Every finding on record at Norwich Sub-Acute and Nursing

Based on review of the clinical record, facility documentation/policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) who required assistance with Activities of Daily Living (ADL's), the facility failed to ensure safe bed level care for a cognitively impaired resident who required the assistance of two staff for bed mobility. Specifically, staff performed a one person turn using an unsafe technique, which resulted in the resident sliding from the bed and sustaining an acute fracture of the right tibia. The findings include:Resident #1's diagnoses included chronic obstructive pulmonary disease, dementia, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0), was impaired on the lower extremity on one side, required maximum assistance with all care, and was dependent on staff for transfers.The Resident Care Plan dated 4/24/26 identified Resident #1 had a self-care deficit and was at high risk for falls. Interventions directed assistance of two (2) to turn and reposition every two (2) hours, side rails for positioning, provide incontinent care every two (2) hours, provide a low-level air mattress, keep call bell in reach, apply proper footwear, and physical therapy as needed.The fall report dated 5/9/26 at 4:50 AM identified Resident #1 required assistance of two (2) for bed mobility.A written statement dated 5/9/26 at 4:50 AM by NA #2 identified NA #2 was changing Resident #1's bed sheets and Resident #1 was rolled onto the side. When NA #2 attempted to pull out the sheet under Resident #1, Resident #1 started sliding off the bed and onto the floor.The nurse's note by RN #1 (the 11:00 PM to 7:00 AM supervisor) dated 5/9/26 at 8:29 AM identified the nurse was called to Resident #1's room after Resident #1 fell. NA #2 (the 11:00 PM to 7:00 AM nurse aide) stated she turned Resident #1 onto his/her side and when pulling the sheet towards herself, Resident #1 slid out of the opposite side of the bed onto the floor. Resident #1 was lying on his/her left side on the door side of the bed, between the bed and the bedside table. Upon assessment Resident #1 complained of right knee pain and the area below the right knee was slightly swollen. The physician directed an x-ray to the right hip, knee, tibia, and fibula, and Tylenol was administered.The nurse's note by RN #2 (the 3:00 PM to 11:00 PM supervisor) dated 5/9/26 at 4:38 PM identified the x-ray results were positive for an acute fracture to the right tibia. Resident #1's daughter and the Advanced Practice Registered Nurse (APRN) were updated and directed to send Resident #1 to the Emergency Department (ED) for further evaluation.The nurse's note by RN #1 dated 5/9/26 at 9:50 PM identified Resident #1 returned to the facility wearing an immobilizer splint to the right leg. After further tests were performed in the ED, Resident #1 was diagnosed with tibial fracture. Orders directed non weightbearing to the right lower extremity, use of the splint and a follow up appointment with orthopedics.The APRN note dated 5/12/26 at 8:45 AM identified an unspecified fracture of the upper end of the right tibia and mild arthritic changes to the right hip. Orders directed to continue with the ordered splint and follow up with orthopedics.An interview with PT #1 (the Rehabilitation Director) on 6/3/26 at 1:50 PM identified before Resident #1 fell on 5/9/26 the resident's level of care was at bed level and required two (2) staff to assist the resident due to a diagnosis of dementia, an inability to follow direction and an inability to actively participate in any purposeful movement in bed. PT #1 identified Resident #1 had been at this level for at least the past year. PT #1 further identified if a staff member were to roll a resident without the assistance of a second staff member, the safest way to roll the resident would be in the direction of the staff member rather than to roll the resident away from the staff member.An interview with NA #1 on 6/3/26 at 2:20 PM identified on 5/9/26 NA #1 was in her first week of orientation at the facility and was in Resident #1's room when the resident fell. NA #1 was assisting Resident #1's roommate behind the closed privacy curtain when she heard NA #2 say, oh, shoot. NA #1 then walked around the curtain and saw Resident #1 fall out of the bed and onto the floor on the opposite side of where both NA #1 and NA #2 were standing.An interview with the DON on 5/5/26 at 12:00 PM identified Resident #1 required bed-level care and was an assist of two (2) for bed mobility. The DON defined bed mobility as any significant change in bed position which would require 2 staff to assist, such as boosting a resident up in bed. The DON further identified that the safest way for NA #1 to have independently rolled Resident #1 would have been to roll Resident #1 toward NA #1, not away from NA #1. She identified that if NA #1 had rolled Resident #1 toward her rather than away from her, Resident #1 would not have fallen on the floor on the opposite side of the bed. The DON further identified she initiated training for safe turning practice.Although attempted, an interview with NA #2 was not obtained.Although requested, a policy for bed mobility was not provided.Review of the facility Fall Risk Management Program identified prevention plans based on each resident's risk factors can eliminate or reduce the incidents of resident falls as well as prevent major injury to the resident. The program further identified it would focus, in part, on the assessment process, care planning, and consistent implementation of fall interventions.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for falls, the facility failed to provide adequate supervision for a resident identified at risk for falls, to prevent a fall with injury. The failure resulted in a resident fall with laceration that required seven (7) stitches. The findings include: Resident #1 was admitted to the facility with diagnoses that included Alzheimer's disease, dementia, anxiety, generalized muscle weakness, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 that indicated severe cognitive impairment, and required staff assistance for transfers. The Resident Care Plan (RCP) dated 7/11/2025 identified Resident #1 was at risk for falls due to confusion, deconditioning and gait/balance problems. Interventions directed assistance of two (2) staff for turning and repositioning, beveled edge mattress, and to transfer per physician orders.A physician order dated 9/5/2025 directed assistance of one (1) staff for transfers and mobility. Review of facility documents identified Resident #1 experienced falls without injury on 8/2 and 8/10/2025 due to attempts to stand without assistance. A facility reportable event (RE) form dated 9/15/2025, identified on 9/12/2025 at 8:00 AM Resident #1 was observed sitting on the edge of the bed, leaned forward and fell striking his/her head. Resident #1 had a left eyebrow laceration with bleeding and complaint of left upper arm and shoulder pain. Resident #1 was transferred to the hospital for evaluation and returned with sutures. A hospital provider note dated 9/12/2025 at 8:44 AM identified Resident #1 experienced a ground level fall resulting in a laceration to the left eyebrow that was repaired as per procedure note for skin repair that required seven (7) nylon sutures for closure. The RE summary dated 9/19/2025 identified Resident #1 required one (1) staff assist for transfers, and staff observed Resident #1 fall when waiting for the Nurse Aide (NA) to return with his/her wheelchair to transfer him/her out of bed. The NA indicated Resident #1 was leaning too far forward and fell to the floor. Record review identified Resident #1 returned to the facility on 9/12/2025 at 8:00 PM. Left side of face bruised, cheek with a large hematoma, and Tylenol 1000 mg was administered for knee pain. Interview with NA #1 on 10/15/2025 at 10:00 AM identified she provided care for Resident #1 on 9/12/2025 and was aware he/she required one (1) staff assist for transfers. NA #1 stated she also was aware Resident #1 was a fall risk and was known to stand up without assistance to attempt to self-transfer. After AM care was provided on 9/12/2025, NA #1 assisted Resident #1 to sit on the edge of the bed facing the window, dressed and ready to stand pivot transfer to the wheelchair with NA #1's assistance. NA #1 stated Resident #1's roommate had called out for assistance repeatedly while she was providing care for Resident #1, and had become insistent that assistance was needed. NA #1 turned and walked to the end of Resident #1's bed with her back towards Resident #1, to see the roommate. NA #1 stated she routinely pulled the privacy curtain but could not recall if she had the curtain drawn between Resident #1 and the roommate at that time. As NA #1 was at the foot of Resident #1's bed and turned towards the roommate's bed, she observed Resident #1 falling forward out of the bed towards onto his/her left side, hitting his/her head on the floor. NA #1 stated she could not reach Resident #1 in time to prevent the fall. Interview with RN #1 on 10/15/2025 at 10:15 AM identified she was the nursing supervisor on 9/12/2025 and assessed Resident #1 after the fall. RN #1 stated NA #1 had left Resident #1's side when he/she was sitting on the side of the bed and NA #1 should not have left Resident #1 alone when sitting on the side of the bed. Resident #1 was known to be impulsive, was a known fall risk and had previously fallen due to attempts stand without assistance. RN #1 stated NA #1 should have transferred Resident #1 into the wheelchair before she left Resident #1's side. Interview with LPN #1 on 10/15/2025 at 11:20 AM identified she regularly cared for Resident #1, and stated Resident #1 was a known fall risk to due to poor safety awareness. LPN #1 continued that Resident #1, once awake, needed her/his care needs addressed immediately or Resident #1 would attempt to get out of bed without assistance. LPN #1 stated staff knew to complete care and transfer Resident #1 into the wheelchair promptly to maintain safety. LPN #1 responded to the room after the fall and observed bleeding from a cut above the left eyebrow. NA #1 reported Resident #1's roommate was repeatedly asking for assistance and NA #1 decided to leave Resident #1 sitting on the edge of the bed to see what the roommate needed. NA #1 reported she had turned her back to Resident #1 when Resident #1 fell onto the floor and hit his/her head. LPN #1 stated NA #1 should not have left Resident #1 sitting on the side of the bed, as Resident #1 was a known fall risk with poor safety awareness; NA #1 should have completed the transfer and then addressed the roommate's needs. Interview with the DON and facility documentation review on 10/15/2025 at 11:36 AM identified that Resident #1 was dressed and was sitting at the side of the bed ready for transfer when NA #1 left Resident #1 sitting on the side of the bed. The DON stated she though NA #1 left the room to get Resident #1's wheelchair and when NA #1 returned she witnessed Resident #1 falling off the bed to the floor. The DON stated NA #1 should not have left Resident #1 sitting on the side of the bed alone, turned her back on Resident #1, or left the room when Resident #1 was sitting on the edge of the bed as Resident #1 was a fall risk. The DON stated she did not know why NA #1 turned away from Resident #1. Interview with PT #1 at 2:30 PM identified Resident #1 had a history of leaning to the left side when sitting, was known to be impulsive and should not have been left at the edge of the bed without supervision. Review of a facility form A Conference dated 9/15/2025 identified that NA #1 could have activated call light to obtain additional staff to assist in the room (without leaving Resident #1 sitting on the side of the bed). The Facility Policy Fall Prevention dated 6/2023 directed in part, to reduce resident fall risk factors.

Based on clinical record review, facility documentation review, and interviews for one sampled resident (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders and the plan of care to prevent a fall with injury. The failure resulted in an acute mildly displaced fracture of the distal aspect of the fibula. The findings include: Resident #1's diagnoses included deep vein thrombosis (blood clot) of the left lower extremity and anxiety. Physician orders dated 6/6/2025 directed mobility status was an assist of two persons with rolling walker, stand pivot only for transfers, and ambulation with therapy only. Nursing admission note dated 6/6/2025 identified Resident #1 was alert and oriented. The Resident Care Plan dated 6/9/2025 identified Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions directed to transfer and ambulate per physician orders. The Nurse Aide (NA) Care Card dated 7/7/2025 directed to provide assist of two with transfers, stand pivot with rolling walker, and to transfer and ambulate per physician orders. The Facility Incident Report dated 7/8/2025 at 11 AM identified Resident #1 was alert and oriented, required two (2) staff assistance for stand pivot transfers and Resident #1 had a fall with a mildly displaced fracture of right distal (away from the center of the body) fibula (leg bone). The Report further indicated that while NA #1 transferred Resident #1 from the bed to the chair, Resident #1 stated my knee gave out, and twisted my leg, and Resident #1 was transferred to the hospital for evaluation. A nursing note written by RN #1, dated 7/8/2025 at 11:04 AM identified she assessed Resident #1 after he/she was lowered to the floor, and Resident #1 was unable to move his/her right ankle or knee due to pain. Resident #1 indicated his/her knees became weak while NA #1 was transferring him/her, and NA #1 lowered the resident to the floor. The APRN was notified, and Resident #1 was transferred to the hospital. The hospital CT (computed tomography) scan dated 7/8/2025 identified Resident #1 had an acute mildly displaced fracture of the distal aspect of the fibula. The hospital Discharge summary dated [DATE] identified Resident #1 was discharged with a splint application to right lower extremity and required follow up with orthopedic. A nursing note dated 7/8/2025 at 9:07 PM identified Resident #1 returned from hospital at 5:30 PM via stretcher with a splint in place. Positive pedal (foot) pulse to right lower extremity, and Tylenol (analgesic for pain) was given for discomfort with good effect. Physician order dated 7/8/2025 directed splint to remain on at all times until seen by orthopedics; may remove splint for skin checks. The facility incident summary dated 7/15/2025 identified when NA #1 assisted Resident #1 with a transfer out of bed using a rolling walker. Resident #1's knee gave out during the transfer, his/her foot did not move, and Resident #1 twisted his/her leg and NA #1 assisted Resident #1 to the floor. The facility investigation identified at the time of the fall Resident #1 required assistance of two (2) staff for transfers. After Resident #1 was readmitted from the hospital, he/she was non-weight bearing (NWB) to the right lower extremity, required a Hoyer lift for transfers and follow up with orthopedics. Orthopedic Consult dated 7/16/2025 identified Resident #1 stated that on 7/8/2025, he/she was trying to get up to transfer and only had one (1) NA with him/her, and physical therapy had previously told him/her that two (2) staff were required for transfers. Pain was improved with Tylenol, rest, heat, and ice, with current pain as a 5 out of 10 on the pain scale. Current Plan: stable injury amenable to conservative management and recommend transition from the short leg splint to a tall cam boot to support healing fracture for six (6) weeks; cam boot applied. Cam boot applied, may be removed for sleep, hygiene and range of motion, and weight bearing as tolerated (WBAT). May elevate and use ice for pain. Return appointment in five (5) to six (6) weeks with plan to transition to a lace up ankle brace. Interview with the Director of Rehabilitation (DOR) on 7/30/2025 at 9:55 AM identified prior to Resident #1's fall on 7/8/2025, his/her transfer status was an assist of two (2) staff, stand pivot transfers only, and Resident #1 ambulated with therapy only. The DOR stated NA #1 did not follow Resident #1's plan of care when he transferred Resident #1 alone on 7/8/2025, and NA #1 should have obtained assistance from another staff member for the transfer. Interview with NA #1 on 7/30/2025 at 11:05 AM identified on 7/8/2025 at approximately 10:00 AM, he began to transfer Resident #1 into the wheelchair when the resident's knee buckled, and he lowered Resident #1 to the floor. NA #1 identified he believed Resident #1 was an assist of one person and stated he did not verify Resident #1's transfer orders prior to this incident. NA #1 stated he should have verified Resident #1's transfers status on the care card/care plan prior to attempting to transfer the resident alone. Interview with Resident #1 on 7/30/2025 at 12:50 PM identified on 7/8/2025, he/she requested to transfer into his/her wheelchair and NA #1 provided the assistance alone. Resident #1 stated his/her legs started to feel heavy during the transfer and NA #1 told Resident #1 that they had about two (2) more inches to go. Resident #1 indicated he/she started to go down to the floor, but NA #1 was distracted and looking at the TV. NA #1 attempted to stop the fall by grabbing onto Resident #1's shirt/pants, but ultimately, he/she landed on the floor. Resident #1 stated after the fall, his/her right leg was hurting very badly, he/she was sent to the hospital, and they found a fracture in his/her right leg. Interview with the DON (Director of Nursing) on 7/30/2025 at 11:50 AM identified NA #1 failed to follow the physician orders and the plan of care to have two (2) staff for transfers, and that resulted in Resident #1's injury. NA #1 was subsequently terminated from his position, and all nursing staff were re-educated to follow the physician orders and resident care cards for transfers and care.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure the resident was supervised outside of the facility leading to a fall with injury. The findings include: Resident #1's diagnoses included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation (irregular heartbeat), anxiety disorder and personality disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) of 13), required substantial assistance for bed mobility and was dependent on staff for transfers. Review of the Morse Fall Scale Evaluation dated 4/24/25 identified Resident #1 had a history of falls, was observed with a weak gait (difficulty walking) and overestimates or forgets his/her limits, putting Resident #1 at a high risk for falling. The Resident Care Plan (RCP) dated 4/25/25 identified Resident #1 as a high risk for falls due to gait/balance problems and incontinence. Interventions included ensuring Resident #1 was wearing appropriate footwear when ambulating or mobilizing in the wheelchair, anticipating and meeting Resident #1's needs and ensuring a safe environment. A nurse's note dated 5/25/25 at 9:05 PM by RN #1 (3:00 PM to 11:00 PM nursing supervisor) identified Resident #1 fell, and upon assessment, Resident #1 was lying on the ground in front of his/her wheelchair with a laceration to the forehead/hairline with a moderate amount of blood and that pressure was applied to the area. The note identified Resident #1 was alert and at baseline cognition, range of motion to all extremities was within normal limits, and Resident #1 was complaining of a moderate headache. The family and the Advanced Practice Registered Nurse (APRN) were notified, and Resident #1 was transferred to the hospital around 7:10 PM. Review of the facility Accident and Investigation (A&I) report dated 5/25/25 identified that at 6:30 PM, Resident #1 was found outside on the ground near the facility main entrance. Resident #1 leaned forward out of the wheelchair to pick something up from the ground and tumbled out of the chair, hitting his/her head. The A&I identified Resident #1 was on an anticoagulant (a blood thinner that prevents blood clots from forming or growing larger) and sustained a laceration to the scalp/hairline and an abrasion to the bridge of his/her nose. The report identified Resident #1 was educated on spending outdoor time in the facility courtyard rather than the facility main entrance and Physical Therapy would evaluate Resident #1 for the use of a reacher/grabber. RN #3's statement dated 5/25/25 identified at approximately 6:30 PM, he was off duty driving by the facility when he observed Resident #1 sitting outside of the front of the facility in his/her wheelchair. RN #3 indicated he knew Resident #1 to be confused and was concerned Resident #1 was unsupervised, so pulled into the facility and tried to locate a nursing supervisor. He identified that once he located RN #1 and they ran to the main entrance of the facility, Resident #1 was already on the ground, RN #1 started her assessment, and he called the DNS to alert her of the incident at 6:47 PM. Review of hospital documentation dated 5/25/25 identified Resident #1 was evaluated in the ED after he/she was found on the ground outside of the nursing home, had an unknown loss of consciousness and presented with an injury to the forehead and was diagnosed, in part, with a head contusion (a bruise) and a forehead laceration. The facial wound was cleaned and closed with Dermabond (a tissue adhesive used to close wounds, like sutures, but without the need for subsequent removal) and Resident #1 was transported back to the facility. Observation of the front entrance of the facility on 6/9/25 at 9:30 AM identified a fairly steep decline down to the parking area. There were approximately ten (10) feet on either side of the main entrance door that was flat before a change in the downwards slope. It did not appear to be safe for residents in wheelchairs to be sitting outside the front entrance. Interview and observation with Resident #1 on 6/9/25 at 10:09 AM identified that on 5/25/25 around dinner time, he/she rolled him/herself in the wheelchair to the receptionist desk to request money from his/her account. Resident #1 reported that when no one was present at the receptionist desk area, he/she decided to go through the main entrance doors, which opened as he/she approached them, to sit outside in the main entrance area. Resident #1 identified that he/she started to read a book and then noticed paper on the ground, so leaned over to pick up the paper and stated, the next thing I knew I was on the ground. Resident #1 indicated he/she slipped out of the wheelchair face first onto the ground. On observation, Resident #1 was noted with a scabbed area to the bridge of his/her nose and a band aid (dated 6/7) placed vertically covering an area between the eyebrows. Resident #1 identified that he/she looked like a racoon last week with bruising surrounding both eyes. Interview with RN #1 (3:00 PM to 11:00 PM nursing supervisor) on 6/9/25 at 10:46 AM identified that on 5/25/25, she was alerted by another staff member (could not recall who) that Resident #1 was sitting unattended outside of the main entrance. She reported that she immediately went to the scene and observed Resident #1 on the ground with a laceration to the forehead and that she applied pressure to control bleeding. RN #1 identified Resident #1 was transferred to the ED for evaluation due to the head strike. RN #1 reported she could not recall if the brakes on the wheelchair were locked and identified she was unsure how Resident #1 got outside or how long he/she was outside. Interview with the DNS on 6/9/25 at 11:09 AM identified Resident #1 should not have been outside the facility main entrance unattended. The DNS identified her investigation discovered NA #2 changed the main entrance door from night mode (door is locked and anyone trying to leave must enter a code to disengage the door and anyone trying to enter must push a buzzer on the outside of the building for staff to manually push a button behind the receptionist desk to open the door) to day mode (door automatically opens when someone approaches to exit or enter the building). She reported that Receptionist #1 left early on 5/25/25 and changed the door to night mode prior to leaving. She identified the receptionist desk is usually staffed until 7:00 PM but she was unsure if staff on all the units were aware there was no staff at the receptionist desk so that residents were supervised accordingly. She was unable to provide statements identifying when Resident #1 was last seen prior to RN #1 observing Resident #1 outside at 6:30 PM and was unable to explain why statements were not obtained from all staff that could have had contact with Resident #1 that evening. The DNS identified that following the 5/25/25 incident, NA #2 was sent home and suspended for three (3) days, staff were educated on the use of the main entrance door afterhours, Resident #1 was educated to use the courtyard if he/she wishes to go outside and PT was requested to evaluate Resident #1 for the use of a reacher/grabber. Review of Receptionist #1's timecard identified that she worked from 9:30 AM to 4:15 PM on 5/25/25. Review of facility education documentation dated 5/25/25 identified that, at no time, should the main entrance doors be set to day mode without an attendant at the desk, and if there is no receptionist on duty, the door must remain on night mode and visitors must be let in and out by the button at the desk only. Interview with OT #1 (Rehab Manager) on 6/9/25 at 1:07 PM identified Resident #1 was receiving Occupational Therapy services on 5/25/25, he/she was not safe to be outside unattended on 5/25/25 and he/she required supervision while in the wheelchair due to cognition and poor safety awareness. He identified Resident #1 was not safe to be sitting outside the main entrance of the building as it was a downwards hill and Resident #1 did not have sufficient lower extremity strength to stop him/herself if the wheelchair was on an uneven surface or if it started to roll. OT #1 further indicated Resident #1 required a Hoyer (mechanical) lift for transfers for years due to lower extremity weakness. Interview with NA #2 on 6/9/25 at 3:04 PM identified that on 5/25/25 she was working on the North Unit, which was the unit closest to the main entrance. She reported that Receptionist #1 left early, and that she (NA #2) was repeatedly interrupted by the front door buzzer while performing evening care for residents. She reported she felt like she was putting the residents at risk for falls by having to leave them to open the front door, so she changed the front door from night mode to day mode so people could enter and exit through the main entrance freely rather than interrupt her. NA #2 identified she should not have touched the settings on the door and was suspended for three (3) days following the incident. Although attempted, interviews with NA #1, LPN #1 and RN #1 were not obtained. Although requested, facility policies for locking of the main entrance door and criteria for allowing residents to be outside of the building on facility grounds unattended were not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure a resident, who was not assessed as an elopement risk, was free from involuntary seclusion, when a Wanderguard device (a bracelet which is a part of a wander management system designed to prevent those at risk for wandering from leaving a protected area) was applied without the resident's consent. The findings include: Resident #1's diagnoses included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation (irregular heartbeat), anxiety disorder and personality disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) of 13), required substantial assistance for bed mobility and was dependent on staff for transfers. Review of the Morse Fall Scale Evaluation dated 4/24/25 identified Resident #1 had a history of falls, was observed with a weak gait (difficulty walking) and overestimates or forgets his/her limits, putting Resident #1 at a high risk for falling. Review of an Elopement Evaluation dated 4/24/25 identified Resident #1 was oriented to person and place, was not exit seeking, had not attempted to elope in the last 30 days and was not at risk for elopement. The Resident Care Plan (RCP) dated 4/25/25 identified Resident #1 as a high risk for falls due to gait/balance problems and incontinence. Interventions included ensuring Resident #1 was wearing appropriate footwear when ambulating or mobilizing in the wheelchair, anticipating and meeting Resident #1's needs and ensuring a safe environment. The RCP did not identify a risk for elopement. A nurse's note dated 5/25/25 at 9:05 PM by RN #1 (3:00 PM to 11:00 PM nursing supervisor) identified Resident #1 fell, and upon assessment, Resident #1 was lying on the ground in front of his/her wheelchair with a laceration to the forehead/hairline with a moderate amount of blood and that pressure was applied to the area. The note identified Resident #1 was alert and at baseline cognition, range of motion to all extremities was within normal limits, and Resident #1 was complaining of a moderate headache. The family and the Advanced Practice Registered Nurse (APRN) were notified, and Resident #1 was transferred to the hospital around 7:10 PM. Review of the facility Accident and Investigation (A&I) report dated 5/25/25 identified that at 6:30 PM, Resident #1 was found outside on the ground near the facility main entrance. Resident #1 leaned forward out of the wheelchair to pick something up from the ground and tumbled out of the chair, hitting his/her head. The A&I identified Resident #1 was on an anticoagulant (a blood thinner that prevents blood clots from forming or growing larger) and sustained a laceration to the scalp/hairline and an abrasion to the bridge of his/her nose. The report identified Resident #1 was educated on spending outdoor time in the facility courtyard rather than the facility main entrance and Physical Therapy would evaluate Resident #1 for the use of a reacher/grabber. Review of hospital documentation dated 5/25/25 identified Resident #1 was evaluated in the ED after he/she was found on the ground outside of the nursing home, had an unknown loss of consciousness and presented with an injury to the forehead and was diagnosed, in part, with a head contusion (a bruise) and a forehead laceration. The facial wound was cleaned and closed with Dermabond (a tissue adhesive used to close wounds, like sutures, but without the need for subsequent removal) and Resident #1 was transported back to the facility. Review of an Elopement Risk Scale dated 5/26/25 identified Resident #1 could communicate and follow instructions, move without assistance while in the wheelchair, had no history of wandering, knew how to return to his/her unit, had no episodes of walking aimlessly and had no diagnosis of dementia. A physician's order dated 5/26/25 directed for a Wanderguard to be intact to Resident #1's wheelchair and for staff to check placement and function every shift. Interview and observation with Resident #1 on 6/9/25 at 10:09 AM identified that on 5/25/25 around dinner time, he/she rolled him/herself in the wheelchair to the receptionist desk to request money from his/her account. Resident #1 reported that when no one was present at the receptionist desk area, he/she decided to go through the main entrance doors, which opened as he/she approached them, to sit outside in the main entrance area. Resident #1 identified that he/she started to read a book and then noticed paper on the ground, so leaned over to pick up the paper and stated, the next thing I knew I was on the ground. Resident #1 indicated he/she slipped out of the wheelchair face first onto the ground. Resident #1 identified he/she did not know what a Wanderguard was, no one discussed the use of a Wanderguard with him/her and he/she never tried to leave the facility without permission. The back of Resident #1's wheelchair was maroon in color, 'Jay J3' model, and was labeled with Resident #1's last name. A Wanderguard was attached to the front left of the wheelchair just above the left wheel. Interview with RN #1 (3:00 PM to 11:00 PM nursing supervisor) on 6/9/25 at 10:46 AM identified she never observed Resident #1 wandering or exit seeking and indicated Resident #1 was not at risk for elopement before or after the fall incident. Interview with the DNS on 6/9/25 at 11:09 AM identified Resident #1 should not have been outside the facility main entrance unattended for safety reasons. She identified that an Elopement Risk Assessment was completed on 5/26/25 which did not identify exit seeking behavior or wandering. She further identified a Wanderguard was placed on Resident #1's wheelchair subsequent to the 5/25/25 fall incident to remind Resident #1 not to go out the front door. She identified Resident #1 was not conserved and was self responsible. She identified she did not discuss the use of the Wanderguard with Resident #1 or request consent for the use of the Wanderguard. She indicated she did not associate the use of the Wanderguard with involuntary seclusion even though the device caused the exit doors to lock. Review of the facility At Risk for Elopement binder with the Business Office Manager on 6/9/25 at 12:02 PM, located at the receptionist desk, failed to identify Resident #1's picture or information within the binder identifying he/she was at risk for elopement. Although attempted, interviews with NA #1 and LPN #1 were not obtained. Review of the Wanderguard Security System policy dated 7/2023 directed, in part, that a Wanderguard Security Device will be placed on any resident that the resident care team decides is at risk for wandering away from the facility. When the Wanderguard door alarm sounds, the nearest employees shall immediately respond to that door. Although requested, a facility policy on involuntary seclusion was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #4) reviewed for elopement, the facility failed to ensure a comprehensive care plan was developed for a resident who was at risk for elopement and had a provider ordered Wanderguard (a bracelet which is a part of a wander management system designed to prevent those at risk for wandering from leaving a protected area). The findings include: Resident #4's diagnoses included dementia with behavioral disturbances and adjustment disorder with anxiety. A physician's order dated 5/30/24 directed a Wanderguard be affixed to Resident #4's wheelchair at all times. An Elopement Evaluation dated 12/11/24 identified Resident #4 was exit seeking, oblivious to needs or safety, wanted to go home or leave, had a diagnosis of Alzheimer's disease (a progressive dementia that destroys memory and important mental functions) and was at risk for elopement. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 3), was dependent on staff for personal hygiene, bed mobility and transfers. The MDS identified wandering behaviors were not present. An Elopement Evaluation dated 3/4/25 identified Resident #4 was not exit seeking, displayed behaviors of wanting to go home, watched others go out the doors, expressed/experienced feelings of fear/anger of abandonment and had a diagnosis of Alzheimer's disease. A nurse's note dated 5/22/25 at 1:42 PM identified Resident #4 continued to tell staff that he/she is going to quit this job and take the bus home. A nurse's note dated 5/23/25 at 12:05 PM identified that family was in to visit and discussed increased confusion related to bed relocation (5/21/25). Resident #4 was looking for his/her friend, wanted to go home to his/her mother and father, and believed people were looking at him/her through the window. A nurse's note dated 5/27/25 at 5:21 PM identified Resident #4 reported he/she was going home with his/her brother because he/she needed to go home to his/her parents. A nurse's note dated 6/2/25 at 12:27 PM identified Resident #4 believed he/she was an employee of the facility, wanted the afternoon off, continued to believe he/she was going home to his/her parent's house and was redirected with little effect. A nurse's note dated 6/4/25 at 12:08 PM identified Resident #4 was sitting in the common area stating he/she was bored, needed to find a new job and that he/she was leaving with his/her spouse to their house in Pennsylvania. Review of the May and June 2025 Medication Administration Record (MAR) identified behavior monitoring for pacing but failed to identify a behavior of exit seeking, wanting to go home or leave the facility, watching others go out of doors, or expressing/experiencing feelings of fear/anger of abandonment. Review of the facility At Risk for Elopement binder, on 6/9/25 at 12:02 PM, which was located at the receptionist desk, identified Resident #4's picture and information identifying he/she was at risk for elopement. Observation of Resident #4 on 6/9/25 at 12:49 PM, identified a Wanderguard intact to the front right of Resident #4's wheelchair. Resident #4 reported that after lunch, he/she was going to work. Interview with RN #2 (MDS Coordinator) on 6/9/25 at 1:29 PM identified she completed the Elopement Evaluation dated 3/4/25 which identified Resident #4 had exit seeking behaviors but was not at risk for elopement. She further identified Resident #4 often had exit seeking behaviors and expressed he/she wanted to leave the facility. Additionally, RN #2 identified she was unaware behavior monitoring did not include exit seeking behaviors to include wanting to go home or leave, watching others go out of doors or expressing/experiencing feelings of fear/anger of abandonment. She identified that since there was a physician's order for a Wanderguard and the Wanderguard was currently in place, staff should have been documenting exit seeking behaviors as part of the facility's behavior monitoring. She identified that she should have discovered the lack of documentation when she completed the comprehensive assessment. RN #2 further identified that any resident who had a Wanderguard should have a care plan in place for elopement with interventions to prevent elopement. Interview with the DNS on 6/9/25 identified Resident #4 was at risk for elopement, the Elopement Evaluation should have identified the elopement risk and an elopement care plan should have been developed. The DNS identified that RN #2 was responsible for the evaluation, the care plan and ensuring behavior monitoring matched actual behaviors. The DNS identified RN#2 should have notified her with any discrepancies. Subsequent to surveyor inquiry, a Resident Care Plan (RCP) dated 6/9/25 identified Resident #4 was at risk for elopement and wandering related to disorientation to place, history of attempts to leave the facility unattended and impaired safety. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books and that the resident was a wander alert and had a Wanderguard bracelet on his/her wheelchair. Review of the Care Plans policy dated 6/2023 directed, in part, that the care plan will be developed no later than seven (7) days after the completion of the comprehensive assessment (MDS). The Resident Care Plan (RCP) will include the residents' needs, realistic goals, and the care and services needed to meet these goals. The MDS coordinator is responsible for ascertaining that all MDS triggered items have been addressed. The RCP of each resident is completed and reviewed by the 21st day after admission and quarterly thereafter at the Resident Care Conference (RCC). RCP's can also be revised, as needed, at any time, on an interim basis. RCP's will include physical, cognitive and psycho-social problems and will address the residents' needs on an individual basis.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure that a laceration sustained from a fall was treated in accordance with physician's orders. The findings include: Resident #1's diagnoses included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation (irregular heartbeat), anxiety disorder and personality disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) of 13), required substantial assistance for bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 5/29/25 identified that Resident #1 had an actual impairment to skin integrity of the face and forehead related to an abrasion and a laceration sustained from a fall. Interventions included following facility protocols for treatment of an injury and monitoring and documenting the location, size and treatment of the skin injury. A nurse's note dated 5/25/25 at 9:05 PM by RN #1 (3:00 PM to 11:00 PM nursing supervisor) identified Resident #1 fell, and upon assessment, Resident #1 was lying on the ground in front of his/her wheelchair with a laceration to the forehead/hairline with a moderate amount of blood and that pressure was applied to the area. The note identified Resident #1 was alert and at baseline cognition, range of motion to all extremities was within normal limits, and Resident #1 was complaining of a moderate headache. The family and the Advanced Practice Registered Nurse (APRN) were notified, and Resident #1 was transferred to the hospital around 7:10 PM. PM. A physician's order dated 6/8/25 directed for the forehead laceration to be cleansed with normal saline, patted dry, bacitracin (a topical antibiotic used to help prevent skin infections from cuts, scrapes and burns) to be applied to the area and covered with a band aid daily and as needed. Observation of Resident #1 on 6/9/25 at 10:09 AM identified a band aid dated 6/7 placed vertically covering an area between both eyebrows. A dark drainage was noted under the band aid. Observation of Resident #1 with the DNS on 6/9/25 at 11:06 AM identified a band aid dated 6/7 placed vertically covering an area between both eyebrows. A dark drainage was noted under the band aid. Review of the June 2025 Treatment Administration Record (TAR) identified that the treatment to Resident #1's forehead was signed off as completed on 6/8/25 by LPN #2. Review of nurse's notes dated 6/8/25 failed to identify documentation related to the forehead dressing. Interview and clinical record review with the DNS on 6/9/25 at 11:09 AM identified that per physician's order the treatment to Resident #1's forehead should have been completed daily on the 3:00 PM to 11:00 PM shift and as needed. Subsequent to surveyor inquiry, the treatment to Resident #1's forehead was signed off as completed in the TAR on 6/9/25 at 11:13 AM. Observation of Resident #1 on 6/9/25 at 11:38 AM identified the band aid to his/her forehead was noted to be clean, dry and intact and was dated 6/9. Interview with LPN #2 on 6/9/25 at 11:49 AM identified that on 6/8/25, she signed off the forehead treatment as administered prior to completing the treatment. She identified that when she went to administer the treatment around 8:30 PM, the resident was already sleeping so she did not assess the area or change the dressing as ordered. She identified she should never sign off orders as administered prior to completing them and that she was in a rush. Re-interview with the DNS on 6/9/25 at 2:47 PM identified that licensed nurses should not sign off orders until they are administered. Although requested, a facility policy for physician's orders and treatment administration were not provided.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for nutrition, the facility failed to provide ensure a resident with difficulty swallowing was served the correct diet consistency in accordance with physician orders. The findings include: Resident #1 was admitted with diagnoses that included myoneural disorder (progressive muscle weakness), dysphagia (difficulty swallowing), dementia, and aphasia. The quarterly MDS assessment dated [DATE] identified Resident #1was alert and oriented, and independent for eating. A RCP dated 4/18/2024 identified a problem with nutritional status and that Resident #1 was on a mechanically altered diet and wore dentures. The RCP directed diet as per physician's order, adjust texture as needed to facilitate eating. A physician order dated 4/2/2024 directed International Dysphagia Diet Standardization Initiative (IDDSI) 5 minced and moist solids; allow crustless soft sandwiches (chicken or egg salad) cut into bite-sized pieces, allow IDDSI 6 kielbasa and sauerkraut; IDDSI 0 - thin liquids. A facility incident report dated 4/28/2024 at 1:13 PM identified Resident #1 was seen by a family member to be red in the face while eating lunch and the family member called for help, removed Resident #1's bottom dentures and provided the Heimlich maneuver. When LPN #1 arrived, a family member swept Resident #1's mouth and removed a piece of beet that was not diced. Resident #1's diet was downgraded to puree and a speech language pathologist (SLP) screen was to be completed. A facility summary dated 5/1/2024 identified that on 4/28/2024 a SLP evaluation was completed, and Resident #1's diet was upgraded back to IDDSI 5 minced with moist solids and thin liquids. Nursing and dietary staff were educated on IDDSI diets. Interview with SLP #1 on 5/17/2024 at 9:50 AM identified that Resident #1 had dysphagia and required a diet with minced/moist food (IDDSI 5 diet) because Resident #1 had a reduced oral phase (not chewing long before a swallow was initiated). SLP #1 stated Resident #1 did not chew food down into little pieces for safe swallowing, and the altered diet did not require biting, only required minimal chewing and lumps were able to be mashed by the tongue and only four (4) millimeters in size. SLP #1 stated Resident #1 could not effectively swallow a sliced beet, or mash it with her/his tongue, and it was not part of the ordered diet. Interview with the Acting Food Service Director (FSD #1) on 5/17/2024 at 10:15 AM identified that residents physician diet orders are entered into the kitchen's menu system by the kitchen staff and a meal ticket with diet orders and food preferences was printed at the time of a resident's meal. The meals are plated from a steam table on the unit by the cook when the meal is called out from the ticket by another member of the dietary staff and then another dietary staff member delivered it to Resident #1. Further, dietary staff was responsible for setting up the resident to eat if the resident is an independent eater. FSD #1 identified that on 4/28/2024, there was a certified cook (Cook #1) plating lunch from the steam table and the Food Service Director (FSD #2) was the second staff dietary staff member assisting with meal delivery on the unit. She continued that both were trained and resources to staff for meal consistency and the IDDSI requirements. FSD #1 stated dietary staff had not recognized that sliced beets should not have been served to Resident #1 who was ordered an IDDSI 5 diet. She identified that both [NAME] #1 and FSD #2 had been terminated due to the 4/28/2024 incident where Resident #1 had been served a sliced beet during lunch service in error. Interview with LPN #1 on 5/17/2024 at 10:30 AM identified that she was the charge nurse on Resident #1's unit on 4/28/2024 on the day shift when at approximately 12:30 PM she heard Resident #1's family member calling for help from Resident #1's room. As she entered the room, the family member was behind the wheelchair with arms around Resident #1 performing the Heimlich maneuver. Resident #1 was making audible noises; face was reddened. LPN #1 moved to position herself to continue to provide the Heimlich behind Resident #1 and the family member moved around the front of Resident #1 and proceeded to perform a mouth sweep removing a quarter sized round beet from Resident #1's mouth. Resident#1 was assessed and had no change to her/his baseline. Resident #1's diet was changed to pureed until a SLP evaluation was completed. A new pureed lunch was provided, and Resident #1 ate approximately 50 to 75 percent of it without issue. Interview with the DON on 5/17/2024 at 11:30 AM identified the FSD #2 had reported that he thought the beets were soft and had served them to Resident #1. FSD #2 identified he knew Resident #1's ordered diet and still served Resident #1 the sliced beets. The DON stated Resident #1 was independent for eating, should not have received the beets, and nursing staff did not serve or assist the Resident with the lunch meal on 4/28/2024. Although requested, a facility policy for IDDSI diet was not provided for surveyor review during the survey.

Based on clinical record review, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was reviewed for an injury of unknown origin, the facility failed to report the injury to the Administrator or the Director of Nursing at the time the allegation of abuse was identified. The findings include: Resident #1's diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required total two (2) person assistance with getting in and out of the bed and chair, toilet use, and personal hygiene, extensive one (1) person assistance with turning and repositioning while in the bed and dressing, and was always incontinent of bowel and bladder. The Facility Reported Incident form dated 6/19/23 at 5:30 PM identified blood was noted on Resident #1's teeth, lips, tongue, and a scratch on the left facial cheek, the left upper lip had swelling, and the left cheek had swelling and a bruise and there was a small scratch measuring 1.2 centimeters at the left jaw line. The form identified that although the hospice nurse, a family member and the Advanced Practice Registered Nurse were notified, the form failed to reflect documentation the Administrator or Director (DON) had been notified of the injury of unknown origin at this time. The nurse's note dated 6/19/23 at 10:55 PM identified Resident #1 was restless and attempted to get out of bed twice and the as needed medication Ativan was administered at 5:48 PM with good effect. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 6/22/23 at 1:13 PM identified she was a charge nurse that night as well as the Nursing Supervisor. RN #1 indicated she felt Resident #1 was safe and she did not report the incident to the Administrator or the DON because she thought the facility had seventy-two (72) hours to report the incident. Interview and review of the clinical record with the Regional Nurse, Registered Nurse (RN) #3, on 6/22/23 at 3:45 PM identified the incident happened on 6/19/23 at 5:30 PM and the injry was reported to the state agency on 6/20/23 on the 7AM-3PM shift as soon as the DON found out Resident #1 had a bruise to his/her face and had a missing tooth. RN #3 indicated the incident should have been reported to the DON or the Administrator at the time injury was identified. Review of the Abuse Reporting policy directed all personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property. All alleged violations including mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, must be reported to the administrator or his/her designee, i.e., immediate supervisor. The DON was unavailable for an interview.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for an injury of unknow origin, the facility failed to review and revise Resident #1's care plan to address the resident's behavioral symptoms, (agitation, restlessness, and combativeness), to prevent an injury. The findings include: Resident #1's diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, did not exhibit physical or verbal behavioral symptoms, required total two (2) person assistance with getting in and out of the bed and chair, toilet use, and personal hygiene, extensive one (1) person assistance with turning and repositioning while in the bed and dressing, and was always incontinent of bowel and bladder. Review of the Resident Care Plan dated 4/27/23 identified there was no problem that Resident #1 had exhibited behavioral symptoms. The nurse's note dated 6/10/23 at 10:30 PM identified Ativan was administered at 10:15 PM for restlessness and crying out. The nurse's note dated 6/12/23 at 6:47 AM identified Resident #1 was crying and agitated and the as needed Ativan was administered with good effect. The nurse's note dated 6/15/23 at 4:05 AM identified Resident #1 was agitated at the start of the shift, the as needed Ativan was administered by the previous shift, Resident #1 calmed down significantly, however remained awake and chatting to self, there was some mild restless behaviors throughout the night and Resident #1 was noted to be balling up the sheets and removing the johnny. The nurse's note dated 6/16/23 at 8:10 PM identified the as needed Ativan was administered for combativeness and excessive crying, during evening care Resident #1 began hitting staff, and the supervisor was made aware. The nurse's note dated 6/19/23 at 10:55 PM identified Resident #1 was restless and attempted to get out of bed twice, the as needed Ativan was administered at 5:48 PM with good effect. The nurse's note dated 6/20/23 at 12:57 AM identified upon entering room the Nursing Supervisor noted a nurse aide was with Resident #1, Resident #1 was lying in the center of the bed on his/her back, Resident #1 had bloody teeth, tongue, and lips. The note indicated Resident #1's left lip was lifted and on the left upper gum there was a broken tooth. The note identified while trying to assess Resident #1, Resident #1 was combative pushing at anyone who was trying to get closer to him/her and the charge nurse was asked to medicate Resident #1with the as needed medication for agitation and anxiety. The note identified on return the Nursing Supervisor was able to wash a small amount of blood off Resident #1's cheek and noted an approximately four (4) centimeter superficial scratch. The note indicated Resident #1 continued to be combative, and an assessment would have to wait until the staff could get closer to Resident #1. The note identified Resident #1's family member was there, was able to wash Resident #1 's face and mouth and asked the staff not to disturb Resident #1 at this time as Resident #1 was calm. Review of the care plan identified a problem was developed related to the facial injury sustained on 6/19/23 with an intervention to pad bilateral side rails for protection, however the care plan failed to address Resident #1's physical and behavioral symptoms. Interview with a 3-11PM nurse aide, Nurse Aide (NA) #1, on 6/22/23 at 11:47 AM identified occasionally Resident #1 was a little combative, however nothing to the point where Resident #1 had ever made him/herself bleed. NA #1 indicated Resident #1 would hit, grab, pinch, and mainly did it when he/she was in pain. NA #1 identified Resident #1 was able to move in bed independently, he/she tended to wiggle and end up sideways on the bed. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 6/22/23 at 12:04 PM identified Resident #1's behavior was changing, and the nurse aides stated Resident #1 was screaming out, yelling out and crying. LPN #1 indicated Resident #1 had been combative with care more recently and Resident #1's behavior started to change a couple of weeks ago. Interview with a 3-11PM nurse aide, Nurse Aide (NA) #2, on 6/22/23 at 1:50 PM identified she had helped a coworker change Resident #1 and in the past Resident #1 was combative, tried to get out of bed and that was why Resident #1 had bed alarm. Interview with a 3-11PM nurse aide, Nurse Aide (NA) #3, on 6/22/23 at 3:00 PM identified when Resident #1 was in a lot of pain, he/she got very agitated, thrashed out, and would try to hit the staff. NA #3 indicated Resident #1 would get progressively more aggressive, would thrash in bed, would be halfway out of bed and would not sit still. NA #3 identified she had to reapproach Resident #1 several times because Resident #1 was getting very aggressive and tried to hit her. Interview with the Minimum Data Set (MDS) Coordinator, Registered Nurse (RN) #4, on 6/22/23 at 2:48 PM identified she was unaware Resident #1 exhibited combative, aggressive behaviors. RN #4 indicated the change in any resident's behavior was usually communicated during morning report and the MDS Coordinator would review and revise the plan of care. Interview and review of the clinical record with the Regional Nurse, Registered Nurse (RN) #3, on 6/22/23 at 2:30 PM identified Resident #1's care plan did not have a care plan to address Resident #1's combative and aggressive behaviors prior to the incident on 6/19/23. RN #3 indicated the MDS Coordinator was responsible to review and revise the resident care plan. Review of the Care Planning policy directed to have an interdisciplinary care plan to achieve and maintain optimal status for each resident. The resident care plan will include physical, cognitive and psycho-social problems and will address the residents needs on an individualized basis.

Based on clinical record review, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who required dental care, the facility failed to ensure Resident #1 received dental services. The findings include: Resident #1's diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. The care conference report dated 1/27/23 identified the care team met after meeting with Resident #1, Resident #1's family member was present, the current orders, code status, plan of care and consults were reviewed, Resident #1 was on a modified diet and on the list for the dentist to see for a chipped tooth. Review of the clinical record and facility documentation failed to reflect documentation Resident #1 was seen by the dentist as requested by the family member on 1/27/23. Interview with the Medical Records/Unit Coordinator on 6/22/23 at 1:38 PM identified in January 2023, she was requested to add Resident #1 to the dental list, and she had to contact Resident #1's family member to obtain dental consent. The Medical Records/Unit Coordinator identified Resident #1's family member decided to sign up to see the facility dentist and indicated the family member stated to her at that time it was not a priority because Resident #1 was not in pain. The Medical Records/Unit Coordinator identified the dentist came into the facility in February, however the dentist saw a different resident with the same last name who was also on the list of services. The Medical Records/Unit Coordinator indicated she pointed out to the dentist Resident #1 was not treated, the dentist admitted the mistake, stated Resident #1 would be added to the list and would get back to her when the dentist was coming again. The Medical Records/Unit Coordinator identified she did not receive a follow up from the dentist and she also did not follow up because Resident #1 signed onto Hospice services in March. The Medical Records/Unit Coordinator indicated to her Hospice services meant comfort measures only and no more treatments, that was why she did not follow up with the dentist. Review of the Dental Services policy directed the facility will provide qualified dentist services for all residents. Subsequent to surveyor inquiry Resident #1 was scheduled to be seen by the dentist on 6/23/23.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #2) reviewed for medication administration, the facility failed to administer medications timely as ordered. The findings include: Resident #2 was admitted to the facility with diagnoses that included orthopedic aftercare, stroke, type II diabetes and inflammatory and infection reaction due to internal joint prosthesis. The care plan dated 5/6/23 identified Resident #2 had an alteration in cardiac status secondary to hypertension. Interventions included medications per physician order. Physician's order dated 5/6/23 directed aspirin 81 mg twice a day for blood thinner. Physician's order dated 5/6/23 directed Lopressor 50 mg every 12 hours for high blood pressure. Physician's order dated 5/6/23 directed metformin 500 mg every 12 hours for type II diabetes. Physician's order dated 5/6/23 directed Neurontin 300 mg three times a day for inflammatory reaction due to internal joint prosthesis . Physician's order dated 5/6/23 directed senna plus one tablet at bed time for hypertension. The admission MDS dated [DATE] identified Resident #2 had no impairments in cognition, was continent with bowel and urine and was an extensive assist of one staff for toilet use and personal hygiene. Review of the medication administration report dated 5/9/23 identified the following medications were scheduled to be administered at 8:00 PM and were documented as administered at 11:15 PM; Aspirin 81 mg, Lopressor 50 mg, Metformin 500 mg, Neurontin 300 mg and Senna plus. Interview with RN #1 on 5/30/23 at 2:00 PM identified if he documented the medication administration as late then it was late. He identified he was newer to unit and could have had other things could on that night that needed attention. Review of the administration of medications policies and procedures directed that medications are to be given at the time ordered or with 60 minutes before or after the time designated.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for allegations of neglect, (Resident #2), the facility failed to document a thorough investigation of a resident's allegation of neglect. The findings include: Resident #2 had diagnoses that included morbid obesity and depression. A care plan dated 5/6/23 identified Resident #2 had an alteration in activities of daily living (ADL's) with interventions that included moderate assist of one for toileting and upper/lower body self care, allow adequate time for Resident #2 to perform ADL activity, encourage Resident #2 to do as much for his/herself as possible and provide assistive/adaptive devices. The care plan was updated on 5/9/23 for two staff for care at all times due to accusatory behavior. Occupation Therapy evaluation and plan of treatment dated 5/8/23 identified staff provide 100% of assistance for toileting due to Resident #2 being bed level at that time and no applicable for toilet/commode transfers. A nurse's note dated 5/9/23 at 4:39 PM identified Resident #2 was heard shouting and calling staff names because he/she was on the bedpan and uncomfortable. Resident #2 continued to make negative comments while cursing and name calling. Two staff were present for any interactions for the remainder of the shift. A former DNS note dated 5/9/23 at 2:19 PM identified Resident #2 was to be two for care at all times related to accusatory behavior. The admission MDS dated [DATE] identified Resident #2 had no impairments in cognition, was continent with bowel and urine and was an extensive assist of one staff for toilet use and personal hygiene. Review of the grievance log failed to identify a grievance was completed for Resident #2. Review of Resident #2's record failed to identify an accident and incident form was completed for Resident #2. Interview with the former DNS on 5/25/23 at 11:00 AM identified Resident #2 reported to her that she was left on the bedpan for 45 minutes on 5/9/23. She identified she investigated the concern and spoke with the NA who cared for him/her (NA #5). She identified NA #5 identified Resident #2 was placed on the bedpan and had to leave the room to care for another resident and that she was gone for less than 10 minutes. She identified she spoke with Resident #2 about the event and Resident #2 agreed it was less than 45 minutes that he/she was on the bedpan and that Resident #2 was ok after the discussion. She identified after talking with NA #5 and Resident #2 she thought it did not warrant neglect, however, she did not complete an accident and incident or grievance because it was not advised by her trainer. She further identified Resident #2 was two staff for all care following this event due to accusatory behaviors. Although requested, a copy of the former DNS's investigation documentation related to this event was not provided. Interview with NA #5 on 5/31/23 at 12:26 PM identified another NA had put Resident #2 on the bed pan, however, she did not know who or when. She identified Resident #2's call bell went on while she had another resident on the toilet. She identified she entered Resident #2's room and Resident #2 identified he/she was ready to get off the bed pan. NA #5 asked Resident #2 if she could have 5 minutes to get another resident off the toilet and Resident #2 identified that was okay. NA#5 got the resident off the toilet and Resident #2's call bell went on again and NA #5 identified she answered it within the minute. She identified Resident #2 told her she didn't care about him/her, that she wasn't the one on the bed pan for half an hour and proceeded to be rude and accusatory toward NA #5. She identified she did not feel comfortable caring for Resident #2 alone and asked the nurse to come in with her. She identified the DNS spoke with Resident #2 and changed Resident #2 to two staff members with care due to accusatory behaviors. Interview with the Regional Director of Nursing on 5/25/23 at 2:12 PM identified she would expect a grievance to be completed for a resident complaint of being left on a bedpan for 45 minutes. Review of the abuse reporting policy identified neglect is defined as the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid harm, pain, mental anguish or emotional distress. It identified the charge nurse or supervisor must complete a reportable event form and obtain a written, signed and dated statement from the person reporting the incident. Review of the bedpan, placement and removal policy and procedure directed to tell the resident to call when finished and to be sure the call light and toilet paper are within easy reach of the resident.

Based on observation, review of facility policy, and staff interviews, during a tour of the kitchen, the facility failed to store food according to professional standards. The findings include: Observation in the Dietary Department with the Food Service Manager on 3/15/23 at 9:50 AM identified the following items found in the walk- in refrigerator: 1.French dressing 1 Gal- noted to be open and with a received date of 9/15/22. The container lacked opened and expiration dates. 2. [NAME] Italian 1 Gal- noted to be open with approximately 1/8th of the contents missing, and with a received date of 3/9/23. The container lacked opened and expiration dates. 3. Sweet Relish- noted to be open with 1/2 of the contents missing, and with a received date of 2/10/23. The container lacked opened and expiration dates. 4. Mayonnaise 1 Gal, noted to be open with 3/4 of the contents missing, and with a received date of 2/10/23. The container lacked opened and expiration dates. 5. Ken's Ranch 1 Gal, noted to be open with 3/4 of the contents missing. The container lacked received, opened, and expiration dates. During the continued kitchen tour, in the Walk- in Freezer the following were noted to be open and lacked an open date: 1. 1 Bag of Salisbury Steak patties 2. Pre-formed egg discs in an open 3. One box of 11 ground- beef patties Interview and review of the facility food storage policy with the Food Services Manager on 3/15/23 at 10:15 AM identified he could not locate an opened, expiration, and/or received date for the above listed items in the walk-in refrigerator. The Food Services Manager indicated the items should have been labeled with the date when the item was opened. Additionally, the open items in the walk in freezer should have been wrapped in plastic wrap once opened and labeled with an opened date. Subsequent to surveyor inquiry, re-interview with the Food Services Manager on 3/15/23 at 11:58 AM identified he threw out all the unlabeled condiments listed above and would be in-servicing the staff on proper food storage. Review of the Facility Food Storage Policy, Revised 8/15/2013 directed, in part, open boxes of food shall be re-wrapped, dated, and used up as soon as possible, before other boxes are opened.

Based on review of the clinical record review, facility documentation, facility policy and interview for 1 resident (Resident #447) reviewed for choices, the facility failed to ascertain and implement the resident's choice related to showering. The findings include: Resident #447 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia, atrial fibrillation, and stress incontinence. The care plan dated 3/6/23 identified that Resident #447 needed assistance with activities of daily living due to weakness and deconditioning. Interventions included encouraging the resident to do as much as he/she can for him/herself. The physician's orders dated 3/7/23 directed to provide Resident #447 a shower and weekly body audit every Sunday on the 7:00 AM - 3:00 PM shift. The admission MDS dated [DATE] identified Resident #447 had intact cognition and felt it was very important to choose between a tub bath, shower, bed bath or sponge bath while at the facility. Interview with Resident #447 on 3/15/23 at 2:18 PM identified that he/she had not been offered or received a shower since his/her admission to the facility on [DATE], 9 days and had been using the bathroom sink daily to wash up. Resident #447 indicated on 3/14/23 a facility staff member told him/her that his/her scheduled shower day was on Sundays. Resident #447 identified that he/she had not been offered a shower on 3/12/23. Interview with Resident #447 on 3/20/23 identified he/she got his/her first shower on Sunday 3/19/23,13 days after admission. Interview with LPN #1 on 3/22/23 at 10:37 AM identified although she signed off on the TAR that Resident #447 had received a shower on 3/12/23, she did not actually see Resident #447 shower on 3/12/23. LPN #1 identified she just signed the task off since it included the body audit. LPN #1 also identified that if Resident #447 had told her that he/she didn't get a shower on the assigned day, she would have notified the nurse aide to make sure it was done. Interview with the DNS on 3/22/23 at 11:42 AM identified that all facility residents have the option to shower multiple days per week if they wish. The DNS indicated she was not sure how residents are notified of their scheduled shower day, but she does expect the facility staff to notify a resident of their shower day if they ask. The DNS identified that she was not sure why LPN #1 signed that Resident #447 had a shower on 3/12/23 if he/she did not have a shower and could not explain why Resident #447 was not offered a shower prior to 3/19/23. Review of an undated east wing shower list failed to reflect Resident #447's shower day. The bath and shower policy directed a resident should be given a shower by the established shower schedule and should receive a minimum of one shower a week. The activities of daily living policy directed that the abilities of each resident to meet the demands of daily living will be assessed by a nurse with the goal of returning to a maximal level of independence and an acceptable quality of life. The policy further directed to schedule and provide showers/baths as requested. Although requested, the facility failed to provide the temp/shower log list for 3/12/23.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #29) reviewed for hospitalization and anticoagulant use, the facility failed to complete an admission assessment upon the resident's return from the hospital and failed to ensure the physician order was followed related to the administration of an anticoagulant medication, and for 1 resident (Resident #447) reviewed for choices, the facility failed to ensure that weekly body audits were completed per facility policy. The findings include: 1. Resident # 29's diagnoses included a cerebral infarction, pathological dislocation of the right shoulder and pneumonia. The admission MDS assessment dated [DATE] identified Resident #29 had moderate cognitive impairment, required extensive assistance for bed mobility, transfers, ambulation, locomotion, dressing, toileting, and personal hygiene. The Resident Care Plan (RCP) dated 12/2/23 identified Resident #29 had an ADL (activities of daily living) self-care deficit with interventions that included physical and occupational therapy, assistance with the performance of ADL care. The RCP further identified Resident #29 was on an anticoagulant with interventions that included medication administration as ordered and monitoring for bleeding or bruising. A nurse's note dated 2/6/23 at 8:03 PM identified Resident #29 was seen by the APRN at 6:45 PM for decreased pulmonary oxygenation level, increased heart rate and fever. The resident was sent to the hospital. A nurse's note dated 2/7/23 at 4:08 AM identified that the resident was admitted to the hospital for sepsis and pneumonia. The hospital discharge summary dated 2/13/23 identified the resident was admitted to the hospital on 2/6/23 with a diagnosis of aspiration pneumonia. A nurse's note dated 2/14/2023 indicated Resident #29 returned to the facility at 3:20 PM on 2/13/2023. A review of Resident #29's clinical record failed to identify that a nursing admission assessment was completed upon the resident's readmission to the facility on [DATE], inclusive of the following assessments: Braden scale, elopement risk, pain, oral cavity, influenza/pneumonia vaccine status, bowel and bladder continence, and abuse/neglect risk. Interview with DNS on 3/21/23 at 1:30 PM identified that when a resident returns to the facility after a hospitalization , all admission documents including assessments and progress notes are to be completed. The DNS further indicated that the charge nurse at the time of re-admission is responsible to complete those documents. Review of the facility's Admission policy and procedure identified that a nursing assessment form is to be completed by the admitting nurse. A policy for re-admission was requested but was not provided. Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #29) reviewed for hospitalization , the facility failed to complete an admission assessment upon the resident's return from the hospital. The findings include: Resident # 29's diagnoses included a cerebral infarction, pathological dislocation of the right shoulder and pneumonia. The admission MDS assessment dated [DATE] identified Resident #29 had moderate cognitive impairment, required extensive assistance for bed mobility, transfers, ambulation, locomotion, dressing, toileting, and personal hygiene. The Resident Care Plan (RCP) dated 12/2/23 identified Resident #29 had an ADL (activities of daily living) self-care deficit with interventions that included physical and occupational therapy, assistance with the performance of ADL care. The RCP further identified Resident #29 was on an anticoagulant with interventions that included medication administration as ordered and monitoring for bleeding or bruising. A nurse's note dated 2/6/23 at 8:03 PM identified Resident #29 was seen by the APRN at 6:45 PM for decreased pulmonary oxygenation level, increased heart rate and fever. The resident was sent to the hospital. A nurse's note dated 2/7/23 at 4:08 AM identified that the resident was admitted to the hospital for sepsis and pneumonia. The hospital discharge summary dated 2/13/23 identified the resident was admitted to the hospital on 2/6/23 with a diagnosis of aspiration pneumonia. A nurse's note dated 2/14/2023 indicated Resident #29 returned to the facility at 3:20 PM on 2/13/2023. A review of Resident #29's clinical record failed to identify that a nursing admission assessment was completed upon the resident's readmission to the facility on [DATE], inclusive of the following assessments: Braden scale, body audit, elopement risk, pain, oral cavity, influenza/pneumonia vaccine status, bowel and bladder continence, , and abuse/neglect risk. Interview with the DNS on 3/21/23 at 1:30 PM identified that when a resident returns to the facility after a hospitalization , all admission documents including assessments and progress notes are to be completed by the charge nurse at the time of readmission or admission. Review of the facility's admission policy and procedure identified that a nursing assessment form is to be completed by the admitting nurse. A policy for re-admission was requested but was not provided. 2. Resident # 29's diagnoses included pulmonary embolism, cerebral infarction, a pathological dislocation of the right shoulder and hypertensive heart disease. The admission MDS assessment dated [DATE] identified Resident #29 had moderate cognitive impairment, required extensive assistance for bed mobility, transfers, ambulation, locomotion, dressing, toileting, and personal hygiene. The Resident Care Plan (RCP) dated 12/2/23 identified Resident #29 had an ADL (activities of daily living) self-care deficit with interventions that included physical and occupational therapy, assistance with the performance of ADL care. The RCP further identified Resident #29 was on an anticoagulant with interventions that included medication administration as ordered and monitoring for bleeding or bruising. Review of physician's orders identified a physician's order dated 12/2/22 that directed to administer Xarelto 20 mg daily. A physician's order dated 1/18/23 directed to hold blood thinners for 5 days prior to a scheduled appointment for an image guided Cortisone injection to the right shoulder. A physician's order dated 1/19/23 directed to hold Xarelto starting 1/20/23 for a scheduled right shoulder injection on 1/25/23. Review of the medication administration record (MAR) for Resident #29 for January 2023 identified that Xarelto was held from 1/20/23 through 1/27/23 and not resumed until 1/28/23 (4 doses following the Cortisone injection on1/25/23). A nurse's note dated 1/29/23 at 5:00 PM identified Resident #29 became aphasic with right sided weakness, had difficulty ambulating, and was transferred to the hospital emergency department. The hospital discharge summary dated 2/5/23 noted that Resident #29 had an acute stroke due to embolism of the left middle cerebral artery, and noted that blood thinners had been on hold. The resident was discharged from the hospital back to the facility with an order for Heparin (injectable anticoagulant medication). Interview with the DNS on 3/22/23 at 12:00 PM identified that the nurse who took the order to hold the Xarelto was no longer employed by the facility. The DNS identified, that based on the way the order was written, the Xarelto should have been held on 1/21, 1/22, 1/23, 1/24 and 1/25/23, and resumed on 1/26/23. The DNS was unaware that the Xarelto was not resumed until 1/29/23. Interview with MD #1 on 3/23/23 at 12:20 PM identified that he did not write the order to hold the Xarelto. MD #1 further identified that his recommendation for holding Xarelto for a Cortisone injection would have been to hold for a few days before the procedure and to resume the day after. MD #1 noted that he could not conclude that holding the Xarelto for the number of days it was held contributed to Resident #29's stroke. Review of the facility's anticoagulation policy did not include instructions on anticoagulation medication holds. 3. Resident #447 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia, atrial fibrillation, and stress incontinence. The care plan dated 3/6/23 identified Resident #447 had stress incontinence with interventions that included to monitor skin integrity and report significant findings. The physician's orders dated 3/7/23 directed to provide Resident #447 a shower and complete a weekly body audit every Sunday on the 7:00 AM - 3:00 PM shift. Review of the March 2023 TAR identified LPN #1 signed the weekly body audit as completed for Sunday on the 7:00 AM - 3:00 PM shift. Review of the weekly body audit report dated 3/12/23 at 2:05 PM, completed by LPN #1, identified Resident #447 had intact skin. The admission MDS dated [DATE] identified Resident #447 had intact cognition and had no identified skin injuries or conditions. Interview with Resident #447 on 3/15/23 at 2:18 PM identified that he/she had not been offered or received a shower since his/her admission to the facility on [DATE], 9 days and had been using the bathroom sink daily to wash up. Resident #447 indicated on 3/14/23 a facility staff member told him/her that his/her scheduled shower day was on Sundays. Resident #447 identified that he/she had not been offered a shower on Sunday 3/12/23. Interview with Resident #447 on 3/20/23 identified he/she got his/her first shower on Sunday 3/19/23,13 days after admission. Interview with LPN #1 on 3/22/23 at 10:37 AM identified that she did not actually see Resident #447 shower on 3/12/23 and just signed the task off as completed since it included the body audit. LPN #1 identified she didn't always complete a full head to toe skin audit and stated sometimes if they are in the bathroom I will look, or I will just look at their arms, sometimes they are in the bed and I look when they are laying down. Interview with Resident #447 on 3/22/23 at 11:09 AM identified he/she did not have a full head to toe skin assessment completed on 3/12/23, and no one from the facility had ever looked at his/her skin from head to toe while undressed in a gown, while in bed, or while in the bathroom. Interview with the DNS on 3/22/23 at 11:42 AM identified that residents of the facility should have a full head to toe body/skin audit on shower days, with the resident undressed either in the shower room or in their room, and the audit would include all skin areas including the back of the knees and the heels. The DNS reviewed the March 2023 TAR documentation from 3/12/23 completed by LPN #1 that indicated Resident #447 had a shower and body audit. The DNS identified that she was not sure why LPN #1 signed that Resident #447 had a shower on 3/12/23 if he/she did not have a shower or a full body/skin audit. The bath and shower policy directed a resident should be given a shower by the established shower schedule and should receive a minimum of one shower a week. The policy further directed that any unusual skin issues noted during the shower should be reported, including bumps, lumps, bruises, rashes, and skin breaks. Although requested, the facility failed to provide policies on weekly body audits or assessments. 47826

Based on clinical record review, observations, facility documentation, and interviews for 1 of 3 sampled residents (Resident #25) reviewed for pressure ulcers, the facility failed to ensure that the low air loss mattress (LAL) was at the correct setting per physician orders on multiple observations. The findings include: Resident #25 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right lower limb, a terminal illness and chronic venous hypertension (idiopathic) with ulcers of bilateral lower extremities. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 was moderately cognitively impaired and required extensive assistance of one for bed mobility, dressing and hygiene. Additionally, the MDS identified Resident #25 required extensive assistance of one for toilet use, supervision of 1 with ambulation and was independent after being setup for eating. Nurse's notes dated 1/23/23 at 3:40 PM identified Resident #25 complained of difficulty swallowing, unable to swallow liquids without choking, neck swollen, APRN in to access and sent to hospital for evaluation. Nurse's notes dated 2/9/23 at 3:45 PM identified Resident #25 was readmitted to the facility at 1:30 PM via private car with a diagnosis of a Stage 4 pressure ulcer to the coccyx. A Braden Risk Assessment (a tool used to identify the risk for developing a pressure sore) dated 2/9/23 identified Resident #25 was at a mild risk for the development of pressure ulcers. A Resident Care Plan dated 2/9/23 identified a problem with having a Stage 4 pressure ulcer on the sacrum. Interventions included to order an air mattress or equivalent, assess and record the skin surrounding the pressure ulcer, assess pressure ulcer weekly, treatment as ordered and report any further signs of breakdown. A physician's order dated 2/9/23 directed to place the resident on a LAL mattress set at 120 and to check for placement and function every shift, day, evening, and night. Resident #25's weight record identified on 2/9/23 Resident #25 weighed 126 pounds. Observation on 3/15/23 at 10:32 AM identified Resident #25 to be seated on the side of the bed on a LAL mattress that was set for a weight of 60 pounds (despite Resident #25 being 126 pounds and a physician order directing a setting of 120 pounds). Resident #25's weight record identified on 3/20/23 Resident #25 weighed 109.3 pounds. An additional observation with RN #2 (Nursing Supervisor) on 3/21/23 at 10:06 AM identified Resident #25 to be seated on the side of the bed on a LAL mattress that was set for a weight of 60 pounds (despite Resident #25 being 109.3 pounds and the physician order directing a setting for 120 pounds). Interview with RN #2 (Nursing Supervisor) on 3/21/23 at that time identified maintenance sets up the LAL mattress and nursing should check the settings. An interview on 3/21/23 at 10:26 AM with the Maintenance Director identified they are responsible for delivering the LAL mattress to residents, nursing assistants are responsible for placing the mattress on the bed and nurse's are responsible to set the setting of the mattress. The Maintenance Director identified that they are not allowed to make adjustments to the settings or set the settings on the mattress. On 3/21/23 at 10:27 AM, LPN #3 questioned Resident #25 regarding if he/she tampered with the LAL mattress setting, in which Resident #25 denied altering the setting stating I wouldn't even know how to do that. Although the Treatment Administration Record dated 3/1/23 to 3/21/23 identified to check the LAL mattress for function and placement every shift, it failed to identify to check for appropriate settings at the time of function/placement checks.

Based on clinical record review, observations, facility documentation, and interviews for 1 of 1 sampled resident (Resident #25) reviewed for podiatry services, the facility failed to provide foot care for a resident with long toenails. The findings include: Resident #25 was admitted to the facility as a short term stay (rehabilitation) resident on 1/7/23 with diagnoses that included cellulitis of the right lower limb, a terminal illness and chronic venous hypertension (idiopathic) with ulcers of bilateral lower extremities. Admission nurses notes dated 1/7/23 at 5:15 PM identified Resident #25 was observed to have thick, overgrown, and yellow toenails. The Resident Care Plan dated 1/7/23 identified a problem with impaired mobility related to weakness and deconditioning status post hospitalization for cellulitis of the lower extremities. Interventions included to continue with therapy, provide positive feedback, assist with toilet use, and encourage frequent position changes. A Consent for Services document dated 1/18/23 and signed by Resident #25 identified he/she did not wish podiatry services through the facility provided contractor. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 was moderately cognitively impaired and required extensive assistance of one for bed mobility, dressing and hygiene. Additionally the MDS identified Resident #25 required extensive assistance of one for toilet use and was independent after being setup for eating. A Consent for Services document dated 1/18/23 and signed by Resident #25 (who was identified as being moderately cognitively impaired on the MDS) identified he/she did not wish podiatry services through the facility provided contractor. On 3/15/23 at 11:46 AM Resident #25 was observed to be seated at the side of the bed, his/her right sock was not applied and his/her toenails were noted to be long, thick, unkept, discolored with the great toe and second toenail curved over and touching the adjacent toenails (visible from the doorway). Resident #25 further identified that he/she doesn't wear a sock on the right foot because the toe nail snags on the sock when applied. Resident #25 further noted that he/she reported to the nurse wanting to see the podiatrist but could not recall the date he/she requested and whom he/she made the request to. On 3/21/23 at 10:06 AM observation with RN #2 (Nursing Supervisor) identified Resident #25 was observed to be seated at the side of the bed, his/her right sock was not applied and his/her toenails were noted to be extremely long, thick, unkept, discolored with the great toe and second toenail curved over and touching the adjacent toenails. On 3/21/23 at 10:15 AM interview with the Medical Record Unit Coordinator identified she was responsible for scheduling podiatry visits and Resident #25 entered the facility as a short term stay resident. Additionally, she identified podiatry comes to the facility every 60 days, and since most short term stay residents are not in the facility for that long, do not get placed on the podiatry list. She further identified if there are podiatry issues with a short term stay resident, she refers them to the Nursing Supervisor. Additionally, she identified the podiatrist had been at the facility on 3/13/23 to provide foot care to residents but did not provide treatment to Resident #25 because he/she was not on the list to be seen. On 3/21/23 at 10:53 AM interview with Person #1 identified being aware of Resident #25's foot condition and stated Resident #25 told him/her that the facility was scheduling a podiatry appointment but that was a long time ago. Although on 1/18/23 Resident #25 initially did not consent for services by the facility contracted Podiatrist, the facility subsequently had not offered foot care for his/her extremely long toenails. On 3/22/23 at 10:57 AM interview with LPN #3 identified Resident #25 was added to the list for foot care services at the next podiatry visit. Although requested, the facility did not have a policy for podiatry visits.

Based on a tour of the environment, observations, and interviews, the facility failed to ensure the area outside of the East Wing was free of cigarette butts and failed to ensure the staircase landing and steps to the basement were clean. The findings include: Observations of the rear parking lot from the East Wing exit on 3/15/23 at 10:15 AM identified the grounds near the exit door were littered with cigarette butts and an empty cigarette pack. There was a smoking receptacle in the vicinity and signage which directed no smoking. Observation of the basement steps (located outside the Dietary hallway) and staircase landing on 3/15/23 at 10:20 AM and on 3/15/23 at 12:55 with the Administrator identified a large amount of debris, dust, black particles, and grime. Interview with the Directory of Dietary on 3/15/23 at 10:17 AM identified that some facility staff members, not residents, would smoke in the area outside of the East Wing exit. He also indicated that the Director of Maintenance would be responsible to oversee the upkeep of both the staff smoking area and the basement staircase and landing. Interview with the Facility Administrator on 3/15/23 at 12:55 PM identified that the facility was a non-smoking facility, but staff are allowed to smoke out back. The Administrator indicated that the Director of Maintenance should oversee daily cleaning of the area. Additionally, the facility Administrator identified that there was no scheduled cleaning for the basement stairway and landing because it was a non-resident area. Interview with the Maintenance Director on 3/15/23 at 2:00 PM indicated that last week, there was a leak from the grease trap. The debris on the staircase and landing was due to an increase in foot traffic during the grease trap repair, and the area was not typically littered with debris. The Maintenance Director also indicated that there was no routine cleaning schedule for the landing and stairs leading to the basement. Subsequent to surveyor inquiry, the Maintenance Director indicated that the parking lot behind the East Wing had been cleaned and the cigarette butts on the ground had been removed. The facility did not have a smoking policy for staff members.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #29) who was transferred to the hospital on two occasions, the facility failed to provide the required notification of the transfers to the state Ombudsman office. The findings include: Resident # 29's diagnoses included a cerebral infarction, a pathological dislocation of the right shoulder and pneumonia. The admission MDS assessment dated [DATE] identified Resident #29 had moderate cognitive impairment, required extensive assistance for bed mobility, transfers, ambulation, locomotion, dressing, toileting, and personal hygiene. Resident #29's care plan dated 12/2/22 identified Resident #29 had an ADL (activities of daily living) self-care deficit with interventions that included physical therapy, occupational therapy, and assistance to perform ADLs. The care plan further identified Resident #29 was on an anticoagulant with interventions that included medication administration as ordered and monitoring for bleeding or bruising. The care plan further identified the potential for pain with interventions that included the administration of pain medication and pain monitoring. A nurse's note dated 1/29/23 at 5:00 PM identified Resident #29 was observed to have garbled speech, a new onset of right upper extremity weakness, pupils reactive but sluggish and resident was unable to follow directions. The note further identified that the APRN was notified, and orders obtained to transfer resident to hospital emergency department. A nurse's note dated 2/5/23 at 1:49 PM identified that the physician was aware of Resident #29's readmission from the hospital. A dietitian's note dated 2/6/23 at 11:22 AM indicated Resident #29 was readmitted from the hospital with a diagnosis of post-acute stroke. A nurse's note dated 2/6/23 at 8:03 PM identified Resident #29 was seen by the APRN at 6:45 PM for decreased pulmonary oxygenation level, increased heart rate and fever. The resident was sent to the hospital. A nurse's note dated 2/7/23 at 4:08 AM identified that the resident was admitted to the hospital for sepsis and pneumonia. The hospital discharge summary dated 2/13/23 identified the resident was admitted to the hospital on 2/6/23 with a diagnosis of aspiration pneumonia. Review of the nurses' notes, and social service notes during the time frame of Resident #29's hospitalization s (1/29/23-2/5/23 and 2/6/23-2/13/23) failed to indicate that the Ombudsman's office was notified of the facility-initiated transfers to the hospital. Interview with the Administrator on 3/22/23 at 10:10 AM identified that the facility updates the Ombudsman's office monthly of all discharges utilizing a report form entitled Admit/Discharge report, however the facility had failed to include residents that were discharged to the hospital with an anticipated return to the facility. The administrator further identified that the Ombudsman's office had not been notified of Resident #29's two transfers to the hospital. Subsequent to surveyor inquiry, on 3/22/23 the facility updated the Ombudsman's office of Resident #29's transfers to the hospital for the dates of 1/29/23 and 2/6/23. Review of the facility's policy on Bed Holds, did not identify the process for notifying the Ombudsman regarding transfers to the hospital.