Every finding on record at Mission at Richfield Nursing and Rehabilitation

Based on observation, interview, and record review it was determined, for 3 out of 36 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, residents' room doors slammed closed, multiple walls in resident's rooms were in disrepair, and resident's personal belongings were lost with no process put in place to locate or replace them. Resident identifiers: 1, 2 and 4.Findings included:DOORS:On 6/8/26 at 10:15 AM, an interview was conducted with resident 1 who stated the staff always slammed his door closed, even when he asked them not to. Resident 1 stated it was constantly happening and stated loudly, It drives me crazy! Resident 1 stated that the staff had not done anything about it when he had asked and it had been going on since he arrived at the facility in April 2026.On 6/8/26 at 11:00 AM, registered nurse (RN) 1 was observed to enter resident 1's room and close the door. The door slammed shut and resident 1 yelled, Don't slam the damn door!The following observations were made of doors slamming closed at the facility:a. On 6/9/26 at 10:59 AM, 11:20 AM and 11:27 AM, an observation was made of a resident's door in the North hallway slamming closed. Residents were noted to occupy other rooms of the North hallway. b. On 6/10/26 at 9:04 AM and 9:06 AM, an observation was made of a door in the North hallway slamming closed. c. On 6/10/26 at 9:37 AM and 9:39 AM, an observation was made of resident room [ROOM NUMBER] in the [NAME] hallway slamming closed. d. On 6/10/26 at 10:42 AM, an observation was made of a door in the East hallway slamming closed.e. On 6/10/26 at 10:47 AM, an observation was made of resident room [ROOM NUMBER] in the [NAME] hallway slamming closed. f. On 6/11/26 at 9:28 AM, an observation was made of a door in the North hallway slamming closed. WALLS:On 6/8/26 at 10:15 AM, an observation was made of resident 1's room. The south and west walls were observed to have multiple nails placed in the walls in various locations and multiple additional holes in the walls. Resident 1 stated the walls were ugly and they needed to be painted. Resident 1 stated, It would make this place feel better if they would fix them.On 6/8/26 at 11:05 AM, an observation was made of resident 4's room. The west wall was observed to have a large gouge with missing paint and sheetrock above the resident's small refrigerator. The south wall was observed to have numerous areas of scratches and missing paint. PERSONAL BELONGINGS:On 6/8/26 at 10:15 AM, an interview was conducted with resident 1 who stated he was missing some pants. Resident 1 stated the pants were new and still had the tags on them. Resident 1 stated he had asked the staff where they were but no one knew or had found his pants. On 6/8/26 at 12:03 PM, an interview was conducted with resident 2 who stated his Hoka shoes had gone missing. Resident 2 stated that he had told the staff about it but they hadn't done anything to find them. During the interview RN 1 was observed to enter resident 2's room. Resident 2 was observed to tell RN 1 that his Hoka shoes were missing and no one had found them for him. RN 2 was observed to say, That's sad, those are some nice shoes to go missing.On 6/9/26 at 10:01 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1 who stated if the residents said there was something missing then CNAs looked for it in the laundry. CNA 1 stated if they could not find it then they escalated it up the chain of command, but stated we usually find it. CNA 1 did not know if there was a form that needed to be filled out and she would just pass the information on verbally to the other staff at change of shift. Resident 1 has not said anything about any missing pants to me. On 6/9/26 at 10:17 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1 who stated the housekeepers clean and do the laundry for the residents. LPN 1 stated if there is something missing the staff will look for it in the laundry and if they can't find it then they report it to the resident advocate and they would replace it. LPN 1 was unsure if there was a form they filled out for missing items. On 6/9/26 at 10:19 AM, an interview was conducted with the Resident Advocate (RA) who stated the staff would let her know if a resident was missing something and it couldn't be found. The RA stated the staff should fill out a grievance form and get it to me. The RA stated that she had not heard of resident 1 missing any pants or resident 2 missing any shoes. On 6/9/26 at 10:23 AM, an interview was conducted with the Housekeeper (HSK) who stated she cleaned the rooms and also did the resident's laundry. The HSK stated the CNAs let them know if there was any resident missing clothing. The HSK stated they had a lost and found bin in the laundry room. The HSK stated if they could not find it then they let the Maintenance/Housekeeping Manager (MHM) know and then kept a look out for the missing items. The HSK also stated they would look in the resident's closets when they were putting the laundry away. The HSK stated that she did know about some green checkered pants that resident 1 was missing. The HSK stated they had been missing for about a month and they could not find them. The HSK stated she did not fill out a grievance form and that she did not know what happened if they could not find the missing item. On 6/9/26 at 10:40 AM, an interview was conducted with the MHM who stated the staff were supposed to tell him if the residents were missing something. The MHM stated that they would go through and look for the item and if they couldn't find it then they replaced it. The MHM stated he was unsure if they filled out any paperwork for the missing item. The MHM stated he had heard about resident 1 missing some pants, he was told about it yesterday after the staff were made aware of by the survey team.On 6/10/26 at 11:30 AM, an interview was conducted with the Administrator (ADM) who stated they had plans to repaint the facility and make it better. The ADM stated the plan included painting and basically an overhaul of the building. The ADM stated he did not know the doors or paint were bothering the residents and they would do what they could to make it a better environment for the residents. The grievance binder was reviewed for the 2026 year, no grievance forms were located for resident 1's missing pants and resident 2's missing shoes.

Based on record review and interview, it was determined that for 1 out of 36 sampled residents, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions; the facility's discharge planning process must include regular re-evaluation of residents to identify changes that required modification of the discharge plan; the discharge plan must be updated, as needed, to reflect these changes; involve the interdisciplinary team (IDT) in the ongoing process of developing the discharge plan; involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan; address the resident's goals of care and treatment preferences; document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan; the results of the evaluation must be discussed with the resident or resident's representative; and alll relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. Specifically, one resident was discharged without a documented update to their discharge plan. The medical record lacked evidence of collaboration with the resident, their representative, or the Interdisciplinary Team [IDT], and failed to reflect the resident's specific goals and preferences for discharge. Resident identifier: 6.Findings included:Resident 6 was admitted to the facility on [DATE] and discharged on 6/4/26 with diagnoses which included orthostatic hypotension.Resident 6's medical record was reviewed 6/8/26 through 6/11/26.A physician's order dated 6/4/26 at 8:38 AM indicated, May transfer to [inpatient rehabilitation hospital name redacted] on 6/3/26. Orders for PT [physical therapy] and OT [occupational therapy]. Intermittent catheterization. Regular diet.A Nursing Progress Note dated 6/4/26 at 2:07 PM indicated, Resident was discharged from the facility to be transferred to [inpatient rehabilitation hospital name redacted]. He was accompanied by their facility transporter. Transfer face sheet, med [medication] list, and copy of POLST [Physician Orders for Life-Sustaining Treatment] form sent with [name redacted]. Meds were sent home with [name redacted], wife. Nurse to nurse report was given to new facility. Belongings were packed and sent with [Wife's name redacted]. He left facility approx. [approximately] 1330 [1:30 PM].It should be noted that the medical record did not contain the reason for transfer, a detailed explanation of why the facility could not meet the resident's needs, or a post-discharge plan.On 6/10/26 at 1:50 PM, an interview was conducted with the Resident Advocate (RA) who stated she was responsible for discharge planning. The RA stated the discharge plan started when the resident was admitted and that resident 6 did have a discharge plan that indicated the resident and his wife wanted him to go home. The RA stated resident 6 did not travel well due to his blood pressures and that the inpatient rehabilitation hospital had more resources available for him. The RA stated he was discharged during a week when she was not working.On 6/10/26 at 2:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that resident 6 discharged to the inpatient rehabilitation hospital because his insurance had only approved for him to be at the facility through the 21st of May, so he was paying privately, but his insurance would pay for a higher level of care.On 6/10/26 at 2:36 PM a follow-up interview was conducted with the RA who stated resident 6's wife was in daily and that she was sure that the ADON, Director of Nursing (DON), and the Administrator (ADM) had a conversation with the resident and his wife about how he felt about being closer to his medical appointments due to his difficulty with traveling. The RA stated that she would have updated the discharge plan, completed a progress note that indicated the resident and their family were included in the decision to discharge, and that an IDT meeting would usually be completed.On 6/11/26 at 8:24 AM, an interview was conducted with the Director of Rehabilitation (DOR) who stated that resident 6 and his wife were the ones who initially contacted the inpatient rehabilitation hospital to get that going and had worked on that for a couple of weeks. The DOR stated that the RA or IDT would normally document the resident's and family's participation and that rehab did not usually do that.On 6/11/26 at 8:39 AM, an interview was conducted with the DON who stated that the RA was the one who did discharge planning but the ADON helped with resident 6's discharge. The DON stated that they usually did an IDT meeting to plan a resident's discharge and documented the participation of the resident.

Based on record review and interview, it was determined that, for 1 out of 36 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, one resident's care plan was not updated to include revised interventions after he removed his wander guard for a fourth time and eloped. Resident identifier: 13.Findings included: A facility reported incident dated 2/9/26 at 6:56 PM indicated that on 2/9/26 at 5:45 PM Registered Nurse (RN) 3 was unable to locate resident 13 for his evening medications. It indicated Certified Nurse Assistant (CNA) 3 reported being with resident 13 in the dining room until 5:30 PM when he left after he finished dinner. It further indicated that staff began to look for resident 13 and he was found off of the premises at 6:07 PM.Resident 13's medical record was reviewed 6/8/26 through 6/11/26.Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia, type 2 diabetes mellitus, anxiety disorder, muscle weakness, and insomnia.A Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment.A Nursing Progress Note dated 12/28/25 at 6:37 PM indicated, Resident has made multiple attempts to leave the facility grounds. He has set off multiple alarms on the locked doors. On call suggested a wander guard.It will be checked for placement once a shift and then another order for every Sunday to ensure it's working. Resident is continent [sic] with this option as he gets confused and can't remember where he's going and this will help keep him safe. He will be on alert charting for three days.A Nursing Progress Note dated 12/29/25 at 10:49 AM indicated, resident has been placed on alert charting. He had cut his wander guard off this morning when I checked for placement. I educated the patient that this needs to stay on to keep him safe. He agreed and stated he would keep it on. He has not tried to exit the facility today or even ask to walk outside today.The care plan was not updated with revised interventions after this incident.A Nursing Progress Note dated 1/4/26 at 9:02 AM indicated, when nurse checked for his wander guard, it was not on his ankle. nurse found it on his nightstand next to a pair of scissors. replaced the band on his left ankle. scissors were removed from the room.The care plan was not updated with revised interventions after this incident.An Administration Note dated 2/1/26 at 11:46 AM indicated, Check to ensure wander guard is working by taking resident to the door and ensure the alarm turns on one time a day every Sun [Sunday] for wander guard working Wander guard not on either leg. It should be noted that there was no other information found in the medical record regarding the wander guard not found on resident 13's leg.The care plan was not updated with revised interventions after this incident.A Nursing Progress Note dated 2/9/26 at 7:26 PM indicated, At approx [approximately] 1750 [5:50 PM], nurse was delivering HS [hour of sleep] meds [medications] to resident in the dining room, as he was eating dinner in there tonight. Nurse did not see him in the dining room, went to residents bedroom to check there, was not there. nurse immediately notifed [sic] other floorstaff [sic] that he was not in his usual places. All floor staff available began to look for resident, inside and outside. Nurse got in car and began to drive the main street searching for him. [Administrator] notified of possible elopement at 1800 [6:00 PM]. while driving the main street headed south, nurse received a call from another staff nurse at 1801 [6:01 PM] stating that she received a call from a clinic nurse asking if she knew him. It was [resident 13]. Clinic had notified police. police and floor nurse arrived at the same time to the clinic regarding the resident. Police asked nurse to identify resident via name. Nurse loaded resident into personal car and drove him back to the facility, arriving at 1810 [6:10 PM]. assessment done, no injury noted. no wander guard in place. Facility locked down until more wander guards are received.An Administration Note dated 2/10/26 at 4:23 AM indicated, .wander guard was cut off by resident will monitor till get new wanderguard.On 6/9/26 at 1:57 PM, an interview was conducted with Registered Nurse (RN) 3 who stated that resident 13 was assessed when he returned from his elopement on 2/9/26 and that he was not wearing his wander guard. RN 3 stated she found the wander guard in his room and that it had been cut off with some scissors so she removed the scissors and any other items he could have used to cut it off with. RN 3 stated that they immediately locked all of the doors of the facility. RN 3 stated that prior to this elopement, resident 13 would try to elope a couple times a week by exit seeking and attempting to go out the facility doors. RN 3 stated that if a resident was attempting to elope, they would only document it if the attempts to redirect did not change the behavior.On 6/10/26 at 3:01 PM an interview was conducted with the Director of Nursing (DON) who stated that resident 13 had a wander guard ordered and placed after his first elopement on 12/28/25. The DON stated additional interventions that were placed at that time included being put on alert charting that monitored if he was having exit-seeking behaviors and frequent safety checks, which included being checked on every 30 minutes by the nurses and CNAs, but that there was no documentation for that. The DON stated the facility was not locked at that time until after his second elopement on 2/9/26. The DON stated the care plan should have been updated after he was found without his wander guard on.

Based on interview and record review it was determined, for 1 of 36 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident's colostomy care was not provided timely and the resident experienced pain, redness, and tearfulness. Resident identifiers: 48.Findings included:Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included progressive multiple sclerosis, chronic obstructive pulmonary disease, kidney disease stage 4, chronic pain syndrome, edema and functional quadriplegia. On 6/9/26 a facility reported incident dated 11/11/25 was reviewed and documented that resident 48 claimed her colostomy bag failed and she was left sitting in her bodily fluids for an extended amount of time which caused her discomfort. Staff interviews documented the resident did ask staff for assistance with her colostomy care and had to wait 30 minutes for assistance. The staff reported they were in the hallway when resident 48 called for help but they were taking other residents to the dining room when resident 48 requested assistance. The staff reported they did not go back to check on resident 48 until 30 minutes had passed. The staff reported at that time the resident was crying, expressed pain, and redness was observed in her groin and buttock areas. The finding of the investigation into neglect came back inconclusive. The form documented the investigation conclusion as, It is obvious that there was not any intention of abuse, the resident was not forgotten or left for an incredible amount of time. Communication and lack of understanding of priorities led to this incident with positive learning and understanding gained through this experience. A Minimum Data Set (MDS) dated [DATE] documented resident 48 was dependent on staff for her toileting hygiene needs. Resident 48 was documented as having a Brief Interview of Mental Status (BIMS) score of 14 which determined she was cognitively intact. Resident 48's medical record documented in the Special Instructions section, [resident 48] required total 2-person dependence with ADL's [activities of daily living] [resident 48] transfers by lift. She has a colostomy, urostomy and nephrostomy which requires assistance with emptying and changing from staff .A care plan focus revised on 10/31/25 documented resident 48 utilized ostomies including colostomy, urostomy, and nephrostomy. With a goal initiated on 12/9/24 that resident 48 would be/remain free from ostomy related trauma. With interventions which included, monitor, document and report any pain/discomfort due to ostomy. Report to the nurse and/or medical provider and adjust the plan of care as directed. Monitor, document and report s/sx (sign/symptom) of complications due to ostomy: i.e. (in other words) skin breakdown, change in frequency/consistency of stool, odor, etc. Ostomy care every shift. A physician order dated 10/30/25 documented, colostomy care Q [every] shift. Change colostomy wafer and bag Q 3 days and prn [as needed].Resident 48's November 2025 medication administration record (MAR) documented, resident 48's colostomy was not changed on 11/11/25, the day of the incident, but was recorded as being changed on 11/12/25. Progress notes reviewed and no documentation was found in regard to the colostomy incident. Skin checks were completed daily on 11/11/25, 11/12/25 and 11/13/25 and no skin changes were documented. On 6/10/26 at 12:43 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2 who was involved in the incident and CNA 2 stated resident 48 was compliant with most cares and needed assistance with all cares. CNA 2 stated resident 48 was a 2 person extensive assist with a Hoyer lift used for transfers. CNA 2 stated resident 48's colostomy broke and CNA 2 and an unknown CNA called for assistance from Registered Nurse (RN) 2. CNA 2 stated she had worked at the facility for about 6 months so she was still being trained. CNA 2 stated she could not remember the name of the CNA who was training her. CNA 2 stated the unknown CNA decided to change resident 48's colostomy bag. CNA 2 stated the unknown CNA replaced the entire bag, wafer included. CNA 2 stated the CNAs could burp and empty resident 48's colostomy bag when needed, but it was not common for them to change a colostomy. CNA 2 stated resident 48 did not call her while CNA 2 was out in the hallway because CNA 2 was in the room with resident 48 the entire time. On 6/10/26 at 1:38 PM, an interview was conducted with the Regional Administrator Consultant (RAC) who was involved in the investigation. RAC stated resident 48's colostomy tore open. CNA 2 requested help from the nurse and continued to take other residents to the dining room. After about 30 minutes RN 2 did go check on resident 48 and found her crying and expressed pain. The RAC stated they investigated the situation as abuse with the intent to cause harm and not neglect. The RAC stated he could see how the situation could be neglect or more reasonably a delay in care. The RAC stated they did talk to the staff and the staff believed there were other priorities that took precedence over resident 48's needs. The RAC stated education was provided to all of the staff about resident care.On 6/10/26 at 1:40 PM, an interview was conducted with the Administrator (ADM) who stated one of the reasons they did not deem the incident as neglect was based on the fact that resident 48 expressed she did not want to get anyone in trouble. The ADM stated that even though resident 48 yelled out to the nursing staff for assistance she had the call light within reach and she could have pushed the call light. The ADM stated resident 48 stated that she could have pressed her call light after she had requested assistance verbally and the staff would have been reminded to go to her. The ADM stated the redness was gone by the next day when resident 48 was assessed. The ADM stated making the resident wait a long time for care was not appropriate and we watch call lights closely. The ADM stated they did educate the staff on communication and what resident needs took priority. On 6/10/26 at 2:55 PM, an interview was conducted with the Director of Nursing (DON) who stated CNA 2 relayed the information to the oncoming CNA that was why the oncoming CNA went and cared for resident 48. The DON stated that CNAs did not change resident colostomies, only nursing staff did that. The DON stated there was not another CNA in the room with CNA 2 when the incident took place. The DON stated the resident was alert and oriented and could have pressed her call light if she did not get the care that was needed. The DON stated the staff were expected to provide prompt care to all residents. The DON stated they did colostomy care education to all staff.

Based on record review and interview, it was determined that for 2 out of 36 sampled residents, the facility failed to ensure each resident's environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident required an extensive two-person assist with brief changes and a Certified Nursing Assistant changed the resident's brief alone. Additionally, during the brief change the resident rolled out of bed and sustained a laceration and femur fracture. In addition, one resident removed his wander guard for a fourth time and eloped. Resident identifiers: 13 and 46.Findings included:1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, morbid (severe) obesity due to excessive calories, generalized muscle weakness, muscle wasting and atrophy, difficulty in walking, other lack of coordination, and other reduced mobility.A review of the facility's exhibit 358 reported to the State Survey Agency revealed an incident dated 5/8/24, CNA [Certified Nursing Assistant] providing peri [perineal] care when resident rolled herself using her grab bar. The resident rolled out of bed landing on her knees and still holding the grab bar. Staff laid resident down and upon assessment found a laceration to the left knee with apparent adipose tissue exposed. Resident complained of extreme pain to left leg. EMS [Emergency Medical Services] called at 0836 [8:36 AM] and transferred to ER [Emergency Room]. Resident is often a 1 person assist for brief changes.Resident 46's Minimum Data Set (MDS) dated [DATE] revealed that resident 46 was dependent on toileting, dependent on lower body dressing, dependent on personal hygiene, dependent on rolling left and right, dependent on sitting to lying, dependent on lying to sitting, and the resident refused a toilet transfer. Dependent indicated that the helper does all of the effort. The resident does none of the effort to complete the activity or the assistance of 2 or more helpers was required for the resident to complete the activity.Resident 46 had a care plan focus initiated on 6/2/23 with a revision on 6/9/23 which documented that resident 46 had impaired physical mobility. Interventions initiated on 6/2/23 included providing supportive care, assistance with mobility as needed. Document assistance as needed. A care plan focus initiated on 6/2/23 with a revision on 6/9/23 documented that resident 46 was at risk for falls. Interventions included that resident 46 prioritized her safety, independence, and comfort through responsive, proactive support. Staff were to ensure that resident 46's call light was always within reach for prompt assistance and confirm that essential items were accessible before leaving her room. A review of resident 46's progress notes revealed:a. On 4/20/24 at 4:39 PM, a nursing note documented, The resident was very sob [shortness of breath] on Thursday when I was here late. I turned up her O2 [oxygen] to 4 liters and gave her some mucinex.At about 3:30 pm she asked the CNA to get me because she felt like she couldn't catch her breath.The resident weighs 300 pounds and was unable to help with a transfer, she was still in respiratory distress and I did not feel that using the hoyer to lift her would be safe. We tried to roll her in her bed and waited for another CNA to arrive. We decided that the 3 of us were not strong enough to push her on the uneven ground of the parking lot. Dispatch sent an officer to help us but he was also unsure of being about [sic] to get her across the parking lot.b. On 4/23/24 at 12:42 PM, an advanced clinical admission note documented, .Functional : 0 Wheelchair (manual or electric).Able to move all extremities. Upper extremity ROM [range of motion] : No impairment. Lower extremity ROM: No impairment. Gait is unsteady. Balance is poor. Resident prefers self activity. Resident is bedfast all or most of the time. Functional Note: Patient is a 2 person total assist for transfers (with the hoyer), brief changes, upper and lower body dressing; 1 person total assist for putting on footwear, WC [wheelchair] mobility; 1 person setup assist for meals.c. On 5/1/24 at 10:42 PM, a nursing progress note documented, WEEKLY: The resident was readmitted to the facility with RSV [respiratory syncytial virus] and was placed on droplet precautions upon arrival to our facility. The resident also has chronic afib [atrial fibrillation], COPD [chronic obstructive pulmonary disease], HTN [hypertension], HLD [hyperlipidemia], AKF [acute kidney failure] and morbid obesity. She requires two person extensive assist for transferring with the Hoyer lift. She is incontinent of both bowel and bladder. She wears a brief for protection. She is also a two person extensive assist for all brief changes. She requires extensive, one person assist, with all other ADLs [Activities of Daily Living].d. On 5/8/24 at 9:30 AM, a nursing progress note documented, Resident sustained a witnessed fall around 0830 [8:30 AM] this morning. Resident is alert and oriented and at baseline prior to fall. Staff was assisting with a brief change when the resident rolled herself onto her left side using the grab bar. Resident over turned herself and rolled out of bed. resident landed on her knees and was still holding on to the grab bar. Staff yelled for assistance this nurse responded at that time. Cna and Nurse repositioned the resident to a supine position. Nurse noted a laceration to the left knee with adipose tissue exposed. resident complaining of extreme pain to left leg. resident stated she felt like she was going to pass out. Additional nursing staff responded and EMS called to assist. Resident assisted to gurney via hoyer lift and transferred to emergency department. A review of the facility's exhibit 359 revealed that resident 46 prior to the incident was assessed at her baseline, alert and oriented between 7:00 AM and 8:10 AM. At approximately 8:30 AM CNA 3 assisted resident 46 with a brief change but the resident rolled out of bed while using the grab bar and landed on her knees. Responding staff found resident 46 sitting against the bed and heard resident 46 complain of extreme pain and feeling of light headedness. Nursing staff observed a laceration on resident 46 above the left knee with exposed adipose tissue, bruising on both knees and swelling, alongside a pool of blood on the floor. Staff placed resident 46 in a supine position, obtained a physician's order for transfer, and utilized a Hoyer lift to transfer resident 46 to a gurney for EMS transport to the emergency department. Resident 46 was admitted to the hospital with a femur fracture and a laceration.On 6/10/26 at 3:33 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated resident 46's care plan had how she transferred and if resident 46 used grab bars to assist with mobility. The RNC stated that if resident 46 used a Hoyer lift then she would need two people for assistance.On 6/10/26 at 3:51 PM, a follow-up interview was conducted with the RNC. The RNC stated that she was able to get into contact with the previous facility administrator. The previous facility administrator stated that it was the facility policy at the time to not document in resident's care plans what type of assistance was needed for company liability reasons. The RNC stated that she was unable to find any documentation that stated that resident 46 was only a 1 person assist with brief changes. 2. A facility reported incident dated 2/9/26 at 6:56 PM indicated that the facility reported that on 2/9/26 at 5:45 PM Registered Nurse (RN) 3 was unable to locate resident 13 for his evening medications. It indicated Certified Nurse Assistant (CNA) 3 reported being with resident 13 in the dining room until 5:30 PM when he left after he finished dinner. It further indicated that staff began to look for resident 13 and he was found off of the premises at 6:07 PM.Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia, type 2 diabetes mellitus, anxiety disorder, muscle weakness, and insomnia.A Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment.A Nursing Progress Note dated 12/28/25 at 6:37 PM indicated, Resident has made multiple attempts to leave the facility grounds. He has set off multiple alarms on the locked doors. On call suggested a wander guard.It will be checked for placement once a shift and then another order for every Sunday to ensure it's working. Resident is continent [sic] with this option as he gets confused and can't remember where he's going and this will help keep him safe. He will be on alert charting for three days.A Nursing Progress Note dated 12/29/25 at 10:49 AM indicated, resident has been placed on alert charting. He had cut his wander guard off this morning when I checked for placement. I educated the patient that this needs to stay on to keep him safe. He agreed and stated he would keep it on. He has not tried to exit the facility today or even ask to walk outside today.The care plan was not updated with revised interventions after this incident.A Nursing Progress Note dated 1/4/26 at 9:02 AM indicated, when nurse checked for his wander guard, it was not on his ankle. nurse found it on his nightstand next to a pair of scissors. replaced the band on his left ankle. scissors were removed from the room.The care plan was not updated with revised interventions after this incident.An Administration Note dated 2/1/26 at 11:46 AM indicated, Check to ensure wander guard is working by taking resident to the door and ensure the alarm turns on one time a day every Sun [Sunday] for wander guard working Wander guard not on either leg. It should be noted that there was no other information found in the medical record regarding the wander guard not found on resident 13's leg.The care plan was not updated with revised interventions after this incident.A Nursing Progress Note dated 2/9/26 at 7:26 PM indicated, At approx [approximately] 1750 [5:50 PM], nurse was delivering HS [hour of sleep] meds [medications] to resident in the dining room, as he was eating dinner in there tonight. Nurse did not see him in the dining room, went to residents bedroom to check there, was not there. nurse immediately notifed [sic] other floorstaff [sic] that he was not in his usual places. All floor staff available began to look for resident, inside and outside. Nurse got in car and began to drive the main street searching for him. [Administrator] notified of possible elopement at 1800 [6:00 PM]. while driving the main street headed south, nurse received a call from another staff nurse at 1801 [6:01 PM] stating that she received a call from a clinic nurse asking if she knew him. It was [resident 13]. Clinic had notified police. police and floor nurse arrived at the same time to the clinic regarding the resident. Police asked nurse to identify resident via name. Nurse loaded resident into personal car and drove him back to the facility, arriving at 1810 [6:10 PM]. assessment done, no injury noted. no wander guard in place. Facility locked down until more wander guards are received.An Administration Note dated 2/10/26 at 4:23 AM indicated, .wander guard was cut off by resident will monitor till get new wanderguard.On 6/9/26 at 1:57 PM, an interview was conducted with Registered Nurse (RN) 3 who stated that in February, resident 13 had been eating dinner in the dining room that was served at 5:00 PM and that she was giving night medications sometime before 6:00 PM. RN 3 stated when she went to give him his medications in the dining room he was not in there so she went to his room and he was not there either. RN 3 stated she alerted all floor staff, including housekeeping and kitchen staff, to search in-house and all the grounds. RN 3 stated they did not find him so she got in her car and went on the mainstreet to look for him. RN 3 stated that while she was out looking, a health clinic staff member called the facility and asked facility staff if they were missing a resident. RN 3 stated the facility then called her and told her that resident 13 was found at another health clinic so she went there and arrived at the same time a police officer got there. RN 3 stated she had to identify resident 13 and then she was able to bring him back to the facility. RN 3 stated the clinic he was found at was about a block from the facility and that he would have had to cross the main street to get to the clinic. RN 3 stated she assessed him when they returned to the facility and found no wander guard on him. RN 3 stated she found the wander guard in his room and that it had been cut off with some scissors so she removed the scissors and any other items he could have used to cut it off with. RN 3 stated that they immediately locked all of the doors of the facility. RN 3 stated that prior to this elopement, resident 13 would try to elope a couple times a week by exit seeking and attempting to go out the facility doors. RN 3 stated that if a resident was attempting to elope, they would only document it if the attempts to redirect did not change the behavior.On 6/10/26 at 3:01 PM an interview was conducted with the Director of Nursing (DON) who stated that resident 13 had a wander guard ordered and placed after his first elopement on 12/28/25. The DON stated additional interventions that were placed at that time included being put on alert charting that monitored if he was having exit-seeking behaviors and frequent safety checks, which included being checked on every 30 minutes by the nurses and CNAs, but that there was no documentation for that. The DON stated the facility was not locked at that time until after his second elopement on 2/9/26.

Based on observation, interview, and record review, the facility must ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 36 sampled residents, a resident receiving dialysis did not have a physician's order for dialysis and communication notes with the dialysis center were incomplete. In addition, the staff were not monitoring the dialysis fistula for the thrill and bruit and there were no physician orders to monitor the dialysis fistula for the thrill and bruit. Resident identifier: 3.Findings included:Resident 3 was admitted to the facility on [DATE] with diagnoses which included hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease and type 2 diabetes mellitus.On 6/9/26 at 7:16 AM, an interview was conducted with resident 3. Resident 3 stated that she had dialysis on Monday, Wednesday, and Friday. Resident 3 stated that she had a fistula in her right arm.Resident 3's physician orders included: Check fistula right lower arm near wrist for s/s [signs and symptoms] of infection. Every shift for infection related to hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. It should be noted that there was no order for dialysis located in the medical record. The facility's dialysis communication and observation form was reviewed. The form documented SNF (skilled nursing facility) Pre-Dialysis Assessment which contained a box that included areas to document the resident's name, vital signs, cognitive assessment, ADL (activities of daily living) assessment, shunt site type, dressing, and condition, bruit/thrill, a fasting blood sugar, insulin dose given, medications administered in the past 6 hours prior to dialysis, medication changes, lunch or snack provided, time of last meal, and any changes in the resident's condition since the last dialysis treatment. The SNF Post-Dialysis Assessment contained a box that included areas to document the time the resident returned to the community, the date, post-dialysis weight, vital signs, bruit/thrill, dressing assessment, if the resident was seen by the doctor, if labs were drawn, the resident condition upon return from dialysis, and any other comments. It should be noted that both the pre and post dialysis assessments required a nursing signature,A review of resident 3's dialysis communication notes revealed the following: a. On 4/20/26, pre-dialysis assessment was incomplete and did not include medications given prior to dialysis, time of last meal, any changes in the resident's condition, and last weight on the resident. The post-dialysis assessment was incomplete and only included the date and time the resident returned to the facility. There was no documentation of resident 3's vital signs, fistula assessment, and post-dialysis weight.b. On 4/24/26, post-dialysis assessment was blank. There was no assessment completed on resident 3 after dialysis.c. On 4/27/26, post-dialysis assessment was incomplete. There was no assessment for resident 3's fistula site and no post-dialysis weight completed. d. On 5/6/26, post-dialysis assessment was incomplete. There was no assessment completed on resident 3's fistula site and a post-dialysis weight was not completed.e. On 5/11/26, post-dialysis assessment was incomplete. There were no post-dialysis vital signs, fistula assessment, and post-dialysis weight documented.f. On 5/13/26, post-dialysis assessment was incomplete. There were no post-dialysis vital signs, fistula assessment, and post-dialysis weight documented.g. On 5/18/26, pre-dialysis assessment was incomplete and did not include medications given 6 hours prior to dialysis. The post-dialysis assessment was incomplete and did not include post-dialysis vital signs, fistula assessment, and post-dialysis weight.h. On 5/22/26, pre-dialysis assessment was incomplete and did not include medications given 6 hours prior to dialysis. The post-dialysis assessment was incomplete and did not include post-dialysis vital signs and post-dialysis weight.i. On 5/25/26, pre-dialysis assessment was incomplete and did not include medications given 6 hours prior to dialysis. The post-dialysis assessment was blank. There was no assessment on resident 3 after dialysis.j. On 5/27/26, post-dialysis assessment was blank. There was no assessment on resident 3 after dialysis.k. On 6/5/26, post-dialysis assessment did not include post-dialysis vital signs and post-dialysis weight.On 6/10/26 at 9:20 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 3 received dialysis 3 times a week. RN 3 stated that resident 3 had orders to assess the fistula for any signs of infection or redness. RN 3 stated that there was a dialysis form that was filled out by nursing staff before and after dialysis. RN 3 stated that the dialysis form was uploaded into resident 3's chart after it was completed. RN 3 stated that the entire form should be completed to inform nursing staff if there were any changes with resident 3's condition. RN 3 stated that she did not document in a progress note about dialysis and just used the dialysis form that was uploaded into the medical record.On 6/10/26 at 9:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was a dialysis communication assessment sheet that was completed before and after dialysis. The DON stated that the form should be filled out in its entirety unless there was something that was not applicable to resident 3 and then staff should document that this was not applicable and not leave the section blank. The DON stated that staff checked the fistula site for infection and the assessment was not specifically checking for a bruit and thrill. The DON stated there was no documentation on progress notes related to dialysis in resident 3's medical record and the facility just used the dialysis communication forms. The DON stated that she had noticed that dialysis communication notes were not filled out completely and she implemented a Performance Improvement Plan (PIP) with one of the nurses regarding completion of the dialysis communication form on 5/13/26. The DON stated that dialysis communication forms continued to not be up to facility standards and she needed to provide education to the nursing staff.

Based on record review and interview, it was determined that, for 2 out of 36 sampled residents, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Specifically, one resident had a discharge notice and one resident had wound care notes that were not located in the medical record. Resident identifiers: 6 and 25.Findings included:1. Resident 6 was admitted to the facility on [DATE] and discharged on 6/4/26 with diagnoses which included orthostatic hypotension.A Nursing Progress Note dated 6/4/26 at 2:07 PM indicated, Resident was discharged from the facility to be transferred to [inpatient rehabilitation hospital name redacted]. He was accompanied by their facility transporter. Transfer face sheet, med [medication] list, and copy of POLST [Physician Orders for Life-Sustaining Treatment] form sent with [name redacted]. Meds were sent home with [name redacted], wife. Nurse to nurse report was given to new facility. Belongings were packed and sent with [Wife's name redacted]. He left facility approx. [approximately] 1330 [1:30 PM].It should be noted that the medical record did not contain the reason for transfer, a detailed explanation of why the facility could not meet the resident's needs, or a post-discharge plan.On 6/10/26 at 1:50 PM, an interview was conducted with the Resident Advocate (RA) who stated that she would normally fill out a discharge form that included health information on the resident, where they were transferred to, and why, but it was not completed. The RA stated that the resident was given a discharge notice when he was discharged but that it was not in the medical record. It should be noted that the discharge document was not provided when requested from staff.On 6/11/26 at 8:39 AM, an interview was conducted with the Director of Nursing (DON) who stated that the RA usually completed the discharges but she was off and the Assistant Director of Nursing helped with his discharge. The DON stated she would look for the discharge documents that were requested. It should be noted that no supplemental documentation was provided.2. Resident 25 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, chronic respiratory failure, morbid obesity, pulmonary hypertension, congestive heart failure, atrial fibrillation, end stage renal disease, and cirrhosis of liver.A Skin/Wound Note dated 1/20/26 at 11:30 AM indicated, resident has a new wound to right lower [NAME] [sic]. this area has had wounds previously and has discoloration to area d/t [due/to] this. the new wound started as a circle that was open around the edges and intact in the middle. today the middle has become slough. Therewas [sic] also skin breakdown to the area around it with an open area laterally to this wound and scabbing to medial side of wound. there was moderate drainage to middle wound. wound specialist did telehealth and gave orders to culture wound and the update tx [treatment] to ssd [Silver Sulfadiazine] and cover daily.A Nursing Progress Note dated 5/14/26 at 3:36 PM indicated, Met with [resident 25] and his sister for IDT [Interdisciplinary Team] today to discuss wound worsening despite continued tx and new interventions in place as well as receiving out pt [patient] wound care at [name redacted]. Both MD [Medical Doctor] and NP [Nurse Practitioner] are recommending in patient specialty wound care at [name redacted] specialty hospital until wound is stable. [Resident 25] was educated on the importance of treatment and agreed that temporary transfer for inpatient care would be best for his overall health. [Name redacted] Specialty Hospital was contacted and referral was sent.A Skin/Wound Note dated 5/19/26 at 8:53 AM indicated, resident will be discharging to go to a specialty hospital for a few weeks this am [morning], to address his wound to right pannus. dressing changed this am. he has heavy serosanguinous drainage. the wound continues to have adipose fat protruding out. some of this came off when cleansed. the wound continues to decline. there were two large openings beside each other and these have connected to under the skin now. denies any pain to area.It should be noted that resident 25's progress notes indicated he was seen by the wound care specialist from the development of this wound on 1/20/26 until he transferred to another facility on 5/19/26. There were no wound care specialist notes found in the medical record. On 6/11/2026 at 8:59 AM, an interview was conducted with the DON who stated the wound care notes from the wound care specialist should have been in the medical record.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 6 out of 36 sampled residents, hand hygiene was not performed before and after resident contact. Additionally, gloves and gowns were not worn when performing high-contact resident care for a resident with Enhanced Barrier Precautions (EBP). Resident identifiers: 3, 5, 7, 17, 25, and 43. Findings included:On 6/10/26 during morning medication pass the following observations were made:a. At 7:00 AM, Registered Nurse (RN) 4 was observed to pick up a medication cup for resident 5 without performing hand hygiene. RN 4 proceeded to touch multiple items on top of the medication cart and her computer keyboard. RN 4 was observed to touch the inside of the medication cup with an ungloved finger. b. At 7:11 AM, RN 4 was observed to not perform hand hygiene after completing medications for resident 5 and exiting resident 5's room. RN 4 was observed to enter resident 43's room and adjusted his oxygen level on his concentrator. RN 4 was observed to enter the medication area and picked up a medication cup without performing hand hygiene. RN 4 was observed to touch the rim of the medication cup. c. At 7:17 AM, RN 4 was observed to administer medications to resident 43. RN 4 was observed to then turn on the light in resident 43's room to assess his left eye with an ungloved hand. RN 4 was observed to turn the light off and exit the room without performing hand hygiene. d. At 7:18 AM, RN 4 was observed to enter resident 7's room and don gloves without performing hand hygiene. Resident 7 was on Enhanced Barrier Precautions for a tube feed. RN 4 was observed to reattach resident 7's feeding tube and was not wearing a gown. RN 4 was observed to discard the gloves and exit the room. RN 4 was observed getting a 4X4 gauze package and re-enter resident 7's room. RN 4 was observed to don gloves without performing hand hygiene and replace the gauze dressing around resident 7's feeding tube site. RN 4 was not wearing a gown. RN 4 was observed to discard the gloves and exit the room without performing hand hygiene.e. At 7:22 AM, RN 4 was observed to pick up a medication cup and place an ungloved finger inside the medication cup without performing hand hygiene. RN 4 then exited the medication area and proceeded down the hall to the Pyxis machine to retrieve medication for resident 25. RN 4 opened the medication and placed it in the medication cup. RN 4 was observed to perform hand hygiene. RN 4 then entered the day room to obtain water out of the sink and touched multiple surfaces. RN 4 was then observed to enter resident 25's room and poured the medication into resident 25's mouth. RN 4 was observed to exit the room without performing hand hygiene.f.At 7:44 AM, RN 4 was observed to pick up a medication cup and touch multiple surfaces on her computer keyboard and mouse. RN 4 was observed to pick up a cup for water by placing her fingers inside the cup. RN 4 was observed to administer medications to resident 17 and assisted her with drinking from the water cup.g. At 7:49 AM, RN 4 was observed to pick up a medication cup by the rim without performing hand hygiene. RN 4 was observed to take her personal cell phone out of her pocket and touch multiple surfaces on her cell phone. RN 4 was observed to pick up the blood sugar caddy with a facility glucometer inside of it. RN 4 was observed to don gloves without performing hand hygiene. RN 4 was observed to perform a glucose check on resident 3. RN 4 was observed to place the glucometer with blood on the top of it back inside the blood sugar caddy without cleaning the glucometer. RN 4 was observed to discard the gloves and did not perform hand hygiene. h. At 8:00 AM, RN 4 was observed to remove the facility glucometer and wrap it in a sani-cloth. RN 4 stated that there was some blood near where the testing strip was and she had not noticed it until now.On 6/10/26 at 8:01 AM, an interview was conducted with RN 4. RN 4 stated that she performed hand hygiene between every resident and if she touched any resident. RN 4 stated that she should perform hand hygiene before she donned gloves and after she removed them. RN 4 stated that she did not like to perform hand hygiene before donning gloves because her hands were wet and this made putting gloves on difficult. RN 4 stated that she only needed to wear gloves for residents with feeding tubes because she was not changing the residents' brief. RN 4 stated that she would only wear a gown if she was showering or changing the resident.On 6/10/26 at 10:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that nurses should sanitize their hands before and after administering medications to residents. The DON stated that nurses should be performing hand hygiene before and after entering a resident's room. The DON stated that if the nurse was touching multiple surfaces while preparing medications then hand hygiene should be performed. The DON stated that EBP should be worn for a resident with a tube feeding especially if the nurse was changing a dressing. The DON stated that gloves and a gown needed to be worn for EBP residents to protect the resident from getting an infection. The DON stated that glucometers should be sanitized immediately and if there was visible blood on it.

Based on interview and record review it was determined the facility did not ensure that each resident who was given a psychotropic drug had an adequate indication for use of the medication; that psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated; as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the practitioner documented a clinical rationale to extend beyond 14 days with a duration of use for the order. Specifically, for 1 out of 36 sampled residents, the facility did not document a practitioner rationale for continuing a PRN psychotropic medication past 14 days. Resident identifier: 3.Findings included:Resident 3 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and major depressive disorder.Resident 3's physician orders included Lorazepam Oral Tablet 1 MG [milligram] (Lorazepam) Give 1 tablet by mouth every 12 hours as needed for anxiety related to Generalized Anxiety Disorder (F41.1). This medication had a start date of 5/11/26, but no end date, and symptom monitoringOn 6/11/26 at 7:34 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 3 took lorazepam for sadness. RN 2 stated that resident 3 was sad because of her health situation and having to be in a care facility. RN 2 stated that resident 3 did not have any behaviors that she was monitoring. On 6/11/26 at 7:43 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 3 was reviewed in a psychotropic meeting on 4/28/26 and she was to continue her medications as ordered. The ADON stated the original prescriptions of lorazepam had stop dates after 14 days and then they were reordered. The ADON stated that on 5/11/26 the night shift nurse called the medical provider for a new lorazepam prescription and this order did not include a stop date. The ADON stated that the medical provider did not document the rationale to extend the lorazepam or indicate the duration for the PRN order.

Based on interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident that required extensive assistance of two or more persons for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and fractured their right hip. Resident identifier: 34. Findings included: Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Multiple Sclerosis, atrial fibrillation, type 2 diabetes mellitus, mood disorder due to known physiological condition with major depressive like episode, nondisplaced intertrochanteric fracture of right femur, reduced mobility, repeated falls, and chronic pain syndrome. Resident 34's medical record was reviewed on 2/6/24. A care plan Focus initiated on 7/27/17 and revised on 11/12/21, documented [Resident 34] needs assist with ADL [activities of daily living] self-care performance. [Resident 34] has Multiple Sclerosis. The interventions initiated on 10/26/17, included: a. Discuss with resident, family, and Power Of Attorney any concerns related to loss of independence and decline in function. b. Encourage resident to discuss feelings about self-care deficit. c. Encourage resident to participate to the fullest extent possible with each interaction. d. Monitor, document, and report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 34 required extensive assistance of two or more persons for bed mobility, transfers, toilet use, and personal hygiene. The MDS assessment documented that resident 34 had a Brief Interview for Mental Status (BIMS) score of 8. A BIMS score of 8 to 12 would suggest moderately impaired cognition. On 4/19/23 at 5:46 PM, a Nursing Note documented LATE ENTRY Note Text : Weekly Note: Resident has been in bed most of the day. Requires assistance with all ADLs. Can eat and drink with set-up and some coaxing. Takes snacks but often refuses to eat them. 2 person assist for transfers. Dependent on staff to change brief. Skin is intact, redness beneath breasts is resolving. On 5/24/23 at 6:23 PM, a Nursing Note documented Note Text: Weekly NN [Nurses Note]- Resident is alert and oriented to self and place. She ambulates with the use of a wheelchair pushed by staff. She is dependent on staff for bed mobility, showering, dressing, and grooming. Her meals are set up and monitored by staff. She has a fair appetite. On 6/7/23 at 9:50 AM, a Nursing Note documented Note Text : Weekly NN- Resident is alert and oriented to self, otherwise confused. She is able to verbalize her needs and wants. She ambulates by wheelchair pushed by staff. She requires 1 staff extensive assist with bed mobility, brief changes, transfers, showering, dressing and grooming. Her meals are set up and monitored by staff. She has a good appetite. On 6/10/23 at 5:26 AM, a Nursing Note documented Note Text: At approximately 0512 [5:12 AM] hrs [hours] the CNA was in the process of changing the resident's brief and providing peri care, she rolled off the opposite side of the bed and onto the floor. The resident hit her head on the night stand and her back landed on the floor. The CNA then called for the nurse who found the resident on the floor with the CNA holding her head. A through [NAME] [neurological] check of the resident did not identify any noticeable injuries at the time. With the assistance of an additional CNA, the nurse and the attending CNA placed the resident back onto her bed where another complete body check was conducted by the Nurse with the assistance of the CNA. The results were negative in finding any additional wounds. At approximately 0520 [5:20 AM] hrs, a voice mail was left for the resident's sister to call back so she can be informed of the incident. At approximately 0525 [5:25 AM] hrs the [NAME] [sic] [Assistant Director of Nursing] was notified of the incident. The PA [Physician Assistant] was notified via text. Information was passed on to the oncoming Day shift staff. [NAME] checks and checklist was started at the initial [NAME] check. Will continue to monitor for safety. On 6/10/23 at 8:16 AM, a Nursing Note documented Note Text : FALL CHARTING: Resident had a witnessed fall this morning just before the start of my shift. Neuro checks continuing, no change noted from her baseline. Generalized mild pain noted, Tylenol given. No immediate concerns at this time. WCTM [will continue to monitor] closely. On 6/10/23 at 10:58 AM, the Radiology Report documented CT [computed tomography] right hip. IMPRESSION: Fracture of the base of the freater [sic] trochanter, with mild distraction/displacement. No definite fracture line is seen through the intertrochanteric region or femoral neck, though that possibility is not excluded given the diminished bone mineral density. Further evaluation with MRI [Magnetic Resonance Imaging] is suggested. On 6/10/23 at 11:29 AM, a Nursing Note documented Note Text : FRACTURE: This resident started complaining of right hip pain this morning at approximately 0930 [9:30 AM]; I assessed the patient and found that her right hip is swollen and painful to the touch. VS [vital signs]: BP [blood pressure]: 150/90, HR [heart rate]: 96, Spo2 [oxygen saturation]: 91% on RA [room air], RR [respiratory rate]: 22. PA notified, new order received for an XR [x-ray] of the right hip and pelvis. Family notified at 0953 [9:53 AM]. Resident taken over to the hospital and the XR was inconclusive for a fracture, so the MD [Medical Doctor] at the hospital put an order in for a CT scan. CT scan showed the following: 'Fracture of th [sic] base of the grater trochanter, with mild distraction/displacement. No defginite [sic] fracture line is seen through the intratrochanteric [sic] region or femoral neck, though that possibility is not excluded given the diminished done [sic] mineral density. Further evaluation with MRI is suggested' Even though MRI was suggested, there are no staff available today at the hospital to do an MRI. The Dr [doctor] Physician, [name removed], consulted with ortho [orthopedics] and ortho found her fracture to be non-operable and suggested treating her pain and following up with Dr. [name removed] next week. Family was updated with this information, however they were also concerned about her right knee (slightly swollen and abrasions present); Dr. [name removed] put an order in for an xr of the right knee; results still pending. Family updated again. PA updated with all the above information and new order received for Tramadol 50mg [milligrams] PO [by mouth] q6h [every six hours] PRN [as needed] pain. Resident to be returned to facility via staff transportation shortly. On call nursing management also notified. WCTM patient closely. On 6/10/23 at 1:42 PM, a Nursing Note documented Note Text : XR RESULTS RIGHT KNEE: Spoke to Dr. [name removed] in the ER [emergency room ]; he said that there is no fracture to her right knee. Family and patient made aware as well. On 6/10/23 at 1:43 PM, a Nursing Note documented Note Text : NEW INJURIES NOTED POST FALL: In addition to her right hip fracture, a couple other wounds have been noted from her fall that occurred just before day shift started today: 1) right hip edema & right hip fracture (see previous nursing note for details) 2) right knee bruising and edema 3) right knee abrasions: two small abrasion present to the anterior aspect of her knee; . , no need for a bandage at this time. 4) small lump on the right side of her posterior head, but no changes or concerns noted with her neuros. On 6/10/23 at 8:10 PM, a Nursing Note documented Note Text : Resident s/p [status post] fall from this morning. Upon going in to give her PM meds [medications], resident appeared to be in pain. HR and BP elevated. O2 [oxygen] at 80. PRN med given as ordered, prn albuterol neb [nebulizer] given. Residents family is concerned about shunt to R [right] side of head not beingassessed [sic]. SN [Skilled Nurse] called and notified [name removed], resident sent over to ER at 2000 [8:00 PM] to get shunt checked out. Family with resident at the hospital at this time. On 6/11/23 at 1:25 PM, a Nursing Note documented Note Text : Resident arrived back from hospital. CT scan of head came back clear. UA [urinalysis] was done, resident has UTI [urinary tract infection]. Resident given naloxone at the hospital and rocephin via IV [intravenous]. Tolerated well. MD at hospital ordered levaquin 750mg QD [daily] x7D [days]. [Name removed] made aware, waiting call back. Resident resting in bed asleep. VS WNL [within normal limits]. Continue to monitor. On 6/11/23 at 11:54 PM, an Alert Note documented Note Text : WITNESSED FALL - Resident had a WF [witnessed fall] yesterday. She is resing [sic] /sleeping at this time. She was given tylenol for pain. Her bed is at the lowest point and she is being monitored by staff for safety. On 6/14/23 at 7:33 PM, a Nursing Note documented Note Text : WEEKLY: . Pt [Patient] did have a fall and fractured her pelvis. s/s [signs and symptoms] of pain observed due to her hip fracture. Resident is unable to sit up or ambulate due to her fracture and the pain she experiences. On 6/14/23 at 7:39 PM, a Nursing Note documented Note Text : DOCTOR VISIT: Pt visited Dr. [name removed] (ortho) today. The following are the clinic notes and orders from the Dr: 'Weight bearing as tolerated on right low extremity. Pillows in between legs in bed for abduction and external rotation of right leg. Continue with current pain meds. On 2/6/24 at 12:22 PM, an interview was conducted with CNA 1. CNA 1 stated if a resident could help to roll or there was a grab bar on the bed the resident was usually a one person assist. CNA 1 stated if a resident could not roll or the CNA felt like they needed help for safety she would request another CNA to help with a resident brief change. CNA 1 stated that most residents at the facility were a two person assist. CNA 1 stated that she would radio for another CNA if she needed help and unless they were short staffed a CNA would assist. CNA 1 stated that the facility was not short staffed often. CNA 1 stated that resident 34 towards the end of her stay at the facility went from a one person assist to a two person assist. CNA 1 stated that the last two years resident 34 required a two person assist. CNA 1 stated that resident 34 would get up but resident 34 was only able to move her hands and arms. CNA 1 stated that resident 34 was able to transfer her self when she was first admitted to the facility and the last two years resident 34 required more help. CNA 1 stated that resident 34 was a smoker and required supervision. On 2/7/24 at 10:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 34 required full assistance with cares. LPN 1 stated by the time resident 34 left the facility she could not walk at all. LPN 1 stated that resident 34 required two people for a brief change. LPN 1 stated that earlier on there was not a problem with resident 34 rolling in bed and resident 34 had been at the facility for several years. LPN 1 stated if resident 34 rolled out of the bed resident 34 should have had two people assisting with cares. LPN 1 stated that yes resident 34 should of had two people to assist with a brief change. On 2/7/24 at 11:33 AM, an interview was conducted with CNA 2. CNA 2 stated she had worked at the facility since June 2023. CNA 2 stated resident 34 was full cares with ADLs. CNA 2 stated that resident 34 required a brief change and it would depend on how resident 34 was that day if resident 34 required two CNAs. CNA 2 stated if resident 34 was fully aware then one CNA would be able to assist resident 34, if resident 34 was tired then two CNAs were required to assist resident 34. On 2/7/24 at 1:18 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 34 had been at the facility for a very very long time. The DON stated that resident 34 required extensive assist with most ADLs since the DON had been at the facility since June 2021. The DON stated that resident 34 liked to stay in her bed but would go out occasionally to smoke. The DON stated that resident 34 ate most meals in her room and was content and happy. The DON stated that resident 34 had a fall where the CNA went in alone to do a brief change. The DON stated that the CNA thought she was good and when she rolled resident 34 the CNA tried to grab resident 34 but resident 34 fell out of the bed. The DON stated there were no injuries noted from the initial nurse assessment. The DON stated that resident 34 was alert and oriented and neuro checks were started. The DON stated the on coming nurse came into the facility about 10 minutes after resident 34 fell and resident 34 was complaining about her hip. The DON stated an xray was done, resident 34 was shipped out of the facility, and there was a fracture. The DON stated there should have been two CNAs for the brief change with resident 34 and the incident should have been reported to the State Survey Agency. On 2/7/24 at 2:55 PM, a telephone interview was conducted with LPN 2. LPN 2 stated that he was at the main nurses station in the center of the facility with another CNA the evening of the incident. LPN 2 stated that the CNA that was helping resident 34 came out to the hallway and yelled that resident 34 just fell on the floor. LPN 2 stated when he entered resident 34's room the bed was at a pretty high level and resident 34 had fallen between the bed and the window. LPN 2 stated that he did an assessment and neuro checks were immediately started. LPN 2 stated if he remembered right resident 34 had a bump on her head and maybe a scrape on her knee. LPN 2 stated that resident 34 told him that she was hurting but LPN 2 figured it was from the fall and there was nothing out of the ordinary. LPN 2 stated that resident 34's legs at the time were at the same length. LPN 2 stated he brought resident 34's bed down to the lowest position and with the CNAs they got resident 34 back in bed. LPN 2 stated the CNA was changing resident 34 and stated to him that she had done it that way for years. LPN 2 stated the CNA had resident 34 laying on her side on the far end of the bed from the CNA and the CNA was doing a bed strip. LPN 2 stated the CNA was positioned on the left side of the bed opposite of resident 34 and resident 34 was on the right side of the bed. LPN 2 stated when resident 34 started to fall the CNA tried to grab resident 34's gown but resident 34 fell off the bed. LPN 2 stated oh yes the CNA should of had two staff in the room to assist. LPN 2 stated resident 34 was not obese but resident 34 was not that mobile and required a Hoyer lift to move to the wheelchair. LPN 2 stated that resident 34 required two people and the CNA at the time knew that. LPN 2 stated the CNA worked agency and since the incident she had not been back to the facility.

Based on interview and record review, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 2 out of 18 sampled residents, residents were treated with an antibiotic for a Urinary Tract Infection (UTI) without verifying that the antibiotic used was susceptible to the microorganism identified. Resident identifiers: 2 and 10. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease, urinary tract infection, and history of methicillin resistant staphylococcus aureus infection. Resident 2's Medical Record was reviewed on 2/6/24. On 6/5/23, a nursing note documented, Resident is c/o [complained of] of burning upon urination and her stomach hurting all day. She requested a UA [urinalysis] to be done. On 6/6/23, a physician's order documented, UA with culture and sensitivity if indicated. On 6/6/23, a nursing note documented, UA positive for UTI start Bactrim DS [double strength] BID [twice a day] x 3 days. On 6/6/23, a physician's order documented, Bactrim give 1 tablet by mouth two times a day for UTI for 3 days. [Note: A culture and sensitivity were not located in the medical record.] On 6/6/23, resident 2's UA documented the following out of range values: [NAME] Blood Cells (WBC) greater (>) than 30, Red Blood Cells (RBC) > 30, Epithelial Cells 2. On 6/20/23, a physician's order documented, UA with culture and sensitivity if indicated, one time only until 6/21/23. On 6/20/23, resident 2's UA documented the following out of range values: WBC greater > 30, RBC 10, Epithelial Cells 4. The UA documented a Urine Culture was ordered. A document titled clinical laboratory requisition documented UA with microbiology, culture and sensitivity if indicated. Greater than 5 WBC less than 6 epithelial. On 6/26/23, a nursing note documented, clinic called and stated that residents culture came back from ua and positive for UTI. Pa [Physician Assistant] . ordered Macrobid 100mg [milligrams] bid x7 days. On 6/26/23, a physician's order documented, macrobid oral capsule 100 mg, give 1 capsule by mouth two times a day for UTI for 7 days. [Note: A culture and sensitivity were not located in the medical record.] 2. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and urinary incontinence. Resident 10's Medical Record was reviewed on 2/6/24. On 4/12/23, a nursing note documented, The MD [Medical Director] rounded on this patient today. The patient c/o burning when she urinates. UA drawn last week, MD reviewed sensitivity and he started this patient on Macrobid for a UTI. No other changes made. On 4/12/23, a physician's order documented, Macrobid Oral capsule 100 MG capsule, give 1 capsule by mouth two times a day for UTI for 7 days. On 4/13/23, a nursing note documented, The resident is on macrobid for a UTI. She did receive her first dose this pm. She has had frequency and burning with urination. She has had no s/s [signs and symptoms] of adverse reaction to her medication this pm. On 4/18/23, a physician's order documented, Bactrim Oral tablet 800-160 MG, Give 1 tablet by mouth two times a day related to urinary tract infection . [Note: UA results and a culture and sensitivity were not located in the medical record.] On 2/7/24 at 10:12 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when a resident had a suspected UTI, the nurses would contact the doctor and ask for a UA. RN 1 stated that the doctor had a protocol for if a culture was indicated after a UA was completed. RN 1 stated that the protocol included if the white blood cells on a UA were greater than 5 and or the epithelial cells were less then 6, then a culture was indicated. On 2/7/24 at 10:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident was suspected of a UTI, the staff would notify the MD to get an order for a UA. The DON stated the lab order would go to the MD then a culture and sensitivity would be done if applicable. On 2/7/24 at 1:32 PM, a second interview was conducted with the DON. The DON stated that a resident placed on an antibiotic with out a culture and sensitivity would make it hard to tell if it was the correct antibiotic. The DON stated that a culture and sensitivity were applicable for resident 2 and resident 10 with the UA lab results. The DON stated that she looked for the culture and sensitivity for the residents and they were not located in their chart. The DON contacted the lab that was used and the culture and sensitivities were not located at the lab.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 18 sampled residents, notification to the SSA and APS were not done when a resident that required extensive assistance of two or more persons for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and fractured their right hip. In addition, a resident that had a fall in the bathroom and fractured the tip of their scapula was not reported to the SSA and APS. Resident identifiers: 24 and 34. Findings included: 1. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Multiple Sclerosis, atrial fibrillation, type 2 diabetes mellitus, mood disorder due to known physiological condition with major depressive like episode, nondisplaced intertrochanteric fracture of right femur, reduced mobility, repeated falls, and chronic pain syndrome. Resident 34's medical record was reviewed on 2/6/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 34 required extensive assistance of two or more persons for bed mobility, transfers, toilet use, and personal hygiene. The MDS assessment documented that resident 34 had a Brief Interview for Mental Status (BIMS) score of 8. A BIMS score of 8 to 12 would suggest moderately impaired cognition. On 6/10/23 at 5:26 AM, a Nursing Note documented Note Text: At approximately 0512 [5:12 AM] hrs [hours] the CNA was in the process of changing the resident's brief and providing peri care, she rolled off the opposite side of the bed and onto the floor. The resident hit her head on the night stand and her back landed on the floor. The CNA then called for the nurse who found the resident on the floor with the CNA holding her head. A through [NAME] [neurological] check of the resident did not identify any noticeable injuries at the time. With the assistance of an additional CNA, the nurse and the attending CNA placed the resident back onto her bed where another complete body check was conducted by the Nurse with the assistance of the CNA. The results were negative in finding any additional wounds. At approximately 0520 [5:20 AM] hrs, a voice mail was left for the resident's sister to call back so she can be informed of the incident. At approximately 0525 [5:25 AM] hrs the [NAME] [sic] [Assistant Director of Nursing] was notified of the incident. The PA [Physician Assistant] was notified via text. Information was passed on to the oncoming Day shift staff. [NAME] checks and checklist was started at the initial [NAME] check. Will continue to monitor for safety. On 6/10/23 at 11:29 AM, a Nursing Note documented Note Text : FRACTURE: This resident started complaining of right hip pain this morning at approximately 0930 [9:30 AM]; I assessed the patient and found that her right hip is swollen and painful to the touch. VS [vital signs]: BP [blood pressure]: 150/90, HR [heart rate]: 96, Spo2 [oxygen saturation]: 91% on RA [room air], RR [respiratory rate]: 22. PA notified, new order received for an XR [x-ray] of the right hip and pelvis. Family notified at 0953 [9:53 AM]. Resident taken over to the hospital and the XR was inconclusive for a fracture, so the MD [Medical Doctor] at the hospital put an order in for a CT [computed tomography] scan. CT scan showed the following: 'Fracture of th [sic] base of the grater trochanter, with mild distraction/displacement. No defginite [sic] fracture line is seen through the intratrochanteric [sic] region or femoral neck, though that possibility is not excluded given the diminished done [sic] mineral density. Further evaluation with MRI [Magnetic Resonance Imaging] is suggested' Even though MRI was suggested, there are no staff available today at the hospital to do an MRI. The Dr [doctor] Physician, [name removed], consulted with ortho [orthopedics] and ortho found her fracture to be non-operable and suggested treating her pain and following up with Dr. [name removed] next week. Family was updated with this information, however they were also concerned about her right knee (slightly swollen and abrasions present); Dr. [name removed] put an order in for an xr of the right knee; results still pending. Family updated again. PA updated with all the above information and new order received for Tramadol 50mg [milligrams] PO [by mouth] q6h [every six hours] PRN [as needed] pain. Resident to be returned to facility via staff transportation shortly. On call nursing management also notified. WCTM [will continue to monitor] patient closely. On 6/10/23 at 1:43 PM, a Nursing Note documented Note Text : NEW INJURIES NOTED POST FALL: In addition to her right hip fracture, a couple other wounds have been noted from her fall that occurred just before day shift started today: 1) right hip edema & right hip fracture (see previous nursing note for details) 2) right knee bruising and edema 3) right knee abrasions: two small abrasion present to the anterior aspect of her knee; . , no need for a bandage at this time. 4) small lump on the right side of her posterior head, but no changes or concerns noted with her neuros [neurological]. On 2/7/24 at 1:18 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 34 had been at the facility for a very very long time. The DON stated that resident 34 required extensive assist with most activities of daily living (ADLs) since the DON had been at the facility since June 2021. The DON stated that resident 34 liked to stay in her bed but would go out occasionally to smoke. The DON stated that resident 34 ate most meals in her room and was content and happy. The DON stated that resident 34 had a fall where the CNA went in alone to do a brief change. The DON stated that the CNA thought she was good and when she rolled resident 34 the CNA tried to grab resident 34 but resident 34 fell out of the bed. The DON stated there were no injuries noted from the initial nurse assessment. The DON stated that resident 34 was alert and oriented and neuro checks were started. The DON stated the on coming nurse came into the facility about 10 minutes after resident 34 fell and resident 34 was complaining about her hip. The DON stated an xray was done, resident 34 was shipped out of the facility, and there was a fracture. The DON stated there should have been two CNAs for the brief change with resident 34 and the incident should have been reported to the SSA. 2. Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, chronic obstructive pulmonary disease, chronic kidney disease stage 3A, anxiety disorder, fracture of unspecified part of scapula left shoulder, displaced fracture of second cervical vertebra, reduced mobility, history of falling, and major depressive disorder. Resident 24's medical record was reviewed on 2/6/24. An annual MDS assessment dated [DATE], documented that resident 24 did not have a BIMS score completed due to resident 24 rarely or never understood. On 12/28/23 at 8:28 AM, a Nursing Note documented Note Text: Resident observed sitting on the right side of her toilet with her right arm against the wall on her right side. This nurse transferred resident onto the toilet correctly. CNA notified that resident was on the toilet and would need assistance with toileting. On 12/28/23 at 8:50 AM, a Nursing Note documented Note Text: Upon CNA interview, it was noted by CNA's that they attempted to toilet resident around 0730 [7:30 AM]. CNA states that the resident was resistive to cares and became verbally aggressive. CNA states they left the room to let the resident calm down. The CNA reports the resident was laying in her bed at that time. On 12/28/23 at 8:56 AM, a Nursing Note documented Note Text: Dr [name removed] notified regarding residents incident and left shoulder hurting. Dr [name removed] ordered an Xray of her left shoulder. On 12/28/23 at 3:13 PM, a Nursing Note documented Note Text: X-ray results received. Results state 'suspected fracture of the inferior tip of the scapula.' Dr. [name removed] was contacted at 1451 [2:51 PM]. He states there isn't anything surgical they can do to repair this fracture. He states to use tylenol and ice to treat pain. Nursing to implement frequent toileting. On 12/29/23 at 7:31 AM, a Nursing Note documented Note Text: ALERT CHARTING: Resident had a fall yesterday; it was reported to me that she broke her left scapula; patient appears to be in no pain; no report of pain to me this morning. Neuro's continuing; no concerns at this time. Will continue with current POC [plan of care]. On 12/29/23 at 7:43 AM, a Physician/Practitioner Note documented Note Text: I received a call from the nursing staff, that the patient sustained a ground-level fall yesterday morning on 12/28/23, when the patient was going to the bathroom, hit herself on the ground, not LOC [loss of consciousness] or apparent major injury, however, she was complaining of shoulder pain The staff assisted to get back to her room, but raised the concern of apparent injury as she has had previous fractures fracture of scapula An x-ray of the shoulder - scapula was ordered, and I was notified that there was a fracture on the tip of the scapula Staff reported that pain was manageable since there is no surgical indication but conservative treatment; I asked the staff to notify her family, apply ice packs and conservative treatment, including Tylenol, and assist with her ADLs. Due to her advanced age, other medications such as opioids and NSAIDs [Non-steroidal anti-inflammatory drugs] may be more harmful than beneficial, especially as staff reports that her symptoms are under control. On 2/7/24 at 10:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she found resident 24 between the toilet and the wall. LPN 1 stated resident 24 must have sat down between the toilet and the wall. LPN 1 stated that resident 24 could possibly get herself to the bathroom but resident 24 required assistance. LPN 1 stated that she could not say either way if the CNA assisted resident 24 to the bathroom. LPN 1 stated it did not take much to break things at resident 24's age. On 2/7/24 at 11:31 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 24 required brief changes. CNA 2 stated that resident 24 was incontinent and would tell staff she did not need to be changed. CNA 2 stated that she would let resident 24 calm down and would go back in the room and try again. CNA 2 stated that resident 24 could ambulate to the bathroom but the staff kept an eye on resident 24 as she was ambulating. CNA 2 stated that she heard about the incident in the bathroom with resident 24 but CNA 2 was not sure how resident 24 got to the bathroom. On 2/7/24 at 1:12 PM, an interview was conducted with the DON. The DON stated that resident 24 was complaining of shoulder pain and the staff got an xray. The DON stated that she had interviewed the CNA staff and through interview they had checked on resident 24 and resident 24 had been verbally aggressive and refusing cares. The DON stated that resident 24 was left in her bed safely to calm down. The DON stated that resident 24 was found in the bathroom. The DON stated when resident 24's injury was noticed the DON notified the previous Administrator and the Administrator notified his boss the Regional Director of Operations. The DON stated they were given the flow chart for reporting. The DON stated with the investigation it was discovered the CNAs had been checking on resident 24 and had attempted cares. The DON stated resident 24 told her that she got herself to the restroom. The DON stated the previous Administrator and Regional Director of Operations decided that the incident was not reportable to the SSA.

Based on observation, interview and record review it was determined, for 1 of 22 sample residents, that the facility did not provide each resident with reasonable accommodation of resident needs and preferences. Specifically, a resident's foot board was removed because he was taller than the bed and the resident's feet hung over then bed. Resident identifier: 41. Findings include: Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/13/22 at 3:11 PM, an interview was conducted with resident 41. Resident 41 stated his bed was comfortable but his feet hang off and it was the biggest bed the facility had. Resident 41 stated that the staff removed the foot board so his feet did not press against it. On 6/15/22 at 8:51 AM, a follow up interview was conducted with resident 41. Resident 41 stated the facility was unable to find a bed big enough for him so the foot board was removed. Resident 41 stated he was discharge home tomorrow and was excited about his king sized mattress. Resident 41 stated his bed reminded him of his old freight liner bed. Resident 41's medical record was reviewed on 6/15/22. Resident 41's History and physical dated 5/27/22 revealed the resident was 531 pounds. Resident 41's height was on 5/27/22 was 79 inches. On 6/15/22 at 8:25 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 41's foot board was removed from his bed because he was 6 foot 7 inches tall. RN 1 stated the Central Supply Staff Member ordered beds and medical equipment. RN 1 stated she did not know why resident 41 did not have a longer bed. On 6/15/22 at 8:28 AM, an interview was conducted with the Wound Specialist (WS). The WS stated resident 41 was tall and complained of sliding in bed. The WS stated that resident 41 complained the foot board bothered him at night. The WS stated he was 79 inches and her dad was at the facility and he was 6 foot 6 inches and he fit in the beds. On 6/15/22 at 8:30 AM, an interview was conducted with the Central Supply Staff Member. The Central Supply Staff Member stated she rented beds and the only beds she was able to rent were bariatric beds which was what resident 41 had. The Central Supply Staff Member stated she was usually able to get equipment the next day. The Central Supply Staff Member stated that the Maintenance Director thought the facility had an extended bed but she was not sure if resident 41 had it. The Central Supply Staff Member stated the Administrator removed the foot board from the bed and resident 41 was fine with that. The Central Supply Staff Member stated resident 41 told staff the removal of the foot board made all the difference in the world. The Central Supply Staff Member stated the facility was going to rent a bed for resident 41 but did not end up renting one. On 6/15/22 at 8:38 AM, an interview was conducted with Clinical Resource Nurse (CRN). The CRN stated the longest beds made were 6 foot 4 inches long. The CRN stated there was an XX long with an extender for the bed to be 80 inches. On 6/15/22 are 8:29 AM, an interview was conducted with the Administrator. The Administrator stated that resident 41 was very tall and she went to the facility over the weekend to removed the foot board because his feet pressed against it. The Administrator stated there was not a bed long enough bed for resident 41 at the facility. The Administrator stated that she offered to rent one but resident 41 seamed happy with the footboard off. The Administrator stated maybe the facility needed some extra long beds just incase.

Based on observation and interview it was determined, for 5 of 22 sample residents, that the facility did not ensure each resident had the right to a dignified existence. The facility did not treat each resident with dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident's pants were observed to fall below his buttock, exposing his buttock to four female residents. Resident identifiers: 17, 27, 30, 34 and 37. Findings include: Resident 34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/13/22 at 12:35 PM, an observation was made of resident 34. Resident 34 was in the dining room of the secured unit ambulating with his zipper down on his shorts. Resident 34 was observed to wheel the meal cart from outside the dining room to inside the dining room. Resident 34 was observed to open the meal cart and his shorts were observed to fall below his buttock. Resident 27, resident 37, resident 30 and resident 17 were observed to be sitting behind resident 34 when his buttock was exposed. Licensed Practical Nurse (LPN) 1 was observed to tell resident 34 thank you and staff would serve him food. Resident 34 was observed to pull up his pants and hold onto his pants while he walked to his table. Resident 34's medical record was reviewed on 6/14/22. A skin and weight progress note dated 6/8/22 revealed he had a weight loss of 3% which was desired since his Body Mass Index was 39. On 6/15/22 at 9:02 AM, an interview was conducted with LPN 1. LPN 1 stated resident 34 had trouble dressing himself. LPN 1 stated that morning he came out with his pants upside down and backwards on 1 leg. LPN 1 stated he allowed staff to help him adjust his shorts. LPN 1 stated she saw resident 34's pants fall down on 6/13/22. LPN 1 stated he had a couple pairs of cargo shorts that were big and fell down. LPN 1 stated he had a few shorts replaced with sports shorts that did not fall down but he still had the navy blue colored cargo shorts that fell down. LPN 1 stated resident 34 did not want staff to mess with his clothing. LPN 1 stated one pair of resident 34's shorts that were to big did not come back from laundry and were replaced. LPN 1 stated resident 34's buttock being exposed was definitely a dignity thing. LPN 1 stated resident 34 did not understand that his buttock was exposed to other residents. On 6/15/22 at 9:36 AM, an interview was conducted with the Wound Specialist (WS). The WS stated she had not noticed or been notified that resident 34's shorts had fallen down. The WS stated if she had been notified she would have gone through resident 34's clothing and made sure they fit. The WS stated resident 34 had money to buy new shorts in his personal funds account. On 6/15/22 at 9:42 AM, an interview was conducted with the Central Supply Staff member. The Central Supply Staff Member stated resident 34 received new shoes yesterday and wore them and walked around. The Central Supply Staff Member stated resident 34 was happy with his new shoes. On 6/15/22 at 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 34 changed his clothing multiple times per day. The DON started some of resident 34's shorts were to big for him but he was particular about how staff handled his clothing. The DON stated resident 34 had shorts that fit him. The DON stated if she knew resident 34's shorts had fallen down she would have definitely been looking at getting him smaller shorts.

Based on observation, interview, and record review it was determined, for 2 of 22 sample residents, that the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident that was determined to be at risk for developing a pressure ulcer did not have interventions in place to prevent pressure ulcers from developing. The resident developed pressure ulcers that enlarged and one became infected. In addition, another resident's wound was enlarging in size and was not offered to be turned and repositioned. The resident's admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Resident 45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/6/20 at 11:40 AM, resident 45 was observed sitting in a wheel chair with bilateral heel protectors. Resident 45's medical record was reviewed on 1/8/20. A Braden Scale for Predicting Pressure Sore Risk dated 9/10/19, documented that resident 45 was at risk for pressure sores with a score of 18. [Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.] A Care Plan focus initiated on 9/10/19, documented [Resident 45] has potential for impairment to skin integrity. The goal developed was [Resident 45] will maintain or develop clean and intact skin by the review date. The following interventions were developed: a. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. b. Educate resident 45, family, and caregivers of causative factors and measures to prevent skin injury. c. Encourage good nutrition and hydration in order to promote healthier skin. d. Identify and document potential causative factors and eliminate and resolve where possible. e. Keep skin clean and dry. Use lotion on dry skin. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 45 was at risk of developing pressure ulcers. The MDS further documented that resident 45 had a pressure reducing device for chair and bed. The Care Area Assessment section of the MDS documented that Pressure Ulcer was a triggered care area and was addressed in the care plan. [Note: The skin integrity care plan initiated for resident 45 did not include interventions to prevent pressure ulcers including the pressure reducing device for the chair and bed.] Additionally, resident 45 was documented as having a Brief Mental Interview Status (BIMS) score of 3. [Note: A resident that was severely impaired cognitively would have a BIMS score of 00 to 07.] Resident 45 was also documented as requiring extensive one person physical assistance with bed mobility and transfer. [Note: Bed mobility was defined as how a resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture.] A Nutritional Screen dated 9/13/19 at 3:22 PM, documented that resident 45 was at Normal nutritional status. [Note: A Nutritional Evaluation calculating resident 45's nutritional needs including calories and protein was unable to be located in the medical record.] A Nursing Progress Note dated 12/2/19 at 3:05 PM, documented Resident has a blister on each heel. New order to keep heels floated while in bed. Apply skin prep to heels BID (two times daily). A Nursing Progress Note dated 12/3/19 at 10:42 AM, documented Resident is alert and oriented to self only. she has been spending most of her time in bed over the last few weeks. she will sleep most of the day and can be difficult to arouse. A Nutrition/Dietary Progress Note dated 12/3/19 at 11:11 AM, documented Resident with BMI (body mass index) of 28.4, overweight. Current weight of 150.2# (pounds). Resident is on a regular diet, mechanical soft texture, thin liquids, small portions. PO (by mouth) intake is 50-75% of meals. Resident has blisters to left heel and right medial malleolus. Recommend adding vitamin C and multivitamin/mineral to aid in skin integrity at this time. Will continue to observe. A Nutrition/Dietary Progress Note dated 12/3/19 at 1:58 PM, documented New order obtained for MVI (multivitamin) with minerals one po QD (every day), Vit (vitamin) C 500 mg (milligrams) po BID. CBC (complete blood count) CMP (complete metabolic panel) scheduled 12/16/19. Will also add to weekly weight monitoring. A Nursing Progress Note dated 12/3/19 at 2:00 PM, documented New order to increase Skin Prep to Bilat (bilateral) Heels from BID to QID (four times daily). A Nursing Skin and Nutrition Review dated 12/3/19 at 3:30 PM, documented that for the last 7 days [Resident 45] had an ER (emergency room ) visit dt (due to) lethargy. diagnosed with [CONDITION(S)] and [CONDITION(S)] (urinary tract infection). New orders for O2 (oxygen) to keep sats (saturations) > (greater than) 90%. Antibiotic ordered. MD (Medical Doctor) later dc'd (discontinued) abx (antibiotic) dt no active [CONDITION(S)] noted on UA (urinalysis). Bilat heel blisters noted. Skin Prep and vitamin supplements ordered. A Braden Scale for Predicting Pressure Sore Risk dated 12/3/19, documented that resident 45 was at risk for pressure sores with a score of 16. [Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.] A Care Plan focus initiated on 12/3/19, documented [Resident 45] has a pressure ulcer (R (right) heel). Additionally, a Care Plan focus initiated on 12/3/19, documented [Resident 45] has a pressure ulcer (L (left) heel). The following interventions were developed for both of the initiated Care Plan focuses: a. Administer medications as ordered. Monitor and document for side effects and effectiveness. b. Administer treatments as ordered and monitor for effectiveness. c. Assess, record, and monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. d. Follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] e. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. A Nursing Progress Note dated 12/9/19 at 4:08 PM, documented WCC (wound care consultant) Wound nurse in to see resident today and to assess the wounds on both heels. Resident was in bed with heels floating. WCC stated that one of the wounds is miss classified and should be staged as a deep tissue injury rather than a blister. Floor nurse informed and will update the change in classification during her documentation. SW (Social Worker) bought some soft slippers for resident to wear while she is up in her wheelchair to keep her shoes from adding pressure and causing pain, but the slippers are too small and are being taken back for a larger pair. A Nutritional Screen dated 12/10/19 at 9:05 AM, documented that resident 45 was at Normal nutritional status. [Note: On 12/2/19, resident 45 had developed blisters on bilateral heels. On 12/10/19, resident 45's right medial malleolus blister was reclassified as a right heel pressure deep tissue injury. Resident 45's Weight Summary was reviewed. On 12/3/19, a weight of 154.2# was recorded. On 12/10/19, a weight of 146.8# was recorded. Resident 45 had a 4.80% weight loss in one week. A Nutritional Evaluation calculating resident 45's nutritional needs including calories and protein was unable to be located in the medical record.] A MD visit note dated 12/11/19, was reviewed. [Note: The MD did not document in the visit note that resident 45 had pressure ulcers to both heels. The MD did not document any treatment orders implemented for resident 45's pressure ulcers.] A Braden Scale for Predicting Pressure Sore Risk dated 12/13/19, documented that resident 45 was at risk for pressure sores with a score of 16. [Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.] A Nursing Progress Note dated 12/24/19 at 10:44 AM, documented [Resident 45] has deep tissue injuries to bilat feet. Her recent labs show [MEDICATION(S)] is normal. Her weight is stable. 0.41% gain this week. RD (Registered Dietitian) recommends Zinc 220 mg po QD times 14 days. Order obtained. A Nursing Progress Note dated 12/25/19 at 4:44 PM, documented Resident is alert with confusion. She c/o (complains of) pain to bilat heels. She receives extensive assist with adls (activities of daily living). A Nursing Progress Note dated 12/31/19 at 4:46 PM, documented Resident is alert with confusion. Nurse noted that wounds to heels are smaller but the right heel has purulent drainage noted from it. Area is tender to touch. MD notified of the drainage to the wounds. [MEDICATION(S)] 300 mg tid (three times daily) times 7 days ordered. Skin prep applied to heels with dry dressing to cover. Son notified of infection. Resident receives extensive assist with adls and transfers. She takes her meals with set-up assist. Her appetite is fair. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note dated 1/1/20 at 4:45 AM, documented Resident had c/o pain when right heel wound was touched at dressing change. Purulent drainage and foul odor noted. Resident kept rubbing her feet on each other, then dressings were noted to be off. She was encouraged to leave the dressings to both heels alone. Abx therapy ongoing. Will continue to monitor. A Nursing Progress Note dated 1/1/20 at 9:58 AM, documented Infection note: resident is on abx therapy for wounds on heels. the (sic) is slight purulent drainage that is foul smelling to right heel. dark callusing present. left heel is not draining at this time and has the dark callusing. fluids encouraged. heels floated. A Nursing Progress Note dated 1/2/20 at 9:18 AM, documented Infection note: Resident has dark callusing to bilateral heels. right heel has some slight purulent drainage. it has a foul odor. abx admin (administered) as ordered. dressing done as ordered. heels floated. A Care Plan focus initiated on 1/2/20, documented [Resident 45] has an infection to deep tissue injury on right heel. The goal initiated was [Resident 45] will be free from complications related to infection through the review date. The following interventions were developed: a. Administer antibiotic as per MD orders. b. Maintain universal precautions when providing resident care. c. Monitor, document, and report to MD signs and symptoms of [CONDITION(S)]. d. Podiatry consult. e. Treatment per order. Monitor often and notify MD if no improvement. A Nursing Progress Note dated 1/3/20 at 11:07 AM, documented MD also ordered Podiatry consult. [Resident 45] will be seen 1/6/20 at facility. A Nursing Progress Note dated 1/3/20 at 5:02 PM, documented Resident had c/o pain to right heel wound at dressing change. Purulent drainage and foul odor noted. Abx therapy ongoing. Will continue to monitor. A Nursing Progress Note dated 1/3/20 at 10:44 PM, documented Alert charting: Purulent drainage and foul odor noted to right heel. Abx therapy ongoing. dry dressing applied to bilat heels. Will continue to monitor. A Nursing Progress Note dated 1/4/20 at 3:17 PM, documented Residents right heel has a small amt. (amount) serosanguineous drainage. Abx continues as ordered and tolerated well. A Nursing Progress Note dated 1/5/20 at 3:00 PM, documented Resident continuous on abx for right heel infection. There is a moderate amount of purulent drainage on dressing removed. Wound is painful to the touch. Dry dressing with [MEDICATION(S)] for drainage. A Nursing Progress Note dated 1/6/20 at 2:36 PM, documented Resident continues on abx for right heel infection, which seems to be tolerated well. Resident saw [Podiatrist] today for her heels, see referral for new orders. A Podiatrist visit note dated 1/6/20, documented that resident 45 was brought over by the care center for evaluation, treatment, and recommendation of bilateral heel ulcers. The duration of the ulcers was several weeks. The care center had been treating with various topical treatments and off weighting heel boots were in place. The ulceration of the left posterior lateral aspect was measured at 1.5 centimeters (cm) x 1.8 cm, granulating, stage 2. The ulceration of the right heel posterior lateral aspect was measured at 2.2 cm x 3 cm, unstable [MEDICATION(S)]. Upon debridement of the right heel the subcutaneous tissue was exposed. A Nursing Progress Note dated 1/7/20 at 1:06 AM, documented Alert charting: Resident continues on abx for right heel infection. There is a moderate amt of purulent drainage on dressing removed. Wound is painful to the touch. Dry dressing applied as ordered. Will continue to monitor. A Nursing Progress Note dated 1/7/20 at 9:22 AM, documented Infection note: Resident has dressing in place to heels. there is no drainage noted to be coming through the dressing. she does c/o pain to the right heel. abx admin as ordered. fluids encouraged. heels floated. A Nursing Skin and Nutrition Review dated 1/7/20, documented that resident 45 eats meals in the Journeys unit. Resident 45 feeds herself with set up and appetite continues to be fair. Resident 45's weight is up 0.14% from last week but significant loss for one month 6.49%. RD recommends no dietary changes at this time. Resident 45 had no ordered snacks or supplements. Resident 45 had a Zinc supplement times 14 days. [Note: The last Nutritional Screen for resident 45 was completed on 12/10/19. On 12/31/19, resident 45's right heel developed purulent drainage and an antibiotic was initiated. Resident 45's Weight Summary was reviewed. On 12/3/19, a weight of 154.2# was recorded. On 1/7/20, a weight of 144.2# pounds was recorded. Resident 45 had a 6.49% weight loss in one month A Nutritional Evaluation calculating resident 45's nutritional needs including calories and protein was unable to be located in the medical record.] A review of the Wound Evaluation forms documented the following measurements for the left heel blister: a. On 12/2/19, 1.51 cm x 1.86 cm. The wound bed was an intact serum filled blister. Treatment included heel suspension protection device. b. On 12/10/19, 1.62 cm x 1.45 cm. The wound bed was a scab. c. On 12/17/19, 2.18 cm x 2.6 cm. d. On 12/24/19, 3.18 cm x 2.86 cm. e. On 12/31/19, 1.81 cm x 1.38 cm. f. On 1/9/20, 1.49 cm x 1.43 cm. A review of the Wound Evaluation forms documented the following measurements for the right heel: a. On 12/2/19, right medial malleolus blister 3.35 cm x 3.04 cm. The wound bed was an intact serum filled blister. Treatment included heel suspension protection device. b. On 12/10/19, 3.6 cm x 3.81 cm. The wound bed was pink/red. c. On 12/10/19, right heel pressure deep tissue injury 3.09 cm x 3.16 cm. The wound bed was pink/red. [Note: The right medial malleolus blister was reclassified as a right heel pressure deep tissue injury.] d. On 12/17/19, 3.13 cm x 1.81 cm. e. On 12/24/19, 4.93 cm x 3.51 cm. f. On 12/31/19, 1.21 cm x 2.42 cm. g. On 1/9/20, 2.4 cm x 2.19 cm. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 12/2/19, Skin prep to both heels BID. Float heels while in bed. two times a day for Prophylaxis related to [CONDITION(S)]. Order was discontinued on 12/3/19. b. On 12/3/19, Apply Skin Prep to Left heel would QID four times a day for L heel wound. Order was discontinued on 1/3/20. c. On 12/3/19, Apply Skin Prep to R heel wound Four times daily four times a day for R heel wound. Order was discontinued on 1/3/20. d. On 12/3/19, [MEDICATION(S)] Tablet 500 MG Give 1 tablet by mouth every shift for Supplements. e. On 12/4/19, Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for Supplement. f. On 12/25/19, Zinc-220 Capsule (Zinc Sulfate) Give 220 mg by mouth one time a day for Altered skin integrity for 14 Days. g. On 12/31/19, [MEDICATION(S)] HCl ([MEDICATION(S)]) Capsule 300 MG Give 1 capsule by mouth three times a day for infection in heels for 7 Days. h. On 12/31/19, cover left heel with dry dressing every shift for to promote healing. Order was discontinued on 1/6/20. i. On 12/31/19, cover right heel with dry dressing every shift for to promote healing. Order was discontinued on 1/6/20. A Clinic Visit and Progress Note from the Podiatrist dated 1/6/20, documented the following orders: a. Right heel: [MEDICATION(S)] with gauze bandage. Change every 2 to 3 days. b. Left heel: Hydrogel with collagen powder. Change every 2 to 3 days. c. Continue to protect heels from pressure. On 1/8/20 at 4:01 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 45 had been more confused since admission. CNA 2 stated that resident 45 required assistance with going to the bathroom. CNA 2 stated that resident 45 was able to eat and drink on her own. CNA 2 stated that resident 45 wore oxygen at night and required that her feet were elevated while she was in bed. On 1/8/20 at 4:04 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 45's heel pressure ulcers started the beginning of December. LPN 1 stated that skin prep was initially started on resident 45's heels because the skin was closed. LPN 1 stated that when the skin started to open and had a foul smell resident 45 was started on an antibiotic. LPN 1 stated that the MD did not order cultures of the heel. LPN 1 stated that the facility MD ordered the consult with the podiatrist and the antibiotic on December 31. LPN 1 thought the heel protectors were ordered the middle of December. LPN 1 stated that resident 45 required to have her legs elevated while in bed, skin care with lotion, and repositioned. LPN 1 stated that she had noticed the wounds on resident 45's heels and the shoes that resident 45 was admitted with did not fit right due to resident 45's legs swelling. Resident 45 stated that the heel area of resident 45's shoes were hard. LPN 1 stated that a staff member got resident 45 some slippers. On 1/9/20 at 7:45 AM, an interview was conducted with CNA 4. CNA 4 stated that turning and repositioning of a resident would be charted under the bed mobility task. CNA 4 stated that she would try and get resident 45 to reposition but resident 45 liked to sleep on her back. CNA 4 stated resident 45 would keep the heel protectors on now that the wounds hurt. CNA 4 stated that prior to the wounds hurting resident 45 would kick the heel protectors off. CNA 4 stated that resident 45's heels were slightly red on admission. CNA 4 stated that it had been the last month and a half that she had tried to put the heel protectors on resident 45. CNA 4 stated that she would try and float resident 45's heels because resident 45 would not float them on her own. On 1/9/20 at 8:25 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 45's wounds started as blisters on both heels and they were found on a skin check. The ADON stated that resident 45 had gotten sick and was spending more time in bed. The ADON stated that skin prep was being used on the heels to help toughen up the skin and that would usually work to resolve the blisters. The ADON stated that resident 45's wounds got progressively worse. The ADON stated that the wound specialist had been working with the DON on orders for resident 45's wounds. The ADON stated that resident 45's right heel became infected. The ADON stated that the staff were floating resident 45's heels and slippers were obtained for resident 45 after the blisters were discovered. The ADON stated that a multivitamin with minerals and vitamin C were started. The ADON stated that the RD wanted to wait for resident 45's [MEDICATION(S)] prior to making any further recommendations. The ADON stated that when resident 45's laboratory results were received the RD did not recommend a protein supplement but a 14 day course of Zinc was recommended. The ADON stated that a new treatment order was received from the podiatrist on 1/6/19. The ADON stated that the facility MD was at the facility weekly. The ADON stated that the facility MD was made aware when the skin prep was ordered and he was made aware when resident 45's wounds got worse. On 1/9/20 at 8:30 AM, an interview was conducted with CNA 4. CNA 4 was in the dining room with resident 45 during the breakfast meal. CNA 4 stated that resident 45 ate 100% of her breakfast meal. CNA 4 stated that resident 45 had 1 slice of french toast, oatmeal, sausage, milk, and juice. CNA 4 stated that resident 45 did not drink supplements. CNA 4 stated that resident 45 was able to feed herself independently. CNA 4 stated that resident 45 liked coffee with 2 tablespoons of sugar. CNA 4 stated that resident 45 ate snacks like fig bars and crackers. On 1/9/20 at 8:52 AM, a phone interview was conducted with the RD. The RD stated she completed a nutritional screen on all residents after admission. The RD stated that if the resident was at risk for malnutrition or had malnutrition then she would complete a nutritional evaluation. The RD stated that resident 45 was not at nutritional risk so she did not complete a nutritional evaluation. The RD stated that since resident 45 was eating good and her cognition was not hindering her oral intake then she did not mark that area of the nutritional screen. The RD stated that if she did not perform a nutritional evaluation then calories and protein needs were not calculated for a resident. The RD stated that a small regular meal provided 1500 to 1800 calories and 88 grams of protein. The RD stated that resident 45 was eating 75 to 100% of meals so she did not feel that resident 45's diet needed to be changed. The RD stated that she calculated resident 45's calorie needs based on resident 45's current weight of 144.2 pounds. The RD stated that she would use 25 to 30 calories per kilogram (kg) of body weight for a total of 1636 to 1963 calories per day. The RD stated that she would use 1.2 to 1.4 grams (g) per kg of body weight to calculate protein needs of 78 to 88 g of protein per day. The RD stated that since resident 45 had a deep tissue injury (DTI) she would not increase resident 45's calculated need to 1.5 to 2.0 g until the DTI was staged high like a stage 3 or 4 pressure ulcer. The RD stated that resident 45 had a DTI and it was not staged at a 3 or 4 pressure ulcer. The RD stated that resident 45 was admitted at a higher weight so she was not concerned that resident 45 had a significant weight increase and then a significant weight decrease because her BMI was considered overweight. The RD stated that weight loss was desirable but did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD stated she was not aware of how much protein resident 45 was eating because she took the percent of meal intake and divided it by how many grams of protein the meal offered and used that to determine resident 45's protein intake. The RD stated she did not know if residents were eating protein foods or not and it was all based on the percentages that the CNAs document. On 1/9/20 at 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the RD came into the facility twice weekly and the RD would look at the residents percentage weekly intake. The DON stated that the skin and weight meetings were conducted weekly and the RD was in attendance. The DON stated that the RD would email her recommendations and a conference call would be scheduled weekly with the RD. The DON stated that a resident's nutritional evaluation was done weekly and the RD made recommendations. The DON stated that the WCC nurse was a resource for wound care products. The DON stated that the WCC nurse would come to the facility monthly and give order suggestions. The DON stated that if a pressure ulcer got worse she would expect to get as many eyes on the wound as possible. The DON stated that the facility MD and the WCC nurse saw resident 45's wounds. The DON stated that the WCC nurse resided in Washington State and was not an employee of the facility. The DON stated that the facility had a contract with the company that the WCC nurse worked for. The DON stated that the WCC nurse assessed resident 45's wounds but the WCC nurse would not have notes on resident 45. [Note: The contract was reviewed for the company that employed the WCC nurse. The contract was titled a Business Associate Agreement. A Business Associate Agreement was a written arrangement that specifies each party's responsibilities when it comes to Protected Health Information.] On 1/9/20 at 11:00 AM, an observation of resident 45's dressing change was conducted with LPN 1. LPN 1 was observed to remove the dressings from resident 45's left and right heel. LPN 1 was observed to take pictures of resident 45's wounds on the left and right heel. LPN 1 stated that the camera images were uploaded into the Wound Evaluation section of the resident medical record. LPN 1 stated that the camera image would automatically do the measurements. LPN 1 stated that once the image was captured she would trace around the wound image on the camera screen and the program would determine the measurements of the wound. LPN 1 stated that the measurements were dependant on the angle the image was captured. 2. Resident 21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/6/20 at 2:50 PM, an interview and observation was conducted with resident 21. Resident 21 stated that she had a wound on her backside that was almost healed. Resident 21 was observed to be sitting in a high back wheelchair in her room. Resident 21 was observed to have a regular mattress. The facility matrix revealed that resident 21 had a stage 2 pressure ulcer on her buttocks. Resident 21's medical record was reviewed on 1/8/20. An admission MDS assessment dated [DATE], revealed that resident 21 was admitted with a stage 2 pressure ulcer. The MDS further revealed that resident 21 had a pressure relieving device to chair and bed, pressure ulcer care, and ointment or medications applied. A care plan dated 10/23/19 and revised on 10/25/19, revealed [Resident 21] has potential for impairment to skin integrity. [Resident 21] has a wound to her coccyx and surgical wounds to bilat great toes. The goal developed was [Resident 21] will maintain or develop clean and intact skin by the review date. The interventions developed were [Resident 21] will not sustain thermal burn injury related to hot beverage consumption through the next review. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate [resident 21]/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin as needed. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Resident 21's admission Discharge Orders from the local hospital dated 10/23/19, revealed Discharge Wound Care Instructions to cleanse with NS (normal saline), apply [MEDICATION(S)] and a PUP (pressure ulcer pad) pad. Resident 21's October, November, and December 2019 Treatment Administration Record (TAR) was reviewed and revealed the following treatment ordered on 10/27/19 and discontinued on 12/8/19, Duoderm to right buttocks every day shift every 3 days for open wound. The December 2019 TAR revealed on 12/4/19, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutrition Screen dated 10/26/19, revealed that resident 21's most current weight was 157.8 pounds which was obtained on 12/4/18. The RD documented PO intake is varied with an average of 50-75% of meals. Pressure wound to right buttock, surgical incisions to right and left 1st toes. Recommend adding multivitamin/mineral and vitamin C to aid in wound healing. Protein status is WNL (within normal limits), Alb ([MEDICATION(S)]) 4.0. A care plan on the form reveled a Focus of The resident has nutritional problem or potential nutritional problem. The care plan goals on the form were [Resident 21] will maintain adequate nutritional status as evidenced by maintaining or gradually losing weight, no s/sx (signs or symptoms) of malnutrition through review date. The interventions developed were Administer medications as ordered. Monitor/Document for side effects and effectiveness. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN (as needed). weight per facility protocol. [Note: Resident 21's calories and protein needs were not calculated on the Nutrition Screen.] A wound evaluation dated 10/27/19, revealed that resident 21 had a stage 2 pressure ulcer to the right buttock. The measurements were 5.33 centimeters squared (cm 2) of the area, the length was 2.45 cm, and the width was 2.84 cm. A nursing progress note on 10/29/19 at 3:11 PM, revealed RD at facility and reviewed chart d/t (due to) new admit. Recommended MVI with minerals 1 po qday and Vitamin C 500mg po BID to promote wound healing. MD notified and order received, [name removed] aware. Weight is stable at this time. Will monitor po intake, skin and weight weekly. Resident 21's weight after admission on 10/29/19 was 172.8 pounds. A Nutrition Evaluation dated 10/29/19, revealed Resident with BMI of 31.6, obese class 1. Weight gain of 9.5% bw (Body weight) x 10 months between previous discharge and current admission. Admission weight is 172.8#. Ideal body weight of 110#. Resident is at 157% of her ideal body weight. Resident is on a vegetarian diet, regular texture, thin liquids. PO intake is varied with an average of 50-75% of meals. Skin with stage 2 pressure wound to right buttock, surgical incisions to left and right first toes. Recommend adding a multivitamin/mineral and vitamin C to aid in wound healing. Protein status is WNL at this time, Alb 4.0. [CONDITION(S)] noted BLE (bilateral lower extremities) per nursing. No adverse GI (gastrointestinal) s/sx at this time. No adverse behaviors affecting PO intake. Fluids offered meets estimated needs. Labs 10/9/19: Alb 4.0 (WNL), Hgb/Hct (hemaglobin/hematocrit) (H (High)), 10/22/19: Glu (glucose)115 (H), Creatinine .52 (L (Low)). Recommend encouraging fluid intake to aid in hydration status. Will continue to monitor and follow up as needed. A wound evaluation dated 11/5/19 revealed that resident 21 had a stage 2 pressure ulcer to the right buttock. The measurements were 5.38 cm 2, the length was 2.47 cm, and the width was 2.97 cm. Resident 21's weight on 11/5/19, was 170.4 pounds. A wound evaluation dated 11/12/19, revealed that resident 21 had a stage 2 pressure ulcer to right buttock. The wound measurements were 3.96 cm 2 of the area, the length was 2.28

Based on observation, interview, and record review it was determined, for 3 of 22 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, resident's did not have care plans with individualized interventions for pressure ulcers and [MEDICAL CONDITION]. Resident identifiers: 21, 43, and 45. Findings include: 1. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/6/20 at 2:50 PM, an interview and observation was conducted of resident 21. Resident 21 stated that she had a wound on her backside that was almost healed. Resident 21 stated that she was vegetarian. Resident 21 was observed to be sitting in a high back wheelchair in her room. Resident 21 was observed to have a regular facility mattress. The facility matrix revealed that resident 21 had a stage 2 pressure ulcer on her buttocks. Resident 21's medical record was reviewed on 1/8/20. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 21 was admitted with a stage 2 pressure ulcer. The MDS further revealed that resident 21 had a pressure relieving device to chair and bed, pressure ulcer care, and ointment or medications were applied. A care plan dated 10/23/19 and revised on 10/25/19, revealed (Resident 21) has potential for impairment to skin integrity. (Resident 21) has a wound to her coccyx and surgical wounds to bilat (bilateral) great toes. The goal developed was (Resident 21) will maintain or develop clean and intact skin by the review date. The interventions developed were, (Resident 21) will not sustain thermal burn injury related to hot beverage consumption through the next review. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate (resident 21) /family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin as needed. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. (Note: There were no interventions developed for the treatments, dietary concerns because resident 21 was a vegetarian, or a cushion in resident 21's wheelchair.) A Dietary Screen dated 10/26/19, revealed that resident 21's most current weight was 157.8 pounds which was taken from 12/4/18. The Registered Dietician (RD) documented PO (oral) intake is varied with an average of 50-75% of meals. Pressure wound to right buttock, surgical incisions to right and left 1st toes. Recommend adding multivitamin/mineral and vitamin C to aid in wound healing. Protein status is WNL (within normal limits), Alb ([MEDICATION NAME]) 4.0. The care plan goals on the form were (Resident 21) will maintain adequate nutritional status as evidenced by maintaining or gradually losing weight, no s/sx (signs or symptoms) of malnutrition through review date. A care plan on the form reveled a Focus of The resident has nutritional problem or potential nutritional problem. The interventions developed were Administer medications as ordered. Monitor/Document for side effects and effectiveness. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN (as needed). weight per facility protocol. (Note: The resident 21's calories and protein needs were not calculated on the Dietary Screen.) A wound evaluation dated 10/27/19, revealed that resident 21 had a stage 2 pressure ulcer to the right buttock. The measurements were 5.33 centimeters squared of the area, the length was 2.45 centimeters (cm), and the width was 2.84 cm. A nursing progress note on 10/29/19 at 3:11 PM, revealed RD at facility and reviewed chart d/t (due to) new admit. Recommended MVI (multi vitamin) with minerals 1 po qday (every day) and Vitamin C 500mg (milligrams) po BID (twice daily) to promote wound healing. MD (Medical Doctor) notified and order received, (name removed) aware. Weight is stable at this time. Will monitor po intake, skin and weight weekly. A progress note dated 12/10/19 at 1:16 PM, WCC (wound care consultant) wound nurse reviewed resident's wounds yesterday 12/09/19. He felt that the treatment was appropriate and asked that we continue to encourage the resident to let us re-position her more often. Resident likes to lay in bed on her back all day and all night. She gets up for at least 2 meals most days. Unable to re-position herself in bed or wheelchair. (Note: There was no intervention regarding repositioning resident 17 on the care plan.) On 1/9/20 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MDS coordinator updated care plans. The DON stated that when an evaluation was completed in a resident's electronic medical record, the care plans were automatically created based on the evaluation. The DON stated that all nurses were able to personalize care plans. The DON stated that resident 21 had a gel pad in her wheelchair which was the best thing they did to help heal the pressure ulcer. The DON stated that the intervention was not on the care plan and the care plan was not personalized. 2. Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/6/20 at 3:00 PM, an interview was conducted with resident 43. Resident 43 stated that her feet were swollen. Resident 43 stated that her feet were uncomfortable and she had sores on her legs because of the swelling. Resident 43 was observed to have gripper socks on. Resident 43 stated that her right sock was wet from her leg. Resident 43's sock was observed to be wet. On 1/7/20 at 4:30 PM, an observation was made of resident 43. Resident 43 was observed to have a wet bed on the lower right side. Resident 43's right pant leg was wet. Resident 43 stated that her leg was leaking fluid. Resident 43 was not observed to have compression stockings on her legs. Resident 43's left leg was observed to be swollen. On 1/7/20 at 4:45 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 43 did not have stocking on. CNA 2 stated that staff tried to elevate resident 43's legs but resident 43 would refuse. CNA 2 stated that resident 43's right leg was leaking and soaked her bed, pant leg, sock, and was on the floor. CNA 2 stated that resident 43 did not have compression stockings or ted hose ordered to apply. On 1/7/20 at 4:50 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 43's pant leg and bed were wet. CNA 3 stated there was a clear liquid on resident 43's floor in her room and on her pant leg. CNA 3 stated she did not know why resident 43's pant leg and bed were wet. CNA 2 stated to CNA 3 that resident 43's fluid must be coming from her leg. CNA 2 was observed to notify Registered Nurse (RN) 1. RN 1 was observed to enter resident 43's room and was observed to look at resident 43's right leg. CNA 3 stated that resident 43 did not have ted hose or compression stockings to apply. Resident 43's medical record was reviewed on 1/7/20. An admission MDS assessment dated [DATE], revealed that resident 43 received diuretics seven times in seven days. A care plan dated 12/10/19 and revised on 12/31/19, revealed (Resident 43) is on diuretic therapy. The goal developed was (Resident 43) will be free of any discomfort or adverse side effects of diuretic therapy through the review date. The interventions developed were Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Monitor Dose. (MONTH) require modification in order to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives are prescribed simultaneously. When discontinuing, gradual tapering may be required to avoid adverse consequences caused by abrupt cessation. Monitor/document/report PRN adverse reactions to DIURETIC therapy: dizziness, postural [MEDICAL CONDITION], fatigue, and an increased risk for falls. Report pertinent lab (laboratory) results to MD. An initial Physician's Assistant (PA) note dated 12/11/19, revealed that resident 43 had 2+ pedal [MEDICAL CONDITION]. The PA note further revealed that resident 43 had [MEDICAL CONDITION] (chronic) peripheral (resident 43) has been taking 2 [MEDICATION NAME] tablets. I recommend compression stocking to bilateral lower extremity. ( Note: There was no information regarding the need for compression stocking to be applied on the care plan.) Resident 43's progress notes revealed the following entries: a. On 12/10/19 at 1:58 PM, [AGE] year old female admitted .She has 2+ bilat. pedal [MEDICAL CONDITION], is alert and oriented x 3 (person, place and time) . b. On 1/3/20 at 4:03 PM, .[MEDICAL CONDITION] 3+ to BLE (bilateral lower extremity).; . c. On 1/5/20 at 3:07 PM, .1+ bilat. pedal [MEDICAL CONDITION].; . d. On 1/7/20 at 10:25 PM, .[MEDICAL CONDITION] LLE (left lower extremity) +3, LRE (right lower extremity) +2. On 1/7/20 at approximately 4:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 43 had 1+ [MEDICAL CONDITION] in left leg and no [MEDICAL CONDITION] in her right leg last week when she worked. LPN 2 stated resident 43 had been up since 2:30 AM that morning and was refusing to lay down. LPN 2 stated that was why resident 43 was having weeping [MEDICAL CONDITION] from her right leg. LPN 2 stated that resident 43 did not have orders for ted hose and was currently texting the doctor for an order for [REDACTED]. LPN 2 stated she would try to put resident 43 in her recliner daily but resident 43 refused to be in the recliner for more than an hour, before resident 43 would ask to be put back in her wheelchair. On 1/8/20 at 11:26 AM, an interview was conducted with LPN 1. LPN 1 stated that resident's were assessed for [MEDICAL CONDITION] upon admission. LPN 1 stated if resident's were on diuretics their [MEDICAL CONDITION] would be monitored twice daily. LPN 1 stated that resident 43's legs had been weeping for probably over a week. LPN 1 stated that the PA visited resident 43 regarding her legs about a week ago. LPN 1 stated that she went in with the PA and he said to keep resident 43's legs elevated. LPN 1 stated there were no orders to wrap or use ted hose or anything else to prevent [MEDICAL CONDITION]. LPN 1 stated that the physician gave orders for unna wraps yesterday because resident 43's legs were weeping. On 1/8/20 at 2:58 PM, an interview was conducted with the DON. The DON stated that if a resident was to have compression stockings or ted hose the physician wrote an order. The DON stated that the nurse told her yesterday that she was going to try and get some unna boots or [MEDICATION NAME] ordered for resident 43. The DON stated that there was not a physician's orders [REDACTED]. The DON stated if resident 43 refused to wear compression stockings it would be documented on the Treatment Administration Record (TAR). The DON stated there was no documentation in the TAR. The DON stated the compression stockings order was not entered into the electronic medical record. On 1/9/20 at 12:30 PM, an interview was conducted with the DON. The DON stated resident 43 did not have compression stockings as an intervention on her [MEDICAL CONDITION] care plan. The DON stated that the MDS coordinator updated care plans. The DON stated that nurses were able to personalize care plans. 3. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/6/20 at 11:40 AM, resident 45 was observed sitting in a wheel chair with bilateral heel protectors. Resident 45's medical record was reviewed on 1/8/20. A Braden Scale for Predicting Pressure Sore Risk dated 9/10/19, documented that resident 45 was at risk for pressure sores with a score of 18. (Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.) A Care Plan focus initiated on 9/10/19, documented (Resident 45) has potential for impairment to skin integrity. The goal developed was (Resident 45) will maintain or develop clean and intact skin by the review date. The following interventions were developed: a. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. b. Educate resident 45, family, and caregivers of causative factors and measures to prevent skin injury. c. Encourage good nutrition and hydration in order to promote healthier skin. d. Identify and document potential causative factors and eliminate and resolve where possible. e. Keep skin clean and dry. Use lotion on dry skin. An admission MDS assessment dated [DATE], documented that resident 45 was at risk of developing pressure ulcers. The MDS further documented that resident 45 had a pressure reducing device for chair and bed. The Care Area Assessment section of the MDS documented that Pressure Ulcer was a triggered care area and was addressed in the care plan. (Note: The skin integrity care plan initiated for resident 45 did not include interventions to prevent pressure ulcers including the pressure reducing device for the chair and bed.) A Nursing Progress Note dated 12/2/19 at 3:05 PM, documented Resident has a blister on each heel. New order to keep heels floated while in bed. Apply skin prep to heels BID. A Braden Scale for Predicting Pressure Sore Risk dated 12/3/19, documented that resident 45 was at risk for pressure sores with a score of 16. (Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.) A Care Plan focus initiated on 12/3/19, documented (Resident 45) has a pressure ulcer (R heel). Additionally, a Care Plan focus initiated on 12/3/19, documented (Resident 45) has a pressure ulcer (L heel). The goal initiated was (Resident 45's) pressure ulcer will show signs of healing and remain free from infection by/through review date. The following interventions were developed for both of the initiated Care Plan focuses: a. Administer medications as ordered. Monitor and document for side effects and effectiveness. b. Administer treatments as ordered and monitor for effectiveness. c. Assess, record, and monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. d. Follow facility policies and protocols for the prevention and treatment of [REDACTED]. e. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. (Note: The pressure ulcer care plan initiated for resident 45 did not include interventions that had been implemented to treat and prevent pressure ulcers including heel protectors and the pressure reducing device for the chair and bed.) On 1/8/20 at 3:38 PM, resident 45 was observed with heel protectors on both heels. Resident 45's room was observed and resident 45's bed had a standard facility bed mattress. On 1/9/20 at 12:30 PM, an interview was conducted with the DON. The DON stated that the MDS coordinator updated care plans. The DON stated that when an evaluation was completed in a resident's medical record, the care plans were automatically created based on the evaluation. The DON stated that all nurses were able to personalize care plans.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with profession standards for food service safety. Specifically, there were soiled areas in the kitchen and plastic cups and Styrofoam plates were used for resident dining. Findings include: 1. On 1/6/20 at 10:46 AM, an initial tour of the kitchen was conducted. The following observations were made: a. There was dried substance under the shelf above the trayline. b. There was a bungee cord attached to the handle on the lid of the plate warmer to the pole. c. The toaster was dirty with a rust color on the top of it. d. The counter with a coffee machine was soiled with a white substance. e. There was a fan pointed toward trayline and the food preparation area that was dusty and soiled. 2. On 1/7/20 at 5:47 PM, an observation was made of the dining meal. The salad was served in a clear disposable cup and the dessert was served to some of the residents on a Styrofoam plate. 3. On 1/8/20 at 1:00 PM, a follow up tour of the kitchen was conducted. The following was observed: a. There was a brown substance behind the counter with the juice machine on it. b. There were 5 Teflon pans that had large scrapes in the Teflon. c. There was a plastic bin with container lids soiled with white substance on the outside. An interview was conducted with Cook 1. Cook 1 stated that the Teflon pans were used for food preparation. An interview was conducted with the Dietary Manager (DM). The DM stated that the bungee cord was used to hold the plate warmer lid open. The DM stated that the fan was taken out on Thanksgiving and it had not been cleaned. The DM stated that there were not enough bowls to serve the salad and dessert, so plastic and Styrofoam was used to serve food to the residents.

Based on interview and record review it was determined, for 1 of 22 sample residents, that the facility did not assess if a resident was clinically appropriate to administer medications. Specifically, a resident was not assessed to administer her own inhaler. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/6/20 at 2:58 PM, an interview was conducted with resident 43. Resident 43 stated that she wanted to have her inhaler on her overbed table and be able to administer it. Resident 43's medical record was reviewed on 1/7/20. A physician's orders [REDACTED]. There was no assessment or nurses notes regarding how the decision was made that resident 43 was unable to administer her medications. On 1/8/20 at 11:19 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that there were no residents administering their own medications. LPN 1 stated that the physician had to approve the resident for administering their own medications and a lock box would be provided to the resident in their room. LPN 1 stated that resident 43's family member had requested for resident 43 to have her inhaler to administer when she needed it. LPN 1 stated the family made the request about a week ago. LPN 1 stated that she became busy and forgot to talk to resident 43 about administering her own inhaler. LPN 1 stated that upon admission an assessment was completed to determine if residents can self administer medications. LPN 1 stated that all residents have an evaluation completed. LPN 1 stated she thought resident 43 had an evaluation done. LPN 1 was observed to look at resident 43's electronic medical record and stated resident 43 did not have an evaluation completed. On 1/8/20 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she had not heard of anyone who requested to administer their own medications. The DON stated if a resident had a strong desire then staff would monitor and make sure they know how to administer the medications. The DON stated that she had not evaluated resident 43 for administering her own inhaler. On 1/8/20 at 10:30 AM, the DON provided a template assessment used to evaluate if a resident was safe to administer their own medications. The DON stated that resident 43 did not have an evaluation completed.

Based on observation, interview, and record review it was determined, for 1 of 22 sample residents, that the facility did not provide appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, a female resident was observed to have long chin hair. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/6/20 at 3:00 PM, an observation was made of resident 43. Resident 43 was observed to have chin hair approximately a half inch long. On 1/7/20 at 4:00 PM, an observation was made of resident 43. Resident 43 was observed to have chin hair approximately a half inch long. On 1/8/20 at 8:15 AM, an observation was made of resident 43. Resident 43 was observed to have chin hair approximately a half inch long. Resident 43's medical record was reviewed on 1/8/20. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed resident 43 required 2 person extensive assistance for personal hygiene which included shaving, applying makeup, washing/drying face and hands. The MDS further revealed a Brief Interview of Mental Status score of 10 which revealed resident 43 had moderate cognitive impairment. A care plan dated 12/10/19, revealed [Resident 43] has an ADL (activities of daily living) self-care performance deficit. The goal developed was [Resident 43] will maintain current level of ADL function through the review date. The interventions developed were Discuss with [resident 43] /family/POA (power of attorney) care any concerns related to loss of independence, decline in function. Encourage [resident 43] to participate to the fullest extent possible with each interaction. Praise all efforts at self care. [Note: There was no information regarding resident 43 refusing cares.] On 1/7/20 at 4:07 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that if she noticed chin hairs on a female resident then she shaved them when they were in the shower. CNA 3 stated that she asked female residents if they would want to have their faces touched up. CNA 3 stated that she would document if a resident refused ADLs on a Chart Sheet. CNA 3 stated that the Chart Sheet had CNA responsibilities on it. CNA 3 provided the Chart Sheet. CNA 3 stated that resident 43 refused to be showered on 1/6/20 but was showered on 1/3/20. CNA 3 stated there was no information documented about resident 43 not wanting her facial hair removed. On 1/7/20 at 4:33 PM, an interview was conducted with CNA 2. CNA 2 stated normally I will ask if they (resident's) want to be shaved. CNA 2 stated if a resident was unable to respond because they were not cognitively intact, then she would shave the resident during their shower or when getting a bed bath. CNA 2 stated that she was not aware of any female residents that refuse to have their chins shaves. CNA 2 stated that female residents usually wanted their chins shaved. CNA 2 stated that resident 43 might refuse to have her chin hair shaved. CNA 2 stated that she had not showered resident 43. CNA 2 stated that resident 43 had dementia and would forget things. On 1/8/20 at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNA's shaved resident's during bathing. The DON stated that some residents would refuse to have their ADLs completed. The DON stated that some of the CNA's were afraid of how to approach females with their facial hair. On 1/8/20 at 3:40 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 43 requested a bed bath on 1/3/20. CNA 1 stated that resident 43, then decided she wanted a shower. CNA 1 stated that she provided resident 43 a shower and resident 43 became anxious and wanted to be done with the shower. CNA 1 stated that she did not remove resident 43's chin hair. CNA 1 stated that she had not asked resident 43 about trimming her facial hair. On 1/9/20 at 12:15 PM, an observation and interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that resident 43 was not responding so she was changing her oxygen tank. Resident 43 was observed to have chin hairs. Resident 43's eyes were closed and resident 43 was not responding to questions. Resident 43 was asked about having her chin hairs removed and did not respond. NA 1 stated that resident 43 had not refused cares. NA 1 stated that she had provided cares to resident 43 for the last 2 days. NA 1 stated that she had not offered to clear resident 43's chin hair and was not sure why resident 43 had not had the chin hair removed. Additional information provided by the facility DON on 1/10/20 revealed, When visitors enter our building, we treat them with dignity and respect and do not ask them to alter their appearance or personal grooming to fit other peoples' expectations of how they should look. If we had made suggestions to help them conform to other's expectation, I am sure they would be offended. I feel that we should give our residents the same respect. I do not believe there is an official standard of what is and is not acceptable as far a (sic) dignified resident appearance. Assuming that the presence of lack of facial hair is part of the residents 'normal' is just an opinion. To respect a resident's rights we need to maintain their perception of normal. As explained to one of our surveyors, women residents with facial hair are usually not aware that it exists and are not harmed by it. Many CNAs are very good at helping residents feel good about shaving. Some CNAs can help the resident come away feeling as if they had gone to a Spa and had a facial. But if a resident is not concerned about facial hair, reminding them it is there and pressuring them to have it removed frequently is benefiting the caregiver more than the resident. The statement was signed by the DON. [Note: There was no information located in resident 43's medical record that resident 43 desired to keep her facial hair.]

Based on observation, interview, and record review it was determined, for 4 of 22 sample residents, that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, resident's wheelchairs were dirty, had cracked arm rests, tape on arm rests, and a piece of foil on the back of the motorized wheelchair. Resident identifiers: 4, 36, 43, and 44. Findings include: On 1/6/20 at 11:44 AM, an observation was made of resident 44's wheelchair. Resident 44's wheelchair was observed to have bright orange tape on the right arm rest. On 1/9/20 at 7:53 AM, an observation was made of resident 44's wheelchair. Resident 44's wheelchair had bright orange tape on the right arm rest. Resident 44's wheelchair was observed to have dust and debris on the foot rests. On 1/6/20 at 3:01 PM, an observation was made of resident 43's wheelchair. Resident 43's wheelchair was observed to be soiled. On 1/9/20 at 9:30 AM, an observation was made of resident 43's wheelchair. Resident 43's wheelchair was soiled. On 1/9/20 at 7:55 AM, an observation was made of resident 36's wheelchair. Resident 36's wheelchair arm rests were observed to be cracked. On 1/9/20 at approximately 8:00 AM, an observation was made of resident 4. Resident 4's motorized wheelchair was observed to have a piece of foil covering the back of the wheelchair. On 1/9/20 at 8:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that when a wheelchair needed to be repaired staff would inform the maintenance director. CNA 4 stated that resident 44's wheelchair had the orange tape on the arm rest. CNA 4 stated that resident 44 liked tape and probably placed it there himself. CNA 4 stated that resident 44 was confused. CNA 4 was observed to look at resident 44's wheelchair. CNA 4 stated that resident 44's arm rest was worn under the orange tape. CNA 4 stated that resident 36's wheelchair arm rest was cracked and torn. On 1/9/20 at 8:05 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if a wheelchair needed to be fixed the staff would tell the Maintenance Director. RN 1 stated there was a form for staff to write down wheelchairs that needed to be repaired. On 1/9/20 at 8:10 AM, an interview was conducted with CNA 8. CNA 8 stated that the maintenance director fixed resident's wheelchairs. CNA 8 stated that resident 4 received her motorized wheelchair back yesterday and she was not aware there was foil on the back of the wheelchair. On 1/9/20 at 9:40 AM, an interview was conducted with the Maintenance Director (MD). The MD stated if a wheelchair arm rest needed to be repaired staff told him. The MD stated that he had arm rests and was able to replace them in the facility. The MD stated he was unaware that resident 44's and resident 36's arm rests were cracked. The MD stated that he was not aware that resident 4's wheelchair had foil on the back of it. The MD stated that he could get reflective tape for resident 4's wheelchair. The MD stated that staff were able to fill out a work order to write things down that needed to be fixed. The work order form was observed and there were no entries for arm rests or foil. On 1/9/20 at 9:45 AM, an interview was conducted with resident 4 and her family member. Resident 4 stated that she received her wheelchair back yesterday. The family member stated that she placed the foil on the back of the wheelchair so that resident 4 was safe at night time. Resident 4 stated that she had not been offered a reflector or reflective tape but would love to have those to be safe.