Every finding on record at Neville Center at Fresh Pond for Nursing & Rehab

Based on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety, potentially putting the residents at risk for foodborne illness. Specifically, 1. The facility failed to ensure that food was stored, labeled, and dated properly, and that food/beverages were not expired and personal drinks were not stored in the kitchen refrigerator.2. The facility failed to ensure staff wore beard coverings and staff did not handle ready-to-eat food with contaminated gloves.3. The facility failed to consistently monitor the effective use of a low temperature manual chemical sanitization station and failed to document the parts per million (PPM) of the sanitizing solution, to ensure effective sanitization. Findings include:Review of the facility policy titled Food Storage Guideline, dated 1/3/22, indicated but was not limited to the following: Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 7b. Food should be dated as it is placed on shelves if required by state regulation. 7c. Date marking should be visible on all high-risk food to indicate the date by which ready-to-eat, TCS (time/temperature control for safety) food should be consumed, sold, or discarded. 8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.10. Perishable food such as meat, poultry, fish, dairy products, fruits, vegetables, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. 11. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded per the 2017 Federal Food Code. Prepared left-over food that has been used on the meal service line one time may be stored in covered containers or wrapped carefully and securely and dated before being refrigerated and shall be discarded within 72hours. 12. Refrigerated food storage:f. All food should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 13. Frozen foods:b. Frozen foods must be maintained at a temperature to keep the food frozen solid. c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 1. On 5/11/26 at 7:04 A.M. the surveyor made the following observations during the initial walkthrough of the main kitchen:- An open box of 15 dozen unpasteurized eggs dated 2/25/26 with a manufacturers label indicating a sell by date of 3/26/26. The box had 53 eggs remaining in the box. - A container labeled Seafood Salad opened and dated 4-26. - A container of coleslaw opened and undated in the walk-in refrigerator.- A box of frozen cinnamon French toast open but undated. The bag inside the box was opened and the French toast was not frozen. The box had Keep Frozen printed on the outside. - One opened half empty can of energy drink in the walk-in refrigerator.- One opened half empty bottle of soda in the walk-in refrigerator. - One opened container of half and half open and undated in the walk-in refrigerator. - One opened box of chocolate sprinkles dated opened 5/12/25, in a bin on a shelf in the dry storage area. The top of the box was open to air and not sealed. During an interview on 5/12/26 at 1:20 P.M., the Foodservice Director (FSD) said food items must be dated when opened and are good for 7 days and should be removed and discarded. The FSD said the unpasteurized expired eggs should have been removed as they are not safe to use. The FSD said the container of coleslaw and seafood salad should have been discarded and said they are not safe to consume as they could be spoiled. The FSD said staff have been told not to store personal drinks in the refrigerator and said the soda and energy drink should not be kept with kitchen stock food items. The FSD said the opened box of chocolate sprinkles is very old and needs to be discarded as the box is unusable. 2. Review of the facility policy titled Bare Hand Contact with Food and Use of Plastic Gloves, undated, indicated but was not limited to the following:Single use gloves or other barriers will be used when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Barehand contact with food is prohibited. 2. Staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. 3. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready-to-eat (RTE) food or with raw animal food, used for no other purpose and discarded when damaged or soiled, or when interruptions occur in the operation.6. Anytime a contaminated surface is touched, the gloves must be changed and hands must be washed: b. After handling garbage or garbage cans.d. After handling anything soiled. k. Any time a contaminated surface is touched. The surveyor made the following observations during the lunch tray line on 5/12/26: At 11:07 A.M., a dietary aide was scooping and preparing fruit cups in the food prep area, the dietary aide had a visible beard approximately one inch long and was not wearing a beard net. At 11:22 A.M., a dietary aide used his bare hands to move a food cart by touching the handle then used his bare contaminated hands and grabbed the inside of several fruit bowls while lining them on a tray to be filled. The dietary aide then used his bare hands and picked up a can containing mixed fruit, he then used his other bare hand to hold the handle and scoop the fruit into the bowls. The dietary aide then used his bare hands and touched the insides of the plastic lids to cover the fruit cups. The dietary aide was not wearing gloves and did not wash his hands during the observation. At 11:24 A.M., a dietary aide was observed making sandwiches with gloved hands, then with her gloved hand she picked up a container of plastic wrap and she then with her contaminated gloved hand she picked up the sandwiches and wrap and wrapped them individually in plastic wrap, touching the sandwiches with her contaminated gloved hands. The dietary aide with her gloved hands then picked up a packet of stickers and she placed stickers on the sandwiches she just wrapped. The dietary aide then picked up the plate of sandwiches and used her contaminated gloved hands and opened the refrigerator door. The dietary aide then removed her gloves and she performed hand hygiene, she used paper towels to dry her hands, then with her bare hands she picked up the lid from the trash container, she discarded the paper towels in the trash container, and she then placed the trash lid back on the container to close it. The lid to the trash container had visible dried food and stains throughout. The dietary aide with her contaminated hands then picked up a knife and several bowls, she was observed to be touching the insides of the bowls with her bare contaminated hands, and she then placed them on a counter. The dietary aide without performing hand hygiene, she then put on gloves, and she began to touch and cut up watermelon and scoop watermelon into several bowls. The dietary aide continued to touch the watermelon, knife and bowls throughout the observation. At 11:30 A.M., the cook was observed lifting the lid of the trash container with his bare hands and then placed the lid back onto the trash container. The lid to the trash container had visible dried food and stains throughout. The cook without performing hand hygiene, was observed touching the stove dials, steam tray lids, pans and food scoops with his bare hands. The cook then used his bare hand and touched the inside of several plates. The cook without performing hand hygiene, was observed putting on gloves and the cook picked up a spatula with his gloved hand, scooped up butter, then used his contaminated gloved hand and touched bread as he prepared grilled cheese over the stove. The cook then used his contaminated gloved hands to touch the grilled cheese several times during the observation. The cook then removed the grilled cheeses from the pan and with his gloved hand he touched the grilled cheese with one hand as he cut the sandwiches in half. The cook then walked over to the steam table while using the same contaminated gloves, removed the cover from the meatloaf steam tray and he touched the outside of the pan. The cook then used one gloved hand and grabbed a knife handle and he used the other contaminated gloved hand to touch the meatloaf to make slices. The cook then removed his gloves, lifted the trash container lid with his bare hands, discarded his gloves and with his bare hand, the cook placed the trash lid back on to the trash container. The cook then washed his hands, then wiped his hands with paper towels and with his bare hand he lifted the trash container lid and discarded the paper towels he used to dry his hands. The cook then used his bare hands to close the trash container lid, again contaminating his hands. The cook then walked over to the tray line, put on a pair of gloves and picked up scoops and moved several plates with his gloved hands. The cook then used the contaminated gloved hands and placed his palm on the inside of plates to slide them down the tray line as he scooped food on to the plates. At 11:41 A.M., a dietary aide was observed lifting the lid off the trash container with his bare hands, placing items into the trash container and with his bare hands he closed the lid. The dietary aide then used his contaminated hands and picked up plates touching the insides of the plates and proceeded to use the plate warmer and pass plates to the cook. During an interview on 5/12/26 at 12:04 P.M., the Foodservice Director (FSD) said she expects staff to wash their hands before putting on new gloves and to wash their hands after removing gloves. The FSD said the dietary aide with a beard should have it covered when in the food prep area. The FSD said staff should not touch food with contaminated bare hands or with gloves that are contaminated and said staff should not touch the lid to the trash container because it is dirty. The FSD said she needs to get a new trash system, so they do not need to touch the lid. 3. Review of the current manufacturer's guidelines, for the three-bay chemical sanitization station, Multi-Quat 146 Sanitizer is an effective sanitizer against Escherichia coli and Staphylococcus aureus on food contact surfaces when used at 0.26-0.68 (ounces) oz per 1 gallon of 400 ppm hard water (150 ppm-400 ppm active quat) and indicated that chemical sanitization solution PPM should be checked with each use. During an observation and interview on 5/11/26 at 7:08 A.M., and on 5/12/26 at 10:56 A.M., the surveyor observed a kitchen staff member washing dishes in a three-bay sink. There was one sink dedicated for chemical sanitization. There was a Sanitization Range Testing kit and instructions mounted on the wall above the three-bay sink. There were no documented sanitization PPM in the Pot Sink Log hanging on the wall. The Kitchen staff member said he does not check the PPM and said the levels were not checked. Review of the temperature log titled Pot Sink Log dated May 2026 indicated the last documented sanitization PPM testing was completed at 6:00 P.M., on 5/10/26. There was no indication that the facility tested the PPM of the chemical machine to assess proper sanitization after 5/10/26. During an observation and interview on 5/13/26 at 7:10 A.M., the surveyor observed a kitchen staff member washing dishes in a three-bay sink. There were no documented sanitization PPM in the Pot Sink Log hanging on the wall. The Kitchen staff member said he does not check the PPM and said the levels were not checked. During an interview on 5/12/26 at 12:48 P.M., the Food Service Director (FSD) said the testing of the sanitization bays needs to be done with each use three times per day or more and documented to make sure the range is appropriate for sanitizing the dishes. The FSD said she is not sure why the PPM was not checked and said it must be checked and documented when in use. The FSD said the levels must be checked to make sure it is effective to properly sanitize the dishes.

Based on observation, record reviews and interviews, the facility failed to ensure that one Resident (#74) was provided with treatment and care to maintain good foot health, out of a total sample of 21 residents. Specifically for Resident #74 who was last seen by the podiatrist on 2/12/26, and the podiatrist recommended that Resident #74 be seen as medically necessary but no sooner than 60 days, the facility failed to ensure the Resident was seen on 5/4/26, when his/her nails needed services. Finding include:Review of the facility policy titled Consultant Services (Audiology, Podiatry, Dental, Optometry) Guideline, dated 9/20/20, indicated but was not limited to the following: Each resident (responsible person) shall be offered the services of (Consultant Services) for audiology, podiatry, dental and optometry while residing in the center. 1. During the admission process, the licensed nurse shall review with each resident or responsible person that professional services covering audiology, dental, podiatry, and optometry are available through Consultant Services. 2. If in agreement, a consent for services will be signed. 5. Consultant Services will see individual residents and will in turn provide a record of the visit as an electronic upload into the resident's electronic health record. 6. Consultant Services will send a copy of the visit summary to the resident's unit (nurse manager) for review by the attending MD (Medical Doctor) or NP (Nurse Practitioner).7. The nurse will review any identified recommendations with the attending MD or NP for further orders if in agreement. 8. If a resident refuses a visit, it is documented on the visit summary. Resident #74 was admitted to the facility in September 2024 with diagnoses including type two diabetes mellitus, weakness, and age-related osteoporosis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #52 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated Resident #74 required substantial to maximal assistance with personal care. During an interview and observation on 5/11/26 at 8:13 A.M., Resident #74's said his/her toenails are long and need to be cut. Resident #74 said he/she was due to be seen by the podiatrist but has not seen the podiatrist. Resident #74 also said he/she asked the nursing staff to be seen in April and May but was not. Resident #74 said he/she has diabetes. Resident #74's toenails appeared to be thickened in appearance as well as multiple toenails starting to curl inwards towards the bottom of the feet. Review of the Consultant Services Consent form dated 4/25/23, indicated Resident #74 consented to be seen by Podiatry. Review of Resident #74's physician's order, dated 9/27/24, indicated the following:- May be evaluated and treated by Podiatry. Review of Resident #74's diabetic care plan dated as last revised 11/6/23, indicated: Resident is at risk for alteration in BS (blood sugar) and adverse effects of DM (diabetes mellitus). Interventions included: Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Dated 2/2/22. Review of Resident #74's skin potential care plan dated as last revised 8/30/24, indicated the following intervention: Diabetic foot care /Diabetic snacks as ordered [SIC]. Dated 2/2/22 Review of Resident #74's Podiatry visit note dated 12/10/25 and 2/12/26, indicated: Resident seen for RFC (routine foot care) with DM (diabetes mellitus)/ increased ROI (risk of infection).- Reviewed medical record; Trimmed and debrided nail(s) to patient's tolerance. No signs of infection. Non-professional treatment is hazardous to the patient.- Podiatric Diagnosis(es): onychomycosis (fungal infection); Hallux valgus (bunion/bony bump), Diabetes type two with peripheral neuropathy (weakness, numbness, pain in feet or hands); atherosclerosis of the extremities (buildup of plaque in the arteries reducing blood flow); onychodystrophy (abnormal nail growth); History of hyperkeratosis (thickening of the skin). -Recall: (Follow-up) As medically necessary but no sooner than 60 days. During an interview on 5/12/26 at 8:15 A.M., Nurse #1 said when a Resident needs an outside service such as podiatry, the facility will fax over the consent form to the consultation service so the Resident can be scheduled to be seen. Nurse #1 said Resident #74 is seen regularly by the podiatrist and the Resident should have been seen earlier this month when the podiatrist was here. During an interview on 5/12/26 at 8:22 A.M., the Assistant Director of Nursing (ADON) said Resident #74 should have been seen by the podiatrist because he/she is diabetic and is seen every 60 days and is on the podiatrist's list. The ADON then showed the surveyor a visit summary of Residents needing outside podiatry service and the ADON then confirmed the Resident was last seen on 2/12/26 and Resident #74 was not seen during the last podiatry visit on 5/4/26. The ADON said Resident #74 should have been seen but was not on the list and the Resident should have been. During an interview on 5/12/26 at 9:42 A.M., the Director of Nurses said Resident #74 should have been seen by the podiatrist but was not and said he/she should be seen every 60 days and is on the list. On 5/13/26 at 8:36 A.M., the surveyor and Nurse #3 observed Resident #74 sitting up in bed. Resident #74 said to Nurse #3 that his/her toenails are sore and long and said he/she has been asking to see podiatry because he/she was not seen earlier this month when the Podiatrist was in the building. Nurse #3 said she is not sure why Resident #74 was not seen and said the Resident needs to have his/her toes checked.

Based on observation, record review and interview, the facility failed to ensure medications were stored as required for one Resident (#78), out of a total sample of 21 residents. Specifically, the facility failed to ensure that medications were not left at the bedside for Resident #78 while unsupervised by staff. Findings include:Review of the facility policy titled General Dose Preparation and Medication Administration, dated as revised 11/15/24, indicated but was not limited to the following: 2. Dose Preparation: Facility should take all measures required by facility policy and applicable law, including, but not limited to the following:-2.8 Facility staff should not leave medications or chemicals unattended. 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to:5.4 Administer the medications within timeframes specified by facility policy or manufacturers information. 5.9 Observe the resident's consumption of the medication(s). Resident #78 was admitted to the facility in June 2025 with diagnoses including vascular dementia, cognitive communication deficit, and anxiety disorder. Review of Resident #78's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #78 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15. On 5/11/26 at 7:48 A.M., the surveyor observed a medication cup containing two small light-purple-colored pills with the letters JSP on them, identified as Levothyroxine, a thyroid replacement medication, located on Resident #78's overbed table. Resident #78 said the overnight nurse left those for me to take this morning, but I haven't taken them yet. Review of Resident #78's physician orders, care plans and assessments failed to indicate that the Resident had met criteria to self-administer medications at his/her bedside. Review of Resident #78's physician order, dated 9/13/25, indicated: Levothyroxine Sodium Oral Tablet 75 micrograms (mcg) (Levothyroxine Sodium), give 2 tablets by mouth in the morning every Mon, Tue, Wed, Thu, Fri, Sat for thyroid 2 tabs x 75mcg =150mcg total dosage. Scheduled for 6:00 A.M. Review of Resident #78's May 2026 Medication Administration Record indicated that Resident #78's scheduled Levothyroxine was signed off as administered to Resident #78 on 5/11/26 at 6:00 A.M. During an interview on 5/12/26 at 7:20 A.M., Nurse #1 said Resident #78 should not have medications left at the bedside and said Resident #78 takes two Levothyroxine pills in the morning at 6 A.M., but he/she needs to take them with a nurse present. Nurse #1 said Resident #78 does not have a signed self-administration of medication form on file and said staff need to stay with the Resident to make sure he/she takes the medication when it is given. During an interview on 5/13/26 at 8:06 A.M., Unit Manager #2 said medications should not be left at the bedside unless a resident has been assessed for self-administration. Unit Manager #1 said nurses are to stay with the Resident until all the medication is taken. During an interview on 5/13/26 at 8:07 A.M., the Assistant Director of Nurses (ADON) said Resident #78 does not have an assessment in place for self-administration of medication and said medications should not have been left at his/her bedside because the Resident may not take them on time. The ADON said the medication was not given and should not be documented as administered if it was not. During a telephone interview on 5/13/26 at 10:17 A.M., Nurse #4 said she worked the overnight shift and brought Resident #78 his/her medication in a cup with some water and said she thinks the Resident took the medications but does not remember if he/she took them because she was also taking his/her blood sugar at the same time. Nurse #4 said medications should not be left at the bedside with the Resident. Nurse #4 said Resident #78 cannot self-administer medications.

Based on observations, record reviews and interviews, the facility failed to consistently accommodate resident food allergies, intolerances, and preferences for two Resident (#42 and #104) out of a total sample of 21 residents. Specifically,1. For Resident #42, who had allergies listed as wheat and lactose, the facility served the Resident French toast, bacon (a dislike), a cookie containing wheat and milk, and scrambled eggs with cheese.2. For Resident #104, who required a vegan (diet that avoids all animal derived products such as meat and dairy) diet and had dairy listed as a dislike, the facility served Resident #104 half and half creamers containing dairy on three occasions. Findings include:Review of the facility policy, Resident's Choice Meals, dated September 2025, indicated in post-acute care settings, residents may have input into menu planning and may select the menu for meals on a regular basis once a month or more often if deemed appropriate. 1. The director of food and nutrition services will meet with residents via resident council meetings to get input on the menu and discuss their menu requests. 1. Resident #42 was admitted to the facility in May 2026 with diagnoses including dysphagia (difficulty swallowing), multiple sclerosis, and severe protein-calorie malnutrition (insufficient intake of protein and calories). Review of Resident #42's Brief Interview for Mental Status assessment, dated 5/6/26, indicated a score of 15 which indicated the Resident was cognitively intact. Review of Resident #42's physician order, dated 5/3/26, indicated: House Diet, Regular (Regular- RG7) texture, Thin (Thin - TNO) consistency. Review of Resident #42's NUT-Food Preference Survey - V 2 assessment, dated 5/4/26, indicated:- Allergies/Intolerances/Preferences: coffee, wheat, lactose intolerant.- Breakfast Dislikes: no bacon, no sausage, no yogurt, no milk. Review of Resident #42's NUT - Nutrition/Hydration Assessment V3 - V 4 assessment, dated 5/6/26, indicated:- Food Allergy / Intolerances: Wheat, Dairy, Coffee, Lactose.-Cultural/Religious/Ethnic Preferences/Food Preferences: See preferences assessment. No red meat, No white sugar or bread, no pasta. Review of Resident #42's plan of care related to nutrition, dated 5/6/26, indicated: Provide diet as ordered.Review of Resident #42's allergies listed in the electronic health record included: dairy products, lactose, and wheat. On 5/11/26 at 8:24 A.M., the surveyor observed Resident #42's breakfast tray. Resident #42's tray ticket indicated two slices of gluten free French toast and two slices of bacon. Resident #42 had two slices of French toast and two slices of bacon. Resident #42 said he/she does not eat bread or bacon, and Resident #42 said he/she does not always get what he/she wants from the kitchen and it takes a long time for staff to bring back alternative choices. On 5/11/26 at 12:48 P.M., the surveyor observed Resident #42's lunch tray and the lunch ticket indicated gluten free allergic to lactose and wheat. On Resident #42's lunch tray there was a cookie that was wrapped in packaging, the packaging indicated the cookie contained wheat, soy, and milk. On 5/11/26 at 1:14 P.M., the surveyor observed Resident #42's lunch tray and observed that half of the cookie had been consumed, Resident #42 said he/she ate half the cookie and Resident #42 said my stomach couldn't handle it. On 5/13/26 at 8:18 A.M., the surveyor observed Resident #42's breakfast tray, the tray ticket indicated allergy to lactose. There were scrambled eggs with cheese and two creamers on the tray. Resident #42 said that he/she was eating the eggs and was eating around the cheese. Resident #42 said that it takes too long for people to come back with his/her food and he/she was hungry. Resident #42 said if he/she eats cheese it causes him/her to cough. On 5/13/26 at 8:20 A.M., the surveyor and Nurse #2 observed Resident #42's breakfast tray. Nurse #2 said that Resident #42's breakfast ticket indicated no lactose, and Nurse #2 said she delivered Resident #42 his/her breakfast tray. Nurse #2 said she was not sure if Resident #42 could have eggs with cheese. During an interview on 5/13/26 at 8:23 A.M., Unit Manager #1 said even if the diet slip has allergies and dislikes on the diet slip, the Resident can still get those items as it is their right. Unit Manager #1 observed the eggs with the cheese, and she said he/she must have wanted it. During an interview on 5/13/26 at 9:58 A.M., the Food Service Director (FSD) said that residents like Resident #42 report allergies that are not always an allergy and residents will report foods that sometimes just bother them. The FSD said that she meets with new admissions and she will go over likes and dislikes with Residents. The FSD showed the surveyor Resident #42's dislikes in the meal tray tracking system which indicated Resident #42 disliked bread products and cheese. The FSD said she was not sure why bacon was not listed as a dislike since it was listed in Resident #42's assessment that she completed. The surveyor reviewed the observations of the meals that were provided to Resident #42 and said, well those are his/her choices. During an interview on 5/13/26 at 11:40 A.M., the Director of Nursing (DON) said that the kitchen and nursing should follow allergies, intolerances, and honor preferences for all residents. The DON said that if a Resident is requesting something they have an intolerance to staff should discuss this with the physician and the resident and nursing should document the conversation in the electronic health record. During an interview on 5/13/26 at 12:04 P.M., the Dietitian said that staff should follow allergies, intolerances, and honor preferences for all residents. 2. Resident #104 admitted to the facility in May 2024 with diagnoses including severe protein-calorie malnutrition, weakness, and ataxia (poor muscle control). Review of Resident #42's Brief Interview for Mental Status assessment, dated 5/5/26, indicated a score of 15 which indicated the Resident was cognitively intact. Review of Resident #104's physician's order, dated 5/4/26, indicated: House Diet, Regular (Regular- RG7) texture, Thin (Thin - TNO) consistency, VEGAN. Review of Resident #104's NUT-Food Preference Survey - V 2 assessment, dated 5/5/26, indicated:- Allergies/Intolerances/Preference: Vegan.- Breakfast/Lunch/Dinner Dislikes: no dairy.Review of Resident #104's NUT - Nutrition/Hydration Assessment V3 - V 3, dated 5/8/26, indicated:- Food Allergy / Intolerances: no known food allergies (NKFA), lactose intolerant, and vegan. On 5/11/26 at 8:28 A.M., the surveyor observed Resident #104's tray ticket which indicated DO NOT SERVE DAIRY OF ANY KIND. There were two half and half individual creamers that indicated 'contains milk' on Resident #104's meal tray. Resident #104 said he/she is vegan and does not eat any dairy. Resident #104 said he/she does not want any creamers and is not sure why they are always on his/her meal tray. On 5/12/26 at 8:19 A.M., the surveyor observed three half and half individual creamers on Resident #104's breakfast tray. Resident #104 said that he/she does not want the creamer on his/her tray. On 5/12/26 at 1:06 P.M., the surveyor observed two half and half individual creamers on Resident #104's lunch tray. Resident #104 said he/she does not want the creamers on his/her tray. Resident #104 said he/she is lactose intolerant and if he/she uses the creamer he/she would have diarrhea. During an interview on 5/13/26 at 8:24 A.M., Unit Manager #1 said that Resident #104 doesn't need to use the creamers on his/her tray if he/she doesn't want to. During an interview on 5/13/26 at 10:01 A.M., the FSD reviewed Resident #104's dislikes in the tray tracking system which included milk. The FSD said that it is the facilities practice to place creamers on all Resident's trays including Resident #104's tray despite the intolerance because Resident #104 may decide he/she wants cream with his/her coffee. During an interview on 5/13/26 at 11:37 A.M., the DON said that nursing should make sure that Resident's should not receive intolerances. During an interview on 5/13/26 at 12:03 P.M., the Dietitian said that diet intolerances should not be served to Residents.

Based on observation, record review and interviews, the facility failed to ensure all equipment is maintained in safe operating condition. Specifically, 1. The facility failed to ensure the grease trap was maintained according to manufacturer's recommendations.2. The facility failed to ensure the two bays of the three-bay sink were in safe operating condition. Findings include:1. On 5/11/26 at 7:10 A.M., the surveyor observed in the main kitchen area, the floor under and around the three-bay sink, there was a pipe covered in a buildup of thick, dark brown, black, yellow, tan, gray shiny substance that extended to the pipes, onto the floor, was coming out of the grease trap container and had an odor. A kitchen staff member was observed washing dishes and said the grease trap and under sink area has looked like that for a while. During an interview on 5/12/26 at 12:27 P.M., the Food Service Director (FSD) said the grease trap is cleaned monthly and is handled by the Maintenance Director. The FSD said she keeps a cleaning and service log. The surveyor requested the last service log/invoice from when the grease trap was cleaned. The FSD said she did not call the service company because they usually just come out every month, but they have not been out.Review of the most recent grease trap cleaning consultant Summary of Service & invoice, dated 3/17/26, indicated the grease trap was serviced and indicated the following:Three-bay sink sanitizer, 2 inches of grease on top. 10 inches of water. 2 inches of bottom sludge. 30 gallons removed. Both baffles/[NAME] are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left zero bottles of drain master. [NAME] (Board of Health) logs Signed.- Recommended drain cleaning.- Recommended drain cleaning for preventative maintenance. Review of the Board of Health Grease Trap Maintenance Log indicated the last documented service was on 3/17/26. Further review of the log indicated monthly service had been conducted up until March 2026. During an interview on 5/12/26 at 2:35 P.M., the FSD said the facility has a contract with the consultant company that would come out monthly to service the grease trap and said she does not know why they have not been out to service the grease trap. The FSD said the grease trap has looked like that for a while. The FSD said they have not had the drain cleaned as recommended in March 2026 and said she does not know why. On 5/13/26 at 7:05 A.M., the surveyor and the Administrator observed the three-bay sink area and grease trap. The Administrator said he was not aware of the leaking water or grease trap overflowing and the Administrator said this is the first time he is seeing or hearing about it, and he said the grease trap should be serviced and emptied monthly. The Administrator said he was not aware that the last time it was serviced was in March 2026 and said he is not aware of any drain cleaning problems. During an interview on 5/13/26 at 7:43 A.M., the Maintenance Director said he does not manage the cleaning of the kitchen or any maintenance to the grease trap and said the FSD coordinates the monthly grease trap service. The Maintenance Director said he was not aware of the leaking sink or overflowing grease trap until yesterday when the FSD told him. During a follow-up interview on 5/13/26 at 9:20 A.M., with the Administrator and Maintenance Director, the Administrator said the grease trap is concerning because it has not been cleaned and the consultant company should have been contacted for service because it should not be overflowing out onto the floor. The Maintenance Director said the grease trap could cause issues with the sink not working properly and leaking and said he was not aware of any of the issues and said he would expect to be notified. During a telephone interview on 5/14/26 at 3:51 P.M., the representative from the consultant company said at this time they have stopped all future services at the facility until we receive a call back from the facility regarding the account and said they have tried to contact the facility and sent notices without any response. The representative said the grease trap needs to be emptied monthly could lead to more issues with other equipment breaking and not working, safety issues and environmental concerns if not emptied and said if financial obligations are not paid, we are not able to come out to do the service, but it needs to be done. 2. On 5/11/26 at 7:08 A.M., the surveyor observed the three-bay sink in the kitchen had one toilet plunger propped up against the drain handle under the first wash sink bay and one toilet plunger was propped up against the drain handle under the third sanitize sink bay. The floor under and around the sink was wet and appeared to be leaking water. A kitchen staff member was observed washing dishes and said the handles have been broken for a while and water is often on the floor. On 5/12/26 at 10:56 A.M., the surveyor observed dishes in the three-bay chemical sanitization station. One toilet plunger was propped up against the drain handle under the first wash sink bay, and one toilet plunger was propped up against the drain handle under the third sanitize sink bay. The floor under and around the sink was wet and appeared to be leaking water. During an interview on 5/12/26 at 11:22 A.M., the Food Service Director (FSD) said the stem (drain handle) for the two sinks are loose and need to be replaced because they keep draining and leaking. The FSD said staff propped up the handle with the plungers to keep it from leaking so they could clean the dishes because the main high temperature dishwasher has been breaking down intermittently. The FSD said she does not know how long they have been broken but said it has been a long time. During an interview on 5/12/26 at 1:23 P.M., Dietary Staff #1 said the three-bay sink has had issues with leaking, especially the sanitization sink near the grease trap and said he notified the FSD and they got plungers to prop of the handle to keep the sinks from leaking all over the floor. On 5/13/26 at 7:09 A.M., the surveyor and the Administrator observed the three-bay sink area. The Administrator said he was not aware of the leaking water and said this is the first time he has seen or heard about it and said if the sink was not working and leaking then it should have been reported and fixed. The Administrator said he did not know staff had been using toilet plungers in the sink area to stop the leaking. During an interview on 5/13/26 at 7:43 A.M., the Maintenance Director said he was not aware of the leaking sinks or loose drain handles and said the FSD just notified him of this yesterday, so he tried to tighten them but said the handle near the grease trap needs to be replaced because it won't stop leaking.

Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new pressure ulcers from developing for two Residents (#3 and #60) out of 19 total sampled residents. Specifically, 1.) For Resident #3, who had a left heel pressure ulcer, the facility failed to implement booties (heel offloading devices which are designed to prevent and treat pressure ulcers) as ordered by the physician. 2.) For Resident #60, who had a history of a heel pressure ulcer, the facility failed to implement booties as ordered by the physician. Findings include: Review of the facility policy titled 'Skin Management Guideline', revised 8/10/17, indicated: - The purpose of this guideline is to provide information regarding the management of skin conditions and identification of pressure ulcer/injury risk factors and interventions for specific risk factors. - Risk Assessment: Reposition the resident as indicated in the care plan. - Mobility/Repositioning: Provide support devices and assistance as needed. - Monitoring: Review the interventions and strategies for effectiveness on an ongoing basis. 1.) Resident #3 was admitted to the facility in September 2018 with diagnoses including chronic kidney disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/16/25, indicated Resident #3 had severe cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. This MDS indicated Resident #3 did not have a pressure ulcer but was at risk of developing pressure ulcers. This MDS further indicated Resident #3 required substantial/maximal assistance with putting on/taking off footwear. Review of Resident #3's assessment titled 'Admission/readmission Evaluation', dated 5/19/25, indicated he/she was readmitted to the facility with a new left heel unstageable pressure ulcer. Review of Resident #3's assessment titled 'Norton Scale', dated 5/19/25, indicated the Resident was at high risk for pressure ulcer development as evidenced by a score of five. Review of Resident #3's active physician's orders indicated: - Booties to bilateral heels while in bed, every shift for heels, initiated 12/29/24. - Float left heels in bed; off-load wound, every shift, 1/22/2025. - Monitor L (left) heel unstageable every shift for signs/symptoms of infection, every shift, initiated 5/19/25. On 5/27/25 at 8:03 A.M., and 5/28/25 at 6:55 A.M. and 7:52 A.M., the surveyor observed Resident #3 in bed with his/her heels directly on the mattress. Resident #3's was not wearing bilateral booties, and his/her heels were not offloaded. There were two blue booties visible in the room on his/her wheelchair, which was not within reach of the Resident during each of these observations. During an interview on 5/28/25 at 7:53 A.M., Resident #3 said he/she had a wound on his/her left heel, and it hurt when it rubbed on the mattress. Resident #3 said he/she had not worn booties on his/her heels for a while but would wear them if they were offered. Resident #3 said staff never offers to apply them. Review of Resident #3's plan of care related to skin, revised 2/18/25, indicated Resident #3 was at risk for impaired skin integrity and had a history of pressure ulcers. This care plan also indicated: - Refer to TAR (Treatment Administration Record) for current treatment regimen. Review of Resident #3's Treatment Administration Record (TAR), dated 5/27/25 and 5/28/25, indicated nursing had documented the physician's orders for booties to bilateral heels while in bed and float heels in bed, off-load wound as implemented every shift. Review of Resident #3's nursing progress notes and TAR, dated 5/27/25 and 5/28/25, failed to indicate any refusal or rationale for why his/her booties were not in place or heels offloaded. During an interview on 5/28/25 at 8:11 A.M., Certified Nurse Assistant (CNA) #1 said Resident #3 was not supposed to wear the booties or offload heels on the day shift, only on night shift. CNA #1 said Resident #3 was receptive to wearing the booties and never refuses them. CNA #1 was unaware Resident #3 had a wound on his/her left heel. During an interview on 5/28/25 at 8:18 A.M., Nurse #1 said Resident #3 had a scab on his/her left heel. Nurse #1 said if the physician's order was to have booties on or heels offloaded while in bed, then they should have been implemented while Resident #3 was bed. Nurse #1 said if Resident #3 did not wear the booties or have heels offloaded then it should not have been documented as implemented. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said if the physician's order was to have booties on or heels offloaded while in bed, then they should have been implemented while Resident #3 was bed. The Regional Director of Clinical Education and Administrator said if Resident #3 did not wear the booties or have heels offloaded then it should not have been documented as implemented. 2.) Resident #60 was admitted to the facility in December 2022 with diagnoses including malnutrition and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/25, indicated Resident #60 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #60 had one stage three pressure ulcer and was at risk of developing pressure ulcers. This MDS further indicated Resident #60 was dependent on staff for putting on/taking off footwear. Review of Resident #3's assessment titled 'Norton Scale', dated 4/27/25, indicated the Resident was at high risk for pressure ulcer development as evidenced by a score of eight. Review of Resident #60's active physician order, initiated 4/19/25, indicated: - Ensure pt (patient) is wearing Prevelon (brand name) (sic) boots while in bed, every shift for pressure injury. On 5/27/25 at 8:27 A.M. and 11:38 A.M., and on 5/28/25 at 6:53 A.M. and 8:01 A.M., the surveyor observed Resident #60 in bed with his/her heels directly on the mattress. Resident #60's was not wearing bilateral booties, and his/her heels were not offloaded. There were no booties visible in the room. During an interview on 5/28/25 at 8:22 A.M., the surveyor observed Resident #60 in bed with his/her heels directly on the mattress. Resident #60's was not wearing bilateral booties, and his/her heels were not offloaded. Resident #60 said he/she used to have a heel wound, but it had healed. Resident #60 said staff had not offered booties in a long time, so he/she thought they were longer needed. Resident #60 said if the facility thought he/she needed them, he/she would wear them. Review of Resident #60's Treatment Administration Record (TAR), dated 5/27/25 and 5/28/25, indicated nursing had documented the physician's order to ensure pt is wearing Prevelon (sic) boots while in bed as implemented every shift. Review of Resident #60's nursing progress notes and TAR, dated 5/27/25 and 5/28/25, failed to indicate any refusal or rationale for why his/her booties were not in place or heels offloaded. During an interview on 5/28/25 at 8:03 A.M., Certified Nurse Assistant (CNA) #2 said Resident #60 should wear booties when in bed because he/she used to have a wound on his/her heel. CNA #2 said she was unaware that he/she was not wearing them. CNA #2 said she had not offered them this morning. During an interview on 5/28/25 at 8:06 A.M., Nurse #3 said Resident #60 does not wear booties during the day shift and is only supposed to wear them at night. Nurse #3 reviewed Resident #60's physician's order and said based on the order he/she should always wear booties when in bed but had not been. Nurse #3 said Resident #60's booties were always off before her shift begins and he/she did not have a history of refusing them. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said if the physician's order was to have booties on while in bed, then they should have been implemented while Resident #60 was bed. The Regional Director of Clinical Education and Administrator said if Resident #60 had not worn the heel booties it should not have been documented as implemented. REFER TO F842.

Based on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of two Residents (#8 and #28) out of a total sample of 19 residents.Specifically, 1. For Resident #8,the facility failed to follow up on a significant weight change. 2.For Resident #28,the facility failed to follow a physician's order for a fluid restriction. Findings include: Review of the facility policy titled 'Weight Management' dated 6/2024, indicated the following but not limited to: -A discrepancy of plus or minus three (3) pounds weekly for a weekly weight will require that the resident be re-weighed to validate weight discrepancy by a licensed nurse. A discrepancy of plus or minus five (5) pounds for a monthly weight will require that the resident be re-weighed to validate the weight discrepancy by a licensed nurse. -The Registered Dietician (RD) shall be notified of the validated weight gain or loss at this time. Resident #8 was admitted to the facility in April 2024 with diagnoses including chronic kidney disease and dysphagia. Review of Resident #8's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 9 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was moderately cognitively impaired. The MDS further indicated the Resident weighed 141 pounds (lbs.) and was on a mechanically altered diet. Review of Resident #8's Nutrition care plan initiated on 4/21/25 indicated the following interventions: -Monitor weights according to facility weight management protocol. -Provide feeding assistance as needed. -Provide supplement mighty shake. Review of the weight record for Resident #8 indicated the following weights: -4/18/25- 140.2 lbs. -4/21/25- 140.6 lbs. -5/8/25- 125.5 lbs. (10.74% significant loss from previous weight) -5/12/25- 125.4 lbs. -5/19/25- 126 lbs. -5/26/25-126 lbs. Review of the weights indicated Resident #8 had a significant weight loss from 4/21/25 to 5/8/25. Review of the medical record failed to indicate that neither the Registered dietician nor the MD (physician) were notified of the significant weight loss. During an interview on 5/28/25 at 11:32 A.M., the Registered Dietician (RD) said that she usually checks all the weights on Mondays and follows up on the discrepancies. The RD said if there is significant change she will assess the resident then notify the nurse or unit manager to ensure the MD and healthcare proxy are made aware. The RD further said Resident #8 had moved floors and the weight discrepancy could be an oversight but still required a follow up. During an interview on 5/28/25 at 12:41 P.M., the Regional Director of Clinical Education and Administrator said the nursing staff should have reweighed the Resident to validate the weight and then notify the Dietician. 2.For Resident #28, the facility failed to follow a physician's order for a fluid restriction. Findings include: Review of the facility policy titled 'Fluid Restriction Guideline', dated 2/16/2018, indicated the following but not limited to: -A fluid restricted diet is one in which a resident is advised to consume a reduced amount of fluids along with foods that are high in water content (example soup, gelatin, sherbet, ice cream). A fluid restriction is ordered by a physician or practitioner for residents who have fluid intake concerns related to congestive heart failure, acute/chronic renal failure, edema (swelling that occurs when fluid builds up in the body's tissues), ascites (abdominal swelling caused by accumulation of fluid). -The following is recorder in the resident's record and the medical doctor (MD) is made aware: -Fluid restriction non-compliance -Any changes in the resident's condition. -Nursing staff will record the residents' consumption of fluids during meals and with medication pass using a facility intake and output documentation form. -A licensed nurse must check each meal tray and determine that the fluid allotment is not exceeded on the tray. Resident #28 was admitted to the facility in August 2023 with diagnoses including heart failure and chronic respiratory failure. Review of Resident #28's Minimum Data set (MDS), dated [DATE], indicated the Resident scored a 14 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated that the Resident had an active diagnosis of heart failure. During an observation on 5/27/25 at 8:22 A.M., the Resident was lying in his/her bed, there was a bottle of red juice half consumed on the bedside table as well as a small bottle of water. Review of the physician's orders indicated Resident #28 required a 1000 milliliter (ml) fluid restriction per every 24 hours. The breakdown of the fluid restriction indicated the following: -7-3 shift to give nursing 60 ml, breakfast 360 ml and lunch 240 ml. -3-11 shift to give nursing 60 ml, supper 240 ml. -11-7 shift to give nursing 40 ml. Review of the Medication Administration Record (MAR) for May 2025 indicated Resident #28 received the following amount of fluid in 24 hours: -1,200 ml on 5/2/25 -1,200 ml on 5/3/25 -1,200 ml on 5/4/25 -1,200 ml on 5/5/25 -1,200 ml on 5/6/25 -1,200 ml on 5/7/25 -1,100 ml on 5/9/25 -1,100 ml on 5/10/25 -1,100 ml on 5/11/25 -1,100 ml on 5/23/25 -1,100 ml on 5/24/25 -1,100 ml on 5/25/25 -1,100 ml on 5/26/25 -1,100 ml on 5/27/25 -1,100 ml on 5/28/25 Review of Resident #28's medical record failed to indicate the Resident was non-compliant with the fluid restriction or that the MD was made aware of fluid intake over the 1,000 ml fluid restriction. During an interview on 5/28/25 at 11:43 A.M., Nurse #3 said the Resident was on a 1,000 ml fluid restriction and nurses are supposed to follow the physician orders with the fluid restriction, if the total fluid intake was over the restriction the MD would be made aware. She further said if the Resident was non-compliant with the fluid restriction this would be documented in the medical record as excess consumption and could lead to fluid overload (too much water in the body). During an interview on 5/28/25 at 11:51 A.M., Resident #28 said he/she was aware of the 1,000 ml fluid restriction and pointed out to a dietary slip taped on his/her closet indicating that's what he/she is supposed to follow. During an interview on 5/28/25 at 12:39 P.M., the Regional Director of Clinical Education and Administration said Resident's on fluid restriction should be monitored adequately and if intake is documented above the fluid restriction orders it should be reported to MD as this could cause a resident to go into fluid overload.

Based on observations, interviews, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#60), out of a total sample of 19 residents. Specifically, for Resident #60, the facility failed to implement a physician's order for weekly routine PICC dressing changes, as required. Findings include: Review of the facility policy titled 'Central Vascular Access Device (CVAD) Dressing Change', revised 1/25/04, indicated: - Verify prescriber order. - Perform sterile dressing changes using Standard - Aseptic Non Touch Technique: at least weekly. Resident #60 was admitted to the facility in December 2022 with diagnoses including sepsis and urinary tract infection. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/25, indicated Resident #60 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #60 received intravenous medications. Review of Resident #60's physician's order, initiated 5/9/25, indicated: - Change PICC Line Catheter Site Dressing, every day shift every 7 day(s). - Change PICC Line Catheter Site Dressing, as needed. On 5/27/25 at 8:27 A.M., the surveyor observed Resident #60 in bed with a PICC dressing on his/her right arm which was dated 5/9/25, which was 19 days prior to observation. The bottom quarter of the PICC dressing was lifting, exposing the catheter to air. Resident #60 said the PICC dressing had not been changed recently and had only been changed twice since he/she was readmitted to the facility 4/19/25. During an interview on 5/27/25 at 11:38 A.M., Nurse #2 and the surveyor observed Resident #60's PICC dressing. Nurse #2 said the PICC dressing was dated 5/9/25. Nurse #2 said the PICC dressing should have been changed every seven days, and it was overdue to be changed. Nurse #2 further said that this PICC dressing should have been changed because it was lifting and not intact. Review of Resident #60's nursing progress note, dated 5/9/25 to 5/27/25, failed to indicate any rationale for PICC dressing not being changed according to the physician's order. Review of Resident #60's Treatment Administration Record (TAR), dated 5/10/25 to 5/27/25, indicated: - 5/16/25: Nurse #1 documented the physician order to Change PICC Line Catheter Site Dressing as completed, when it was not. - 5/23/25: Nurse #4 documented the physician order to Change PICC Line Catheter Site Dressing as completed, when it was not. - The physician order to Change PICC Line Catheter Site Dressing, as needed was not implemented during this time frame. During an interview on 5/27/25 at 11:40 A.M., Nurse #2 and the surveyor reviewed the TAR, dated 5/10/25 to 5/27/25. Nurse #2 said since the PICC dressing had not been changed since 5/9/25, it should not have been documented as completed. On 5/28/25 at 12:05 P.M., the surveyor attempted to contact Nurse #4 by telephone. Nurse #4 did not return the telephone call. During an interview 5/28/25 at 12:11 P.M., Nurse #1 said she absolutely did not change Resident #60's PICC dressing on 5/16/25 and was unsure why it is documented that she did. During an interview on 5/27/25 at 2:18 P.M., Unit Manager #1 said Resident #60's PICC dressing should have been changed every seven days but was not. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said PICC dressings should be changed as ordered by the physician. REFER TO F842.

Based on policy review, observation and staff interview, the facility failed to ensure pharmaceutical services met the needs of each resident. Specifically, the facility failed to ensure insulin and intravenous emergency kits were replaced by the pharmacy after being opened on two out of three units. Findings include: Review of the facility policy titled 'Emergency Medication Supplies (Emergency kits), dated 11/15/24, indicated the following: -The facility may request an on-demand exchange of the emergency kit as needed by calling the pharmacy and arranging the exchange. -To indicate the emergency kit was opened by the facility staff and replacement of the box or replenishment of removed doses is needed, the tamper -evident lock or seals provided by the pharmacy may be a different color than the original one placed by the pharmacy. On 5/28/25 at 10:03 A.M., during the inspection of the medication room on the second floor. The surveyor observed an insulin kit in the refrigerator; the kit was opened and some of the contents had been removed from the kit. There was no documentation indicating what had been removed, when it was removed and who had removed the items. There was no way of knowing if the kit had been reordered from the pharmacy for a replacement kit. During an interview on 5/28/25 at 10:09 A.M., Nurse #1 said when the emergency kits are opened, they need to be reordered immediately. She further said she was not sure when the kit had been accessed and if it had been reordered. On 5/28/25 at 10:38 A.M., during an inspection of the medication room on the third floor. The surveyor observed an intravenous (IV) kit was opened and some of the contents had been removed from the kit. There was no documentation indicating what had been removed, when it was removed and who had removed the items. There was no way of knowing if the kit had been reordered from the pharmacy for a replacement kit. During an interview on 5/28/25 at 10:41 A.M., Nurse #5 said no residents were receiving any type of intravenous medication on the unit. She said she does not know when the kit was opened. Nurse #5 said the kit should be reordered from the pharmacy once it's opened. During an interview on 5/28/25 at 12:36 A.M., the Regional Director of Clinical Education and Administrator said the emergency kits should be reordered upon accessing them.

Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, nursing failed to ensure medications were dated once opened, and stored according to manufacturer's guidelines, in one of three medication carts observed. Findings include: Review of the facility policy titled 'Storage and Expiration Dating of Medications and Biologicals', dated 8/1/24, indicated the following: -Once any medication or biological is opened, facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (example, vial, bottled, inhaler) when the medication has a shortened expiration date once opened. On 5/28/25 at 9:56 A.M., the surveyor and Nurse #1 observed the second floor medication cart: -Two bottles of Lumigan eye drops, opened and undated. -One bottle of pilocarpine eye drops, opened and undated. -One bottle of latanoprost eye drops, opened and undated. -One bottle of timolol eye drops, opened and undated. During an interview on 5/28/25 at 10:02 A.M., Nurse #1 said nurses are responsible for dating the eye drops when they are opened. During an interview on 5/28/25 at 12:38 P.M., the Regional Director of Clinical Education and Administration said eye drops should be dated upon opening.

Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for two Residents (#60 and #3) out of 19 total sampled residents. Specifically, 1.) For Resident #60, the nurses inaccurately documented: a.) a peripherally inserted central catheter (PICC) dressing change as being completed when it was not; b.) heel booties (heel offloading devices which are designed to prevent and treat pressure ulcers) as being implemented when they were not; and c.) side rails were padded when they were not. 2.) For Resident #3, the nurses inaccurately documented heel booties being implemented and heels being offloaded when they were not. Findings include: Review of the facility policy titled 'Charting and Documentation', revised 2/4/17, indicated: - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1.) Resident #60 was admitted to the facility in December 2022 with diagnoses including sepsis, urinary tract infection, and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/25, indicated Resident #60 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #60 received intravenous medications and was dependent on staff for putting on/taking off footwear. 1a.) Review of Resident #60's physician's order, initiated 5/9/25, indicated: - Change PICC Line Catheter Site Dressing, every day shift every 7 day(s). On 5/27/25 at 8:27 A.M., the surveyor observed Resident #60 in bed with a PICC dressing on his/her right arm which was dated 5/9/25, which was 19 days prior to observation. Resident #60 said the PICC dressing had not been changed recently and had only been changed twice since he/she was readmitted to the facility 4/19/25. During an interview on 5/27/25 at 11:38 A.M., Nurse #2 and the surveyor observed Resident #60's PICC dressing. Nurse #2 said the PICC dressing was dated 5/9/25. Nurse #2 said the PICC dressing should have been changed every seven days, and it was overdue to be changed. Review of Resident #60's Treatment Administration Record (TAR), dated 5/10/25 to 5/27/25, indicated: - 5/16/25: Nurse #1 documented the physician order to Change PICC Line Catheter Site Dressing as completed, when it was not. - 5/23/25: Nurse #4 documented the physician order to Change PICC Line Catheter Site Dressing as completed, when it was not. During an interview on 5/27/25 at 11:40 A.M., Nurse #2 and the surveyor reviewed the TAR, dated 5/10/25 to 5/27/25. Nurse #2 said since the PICC dressing had not been changed since 5/9/25, it should not have been documented as completed. On 5/28/25 at 12:05 P.M., the surveyor attempted to contact Nurse #4 by telephone. Nurse #4 did not return the telephone call. During an interview 5/28/25 at 12:11 P.M., Nurse #1 said she absolutely did not change the PICC dressing on 5/16/25 and was unsure why it is documented that she did. During an interview on 5/27/25 at 2:18 P.M., Unit Manager #1 said Resident #60's PICC dressing should have been changed every seven days but was not. Unit Manager #1 said the PICC dressing should not have been documented as completed if it was not. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said PICC dressings should be changed as ordered by the physician. The Regional Director of Clinical Education and Administrator further said the PICC dressing should not have been documented as completed if it was not. 1b.) Review of Resident #60's active physician order, initiated 4/19/25, indicated: - Ensure pt (patient) is wearing Prevelon (brand name) (sic) boots while in bed, every shift for pressure injury. On 5/27/25 at 8:27 A.M. and 11:38 A.M., and on 5/28/25 at 6:53 A.M. and 8:01 A.M., the surveyor observed Resident #60 in bed with his/her heels directly on the mattress. Resident #60's was not wearing bilateral booties, and his/her heels were not offloaded. There were no booties visible in room. During an interview on 5/28/25 at 8:22 A.M., the surveyor observed Resident #60 in bed with his/her heels directly on the mattress. Resident #60's was not wearing bilateral booties, and his/her heels were not offloaded. Resident #60 said he/she used to have a heel wound, but it had healed. Resident #60 said staff had not offered booties in a long time, so he/she thought they were longer needed. Resident #60 said if the facility thought he/she needed them, he/she would wear them. Review of Resident #60's Treatment Administration Record (TAR), dated 5/27/25 and 5/28/25, indicated nursing had documented the physician's order to Ensure pt is wearing Prevelon (sic) boots while in bed as implemented every shift. Review of Resident #60's nursing progress notes and TAR, dated 5/27/25 and 5/28/25, failed to indicate any refusal or rationale for why his/her booties were not in place or heels offloaded. During an interview on 5/28/25 at 8:03 A.M., Certified Nurse Assistant (CNA) #2 said Resident #60 should wear booties when in bed because he/she used to have a wound on his/her heel. CNA #2 said she was unaware that he/she was not wearing them. CNA #2 said she had not offered them this morning. During an interview on 5/28/25 at 8:06 A.M., Nurse #3 said Resident #60 does not wear booties during the day shift and is only supposed to wear them at night. Nurse #3 reviewed Resident #60's physician's order and said based on the order he/she should always wear booties when in bed but had not been. Nurse #3 said Resident #60's booties were always off before her shift begins and he/she did not have a history of refusing them. Nurse #3 said the physician's order to Ensure pt is wearing Prevelon (sic) boots while in bed should not have been documented as implemented when it was not. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said if the physician's order was to have booties on while in bed, then they should have been implemented while Resident #60 was bed. The Regional Director of Clinical Education and Administrator said if Resident #60 had not worn the heel booties it should not have been documented as implemented. 1c.) Review of Resident #60's active physician order, initiated 4/19/25, indicated: - Padded side rails when in bed, every shift, for seizure. On 5/27/25 at 8:27 A.M. and 11:38 A.M., and on 5/28/25 at 6:53 A.M. and 8:01 A.M., the surveyor observed Resident #60 in bed with both side rails in place and not padded. There were blue side rail pads placed on the floor against the wall in the Resident's room. During an interview on 5/28/25 at 8:22 A.M., the surveyor observed Resident #60 in bed with both side rails in place and not padded. Resident #60 said he/she does not like the side rail pads because they pop off and hit him/her in the face. Resident #60 said the side rail pads have not been in place for a long time. Review of Resident #60's Treatment Administration Record (TAR), dated 5/27/25 and 5/28/25, indicated nursing had documented the physician's order for padded side rails when in bed as implemented every shift. During an interview on 5/28/25 at 8:03 A.M., Certified Nurse Assistant (CNA) #2 said Resident #60 refuses to have the side rail pads applied because he/she doesn't like them. CNA #2 said the CNAs should alert the nurse every time the Resident refuses them so the nurse can document it as refused. CNA #2 further said that the side rail pads had been against the wall and had not been applied to the side rails in a long time, but are kept handy in case they are needed. During an interview on 5/28/25 at 8:06 A.M., Nurse #3 was unaware Resident #60 required the side rails to be padded. Nurse #3 said the order for padded side rails when in bed should not be documented as implemented if they were not in place. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said if the physician's order was to have padded side rails when in bed, then they should have been implemented while Resident #60 was bed. The Regional Director of Clinical Education and Administrator said if Resident #60 refused the side rail pads it should not have been documented as implemented. 2.) Resident #3 was admitted to the facility in September 2018 with diagnoses including chronic kidney disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/16/25, indicated Resident #3 had severe cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15. This MDS indicated Resident #3 required substantial/maximal assistance with putting on/taking off footwear. Review of Resident #3's active physician's orders indicated: - Booties to bilateral heels while in bed, every shift for heels, initiated 12/29/24. - Float left heels in bed; off-load wound, every shift, 1/22/2025 On 5/27/25 at 8:03 A.M. and 5/28/25 at 6:55 A.M. and 7:52 A.M., the surveyor observed Resident #3 in bed with his/her heels directly on the mattress. Resident #3's was not wearing bilateral booties, and his/her heels were not offloaded. There were two blue booties visible in room on his/her wheelchair, which was not within reach of the Resident during each of these observations. During an interview on 5/28/25 at 7:53 A.M., Resident #3 said he/she had a wound on his/her left heel, and it hurt when it rubbed on the mattress. Resident #3 said he/she had not worn booties on his/her heels for a while but would wear them if they were offered. Resident #3 said staff never offers to apply them. Review of Resident #3's Treatment Administration Record (TAR), dated 5/27/25 and 5/28/25, indicated nursing documented physician's orders for booties to bilateral heels while in bed and float heels in bed, off-load wound as implemented every shift. Review of Resident #3's nursing progress notes and TAR, dated 5/27/25 and 5/28/25, failed to indicate any refusal or rationale for why his/her booties were not in place or heels offloaded. During an interview on 5/28/25 at 8:11 A.M., Certified Nurse Assistant (CNA) #1 said Resident #3 is not supposed to wear the booties or offload heels on the day shift, only on night shift. CNA #1 said Resident #3 was receptive to wearing the booties and never refuses them. During an interview on 5/28/25 at 8:18 A.M., Nurse #1 said if the physician's order was to have booties on or heels offloaded while in bed, then they should have been implemented while Resident #3 was bed. Nurse #1 said if Resident #3 did not wear the booties or have heels offloaded then it should not have been documented as implemented. During an interview on 5/28/25 at 10:14 A.M., the Regional Director of Clinical Education and Administrator said if the physician's order was to have booties on or heels offloaded while in bed, then they should have been implemented while Resident #3 was bed. The Regional Director of Clinical Education and Administrator said if Resident #3 did not wear the booties or have heels offloaded then it should not have been documented as implemented.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy, and upon admission had given signed consent for him/her to be administered the COVID-19 Vaccination, the Facility failed to ensure he/she was given the vaccine, increasing Resident #1 risk for acquiring the infection. Findings include: Review of the Facility's Policy, titled Coronavirus/COVID-19 Disease: Vaccination-Resident and Staff, dated 04/01/24, indicated the Facility will offer an updated 2023-2024 COVID-19 vaccine to residents and staff who have not received a monovalent vaccine, and who wish to be considered Up to Date with COVID-19 vaccine administration. Resident #1 was admitted to the Facility in September 2024, diagnoses included moderate dementia with mood disturbance, cognitive communication deficit, syncope and collapse, repeated falls, hypertension heart disease, delusional disorder, weakness, major depression disorder, anxiety, and difficulty with walking. Review of Resident #1's Medical Record indicated Resident #1's Health Care Agent Activation Form (the doctor determines that the person is incapacitated and can no longer make their own healthcare decisions) was signed by Resident #1's Physician on 09/04/24. Review of Resident #1's Medical Record indicated Resident #1's COVID-19 Vaccination Consent and Administration Form was signed, per Director of Nurses (DON) on 09/03/24, to give consent for Resident #1 to receive the COVID-19 vaccine. Review of Resident #1's Medical Record indicated Resident #1 had last received a COVID-19 Vaccination while in the community on 10/10/23. Further review of Resident #1's Medical Record indicated he/she did not receive the COVID-19 vaccine at the Facility, and Resident #1 tested positive for COVID-19 on 11/06/24. During a telephone interview on 12/18/24 at 12:37 P.M., the Unit Manager said she was aware Resident #1's Health Care Agent had signed Resident #1's COVID-19 Vaccination Consent Form on 09/03/24. The Unit Manager said she was waiting for the Facility to hold a COVID-19 Vaccination Clinic to administer the COVID-19 vaccine to Resident #1. The Unit Manager said it had been her practice was to hold onto the Residents' COVID-19 Vaccination Consent Forms until a COVID-19 Vaccination Clinic was scheduled at the facility. The Unit Manager said when the Facility's COVID-19 Vaccination Clinic was scheduled, she would then notify the Infection Control Nurse how many vaccines were needed and would obtain Physicians' Order for administration when the vaccine was delivered to the Facility. The Unit Manager said this was the Facility's COVID-19 Vaccination process. The Unit Manager said she was not aware of the Facility's COVID-19 Vaccination Policy and Procedures and had not reviewed the Facility's Policy. During an interview on 12/03/24 at 5:29 P.M., the Director of Nursing (DON) said she was informed on 11/18/24 that Resident #1's Health Care Agent had completed Resident #1's COVID-19 Vaccination Consent Form on 09/03/24 and that Resident #1 had not received the COVID-19 vaccine. The DON said she spoke to the Unit Manager who said she was waiting until four more residents needed the COVID-19 vaccine prior to administrating the vaccine to Resident #1. The DON said when she spoke to the Unit Manager again, she said she had been waiting for the Facility to hold a COVID-19 Vaccination Clinic to administer the COVID-19 vaccine to Resident #1, and other residents. The DON said it was her expectation that the Unit Manager should have obtained a Physician Orders for the COVID-19 vaccine, ordered the COVID-19 vaccine (contact the Pharmacy or inform the Infection Control Nurse to order the vaccine) and administer the COVID-19 vaccine to Resident #1 when available. The DON said the Facility can obtain the COVID-19 vaccine without any delays and the Facility Nursing staff are able to administer the COVID-19 vaccine at any time when requested, that staff do not need to wait for a Vaccination Clinic to be held in the Facility. On 12/03/24, the Facility was found to be in Past Noncompliance and presented the Surveyor with a plan of correction (with an effective date of 11/20/24) that addressed the area(s) of concerns as evidenced by: A) On 11/07/24, Resident #1 tested positive for and required treatment for COVID-19, and remained in the facility. B) On 11/18/24, the Director of Nurses and the Infection Control Nurse completed a Facility Audit to ensure all Resident Vaccination Consent Forms were accurately completed, signed and that Resident's/HCA/Legal Representatives who requested the vaccine, had been administered the vaccine. C) On 11/18/24 and ongoing, as needed, the Director of Nurses (DON) and the Infection Control (IC) Nurse educated all Licensed Nursing Staff including Per-Diem Staff regarding the following; - Facility Policies and Procedures for vaccinations - Completion of Vaccination Consent Forms- - Obtaining Physician Orders - Pharmacy request for vaccination - Vaccination Administration D) 11/18/24 and ongoing, DON and IC Nurse inservice for nursing also included education on changes to Procedure for Vaccines which included Unit Manager(s) to verify on the day after resident admission all Vaccination Consent Forms were obtained and Unit Manager, Infection Control Nurse and Director of Nurses to be informed of request E) Effective 11/18/24 and going forward, the 11:00 P.M. to 7:00 A.M. Nurse Supervisor will review all new admissions and run a daily report of Physician Orders, vaccinations will be discussed Morning Clinical Meetings and during Resident's Care Plan meetings (medication review) of Residents Vaccination status. F) The Director of Nurses and Assistant Director of Nurses conducted Facility Random Audits related to all vaccinations, going forward they will be conducted twice a week for four weeks, then weekly for four weeks, and will determine need for continued Audits, based on determination of compliance. G) The Director of Nurses/Designee will bring the results of the Facility's Vaccination Audits to be reviewed and discussed at QAPI committee meeting. H) Adminstrator and/or Designee are responsible for overall compliance.

Based on observation and interview, the facility failed to provide residents with a dignified dinning experience on one of three units. Findings include: On 7/22/24 at 8:41 A.M., the surveyors observed residents on the 3rd floor unit being served on institutional trays in the dining room during the breakfast meal. On 7/23/24 at 8:32 A.M., the surveyors observed residents on the 3rd floor unit being served on institutional trays in the dining room during the breakfast meal. On 7/23/24 at 12:34 A.M., the surveyors observed residents on the 3rd floor unit being served on institutional trays in the dining room during the lunch meal. During an interview on 7/23/24 at 12:41 P.M., Unit Manager #1 said that all the meals are served on trays in the dining rooms.

Based on record review and interview, the facility failed for one Resident (#81) of 25 sampled residents, to develop a baseline care plan to address his/her risk for falls. Findings include: The facility policy Accident and Incidents Guideline dated 2/8/2018, indicated: - The interdisciplinary team (IDT), based upon the identified potential risk factors develops and implements an individualized plan of care. Resident #81 was admitted to the facility in July 2024, and had diagnoses which included difficulty in walking, ataxia (loss of coordination of voluntary muscle movements), repeated falls, Parkinson's disease, syncope (fainting) and collapse, and orthostatic hypotension (low blood pressure that happens when standing after sitting or lying down and can cause dizziness or lightheadedness and possibly fainting). Review of Resident #81's Fall Risk assessment dated [DATE], indicated he/she was at a moderate risk for falls. The assessment indicated a falls care plan was to be developed and it included specific goals and interventions. Review of Resident #81's Fall Incident Assessment, dated 7/8/24, indicated he/she fell at approximately 2:30 A.M. and staff found the Resident on the floor next to the bed. The assessment indicated Resident #81 did not sustain any injuries. The assessment indicated there was no fall care plan, or goals and interventions to manage this risk. On 7/22/24 at approximately 1:00 P.M., the surveyor reviewed Resident #81's care plan in the electronic medical record and noted there was no baseline care plan to address his/her risk for falls, as identified in the fall assessments. The surveyor re-reviewed the record and determined a baseline or comprehensive fall-risk care plan had not been developed. Review of Resident #81's physician orders dated July 2024, indicated there were no orders for interventions to manage his/her risk for falls. On 7/23/24 at approximately 8:20 A.M., the surveyor requested a hard copy of Resident #81's baseline care plans from staff. The care plans provided included a falls care plan, developed by Unit Manager #3. Review of Resident #81's falls care plan indicated it was initiated on 7/7/24 (date of admission) but created on 7/23/24. The falls care plan also had a revision date of 7/23/24. Further review of the falls care plan with a creation date of 7/23/24, indicated the focus: Fall Risk - Resident is at risk for fall and/or injury. Has a change in mobility. Has a change in transfer ability. Newly admitted to different environment. During an interview with the MDS (minimum data set) Director on 7/23/24 at approximately 10:00 A.M., she opened Resident #81's electronic medical record. The MDS Director and surveyor observed that a baseline falls care plan was present. The baseline falls care plan had a documented initiation date of 7/7/24, a creation date of 7/23/24, and a revision date of 7/23/24. The MDS Director said she did not understand how the care plan could be initiated on 7/7/24 yet created on 7/23/24. During an interview with Unit Manager #3 on 7/23/24 at approximately 1:00 P.M., she said she completed Resident #81's Fall Risk Assessment on 7/7/24. She said Resident #81's Fall Risk Assessment would have triggered the creation of a baseline falls care plan, and included in it would be the focus, goals, and interventions auto populated from the assessment. Unit Manager #3 said that on 7/23/24 she noticed the goals section of the assessment did not auto populate to the care plan so she entered this revised information into the falls care plan on this date. Unit Manager #3 said she was unable to explain why the creation date for the falls care plan was 7/23/24.

Based on observation, record review and interview the facility failed to develop a dental care plan for one Resident (#87) out of 25 sampled residents. Findings include: Resident #87 was admitted to the facility in February 2024 with diagnoses including malnutrition, kidney disease and depression. On 7/22/24, at 8:50 A.M. the surveyor observed Resident #87 to have only two top teeth, both of which were carious. During an interview on 7/22/24 at 8:50 A.M. Resident #87 said that he/she wants to see a dentist. Resident #87 then said that he/she thinks that his/her partial plates were lost in the move to the facility. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the facility document titled NUT-Nutrition/Hydration Assessment V3-V4 dated 5/8/24, section V. Oral Status/Swallowing indicated that Resident #87 had missing or broken teeth and had a partial lower denture as well as mild dysphagia (difficulty swallowing) due to lack of dentition, per Speech Language Therapy (SLP). Review of the facility documents titled SLP Evaluation and Plan of Treatment, dated 5/22/24, indicated the following: Patient with no lower denture found in mouth or anywhere in the room, not safe for upgrade (in diet texture) due to no denture. Review of the facility document titled Speech Therapy Treatment Encounter Note(s), dated 5/22/24, indicated the following: Patient with signs/symptoms dysphagia including impaired mastication (chewing) due to poor dentition/missing partials. Review of the care plan dated initiated on 2/9/24 failed to indicate a plan of care for dental care. During an interview on 7/23/24 at 9:44 A.M., Unit Manager #1 said that she would expect that a care plan would be in place for Resident #87's dental concerns. During an interview on 7/23/24 at 12:15 P.M., MDS Nurse #1 said that he gets the information to document the admission MDS from the Admission Nursing Assessment. MDS Nurse #1 then said that the Admission Nursing Assessment is incorrect.

Based on observations, interviews and record review, the facility failed to ensure the environment was free from hazards that could cause accidents for one Resident (#79) out of a sample of 25 Residents. Specifically, the facility failed to pad the Resident's side rails as ordered. Findings include: A review of the facility's policy titled 'Accident & Incidents Guideline' with a revision date of February 2018 indicated the following: -It is the center's policy to provide an environment that is free from hazards over which the center has control. The intent of this policy is that the center identifies each resident at risk for accidents, and adequately plans care and implements procedures to prevent accidents. Resident #79 was admitted to the facility in December 2022 with diagnoses including localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that the Resident has a diagnosis of seizure disorder or epilepsy. On 7/22/24 at 8:15 A.M., the surveyor observed the Resident in bed with two quarter side rails up on the right and left side of the bed. The two quarter side rails were not padded. On 7/23/24 at 8:09 A.M., the surveyor observed the Resident in bed with two quarter side rails up on the right and left side of the bed. The two quarter side rails were not padded. A review of the July 2024 physician's orders indicated the following: -Use 1/4 siderails on right and left side of the bed. -Monitor for seizures every shift. -Padded side rails when in bed every shift. A review of the care plan initiated 12/22/22 indicated the following: -Focus: Seizure Disorder-Resident is at risk for injury related to seizure disorder. -Intervention: Pad side rails on the bed. During an interview and observation on 7/23/24 at 11:02 A.M., Certified Nurses Assistants (CNAs) #1 and #2 and surveyor observed the Resident in bed, the two quarter side rails on the left and right side of the bed were up and not padded. They said the Resident recently moved from a different room. They said they have not seen his/her side rails padded since he/she moved to this room, they both looked around the room and could not locate any side rails pads. The CNAs said they were not aware that the Resident's side rails should be padded. The CNAs said the Unit Manager, or the Nurse has not informed them that the Resident should have padded side rails while in bed. During an interview and observation on 7/23/24 at 9:16 A.M., the surveyor and Nurse #2 observed the Resident in bed with two quarter side rails up on the left and right side of the bed. The two quarter side rails were not padded. Nurse #2 said that both side rails should be padded if the physician's orders indicated so. A review of a social services progress note dated 7/8/24 indicated the following: -Due to roommate incompatibility, the Resident will be moved from 205 B to 212 A. Roommate change form completed and filed. During a telephone interview on 7/25/24 at 10:09 A.M., Social Worker #1 said Resident # 79 changed rooms on 7/8/24. During an interview and observation on 7/23/24 at 9:35 A.M., Unit Manager #2 and surveyor observed the Resident in bed, the quarter side rails on the left and right side of the bed were up and not padded, she said physician's orders should be followed as indicated. During an interview on 7/23/24 at 11:58 P.M., the Director of Nurses and Assistant Director of Nurses said Resident #79 has a history of seizures and his/her right and left side rails should be padded while he/she is in bed. They said he/she recently changed rooms and staff did not move his/her side rail pads to his/her new bed. They both said physician's orders should be followed.

Based on interviews, policy review and observations, the facility failed to secure medication on one of three units (second floor). Findings include: Review of the facility policy Storage of Medications dated [DATE], indicated: - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. On [DATE] at 8:42 A.M., on the second floor unit, the surveyor observed Nurse #1 remove an expired bottle of liquid Trazodone, 5 milligrams per milliliter, from the refrigerator located in the unit's locked medication room. Nurse #1 gave the medication to Unit Manager #2, who then placed it on the nursing station desk, which was located approximately two feet from the common area hallway. Trazodone is a prescription medication used for the treatment of depression. On [DATE] at 9:33 A.M., the surveyor returned to the second floor unit and observed the same bottle of liquid Trazodone on the nursing station desk. No staff were at the desk or the nursing station, and none within view. The surveyor observed a resident walking in the hallway with a rehabilitation therapist, passing the nursing station desk. On [DATE] at 9:41 A.M., Unit Manager #2 entered the nursing station and sat down next to the medication. Unit Manager #2 said she was looking into whether the physician wanted to reorder or discontinue the Trazodone. The surveyor told Unit Manager #2 he had observed the Trazodone on the desk unsecured and unattended for almost 10 minutes. Unit Manager #2 said the Trazodone should have been either secured or attended to by nursing staff. On [DATE] at 9:47 A.M., Unit Manager #2 stood up and left the nursing station. The Trazodone remained on the desk, unsecured, and no other nursing staff were in the area. On [DATE] at 9:51 A.M., Unit Manager #2 returned to the nursing station and entered the medication room. Unit Manager #2 then left the medication room and sat at the nursing station desk, in front of the Trazodone. Unit Manager #2 said she was still looking into whether the physician wanted to reorder or discontinue the Trazodone. The surveyor told Unit Manager #2 the Trazodone had, again, been left on the desk, unsecured and unattended by staff. Unit Manager #2 said the Trazodone should not have been left unsecured and unattended on the desk.

Based on records reviewed and interviews for two Residents (#87 and #89) out of a total sample of 25, the facility failed to provide dental care. Specifically: 1. For Resident #87, who had broken/carious teeth and lost his/her lower dentures, the facility failed to ensure he/she had a timely dental consultation. 2. For Resident #89, the facility failed to follow up on the recommendation for the fabrication of the upper dentures, three months after originally recommended. Findings Include: Review of the facility policy titled Dental Care guideline dated 5/23/18, indicated the following: The facility will if necessary or requested, assist the resident with making appointments or arrange dental services. A dentist will be made available for each resident through a contractual agreement by an approved dental provider that services the center or from the community. 1. Resident #87 was admitted to the facility in February 2024 with diagnoses including malnutrition, kidney disease and depression. On 7/22/24 at 8:50 A.M. the surveyor observed Resident #87 to have only two top teeth, both of which were carious. During an interview on 7/22/24 at 8:50 A.M. Resident #87 said that he/she wants to see a dentist. Resident #87 then said that he/she thinks that his/her partial plates were lost in the move to the facility and his/her teeth need fixing. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the medical record indicated a consent for dental services dated 5/28/24. Review of the facility document titled NUT-Nutrition/Hydration Assessment V3-V4 dated 5/8/24, section V. Oral Status/Swallowing indicated that Resident #87 had missing or broken teeth and had a partial lower denture as well as mild dysphagia (difficulty swallowing) due to lack of dentition, per Speech Language Therapy (SLP). Review of the facility document titled SLP Evaluation and Plan of Treatment, dated 5/22/24, indicated the following: Patient with no lower denture found in mouth or anywhere in the room, not safe for upgrade (in diet texture) due to no denture. Review of the facility document titled Speech Therapy Treatment Encounter Note(s), dated 5/22/24, indicated the following: Patient with signs/symptoms dysphagia including impaired mastication (chewing) due to poor dentition/missing partials. During an interview on 07/23/24 at 9:44 A.M., Unit Manager #1 said that she would expect that Resident #87 would have been seen by a dentist. 2. Resident #89 was admitted to the facility with diagnoses including cancer, heart disease and anxiety. During an interview on 7/22/24, at 10:43 A.M. Resident #89 said that he/she needs to see a dentist to have dentures redone. Review of the minimum Data Set (MDS) dated [DATE] indicated Resident #89 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated that Resident #87 has decayed, broken teeth and a loosely fitting full upper denture. Review of the doctor's orders dated July 2024 indicated an order initiated on 3/8/24, may be seen by dentist as needed. Review of the care plan dated 3/11/24 indicated a focus for dental with an intervention to coordinate arrangements for dental care. Review of the medical record indicated a consent for dental services dated 4/10/24. Review of the facility documents titled Risk progress Assessment (LMHS) dated 4/28/24 and 5/20/24, indicated that Resident #89 had been approved for denture fabrication. During an interview on 7/23/24 at 8:23 A.M., Unit Manager #1 said that the dentist's recommendation for new dentures should have been followed up on. During an interview on 7/23/24 at 10:25 A.M., the Director of Nursing said that the dental service had seen the Resident on 4/15/24 and sent a letter to the Resident's financial power of attorney with the expected costs, but the facility had not followed up with the dental service to find out what the status of the refabrication of the denture was, now more than three months later.

Based on observation, record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for two Residents (#87 and #79) out of a total sample of 25 residents. Specifically: 1. For Resident #87, the facility failed to accurately document the dental status on the nursing admission assessment, 2. For Resident #79, the facility failed to accurately document the presence of side rail pads after Resident #79's room change. Findings include: Review of the facility policy titled Nursing Admission guideline dated as revised on 12/20/22, indicated that the purpose of this guideline is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (minimum data set). Further review indicated that the nurse conducts an admission assessment including a review of systems to include teeth and gums as well as all active patient problems. Further review indicated that all relevant assessment data obtained is documented in the resident's medical record. 1. Resident #87 was admitted to the facility in February 2024 with diagnoses including malnutrition, kidney disease and depression. Review of the MDS dated [DATE], indicated that Resident #87 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Further review indicated that Resident #87 has no broken or carious teeth. On 7/22/24 at 8:50 A.M. the surveyor observed Resident #87 to have only two top teeth, both of which were carious. During an interview on 7/22/24 at 8:50 A.M. Resident #87 said that he/she wants to see a dentist. Resident #87 then said that he/she thinks that his/her partial plates were lost in the move to the facility and his/her teeth need fixing. Review of the facility document titled NUT-Nutrition/Hydration Assessment V3-V4 dated 5/8/24, section V. Oral Status/Swallowing indicated that Resident #87 had missing or broken teeth and had a partial lower denture as well as mild dysphagia (difficulty swallowing) due to lack of dentition, per Speech Language Therapy (SLP). Review of the facility document titled SLP Evaluation and Plan of Treatment, dated 5/22/24, indicated the following: Patient with no lower denture found in mouth or anywhere in the room, not safe for upgrade (in diet texture) due to no denture. Review of the facility document titled Speech Therapy Treatment Encounter Note(s), dated 5/22/24, indicated the following: Patient with signs/symptoms dysphagia including impaired mastication (chewing) due to poor dentition/missing partials. Review of the initial nursing assessment titled NSG-Admission/Readmission Evaluation-V4, dated 2/9/24, section G Oral and Nutrition #1, indicated the Resident has no oral, dental, or swallowing issues evident at this time. During an interview on 7/23/24, at 12:15 P.M., MDS Nurse #1 said that he gets the information to complete the admission MDS from the NSG-Admission/Readmission Evaluation-V4. MDS Nurse #1 then said that the admission nursing assessment is incorrect, which is also the reason the MDS is inaccurate. 43807 2. Resident #79 was admitted to the facility in December 2022 with diagnoses including symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus. A review of Resident #79's most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that the Resident has a diagnosis of seizure disorder or epilepsy. On 7/22/24 at 8:15 A.M., the surveyor observed the Resident in bed, the left and right quarter side rails were up. The two quarter side rails were not padded. On 7/23/24 at 8:09 A.M., the surveyor observed the Resident in bed, the left and right quarter side rails were up. The two quarter side rails were not padded. A review of the July 2024 physician's orders indicated the following: -Use 1/4 siderails on right and left side of the bed. -Monitor seizures every shift. -Padded side rails when in bed every shift. A review of the care plan initiated 12/22/22 indicated the following: Focus: Seizure Disorder - Resident is at risk for injury related to seizure disorder. Intervention: Pad side rails on the bed. During an interview and observation on 7/23/24 at 11:02 A.M., Certified Nurses Assistants (CNAs) #1 and #2 and the surveyor observed the Resident in bed. The right and left quarter side rails were up and not padded. The CNAs said the Resident recently moved from a different room. They said they have not seen his/her side rails padded since he/she moved to this room. Both CNAs looked around the room and could not locate any side rails pads. The CNAs said they were not aware that the Resident's side rails should be padded. The CNAs said the Unit Manager or the Nurse had not informed them that the Resident should have padded side rails while in bed. A review of a social services progress note dated 7/8/24 indicated the following: - Due to roommate incompatibility, the Resident will be moved from 205 B to 212 A. Roommate change form completed and filed. During a telephone interview on 7/25/24 at 10:09 A.M., Social Worker #1 said Resident #79 changed rooms on 7/8/24. A review of the July 2024 Treatment Administration Record (TAR) indicated staff had checked off that Resident #79's side rails were padded when the Resident was in bed on all three shifts dated 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24 and 7/22/24. During an interview on 7/23/24 at 12:28 P.M., the Director of Nurses and Assistant Director of Nurses said Resident #79 has a history of seizures and his/her left and right side rails should be padded while he/she is in bed. They said he/she recently changed rooms and staff did not move his/her side rail pads from his/her old bed to his/her new bed. They both said staff are expected to check for equipment before documenting in the medical record. They said Resident #79's medical record was not accurately documented because he/she did not have side rail pads on his/her new bed after the room change on 7/8/24.

Based on observations and interviews the facility failed to maintain resident dignity by applying a privacy cover on a Foley catheter bag for one Resident (#4) out of a total sample of 25 residents. Review of facility policy titled Quality of Life-Dignity with a revision date of 2009 included, but not limited to: -Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep the urinary catheter bag covered. Resident #4 was admitted to the facility in January 2022 with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder and osteoarthritis. Review of Resident #4's most recent Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of possible 15 indicating the Resident has intact cognition. Further review indicated Resident #4 has an indwelling catheter. During an observation on 6/6/23 at 8:11 A.M., Resident #4 was observed sitting up in bed with a Foley catheter visible from the doorway with no privacy cover. Additional observations of the uncovered catheter bag visible from the doorway were made on 6/6/23 at 9:14 A.M., 6/7/23 at 7:53 A.M., and 6/8/23 at 7:36 A.M. During an interview on 6/8/23 at 8:56 A.M., Nurse #2 said a privacy cover should be in place for a resident who has a catheter. Nurse #2 said it is the nurse's responsibility to ensure that the cover is on.

Based on record review, interview and observation, the facility failed to prevent the deterioration of a pressure injury to 1 Resident (#74), out of 33 sampled residents. Findings include: Review of Resident #74's medical record indicated that on 5/10/22, the Wound Physician identified a new pressure injury located on the coccyx and recommended interventions for treatment which included: daily calcium alginate dressing changes covered in gauze, off-load the wound, reposition per facility protocol, and use of a Group 2 mattress. The medical record indicated there was no documentation the facility notified the Physician of the Wound Physician's recommendations until 5/16/22. The facility's policy and procedure for Skin Management & Pressure Ulcer Prevention, dated 8/10/17, indicated Notify the MD/NP and responsible person when there is an alteration in skin integrity that warrants ongoing monitoring, evaluation and treatment. Provide periodic progress notes as indicated. Resident #74 was admitted to the facility in January 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #74's quarterly Minimum Data Set (MDS) assessment, dated 4/13/2022, indicated he/she had severely impaired cognitive skills for daily decision-making, was dependent on staff for all activities of daily living, was at-risk for pressure ulcers and used a pressure relieving device for the bed (type of device not specified). Review of Resident #74's care plan dated 1/21/22, indicated the goal of care was for the skin to remain intact. Interventions included the need for a pressure-relieving/reducing mattress (dated 1/22/22). Review of Resident #74's Wound Physician note, dated 5/10/22, indicated he/she had a stage 3 pressure wound (full skin thickness) located on the coccyx. The wound measured 2 centimeters (cm) long x 0.5 cm wide x 0.3 cm deep. The Wound Physician note also indicated a treatment plan which included an alginate calcium dressing to be applied once daily for 30 days and a recommendation that Resident #74 use a Group 2 mattress setting. Group 2 pressure reducing support surfaces include: powered pressure reducing mattresses, semi-electric hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays, advanced non-powered pressure reducing mattresses and advanced non-powered pressure reducing mattress overlays. Review of Resident #74's weekly skin assessments, treatment administration record, and nursing notes dated prior to 5/16/22 did not mention the coccyx wound, or any communication with the Physician regarding this wound or the Wound Physician's recommendations from the 5/10/22 examination. Review of Resident #74's physician treatment orders, dated 5/16/22, indicated: wash stage 3 pressure ulcer with normal saline, pat dry, apply calcium alginate and cover with site gauze daily until resolved; air mattress setting set at comfort level 2 and to monitor setting and functioning every shift. Review of Resident #74's treatment administration record, dated May 2022, indicated that nursing staff began to monitor and treat his/her coccyx wound during the day shift on 5/16/22. Review of Resident #74's care plan for pressure ulcers, dated 5/16/22, indicated he/she had a stage 3 pressure ulcer to the coccyx, related to immobility (full-thickness skin loss potentially extending into the subcutaneous tissue layer). Care plan interventions included administer treatments as ordered and monitor for effectiveness. Review of Resident #74's nurses notes, dated through 5/18/22, indicated there was no reference to his/her coccyx wound. During an observation of Resident #74 on 5/17/22 at 8:30 A.M., he/she was lying in bed on a air mattress in the supine position. The air mattress (a powered pressure reducing mattress) was not on. During an observation of Resident #74 on 5/18/22 at 10:53 A.M., the air mattress power was on and set at comfort level 4 (physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Nurse #4 on 5/18/22 at 10:53 A.M., in Resident #74's bedroom, she said nursing staff sometimes increase the firmness of the air mattress during care but then forget to reduce the setting to the correct pressure after finished with care. Nurse #4 said Resident #74's air mattress pump may also have been malfunctioning. During an interview on 5/18/22 at 10:24 A.M., and again on 5/19/22 at 11:30 A.M., Unit Manager #3 said she first observed Resident #74's coccyx wound on 5/10/22, while accompanying the Wound Physician during his/her examination. Unit Manager #3 said, based on the treatment administration record and nursing notes, staff did not contact the Physician to communicate the Wound Physician's recommendations for a dressing and Group 2 mattress until 5/16/22. Unit Manager #3 said it was facility policy to immediately treat pressure ulcers to prevent deterioration and that a delay of approximately 6 days was not appropriate nursing care. Unit Manager #3 said she took Resident #74's coccyx wound measurements on 5/10/22 and again on 5/19/22 (accompanied by the surveyor), and that the length of the open wound increased to 2.5 cm and the width increased to 1 cm. Unit Manager #3 said the wound depth was unchanged. Resident #74's skin assessment, dated 5/19/22, indicated the coccyx wound measured 2.5 cm (length) x 1 cm (width) x 0.3 cm (depth).

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) the Facility failed to prevent Resident #1's elopement from the Facility which occurred sometime between 1:00 A.M. and 2:30 A.M. on 12/4/17. The Police Report indicated that the police found Resident #1 in a neighboring town at approximately 2:49 A.M., standing at an intersection one and one-half miles from the Facility, confused with blood and lacerations in the area of his/her left eye. Findings include: Review of Resident #1's plan of care, initiated upon his/her admission to the facility in (MONTH) (YEAR), indicated that he/she was at risk to fall. Resident #1's Minimum Data Set (MDS) assessment, completed 11/15/17, indicated that his/her cognitive patterns were impaired, and he/she ambulated with assistance. The Police Report indicated that on 12/4/17 at 2:49 A.M. police officers found Resident #1 standing at an intersection about one and one-half miles from the Facility. The Police Report indicated that Resident #1 was wearing street clothes, a light jacket, a knit hat, one glove and moccasins. The Police Report indicated that Resident #1 provided Family Member #1's name and address to the police. The Hospital Emergency Department Triage Notes, dated 12/4/17, indicated that Resident #1 arrived to the emergency department via emergency medical service after being found confused and wandering by the police, with a facial injury. The Surveyor interviewed Family Member #1 at 10:30 A.M. on 7/25/18. Family Member #1 said that at about 3:00 A.M. on 12/4/17, police officers woke her by banging on her door. Family Member #1 said that the police officers told her that they picked up Resident #1 and transported him/her to the hospital. Family Member #1 said that she told the police officers that Resident #1 lived at the Facility. Family Member #1 said that she contacted the Facility and told the staff member on the telephone that the police picked up Resident #1 and took him/her to the hospital. Family Member #1 said that although the Facility staff member who took her call initially said that Resident #1 was at the Facility in bed, a staff member subsequently called her back and said that they would investigate how Resident #1 left the Facility. The Nurses' note, dated 12/4/17 at 1:59 A.M., written by Nurse #1 indicated that at 1:20 A.M. Nurse #1 found Resident #1 on the floor next to his/her bed with a 3 centimeter (cm) by 1 cm laceration on his/her head and a 1 cm by 1 cm laceration under his/her eye. The Nurses' note indicated that Resident #1's physician ordered Resident #1 to be transported to the hospital for evaluation and Nurse #1 notified Family Member #1 of Resident #1's fall and transfer to the hospital. The Nurses' note did not indicate which ambulance company transported Resident #1. Family Member #1 said that no one from the Facility notified her that Resident #1 was found on the floor at 1:30 A.M. on 12/4/17. The Surveyor interviewed Nurse #1 at 3:00 P.M. on 7/2018. Nurse #1 said that he found Resident #1 on the floor around 1:30 A.M. on 12/4/17 and he arranged for Resident #1's transfer to the hospital. Nurse #1 said that although he could not recall which ambulance company transported Resident #1, he recalled seeing Resident #1 being wheeled on the stretcher by two ambulance company staff. The Surveyor interviewed the Director of Nurses at 3:20 P.M. on 7/20/18 and asked for a copy of the documentation left by the ambulance staff when they transported Resident #1 to the hospital on [DATE]. The Director of Nurses said documentation could not be located. The Surveyor interviewed the Facility Medical Records Clerk at 1:00 P.M. on 7/20/18. The Medical Record Clerk said that in (MONTH) (YEAR) the Facility used five different ambulance companies for resident transport. The Medical Records Clerk said that she contacted staff at all five ambulance companies on 7/20/18. The Medical Records Clerk said that none of the ambulance companies had any documentation that they picked up Resident #1 at the Facility at 1:30 A.M. on 12/4/17. The Surveyor interviewed Ambulance Company Staff #1 at 10:10 A.M. on 7/24/18. The Surveyor interviewed Ambulance Company Staff #2 at 10:30 A.M. on 7/24/18. The Surveyor interviewed Ambulance Company Staff #3 at 11:15 A.M. on 7/24/18. The Surveyor interviewed Ambulance Company Staff #4 at 11:20 A.M. on 7/24/18. The Surveyor interviewed Ambulance Company Staff #5 at 11:35 A.M. on 7/24/18. Ambulance Company Staff #1, #2, #3, #4 and #5 said that they had no record of receiving a call from the Facility around 1:30 A.M. on 12/4/17 to transport a resident to the hospital.

Based on record review, interview and observation, for one of one sampled resident (Resident #1), who was assessed to be an elopement risk and fall risk, the Facility failed to provide appropriate supervision on 9/9/10 when Resident #1 eloped during a medical appointment at the Hospital. Resident #1 was taken unescorted by chair car to the 1:20 PM appointment, and the Facility was notified at 6:15 PM that Resident #1 could not be found. Resident #1 was located outside on the following day at approximately 8:30 AM, had a bruise to the left cheek, and according to the Daughter, Resident #1 had 2 cuts to the right knee, had reportedly fallen twice and felt scared while being lost. Findings included: The admission Minimum Data Set (MDS) assessment, dated 8/24/10, indicated that Resident #1 had a problem with short-term memory problem; but no problem with long term memory. The MDS indicated that Resident #1 had moderately impaired cognitive skills for daily decision making and Resident #1's mental function varied over the course of the day. The MDS indicated Resident #1 needed extensive assistance with one person for locomotion on and off the unit; and was unsteady while standing but able to rebalance without physical support. The Interdisciplinary Care Plan Meeting Summary Sheet, dated 8/31/10, identified wandering as one of the identified problems. The Plan of Care for Wandering, not dated, indicated Resident #1 would not leave the building or unit without an escort. Interventions included providing supervision when outside of the building; ancillary staff were to be aware of Resident #1's elopement potential and Resident #1 was to wear the wanderguard bracelet at all times. Review of the physician's orders [REDACTED]. Review of Resident #1's two Elopement/Wander Risk Evaluation Forms, both dated 8/13/10, indicated Resident #1 ambulated on and off the unit with assist, had goal directed wandering and aimless or random wandering,and had elopement potential. The Evaluation Forms indicated the daughter stated Resident #1 had tried to elope while in a hospital and might attempt to escape the unit. The nurse's note, dated 9/9/10, indicated Resident #1 was transported to the Hospital by an ambulance company's chair car service for a 1:20 PM appointment. Staff at the ambulance company notified the Facility at 6:15 PM that Resident #1 could not be found and at 7 PM stated that Resident #1 was missing from the Hospital. The nurse's note indicated that Hospital Officials were repeatedly contacted for decision making related to the incident and at 11:30 PM, Resident #1 was still not found. The Social Worker was interviewed on 9/21/10 at approximately 11:20 AM. The Social Worker said the police were contacted by a civilian regarding Resident #1 who was found outdoors on 9/10/10 at about 8:30 AM and was brought to a hospital's emergency room . The nurse's note, dated 9/10/10, indicated Resident #1 returned to the Facility at 6:45 PM after an emergency room visit and dialysis treatment. Resident #1 was found to have a bruise under the left eye. Resident #1's Nurse Practitioner was interviewed on 9/21/10 at approximately 2 PM. The Nurse Practitioner said Resident #1 had a history of [REDACTED]. The Nurse Practitioner said Resident #1 needed supervision at all times and functioned independently with supervision in a controlled environment. The Nurse Practitioner said Resident #1 knew where to go only with direction and would not know what to do out of the scope of a protected environment. The Nurse Practitioner said had the Nurse Practitioner been consulted, the Nurse Practitioner would have stated that Resident #1 on 9/9/10 needed someone to accompany Resident #1 to the appointment at the Hospital. Resident #1's Daughter was interviewed on 10/14/10 at approximately 11:36 AM. The Daughter stated that Resident #1 had been safely going to dialysis at a clinic and transported by chair car service unescorted for three years on a weekly basis. The Daughter said the clinic was small, staff knew Resident #1 well and Resident #1 needed to be "buzzed" in or out of areas in the clinic. The Daughter said on 9/10/10 Resident #1 upon being found was brought to the emergency room . The Daughter said at the emergency room , the Daughter saw that Resident #1 had two cuts to the right knee and a bruise to the left cheek. The Daughter said while in the emergency room Resident #1 tried to console the Daughter. The Daughter said the following day (9/11/10) Resident #1 stated that while Resident #1 was lost, Resident #1 was afraid, was given food by strangers because Resident #1 had no money. The Daughter said Resident #1 said Resident #1 was afraid to ask strangers for help and slept on a hard surface. The Daughter said Resident #1 stated Resident #1 fell twice while lost. The Daughter stated Resident #1 said Resident #1 fell down at a curb, cutting the knee, and Resident #1 managed to get up after no one stopped to help Resident #1. The Daughter said Resident #1 was unable to recall the details of the second fall. Resident #1 had been discharged to home prior to 9/21/10 (date of survey) and was not interviewed. The Director of Nurses (DON) and the Administrator were interviewed on 9/21/10. The Administrator stated at an interdisciplinary meeting Resident #1's ability to go independently to the appointment had been discussed and determined safe. The DON said Resident #1 had been going for dialysis treatment safely alone, however it was a small clinic on one floor which was fairly secure through a "buzzer" system of entering and exiting the clinic. The DON and the Administrator prior to reviewing Resident #1's medical record with the Surveyor on 9/21/10, said they did not know that Resident #1 was at risk for elopement, that Resident #1 wore a wanderguard bracelet or had a Plan of Care for wandering. The Surveyor observed 2 other residents who were care planned to wear wanderguard bracelets. Both residents were wearing the wanderguard bracelets as ordered by their physician; the treatment records indicated the placement and functioning of the wanderguard bracelets was monitored and documented as ordered by the physician.