Every finding on record at Parkville Care Center

Based on review of the clinical record, facility documentation/policies and interviews, for two (2) of four (4) sampled residents (Residents #3 and #4) reviewed for abuse, the facility failed to ensure a safe and abuse free environment when Resident #4 physically assaulted Resident #3. The facility did not provide adequate supervision or timely intervention, resulting in Resident #3 being struck multiple times, sustaining actual physical harm including facial injury, oral laceration, head trauma, and a loose tooth, and requiring hospital evaluation. The findings include:1.Resident #3's diagnoses included bipolar disorder, cognitive communication deficit, and cirrhosis of the liver.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 as moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10) and required touching assistance or supervision with daily living skills. Resident #3 was independent with transfers and bed mobility.The Resident Care Plan (RCP) dated 4/16/26 identified Resident #3 had a self care deficit. Interventions directed assisting with care as needed, promoting self care in all areas, implementing fall risk interventions due to limited mobility including nonskid footwear, monitoring blood sugars, and educating family and friends regarding safety reminders especially during periods of high heat.The Social Services note dated 6/2/26 at 08:43 AM by SW #1 identified follow up with Resident #3 due to an incident in which Resident #3 was physically assaulted by Resident #4, resulting in injury. Resident #3 was provided support and evaluated by psychiatry. The care plan was updated. The nurse's note dated 6/2/26 at 3:46 PM by RN #1 identified Resident #3 suffered a facial injury after being struck multiple times in the head and face by Resident #4 in the dining area as he/she was preparing to play his/her guitar resulting in bleeding from the mouth and a loose right sided tooth. Resident #3 was found lying on the floor and was alert, oriented, and able to recall the incident. He/she complained of a headache but denied dizziness. Vital signs were monitored, a cold compress was applied, and the Advanced Practice Registered Nurse (APRN) requested hospital transfer for evaluation. The physician and the resident's sister were notified.The nurse's note dated 6/3/26 at 8:00 AM by RN #1 identified Resident #3 returned from the hospital. Resident #3 was diagnosed with a closed head injury with internal mouth laceration. CT scans of the head, cervical spine, and maxillofacial bones showed no significant traumatic injury. A follow up with the primary care physician was recommended, and no new orders were given. Resident #3 was alert and oriented, complaining of headache and mouth pain. Tylenol was administered, and neuro assessments initiated.The physician's note dated 6/8/26 at 1:57 PM identified Resident #3 reported near complete resolution of jaw discomfort and no longer felt his teeth were loose. No other medical issues or concerns were identified at the time.2. Resident #4's diagnoses included dementia, schizoaffective disorder. generalized anxiety disorder, and vitamin D deficiency.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 00) and required touching assistance with activities of daily living. Resident #4 was independent with bed mobility, transfers, and ambulation.The RCP dated 5/7/26 identified Resident #4 as having self care deficit related to dementia and taking psychotropic medications due to schizoaffective disorder. Interventions directed allowing the resident to perform as much self care as possible and assisting as needed, re approaching during episodes of care refusal, asking the resident's name before providing care, monitoring for complications related to psychotropic medications, AIMS testing, behavior monitoring, gradual dose reduction as indicated, monitoring for changes in mental status and medication changes, and arranging psychiatric visits as needed.The Social Services note dated 6/2/26 at 8:08 AM identified SW #1 followed up with Resident #4 after an incident in which Resident #4 was physically aggressive toward Resident #3 causing injury. Resident #4 was provided support, evaluated by psychiatry and placed on one-to-one observation. The resident was advised to reach out to staff to resolve personal issues or concerns.The nurse's note dated 6/2/26 at 5:31 PM by RN #1 identified Resident #4 was physically aggressive toward Resident #3, causing injury. The residents were separated. Resident #4 refused vital signs and requested to be left alone following the incident. Emergency Medical Services (EMS) responded, and Resident #4 was transferred to the hospital. The nurse's note by RN #1 dated 6/3/26 at 10:46 AM identified the hospital physician reported Resident #4 was admitted to the psychiatric hospital for further evaluation and treatment where he/she currently remained.Interview with LPN #1 on 7/1/26 at 10:45 AM identified she worked with Resident #4 for three (3) years and never witnessed Resident #4 physically aggressive towards another resident. She witnessed Resident #4 physically aggressive towards a staff member one (1) time within the last year. On 6/2/26 at approximately 2:45 PM LPN #1 was at the nurse's station charting and heard Resident #4 in the resident lounge behind the nurse station talking to him/herself. She then heard Resident #3 screaming for help and saying he/she was bleeding. Resident #3 was observed on the floor and Resident #4 was standing several feet away from Resident #3. Resident #3 stated, He/she (Resident #4) punched me. Resident #4 was very agitated and kept repeating, He/she is minding my business. The psychiatric APRN was present and directed staff to administer Haldol 10 mg by mouth one time to Resident #4. LPN #1 walked Resident #4 back to his/her room, initiated one-to-one observation and waited for the police to arrive. Resident #4 was known to talk to him/herself frequently in Russian and was redirectable when staff would engage in conversation.Interview with Resident #3 on 7/1/26 at 1:20 PM identified he/she recalled being struck by Resident #4. Resident #3 identified that he/she went into the lounge to play the guitar. As he/she was about to open the guitar case Resident #4 approached Resident #3 and began screaming at him/her about playing the guitar then Resident #4 began punching him/her in the face. Resident #3 further identified his/her tooth was initially loose but was no longer loose.Interview with the DON on 7/1/26 at 2:46 PM identified based on the facility Abuse Policy, on 6/2/26, the facility failed to keep Resident #3 free from abuse when another resident struck Resident #3.Review of the facility Abuse Policy identified Residents would not be subjected to abuse by anyone.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a leave of absence, the facility failed to ensure a nurse reviewed the resident's medications and directions for use that were packaged by the pharmacy prior to giving the medications to the resident and responsible party who was leaving the facility on a leave of absence. The findings include: Resident #1's diagnoses included transient ischemic attack, cerebral infarction without residual effects, adjustment disorder with mixed anxiety and depressed mood, and atherosclerosis of the renal artery. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating Resident #1 had some memory recall deficits. The nurse's note dated 5/2/26 at 3:44 PM identified Resident #1 went on a leave of absence (LOA) with family. The pharmacy packing slip signed by the 11PM-7AM charge nurse, LPN #2, on 5/2/26 identified the following medications were received by the facility for Resident #1 to take on the leave of absence: two (2) 80 milligram (mg) tablets of atorvastatin, two (2) 25 mg tablets of Chlorthalidone, two (2) 75 mg tablets of Clopidogrel, four (4) 25 mg tablets of carvedilol, two (2) 1 mg tablets of folic acid, two (2) 90 mg tablets of Nifedipine CC, six (6) 100 mg capsules of Gabapentin, eight (8) 100 mg tablets of hydralazine, two (2) 100 mg tablets of trazodone, two (2) 50 mg tablets of sertraline, two (2) 100 mg tablets of sertraline, six (6) 15 mg tablets of buspirone, two (2) 15 mg tablets of mirtazapine, four (4) 20 milliequivalent tablets of potassium chloride extended release, and two (2) 120 mg tablets of Isosorbide Mononitrate Extended Release. The packing slip also denoted thirty (30) 175 microgram tablets of levothyroxine (used to treat hypothyroidism) for another resident, Resident #2. The nurse's note dated 5/4/26 at 1:47 PM identified Resident #1 remained on the LOA when Resident #1 was scheduled to return on 5/3/26. The note indicated a family called the facility and Resident #1 would return after 3:00 PM today. The nurse's note dated 5/4/26 at 3:31 PM identified Resident #1 returned at 3:30 PM. The Resident Grievance Report dated 5/6/26 identified Resident #1's guardian reported that when Resident #1 went home on the weekend LOA he/she observed Resident #1 was given another resident's medication along with Resident #1's. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 6/1/26 at 12:11 PM identified the pharmacy, following review, would send the appropriate amount of medication, individually packaged, directly to the facility, and the nurse signing for the medications was to reconcile the order prior to distributing the medications to the resident. LPN #1 indicated she had received the sealed bag of Resident #1's medications from the 11PM-7AM charge nurse, LPN #2, at the start of her shift on 5/2/26 and was informed it was all set. LPN #1 explained she did not open the bag containing Resident #1's medications to review the medications to ensure they were Resident #1's medications, she did not review the medications with the resident and responsible party prior to Resident #1 leaving the facility that day, she just gave them to Resident #1's responsible party as she was in the middle of giving shift report. Interview with the Director of Nursing (DON) on 6/1/26 at 12:52 PM identified the standard of practice was for the charge nurse to review the resident's medications with the resident and/or family members prior to exiting the facility for a LOA. Interview with the 11PM-7AM charge nurse, LPN #2, on 6/1/26 at 4:30 PM identified she had received an overnight medication delivery from the pharmacy that had medication for Resident #1, intended for his/her LOA. LPN #2 identified there was a long list of medications on the packing ship which listed Resident #1's name, and upon opening the bag, had realized the medications were for Resident #1's leave of absence. LPN #2 indicated she pushed the medications back into the bag, stapled the bag shut, printed on the back of the packing list Resident #1's name, LOA, and taped it to the bag for the next shift nurse to distribute. LPN #2 identified she expected the 7AM-3PM charge nurse to review Resident #1's medications and directions for use with Resident #1 and the responsible party as Resident #1 would be leaving during LPN #1's shift. LPN #2 indicated she did not reconcile the medications as Resident #1's name was the only name listed on the packing list. Review of the Discharge/Leave of Absence (Out on Pass) Medications Policy directed the nurse shall be responsible for counting all medication(s) (including controlled substances) and entering all of the information on the Out on Pass/Discharge-Release of Medication form, was responsible for obtaining the signature of the resident/responsible party on the Out on Pass/Discharge-Release of Medication form, and was to sign the Out on Pass/Discharge-Release of Medication form after obtaining the resident/responsible party signature.

Based on observation of a test tray, review of facility policy and interviews, the facility failed to ensure food items were attractive, palatable, and at an appetizing temperature. The findings include: Observation of the dietary tray line (preparation of individualized meals for each resident) on 4/9/2025 at 7:30 AM through 8:20 AM with the Dietary Manager identified the main entrée of waffles coming out of the oven slightly overlapping each other in the pan, then placed into a steamer to bring up to temperature before placed on the steam table. The appearance of the waffles was pale, appeared uncooked and were noted to be floppy. The Dietary Manager indicated s/he cannot use the type of toaster the kitchen is equipped with as it cannot accommodate frozen items, so they do not get browned. During a meeting with Resident Council members on 4/9/2025 at 1:30 PM, Resident #6, one of many residents voiced concerns they had said to the Dietary Director during Resident Council meetings, regarding food being either over or under cooked and nothing had changed. An observation and interview on 4/9/2025 at 8:45 AM of a test tray last tray on the last served breakfast unit with the Dietary Manager identified the waffle was noted at 100 degrees Fahrenheit (F). After a couple attempts to provide a higher temperature of the waffle the Dietary Manager was unsuccessful. The Dietary Manager agreed the appearance of the waffles were very pale, floppy and did not hold a temperature. She/he further indicated the waffles should come off the menu. On 4/10/2025 a test tray for surveyors to taste was provided at 12:00 PM. Two surveyors tasted the food items and observed the visual appearance, finding the main entrée of ham pale without browning on the sides or edges. However, the ham tasted like ham and was soft. Although the ham was noted at an appropriate temperature had the appearance of being undercooked and not visually appealing. The sweet potatoes were somewhat visually appealing and noted with lumps of potato with a spicy taste (allspice) that was left in the mouth and throat for several minutes after eating them. The green peas had a basic visual appearance, were soft to the bite and tasted like peas. The fruit which was not visually appealing initially was difficult to determine the type of fruit it was, having a translucent appearance with accentuated dots throughout all the fruit pieces. Some of the fruit was very hard and difficult to chew. The fruit tasted like pears, but the texture was inconsistent, varying from very soft to hard. An interview and observation with the Dietary Manager on 4/10/2025 at 2:45 PM of the pears with the Director of Dietary in the kitchen indicated the pears were canned pears and agreed the textures may be difficult for some residents secondary some hard pieces. He indicated the fruit was packed in water which might cause the fruit to become translucent and the dot areas to be accentuated. The facility policy labeled Meal Presentation/Refusal Policy indicated in part; food will be served attractively, and at a palatable temperature within the resident's prescribed dietary orders. The policy further indicated palatable food temperatures included cold foods equal to or less than 41 degreesF and hot foods equal to or greater than 135 degrees F at the point of receiving the meal.

Based on observations, review of facility documentation, facility policy and interviews for 1`of 6 residents reviewed for environment (Resident #76), the facility failed to ensure a homelike environment in resident rooms and for 1 resident (Resident #237) who utilized the resident lounge on 200-300 unit failed to ensure the home-like environment to ensure the area was free of wheelchair storage to promote easy resident access. The findings included: 1. Resident #76's diagnoses included morbid obesity and heart failure. The annual MDS assessment dated [DATE] identified Resident #76 was cognitively intact and noted it was very important for the resident to choose what clothes to wear and to take care of the resident's personal belongings. Additionally, the MDS assessment identified Resident #76 utilized a wheelchair for mobility and noted independent for upper body dressing. The resident required supervision or touching assistance for lower body dressing.The care plan revised on 1/29/2025 indicated Resident #76 was at risk for self-care performance deficit related to shortness of breath and limited mobility. Interventions included encouraging the resident to participate to the fullest extent possible in each interaction.On 4/7/2025 at 11:12 AM, an observation and interview in Resident #76's room identified a bariatric bed in a double room. The distance between the foot of the bed and the wall appeared to be less than 3 feet. Resident #76 indicated she/he was unable to wheel him/herself through the space between the wall and the foot of the bed to get to the closet. With permission from Resident #76, the closet was observed to contain hangers with four shirts, three pairs of pants, five sweaters, one comforter, and one large pink bag. The drawer under the closet contained undergarments. Resident #76 indicated she/he had spoken to the facility Administrator regarding turning his/her bed sideways several months ago but could not recall the date. The resident indicated at the time, she/he was informed the facility would require a special permit. In the meantime, Resident #76 indicated she/he keep the majority of his/her personal items outside the closet to the side of the bed for convenience, and when she/he need an item of clothing from the closet. Resident # 76 needed to ask staff for help despite being independent.On 4/10/2025 at 11:48 AM, an interview with NA#6 identified Resident #76 kept his/her clothes in boxes and the resident was independent with dressing. NA#6 indicated she was not aware the resident had difficulty getting around the room. NA#6 also indicated Resident #76 would call if she/he required assistance, such as obtaining items from the closet.On 4/10/2025 at 1:52 PM, an observation with the Director of Maintenance identified the space between the foot of the bed and the wall was 28 inches and the distance between the bed frame of Resident #76's bed to the bed frame of their roommate was 16 inches.On 4/10/2025 at 2:57 PM, an interview with the Administrator indicated she had not spoken to the resident about turning his/her bed in a different position for more room and the conversations she had with the resident was regarding placing some of her/his belongings in storage to make more space in the resident's room.2 Resident #237's diagnoses included muscle weakness, unspecified abnormalities of gait and mobility, and depression.The Resident Care plan dated 3/21/25 identified the resident has limited physical mobility. Interventions included ambulation and transfers with assist of one.The admission Minimum Data Set assessment dated [DATE] identified Resident #237 as cognitively intact and requiring partial assistance with bathing, personal hygiene and supervision with toileting.Observation on 4/8/2025 at 11:00 AM of the 200-300-unit lounge identified there were 10 wheelchairs and a crash cart in the resident lounge. Resident #237 was sitting at the table reading and stated he/she likes to go in the lounge in the early AM to read because he/she doesn't want to turn on his/her room light and wake up his/her roommate. Resident # 237 further indicated she/he cannot get into the lounge room that early because it is full of wheelchairs causing difficulty to move his/her wheelchair and get to the table.Observation on 4/9/2025 5:45 AM of the 200-300 unit resident lounge identified 18 wheelchairs, obstructing both exits and a chair obstructing the crash cart. No residents in the lounge at that time. Interview and observation made with MDS Coordinator #1 at 5:50 AM on 4/9/2025 identified wheelchairs were kept in a different room, however, with the construction taking place in that room wheelchairs are now stored in the 200-300 resident lounge. She also indicated the crash cart was blocked by a chair.In an interview and observation with the DNS verified that the chairs were stored in the room that is now under construction and that an in-service would be provided for the staff to ensure the emergency exits and the crash cart are accessible. Further she stated that if a resident wants to watch television in the early hours they can watch in their room or go to an alternate lounge off the unit. When questioned further she confirmed that the residents should be able to access the lounge on their floor. Based on observations, review of facility documentation, facility policy and interviews for 2 of 6 residents reviewed for environment (Resident #56 and #76), the facility failed to ensure a homelike environment in resident rooms andfor 1 resident ( Resident #237) who utilized the resident lounge on 200-300 unit failed to ensure the home-like environment to ensure the area was free of wheelchair storage to promote easy resident access. The findings included:1. Resident #56's diagnoses included dementia and chronic obstructive pulmonary disease. The quarterly MDS assessement dated 2/4/2025 identified Resident #56 had moderate cognitive impairment, independent with toileting and ambulation. An observation on 4/7/2025 at 1:21 PM identified four ceiling tiles in the resident's bathroom with large black and brown stains. A piece of the ceiling grid that holds the ceiling tiles in place was observed to be detached and hanging from one end. An observation and interview with the Director of Maintenance on 4/10/2025 identified the black and brown stains on the ceiling tiles may have been caused by the air vent sweating and it would take some time for the stains to attain size and color. The Director of Maintenance further indicated the ceiling tiles are observed as part of Environmental Rounds with the Infection Control Nurse and indicated Resident #56's bathroom may not have been one of the rooms observed at during the last Environmental Rounds. On 4/11/2025 at 1:00 PM, an interview with the Infection Prevention nurse (LPN#3) identified Environmental Rounds are done quarterly and two to three rooms are observed on each unit are. However, a record of which rooms were selected for observation during rounds were not maintained. A review of the facility's Environmental Rounds dated 2/13/2025 identified Environmental Rounds of resident rooms were performed. There was no indication of which resident rooms were observed/ reviewed during the rounds. The facility policy for Environmental Rounds identified rounds are to be completed quarterly and any corrective action would be completed by the supervisor or department head. 2. Resident #76's diagnoses included morbid obesity and heart failure. The annual MDS assessment dated [DATE] identified Resident #76 was cognitively intact and noted it was very important for the resident to choose what clothes to wear and to take care of the resident's personal belongings. Additionally, the MDS assessment identified Resident #76 utilized a wheelchair for mobility and noted independent for upper body dressing. The resident required supervision or touching assistance for lower body dressing. The care plan revised on 1/29/2025 indicated Resident #76 was at risk for self-care performance deficit related to shortness of breath and limited mobility. Interventions included encouraging the resident to participate to the fullest extent possible in each interaction. On 4/7/2025 at 11:12 AM, an observation and interview in Resident #76's room identified a bariatric bed in a double room. The distance between the foot of the bed and the wall appeared to be less than 3 feet. Resident #76 indicated she/he was unable to wheel him/herself through the space between the wall and the foot of the bed to get to the closet. With permission from Resident #76, the closet was observed to contain hangers with four shirts, three pairs of pants, five sweaters, one comforter, and one large pink bag. The drawer under the closet contained undergarments. Resident #76 indicated she/he had spoken to the facility Administrator regarding turning his/her bed sideways several months ago but could not recall the date. The resident indicated at the time, she/he was informed the facility would require a special permit. In the meantime, Resident #76 indicated she/he keep the majority of his/her personal items outside the closet to the side of the bed for convenience, and when she/he need an item of clothing from the closet. Resident # 76 needed to ask staff for help despite being independent. On 4/10/2025 at 11:48 AM, an interview with NA#6 identified Resident #76 kept his/her clothes in boxes and the resident was independent with dressing. NA#6 indicated she was not aware the resident had difficulty getting around the room. NA#6 also indicated Resident #76 would call if she/he required assistance, such as obtaining items from the closet. On 4/10/2025 at 1:52 PM, an observation with the Director of Maintenance identified the space between the foot of the bed and the wall was 28 inches and the distance between the bed frame of Resident #76's bed to the bed frame of their roommate was 16 inches. On 4/10/2025 at 2:57 PM, an interview with the Administrator indicated she had not spoken to the resident about turning his/her bed in a different position for more room and the conversations she had with the resident was regarding placing some of her/his belongings in storage to make more space in the resident's room. 3. Resident #237's diagnoses included muscle weakness, unspecified abnormalities of gait and mobility, and depression.The Resident Care plan dated 3/21/25 identified the resident has limited physical mobility. Interventions included ambulation and transfers with assist of one. The admission Minimum Data Set assessment dated [DATE] identified Resident #237 as cognitively intact and requiring partial assistance with bathing, personal hygiene and supervision with toileting.Observation on 4/8/2025 at 11:00 AM of the 200-300-unit lounge identified there were 10 wheelchairs and a crash cart in the resident lounge. Resident #237 was sitting at the table reading and stated he/she likes to go in the lounge in the early AM to read because he/she doesn't want to turn on his/her room light and wake up his/her roommate. Resident # 237 further indicated she/he cannot get into the lounge room that early because it is full of wheelchairs causing difficulty to move his/her wheelchair and get to the table.Observation on 4/9/2025 5:45 AM of the 200-300 unit resident lounge identified 18 wheelchairs, obstructing both exits and a chair obstructing the crash cart. No residents in the lounge at that time. Interview and observation made with MDS Coordinator #1 at 5:50 AM on 4/9/2025 identified wheelchairs were kept in a different room, however, with the construction taking place in that room wheelchairs are now stored in the 200-300 resident lounge. She also indicated the crash cart was blocked by a chair. In an interview and observation with the DNS verified that the chairs were stored in the room that is now under construction and that an in-service would be provided for the staff to ensure the emergency exits and the crash cart are accessible. Further she stated that if a resident wants to watch television in the early hours they can watch in their room or go to an alternate lounge off the unit. When questioned further she confirmed that the residents should be able to access the lounge on their floor.

Based on observations of the kitchen, facility policy and interviews, the facility failed to ensure staff items stored in the dry storage area contained name of its contents, stored open dry goods in air-tight containers, ensured syrup was stored to prevent leakage, and failed to ensure items in the freezer were labeled with content and dated. The findings included: An observation and interview on 4/07/2025 from 9:45 AM through 10:30 AM with the Dietary Director identified dry goods including a bag of powdered thickener for drinks left open to air, a box of cornstarch with a loose-fitting piece of plastic wrap surrounding the top of the box with access to its side opening, a large bag of enriched rice was loosely rolled in an attempt to close the bag, and an open box of new sugar free syrup was on its side on a shelf with one bottle leaking its contents onto the cardboard box with drops of the syrup noted on the floor. Two bags of what was identified by the Dietary Manager as unopened frozen taco meat, were in the freezer without labels or dates. The Dietary Manager indicated the items that were not sealed or closed should have been closed without access to air, the leaking sugar free syrup bottle was removed and discarded, and the frozen taco meat was placed in a box located in the freezer area that had the name of its contents and dated. The Dietary Manager was unsure why the bags were out of the original box. The facility policy labeled Food Storage indicated in part; all dry storage items are required to have a date in which the product is delivered or the manufacturer's best by date and opened food items need to be labeled to maintain an expiration date or use by dating system.

Based on clinical record review, observations, facility policy and staff interview for one sampled resident ( Resident # 97), the facility failed to follow physician's orders regarding the application of hand splints as directed. The findings include: Resident #97's diagnosis included contracture of muscles, multiple sites. The physician's orders dated 7/28/2024 directed to check skin before and after application of the left-hand Orthotic and to apply the left-hand orthotic with HS (bedtime care) care and with AM(morning) care. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] indicated Resident #97 had severe cognitive impairment. The care plan dated 3/10/2025 indicated Resident #97 utilized splints. Intervention included : to check skin before and after application of the left-hand orthotic, to apply with bedtime (HS) care and remove with morning(AM) care. An observation on 4/07/25 at 12:00 PM identifed Resident #97 sleeping in bed covered up with the exception of her/his feet. On the bed side table were multiple splints in a wall mounted basket with laminated instructions to use splints to feet, left elbow and left hand. A physician's order dated 4/08/2025 directed patient will tolerate left elbow extension splint to be donned with AM care and doff with PM care with skin checks performed before and after. On 4/08/2025 at 12:20 PM an observation and interview with the Regional Therapy Director identified Resident #97 up in an adaptive wheelchair wearing an elbow splint and the left hand was flexed downward from the wrist. The Regional Therapy Director identified the hand splint is worn overnight as the elbow and hand splint cannot be worn at the same time. An interview and record review with the Director of Nursing Services(DNS) on 4/9/2025 at 11:21 AM identified it is the nurse aide's responsibility to apply splints, and the charge nurse signs off in the Kardex after verifying splints have been applied. On 4/9/2025 at 5:45 AM an interview and record review with NA#9 ( regular nurse aide on the unit) identified she/he was training a new employee and indicated Resident #97 have had issue with the left hand and did not wear any splints. NA#9 hand wrote the assignment on a roster sheet since there were no assignments left in the book and gave the sheet to the new employee to reference the next time working on the assignment. The Roster made no indication of any splints to be utilized for Resident #97 or any other resident. NA#9 identified charting is done electronically which tells nurse aides what care to provide for a resident and to sign off the task. However, the documentation page made no mention of splints. NA#9 further indicated there was no mention of splints for any other resident in her electronic charting assignment. On 4/09/2025 at 11:20 AM an interview and observation with the DNS, Regional RN#2 and the Regional Therapy Director were updated regarding Resident #97 not having his/her left-hand splint in place this morning at 5:30 AM and the nurse aide assigned to the resident on the 11:00 PM-7:00 AM shift indicating Resident #97 did not wear splints. The DNS, reviewing the clinical record, indicated a physician's order was present to apply a left-hand splint with HS (bedtime) care and to remove with AM (morning) care(7-3 PM shift). The Regional RN #2 indicated she and the DNS had been working diligently with the Regional Therapy Director regarding splints, placing pictures of the splints inside the closet doors as well as laminated directions for all residents. RN #2 further indicated they were working to get the physician's orders into the facility software and indicated they would educate the Nurse Aide on the 11:00 PM-7:00AM (11-7 AM) shift. Further review of the clinical record for the 11-7 AM shift for the charge nurse electronic documentation identified no mention Resident #97 wearing a splint overnight, which would have alerted the charge nurse to check to the physician's orders to ensure the application of the splits at HS on Resident # 97 to prevent further contracture. After the surveyor inquiry, the Regional Therapy Director indicated Resident #97's left hand remained unchanged from previous evaluations and there was no need to evaluate the hand at this time. On 4/9/2025 at 11:45 AM an interview with the 3:00PM -11:00 PM nurse( LPN #8) who worked 4/8/2025, indicated the nurse aide applied the splint at around 8:30 PM when providing care to Resident #97. She/he also indicated the splint was on Resident #97's left hand. The facility policy labeled Splints, dated 9/18/2024, indicated splints are applied per the physician orders and the order would include the extremity to be applied and a schedule for use (time on-off).

Based on review of the clinical record, facility documentation, review of facility policy and interviews for 1 sampled resident ( Resident # 57), who received specialized treatment services, the facility failed to ensure staff was knew the location of the emergency kit and the facility failed to obtain physician's orders for vital signs, weight monitoring and evaluation of specialized treatment site and failed to maintained the specialized treatment communication book. The findings included: Resident #57's diagnosis includes end stage renal disease. A physician's order dated 7/28/2024 directed: dialysis site and central venous catheter. A physician's order dated 7 /28/2024 directed not use the access arm to take blood samples, administer intravenous fluids, give injections or to take blood pressure every shift. A physician's order dated 7/28/2024 directed if bleeding occurs from the Access site (post dialysis) apply pressure to the insertion site, call the physician, and call 911 as needed. A physician's order dated 7/28/2024 directed to keep the emergency kit nearby every shift. A physician's order dated 7/28/2024 directed to check site for bleeding and signs or symptoms of infection every shift. The admission nursing assessment note dated 1/8/2025 indicated Resident #57 was admitted with specialized treatment port in the left chest. A physician's order dated 2/14/2025 directed to monitor the left upper arm wound site for signs of infection and swelling, to keep the dressing in place and do not remove until seen by the surgeon. If bleeding occurs reinforce the dressing and notify the supervisor. A physician's order dated 3/05/2025 directed to cleanse the left arm surgical site with normal saline and apply a dry protective dressing daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57's cognitive status was not assessed and the resident had received specialized treatment. The care plan dated 3/31/2025 indicated Resident #57 needed Hemodialysis related to renal failure and noted specialized treatment device access located in the left chest. Interventions included in part; to change the dressing daily at the access site and document, do not draw blood or take blood pressure in arm with graft, monitor for signs of infection to the access site. a.An observation and interview on 4/10/2025 at 11:55 AM with LPN #6 identified part of the care provided for Resident #57 was to check for bruit and thrill of the left arm fistula, nothing was done for the catheter in the chest and an emergency kit was located in the resident's room. Although LPN #6 was unable to locate an emergency kit in Resident #57's room including the bedside stand, the surveyor asked what the clear plastic bag on the bulletin board was and LPN #6 indicated the bag contained a rolled gauze and a dressing. LPN #6 indicated s/he would use a dressing to the left arm access site if bleeding occurred but was unsure how to stop the Permcath (central line) from bleeding. On 4/10/25 at 01:25 PM an interview and record review was conducted with the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS), the Administrator and Regional RN #2. The DNS and RN #2 indicated Resident #57 had an arm fistula and a central line catheter (Permcath). The DNS indicated dialysis was using the Permcath for specialized treatment access as the AV- fistula was surgically placed in February 2025. The DNS indicated s/he would expect the nurses to check the Permcath for signs of bleeding and infection and have the emergency pack available with a clamp and gauze. The DNS further indicated the clamp would be used to clamp off the Permcath if it started to bleed. Although the emergency kit in Resident #57's room did not include a clamp, the ADNS verbalized conducting rounds weekly and noting a black bag labeled with the resident's name was on the wall but not label of the bag did not indicate contents. On 4/10/25 at 1:45 PM the ADNS indicated the black emergency bag was found in the bedside stand but usually kept on the wall and had no label with contents. The DNS also indicated the bag could be mistaken for personal items of Resident #57. The ADNS further indicated a need to clearly label emergency items and have a consistent location for the kit and provided verbal education for LPN #6. b.On 4/11/2025 at 10:15 AM an interview and record review and facility policy review with the DNS, the ADNS, Regional RN#2, and LPN #3 (the Infection Preventionist) identified vital signs including weight were required to be taken and documented prior to leaving for a specialized treatment appointment. Upon review of the clinical record identified vital signs including weights were not documented in the clinical record on specialized treatment days and the facility was unable to provide a copy of the facility communication sheets containing facility information sent with the resident to the specialized appointments from 4/01/2025 through 04/10/2025. Documentation of the evaluation of the access site upon return from specialized treatment center did not include the access site used (the Permcath, central venous catheter). The DNS indicated the physician orders flow into the electronic Medication Administration Record (MAR) and the Treatment Administration Record (TAR) where the nurse would be made aware of the care needed to be provided and sign off if it was or was not completed. The DNS further indicated documentation should also be completed in the specialized treatment communication book, the progress notes, and the vital signs and weight tabs. However, there was no physician's order to obtain vital signs and weight prior to specialized treatment or the evaluation of the access site after specialized treatment were found, leaving licensed nursing staff without the benefit of a prompt to complete the needed tasks as required by the facility policy for a resident who received specialized treatment. While reviewing the physician's orders there was no indication of the name of the access sites, and location of the AV Fistula were found and the physician's orders only indicated the access site not distinguishing between the two separate access sites Resident #57 had or physician's orders for care and evaluation of the two separate sites. Further review of the facility policies, Hemodialysis and Hemodialysis-Care of the Access Site only mentioned 3 types of Access sites: AV Fistula, a graft or shunt. Neither policy contained the use of a Permcath for specialized treatment along with the care needed to be provided by the facility staff. Review of the care plan noted Resident #57 had a Permcath. Intervention indicated to change the dressing daily without clearance from the specialized treatment physician or an physician's order to do so. Regional( RN #2) indicated the facility would review and update the policies and orders as necessary. The facility labeled Hemodialysis reviewed 6/19/2024 indicated in part notes the dialysis communication form would be utilized each time a resident is to receive a dialysis treatment documenting the resident's blood pressure, pulse, respirations, temperature and weight before leaving for the treatment. The policy further indicated upon return of the resident from the dialysis center the communication form would be reviewed for any new recommendations and licensed staff were directed to evaluate the resident upon return from their treatment to include an evaluation of their access site. The facility policy labeled Hemodialysis- Care of the Access Site reviewed 6/19/2024, indicated in part to determine the type of access site the resident has: A-V Fistula, A-V graft, or AV-shunt, to report any signs of infection, bruit and thrill of the fistula, signs of swelling in the distal part of the extremity with the fistula, changes in circulation sensation and functional mobility of the extremity and if the shunt fistula or graft ruptures or bleeds to apply pressure call 911 and if the access site is an external shunt, to use serrated clamps to the ruptured shunt. Neither policy contains how to care for a Permcath(central line) used for dialysis treatment or what to do in an emergency.

Based on observations, review of facility policy and staff interviews, the facility failed to consistently implement their smoking policy regarding appropriate disposal of smoking materials. The findings include: On 4/9/2025 at 10:19 AM observation of supervised smoking of residents with NA#5. Four residents participated in supervised smoking. There were four black cigarette disposal containers. On 4/9/2025 at 10:30 AM, after the smoking session had ended, an observation was made with NA#5 of the smoking area. The observation identified three cigarette butts on the concrete smoking patio by the door and next to a disposal container. Four additional cigarette butts were noted scattered along the remainder of the concrete smoking patio near the building. Additionally, over 50 cigarette butts were observed on the pathways of the courtyard and on gravel flower beds next to the building. On the gravel beds, there were green leafy plants and brown dried leaves. An interview with NA#5 indicated she did not know why there were cigarette butts scattered in the patio and courtyard. NA#5 indicated that smoking supervision is rotated among nurse aides from each nursing unit. NA#5 also indicated she believed residents can smoke in the courtyard with family but would need to obtain smoking materials from the receptionist. On 4/9/2025 at 10:40 AM, an interview with the Receptionist indicated residents may not smoke with family unless they are going on leave of absence. Residents on leave of absence are required to leave the building and not use the courtyard for smoking. The Receptionist further indicated visitors would not smoke in the courtyard because she can see them through video surveillance. An observation with the Receptionist of the video screens identified the smoking patio visible but the rest of the courtyard was not. On 4/9/2025 at 11:00 AM, an observation was made of housekeeping cleaning the concrete smoking patio. An interview with the Director of Housekeeping indicated the housekeeping staff cleans the patio daily and there are not usually a lot of cigarette butts. On 4/9/2025 at 11:15 AM, an observation and interview with the Administrator identified the cigarette butts on the concrete smoking patio had been cleaned. However, the cigarette butts in the gravel beds and the courtyard pathway were still there. The Administrator indicated the smoking patio should be cleaned every day and she/he could not explain why the cigarette buts had been on the patio and the gravel beds of the courtyard. Additionally, the Administrator indicated staff were not allowed to use the courtyard for smoking. The facility policy for smoking given during the survey identified safety standards for resident smoking including smoking materials must be extinguished safely.

Based on observations of the environment and interviews, the facility failed to ensure emergency exits and an emergency response cart were readily accessible in a resident lounge. The findings include. An observation on 4/9/2025 at 5:45 AM of the [NAME] Webster lounge located behind the nurse's station was seen with 18 wheelchairs lined up in rows obstructing the access to emergency exit doors and a standard chair and a charging electric wheelchair obstructing ease of access to the facility emergency response cart. On 4/9/2025 at 5:50 AM an observation and interview of the [NAME] Webster lounge behind the nurse's station with RN #3 indicated the room the wheelchairs used to be kept in was now under construction and staff are keeping the wheelchairs in this lounge overnight. RN # 3 further verbalized the wheelchairs should not be in front of the emergency exit or the emergency cart. After surveyor inquiry, RN # 3 indicated she/he would rearrange wheelchairs and chairs at this time and will educate the staff. On 4/9/25 at 6:50 AM an observation and interview with the Administrator who was provided with pictures of the lounge with wheelchairs and chairs obstructing the emergency exit and the emergency cart and made aware of the interview with RN #3 earlier that she/he would rearrange the wheelchairs and chairs and educate staff. The Administrator indicated the wheelchairs used to be in a room that is under construction but there is another room next to the conference room where the wheelchairs should have been stored overnight. The Administrator indicated after being asked about resident access and use of the lounge overnight in the case residents wanted to use the lounge, the Administrator indicated residents should have access to the lounge on their unit. On 4/9/25 at 08:07 AM an interview with the Administrator indicated the facility plan to in-service staff to bring the wheelchairs to the storage room next to the conference room, however some chairs may need to remain in the lounge overnight without obstructing the emergency exits, the emergency cart or resident access to the television or use of the lounge overnight.

Based on clinical record review, observation, facility policy review and staff interviews for the only resident reviewed for ADL (Resident # 77), the facility failed to ensure the resident who utilized an anticoagulant was assessed for change in condition when the resident was cut by a razor. The findings include:Resident #77's diagnoses included vascular dementia, cerebral infarction, long term (current) use of anticoagulants.The Resident Care plan dated 2/11/25 identified the resident was on an anticoagulant and at risk for bleeding. Interventions included staff reporting any bruising or bleeding from gums, nose, mouth or with bowel movements.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #77 as severely cognitively impaired, and required total assistance for bathing, personal hygiene and ADL.Observation on 4/7/25 at 11:30 AM identified Resident # 77 had a cut on the right side of his/her face with a small amount of blood. It appeared to be a razor cut. Interview with Nurse Aide ( NA#1) on 4/7/25 at 11:30 AM identified she was shaving the resident with a disposable razor and cut him/her as she/he was resisting. NA #1 further stated she/he Resident # 77 was resistive to care, and she told the nurse about the resident.A telephone interview on 4/10/2025 with Licensed Practical Nurse ( LPN #2) at 12:15 PM identified she was the agency nurse on unit 2 on Monday 4/7/25. She identified NA#1 told her that Resident # 77 was bleeding from a razor cut. When asked her what she did about it, LPN # 2 stated she gave NA#1 an alcohol pad because she asked for it. When asked if she assessed Resident # 77 after the cut she stated no, she was too busy, and she was running late. When asked what she would normally do if a resident had a change in condition, she identified she would write a note. However, she did not write a note on Resident #77 because she was too busy. Further questioning of the incident identified LPN 3 2 did not know Resident # 77 was on an anticoagulant and indicated she would not normally review the record to determine if a resident was on an anticoagulant even if the resident was bleeding. When asked what she would do if a resident was bleeding from his/her gums, or a cut or anywhere, LPN # 2 stated she would write a note, but she would not review the record.On 4/10/25 at 12:25 PM an telephone interview with LPN#2 in the presence of Regional Nurse #1 and the Director of Nursing Services ( DNS) identified the facility expectation would be for the nurse to assess any change in condition with a resident. They also identified agency nurses complete an on-line orientation prior to reporting to work.On 4/11/25 an interview with NA #1 to clarify what actions were related to the razor cut. NA #1 stated she cleaned the area around the cut with the alcohol pad the nurse gave her and then applied A&D ointment around the cut. NA 31 further LPN #2 nurse on duty did not give her any direction, however from previous experiences she knew to hold pressure on the area until the bleeding stopped.Review of the Anticoagulation Therapy policy dated 3/20/24, directed in part the resident should be observed for any possible signs of bleeding, including hematuria, hemoptysis, bleeding gums, epistaxis, bruising, dark/tarry stools. Additionally, the policy directed to notify the practitioner of the findings as soon as possible.Review of the Physician Notification-Change of Condition policy dated 6/10/24, in effect at time of survey, directed in part, a change in condition is a significant clinical symptom(s) or development, which requires assessment and intervention.

Based on review of the clinical record reviews, facility policy and interviews for 3 of 3 residents (Residents #12) reviewed for care planning and (Resident # 36 and Resident # 79) reviewed for restraints, the facility failed to hold quarterly care planning meetings. The findings included: 1. Resident #12 's diagnoses included hypertensive heart disease, chronic kidney disease, and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 as cognitively intact and dependent for personal hygiene, bathing, and Activities of Daily Living (ADL). The Resident Care Plan (RCP) with a revision date of 2/13/25 identified the resident had an ADL self-care performance deficit. Interventions included to assist with personal care and ADL. Interview with Resident #12 on 4/7/2025 during the screening process identified he/she has not been involved in a care planning meeting in a long time. Resident #12 was unable to quantify specifically what the time frame was. A physician's order dated 4/10/25 directed to provide care as outlined in the care plan. Resident Care conference documentation for 5/1/24 and 8/15/24 were present in the record. No further care conferences were documented in Resident # 12's record for 2024 and 2025. 2. Resident #36's diagnoses included Gastrointestinal Hemorrhage, dysphagia, and hemiplegia. The Resident Care Plan with a revision date of 1/27/25 identified the resident required tube feedings. Interventions included monthly evaluations by the Registered Dietician. The annual Minimum Data Set assessment dated [DATE] identified Resident #36 as cognitively impaired and dependent for all personal care and ADL. Resident Care Conference documentation for 5/22/25 and 8/7/24 were present in the record. However, no further care conferences were documented in Resident # 36's record for 2024 and 2025. 3. Resident #79's diagnoses included Hereditary Spastic Paraplegia, depression, and dysphagia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #79 as cognitively impaired and dependent for personal hygiene and ADL. The Resident Care Plan with a revision date of 2/3/25 identified the resident required tube feedings. Interventions included monthly evaluations by the Registered Dietician. Resident Care Conference documentation for 5/15/24, 7/17/24, and 2/24/25 were present in the resident record. However, no further care conferences were documented Resident # 79's record for 2024 and 2025. In an interview with Regional Nurse #1 on 4/9/2025 at 10:00 AM identified care conferences should be held quarterly, after the quarterly MDS is completed. Regional Nurse # 1 also stated that the MDS staff schedules the meetings. She was unsure why the meetings hadn't occurred for the residents and indicated the facility had a change in social workers which could be the reason. Review of the Care Plan Policy dated 4/17/24, currently in effect, directed in part, Resident Care Conference is held within 7 days of completion of the admission MDS, at least quarterly, annually, and when a significant change in status assessment when needed.

Based on observations, review of facility documents, facility policy and interviews, the facility failed to act promptly on residents' grievance and ensure grievance forms were within reach of residents who utilized a wheelchair. The findings include: Review of Residents Council 3/26/25 minutes indicated Grievance forms run out on resident units. The residents stated we would like staff to introduce themselves and explain the grievance process to residents. On 4/9/25 at 1:30 PM a meeting was held during Resident Council. during the meeting residents expressed their concerns that grievances and recommendations were not responded to timely. Resident# 6 and Resident #76 identified prior to attending Resident Council meeting the forms were still not replenished. Observation on 4/9/25 at 2:11 PM on units 5 and 6 identified the forms were not replenished. Resident #6 pointed out information related to how to fill out grievance was out of reach for residents who are wheelchair bound. Observation on 4/9/25 at 3:43 PM identified the grievance form being replenished. Interview with Regional Director of Behavioral Health on 4/11/25 at 11:53 AM identified the replacement of grievance forms is an collective process for all social work staff. She also reported staff should be replacing the forms when empty. Facilities Resident Grievances policy (reviewed on 1/26/24) indicated in part Facility residents have the right to have prompt effort made by the facility to attempt to resolve grievances. The facility will make prompt efforts to attempt to resolve grievances within 7 business days.

Based on review of clinical records, review of facility documentation, review of facility policy and interviews for two 2 of 2 sample residents (Resident #6 and Resident #51), reviewed for personal funds, the facility failed to provide quarterly statements for personal funds account. The findings include: 1. Resident #51's diagnoses that included chronic kidney disease stage 3, hypertensive heart disease with heart failure, depression, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 as severely cognitively impaired, dependent (required assistance of 2 or more helpers) with toileting hygiene, lower body dressing, personal hygiene and chair and shower transfers. The assessment further identified Resident #51 was non-ambulatory and utilized a wheelchair for mobility. Interview with Person #3 on 4/8/25 at 9:11 AM identified quarterly statements for personal funds account were not provided to them by the facility. Further, Person #3 indicated that he/she has never received a quarterly statement for personal funds account and did not realize that they should have received one. 2. Resident #6's diagnoses included chronic kidney disease stage 3, hypertensive heart disease with heart failure, peripheral vascular disease, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #6 as cognitively intact, dependent on care with toileting hygiene, putting on and taking off footwear, and required maximal assistance with shower, lower body dressing, and chair and shower transfers. The assessment further identified Resident #6 was non-ambulatory and utilized a wheelchair for mobility. Interview with Resident #6 on 4/7/25 at 12:08 PM identified he/she does have the personal funds the facility manages and has not received any quarterly statements since he/she has been at the facility. Interview with the Business Office Manager on 4/8/25 at 1:47 PM identified she is responsible for mailing quarterly statements for personal funds to the parties responsible and the Recreation Department delivers to residents in the facility. The Business Office Manager was unable to provide evidence or verification that quarterly statements for personal funds were mailed out or printed and/ or given to the Recreation Department for delivery to residents. She indicated that she would develop a process to ensure residents receive quarterly statements. On 4/8/25 at 3:30 PM, after surveyor inquiry, the Business Office Manager initiated the mailing of personal funds quarterly statements, printing and the delivery to residents in the facility. Review of the facility's Resident Trust Policy dated 01/11/2019 indicated the facility will provide residents and responsible parties with a quarterly accounting of their individual accounts and quarterly statements are printed and sent to the family/responsible party at the end of every quarter. (March, June, September, December of the year).

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to report an allegation of abuse to the State Agency when the incident was reported to the facility pending the investigation. The findings include: Resident #1's diagnoses included Cerebral palsy, anxiety, depression, and disruptive mood disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was independent with ambulating, transferring, and required set up for dressing and eating. The Resident Care Plan dated 10/31/24 identified observe for signs of anxiety. Interventions directed at identifying triggers, approach calmly, encourage diversional activities. The nurse's note dated 10/24/24 at 8:59 PM identified Resident #1 was transferred to the hospital after he/she became very verbally and physically aggressive towards other residents, staff, and a family member. Correspondence to the facility dated 11/14/24 at 8:25 AM identified an accusation of verbal staff abuse on 10/24/24. The documentation identified information was reported that a nurse aide went through the hallway towards the front desk verbalizing if you don't get him/ her the f**k out of here I'm going to leave. The information indicated several residents, visitors, and staff had witnessed this unprofessional behavior. A Reportable Event had not been submitted to the state agency as per policy. In an interview with the Director of Nursing (DON) on 12/19/24 at 10:00 AM identified on 11/13/24 she was made aware of the alleged staff to resident verbal abuse following the incident with Resident #1 on 10/24/24. The DON stated she investigated the allegation with statements and could not substantiate the allegation, and therefore did not report the incident as per policy. Review of the abuse policy dated 3/20/24 identified all allegations of abuse will be reported promptly and thoroughly investigated.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to provide evidence that three (3) allegations of abuse were investigated. The findings include: Resident #1's diagnoses included traumatic subarachnoid hemorrhage (a head injury that causes bleeding in the space between the brain and the thin tissues that cover it), traumatic brain injury, muscle contractures, urinary incontinence, need for assistance with personal care, muscle weakness, cognitive communication deficit, gastrostomy (a surgical procedure that creates an opening in the abdomen into the stomach providing a route for nutritional support/feeding tube), insomnia (difficulty sleeping), depression and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to be assessed for the Brief Mental Interview for Mental Status (BIMS) however, exhibited both short-term and long-term memory problems, was severely cognitively impaired and required maximum assistance with bed mobility and was dependent on staff for transfers and toileting hygiene. The Resident Care Plan (RCP) dated 1/17/24 identified that Resident #1 is incontinent of bladder and bowel with interventions that included providing incontinent care as needed, checking skin during incontinent care for signs of redness, maceration or irritation and applying barrier cream as needed and providing the resident with an adult brief. a. Review of facility grievance dated 3/7/24 identified that per a visitor, there had been two (2) occasions where there had been urine under the area where Resident #1 sits, but did not identify the dates or time of day that these observations had been made. The grievance form identified that a statement had been collected from the 7:00 AM to 3:00 PM primary NA (NA #11) and the resident had been identified as being a heavy and frequent wetter with urinary incontinence. It identified that education and reminders were provided to all shifts on ensuring that the resident is changed on both rounds, as well as changed last on the 7:00 AM to 3:00 PM shift and first on the 3:00 PM to 11:00 PM shift. Review of NA #11's statement dated 3/8/24 at 2:00 PM identified that when she takes care of Resident #1, he/she is incontinent of a large amount of urine, so she always changes him/her at 2:00 PM before the end of shift because she knows that he/she will be wet. The statement reported that she never checks the wheelchair to see if it's wet and assumes that it's dry because he/she is changed on both rounds. Review of facility sign-in dated 3/8/24 identified that staff was educated that when residents are in a wheelchair they should be turned and positioned every two (2) hours, as well as toileted on both rounds. Interview with the DNS on 11/18/24 at 3:17 PM identified that there was no facility Accident & Investigation (A & I) associated with the 3/7/24 grievance on Resident #1, stating that she did not believe it was an allegation of abuse/neglect, as incontinence was expected with Resident #1. She reported that although she obtained a statement from the NA that was on duty when the complaint was made (NA #11), she did not ask NA #11 when Resident #1 had last received incontinent care before the allegation. Additionally, she identified that she was unsure the date when the first observation was made by the visitor and did not obtain any additional statements, reporting that the grievance should have been more detailed. b. Review of Department of Public Health Facility Licensing & Investigations Section Complaint Submission dated 10/23/24 identified that Person #1 emailed Administrator #2 (prior Administrator) on 6/6/24 regarding an incident on 6/1/24, where Resident #1 was found laying in his/her own feces and the lack of attention a family member received when they requested assistance with Resident #1. Review of the email from Person #1 to Administrator #2 dated 6/6/24 identified, in part, that on 6/1/24 at approximately 12:00 PM, another family member went to visit Resident #1 and found him/her laying in his/her own feces and despite the family member's repeated attempts to seek assistance from the attending aide, his/her pleas were met with indifference and neglect. Person #1 requested that Administrator #1 conduct a thorough investigation into the neglectful incident on 6/1/24. Review of the facility grievance dated 6/7/24 identified that the Conservator of Person (Person #1) expressed concerns of care over the weekend. The grievance form identified that the NA, charge nurse and nurse supervisor were interviewed and reported that Resident #1 had been incontinent of bowel and the NA had been gathering supplies to provide care when the family came in. It reported that the resident's room was changed back to station 5 per Person #1's request. Review of the facility census identified that Resident #1's room was changed on 6/7/24. Review of LPN #7's statement dated 6/7/24 identified that she was in Resident #1's room about to administer his/her bolus nutritional feeding when she noticed that Resident #1 had been incontinent. She reported that she held off on the feeding so that the resident could receive care and went to notify NA #12, who was in the shower room. Review of RN #3's statement dated 6/7/24 identified, in part, that she had received a call from Person #1 regarding Resident #1, but that had been in the middle of attending to an emergent matter, so she told Person #1 she would call him/her back. RN #3 reported that when she was complete, she went down to Resident #1's unit and spoke with LPN #7 who identified that the resident had been incontinent of stool when his/her visitors came and that they had been upset but that Resident #1 had since been cleaned up and provided care. Review of NA #12's statement dated 6/10/24 identified that she had been gathering linens so that she could provide care to Resident #1, when LPN #7 walked up to her and reported that Resident #1 needed to be changed. NA #12 identified that Resident #1's family member then also walked up to her and asked if anyone was going to provide care to Resident #1 and asked why he/she had not been changed yet to which she responded that she would be doing it right then. Interview with Social Worker #1 (Director of Social Services) on 11/14/24 at 12:15 PM identified that all concerns and grievances are discussed daily in morning report, reporting that she gives both the Administrator and DNS copies of all grievances to investigate. She identified that she communicates to all residents and families the need to bring up all concerns immediately and not to wait, educating them on residents' rights. Social Worker #1 identified that both the 3/7/24 and 6/7/24 allegations related to Resident #1 could be interpreted as allegations of abuse and/or neglect and identified that both the Administrator and DNS had been notified at the time of the allegations. Interview with Administrator #2 on 11/14/24 at 1:11 PM identified that he received the email from Person #1 on 6/6/24, reporting that the allegations did not sound like neglect to him but that he forwarded it to the DNS, and she should have done an investigation. He identified that he could not recall the 3/7/24 allegation, but identified that there should have been an investigation completed. Interview with the DNS on 11/18/24 at 3:17 PM identified that there was no facility Accident & Investigation (A & I) associated with the 6/7/24 grievance on Resident #1, stating that she was aware of the allegation and did not believe it was abuse/neglect, as she interviewed the staff, and incontinence was expected with Resident #1. She reported that although the allegation should have been fully investigated, she did not ask NA #12 the last time that Resident #1 had received incontinent care prior to the allegation and did not address the allegation that the family member had made repeated attempts to seek assistance from the attending aide that were met with indifference and neglect. c. Review of Department of Public Health Facility Licensing & Investigations Section Complaint Submission dated 10/23/24 identified that during a family visit, Resident #1 was found sitting in front of a television that was off, and it was also reported to Person #1 (does not identify who the reporter was) that Resident #1 was in bed all day on 10/19/24. Review of the grievance book failed to identify the 10/19/24 or 10/20/24 allegations. Interview with Social Worker #1 on 11/14/24 at 3:01 PM identified that she received an email from Person #1 on 10/21/24 alleging that on 10/19/24, Resident #1 was laying in bed all day without a television and on 10/20/24, Resident #1 was found sitting in front of a television that was turned off. She identified that she spoke with Person #1 and communicated that family is responsible for providing a television for the resident, if desired for long term care residents and Person #1 reported that she was unaware and agreed. She reported that she noticed that the email from Person #1 included a previous Administrator that had not worked at the facility for a long time, so she notified and forwarded the email to the current Administrator but reported that she did not make it a grievance because she thought the Administrator was handling it. Interview with the Administrator on 11/14/24 at 3:33 PM identified that she received the email from Person #1 regarding the 10/19/24 and 10/20/24 allegations and reported that the DNS stated that it wasn't possible that Resident #1 was kept in bed all day. She identified that although an investigation was not done and statements were not obtained on the allegations, she stated that she thought they were written up as a grievance and was unsure why they were not. Interview with the DNS on 11/14/24 at 3:44 PM identified that there was no facility Accident & Investigation (A & I) associated with the 10/19/24 or 10/20/24 allegations, stating that she was aware of the allegations but that it was impossible that Resident #1 stayed in bed all day, as he/she is a fall risk and tries to crawl out of bed. She reported that she spoke with the staff, but was unable to provide statements or documentation that an investigation was completed. Review of the facility schedule dated 10/19/24 identified that LPN #2, NA #7 and NA #6 were assigned to Resident #1 on the 7:00 AM to 3:00 PM shift and LPN #1, NA #3 and NA #4 were assigned to Resident #1 on the 3:00 PM to 11:00 PM shift. Interview with NA #6 on 11/18/24 at 1:09 PM identified that she has never placed Resident #1 in front of a television or seen Resident #1 in front of a television that was turned off. She reported that although she could not recall the details of 10/19/24, Resident #1 is usually up out of bed for the day around 10:00 AM and only goes back to bed for care and then gets back up to the wheelchair. She identified that she has never observed Resident #1 in bed the entire shift. Although attempted, interviews with Person #1, LPN #1, LPN #2, NA #3, NA #4 and NA #7 were not obtained. Review of the grievance policy identified that any allegations regarding abuse or neglect will be immediarely reported to the Administrator or designated manager. Review of the Abuse CT policy dated 3/20/24 directed, in part, that allegations of abuse will be reported promptly and thoroughly investigated. An investigation of the witnessed or alleged abusive action or neglect will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or designee to initiate the investigation.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to ensure that two (2) allegations of abuse/neglect were reported immediately to the State Agency as required. The findings include: Resident #1's diagnoses included traumatic subarachnoid hemorrhage (a head injury that causes bleeding in the space between the brain and the thin tissues that cover it), traumatic brain injury, muscle contractures, urinary incontinence, need for assistance with personal care, muscle weakness, cognitive communication deficit, gastrostomy (a surgical procedure that creates an opening in the abdomen into the stomach providing a route for nutritional support/feeding tube), insomnia (difficulty sleeping), depression and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to be assessed for the Brief Mental Interview for Mental Status (BIMS) but exhibited both short-term and long-term memory problems, was severely cognitively impaired and required maximum assistance with bed mobility and was dependent on staff for transfers and toileting hygiene. The Resident Care Plan (RCP) dated 1/17/24 identified that Resident #1 is incontinent of bladder and bowel. Interventions included providing incontinent care as needed, checking skin during incontinent care for signs of redness, maceration or irritation and applying barrier cream as needed and providing the resident with an adult brief. a. Review of facility grievance dated 3/7/24 identified that per a visitor, there had been two (2) occasions where there had been urine under the area where Resident #1 sits, but did not identify the dates or time of day that these observations had been made. The grievance form identified that a statement had been collected from the 7:00 AM to 3:00 PM primary NA (NA #11) and the resident had been identified as being a heavy and frequent wetter with urinary incontinence. It identified that education and reminders were provided to all shifts on ensuring that the resident is changed on both rounds, as well as changed last on the 7:00 AM to 3:00 PM shift and first on the 3:00 PM to 11:00 PM shift. b. Review of Department of Public Health Facility Licensing & Investigations Section Complaint Submission dated 10/23/24 identified that Person #1 emailed Administrator #2 (prior Administrator) on 6/6/24 regarding an incident on 6/1/24, where Resident #1 was found laying in his/her own feces and the lack of attention a family member received when they requested assistance with Resident #1. Review of the email from Person #1 to Administrator #2 dated 6/6/24 identified, in part, that on 6/1/24 at approximately 12:00 PM, another family member went to visit Resident #1 and found him/her laying in his/her own feces and despite the family member's repeated attempts to seek assistance from the attending aide, his/her pleas were met with indifference and neglect. Person #1 requested that Administrator #1 conduct a thorough investigation into the neglectful incident on 6/1/24. Review of the facility grievance dated 6/7/24 identified that the Conservator of Person (Person #1) expressed concerns of care over the weekend. The grievance form identified that the NA, charge nurse and nurse supervisor were interviewed and reported that Resident #1 had been incontinent of bowel and the NA had been gathering supplies to provide care when the family came in. It reported that the resident's room was changed back to station 5 per Person #1's request. Interview with Social Worker #1 (Director of Social Services) on 11/14/24 at 12:15 PM identified that all concerns and grievances are discussed daily in morning report, reporting that she gives both the Administrator and DNS copies of all grievances to investigate, and they decide what is reportable to the State Agency. She identified that she communicates to all residents and families the need to bring up all concerns immediately and not to wait, educating them on residents' rights. Social Worker #1 identified that both the 3/7/24 and 6/7/24 allegations could be interpreted as allegations of abuse and/or neglect and identified that both the Administrator and DNS had been notified at the time of the allegations. Interview with Administrator #2 on 11/14/24 at 1:11 PM identified that he received the email from Person #1 on 6/6/24, reporting that the allegations did not sound like neglect, so it was not reported to the State Agency. He identified that he could not recall the 3/7/24 allegation but identified that the allegation wasn't necessarily a reportable incident, as the resident was incontinent. Interview with the DNS on 11/18/24 at 3:17 PM identified that although she was aware that allegations of abuse and/or neglect are to be reported to the State Agency and then investigated, she reported that she did not substantiate either the 3/7/24 or 6/7/24 allegations of abuse/neglect, as incontinence was expected with Resident #1, therefore they did not report either the 3/7/24 or 6/7/24 allegations. Review of the Abuse CT policy dated 3/20/24 directed, in part, that allegations of abuse will be reported promptly and thoroughly investigated. Allegations of abuse or neglect are to be reported to the Department of Public Health immediately but not later than two (2) hours after the allegation is made if the allegations involve abuse. An investigation of the witnessed or alleged abusive action or neglect will be initiated within 24 hours of its discovery. It is the responsibility of the facility Administrator or designee to initiate the investigation.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #12) reviewed for accidents, the facility failed to ensure the responsible party was notified timely of a change in condition. The findings include: Review of the admission assessment dated [DATE], identified Resident #12 was admitted to the facility during 2/2024 with an admission diagnosis of a fall with a subdural hematoma and had intermittent confusion. The note further identified Resident #1 had an intact head laceration with seven (7) staples, a laceration to the right forearm, and multiple bruising noted over his/her body. The nursing note dated 3/4/2024 at 5:54 AM identified Resident #12 had a fall at 3:31 AM. The note indicated that while staff were providing care to Resident #12's roommate the NA heard a sound, turned, and saw Resident #12 lying on the floor. An RN assessment was completed with no injury identified. Neurological checks and vital signs (temperature, blood pressure, pulse, and respirations) were initiated. The responsible party was called, and the phone number was incorrect. Review of facility incident report dated 3/4/2024 at 3:30 AM identified Resident #12 had an unwitnessed fall and was observed on the floor in his/her room, in a prone position (lying face down). The report indicated the responsible party was notified. Although clinical record review identified additional contact phone numbers for the responsible party, the record failed to identify additional attempts to contact the responsible party. Interview, clinical record review and facility documentation review with SW #1 on 4/2/2024 at 12:13 PM identified Resident #12's emergency contact (responsible party) had two (2) phone numbers listed in the record. Interview, clinical record review, and facility documentation review with the DNS and Regional Nurse #1 on 4/2/2024 at 12:26 PM identified after Resident #12 fell , the RN supervisor/RN #5 called Resident #12's responsible party but was unsuccessful reaching them. The DNS indicated although the clinical record listed two (2) phone numbers (and the hospital discharge paperwork listed alternate emergency contacts with phone numbers), the supervisor only called one (1) number. The DNS further indicated the second phone number should have been used to contact the responsible party, and she did not know why it was not done. Although attempted, an interview with RN #5 was not obtained during the survey. During interview and facility documentation review with the DNS on 4/2/2024 at 1:05 PM, the DNS was unable to provide documentation that staff attempted to reach the responsible party with the alternate numbers or attempted to reach alternate emergency contacts. Review of facility Physician Notification - Change of Condition Policy directed in part, the responsible party will be notified of a change in condition. Review of the facility Fall Management Program dated 10/2/2023 directed in part, to notify the family/responsible party (of a fall).

Based on clinical record review, facility documentation review, facility policy review, for one of three residents reviewed for accidents (Resident #13) the facility failed to ensure the resident was not moved after a fall without direction by the RN, and for one of three residents (Resident #13) the facility failed to ensure the resident was transferred timely after a fall with injury, and for one of three residents (Resident #14) the facility failed to ensure neurological checks were monitored timely after an unwitnessed fall. The findings include: 1. Resident #13's diagnoses included syncope, vascular dementia, history of traumatic injury and history of falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had severe cognitive impairment and required substantial/moderate assistance for ADLs. The Resident Care Plan (RCP) dated 1/3/2024 identified a risk for falls. Interventions directed to observe for decreased balance, leaning, dizziness or fatigue, and to keep call bell in reach. A nurse aide card directed assist of one (1) for transfers, out of bed to wheelchair with assist of one (1), and to ambulate with rolling walker with one (1) assist. The nursing note dated 3/24/2024 at 2:34 PM identified Resident #13 had gotten up independently and fallen in the hallway. RN #3 assessed Resident #13, Resident #13 was alert and responding, a call was placed to the on-call provider, the family was updated, and an order was obtained to call 911 and transfer Resident #13 to the hospital. A facility Reportable Event Form dated 3/24/2024 identified Resident #13 fell on [DATE] at 2:30 PM when self-ambulating. Resident #13 was observed lying on his/her back on the floor with a cut noted to the back of the head. The investigation completed by RN #3 identified Resident #13 lost his/her balance while ambulating and fell in the hallway. The physician was notified, and new orders were obtained. Interview, facility documentation and clinical record review with the DNS and NA #1 on 4/3/2024 at 11:55 AM identified she assisted LPN # 2 when Resident #13 was on the floor in the hallway across the hall and one (1) room away from Resident #13's room. NA #1 stated there were other residents in the hallway that were redirected away from the area, and another resident who had come out of his/her room. NA #1 stated that LPN #2 directed they were going to use a sheet and roll Resident #13 side to side to get the sheet under Resident #13, and then she and LPN #2 used the sheet to drag Resident #13 across the hall, to the next room down and onto the floor in his/her room. Interview, facility documentation and clinical record review with LPN #2 on 4/3/2024 at 12:36 PM identified after RN #3 assessed Resident #13 and had gone to the nursing station to make phone calls, LPN #2 made the decision to place a sheet under Resident #13 and then she and LPN #2 used the sheet to drag Resident #13 across the hall, to the next room down and into his/her room. LPN #2 stated she made the decision to drag Resident #13 across the hall and down one (1) room, back to his/her room without consulting with the RN. Interview, facility documentation and clinical record review with RN #3 on 4/3/2024 at 12:56 PM identified she did not direct LPN #2 and NA #1 to use a sheet to drag Resident #13 back to his/her room. RN #3 stated she would not have directed Resident #13 to be moved, she would not have directed staff to drag Resident #13 on the floor using a sheet, and other residents should have been redirected from the area while waiting for transportation to the hospital. Interview, facility documentation and clinical record review with the DNS and Regional Nurse #1 on 4/3/2024 at 2:47 PM identified LPN #2 made the decision to move Resident #13 using a sheet to drag him/her across the hall and down one (1) room and into his/her own room, and was not directed by the RN. Interview identified although LPN #2 made the independent decision to move of Resident #13 without consult with the RN, the DNS and Regional Nurse #1 indicated no other resident in the facility had previously been moved by dragging across the hall using a sheet, and the DNS and Regional Nurse #1 had never moved a resident who had fallen using a sheet to drag them in the hallway. No facility policy was provided for surveyor review regarding LPN independent decision to move Resident #13 after the fall. a. Review of the clinical record identified Resident #13's fall on 3/24/2024 occurred at 2:30 PM. Clinical record review failed to identify the time Resident #13 was transferred to the hospital. Review of Emergency Medical Services (EMS) run sheet identified dispatch was notified (call from the facility) at 3:30 PM (1 hour after the fall), and EMS was at the resident at 3:39 PM. The report indicated family was present and reported Resident #13 had fallen in the hall, had bleeding from the back of the head, and staff had dragged Resident #13 on a sheet into his/her room because he/she was blocking the hallway. EMS assessment identified dried blood in Resident #13's hair, Resident #13 was placed in a c-collar (cervical collar) because EMS was unable to appropriately clear the c-spine. Resident #13 was transferred to the stretcher and transported to the hospital. Additional clinical record review failed to identify why Resident #13 was not transported to the hospital until one (1) hour after the fall. Interview, clinical record review, and facility documentation review with RN #3 on 4/3/24 at 12:56 PM identified RN #3 assessed Resident #13 after the fall and identified bleeding from the top of the head. Ice was applied, and she left Resident #13 with LPN #2 while she went to call the physician. RN #3 stated she could not send Resident #13 to the hospital without a physician's order, and while Resident #13 was laying on the floor, she waited for a call back before calling 911. RN #3 was unable to provide documentation regarding the time she called the on-call service, the time the on-call service called back, how long she waited, and the time Resident #13 was transferred to the hospital. RN #3 stated she should have sent Resident #13 to the hospital immediately after the fall. Interview and clinical record with APRN #2 on 4/3/2024 at 8:25 PM identified that the on-call service received an in-bound call from the facility at 3:33 PM (one hour after the fall) on 3/24/2024. The staff member reported a resident on aspirin therapy had a fall with bleeding from the occipital (back) area of the head and the facility requested an order for transfer to the hospital. Interview, record review and facility documentation review with the DNS and Regional Nurse #1 on 4/3/24 at 2:47 PM identified the facility policy was to obtain a physician/APRN order prior to transferring a resident to the hospital. Although the interview identified the fall occurred at 2:30 PM, interview failed to identify why the resident was not transferred to the hospital until 3:39 PM. Although requested, a facility policy regarding emergency hospital transfers was not provided for surveyor review during survey. 2. Resident #14's diagnoses included alcohol abuse, and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #14 had no cognitive impairment and was independent with ADL care. The Resident Care Plan (RCP) dated 2/18/2024 identified Resident #14 was at risk for falls. Interventions directed to observe for signs and symptoms of decreased balance, leaning, dizziness, or fatigue, remind to ask for assistance, therapy eval and treat as ordered, and medication review due to anxiety. A facility incident report dated 2/24/2024 at 12:40 AM indicated Resident #14 was observed laying on the floor and had last received care at 12:35 AM. The nurse's note dated 2/24/2024 at 2:34 AM identified Resident #14 was observed laying on the floor outside the dietary entrance at 12:40 AM by a NA. Resident #14 indicated I will sleep here. Resident #14 was assisted back to his/her room, an assessment was completed and no injuries were identified. Review of facility documentation identified neurological checks were initiated on 2/24/2024 at 12:45 AM. Additional review identified two of the designated times were not completed. The space dated 2/24/2024 at 2:30 PM was blank and marked Resident sleeping. The space marked 2/25/2024 at 10:30 PM was blank. Review of the nursing notes failed to identify the neurological checks were completed on 2/24 at 2:30 PM and 2/25/2024 at 10:30 PM. Interview, facility documentation review and facility policy review with the DNS on 4/3/2024 at 10:53 AM identified neurological checks are completed after a fall as per facility policy. Interview identified the two (2) blank spaces on the neurological form for 2/24 at 2:30 PM and 2/25/2024 at 10:30 PM were not completed as per policy, and they should have been completed. The DNS was unable to locate documentation that the neurological checks were completed and was unable to explain why the checks were not completed. Review of facility Fall Management Program Policy dated 10/2/2023 directed in part, if a fall is unwitnessed or a head injury is suspected, to monitor neurological signs. Review of facility Neurological Checks Policy dated 2/12/2023 directed in part residents with suspected head injury will have neurological signs monitored and recorded for seventy-two (72) hours per policy unless otherwise ordered by a physician.

Based on review of facility policy and interview, the facility failed to develop policies and procedures that encourage the residents to exercise their rights regarding leave of absences and smoking without interference, coercion, discrimination, or reprisal from the facility. According to Appendix PP S483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. S483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. S483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Review of the Travel Pass for Leave of Absence policy, dated 11/13/2014, provided to the survey team upon request, identified it is the policy of iCARE Management that all patients will be considered for a Travel Pass for an authorized leave of absence from the facility. A physician's order will be required for consideration for a travel pass. The physician's order shall read: patient is eligible for a travel pass. The licensed nurse or social worker will complete the travel pass request form upon each request made by a patient and/or conservator who desires to leave the facility grounds on a travel pass for leisure. All patients and/or conservators will need to provide a 72-hour notice for each request to be reviewed for consideration by the interdisciplinary team. (Consideration will be given on a case-by-case basis for approval with shorter notice). Once authorized by the physician and signed by the patient and/or conservator, the request shall be honored, and a travel pass will be issued for the specified date and time. b. Upon request, the survey team was provided the current smoking policy dated 9/19/2016 and the smoking agreement dated 12/6/21. Review of the smoking policy identified the purpose was to provide a guide of action to ensure a safe smoking environment for residents who smoke. Smoking is not allowed within the facility or in other areas on facility property that are not designated as smoking areas. On admission, a facility representative will review the smoking agreement with a resident who is an active smoker or was smoking up to the time of hospitalization and/or the conservator and obtain appropriate signatures. Smoking evaluations will be [NAME] upon admission/readmission and after a significant change in a residents condition. All resident smoking at the facility is supervised by staff. In the event of a policy infraction, each residents individual needs/capabilities will be taken into account to determine the most appropriate revision to the residents plan of care/course of action. Corrective actions to promote and ensure safety will be applied by the facility in a progressive manner based on an evaluation of the severity of the infraction and the residents needs. Examples of interventions are re-education on the smoking policy, safety search, smoking cessation program, psychiatric assessment for mental status changes, individualized behavior plan, smoking schedule modification. Review of the smoking agreement, which requires a signature from each resident and/or resident representative, indicated violation of the policies may result in the following. May be placed on frequent checks. A progress modification of smoking schedules up to and including elimination of smoke breaks. Restriction of leave of absence privileges may be necessary if resident continues to return with smoking materials. Smoking privileges may be suspended. Immediate temporary termination of smoking privileges may occur if and when the resident puts other residents or the environment at serious risk. Issuance of a 30-day discharge notice. Interview with RN #6 on 6/27/23 at 11:00 AM identified that the Travel Pass Policy, dated 11/13/2014, provided to the surveyor, is the current policy, and identified that all residents are required to obtain a travel pass to leave the facility. Further, the physician does not write leave of absence orders in advance of a request. RN #6 indicated that although the policy says that 72-hour notice is required for each request to be reviewed for consideration, the policy also states that consideration will be given on a case-by-case basis for approval with shorter notice.

Based on review of the clinical record, facility documentation, facility policy and interview for 2 residents (Resident #130 and 133) reviewed for choices, the facility failed to ensure choices and options were reviewed and provided to residents for meals. The findings include: 1. Resident #130 was admitted to the facility on [DATE] with diagnoses that included bilateral lower extremity amputations, stroke and diabetes. The quarterly MDS dated [DATE] identified Resident #130 had intact cognition, had an indwelling urinary catheter and colostomy, and required the assistance of one staff member with transfers, dressing and bathing and needed set up help only for meals. The care plan dated 6/8/23 identified that Resident #130 would have no ill effects related to choices regarding treatments. Interventions included to educate and counsel Resident #130 on benefits and risks, and approach Resident #130 later if he/she chose to not accept care or treatment. Interview with Resident #130 on 6/25/23 at 9:10 AM identified that there had been issues with meal choices since his/her admission to the facility. Resident #130 identified that the meals included a lot of chicken and rice. Resident #130 also identified that there were no menus provided directly to residents, rather, the facility had a posted menu in the hallway for residents to look at. Resident #130 also identified that an alternative menu option list was also posted in the hallway at times, although there was not an alternative menu option list currently posted, and that unless residents were able to get to the hallway, they wouldn't have access to even see the menus. Resident #130 also identified that no one from the facility ever came to review menu choices and that he/she had no idea how to notify the kitchen of an alternative menu choice. 2. Resident #133 was admitted to the facility on [DATE] for orthopedic aftercare following amputation, pain, and diabetes. The admission MDS dated [DATE] identified Resident #133 had intact cognition, was occasionally incontinent of bladder and always continent of bowel and required the assistance of one staff member with transfers, dressing and bathing and needed set up help only for meals. The care plan dated 6/23/23 identified that Resident #133 may have difficulty adjusting to admission to the facility. Interventions included to ask if Resident #133 had any preferences regarding care and services at the facility and to reasonably accommodate those preferences. Interview with Resident #133 on 6/25/23 at 10:20 AM identified that he/she had an allergy to chicken, and 90% of the meals served at the facility included chicken and rice. Resident #133 identified he/she did not like rice all the time and had even refused meals in the past, but there were no options given to choose and receive alternative meal options. Resident #133 identified that the facility posted a menu in the hallway by the nurse's station on the unit, but there was no information on how to select an alternative meal option or who to contact, and that there was sometimes an alternative of the day menu posted in the hallway as well but not currently. Resident #133 identified that most of the residents on the unit have mobility issues and can't get to the hallway to see the menu and that the facility did not provide the menus to the residents in their rooms, but that we can only see if we go out to the hallway. Resident #133 also identified he/she had discussed his/her concerns regarding the menu choices and alternatives with the Dietitian and she told him there were no options other than what was posted on the menu. Interview with the Dietitian on 6/26/23 at 12:05 PM identified that she had met with Resident #133 to discuss issues with the meal choices. The Dietitian identified that there was an alternative meal posted along with the main meal on the regular menu and that residents had alternative meal options to an extent. The Dietitian identified it was the Dietary Director's responsibility to review how to make meal choices with the residents. Interview with the Dietary Director on 6/26/23 at 1:50 PM identified that the process for residents of the facility to choose alternative meals by notifying the nurse aides who deliver the meal trays. The Dietary Director identified that the menus for the facility are posted on each unit, but the menus were not distributed to residents individually. The Dietary Director was unable to identify why the menus were not given to the residents individually, but identified if a resident did not have mobility to see the menu at the posted area on the unit they can ask the nurse aide. The Dietary Director further identified that she met with newly admitted residents to review meal preferences. The Dietary Director identified that the dietary staff was responsible for reviewing meal options and how to choose alternative options but that the residents of the facility know that they can ask the nurse aides because I have seen it myself. The facility policy on meal presentation and refusals directed that it was the dietary department's responsibility to make reasonable accommodations to provide meals in an event a meal was refused. The policy further directed that alternative menu options and ala carte items would be offered and provided to residents who refuse meals, and that if alternative and ala carte items were not well received, the facility may offer other available food options. The facility policy on resident rights directed that residents of the facility had the right to make choices about aspects of their lives that were significant to them.

Based on observation, review of clinical records, facility documentation review, manufacturer's guidelines review, and interviews, for four (4) of four (4) residents reviewed for blood glucose monitoring, (Resident #4), the facility failed to ensure one licensed staff member disinfected the multi-use glucometer between residents in accordance with manufacturer guidelines which created exposure to potentially contaminated medical equipment, infectious substances and transmission of infectious diseases resulting in Immediate Jeopardy. The finding includes: On 8/13/18 at 11:30 AM, the surveyor observed LPN#1 entering Resident #4's room to perform a blood glucose check with an Assure Platinum glucometer. LPN #1 proceeded to put her supplies on the over-bed table, and wiped the glucometer off with an alcohol (70 % [MEDICATION NAME] alcohol) prep pad. LPN #1 placed the strip in the glucometer and took the lancet to prick R #4's finger. Surveyor stopped LPN #1 and interviewed LPN #1 at the nurse's station. LPN #1 stated she always uses an alcohol prep pad to clean the glucometer between resident use because that is what she was taught to do. LPN #1 identified that she did not have the manufacturer's manual with directions as to how to disinfect the glucometer after resident use, was unable to locate the manual in her medication cart and/or on the nursing unit and subsequently called Central Supply staff to bring the manufacturer manual to the nursing unit. LPN #1 further stated she had used the glucometer to obtain blood sugar levels for R #4, R #5, R #6 and R #7 earlier in her shift, and had cleansed the glucometer with an alcohol prep pad after each use. The Infection Control Nurse (LPN #2) arrived on the unit on 8/13/18 at 11:36 AM with a container of PDI Super Sani-Cloth Germicidal Disposable wipes (bactericidal, tuberculocidal, and virucidal) and directed LPN #1 to use the disinfectant to clean the glucometer. Central Supply Person #1 arrived on the unit at 11:37 AM and provided LPN #1 with the glucometer manufacturer manual. Review of facility education dated 6/1/2016 identified that LPN #1 was educated to clean the glucometer between residents and after each use, to scrub for at least twenty (20) seconds, and to use specialized sani-cloth wipes. If blood is on the glucometer, two (2) wipes are needed, one for removal of blood and the second to clean the machine. During an interview with the Infection Control Nurse (ICN) on 8/13/18 at 11:36 AM, the ICN stated LPN #1 should not have used an alcohol prep pad to disinfect the glucometer, and stated the glucometer should be disinfected with the disinfectant wipe in accordance with manufacturer directions for use. Review of the manufacturer manual with LPN #1 directed to disinfect the glucometer after resident use with a disinfectant wipe. LPN #1 subsequently used the disinfectant wipe provided by the Infection Control Nurse to clean the glucometer, and then proceeded to obtain a blood sugar level from Resident #4. Interview and facility documentation review with the Director of Nursing (DON) on 8/14/18 at 8:50 AM identified although the facility did not have a policy directing the disinfecting of the glucometer, the DON stated the glucometer should be disinfected using a disinfectant wipe after each resident use per the manufacturer guidelines. The DON further stated the Staff Educator was expected to ensure all licensed staff were educated how and when to disinfect glucometer's. Review of the glucometer manufacturer's guidelines identified cleaning and disinfecting the glucometer can be completed by using an EPA-registered disinfectant detergent or germicide wipe. The manual further directed a list of approved disinfectants can be located on their website. Review of the manufacturer website (http://www.arkrayusa.com/diabetes-management/professional-care/support/cleaning-and-disinfecting) identified the PDI Super Sani-Cloth Germicidal Disposable Wipes were an approved disinfectant. On 8/14/18, the facility submitted an immediate action plan to the Department that included in part, reeducation and competency reviews of all licensed nursing staff on blood glucose monitoring technique, care, and cleaning of glucose monitors. The care and cleaning of glucose monitors will be followed by manufacture guidelines. All licensed staff must complete all in-services and competency review prior to starting their next scheduled shift. Consequently, IJ was abated on 8/14/18.

Based on review of clinical record, staff interview, and review of facility documentation and facility policy and procedures, for one sampled resident reviewed for an injury of unknown origin (Resident #15) the facility failed to notify the physician when a new onset of pain was identified. The findings include: Resident #15 [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] identified the resident with impaired cognition, required total assist with Activities of Daily Living (ADL's), and had limited use of the left upper extremity. A care plan dated 12/16/2010 identified a problem with transfers requiring the utilization of a mechanical lift for all transfers and interventions included assist of 2 for all hoyer transfers and to instruct the resident of the steps during transfer to decrease anxiety. Review of the facility Incident/Accident Report dated 1/2/11 at 9:30am identified Resident #15 was noted with discoloration and swelling to the left arm and staff was unable to provide passive and/or active range of motion. An x-ray report dated 1/2/2011 identified a [MEDICAL CONDITION] proximal humerus. Review of the facility investigation identified that while getting Resident #15 out of bed on 12/31/2010 during the 3-11 shift ( 2 days prior to swelling and discoloration of the left arm) Resident #15 was continuously crying out in pain. Licensed Practical Nurse (LPN) #1 on 12/21/2010 at approximately 8:00pm heard the resident moaning in pain while in bed and administered Tylenol. On 12/31/2010 at 11:00pm Resident #15 continued to scream out in pain. During the 11-7 shift on 12/31/2010 Resident # 15 continued to yell out in pain and was given Tylenol at 1:00am. Interview with LPN #1 on 5/5/2011 at 10:35am identified that on 12/31/2010 Resident #15 was crying out in pain during the 3-11 shift. LPN #1 further indicated that this continuous crying out in pain was unusual behavior for this resident. LPN #1 did not report this new onset of pain to the nursing supervisor for further assessment, and failed to notify the physician when Resident #15 was identified with a new onset of pain. Review of the facility policy for notifying Physicians of clinical changes in condition direct the staff in part to ensure that all significant changes in a resident's status are assessed appropriately and documented in the residents medical record, and the physician should be notified at any time when the resident's problem requires immediate assessment. Interview with Physician (MD)#1 on 5/5/2011 at 2:10pm identified he/she would have expected to have been notified when the resident had a change in condition with a new onset of pain.

Based on staff interview, review of clinical record, review of facility documentation for one resident reviewed for an injury of unknown origin (Resident #15), the facility failed to provide services to promote the resident's highest level of well being in that the resident was not assessed for pain in a timely manner. The findings include: Resident #15 [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] identified the resident with impaired cognition, required total assist with Activities of Daily Living (ADL's), and had limited use of the left upper extremity. A care plan dated 12/16/2010 identified a problem with transfers requiring the utilization of a mechanical lift for all transfers and interventions included assist of 2 for all hoyer transfers and to instruct the resident of the steps during transfer to decrease anxiety. Review of the facility Incident/Accident Report dated 1/2/2011 identified Resident#15 was noted with discoloration and swelling to the left arm and staff was unable to provide passive and/or active range of motion. An x-ray report dated 1/2/2011 identified a [MEDICAL CONDITION] proximal humerus. Review of the facility investigation identified that while getting Resident #15 out of bed on 12/31/2010 during the 3-11 shift ( 2 days prior to the identified swelling and discoloration of the left arm) Resident #15 was continuously crying out in pain. Licensed Practical Nurse (LPN) #1 identified that on 12/31/2010 at approximately 8:00pm she heard the resident moaning in pain while in bed and administered Tylenol. On 12/31/2010 at 11:00pm Resident #15 continued to scream out in pain. During the 11-7 shift on 12/31/2010 Resident #15 continued to yell out in pain and was given Tylenol at 1:00am with fair relief. Interview with LPN #1 on 5/5/2011 at 10:35am identified that on 12/31/2010 Resident #15 was crying out in pain during the 3-11 shift, LPN #1 administered Tylenol, and when she went back to check, Resident #15 was fast asleep so she felt the resident was fine. LPN #1 further indicated that although this continuous crying out in pain was unusual behavior for this resident she failed to notify the physician, failed to notify the nursing supervisor, and failed to complete a comprehensive pain assessment when the resident was identified with a new onset of pain.