Every finding on record at Mountain View Center Genesis Healthcare

Based on interview and record review the facility failed to complete accurate resident assessments for 2 of 13 sampled residents (Residents #1 and #2). Findings include:1. Per record review, Resident #1's MDS (Minimum Data Set, an assessment tool used to evaluate resident health, develop personalized care planning, and determine facility reimbursement) dated 4/17/2026 indicates that Resident #1 had a diagnosis of diabetes type II upon admission. Further review of the medical record reveals there was no monitoring, treatment, or orders upon admission to the facility or throughout Resident #1's stay. Review of Resident #1's care plan reveals no focus, goal, or interventions related to diabetes. Per interview with on 7/23/2026 at 6:39 PM, the Registered Nurse (RN) assisting the facility with MDS issues confirmed that Resident #1's diagnosis list and MDS included the diagnosis of diabetes type II and that there were no physician's orders related to diabetes, monitoring, or treatment because they did not have an actual diagnosis of diabetes type II. The RN also confirmed that a modification should be submitted to correct the error. 2. Per record review, Resident #2's MDS that was dated 3/10/2026 was modified and signed on 4/3/2026 by a Registered Nurse who was assisting the facility with the MDS to reflect that the Resident required isolation or quarantine for an active infectious disease. Further record review reveals no documentation to support the Resident #2 had received care and services related to isolation or quarantine.Per interview on 7/22/2026 at 10:50 AM, the facility Administrator confirmed that the MDS inaccurately reflected Resident #2's condition regarding the provision of isolation or quarantine. The Administrator stated that isolation had been coded in error and that a MDS modification had been submitted.Per interview with on 7/23/2026 at 6:39 PM, the Registered Nurse (RN) assisting the facility with MDS issues confirmed that Resident #2's MDS had been coded in error and was not an accurate reflection of the Resident's care needs related to isolation and quarantine.

Based on observation, interview, and policy review, the facility failed to ensure that expired medications were removed from 1 of 2 medication storage rooms observed and 1 of 4 medication carts observed. The facility also failed to ensure medication carts remained locked when unattended during an observation. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 6/4/26. Findings include: 1. Per observation on 6/2/2026 at approximately 9:24 AM, the medication cart on Beach unit was reviewed and Mirtazapine 15 milligrams (mg) for Resident #130 was expired on 5/23/26. The nurse confirmed that the medication was expired. Per observation on 6/2/2026 at approximately 11:22 AM, the Beach unit medication room was reviewed and 2 over the counter bottles of Bisacodyl 5mg expired on 4/2026. Per interview on 6/2/2026 at approximately 11:35 AM, the nurses on the unit confirmed that the 2 bottles of Bisacodyl 5mg were expired. Per the facility's Medication Storage policy revision date 1/26 page 3 of 3 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . 2. On 6/3/26 at 8:48 AM, an observation was conducted at the facility's Cherrytree, a memory care unit. An unlocked medication cart was observed in the common area, where several residents were present. No facility staff was observed at or near the medication cart. During an interview on 6/3/26 at 9:15 AM, the Registered Nurse (RN) assigned to the medication cart confirmed that it should have remained locked at all times when unattended. The RN confirmed she failed to lock the medication cart and stated she made a mistake. Review of the facility's policy titled Storage of Medication, last revised in 1/2026, indicated that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on observation and interview the facility failed to provide privacy during care for 1 of 32 sampled residents (Resident #93). Findings includePer observation on 6/1/26 at 12:16 PM on the Dogwood unit, a Licensed Practical Nurse (LPN) was preparing and gathering supplies from the wound care cart parked outside of Resident #93's room. Resident #93 was sitting on the side of the bed eating lunch. The LPN rolled up Resident #93's right shirt sleeve and began to assess the area where a bandage would be applied. Resident #93 was trying to continue eating their salad while LPN was documenting and labeling the dressing. When the LPN was ready to apply the dressing, he asked the resident to put their salad down. This interaction was observed from the hallway as there was no privacy curtain pulled and the door was open. Five people were observed walking by the room. Per interview at approximately 12:25 PM on 6/1/26, the LPN confirmed the door and privacy curtain were open and that they should have been closed to provide Resident #93 with privacy during wound care.Per interview with Unit Manager of the Dogwood unit on 6/2/26 at approximately 10:40 AM, the Unit Manager confirmed that it is never appropriate for a dressing to be applied or removed during mealtime, and that privacy should always be provided for wound care

Based on interview and record review the facility failed to revise and implement a person-centered care plan for 1 of 32 sampled residents (Resident #48). The care plan was not revised and implemented to address Resident 48's escalating pattern of aggressive verbal and physical behavior. Findings include: Per record review, Resident #48 has diagnoses that include anxiety disorder, major depressive disorder, and dementia. Per an MDS (Minimum Data Set, a resident assessment tool) dated 12/3/25, Resident #48 had a BIMS (Brief Interview for Mental Status) score of 15, indicating fully intact cognition (the ability to perceive, learn, remember, reason, and problem-solve). An MDS dated [DATE] repeated the BIMS score of 15. Per record review, a social service note dated 2/12/26 states that Resident #48 was made aware by the Social Worker that resident makes comments to others and they feel [sh/e] is putting them down, or telling them what they can or cannot do, a concern brought forward by more than one person. In response, Resident #48 swore at the Social Worker. An assessment of Resident #48 dated 3/3/26 and noted as an interdisciplinary evaluation participated in by RN #1, DON (Director of Nursing), NP (Nurse Practitioner), and MD (Medical Doctor) states, Since the last evaluation there has been no change in behavior symptoms. Yelling and accusatory toward others at times. A social service note dated 4/7/26 states that the social worker was walking down the hall and heard Resident #48 swearing and yelling at others. The social worker notes, Resident proceed to call this writer names and said I was the biggest F- B- in this building. A social service note dated 4/30/26 states, Resident expressed that [s/he] was upset that Resident #56 had [her/his] coloring paper and when [s/he] asked for it back, s/he did not give it to [her/him] so [s/he] swatted [her/him]. A facility investigation report dated 5/4/26 states that Resident #48 slapped Resident #56 on their back. This investigation report also states that care plans were updated. A nurses note dated 5/23/26 states that Resident #48 entered the dining room, calling Resident #56 a fat [expletive]. When the nurse attempted to redirect Resident #48 out of the area, Resident #48 told the nurse to f-off. A nurses note dated 5/26/26 notes that Resident #48 stated to Resident #56, Well got anything to say to me now. I dare you. I'll knock you. S/he told the other resident that s/he had no problem fighting them, and Resident #48 was calling other residents names and using profanity as s/he left the room. The nurse notes that she was concerned the situation would escalate. During an interview with the Social Worker on 6/2/26, she confirmed that Resident #48 gets jealous, gets possessive of her/his things or where she/he is sitting and has acted out bother verbally and physically to other residents, including Resident #56. Resident #48 has a care plan focus dated 11/13/23 related to the potential verbal and physical behaviors. The most recent revision to this care plan is dated 5/6/25 with no newer interventions to address Resident #48's continuing pattern of escalating behaviors. Per interview with the Director of Nursing on 6/3/26 at 8:10 AM, he confirmed there had been recent verbal and physical behaviors by Resident #48 and he could not provide evidence of new care plan interventions to address them.

Based on interview and record review, the facility failed to ensure two of 32 sampled residents (Resident #63 and Resident #11) were care planned for concerns related to hearing and communication and positioning. Findings include: 1. Per observation on 6/1/26 at 11:36 AM, Resident #11 was observed sitting in their wheelchair, leaning over the arm rest on the right. Resident # 11 was seated in a high back wheelchair with a head rest, leg rests and a cushioned foot board between the leg rest. They also had two cushioned wedge devices at their hips on the right-hand side. Per interview with a Licensed Practical Nurse (LPN) on 6/1/26 at 12:07 PM, they explained that Resident #11 leans to the right frequently and requires position changes as needed. LPN #1 stated that Resident #11 recently received a new high back wheelchair to assist with their positioning. Per record review, Resident #11 was not care planned for positioning or the use of additional positioning devices while in the wheelchair. Per interview with Unit Manager Registered Nurse on 6/2/26 at approximately 10:00AM, they confirmed that Resident #11 was not care planned for positioning devices, or positioning while they are in their wheelchair and they should be. 2. An interview was conducted with Resident #63 on 6/1/26 at 12:13 PM. Resident #63 stated one of his/her hearing aids broke and was waiting on a replacement. An interview was conducted with the Unit Manager on 6/2/26 at 11:14 AM. The Unit Manager stated the resident's hearing aids were currently being replaced by ENT [otolaryngology]. Per record review of Resident #63's care plan, there was no documentation concerning the resident's hearing, needs for communication, or use of hearing aids. Per review of the facility's OPS416 Person-Centered Care Plan policy [last revised 10/24/22] states, The care plan will be prepared by the interdisciplinary team.The interdisciplinary team, in conjunction with the patient and/or patient representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.Purpose: To attain or maintain the patient's highest practicable physical, mental and psychosocial well-being. An interview was conducted with the DON [Director of Nursing] on 6/2/26 at 12:49 PM. The DON presented a care plan that showed Resident #63 was care planned for hearing. Per record review, the area of concern for hearing and interventions were added the same day as the interview, 6/2/26. The DON confirmed that hearing, communication needs, and hearing aid interventions were not added to Resident #63's care plan until 6/2/26.

Based on the interview and record review, the facility failed to ensure that 1 of 3 sampled Licensed Nursing Assistants possessed the specific competencies necessary to meet residents' needs, as identified through resident assessments and the plan of care. The facility did not ensure that staff operating the mechanical lift were competent in the task per the facility policy, which led to a resident sustaining multiple fractures and skin tears (Resident #1). This has the potential to affect all residents of the facility. Findings include:Based on the interview and record review, the facility failed to ensure that 1 of 3 sampled Licensed Nursing Assistants possessed the specific competencies necessary to meet residents' needs, as identified through resident assessments and the plan of care. The facility did not ensure that staff operating the mechanical lift were competent in the task per the facility policy, which led to a resident sustaining multiple fractures and skin tears (Resident #1). This has the potential to affect all residents of the facility. Findings include:Review of three Licensed Nursing Assistant (LNA) education files showed that LNA #1, contracted staff from Clipboard Health, lacked evidence of assessment for clinical competencies, including Safe Resident Handling, before being assigned to resident care. The packet titled Genesis Mandatory Training Participation Guide indicated that educators would show, explain, and demonstrate resident handling competencies.Per review of the facility-reported incident, on [DATE] at approximately 11:00 AM, LNA #1 was assisting Resident #1 with being transferred, in which the resident fell during the transfer from a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility in a sling) while being assisted from their bed to their wheelchair. Resident #1 was care planned for transfers with two staff members using a Hoyer lift due to mobility issues. Resident #1 was initially assessed by their physician and an X-ray was ordered due to left shoulder pain but was transferred to the hospital for evaluation later in the day due to additional reports of pain. Review of the Emergency Department Note dated [DATE] at 10:22 PM after the incident noted a diagnosis of a fracture of the right femur (thigh bone), and a fracture to the left humerus (upper arm bone), and having skin tears (traumatic, often partial-thickness wounds caused by friction, shear, or blunt force that separate the skin layers) to the resident's right arm and right lower leg plus bruising of right foot. See F689 for more informationPer an interview with the Director of Nursing (DON) on [DATE] at 1:49 PM, he stated that Clipboard Health verifies its employees' competencies, and the employee's signature on the back of the Genesis Mandatory Training Participant Guide packet indicated the person was qualified. Documentation was requested regarding the competency for Safe Resident Handling, as indicated in the packet. The DON stated the packet wasn't the facility's document but was Clipboard Health's. The DON was asked about the Genesis heading on the packet and denied that the packet was from the facility. Per interview with Clinical Support at Clipboard Health, the contracted company, on [DATE] at 2:08 PM, the Clinical Support representative stated the company doesn't review competencies or have specific training provided to employees. The requirements are for employees to provide a copy of their professional license, proof of basic life support (BLS) or cardiopulmonary resuscitation (CPR) certification, a driver's license or state identification card, Tuberculosis (TB) testing, and background checks. The Clinical Support person confirmed that the Genesis Mandatory Training Participation Guide is not part of their requirements or their document.Per interview with the Administrator and DON on [DATE] at 2:50 PM, they confirmed there is no documentation of competencies for the contracted employees. When asked how many employees from this service are used at the facility, the Administrator stated that it varies but thought it was 3 to 4 per day.A review of the facility's list of contracted Clipboard employees over the last 12 months revealed 59 employees had been scheduled at the facility. A review of the shifts worked by LNA #1 indicated that LNA #1 had worked 11 shifts since starting at the facility without evidence of patient care competencies. Per interview with the DON on [DATE] at 3:26 PM, the DON confirmed that all staff listed received the same informational packet as LNA #1 which he believed to be an assessment of competency by the contracted agency, not the facility, that LNA #1 worked 11 shifts without the facility verifying LNA #1's competency, and that the facility failed to verify the competencies of any contracted employees from this service before allowing them to work with residents.

Based on the interview and record review, the facility failed to implement safe mechanical lift procedures to prevent an avoidable accident for 1 of 5 sampled residents (Resident #1). The facility did not ensure that staff operating the mechanical lift were competent in the task per the facility policy. During transfer, Resident #1 sustained multiple skin tears and fractures to their body, including a fracture of the right femur (thigh bone) and a fracture to the left humerus (upper arm bone). This is a repeat violation previously cited in a partial survey dated 9/9/25. Findings include:Per record review, Resident #1 was admitted to the facility on [DATE] and has diagnosis that include rheumatoid arthritis (autoimmune disease that targets the joint lining resulting in pain, stiffness, and swelling), degenerative joint disease (commonly known as osteoarthritis which is the protective cartilage that cushions the ends of the bones wears down over time), and osteoporosis (bone disease where decreased bone mass and density make bones weak, brittle, and prone to fractures). On 4/2/26 at approximately 11:00 AM, the record notes the resident fell during a transfer from a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility in a sling) while being assisted from their bed to their wheelchair. Resident #1 was care planned for transfers with two staff members using a Hoyer lift due to mobility issues. The facility's initial summary report describes an incident on 4/2/26 in which Resident #1, being transferred from bed to a chair using a Hoyer lift, leaned to the left, partially slipping out of the moving device. The transfer was aborted, and the resident was returned to bed and assessed for injury by a nurse. The report continues to state that the assessment revealed left shoulder pain with no loss of range of motion or swelling, and two skin tears. The skin tear measurements are right anterior elbow total flap loss area of 31.96 cm (no tissue flap attached and there is an open wound bed), total flap loss of the right inner forearm having an area of 24.68 cm, and right leg partial flap loss having an area of 3.34 cm (tissue loss extensive enough that only part of the flap can be repositioned over the wound bed). The resident remained at the facility, and the physician ordered an X-ray of the resident's left shoulder after assessing the resident in their room. At 1:45 PM during another transfer from the chair to the bed, the resident reported right hip pain along with noted swelling, and the physician was contacted again. It was determined at that time for the resident to be transferred to the hospital for further assessment.Review of the Emergency Department note from 4/2/26 at 10:22 PM after the incident noted a diagnosis of a fracture of the right femur (thigh bone), and a fracture to the left humerus (upper arm bone), and having skin tears (traumatic, often partial-thickness wounds caused by friction, shear, or blunt force that separate the skin layers) to the resident's right arm and right lower leg plus bruising of right foot.Per interview with Licensed Nursing Assistant #1 (LNA) on 4/7/26 at 2:00 PM, she confirmed that she was transferring Resident #1 from their bed with LNA #2, and that the Resident started moving their shoulders and was slipping from the Hoyer sling. She continued to describe the lift repeatedly hitting the mechanics of the resident's bed, and it was chaotic trying to return the lift back under the bed. She stated, just didn't look right, and the resident was in a straight line instead of appearing 'scooped' in the transfer sling, and the sling was moving back and forth with LNA #2 attempting to help guide the resident back to the bed from the other side. LNA #1 stated that once the resident was above the bed, they slipped out of the sling towards the footboard. LNA #1 was asked what the resident's height above the bed was when they slipped out of the sling, and the LNA gestured with her hands to indicate approximately 12 inches. LNA #1 continued stating the resident sustained skin tears to her right side due to the rubbing on the material of the Hoyer sling, and having skin like paper. Per interview with the Unit Manager (UM) on 4/7/26 at 2:30 PM, she stated that Resident #1 has contractures (permanent, rigid tightening of muscles, tendons, skin, or tissues around a joint, restricting motion and causing deformity) and isn't flexible in movements. The UM reports that the staff transferring the resident stated the resident was stiff during the attempted move. UM was asked the height of the resident when they slipped out of the Hoyer sling, and she gestured with her hands to show approximately twelve inches.Per interview with the Physical Therapist (PT) on 4/8/26 at 8:15 AM, she confirmed the resident's size was appropriate for use of the Hoyer lift, and the resident's contractures wouldn't have impacted the transfer. PT confirmed that Resident #1 had been transferred using the Hoyer lift since admission on [DATE], and no other incidents of slippage from the sling were reported. She confirmed a meeting with Resident #1 after the transfer incident, and the resident complained of discomfort with their left shoulder. Per interview with the Medical Director (MD) on 4/8/26 at 9:25 AM, he confirmed he was aware of the incident involving Resident #1 and that he had evaluated them after the incident. He revealed he ordered an X-ray (medical imaging test) of the resident's left shoulder due to discomfort and didn't believe it was urgent, so they could wait for the X-ray staff to arrive at the facility. He confirmed that, upon notification of the resident's right hip pain, the resident needed to be seen sooner for imaging and was transferred to the hospital. When asked about his understanding of the incident, he stated that two LNAs were transferring the resident from bed to a wheelchair when the resident turned to the left and began slipping. He continued, stating LNA #2 was holding the resident and guiding the resident over the bed. The MD revealed that LNA #2 stated the resident was 12 inches from the bed when they slipped feet-first onto the bed. He confirmed that the resident's injuries could have resulted from a fall of 12 inches, based on the medical diagnosis and treatments they received. He confirmed the skin tears were most likely due to shearing caused by the skin in contact with the Hoyer sling and the resident sliding.Per interview with LNA #2 on 4/8/26 at 10:00 AM, she confirmed Resident #1 was being transferred using the Hoyer Lift with LNA #1, and everything looked fine and normal, but then the resident slid to their side during the transfer. LNA #2 reports trying to save the resident from falling on the floor, and was guiding them over the bed, but when they slid out of the sling, they were twelve inches above the bed. She confirmed the resident sustained skin tears on their right side and was complaining of discomfort in their left shoulder.Per interview with a Licensed Practical Nurse (LPN) on 4/8/26 at 10:30 AM, she stated she was a second set of eyes after the incident during the assessment of Resident #1. She revealed the resident complained of shoulder pain and had skin tears from their skin rubbing against the Hoyer sling.The following statements collected by facility leadership with staff revealed that LNA #2 reported Resident #1 hit the arm of the Hoyer lift when attempting to move them back over the bed, and then they slid out of the sling, and in a later summary with LNA #2, she reports Resident #1 bumped the piston with [his/her] right hip twice. The summary also reveals that when the resident slid out of the sling, they landed on the bottom third of the bed. Per interview with the Director of Nursing (DON) on 4/8/26 at 11:30 AM, the DON was asked about the skill competencies for LNA #1 and confirmed that her competencies in the proper use of the Hoyer lift were not demonstrated before the incident. See 726 for more information.Review of the facility's Accidents/Incidents policy, last revision 3/1/24, includes a definition of an accident as any unexpected or incident which may result in injury. The facility's Safe Resident Handling/Transfer Equipment policy, last revised 3/1/24, states, Staff will complete training and demonstrate competency in the use of safe resident handling equipment. Reference:https://skil-care.com/product/geri-sleeves/https://jamanetwork.com/journals/[NAME]/fullarticle/2790284https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968https://pmc.ncbi.nlm.nih.gov/articles/PMC7950130/https://medlineplus.gov/ency/article/003185.htm

Based on interview and record review the facility failed to implement interventions to ensure residents were free of accidents for 1 of 3 residents (Resident #1). As a result, a resident suffered a fall which required hospitalization related to a fractured hip and pain management. Findings include: Per record review, Resident #1 has diagnoses that include irradiation of the pelvis, epilepsy, presence of an artificial eye, and normal pressure hydrocephalus (a neurologic condition characterized by an abnormal accumulation of cerebrospinal fluid in the brain). Per review of the Minimum Data Set (MDS-a standardized tool used to evaluate residents' needs and improve care planning) dated 5/30/25, in the section titled Functional Limitation in Range of Motion, Resident #1 has an impairment on one side of the upper body and an impairment on both sides of the lower body. Per review of Resident #1's care plan, a focus reveals that Resident requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to chronic disease/condition: limited mobility, legally blind the corresponding intervention reads to provide the resident with 2 assist for Activities of daily living (ADL) care, with an initiation date of 5/5/23.Per review of a facility incident report dated 7/27/25, Resident #1 had a witnessed fall from the bed while receiving care from a Licensed Nursing Assistant (LNA) on 7/26/25. Per review of the 5-day summary report submitted to the State Agency, dated 8/1/25, Resident #1 was non-weight-bearing, at his/her baseline, and required complete care. After the fall, s/he reported pain in his/her right hip, back, and the back of his/her head. Resident #1 was transported to the hospital and was admitted for a left femoral neck (hip) and inferior and superior (Pelvic) pubic rami fracture. A Discharge Planning Form dated 7/27 from the local hospital reveals that Resident #1 was admitted to the hospital for management of severe hip pain. Per interview on 9/9/2025 at 2:38 PM with a Licensed Nursing Assistant (LNA) who was providing care for Resident #1 when the incident occurred, it was revealed that the LNA was providing evening care to the resident without assistance. The resident required a complete change of bed linen. When the LNA attempted to tuck in the sheets, he rolled the Resident #1 to the side of the bed; without assistance, s/he fell onto the floor.Per interview with the Unit Manager (UM) on 9/9/2025 at approximately 2:45 PM, she stated Resident #1 needs 2 people to assist with ADL care as mobility is limited. She states that the care plan includes this intervention, and the expectation is that the staff will follow it for safety. She states the resident would not have fallen had the interventions been followed.

Based on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Findings include: Per observation on 6/01/25 at 5:52 PM, fruit flies were observed flying around and on the juice machine in the kitchen. At 5:53 PM Kitchen Staff Member #1 confirmed there were flies by the juice machine stating, We have a fruit fly problem. On 6/4/25 at 12:50 PM during a second walk-through of the kitchen, fruit flies were observed around the juice machine. Per observation of the walk-in fridge on 6/1/25 at 5:58 PM, there were two gallon white and red tubs of baked beans in the fridge dated 5/27-5/30 [2025]. At 6:00 PM Kitchen Staff Member #1 confirmed these should have been discarded stating, I'll take care of these now. On 6/3/25 at 9:02 AM, a metal container of cranberry sauce dated 3/12-4/12 [2025] was found in the walk-in fridge. The Dietary Manager confirmed at approximately 9:03 AM that this should have been discarded.

Based on observation and interview, the facility failed to ensure resident medications were securely stored and expired medications and treatment materials were removed from possible use on all 4 resident units. Findings include: 1. An observation was conducted on the facility's Beechtree unit on 6/1/25 at 5:49 PM. An unattended medication cart was observed unlocked, with no facility staff present in the hallway where the medication cart was located. Per interview with a staff Registered Nurse at 5:51 PM, the medication cart contained physician prescribed medications for multiple residents and should remain locked at all times but was not. 2. Observations were conducted regarding medication storage on all 4 resident units on 6/2/25. Per observation of the medication storage room on the facility's Beechtree Unit on 6/2/25 at 3:28 PM, the storage room contained: -Silver antimicrobial wound gel, 7 packets, expiration date 3/22/25 -4x4 super absorbent dressing, 11 packets, expiration date 4/14/25 -Ketoconazole 2% cream, expiration March 2025- prescribed for Resident #27. Per interview with a staff nurse on the Beechtree Unit on 6/2/25 at 3:28 PM, all expired items were currently in use or available for treatment of the unit's residents. The staff nurse confirmed the expired items should have been removed and/or disposed of but were not. Per observation of 1 of 2 medication carts on the facility's Dogwood unit on 6/2/25 at 3:58 PM, the medication cart contained: -Budesonide inhalation suspension 0.5 milligrams, expiration date 8/2024 -Ondansetron 4mg tablets, 26 tablets- expiration date 5/27/25 - prescribed for Resident #3. Per interview with a staff nurse on the Dogwood Unit on 6/2/25 at 3:58 PM, all expired items were currently in use or available for treatment of the unit's residents. The staff nurse confirmed the expired items should have been removed and/or disposed of but were not. Per observation of 1 of 2 medication carts on the facility's Cherry Tree unit on 6/2/25 at 4:05 PM, the medication cart contained: -Germicidal Bleach wipes, used for cleaning resident glucometers [an instrument for measuring the concentration of glucose in the blood], expiration date May 2025. Per interview with a staff nurse on the Cherry Tree Unit on 6/2/25 at 4:05 PM, the expired bleach wipes were currently in use for cleaning of resident diagnostic equipment. The staff nurse confirmed the expired item should have been removed and/or disposed of but was not. Per observation of 1 of 2 medication carts on the facility's TCU unit on 6/2/25 at 4:15 PM, the medication cart contained: - micro-bleach wipes, used to clean the resident medication carts- expiration date Feb. 2025. Per interview with a staff nurse on the TCU Unit on 6/2/25 at 4:15 PM, the expired micro-bleach wipes were currently in use for cleaning of resident medication storage carts. The staff nurse confirmed the expired item should have been removed and/or disposed of but was not.

Based on interviews and record review, the facility failed to protect one resident (Resident #281) of 10 sampled residents from abuse. Findings include: Per review of the facility's OPS 300 Abuse Prohibition policy [last revised 10/24/22] states, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation of all residents .Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients of their families . Per review of Resident #281's medical record s/he has diagnoses of acute respiratory failure with hypoxia, CHF [Congestive Heart Failure], and CKD [chronic kidney disease]. S/he had a BIMS [Brief Interview of Mental Status] of 13 out of 15 on 2/14/25 indicating shis/her cognitive function is intact. The MDS [Minimum Data Set] states that Resident #281 is independent with ADLs [Activities of Daily Living] and is continent of bowel and bladder. Per record review of the facility's internal investigation of the alleged abuse dated 2/18/25, Resident #281 reported verbal abuse that occurred on 2/17/25. Per the internal investigation, Resident #281 stated that LNA [Licensed Nursing Assistant] #1 entered his/her room after the resident had episode of incontinence and stated, If you haven't been incontinent at home why are you doing it here? .Do you poop your pants at home? Resident #281 and his/her roommate confirmed the same statements made by LNA#1 in interviews documented in the facility's internal investigation. Per the facility internal investigation, LNA#1 made the following statement: She stated that she did yell but she did tell the resident that it isn't going to help [him/her] here in rehab if [s/he] is doing this and [s/he] normally doesn't do it at home. An email statement from another LNA on 2/19/25 stated, I do not know what she said to [him/her] but I do know that when she came out of the room she was mad that she had to do a full bed on [him/her] because [s/he] was incontinent of stool. She stated that s/he [Resident #1] just Laid there and [expletive] [his/herself] .She was very unhappy to have to clean this resident and made it very clear to me and another LNA. Per record review of the facility's internal investigation, the verbal abuse was confirmed by the facility. Per interview with the Administrator on 6/4/25 at 12:07 PM, the Administrator confirmed that the verbal abuse occurred and that Resident #281 was not free from abuse.

Based on observations, interview, and record review, the facility failed to promote a homelike comfortable environment by not maintaining the room temperature for 1 of 27 sampled residents (Resident #2). Findings include: Per record review, Resident #2 has a diagnosis of Multiple Sclerosis (disease of the central nervous system that often affects body temperature regulation). Per interview with Resident #2 on 6/3/2025 at 9:37 AM, the resident reported that he/she is cold whenever the temperature is below 70 degrees Fahrenheit outside. Resident #2 stated that he/she told a staff member about being cold and they turned the heat up for a couple of days, but then they shut it off. They believe the heat is turned off because it is sunny outside, but when it isn't sunny he/she is cold. Resident #2 has a thermometer in his/her room and reported it dropped down to 65 degrees Fahrenheit a couple nights ago. Resident #2 stated they wanted their room to be warmer so they could be more comfortable. Per observation on 6/4/2025 at 8:13 AM, the temperature in Resident #2's room was 68.9 degrees Fahrenheit, and at 8:56 AM the temperature was 68.5 degrees Fahrenheit. Per interview with the Maintenance Director on 6/4/2025 at 8:56 AM, he confirmed that the temperature was 68.5 degrees Fahrenheit in Resident #2's room and reported that the federal regulation requires the temperature to be between 71 degrees Fahrenheit and 81 degrees Fahrenheit. The Maintenance Director reported that Resident #2 informed him of being cold and he turned up the heat and thought it was working but didn't follow up to see if Resident #2's room temperature increased. The Maintenance Director reported that he did not put Resident #2's temperature issue in TELS (their system for monitoring maintenance issues) and if he had, the process would have been to recheck the issue. Additionally, the Maintenance Director reported he gets notifications on his phone and depending on the severity will come in to address issues right away and that if he would have, he would have come back to check on the temperatue. In regard to Resident #2 being cold, he said that he would have come right away as being cold is a life safety issue. A temperature policy was requested and per an email from the Director of Nursing (DON) on 6/5/2025, they confirmed We do not have our own policy on temperature in the building. We follow the State of Vermont's recommendations. Work Cited Christogianni, A., [NAME], R., [NAME], S. L., [NAME], O., [NAME], M., Evangelou, N., & Filingeri, D. (2018, September 5). Temperature sensitivity in multiple sclerosis: An overview of its impact on sensory and cognitive symptoms. Temperature ([NAME], Tex.). https://pmc.ncbi.nlm.nih.gov/articles/PMC6205043/

Based on interview and record review, the facility failed to protect 2 of 4 of the applicable sample (Residents #34 and # 48) from coercion and reprisal by the facility, as evidenced by reprimanding residents for discussing concerns about the care they received with the State Agency. Findings include: Per a resident council meeting with State Agency representatives on 6/3/2025 at 2:30 PM, Residents #34 and #48 expressed concerns about speaking with the State Agency representatives regarding the care provided by the facility. They explained that they had discussed their concerns with the surveyors during the last survey. When the facility received a citation, they were questioned by the Unit Manager. Resident # 34 stated s/he was afraid to speak out about concerns about his/her care or file a grievance for fear of being questioned or of retaliation that might result in poor care. Resident #48 stated, We should not have to worry about this; we don't trust them anymore. Per record review, a Brief Interview for Mental Status (BIMS) yields a score of 15 for Resident #34, indicating that he/she is cognitively intact. A review of Resident #48's BIMS reveals a score of 15, indicating that s/he is cognitively intact. A review of the Sample List Provided to the Facility (a list provided to the facility by the survey team, where a number is assigned to each resident to protect their anonymity) dated 4/11/2024, reveals that both residents were included in a citation at the facility's annual recertification survey in 2024. Per interview with the Administrator on 6/4/2025 at 8:55 AM, she confirmed that it is a resident's right to discuss their care with State Surveyors, and they should not be questioned, reprimanded, or coerced after voicing concerns.

Based on observation, interviews, and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good hygiene as evidenced by excessively long fingernails, long thick toe nails, not providing showers, shaving, and range of motion exercises, for 4 of 36 sampled residents (Resident #102, #40, #83, and #3). Findings include: 1. Per observation on 4/9/24 at 2:17 PM Resident #102 was noted to have long fingernails with chipped nail polish and brown substance under their nails. Resident #102 was sitting in their wheelchair in their room with their hand up to her/his eye rubbing it. Resident #102 also was noted to have approximately 1/4 inch stubble on their chin. Per record review Resident #102's care plan reflects that staff should provide extensive assist for dressing and personal hygiene. On 4/11/2024 at 4:00 PM during an interview with the Unit Manager (UM) Resident #102's fingernails were again observed long with chipped nail polish and brown substance under the nails. The UM confirmed that Resident #102's nails were long and dirty and that it is the expectation that nursing staff would trim and clean finger nails when needed. The UM confirmed that the resident's nails were long and dirty. Resident #102 also was noted to have facial hair growth on their chin. The UM also confirmed that staff are expected to shave residents when they have hair growth on their face. 46135 2. Per interview on 4/09/24 at 5:18 PM, Resident #3 explained that s/he has not had his/her face shaved in three weeks and his/her preference is to be shaved twice a week. S/He explained that having his/her face shaved is really important to him/her and because s/he cannot use his/her hands to shave his/her face, s/he has to depend on staff entirely to complete this task. S/He stated that staff report to him/her that they are too busy to shave him/her because they are short staffed. Per record review, Resident #3's care plan states Patient is at risk for decreased ability to perform ADL's [activities of daily living] in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, related to: MS [multiple sclerosis] and Limited mobility, weakness, revised on 8/25/2023 with an intervention to Provide 2 assist with ADLs, revised on 5/05/2023. There are no interventions in Resident #3's care plan that describe his/her preference to be shaved twice a week. Per interview on 4/10/24 at 4:45 PM, a Licensed Nurse Aide (LNA) explained that Resident #3 likes to be shaved frequently but staff have a hard time getting to it because they are so busy. This LNA explained that s/he had been shaving Resident #3's face the previous month and was unable to complete the task due to the workload. S/He had informed the oncoming evening shift to shave the other half of Resident #3's face but they never did. It had to be done the next day and Resident #3 was very upset. Per interview on 4/11/2024 at 9:21 AM, the acting Unit Manager explained that Resident #3's shaving preferences should be on his/her care plan. 3. Per observation and interview on 4/9/2024 at 1:36 PM, Resident #83 explained that s/he needs her toenails cut but no one is doing them. His/her toenails are very long, appearing to be at least a half inch past the end of his/her toes. Per record review Resident #83's care plan reveals that Patient is at risk for decreased ability to perform ADLs related to activity intolerance, weakness, limited mobility, Parkinson's disease [a disorder of the central nervous system that affects movement], long term care need, revised on 7/5/2023, with the goal to improve current level of function in ADLs by next review as evidenced by improved ADL scores, revised on 3/1/2024. While there are no interventions related to hygiene, or nail cutting in Resident #83's care plan, a 3/4/2024 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) reveals that s/he is dependent on staff for all personal hygiene. 43524 4. Review of wound documentation for residents pressure ulcer on her/his right great toe that required amputation revealed wound pictures that showed toe nails that were thick and long - each wound assessment picture showed additional growth and thickening of the residents nails. Interview on this date at approximately 2:30 PM with Licensed Practical Nurse (LPN) stated that there is currently no access to podiatry services and residents need to be sent out for these service. Per record review revealed pictures of a wound on the residents right great toe. In a picture taken from the inner side of the residents right foot, dated December 6, 2023 at 07:23 of this wound, showed the resident is noted to have long and thick toenails. A picture taken from the inner side of the residents right foot, of the same wound dated December 14, 2023 at 13:20 revealed the residents nails were longer than in the picture on 12/6/23. A picture taken from the inner side of the residents right foot, of the same wound dated Decemeber 23, 2024 at 13:32 revealed the residents nails were longer than in the picture on 12/14/23. A picture taken from the inner side of the residents right foot, of the same wound dated January 2, 2024 at 12:16, revealed the residents nails were longer than in the picture on 12/23/24. A picture taken at a different angle, looking down at the tips of the residents toes, revealed the same wound dated January 3, 2024 at 10:41, showed the residents nails were noted to be long and thick with a thick placque/debris under their right great toenail. A picture taken on January 11, 2024 at 09:48, from a similar angle to the picture on 1/3/24 revealed long and thick toenails. A picture taken on January 17, 2024 at 08:57 taken from the bottom of the residents right foot, looking at the underside of the toenails, revealed long and thick toenails with the toenail of the great toe extending beyond the end of the residents toe. Interview on 4/11/24 at approximately 4 PM with a unit LPN, who confirmed that the residents toenails were quite long however the facility did not have a podiatrist at the time. When asked what the process was for residents receiving podiatry care, s/he stated that a call is made to the residents doctor for an order and then once the order is received a call is made to a local podiatrist and an appointment is made. S/he stated that there is no log book kept for residents needing podiatry. This was confirmed by an RN who was also present during this interview. The resident has since passed away.

Based on observation and interview the facility failed to serve food that is palatable and at an appetizing temperature to 3 of 36 sampled residents (Resident # 99, #11 and #12) Findings include: 1. Per record review Resident #99 was admitted to facility on 02/04/2024 with the following diagnosis: Alzheimer ' s dementia, stroke with aphasia (inability to express speech), and heart failure. Resident # 99 has the following care plan dated 02/14/2024 that states resident is at risk for malnutrition related to mechanical soft diet, need for assistance with meals. A nursing note written by the Unit Manager (UM) dated 4/10/2024 reflects that Resident # 99 has evidence of weight loss note states Resident triggers for weight loss. Meal intake varies at 50-100% for meals with snacks offered. During observation on 4/09/2024 at 4:30 PM until 6:00 pm in the Cherry Tree Country Kitchen area, Resident # 99 was sitting in his/her wheelchair at the table with two other residents. At 4:50 PM the start of meal service began.At 4:55 pm the two other residents at the table received their dining trays. Resident # 99 was not offered a tray or a beverage. A licensed nursing assistant (LNA) left the resident's table and continued to pass other trays. At 5:40 pm the Dietary Manager entered the dining area. This surveyor alerted them that the resident has still not been assisted with their meal and that meal was sitting on the table, uncovered for several mintues. Requested temperatures be completed on Resident # 99 ' s food prior to it being served as it had been sitting out for 40 minutes. At 5:45 pm using their own thermometer the Dietary Manager and this surveyor checked the temperature of the food on Resident # 99's plate and confirmed the temperature of the food on Resident # 99's plate was no longer palatable. The Dietary Manager confirmed based on the temperature of the meal for Resident # 99 it should not be served and removed the plate from in front of Resident # 99. At 5:55 pm the Kitchen Manager returned with a new plate of food for Resident # 99. 43524 2. Observation on 4/9/24 at 5:45 PM of the [NAME] Tree BLVD (Boulevard) dining room revealed resident's #11, #12 and # 17 sitting at a table together. Resident #17 was eating their dinner while Resident #11 and Resident #12 watched Resident #17 eat. It was noted that at 6:00 PM Resident #11 and Resident #12 had still not received their meals. The RN/Unit Manager was observing the staff passing trays in the dining room, and had observed two surveyors discussing this particular observation. The RN/Unit Manager went over and spoke to an LNA who had been passing trays in the dining room. This LNA gathered a tray from the food cart and brought it to the table for Resident #12. This LNA immediately returned to the food cart and gathered a second tray which they brought to the table for Resident #11. Interview on 4/9/24 at 6:10 PM with an LNA who was preparing drinks for the food trays and who was present at the time of these observations, stated that the food carts had arrived late and staff were trying to get the meals out. They stated that the food carts usually arrive between 5:15 PM and 5:30 PM. This LNA was asked about the dining process and if it is typical for a table of 3 residents to not all have their meals at the same time. S/he stated that they (staff) try to serve restaurant/dining style where everyone gets served together, however, with the food carts arriving late, staff were trying to get all the trays out and this was missed.

Based on interview and record review, the facility failed to ensure that residents who use psychotropic drugs are accurately monitored for behaviors and/or side effects for 3 of 6 sampled residents (Residents #15, #10, and #98). Findings include: 1. Per record review, Resident #15 has diagnoses that include anxiety disorder and major depressive disorder. Resident #15's care plan states, Resident is at risk for complications related to the use of psychotropic drugs- Sertraline- major depressive disorder. Hydroxyzine- anxiety, revised on 10/23/2023. Resident #15 has physician orders for the following psychotropic medications: Hydroxyzine HCl Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet by mouth every 12 hours as needed for anxiety for 30 Days -Start Date- 03/21/2024 and Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression -Start Date- 02/21/2024. Per review of Resident #15's Medication Administration Record (MAR) Resident #15 was administered Hydroxyzine on 3/22/24, 3/23/24, 3/24/24, 3/25/24, 3/27/24, 3/28/24, 3/29/24, 4/1/24, 4/5/24, 4/6/24, 4/8/24, 4/10/24 for anxiety. There is no documentation on Resident #15's MAR, Treatment Administration Record (TAR), or in Resident #15's POC (point of care; electronic documentation system for Licensed Nursing Assistants) that Resident #15 was experiencing any behaviors and there were no orders or tasks to monitor behaviors. Resident #15's care plan did not include interventions to monitor behaviors. 2. Per record review, Resident #10 has diagnoses that include schizophrenia, bipolar disorder, major depressive disorder, and anxiety. Resident #10's care plan states, Resident is at risk for complications related to the use of psychotropic drugs Medication: risperidone-schizophrenia paxil-depression, revised on 1/20/2024 with an intervention to Complete behavior monitoring flow sheet, created on 11/5/2019. Resident #10 has physician orders for the following psychotropic medications: Paroxetine HCl Oral Tablet 10 MG (Paroxetine HCl) [Paxil] Give 0.5 tablet by mouth at bedtime for depression given with 20mg tab to equal 25mg at Bedtime -Start Date- 01/18/2024; Paroxetine HCl Oral Tablet 20 MG (Paroxetine HCl) [Paxil] Give 20 mg by mouth at bedtime for depression -Start Date- 01/19/2024; and risperidone Oral Tablet 1 MG (Risperidone) Give 1 mg by mouth in the morning for antipsychotic -Start Date- 01/19/2024. There is no documentation on Resident #10s MAR, TAR or in Resident #10's POC that Resident #10 was experiencing any behaviors and there were no orders or tasks to monitor behaviors. Per interview on 4/11/24 at approximately 5:45 PM the Director of Nursing stated that behaviors should be monitored 3 times a day for residents taking psychotropic medications and confirmed that Resident #15 and #10 did not have behavior monitoring. 50336 3. Per record review Resident # 98 was admitted to the facility on [DATE] with diagnoses that include dementia with behavioral disturbances, agitation, restlessness, and hyperactive behaviors. Resident # 98 has the following orders written by advance nurse practitioner, prescription last updated on 4/01/2024: Seroquel 50 mg by mouth. Directions give 50 mg of Seroquel two times a day by mouth for delusions, psychosis, and agitation, and 25 mg as needed. Hold for Lethargy (excessive tiredness) and Trazadone 25 mg by mouth three times a day for agitation and 25 mg every 8 hours as needed, hold for lethargy. Resident # 98 has been receiving psychotropic medications since 10/09/2023 without an order to monitor behavior or adverse reaction to medication. Review of medication administration record for March and April 2024 shows that Resident # 98 received all scheduled doses of psychotropic medications without monitoring for behaviors or adverse effects. Resident # 98's care plan initiated on 10/09/2023 Resident is at risk for complications related to the use of psychotropic drugs Medication: Trazadone- agitation, restlessness Seroquel- agitation/psychotropic medications. Monitor for changes in mental status and functional level and report to MD (Physician). Monitor for continued need of medication as related to behavior and mood. Per observations of Resident # 98 on 04/09, 04/10, and 04/11/2024, on the unit in the Cherry Tree Country Kitchen area, Resident # 98 was sleeping in their wheelchair on several occasions. Resident #98 was observed frequently sleeping though meals each day at different mealtimes. Review of the medication administration record for March and April 2024 there is no documented evidence that Resident #98 was evaluated for adverse effects prior to medication administration. There is no evidence that psychotropic medications were held related to sleepiness. Facility Policy Psychotropic Medication Use, last revised, 10/24/2022 states All medications used to treat behaviors must have a clinical indication and be used in the lowest possible does to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for efficacy, risks, benefits, and harm or adverse consequences. Policy also states medications used to treat behaviors will be monitored for harm of adverse consequences. Per interview 4/11/2024 at approximately 3:00 pm the License Practical Nurse (LPN) Unit Manager (UM), confirmed that Resident #98 has had an increase in sleepiness thought to be due to a recent pneumonia. However there is no evidence of monitoring for adverse effects or increased behaviors related to the psychotropic medications. The Unit Manager confirmed that the expectation would be to have an order to monitor and document in the medical record any adverse effects or behaviors. The Unit Manager also confirmed that Resident # 98 received all scheduled doses of Seroquel and Trazadone for the months of March and April 2024.

Based on observation and resident and staff interview, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs impacting 2 of 4 units (Units Dogwood and Cherry Tree). Findings include: 1. Per interview on 4/09/24 at 11:52 AM, Resident #95 expressed frustration that there are not enough staff in the facility and sometimes the staff are miserable because of how few staff are on. S/He explained that she had to wait for 45 minutes for staff to help him/her get off of the toilet recently. S/He explained that s/he would like to get up and walk everyday but there are not enough staff to help him/her do that and s/he ends up just sitting 13 hours straight in his/her wheelchair. Per observation and interview on 4/9/2024 at 1:36 PM, Resident #83 explained that s/he needs her toenails cut but no one is doing them. His/her toenails are very long, appearing to be at least a half inch past the end of his/her toes. Resident #83 explained that s/he has contractures in his/her hand because s/he has Parkinsons. S/He explained that she likes to have staff help him/her open his/her hands at least three times a day so s/he can exercise her hands in order to maintain the function s/he has left in her hands. While s/he was talking, s/he demonstrated for this surveyor how s/he couldn't open his/her hands and wanted to. S/He stated that it is very important to remain as independent as possible. S/He stated that s/he is not getting these things done because there are not enough staff and the ones that are on are too busy. Per interview on 4/09/24 at 3:14 PM, Resident #94 stated that there are many times when there are not enough staff to help. S/He explained that sometimes s/he needs a bed pan and sometimes s/he is incontinent before s/he gets help. S/He explained there is about a 50/50 chance that staff will get to him/her on time to help him/her before s/he has an accident. Per interview on 4/09/24 at 4:16 PM, Resident #15 stated that the facility is short staffed. S/He said it is hard for her to get help doing things, like having someone put lotion on him/her or cut his/her nails. Per interview on 4/09/24 at 5:18 PM, Resident #3 explained that s/he has not had his/her face shaved in three weeks and his/her preference is to be shaved twice a week. S/He explained that having his/her face shaved is really important to him/her and because s/he cannot use his/her hands to shave his/her face, s/he has to depend on staff entirely to complete this task. S/He stated that staff report to him/her that they are too busy to shave him/her because they are short staffed. Per observation and interview on 4/10/24 at 8:32 AM, Resident #107 was sitting in the dining room. S/He explained that s/he has to sit and wait in the dining room for a very long time after s/he finishes eating, sometimes for an hour, before staff are able to bring him/her back to his/her room, every day. S/He said s/he cannot bring herself back to his/her room on his/her own and does not want to be in the dining area. S/He reports that staff tell her they are too busy to take him/her back all the time. 2. Per interview on 4/11/24 at 10:49 AM, LNA #2 stated that aides cannot get all their patient care done when there are only 3 or 4 aides working on the unit. S/He explained that there are many times on weekends when there are only 3 aides working on the unit. Per interview on 4/10/24 at 4:45 PM, a Licensed Nurse Aide explained that it is hard to get resident care done if there are less than 5 aides on the unit and extremely hard if there are less than 4 aides on the unit. She explained that staff run around like chickens with their heads cut off a lot of the time because there is so much work to do. S/He explained that call bells are going off non-stop throughout her shift all the time. 40258 3. Per record review Resident # 99 has the following care plan dated 02/14/2024 that states resident is at risk for malnutrition related to mechanical soft diet, need for assistance with meals. During observation on 4/09/2024 at 4:30 PM in the Cherry Tree Country Kitchen area, Resident # 99 was sitting in his/her wheelchair at the table with two other residents that eat independently. Per record review all three Residents at the table have a diagnosis of Dementia. At 4:50 PM the start of meal service began. At 4:55 pm the two other residents at the table received their dining trays. Resident # 99 was not offered a tray or a beverage. A licensed nursing assistant (LNA) left the resident ' s table and continued to pass other trays. At 5:00 pm the resident to the left of Resident #99 picked up a canned pear off his/her plate and with bare hands handed it to Resident # 99. Resident # 99 took the pear and began to eat it, until it slipped from their fingers and dropped to the floor. Staff who were present in the dining room did not notice the interaction or the dropped pear. At 5:05 pm Resident # 99's tray arrived at the dining area. A LNA placed Resident # 99's plate with a cover over it in the middle of the table out of Resident # 99 ' s reach. The LNA was observed walking away from the table and did not interact with Resident #99. At 5:55 PM, 50 minutes after Resident #99's meal had been placed on the table, after being made aware of the situation, the Kitchen Manager provided a new plate of food for Resident # 99. At 6:00 PM a Licensed Practical Nurse (LPN) began to assist Resident # 99 with their meal, while the other residents left the dining room. The LPN on duty stated that Resident # 99 does require assistance with eating but can also eat on their own. The LPN confirmed Resident # 99 should have been offered their food while others were dining. The LPN stated that some residents who eat in their room require assistance with eating, and others in the dining room, making assisting all residents with their meals at the same time challenging. See F-557

Based on observation, interview, and record review, the facility failed to ensure that the activities program meets the needs of each resident for 5 of 9 Sampled Residents (Residents #91, #19, #15, #95, and #72). Findings include: 1. Per interview on 4/9/24 at approximately 6:00 PM, Resident #91's daughter stated that since admission on 3/21/24, Resident #91 has spent their days sitting in their room with no activities or stimulation other than the television. At home, Resident #91 would color, listen to music, do puzzles or cards, as well as get stimulation from their visiting aides. At the facility, they don't give Resident #91 anything to do. No one in the facility has asked her about what activities Resident #91 likes. Per record review, Resident #91 has diagnoses of Parkinson's Disease and Dementia. Their Admission MDS (Minimum Data Set Assessment) from 3/24/24 lists their BIMS (brief interview of mental status) score as 4, indicating serious impairment of cognitive abilities. Their MDS activities assessment lists having family involved in discussions about care and doing their favorite activities as somewhat important. Resident #91's care plan for activities, created on 3/28/24, lists the following interventions: - It is important for me to have family or a close friend involved in discussions about my care. - I like to listen to music, look out the window, lay down/rest, watch TV/movies by myself in my room. - It is important for me to engage in my favorite activities. Per review of the facility's activities participation logs for Residents, no log could be found for Resident #91. Per observations on 4/9/24 at 2:00 PM, 6:00 PM, and on 4/10/24 at 10:00 AM, 2:00 PM, 5:00 PM, and 6:00 PM, Resident #91 was observed to be sitting in a recliner looking out the window or watching TV with an empty tray table in front of them and no activities or engaging materials in the room. There were also no signs of any visitation by facility staff for the purposes of engagement during these observations. Per observation/interview on 4/11/24 at approximately 9:00 AM, Resident #91 was observed with a packet that contained a list of the day's group activities, a selection of news articles, and a crossword puzzle. This surveyor asked Resident #91 if they were interested in any of the group activities today. Resident #91 said no. This surveyor then asked if Resident #91 would like to do more activities in their room. Resident #91 nodded and said yes. This Surveyor asked if Resident #91 would like to do the crossword puzzle. Resident #91 nodded and looked around for a writing utensil. There were no writing utensils in the room. Per interview on 4/11/24 at approximately 9:10 AM, an activities assistant confirmed that every resident in the building gets a packet each morning with a list of the day's group activities as well as news articles and a puzzle. When asked how residents who choose to/must stay in their rooms are engaged in the activities program, the activities assistant stated that one-on-one visits are done for some residents, but they aren't sure how these residents are determined to need one-on-one visits or how frequently they are expected to happen. The activities assistant stated that every new Resident gets assessed by an activities staff member on admission for their activities interests but that Resident representatives are not regularly included in this assessment, even if the resident has cognitive deficits. Per interview on 4/11/24 at approximately 9:30 AM, the Activities Director stated that they don't attend initial care plan meetings with residents and/or representatives. Newly admitted Residents will have an initial activities assessment done with them to determine their preferences for activities. Resident representatives are only consulted on this assessment if the resident is unable to answer questions, and the Resident's mental status is not taken into account. The Activities Director stated that some Residents receive regular one-on-one visits, but there is no formal process for determining which Residents should receive these or how frequently. One-on-one visits are also not regularly documented as having been conducted on activities logs for Residents. The Activities Director confirmed that Resident #91 does not wish to attend group activities and does not receive one-to-one visits or activities support from the activities program. On 4/11/24 at 11:00 AM and 12:00 AM, Resident #19 was again observed to be sitting in a recliner looking out the window or watching TV with an empty tray table in front of them and no activities or engaging materials in the room. 2. Interview on 4/9/24 at approximately 2:45 PM, Resident #19 stated s/he is not able to leave their room, or sit in a wheelchair because they are not able to support their own weight due poor upper body strength. Resident #19 was asked what activities they are able to participate in, they replied they are not able to leave their room, so they are not able to participate in group activities. This surveyor asked what activities are provided to the resident in their room and s/he stated there is nothing provided to them in their room. When asked if they were happy doing independent activities or if they would like to have additional activities provided to them in their room, they stated they would enjoy some facility activities instead of having to entertain themselves all the time. Review of Resident #19's activity logs for February, March, and April 2024 reveal the following: In February 2024, Resident #19's participation in activities included independent Computer/Tablet/Technology Use for 29 of 29 days, and independent Current Events/News/Mail for 13 of 29 days; in March 2024, Resident #19's participation in activities included independent Current Events/News/Mail for 16 of 31 days; and in April 2024, Resident #19's participation in activities included independent Current Events/News/Mail for 5 of 10 days. Review of Resident #19's current care plan revealed s/he is care planned for activities of [pronoun omitted] preference - it is documented that [pronoun omitted] enjoys doing activities in [pronoun omitted] room like listening to music, using [pronoun omitted] cell phone, watching the news etc. 46135 3. Per interview on 4/09/24 at 11:56 AM, Resident #95 explained that the only thing s/he does is watch TV and play bingo. S/He likes bingo but wished there were other activities to participate in. On 4/11/2024 at 5:44 PM, Resident #95 explained that s/he would like to participate in more activities but they do not have much for him/her to participate in and no one does any kind of activities, like 1 on 1 visits, in his/her room. S/He explained that s/he does not go out for walks or go outside and s/he would like to. S/He said s/he is very bored. Per record review, Resident #95's care plan states While in the facility, [Resident #95] states that it is important that [s/he] has the opportunity to engage in daily routines that are meaningful relative to [his/her] preferences, created on 12/15/2022, with interventions that include [Resident #95] will plan and choose to engage in preferred activities .I like to participate in social activities with groups of people .It is important for me to engage in my favorite activities .It is important for me to go outside when the weather is good and enjoy sitting/relaxing and talking/visiting, all created on 12/15/2022. Resident #95 does not have any activity interventions in their care plan created or revised after 12/15/2022. Review of Resident #95's activity logs for February, March, and April 2024 reveal the following: In February 2024, other than bingo and watching TV, Resident #95's participation in activities included salon/painting nails 5 times, 2 social visits, and receiving the newsletter; in March 2024, other than bingo and watching TV, Resident #95's participation in activities included salon/painting nails 4 times and 2 social visits; and in April 2024, other than bingo and watching TV, Resident #95's participation in activities included 5 social visits and receiving the newsletter. Of note, the activity log for April 2024 was reviewed on 4/11/2024 and the activity log was filled out through the end of the month for TV and social visits. 4. Per interview on 4/10/24 at 10:05 AM, Resident #72 indicated that there is nothing to do for activities that interests him/her in the facility. S/He said, all they have is bingo or toss the ball, but there is nothing to do and they used to have more. S/He said s/he would like to sit outside for a little bit or go for a walk but doubt that will happen since they are short staffed. Per record review, Resident #72's care plan states it is important that [s/he] has the opportunity to engage in daily routines that are meaningful relative to [his/her] preferences, revised on 10/13/2020, with interventions to Encourage and facilitate [Resident #72's] activity preferences .It is important for me to go outside when the weather is good and enjoy sitting, talking/visiting, walking. A recreation assessment dated [DATE] states Recreation will encourage more participation in group activities as they have decreased since the pandemic. Review of Resident #72's activity logs reveals that s/he does not have a log for February or March 2024 and April 2024's log reveals that the only participation Resident #72 had in activities was receiving the newsletter. There is no record of additional group, individual, or independent engagement for this period. There is no evidence on the log that Resident #72 refused to participate in activities. 5. Per interview on 4/09/24 at 12:31 PM, Resident #15 explained that s/he likes bingo, but there is not too much other than that. On 4/11/2024 at 5:20 PM, s/he explained that s/he would like to do more activities in his/her room. S/He explained that s/he would also like to go outside but can't because there is no one to bring [him/her] since they are so short staffed. Per record review, Resident #15's care plan states, While in the facility, [Resident #15] states that it is important that [s/he] has the opportunity to engage in daily routines that are meaningful relative to [his/her] preferences, revised on 5/24/2021, with interventions that include It is important for me to engage in my favorite activities .It is important for me to go outside when the weather is good and enjoy sitting/relaxing, revised on 5/24/2021. Review of Resident #15's activity logs for February, March, and April 2024 reveal that the only participation in activities was receiving the newsletter. There is no record of additional group, individual, or independent engagement for this period.

Based on observation and interview, the facility failed to provide a homelike environment for 1 of 4 units (Unit D) resulting in all residents on the unit being subjected to continuous loud alarms throughout the day. Findings include: Per observation on Unit D during the recertification survey on 4/9/2024 through 4/11/2024, call bell alarms were repeatedly going off for extended periods of time. Unit D has approximately 50 residents. There is a large multipurpose room in the center of the unit which serves as a living area and dining area. There is a television located on the wall. Observations were made during lunch and dinner on 4/9/2024, breakfast, lunch, and dinner on 4/10/204, and lunch and dinner on 4/11/2024. There was an average of 8 to 10 residents eating in the common area during the above meals. Call bell alarms went off for at least 10 minutes and up to 40 minutes straight for all of the meals observed. Once stopped, the call bell alarms usually started back up again a few minutes later. The alarm bell sounds was at a loud volume the entire time; as loud as the surveyors speaking voice. Per observations on 4/9/2024 the call bell alarms were going off on Unit D at 10:50 AM through 11:20 AM straight with only a couple 30 second pauses. 8 residents were sitting in the common area during this time. Per interview on 4/9/2024 at approximately 4:30 PM, Resident #94 stated that the call bell alarms were bothersome. Per observation and interview on 4/10/2024 at 8:30 AM, Resident #30 was sitting in the common area at a table eating breakfast watching TV. S/He stated that s/he hated the call bells and that they were very loud. The call bell alarms were louder than the TV volume. Per interview on 4/10/24 at 4:45 PM, a Licensed Nurse Aide (LNA) explained that the call bells go off non-stop, all day long, every day. Per interview on 4/11/24 at 10:49 AM, LNA #2 stated that the call bell alarms are going off all the time and a Licensed Practical Nurse agreed. Per interview on 4/11/2024 at approximately 5:45 PM, the Administrator confirmed that the alarms were very loud for an area that is frequently used by residents.

Based on observations, interviews and record review the facility failed to develop a person-centered comprehensive care plan for 3 of 36 residents sampled (Resident #72, #3, and #83). Findings include: 1. Per observation and interview on 4/10/24 at 10:05 AM, Resident #72 stated that s/he has lost a lot of weight being at the facility. While s/he is speaking, it appears as though s/he has no top teeth and most of the bottom teeth that remain are extremely decayed and most of his/her bottom teeth are so loose that they are moving around in his/her mouth. Per record review, Resident #72 weighed 175.2 pounds on 7/2/22. The next weight entered into his/her medical record is 139.0 pounds, taken on 2/28/2024. Resident #72's 1/26/24 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) reveals s/he is at risk of malnutrition. While a 1/26/24 Nutritional Assessment completed by the Dietician reveals that there were no nutritional concerns identified, the assessment was completed based on the 7/2/2022 weight. There are no nutritional assessments completed following Resident #72's 2/28/2024 weight of 139.0, a 36 pound difference from the weight used for the previous month's nutritional assessment. Resident #72's care plan does not include goals, measurable objectives, interventions, and timeframes for how staff will meet the resident's needs for nutrition. Per interview on 4/11/2024 at 5:01 PM, the Director of Nursing confirmed that Resident #72's care plan did not adequately address nutrition or risk for weight loss. 2. Per interview on 4/09/24 at 5:18 PM, Resident #3 explained that s/he has not had his/her face shaved in three weeks and his/her preference is to be shaved twice a week. S/He explained that having his/her face shaved is really important to him/her and because s/he cannot use his/her hands to shave his/her face, s/he has to depend on staff entirely to complete this task. Per record review, Resident #3's care plan states Patient is at risk for decreased ability to perform ADL's [activities of daily living] in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, related to: MS [multiple sclerosis] and Limited mobility, weakness, revised on 8/25/2023 with an intervention to Provide 2 assist with ADLs, revised on 5/05/2023. There are no interventions in Resident #3's care plan that describe his/her preference to be shaved twice a week. Per interview on 4/10/24 at 4:45 PM, a Licensed Nurse Aide explained that there is not a system to alert staff about when to shave a resident and indicated that s/he is not sure where s/he would find Resident #3's preferences documented. Per interview on 4/11/2024 at 9:21 AM, the acting Unit Manager explained that Resident #3's shaving preferences should be on his/her care plan. 3. Per observation and interview on 4/9/2024 at 1:36 PM, Resident #83 explained that s/he has contractures in his/her hand because s/he has Parkinson's (a disorder of the central nervous system that affects movement). S/He explained that she likes to have staff help him/her open his/her hands at least three times a day so s/he can exercise her hands in order to maintain the function s/he has left in her hands. While s/he was talking, s/he demonstrated for this surveyor how s/he couldn't open his/her hands and wanted to. S/He stated that it is very important to remain as independent as possible. Per record review, a 12/7/2023 nursing note reveals that Resident #83 has Left upper extremity contracture. Right upper extremity contracture. Left lower extremity contracture. Right lower extremity contracture. Upper extremity impairments on both sides. Lower extremity impairments on both sides. Resident #83's care plan reveals that Patient is at risk for decreased ability to perform ADLs related to activity intolerance, weakness, limited mobility, Parkinson's disease, long term care need, revised on 7/5/2023, with the goal to improve current level of function in ADLs by next review as evidenced by improved ADL scores, revised on 3/1/2024, and an intervention that s/he eats independently after set up, created on 5/4/2023. There are no interventions that address Resident #83's contractures or the care that s/he as expressed as being important to her (such as assistance with range of motion exercises in her hands).

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice related to proper wheelchair positioning and follow through on physical therapy recommendations for 1 resident (Resident #87) and failed to identify and provide needed care and services regarding bowel management to prevent rehospitalization for 1 Resident (Resident #58) in a sample of 31 Residents. Findings include: 1. Per record review of the facility January Bowel Record reveals that resident #58 had no documented bowel movements from 1/1 - 1/7/2023 and 1/23 - 1/27/2023. The Resident experienced untreated constipation resulting in a 15 day rehospitalization . Physician orders written on 10/4/2022 state: Milk of Magnesia Suspension 400mg/5ml (Magnesium Hydroxide) Give 30 ml (milliliters) by mouth as needed for constipation, give at bedtime if no BM (Bowel Movement) in 3 days. Bisacodyl Rectal Suppository 10mg. Insert 1 application rectally every 24 hours as needed for constipation if no result from MOM (Milk of Magnesia). Fleet Enema Rectal Enema (Sodium Phosphates). Insert 1 application rectally as needed for constipation if no result from bisacodyl within 2 hours. However, the Resident's Medication Administration Record (MAR) for the month of January reveals that during the 7-day period from January 1st to January 7th and the 5 day period between 1/23- 1/27/23 the resident did not receive any of the above ordered medications. A Nurse progress note written on 1/21/23 at 4:51 AM states that resident #58 had been complaining of stomachache and cramps all during the night and had had an episode of vomiting with am and no further complaints. S/he was sent to the hospital later in the day with abdominal pain and was admitted . The Resident returned to facility on 1/23/23. On 1/26/2023 at 5:12 PM the resident was vomiting, and claimed s/he had not had a recent bowel movement. The nurse listened to the resident's bowel sounds and they were present in all quadrants, and her/his abdomen was soft and non-tender. On 1/27/23 the Resident continued to complain of nausea and vomiting, and received Milk of Magnesia. At 10:40 AM the Resident was transferred to the hospital with the diagnosis of bowel obstruction (a serious problem that happens when something blocks your bowels, either your large or small intestine). Review of the hospital Emergency Documentation dated 1/27/2023 the Resident's last bowel movement was 1/22/23 and is experiencing coffee ground emesis (vomit that looks like coffee grounds). While at the hospital the Resident underwent a computed tomography scan (CT Scan, a medical imaging technique used to obtain detailed internal images of the body), a nasogastric tube was placed for decompression, the Resident received intravenous fluids, and laxative suppositories resulting in bowel movements. The resident returned to the facility on [DATE], 15 days later. Per interview on 04/04/23 at 2:05 PM with the Unit Manager (UM), Licensed Practical Nurse (LPN) the facilities process for bowel management includes the night nurse is to check all the resident's bowel movement records and make a bowel list every night (a list of residents that have no had a bowel movement in 3 days or more). This list is given to the day shift nurse who starts the bowel protocol. The bowel protocol follows Milk of Magnesia on day 3 of no bowel movement, Bisacodyl suppository to follow on the 4th day of no bowel movement, Fleet enema on 5th day of no bowel movement. The UM confirmed that there was no documentation that the Resident had a bowel movement during 1/1 - 1/7 and 1/23-1/27 and that the facility bowel management protocol had not been followed. The UM also confirmed that the resident should have received the as needed laxatives as ordered but did not. 2. On 04/03/2023 Resident #87 was observed in the common area of the Dogwood Unit positioned in his/her wheelchair as follows: leaning towards the right with no lateral support, the resident's right arm was pressed against the right armrest of the wheelchair putting pressure just below his/her shoulder, and the resident's bilateral lower extremities were noted to be dangling above the floor with no foot pedals attached to the wheelchair. Resident #87 has contractures of his/her left arm, left hand, and bilateral feet. Resident #87 was interviewed on 04/03/2023 at 1:53 PM and stated that s/he has some discomfort of his/her right upper arm associated with his/her positioning in the wheelchair. The resident stated s/he was, possibly getting a new wheelchair and support for my right side, I've been waiting 8 months. Record review on 04/03/2023 shows Resident #87 was admitted to the facility on [DATE] with diagnoses to include: Parkinson's disease, osteoarthritis, unspecified muscle weakness (generalized), age-related osteoporosis, flexion deformity of left finger joints, scoliosis, acquired deformities of the right foot, acquired deformities of the left foot, abnormal posture, flexion deformity of the left wrist, flexion deformity of the left elbow, and adult failure to thrive. This resident's BIMS score (a BIMS score is a Brief Interview for Mental Status, used as an assessment tool to identify cognitive impairment) was recorded as fifteen, which indicates the resident's cognition is intact. This resident was alert, and able to clearly voice concerns upon interview. Upon interview on 04/04/2023 the Dogwood Unit Manager (UM) was asked if Resident #87 complained of discomfort due to wheelchair positioning to her/him or other staff members of which s/he was aware. The UM replied that Resident #87 usually sits in the communal area on the Dogwood Unit where s/he is easily observed and can access staff and voice his/her needs but, has not complained of discomfort to her/him. This surveyor asked the UM when the last time Resident #87 was referred to therapy for wheelchair positioning or other therapy needs, s/he referred me to the therapy department for further information as s/he had no recent evaluation or treatment record s/he could access in the electronic medical record. When asked if this resident could self-propel in his/her wheelchair s/he stated the resident used to be able to but hasn't in months. An interview with a Physical Therapy/Occupational Therapy Assistant (PTA) on 04/04/2023 at 01:20 PM reveals that Resident #87 was evaluated by Physical Therapy in April of 2022 which resulted in an order being placed for adjustable height armrests for this resident's wheelchair. A follow-up to ensure proper positioning and functionality was going to be completed once the equipment was obtained. After the PTA reviewed therapy records, the staff member stated, It looks like the armrests were never followed up on. The PTA stated he/she .remember the armrests were going to cost about $150.00 but I don't know why they weren't received and why there was no follow-up. The PTA also stated, The nursing department was supposed to notify the therapy department when the armrests arrived. The PTA then went to the Dogwood unit to observe the resident's positioning in his/her wheelchair and to confirm the adjustable height armrests were not on the chair. Upon returning from the unit s/he confirmed the armrests were not adjustable and stated the resident's positioning in the wheelchair was horrible. The PTA printed out and provided this surveyor with the PT Initial Evaluation Form from April of 2022 for review. The PTA then went to administration for help in determining the cause of oversight in providing this resident with adjustable height armrests, which also resulted in a lack of re-evaluation for proper functionality and positioning in the resident's wheelchair for the past year from April of 2022 through April of 2023. Review of the Physical Therapy Initial Evaluation Form dated for the period of 04/01/2022-04/30/3022 revealed that Resident #87 was, Referred for PT (physical therapy) due to new complaints of R UE (right upper extremity) discomfort during W/C (wheelchair) mobility. Pt (patient) presents with severe posture abnormalities and L UE and BL LE (left upper extremity and bilateral lower extremity) deformities .Pt would benefit from PT services to assess for optimal W/C seating system to support the above postural abnormalities to promote decreased R UE pain during W/C propulsion .and promote maximal independence with W/C propulsion . Pt demonstrates good rehabilitation potential .Pt reports recent R UE discomfort due to height of W/C armrest. At the time of this therapy evaluation, records show Resident #87 could self-propel for approximately 10 minutes using her/his right upper extremity and bilateral lower extremities but would then experience discomfort as high as a five on a pain scale of 1-10, with ten being the worst pain. Records show the pain would limit further propulsion and risk injury to the right upper extremity. On 04/05/2023 at 08:30 AM The Administrator confirmed the armrests were not obtained and Resident #87 has not had follow-up from the therapy department for wheelchair positioning and functionality for the past year as was the documented plan of action in the Physical Therapy Initial Evaluation Form dated in April of 2022. It was confirmed this oversight resulted in poor wheelchair positioning since April of 2022, discomfort, and the inability for self-propulsion in the current wheelchair for Resident #87. The administrator stated, I didn't work in the facility at the time of the PT evaluation last year so I don't know why the armrests weren't received, but a new wheelchair will be ordered for this resident immediately. The physical therapy screen was already placed (to determine the chair that best meets the resident's needs). Reference: [NAME] Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/[NAME], [NAME] & [NAME], pg 17. 46544