put it over Resident #5's head and sprayed water down his/her face and head. Family Member #1 said the Resident started screaming and said to the CNA you son of a bitch I told you not to wash my hair and I told you no. I just had my hair done!. Resident #5 said CNA #16 continued washing his/her hair and continued to spray water over his/her face and hair. Resident #5 said he/she was man powered and had no control when the CNA overtook her, and said and none of his/her family could protect him/her. Family Member #1 said she immediately reported all the information to the Director of Nursing on 2/28/24 and told her she wanted to file a grievance regarding all of the information reported by Resident #5. The family member said she has not heard back from the facility since the incident and has not received a copy of the grievance report. Family Member #1 said she also spoke with Unit Manager #1 on 2/28/24 and was told that a formal grievance was in the works. Family Member # 1 said she feels this was emotional abuse and it has caused Resident #5 to refuse showers since the incident because he/she is scared. During an interview on 3/07/24 at 12:40 P.M., the hairdresser said she provides salon services to Resident #5 and washed and styled his/her hair and the Resident has been very upset since then, because the CNA made him/her take a shower. During an interview on 3/07/24 at 3:12 P.M., the Director of Nursing (DON) said she does not remember this incident and will check her list of incidents tomorrow. The DON said if Resident #5 refused a shower the CNA should not have forced her to take a shower and should have documented the refusal, notified the nurse and the nurse would enter a note into the computer. The DON said if a resident is forced into doing something, that would be considered a type of abuse. During an interview on 3/08/24 at 4:01 P.M., Nurse Unit Manager #1 said she was made aware of the situation on 2/28/24 by Resident #5's family member and notified the DON of the incident. Nurse Unit manager #1 said the CNA should not have made Resident #5 take a shower, and it is a form of abuse. Unit manager #1 said if Resident #5 said no, and she did it anyway, that is abuse. During an interview on 3/08/24 at 4:08 P.M., with the DON and Administrator, the DON said she was notified of the incident that took place on 2/28/24 and that she spoke with Resident #5's family member on the day of the incident. The DON said CNA #16 should not have showered him/her after the Resident said no. The DON and Administrator said forcing a resident to do something against their will is a form of abuse. 41456 2a. Resident #100 was admitted to the facility in March 2022 with diagnoses including Alzheimer's disease, benign prostatic hyperplasia, and muscle weakness. Review of Resident #100's most recent Minimum Data Set (MDS) assessment, dated 12/02/24, indicated Resident #100 was unable to complete the Brief interview for Mental Status exam and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #100 is dependent on staff for toileting. On 3/07/24 from 2:28 P.M. to 7:19 P.M., Resident #100 was observed out of bed in his/her wheelchair without incontinence care being provided to him/her or any staff members checking the Resident to assess if incontinence had occurred. At 7:19 P.M., the surveyor observed a puddle of urine smelling liquid dripping from the bottom of Resident #100's wheelchair seat. The puddle was gathering enough liquid that it began to stream from his/her chair to approximately 4 feet across the floor. At this time, the surveyor had Resident #100's nurse observe the Resident and the liquid, and the Nurse said he would get the Resident's Certified Nursing Assistant (CNA) to provide incontinence care for the Resident. On 3/07/24 at 7:36 P.M., 17 minutes after the Nurse said he would be getting Resident #100 assistance, the Resident remained in his/her wheelchair and the surveyor and Administrator observed the Resident together. The Administrator said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. On 3/08/24 at 7:03 A.M., the Surveyor observed Resident #100 lying in his/her bed. The Resident's wheelchair was observed in his/her room across from his/her bed. The Surveyor put on clean gloves and with a finger pushed on the wheelchair cushion which caused a yellow liquid to leak out of the cushion and around the Surveyor's finger. The Surveyor then lifted the saturated cushion and noted the seat of the wheelchair seat was observed to be soaked with yellow liquid and had an ammonia smell similar to urine. During an interview on 3/08/24 at 11:06 A.M., Resident #100's daughter said she has been very upset with the level of care provided to the Resident. The Resident's daughter said she has often come in to visit Resident #100 and the Resident is soiled with feces and his/her pants are wet from an incontinent episode with a strong smell of urine. Review of Resident #100's current Activity of Daily Living (ADL) care plan, last revised, 12/28/23, indicated the following: -Bladder: (the Resident) is incontinent of bladder. -Bowel: (the Resident) is incontinent of bowel. -Toilet hygiene: (the Resident) is dependent. -Toilet transfer: (the Resident) is dependent. Review of Resident #100's current bowel incontinence care plan, last revised 12/28/23 indicated the following interventions: -Keep resident clean and dry -Provide peri-care after each incontinent episode. Review of Resident #100's current bladder incontinence care plan, last revised 12/28/23 indicated the following interventions: -Clean peri-area with each incontinence episode -Monitor skin during incontinence care and s/s of UTI. -Remedy cream to be used with incontinent care Review of Resident #100's current potential for pressure area care plan, last revised 12/28/23 indicated the following interventions: -Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of Resident #100's most recent bowel and bladder assessment, dated 3/1/24, indicated Resident #108 was incontinent of both bowel and bladder, was totally incontinent, and had an inconsistent voiding pattern. The assessment also indicated Resident transferred back to bed BID to be toileted/changed and cleaned before final transfer back to be at night to sleep. Review of Resident #100's Kardex (a form indicating the level of assistance a resident requires) indicated Resident #100 is incontinent of both bladder and bowel and was dependent on staff for toileting tasks. Review of the nursing note, dated 3/8/24, the day after the incontinence care was not provided, indicated the following: -This am during am care, (the Resident) was noted to have a 0.125 x 1 cm (centimeter) slightly raised blister/pustule on buttocks, pustule is red with surrounding skin pink, md updated order for nystatin cream area until healed. During an interview on 3/08/24 at 7:23 A.M., Nurse Unit Manager #2 observed Resident #100's skin and said he/she definitely had a new area that was not there prior to today. Nurse Unit Manager #2 said she couldn't say if the skin area was open, but it was definitely a new skin alteration area. Nurse Unit Manager #2 said Resident #100 is incontinent and should receive incontinence care as needed. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 2b. Resident #19 was admitted to the facility in July 2021 with diagnoses including Alzheimer's Disease and dysphagia (difficulty chewing and swallowing). Review of Resident #19's most recent Minimum Data Set (MDS) assessment, dated 12/20/23, indicated Resident #19 had a Brief Interview for Mental Status exam score of 3 out of a possible 15, which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident # 19 required moderate assistance with self-feeding tasks. On 3/07/24 from approximately 8:25 A.M. to 11:45 A.M., and from 2:28 P.M. to 7:19 P.M., Resident #19 was observed out of bed in his/her wheelchair without incontinence care being provided to him/her or any staff members checking the Resident to assess if incontinence had occurred. On 3/07/24 at 7:36 P.M., the surveyor and Administrator observed the Resident together. The Administrator said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. Review of Resident #19's current Activity of Daily Living (ADL) care plan, last revised 1/02/24, indicated the following: -Bladder: (the Resident) is incontinent of bladder. -Bowel: (the Resident) is incontinent of bowel. -Toilet hygiene: (the Resident) is substantial to max assist. -Toilet transfer: (the Resident) is substantial to max assist. Review of Resident #19's current incontinence care plan, last revised 1/02/24, indicated the following interventions: -Check as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. -Clean peri-area with each incontinence episode. Review of Resident #19's current potential for pressure areas care plan, last revised 1/02/24, included the following intervention: -Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of Resident #19's most recent bowel and bladder assessment, dated 12/30/23, indicated Resident #19 was incontinent of both bowel and bladder, was totally incontinent, had an inconsistent voiding pattern, and needed to be toileted during care and around meals to reduce episodes of incontinence. Review of Resident #19's Kardex (a form indicating the level of assistance a resident requires) indicated Resident #19 is incontinent of both bladder and bowel and was dependent on staff for toileting tasks. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 2c. Resident #108 was admitted to the facility in July 2023 with diagnoses including dementia, chronic kidney disease, and benign prostatic hyperplasia. Review of Resident #108's most recent Minimum Data Set (MDS) assessment, dated 1/27/24, indicated Resident #108 was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated the Resident required moderate assistance from staff for toileting hygiene. On 3/07/24 from approximately 2:28 P.M. to 7:19 P.M., Resident #108 was observed out of bed in his/her wheelchair without incontinence care being provided to him/her or any staff members checking the Resident to assess if incontinence had occurred. The Resident was not toileted after either the lunch or dinner meals. On 3/07/24 at 7:36 P.M., the surveyor and Administrator observed the Resident together. The Administrator said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. During an interview on 3/08/24 at 11:30 A.M., Resident #108's spouse said she had to request that Resident #108 be toileted after every meal to keep him/her clean because incontinence care was not being provided regularly. Review of Resident #108's Activity of Daily Living care plan, last revised 2/01/24, indicated the following: -Bladder: (the Resident) is incontinent of bladder. -Bowel: (the Resident) is incontinent of bowel. -Toilet hygiene: (the Resident) is dependent. -Toilet transfer: (the Resident) is substantial to max assist. Review of Resident #108's incontinence care plan, last revised 1/02/24, indicated the following interventions: -Incontinent: check as well as prompt toilet around meals and care times to decrease episodes as (he/she) allows and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. -Offer toileting to (the Resident) immediately after leaving the dining room. -Brief Use: the resident uses disposable briefs. Change PRN. -Clean peri-area with each incontinence episode. Review of Resident #108's most recent bowel and bladder assessment dated [DATE], indicated Resident #108 was incontinent of both bowel and bladder, was totally incontinent, and had an inconsistent voiding pattern. Review of Resident #108's Kardex (a form indicating the level of assistance a resident requires) indicated the Resident is incontinent of both bladder and bowel and was dependent on staff for toileting tasks. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 41105 2d. Resident #26 was admitted to the facility in May 2022 and has diagnoses that includes dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/24, indicated that Resident #26 scored a 7 out of a possible 15 on Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated that Resident #26 had no behaviors, is dependent on staff for toileting hygiene and is always incontinent of bowel and bladder. Review of the current Activities of Daily Living (ADL) care plan, dated 10/31/23, indicated that Resident #26 has been identified as having potential or actual deficits in Activities of Daily living while a resident at our facility. Interventions on the care plan include: -Toilet hygiene: Resident #26 is dependent; -Bladder: Resident #26 is incontinent of bladder; -Bowel: Resident #26 is incontinent of bowel. Review of the current bowel and bladder incontinence care plan, indicated the following interventions: -INCONTINENT: check (as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. -Remedy cream to be used with incontinent care. Review of the current skin integrity care plan, indicated that Resident #26 had the potential for skin impairment due to incontinence. Interventions included: -Incontinent care if applicable. Review of Resident #26's current Resident ADL Guide/Kardex indicated the following care instructions for Resident #26: -Is incontinent; -Dependent for toileting hygiene. On 3/07/24 between 10:30 A.M., to 1:30 P.M., the surveyors were on the unit and observed that Resident #26 was not provided with incontinence care. The Resident was observed in his/her room, sitting on a hoyer pad (the pad used on a mechanical lift), in his/her wheelchair during that entire time. During an interview on 3/07/24 at 2:30 P.M., Certified Nursing Assistant (CNA) #2 said that he was assigned to Resident #26 that day. CNA #2 said that he changes residents on his assignment twice a shift (8 hours). CNA #2 said that he first changed Resident #26 at approximately 7:30 A.M., that morning before he used a mechanical lift to transfer him/her out of bed to a wheelchair. According to CNA #2 he then provided incontinence care to Resident #26 again at 11:00 A.M., contrary to direct observation by 2 surveyors. CNA #2 said that with the assist of CNA #3 they used a mechanical lift to transfer Resident #26 back to bed and then he provided incontinence care. CNA #2 said that CNA #3 then assisted him to mechanically transfer Resident #26 back to the wheelchair. CNA #2 said that he had not checked or changed Resident #26 since 11:00 A.M., 3.5 hours earlier. CNA #2 also said that since he just got back from his break, Resident #26 could next be changed by the staff on the 3-11 shift. During an interview on 3/07/24 at 2:36 P.M., with CNA #3 she said that she had not assisted CNA #2 at any point that day with using the mechanical lift to transfer Resident #26 to or from bed and that she was unsure who had provided Resident #26 with incontinence care. During an interview on 3/07/24 at 2:48 P.M., with the Director of Nursing (DON) she was updated on the observations and interviews and the DON said the following: -It is her expectation that staff provide incontinence care every two hours; She said that every two hours incontinent residents should be both checked and changed, as well as changed as needed at other times. On 3/07/23 between 3:15 P.M., and 7:16 P.M., the surveyor observed Resident #26 seated in a wheelchair in his/her room. During that time Resident #26 was not observed to have been checked for incontinence, nor was he/she changed. At 7:16 P.M., 4 hours and 1 minute since the last time Resident #26 received incontinence care, CNA #9 entered Resident #26's room carrying incontinence supplies and pulled the curtain around him/her. During an interview on 3/07/24 at 7:36 P.M., with the Administrator (NHA) he was updated on the observations. The NHA reiterated the expectation that incontinent residents be changed every two hours and as needed. Review of the CNA assignment on 3/08/24 at 7:20 A.M., indicated CNA #2 was presently working and was again assigned to Resident #26. During an interview with the DON on 3/08/24 at 7:26 A.M., she said that she had not yet had a chance to look at statements collected regarding the allegation of neglect twice the previous day. The DON said that CNA #2 should not be working and should not be assigned to Resident #26 when she had not yet completed the neglect investigation. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 10:33 A.M., the facility submitted a report that Resident #26 did not receive incontinence care the morning of 3/7/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the NHA said that for staff to not have provided the incontinence care for Resident #26, for the length of time they did on 3/07/24, was neglect. 2e. Resident #62 was admitted to the facility in June 2020 and had diagnoses that include neuromuscular dysfunction of bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/06/24, indicated that on the Brief Interview for Mental Status exam Resident #62 scored a 1 out of possible 15, indicating severely impaired cognition. The MDS further indicated Resident #62 had no behavior of rejecting care, is incontinent of bowel and bladder and is dependent for toileting hygiene. Review of Resident #62's current Activity of Daily Living (ADL) care plan indicated Resident #62 is dependent for toileting care. The care plan failed to indicate refusal of incontinence care. Review of Resident #62's current bowel incontinence care plan indicated the following interventions: -Please keep me clean and dry; -Skin care after incontinent episodes. Review of Resident #62's current Resident ADL Guide/Kardex indicated the following care instructions for Resident #62: -Is incontinent; -Dependent for toileting hygiene. Review of the most recent Bladder assessment, dated 1/6/24, indicated: -voiding pattern inconsistent -Staff continues to check and change resident when incontinent. Resident offered urinal/bedpan at care times to decrease episodes when possible. Staff to monitor skin for s/sx of breakdown/infection during care and address as needed. Resident OOB daily for meals. Briefs provided for dignity and containment. On 3/07/23 between 3:15 P.M., and 7:16 P.M., the surveyor observed Resident #62. Resident #62 was not checked for incontinence during that time, nor was he/she changed. During an interview on 3/07/24 at 6:55 P.M., with Certified Nursing Assistant (CNA) #9, who was supervising the unit dining room where Resident #62 was seated, he said that he had been supervising the dining room since approximately 4:30 P.M., which is why the residents present had not been checked or changed for incontinence. CNA #9 said that Resident #62 was on his assignment, however said that he hadn't had a chance to provide incontinence care since his shift started at 3:00 P.M., 3 hours and 55 minutes earlier, and that he wasn't sure when he was going to be able to, as he was responsible to supervise the dining room. On 3/11/24 between 7:28 A.M., and 10:42 A.M., Resident #62 was observed in bed. During that time no staff checked Resident #62 for incontinence or provided incontinence care. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. During a follow-up interview on 3/12/24 at 10:49 A.M., the NHA said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 2f. Resident #90 was admitted to the facility in November 2023 and had diagnoses that include vascular dementia and unspecified urinary incontinence. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/27/24, indicated that on the Brief Interview for Mental Status exam Resident #90 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #90 is frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident #90's current ADL care plan indicated Resident #90 is dependent for toileting care. The care plan failed to indicate refusal of incontinence care. Review of Resident #90's current Resident ADL Guide/Kardex indicated the following care instructions for Resident #90: -Is incontinent; -Dependent for toileting hygiene. Review of the most recent Bladder assessment, dated 1/27/24, indicated: -voiding pattern inconsistent -cooperative with care On 3/07/23 between 3:15 P.M., and 7:16 P.M., the surveyor observed Resident #90. During that time Resident #90 was not checked for incontinence, nor was he/she changed. During an interview on 3/07/24 at 6:55 P.M., with Certified Nursing Assistant (CNA) #9, who was supervising the unit dining room where Resident #90 was seated, he said that he had been supervising the dining room since approximately 4:30 P.M., which is why the residents present had not been checked for incontinence or changed. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to ensure Resident #1 was not financially exploited and funds misappropriated by the Admissions Director who became his/her Durable Power of Attorney (DPOA), charged monthly fees for the service, and withdrew over $158,000 from Resident #1's bank account for personal use as a loan. The Facility failed to conduct a full thorough investigation and did not implement corrective action to protect Resident #1 from further potential misappropriation and exploitation until the DPH investigated the allegation. Findings include: The Facility's Policy and Procedure titled Abuse Prohibition, dated (MONTH) (YEAR), indicated each resident has the right to be free from misappropriation of their property. The Facility's Policy and Procedure titled Abuse Prohibition: Identification, dated (MONTH) (YEAR), indicated to proactively identify any event that may be potential misappropriation of resident property and notify state agencies per state and federal requirements. The Facility's Policy and Procedure titled Abuse Prohibition: Protection, dated (MONTH) (YEAR), indicated whenever a resident suffered physical or psychological harm as a result of an alleged violation, the Facility shall immediately take any and all remedial actions which are reasonably necessary to prevent further harm to that resident and/or other residents and the accused employee will be suspended pending investigation. The Policy and Procedure indicated residents will be free from interference or coercion when reporting an allegation. The Facility's Policy and Procedure titled Abuse Prohibition: Prevention, dated (MONTH) (YEAR), indicated the Administrator will be the Abuse Prevention Coordinator with the ability to delegate tasks to enable a timely resolution of an alleged event. The Policy and Procedure indicated the Administrator will ensure identification, correction and intervention in situations in which misappropriation is more likely to occur. Resident #1's Hospital After Visit Summary, dated 05/25/18, indicated he/she's [DIAGNOSES REDACTED]. Resident #1's Hospital Discharge Summary, dated 05/25/18, indicated he/she was brought to the emergency room under Section 12 (emergency transfer order of persons posing risk of serious harm by reason of mental illness) after a wellness check found he/she was living alone in his/her house with no electricity or running water. The Discharge Summary indicated the house was in total chaos due to hoarding behavior. The Discharge Summary indicated Resident #1 denied any issues with his/her memory, denied any major issues at home and took care of his/her finances without issues. The Discharge Summary indicated Resident #1 denied any financial difficulty as the cause of no electricity or water at the house, and although Resident #1 initially denied missing any payments, he/she later admitted to missing dates for paying bills. The Discharge Summary indicated on brief cognitive testing, Resident #1 performed relatively well (with the exception of delayed recall), however a more formal Montreal Cognitive Assessment was indicated. The Hospital Discharge Summary indicated Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 06/02/18, and his/her Quarterly MDS' dated 09/06/18, 11/28/18 and 02/14/19, indicated that during these assessments he/she presented with intact cognitive functioning. Review of Resident #1's Medication Management Assessments, dated 06/29/18, 07/27/18, 09/28/18, 12/28/18, and 03/22/19 indicated Resident #1 had poor insight and poor judgment. The Admission Director's Personnel File indicated she was hired in a dual role to work also as a Social Worker at the Facility. The Surveyor interviewed the Administrator and the Director of Nurses (DON) at 9:10 A.M. on 05/01/19. The Administrator and DON said Resident #1 did not have any family. The Administrator and DON said Resident #1 had an inactivated Health Care Proxy which appointed Friend #1. The Administrator and DON said the Admissions Director said due to the condition of Resident #1's house and the transition to long term care at the Facility, the Admissions Director hired companies to clean out and sell Resident #1's house. The Administrator and DON said the Admissions Director helped Resident #1 discover, clarify and organize his/her funds and pay bills. The Surveyor interviewed the Admissions Director at 4:20 P.M. on 05/01/19. The Admission Director said Resident #1's home environment, prior to it's sale, was horrendous, or to that effect, due to hoarding, no running water or electricity. The Admission Director said Resident #1's financial situation was initially largely unknown requiring discovery, locating a safety deposit box, and visits to his/her Certified Public Accountant and financial institutions. The Admissions Director said Resident #1 met with Attorneys sometime in (MONTH) (YEAR) or (MONTH) (YEAR), and she was then asked by Resident #1, as recommended by the Attorneys to become his/her DPOA. The Admissions Director said she informed the Administrator, of her intent to be appointed the DPOA for Resident #1, in (MONTH) (YEAR). The Admissions Director said since no one advised her not to accept the appointment as Resident #1's DPOA, she proceeded with the appointment. Resident #1's Durable Power of Attorney document, executed on 09/05/18, appointed the Admissions Director as Resident #1's DPOA. The Admissions Director said throughout the process Resident #1 had not realized he/she had accumulated a net worth 1.5 million dollars. The Admissions Director said on 08/31/18 she had a personal conversation with Resident #1 requesting if she could withdraw money and obtain a joint credit card account to borrow approximately $155,000. The Admissions Director said she told Resident #1 that $85,000 would pay off her (the Admissions Director) credit card debt, and the additional money would be used to repair her (the Admissions Director) house. The Admissions Director said she told Resident #1 that the credit card would be used to charge meals, travel to Disney World and other types of extracurricular expenses. The Admissions Director said Resident #1 was vague in his/her response to the request to borrow $155,000, Resident #1 asked if the loan would be paid back and the Admissions Director confirmed it would be paid back with interest. The Admissions Director said although she had typed the personal loan documents signed by Resident #1, she did not obtain these written documents prior to using Resident #1's funds and credit cards for her own personal use. The Admissions Director said Resident #1 probably did not comprehend the magnitude of her request and act in borrowing $155,000. The Admissions Director said she realized the act of borrowing Resident #1's money was an unethical and unprofessional act, or words to that effect. The Typed Documents signed by the Admissions Director and Resident #1 included the following: -Engagement of DPOA Services and Fees at the monthly rate of $1,250, noted as agreed and accepted on 1/18/19 -Promissory Note from the Admissions Director which indicated that on 03/28/19 (the day after the Protective Service Investigator met with the Admissions Director) she promises to payback a personal loan from Resident #1 for $82,000 that was received (on dates unknown) with interest. The Admissions Director said she met with the Protective Service Investigator on 03/27/19. The Admissions Director said she informed the Administrator upon his return to the facility on [DATE] that she was being investigated by Protective Services for financial misappropriation of Resident #1's funds. The Admissions Director said she provided the Administrator the Protective Service Investigator's business card. The Surveyor interviewed the Protective Service Investigator at 2:50 P.M. on 05/01/19. The Protective Service Investigator said that on 03/27/19 she met with the Admissions Director at the Facility. The Protective Service Investigator said the Admissions Director, on multiple occasions, used Resident #1's credit card and withdrew money from his/her bank account. The Protective Service Investigator said the Admissions Director told her that she was using Resident #1's money as a loan for personal gain. The Protective Service Investigator said after meeting with the Admissions Director on 3/27/19 and interviewing Resident #1, who indicated he/she did not give the Admissions Director permission to use his/her funds for personal gain, she later received a typed letter, dated 3/27/19, signed by Resident #1. The Protective Service Investigator said the typed letter indicated permission was given to the Admissions Director (the DPOA) to borrow money from Resident #1. A typed document addressed to the Protective Service Investigator, dated 03/27/19 and signed by Resident #1, indicated the Admissions Director was his/her DPOA to assist with the sale of his/her house, and to handle banking, credit and investment needs. The typed document to Protective Services also indicated permission was given by Resident #1 to the Admissions Director by Resident #1 to borrow money by using Resident #1's credit card to make payments on the Admission Director's and her Spouse's own credit card. The Protective Service Investigator said that on 04/08/19 she spoke with the Administrator to ensure he was aware that the Admissions Director was using Resident #1's funds for personal gain. The Surveyor interviewed the Administrator at 9:10 A.M. and 5:05 P.M. on 05/01/19. The Administrator said the day after the Protective Service Investigator met with the Admissions Director (03/28/19), the Admissions Director informed him that she was being investigated for misappropriating Resident #1's funds. The Administrator said the Admissions Director told him the bank suggested she obtain DPOA status in order to assist Resident #1 in selling the house and manage his/her bank accounts. The Administrator said the Admissions Director told him she borrowed $87,000 from Resident #1, and a portion had been paid back to him/her. The Administrator said he told the Admissions Director to relinquish her DPOA status and she agreed. The Administrator said subsequently (date not recalled) he discussed the allegation with the Protective Service Investigator. The Administrator said the Facility did not fully investigate or suspend the Admissions Director when becoming aware that Protective Services was investigating an allegation of misappropriation. Review of the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) indicated the Facility did not report the allegation that the Admissions Director misappropriated Resident #1's funds until 04/24/19. The Incident Report Form submitted by the Facility, dated 04/24/19, indicated the DON received a call by the DPH on 04/24/19 at 9:20 A.M. regarding an allegation that the Admissions Director (referred to as the Social Worker) allegedly misappropriated Resident #1's money. The Incident Report Form indicted an investigation has been initiated and Social Worker was suspended. The Surveyor interviewed the DON at 1:20 P.M. on 05/01/19 and at 3:30 P.M. on 05.15/19. The DON said she was not aware that the Admissions Director was appointed the DPOA or that Protective Services was investigating the Admissions Director for an allegation of misappropriation of Resident #1's funds until the DPH contacted her on 04/24/19. The DON said during two interviews with Resident #1, he/she did not recall agreeing to a loan and signing documents consenting to a loan. The DON said the Facility did not consider asking Resident #1's assistance in obtaining bank records and credit card statements to further investigate the allegation. The Admissions Director's Statement, dated 04/25/19, to the Administrator indicated she was appointed Resident #1's DPOA, borrowed approximately $88,000 from Resident #1, paid back $23,700, owed Resident #1 $66,872 (including interest), and she would be writing Resident #1 a check for the balance owed since the funds were obtained through a home equity line of credit. A Notarized Statement to Resident #1 indicated that, effective 04/25/19, the Admissions Director resigned the role of DPOA. The Surveyor interviewed the Administrator and the Director of Nurses (DON) at 9:10 A.M. on 05/01/19. The Administrator said the Admissions Director's employment was not suspended until the Department of Public Health contacted the Facility on 04/24/19. The Administrator said although Protective Services had not concluded their investigation, the Admission Director's employment was reinstated on 04/29/19. The Administrator said the Facility determined the Admissions Director obtained a loan from Resident #1 and misappropriation did not occur. The Surveyor interviewed Visitor #1 at 2:25 P.M. on 05/01/19. Visitor #1 said she was Resident #1's friend for [AGE] years, visited her weekly and was to be Resident #1's Health Care Proxy Agent when activated. Visitor #1 said Resident #1 did not tell her that he/she was financially gifting or loaning money to the Admission Director. Visitor #1 said Resident #1 was known to be economical, and was not known to loan anyone money. Visitor #1 said Resident #1 would not knowingly give anyone the authority to use his/her credit card or access his/her bank account(s). The Surveyor interviewed Resident #1 at 11:50 A.M. on 05/01/19. Resident #1 said he/she identified his/her signature on documents (the Engagement of DPOA Services and Fees, the Promissory Note from the Admissions Director, and the Typed Document addressed to the Protective Service Investigator), but did not recall the meaning of these documents and did not recall signing the documents. Resident #1 said he/she may have given the Admissions Director authority over his/her finances but could not recall. Resident #1 said he/she did not recall being informed of, or signing a document indicating that the Admissions Director would obtain a monthly fee of $1,250 for service as his/her DPOA. Resident #1 said he/she did not recall loaning, gifting or permitting the Admissions Director to withdraw money from his/her bank account(s) or to use his/her credit card for the Admissions Director's own personal use. Resident #1 said he/she would not consider loaning anyone more than $1,000. Resident #1 said she did not recall agreeing to allow the Admission Director borrow over $87,000. The DON was interviewed at 3:10 P.M. on 05/03/19 and at 3:30 P.M. on 05/15/19. The DON said the Admissions Director reported, prior to and on the date of the DPH investigation on 05/01/19, borrowing approximately $82,000 from Resident #1. The DON said on 05/01/19 the Admissions Director's was asked by herself and the Administrator to immediately provide the remainder of funds owed to Resident #1 as her employment was suspended effective immediately. The DON said the Admissions Director on 05/01/19 provided them with a statement and a check for $138,998.30 for Resident #1. The DON said she did not know why the check was dated 04/27/19 when the request and receipt of it was on 05/01/19. Review of the Admissions Director's personal check, dated 04/27/19, indicated it was made payable to Resident #1 for $138,998.30. The Admissions Director Statement of Repayment of Borrowed Funds to Resident #1, dated 04/27/19, indicated the personal check reflected the remainder of the balance plus interest owed from (MONTH) (YEAR) to (MONTH) 2019 as $138,998.30. The Statement indicated the total amount received from Resident #1 was $158,345.22.

Based on records reviewed and interviews, for one of four sampled residents (Resident #1), the Facility failed to follow it's own policy to protect Resident #1 from being financially exploited and funds misappropriated by the Admissions Director, to immediately report the allegation of misappropriation, immediately conduct a full thorough investigation and implement corrective action to protect Resident #1 from further potential misappropriation and exploitation until the DPH investigated the allegation. Findings include: The Facility's Policy and Procedure titled Abuse Prohibition, dated (MONTH) (YEAR), indicated each resident has the right to be free from misappropriation of their property. The Facility's Policy and Procedure titled Abuse Prohibition: Identification, dated (MONTH) (YEAR), indicated to proactively identify any event that may be potential misappropriation of resident property and notify state agencies per state and federal requirements. The Facility's Policy and Procedure titled Abuse Prohibition: Protection, dated (MONTH) (YEAR), indicated whenever a resident suffered physical or psychological harm as a result of an alleged violation, the Facility shall immediately take any and all remedial actions which are reasonably necessary to prevent further harm to that resident and/or other residents and the accused employee will be suspended pending investigation. The Policy and Procedure indicated residents will be free from interference or coercion when reporting an allegation. The Facility's Policy and Procedure titled Abuse Prohibition: Prevention, dated (MONTH) (YEAR), indicated the Administrator will be the Abuse Prevention Coordinator with the ability to delegate tasks to enable a timely resolution of an alleged event. The Policy and Procedure indicated the Administrator will ensure identification, correction and intervention in situations in which misappropriation is more likely to occur. The Admission Director's Personnel File indicated she was hired in a dual role to work also as a Social Worker at the Facility. The Surveyor interviewed the Administrator and the Director of Nurses (DON) at 9:10 A.M. on 05/01/19. The Administrator and DON said the Admissions Director said due to the condition of Resident #1's house and the transition to long term care at the Facility, the Admissions Director hired companies to clean out and sell Resident #1's house. The Administrator and DON said the Admissions Director helped Resident #1 discover, clarify, organize his/her funds and pay bills. The Surveyor interviewed the Admissions Director at 4:20 P.M. on 05/01/19. The Admission Director said Resident #1's home environment prior to it's sale was horrendous, or words to that effect, due to hoarding, no running water or electricity. The Admission Director said Resident #1's financial situation was initially largely unknown requiring discovery, locating a safety deposit box, and visits to his/her Certified Public Accountant and financial institutions. The Admissions Director said throughout the process Resident #1 had not realized he/she had accumulated a net worth 1.5 million dollars. The Admissions Director said Resident #1 met with Attorneys sometime in (MONTH) (YEAR) or (MONTH) (YEAR), and she was then asked by Resident #1, as recommended by the Attorneys to become his/her Durable Power of Attorney (DPOA). The Admissions Director said she informed the Administrator of her intent to be appointed the DPOA in (MONTH) (YEAR). The Admissions Director said since no one advised her not to accept the appointment as Resident #1's DPOA, she proceeded with the appointment. Resident #1's Durable Power of Attorney document, executed on 09/05/18, appointed the Admissions Director as Resident #1's DPOA. The Admissions Director said on 08/31/18 she had a personal conversation with Resident #1 requesting if she could withdraw money and obtain a joint credit card account to borrow approximately $155,000. The Admissions Director said she told Resident #1 that $85,000 would pay off her (the Admissions Director) credit card debt, and the additional money would be used to repair her (the Admission Director) house. The Admissions Director said she told Resident #1 that the credit card would be used to charge meals, travel to Disney World and other types of extracurricular expenses. The Admissions Director said Resident #1 was vague in his/her response to the request to borrow $155,000, Resident #1 asked if the loan would be paid back and the Admissions Director confirmed it would be paid back with interest. The Admissions Director said Resident #1 probably did not comprehend the magnitude of her request and act in borrowing $155,000. The Admissions Director said although she had typed the personal loan documents signed by Resident #1, she did not obtain these written documents prior to using Resident #1's funds and credit cards for her own personal use. The Admissions Director said she realized the act of borrowing Resident #1's money was an unethical and unprofessional act, or words to that effect. Typed Documents signed by the Admissions Director and Resident #1 included the following: -Engagement of DPOA Services and Fees at the monthly rate of $1,250, noted as agreed and accepted on 1/18/19 -Promissory Note from the Admissions Director indicated that on 03/28/19 (the day after the Protective Service Investigator met with the Admissions Director) she promises to payback a personal loan from Resident #1 for $82,000 that was received (on dates unknown) with interest. The Surveyor interviewed Resident #1 at 11:50 A.M. on 05/01/19. Resident #1 said he/she identified his/her signature on documents (the Engagement of DPOA Services and Fees, and the Promissory Note from the Admissions Director), but did not recall the meaning of these documents and did not recall signing the documents. Resident #1 said he/she may have given the Admissions Director authority over his/her finances but could not recall. The Admissions Director said she met with the Protective Service Investigator on 03/27/19. The Admissions Director said she informed the Administrator upon his return to the facility on [DATE] that she was being investigated by Protective Services for financial misappropriation of Resident #1's funds. The Admissions Director said she provided the Administrator the Protective Service Investigator's business card. The Surveyor interviewed the Protective Service Investigator at 2:50 P.M. on 05/01/19. The Protective Service Investigator said on 03/27/19 she met with the Admissions Director at the Facility. The Protective Service Investigator said the Admissions Director on multiple occasions used Resident #1's credit card and withdrew money from his/her bank account. The Protective Service Investigator said the Admissions Director told her that she was using Resident #1's money as a loan for personal gain. The Protective Service Investigator said that on 04/08/19 she spoke with the Administrator to ensure he was aware that the Admissions Director was using Resident #1's funds for personal gain. The Surveyor interviewed the Administrator at 9:10 A.M. and 5:05 P.M. on 05/01/19. The Administrator said the day after the Protective Service Investigator met with the Admissions Director (03/28/19), the Admissions Director informed him that she was being investigated for misappropriating Resident #1's funds. The Administrator said the Admissions Director told him the bank suggested she obtain DPOA status in order to assist Resident #1 in selling the house and manage his/her bank accounts. The Administrator said the Admissions Director told him she borrowed $87,000 from Resident #1, and a portion had been paid back to him/her. The Administrator said he told the Admissions Director to relinquish her DPOA status and she agreed. The Administrator said subsequently (date not recalled) he discussed the allegation with the Protective Service Investigator. The Administrator said the Facility did not fully investigate or suspend the Admissions Director when becoming aware that Protective Services was investigating an allegation of misappropriation. This was not consistent with the Facility's Abuse Prohibition Policies. Review of the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) indicated the Facility did not report the allegation that the Admissions Director misappropriated Resident #1's funds until 04/24/19, approximately 27 days after the Administrator was informed by the Admissions Director of the Protective Services Investigation of her for misappropriation of Resident #1's funds. This was not consistent with the Facility's Abuse Prohibition Policies. The Incident Report Form submitted by the Facility, dated 04/24/19, indicated the DON received a call by the DPH on 04/24/19 at 9:20 A.M. regarding an allegation that the Admissions Director (referred to as the Social Worker) allegedly misappropriated Resident #1's money. The Incident Report Form indicted an investigation has been initiated and Social Worker was suspended. A Notarized Statement to Resident #1 indicated that, effective 04/25/19, the Admissions Director resigned the role of DPOA. The Surveyor interviewed the Administrator and the Director of Nurses (DON) at 9:10 A.M. on 05/01/19. The Administrator said the Admissions Director's employment was not suspended until the Department of Public Health contacted the Facility on 04/24/19. This was not consistent with the Facility's Abuse Prohibition Policies. The Administrator said although Protective Services had not concluded their investigation, the Admission Director's employment was reinstated on 04/29/19. The Administrator said the Facility thought the Admissions Director obtained a loan from Resident #1 and misappropriation did not occur. `

Based on records reviewed and interviews for 2 of 4 sampled residents (Resident #1 and Resident #4), the Facility failed to ensure interventions, which had been identified to prevent the risk of injury and falls for each resident, were implemented. - Resident #1 was assessed as a risk for falls and had Physician order [REDACTED]. On 9/16/2016, Resident #1 was found bleeding from the head on the floor of his/her room and the bed alarm had not been activated. Resident #1 was transferred to the hospital where he/she received 6 staples and was admitted . - Resident #4 had been identified as a risk for falls, was admitted to the Facility with fragile skin, was assessed for functional mobility and determined to require the assistance of 2 for transfers. On 9/9/2016, Resident #4 was being transferred from bed to chair with the assistance of 1 Certified Nursing Assistant (CNA) when he/she sustained a laceration to the left leg and required transfer to the hospital emergency room where Resident #4 received skin adhesive bond and steri-strips (items used to close a wound) to the laceration on his/her left leg. Findings include: Resident #1: Resident #1's admission [DIAGNOSES REDACTED]. A Nursing Progress Note, dated 9/13/16 indicated Resident #1 was alert but forgetful. A Physician Order, dated 9/13/2016, indicated Resident #1 was to have bed and chair alarms, check placement and function every shift. A Facility Incident Investigation Report, not dated, indicated Resident #1 had attempted to self ambulate to the bathroom, on 9/16/2016, when he/she lost his/her balance and fell sustaining a head laceration. The Facility Incident Investigation Report indicated Resident #1's bed alarm had not sounded. The Facility Incident Investigation Report indicated CNA #3 was re-educated on the checking of resident alarms for placement and function. The Surveyor interviewed the Director of Nursing (DON) at 9:50 A.M. on 10/26/2016. The DON said the Facility did not have a written policy or procedure for bed and chair alarms. The Surveyor interviewed Nurse #1 at 1 P.M. on 10/26/2016. Nurse #1 said he found Resident #1 bleeding from his/her head on the floor of his/her room on 9/16/2016. Nurse #1 said Resident #1 was suppose to have a bed alarm as a fall intervention and the bed alarm was not working at the time of the incident. The Surveyor interviewed CNA #3 at 2:56 P.M. on 10/26/2016. CNA #3 said she knew Resident #1 required a bed alarm for fall prevention. CNA #3 said Resident #1 had a bed alarm on his/her bed on 9/16/2016 but she did not check the alarm to ensure it was functioning. CNA #3 said she returned from her break and Resident #1 had been found on the floor by the nurse and was informed the bed alarm had not sounded. Resident #4: A Certified Nursing Assistant Care Plan, dated 8/12/2016, indicated Resident #4 was anxious with transfers and required extensive assistance of 2 or more people with transfers. A Functional Mobility Care Plan, dated 8/13/2016, indicated Resident #4 required maximum assistance of 2 people for bed mobility, transfers, and ambulation. An Admission Minimum Data Set Assessment, dated 8/19/2016, indicated Resident #4 required extensive assistance of 2 people for transfers. A Situation Background Assessment Recommendation (SBAR) Communication Form, dated 9/9/2016, indicated Resident #4 sustained a deep laceration to his/her left lower leg during a transfer from bed to chair. A Facility Incident Report, dated 9/9/2016, indicated Resident #4 sustained a laceration to his/her left leg during a transfer with a CNA from bed to chair, was sent to the emergency room and received a skin adhesive bond and steri-strips (items used to close a wound) to his/her left leg. An Employee Conference Record, dated 9/9/2016, indicated Resident #4 sustained a laceration on his/her left leg and was transferred to the hospital. The Employee Conference Record indicated Resident #4 was from bed to chair with the assistance of 1 CNA and Resident #4's Plan of Care indicated Resident #4 required extensive assistance of 2 people. The Employee Conference Record indicated CNA #4 failed to follow Resident #4's Plan of Care. A Physician's Progress Note, dated 9/23/2016, indicated Resident #4's skin was thin, frail and pink at baseline The Surveyor interviewed Unit Manager #2 at 3:48 P.M. on 10/26/2016. The Unit Manager indicated Resident #4 had fragile skin, would become rigid and anxious with transfers and required the assistance of 2 people with transfers. The Unit Manager said Resident #4 sustained a laceration to his/her left leg during a bed to chair transfer, on 9/9/2016, with the assistance of 1 CNA (CNA #4). The Unit Manager said CNA #4 transferred Resident #4 on 9/9/2016 without proper assistance. The Surveyor interviewed CNA #4 at 2:13 P.M. on 10/27/2016. CNA #4 said he did not look at Resident #4's Plan of Care on 9/9/2016 and transferred Resident #4 without assistance.

Based on observations, staff interviews, and record review, the facility failed to ensure that 2 residents (Residents #1 and #18) from a sample of 22 residents received adequate supervision to prevent falls. Findings include: 1. For Resident #1, the facility failed to provide adequate supervision to prevent a fall from bed on 12/25/13 at 2:00 P.M.. Review of Resident #1's clinical record on 2/20/14 indicated that the resident was admitted to the facility in 9/2010 with [DIAGNOSES REDACTED]. Review of resident's plan of care for personal hygiene and repositioning, dated 12/6/13, indicated that the resident required extensive assistance of 2 staff members for repositioning and personal hygiene. Review of the resident's plan of care for the prevention of falls, dated 12/6/13, indicated that the resident was to have bed sensor alarm on while in bed, floor mats on both sides of the bed, and a perimeter mattress. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/12/13, indicated that the resident had highly impaired hearing, sometimes understood what others said, had short and long term memory loss, and had severe cognitive impairment (unable to complete a Brief Interview for Mental Status). The MDS indicated that the resident required the physical assistance of 2 staff members for bed mobility (turning side to side) and toileting (cleansing after elimination), was always incontinent of bowel and bladder, and had no recent falls. Review of the most recent Fall Risk Assessment, dated 12/12/13, indicated that the resident was at high risk for falls with a score of 12. A score of 10 or higher was considered at high risk. Review of the 12/2013 Certified Nurse Aide (CNA) Flow Sheet indicated that the resident required the physical assistance of 2 staff members for toileting and positioning in bed. Review of the Resident Incident/Falls Report, dated 12/25/13 at 2:45 P.M., indicated that the resident had a fall from bed to the floor and sustained a laceration to the right temple. The report indicated that the resident was assessed by the nursing staff, the physician was notified, and the physician ordered the resident transferred to the hospital for an evaluation. Review of the nurse's note, dated 12/25/13, indicated that the resident returned to the facility at 8:00 P.M. with 6 sutures to his/her laceration on right scalp. Review of the investigation conducted on 12/25/13 and 12/26/13 indicated that CNA #1, with the assistance of another CNA, assisted the resident back to bed. In the written statement, CNA #1 wrote that the resident continued to have loose bowel movements after CNA #1 provided personal care to the resident. CNA #1 wrote that CNA #1 required more supplies to complete the resident's personal care. CNA #1 wrote that CNA #1 covered the resident, lowered the bed to the lowest position, pulled up one half side rail on the right side, and left the resident to obtain a wet towel in the bathroom. CNA #1 wrote that as CNA #1 entered the bathroom, CNA #1 heard a loud "thud" and noticed the resident on the floor. CNA #1 wrote that she called for help. CNA #1 was interviewed in person on 2/24/14 at 11:10 A.M.. CNA #1 said she and another CNA assisted the resident back to bed. CNA #1 said the other CNA left the resident's side of room to assist his/her roommate. CNA #1 said as she started to provide personal care to the resident, the resident had continuous bowel movements. CNA #1 said she needed to obtain more supplies to provide personal care to the resident. CNA #1 said she covered the resident who was lying on his/her left side, pulled up the right one half side rail, placed the bed in the lowest position, and left to obtain more supplies. CNA #1 said as she entered the resident's bathroom (approximately 50 feet from the bottom of the resident's bed), she heard a loud noise. CNA #1 said when she turned to see where the noise came from, she saw the resident lying on his/her right side on the floor. CNA #1 said she called for help. CNA #1 said she did not place the floor mat on the floor as indicated in the plan of care before she left the resident lying on his/her left side to obtain more supplies to complete the resident's personal care. CNA #1 was asked how many staff members were required when positioning the resident and providing personal care. CNA #1 said she could provide care to the resident alone; however, she knew that she should have 2 people when changing the resident's position and when providing personal care to the resident. The Director of Nurses (DON) was interviewed in person on 2/24/14 at 11:30 A.M.. The DON said that according to the resident's CNA Flow Sheet and the most recent MDS assessment, the resident required 2 staff members when repositioning the resident. The DON said CNA #1 did not follow the resident's fall prevention plan of care when she failed to place floor mats on the floor on either side of the bed. The DON said CNA #1 was given a written warning and re-educated to have all supplies needed to provide personal care and to follow the plan of care as indicated for each resident. 2. For Resident #18 the facility failed to prevent 4 falls between 9/2012 and 11/2013. Review of Resident #18's medical record indicated that he/she was admitted in 8/2013 with [DIAGNOSES REDACTED]. Review of the resident's fall care plan, dated 9/9/13, included the following interventions to prevent falls: *anticipate needs. *use of bed and chair alarms. *removal of the wheelchair from the room at night. (added on 11/20/13) Review of the resident's Fall Risk Assessment, dated 12/13/13, indicated that the resident was at a high risk for falls. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 12/13/2013, indicated that the resident scored a 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS). This score was indicative of moderate cognitive impairment. In addition, the MDS indicated that the resident required assistance for transfers and ambulation. Review of an incident /falls report, dated 9/12/13, indicated that at 9:30 P.M., the staff heard the resident yell "help" and found the resident slipped from the bed to the floor. The report did not indicate that the resident had a bed and chair alarm on as per plan of care. Review of an incident/falls report, dated 11/12/13, indicated that the resident fell at 7:25 A.M., after having independently transferred from the bed to the wheelchair. The report did not indicate that the resident had a bed and chair alarm on as per plan of care dated 9/9/13. Review of an incident/falls report, dated 11/26/13, indicated that the resident fell in his/her room at 6:50 A.M., while trying to get to the wheelchair in the room. The report did not indicate that the staff followed through with the intervention to remove the resident's wheelchair from the resident's room during the night. The report indicated that the resident's bed and chair alarm was turned off. In an interview with the DON on 2/25/14 at 10:00 A.M., she said that she did not know why the bed and chair alarm was turned off. The report indicated that the resident had no apparent injuries. The facility failed to provide appropriate interventions to prevent falls.

Based on observation, record review and resident and staff interview, the facility failed to follow the medical care plan for 3 sampled residents (#1,#2 and #18) in a total sample of 22 residents. Findings include: 1. For Resident #1, the facility failed to follow the plan of care for the prevention of the resident's fall from bed on 12/25/13 at 2:00 P.M.. Review of Resident #1's clinical record on 2/20/14 indicated that the resident was admitted to the facility in 9/2010 with [DIAGNOSES REDACTED]. Review of resident's plan of care for personal hygiene and repositioning, dated 12/6/13, indicated that the resident required extensive assistance of 2 staff members for repositioning and personal hygiene. Review of the resident's plan of care for the prevention of falls, dated 12/6/13, indicated that the resident was to have bed sensor alarm on while in bed, floor mats on both sides of the bed, and a perimeter mattress. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/12/13, indicated that the resident had highly impaired hearing, sometimes understood what others said, had short and long term memory loss, and had severe cognitive impairment (unable to complete a Brief Interview for Mental Status). The MDS indicated that the resident required the physical assistance of 2 staff members for bed mobility (turning side to side) and toileting (cleansing after elimination), was always incontinent of bowel and bladder, and had no recent falls. Review of the most recent Fall Risk Assessment, dated 12/12/13, indicated that the resident was at high risk for falls with a score of 12. A score of 10 or higher was considered at high risk. Review of the 12/2013 Certified Nurse Aide (CNA) Flow Sheet indicated that the resident required the physical assistance of 2 staff members for toileting and positioning in bed. Review of the Resident Incident/Falls Report, dated 12/25/13 at 2:45 P.M., indicated that the resident had a fall from bed to the floor and sustained a laceration to the right temple. The report indicated that the resident was assessed by the nursing staff, the physician was notified, and the physician ordered the resident transferred to the hospital for an evaluation. Review of the nurse's note, dated 12/25/13 at 8:00 P.M., indicated that the resident returned to the facility at 8:00 P.M. with 6 sutures to his/her laceration on right scalp. Review of the investigation conducted on 12/25/13 and 12/26/13 indicated that CNA #1, with the assistance of another CNA, assisted the resident back to bed. In the written statement, CNA #1 wrote that the resident continued to have loose bowel movements after CNA #1 provided personal care to the resident. CNA #1 wrote that CNA #1 required more supplies to complete the resident's personal care. CNA #1 wrote that CNA #1 covered the resident, lowered the bed to the lowest position, pulled up one half side rail on the right side, and left the resident to obtain a wet towel in the bathroom. CNA #1 wrote that as CNA #1 entered the bathroom, CNA #1 heard a loud "thud" and noticed the resident on the floor. CNA #1 wrote that she called for help. CNA #1 was interviewed in person on 2/24/14 at 11:10 A.M.. CNA #1 said she and another CNA assisted the resident back to bed. CNA #1 said the other CNA left the resident's side of room to assist his/her roommate. CNA #1 said as she started to provide personal care to the resident, the resident had continuous bowel movements. CNA #1 said she needed to obtain more supplies to provide personal care to the resident. CNA #1 said she covered the resident who was lying on his/her left side, pulled up the right one half side rail, placed the bed in the lowest position, and left to obtain more supplies. CNA #1 said as she entered the resident's bathroom (approximately 50 feet from the bottom of the resident's bed), she heard a loud noise. CNA #1 said when she turned to see where the noise came from, she saw the resident lying on his/her right side on the floor. CNA #1 said she called for help. CNA #1 said she did not place the floor mat on the floor as indicated in the plan of care before she left the resident lying on his/her left side to obtain more supplies to complete the resident's personal care. CNA #1 was asked how many staff members were required when positioning the resident and providing personal care. CNA #1 said she could provide care to the resident alone; however, she knew that she should have 2 people when changing the resident's position and when providing personal care to the resident. The Director of Nurses (DON) was interviewed in person on 2/24/14 at 11:30 A.M.. The DON said that according to the resident's CNA Flow Sheet and the most recent MDS assessment, the resident required 2 staff members when repositioning the resident. The DON said CNA #1 did not follow the resident's fall prevention plan of care when she failed to place floor mats on the floor on either side of the bed. The DON said CNA #1 was given a written warning and re-educated to have all supplies needed to provide personal care and to follow the plan of care as indicated for each resident. 2. For Resident #18, the facility failed to implement the plan of care to prevent 4 falls between 9/2012 and 11/2013. On 2/20/14, review of Resident #18's medical record indicated that he/she was admitted in 8/2013 with [DIAGNOSES REDACTED]. Review of the resident's fall care plan, dated 9/9/13, indicated that the resident was at a high risk for falls. The following interventions and approaches were initiated on 9/9/13: * provide necessary assist with transfer, toileting, ambulation and other ADL's (activities of daily living). *anticipate and meet his/her needs when necessary. *use of either a bed and/or chair alarm at all times. *removal of wheelchair from room at night. On 9/12/13, the Fall Report indicated that the resident slipped to the floor and the report did not indicate that he/she had a bed or chair alarm on at the time. In an interview with the Director of Nurses (DON) on 2/25/14 at 10:00 A.M., she said that she was unsure if an alarm sounded. On 10/19/13, the Fall Report indicated that the resident was in the bathroom and the CNA lowered him/her to the floor. The plan of care indicated that the resident required assistance with transfers. In an interview with the DON on 2/25/14 at 10:00 A.M., she said that she did not know if a gait belt was used with the resident during the transfer. The DON confirmed that a gait belt should be used for a resident who requires one assist from staff to transfer. On 11/2/13, the Fall Report indicated that the resident had self transferred from his/her bed to the wheelchair. The report indicated that a bed alarm was to be initiated. (The bed alarm had been initiated on 9/9/13). The report did not indicate that an alarm was sounding at the time of the fall. On 11/12/13, the following interventions were added to the care plan: *remove wheelchair and equipment (unspecified) from the resident's room at night. *have the Certified Nurses Aides (CNA's) check the resident first thing in the morning (unspecified). On 11/26/13, the Fall Report indicated that the resident had self transferred from the bed to the wheelchair and fell . The fall report indicated that the resident's bed and chair alarm was turned off. In addition, the resident's wheelchair was in the room. This was in conflict with the care plan intervention of removing the wheelchair from the resident's room at night. In an interview with the DON on 2/25/14 at 10:00 A.M., she said that she did not know who had turned the alarm off and did not know why the resident's wheelchair was still in the room. 3. For Resident #2 the facility failed to ensure that the resident's legs were elevated as ordered, even though the nurses documented on the February 2014 Treatment Administration Record (TAR) that the resident's legs were elevated. Resident #2 was admitted to the facility in 9/2013 with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment, dated 9/23/13 and the quarterly MDS assessment dated [DATE], indicated that the resident had impaired short term memory and moderately impaired cognitive skills. Review of the physician orders [REDACTED]. Review of the February 2014 TAR indicated that the nursing staff documented on all days and all shifts from 2/1/14 until 2/19/14 that the resident's legs were elevated as ordered. On 2/20/14 at 10:30 A.M., at 1:30 P.M., at 2:15 P.M. and at 2:40 P.M., on 2/21/14 at 8:00 A.M. and at 10:15 A.M and on 2/24/14 at 7:25 A.M., at 9:45 A.M. and at 12:00 P.M., the resident was observed sitting in the hall with his/her legs down and feet touching the floor. It was also observed that the resident's chair did not have foot rests or any built-in device to assist the resident in elevating his/her legs. During interview on 2/24/14 at 12;00 P.M. the Director of Nurses said that the resident's chair was changed to a scoot chair a while back (unsure of the exact date). She further said that after the chair was changed, the staff stopped elevating Resident #2's legs despite the physician order.