Every finding on record at Pilgrim Manor

Based on review of the clinical record, facility documentation, facility policy and interviews for 1of 2 residents (Resident #61) reviewed for indwelling catheter, the facility failed to obtain a complete physician's order for the indwelling catheter including insertion and ongoing care and management after a voiding trial failed. The findings include:Resident #61 was admitted to the facility in 10/2025 with diagnoses that included abscessed lung with pneumonia and empyema (pus in the pleural space around the lung). The care plan dated 10/6/25 identified Resident #61 was at risk for skin breakdown related to incontinence, impaired mobility and co-morbid conditions. Interventions included monitoring lab values and record intake and output.The admission MDS dated [DATE] identified Resident #61 was cognitively intact and required the assistance of one for bed mobility, transfers, toileting and did not have an indwelling catheter.An APRN progress note dated 10/14/25 at 9:57 AM identified Resident #61 was exhibiting increased gurgling in the upper airway the preceding three days. A chest x-ray was obtained twice which showed pneumonia and small to moderate plural effusion with decreased inferolateral (below and to the side) emphysema. On 10/13/25, Albuterol inhaler was ordered four times daily (medication used to open up bronchial airways), Mucinex (medication that aides in expectorating mucous secretions) was changed to Tussin (medication used to manage secretions) and Scopolamine patch (medication used to dry mucous secretions). Resident #61 was lethargic, minimally verbal with oxygen saturation in the 80's (normal 95% and 100%). Resident #61 was to be transferred to the hospital for further evaluationHospital Discharge summary dated [DATE] identified Resident #61 was admitted with hypoxic respiratory failure and hyponatremia (low sodium). During hospitalization, Resident #61 developed urinary retention. A urinary catheter, #16 French (Fr) with a 10 milliliter (ml) balloon inflation volume was placed on 10/30/25. Resident #61 was subsequently discharged back to the facility on [DATE]. Discharge recommendations included following up with urology for a voiding (urination) trial and exchange Foley (indwelling urinary catheter) every 2 - 4 weeks.Physician's order dated 11/4/25 directed to change the Foley catheter 16 Fr/10ml balloon as needed for leakage, irrigate Foley with 60ml normal saline as needed for blockage or slow urine flow, change catheter bag and monitor intake and output every shift.An APRN progress note dated 11/6/25 identified Resident #61 returned to the facility with a Foley catheter due to urinary retention. Orders in place to monitor output and provide Foley care per nursing. A voiding trial was to be considered the following week. Physician's order dated 11/10/25 directed to remove the indwelling catheter, perform a bladder scan if no urination in eight hours, and straight catheterize for a post void residual greater than 300 cubic centimeters (cc).Nursing notes dated 11/10/25 through 11/13/25 identified Resident #61 was re-admitted to the hospital for an episode of epistaxis and subsequently returned to the facility.Physician's order dated 11/18/25 directed to straight catheterize and replace catheter if not voiding in eight hours or if straight catheterization was greater than 300cc on three occasions for for two days.Subsequent physician's order dated 11/18/25 directed the insertion of a Foley catheter 16 Fr with 5 - 10ml balloon. If not available, an 18 Fr may be inserted, empty bag every shift, and change catheter bag.Physician's order dated 12/2/25 directed de-catheterization (removal of the urinary catheter); bladder scan and straight catheterization for a post void residual greater than 300cc.Nurse's note dated 12/3/25 at 8:00 AM identified Resident #61's Foley catheter was removed at 6:00 AM with the procedure being well tolerated.Nurse's note dated 12/4/25 at 8:36 PM identified Resident #61 complained of pressure in the abdomen with observed distention. Two unsuccessful attempts were made to urinate in the urinal. Resident #61 was catheterized with an #18 Fr catheter for 500 cc of urine once the Foley bag was attached. Resident #61 reported the abdominal pressure was relieved. Review of the physician's orders failed to specify parameters for the indwelling catheter insertion including catheter size, balloon inflation volume and ongoing catheter care and management. Interview with RN #1, the infection control nurse on 12/14/25 at 2:31 PM identified Resident #61's most recent voiding trail was initiated on 12/3/25 when the Foley catheter was removed. On 12/4/25 Resident #61 was unable to void, and the urinary catheter was reinserted. RN #1 indicated it was the charge nurse or nursing supervisor's responsibility to notify the APRN at the time of re-insertion to obtain the orders for indwelling catheter including the catheter size, inflation parameters and any ongoing management of the urinary catheter.Interview with LPN #1 on 2/15/25 at 7:17 AM identified she was the assigned nurse on 12/4/25 during the 7:00 AM - 3:00 PM shift. Resident #61 reported the urge to void but was unable, and eight hours had lapsed since last void. LPN #1 reinserted the urinary catheter using a prior physician's order for size and balloon inflation without notifying the APRN. LPN #1 further identified she would have obtained updated orders if the APRN had been onsite; instead, she notified the nursing supervisor, who was responsible for contacting the APRN by phone for the updated catheter size, balloon volume, and ongoing management orders.Interview with RN #2 on 12/15/25 at 7:34 AM identified she was the assigned nursing supervisor during the 7:00 AM - 3:00 PM shift on 12/4/25. RN #2 indicated it was the charge nurses responsibility to notify the APRN to obtain updated orders. However, RN #2 identified she should have double checked to ensure the appropriate orders for the indwelling catheter included size, balloon inflation and ongoing management were entered into the clinical record.Interview with the DNS on 12/16/25 at 10:32 AM identified orders should have been written for the Foley catheter size, balloon inflation and ongoing care at the time of reinsertion.An interview with APRN #1 on 12/16/25 at 11:07 AM identified when implementing a voiding trial, she would write orders specifying voiding parameters and when to reinsert the catheter if unable to void within a set timeframe if she was onsite. APRN #1 stated she could not recall if she was present when the indwelling catheter was reinserted but indicated that, when not onsite, she relies on nursing staff to obtain additional orders for catheter size, balloon volume, and ongoing management.A review of the facility policy for Foley Catheter Insertion directed to verify a physician's order for the procedure and report information in accordance with facility policy and professional standards of practice.A review of the facility policy for Verbal Orders directed that verbal orders may only be received by licensed personnel including RNs and LPNs. Orders must be reduced in writing by the person receiving the order and recorded in the resident's medical record and countersigned by the physician during the next visit.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #19 and 24) who required supervision with eating, the facility failed to ensure the appropriate supervision was provided during eating. The findings include: Resident #19 was admitted to the facility in September 2024 with diagnoses that included oral phase dysphagia and cognitive communication deficit. The quarterly MDS dated [DATE] identified Resident #19 had moderately impaired cognition, required supervision or touching assistance with eating, and did not have a swallowing disorder. The care plan dated 10/8/25 identified Resident #19 required assistance for ADLs, toileting, transfers, and bed mobility, self feeds, and hoyer lift for transfers, with interventions that included Resident #19 to be out of bed for breakfast and refusals to be communicated to the nurse. The Speech Language Pathologist (SLP) Evaluation and Plan of Treatment dated 11/3/25 identified Resident #19 was seen for a skilled ST dysphagia evaluation during mealtime. Resident #19 was received upright in wheelchair, alert and willing to participate. This clinician conducted an oral mechanical exam revealing poor buccal muscle strength and mild difficulties with lingual range of motion and coordination, however, all the other oral motor functions and detention were within defined limits. Resident #19 participated in oral trials of regular textured solids, chopped, textured solids, and thin liquids via straw sip. Resident #19 demonstrated no overt signs or symptoms of aspiration/penetration across all trials. Oral trials of thin liquids via straw sips were unremarkable. During trials of regular textured solids and chopped textured solids the resident was noted with remarkably delayed mastication, incomplete bolus formation, and lack of swallow initiation requiring this clinician to prompt the resident to remove the bolus from his/her oral cavity. Clinician recommended diet of M5 textured solids and thin liquids. Supervision for oral intake: occasional supervision. Compensatory strategies/positions: to facilitate safety and efficacy, it is recommended that Resident #19 use the following strategies and or maneuvers during oral intake, alternation of liquids and solids, bolus size modifications, finger or utensil sweep, general swallow techniques/precautions and lingual sweep/re-swallow, remain in an upright posture for greater than 30 minutes after meals and upright posture during meals. A physician's order dated 11/3/25 directed a regular diet, thin liquids, texture mechanical soft (ground)/Dysphagia 2/ minced and moist. Notes: 2 handled mug with lid and straw, distant supervision, eating in the dining room, may require occasional cues or feeding. Review of the Speech Therapy Treatment Encounter Notes dated 11/3, 11/5, 11/7, 11/11, 11/12, 11/14, 11/17, 11/19, 11/21, 2/2, 12/6, and 12/7/25 identified Resident #19's SLP outcomes: swallowing is safe with modified diet and moderate cues for use of compensatory strategies, may still require tube feeding/oral supplements to meet nutritional needs, close supervision. Review of the Speech Therapy Treatment Encounter Notes dated 11/13, 11/24, and 12/12/25 identified Resident #19's SLP outcomes: Swallowing is safe with minimal diet modifications, use compensatory strategies, all nutritional needs are met via PO intake, distant supervision. The physician's order dated 12/9/25 directed a regular diet, thin liquids, texture mechanical soft (ground)/Dysphagia 2/minced and moist. Notes: may have soft cookie but no other soft baked goods, 2 handled mug with lid and straw, distant supervision, eating in the dining room, may require occasional cues or feeding. The facility's Grandview Diet List (located in a binder in the dining room) identified Resident #19 had a swallow supervision level of distant. Observation of Resident #19 on 12/14/25 at 9:53 AM identified Resident #19 was alone eating in his/her room, with no supervision. Observation with the Nursing Supervisor (RN #2) of Resident #19 on 12/15/25 at 8:55 AM identified Resident #19 alone eating in his/her room, with no supervision. Interview with RN #2 on 12/15/25 at 8:55 AM identified that Resident #19 usually sits in bed for breakfast, after the nurse aides set up the tray, they check on him/her periodically throughout the meal to offer assistance and provide cueing. RN #2 indicated that Resident #19's diet had recently been downgraded by Speech Therapy due to chewing exhaustion and his/her eating has improved. Interview with NA #1 on 12/15/25 at 9:30 AM identified that she was new to the facility and was currently the nurse aide assigned to Resident #19. NA #1 further indicated that she was aware that Resident #19 required distant supervision with meals; usually Resident #19 would eat breakfast in his/her room and she and the other nurse aides would go into the room periodically and remind him/her to eat. Interview with NA #2 on 12/15/25 at 9:38 AM identified that Resident #19 requires distant supervision with meals, and while he usually is not assigned to Resident #19, he will go into his/her room to check on him/her during breakfast. NA #2 indicated that Resident #19 requires assistance with set-up for meals but can feed him/herself. NA #2 indicated that he goes in and out every 5-10 minutes to prompt the resident and ensure he/she has not fallen asleep, while Resident #19 does fall asleep during meals. NA #2 identified that he/she has not fallen asleep with food in his/her mouth. Interview with the Charge Nurse (LPN #2) on 12/15/25 at 9:48 AM identified that recently Resident #19 and his/her family had requested that he/she remain in bed for breakfast because he/she has been becoming more tired throughout the day and had missed afternoon activities on days that he/she got out of bed for breakfast and lunch, but for a long time before the request, Resident #19 would eat breakfast in the dining room. LPN #2 indicated that she was aware that Resident #19 required distant supervision during meals and to the best of her knowledge that required nursing staff to pop in while he/she was eating for cueing but there was no set frequency for popping in. LPN #2 further indicated that sometimes Resident #19 does fall asleep while eating and the staff will have to remind him/her to eat, but he/she had never observed Resident #19 sleeping with food in his/her mouth. Interview with SLP #1 on 12/15/25 at 1:13 PM identified that Resident #19 required distant supervision, which consisted of eating in the dining room at a table with other residents and a staff member in the room to assist with cueing and ensure safety, for at least 3 months, but she would have to review her notes to verify the date. SLP #1 identified that Resident #19 had oral phase dysphagia and during his/her evaluation had gotten tired with mastication (chewing) and would continue to eat without swallowing, causing a food bolus that would need to be spit out. SLP #1 indicated that since Resident #19's diet had been downgraded to minced and moist, he/she has done much better. Interview with the DNS on 12/15/25 at 11:05 AM identified that Resident #19 does have an order for distant supervision while eating, and that the facility would come up with a way to honor Resident #19's family request to eat breakfast while sitting in bed and maintaining distant supervision. The DNS indicated that moving forward Resident #19 would either eat in the dining room or have a staff member present during meals that were eaten in the room. The DNS further indicated that a QAPI plan would be initiated, and an audit of meal supervision orders would be completed. The facility's Assistance with Meals policy directs that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Supervision related to swallowing: A. Direct Supervision - the person supervising is physically present and available for consultation and/or assistance. B. Close Supervision - the person is supervised at a table with others or in a group with cues provided and feeding assistance as needed. C. Distant Supervision - the person is eating in the dining room, may require occasional cues or feeding. D. Occupational Supervision- the person eating in their room with occasional checks. E. No Supervision - the person is completely independent. 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included dysphagia, dementia, and chronic obstructive pulmonary disease. A physician's order dated 4/28/24 directed aspiration precautions. A speech therapy discharge recommendation dated 10/11/24 identified Resident #24 required distant supervision with meals, which included eating in the dining room and may require occasional cues or feeding. A physician's order dated 11/23/24 directed a mechanical soft diet and distant supervision with meals. The quarterly MDS dated [DATE] identified Resident # 24 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff to assist with transfers, bathing, and set up for meals. The care plan dated 10/24/25 identified Resident #24 had swallowing difficulties due to dysphagia. Interventions included distant supervision with meals, partial assistance, and encouragement at times. Observation on 12/14/25 beginning at 8 AM identified Resident #24 eating breakfast in his/her room. Resident #24 was observed sitting up in bed, with the bedside table and breakfast tray positioned directly in front of him/her. During this observation, it was identified that based on Resident #24's bed position, privacy curtain placement, and bathroom location, Resident #24 was not visible from the unit hallway. Resident #24 was continuously observed from 8 AM - 8:12 AM. During this observation, no staff were observed providing supervision to Resident #24. Constant observation on 12/15/25 beginning at 8:30 AM identified Resident #24 sitting up in bed sleeping, with the bedside table and breakfast tray positioned directly in front of him/her. During this observation, based on Resident #24's bed position, privacy curtain placement, and bathroom location, Resident #24 was not visible from the unit hallway. Observation from 8:30 AM - 9:02 AM identified no staff entered the resident's room or supervised the resident during that time. At 9:02 AM, LPN #1, was in the unit hallway passing medications. At 9:03 AM NA #1 entered Resident #24's room and attempted to provide feeding assistance to Resident #24. At 9:08 AM, Resident #24 declined any more food and NA #1 exited Resident #24's room with his/her meal tray. Interview with LPN #1 on 12/15/25 at 9:10 AM identified that Resident #24 had an order for distant supervision with meals. LPN #1 identified that usually residents who required distant supervision would eat in the dining room, but Resident #24 always refused and only wanted to eat in his/her room. LPN #1 identified that distant supervision was not specific to a number of times staff were required to check in on a resident, but the staff tried to make sure to check in on Resident #24 at least once during a meal. Interview with the DNS on 12/15/25 at 12:40 PM identified that residents who required distant supervision with meals should have their meals in the dining room, but Resident #24 preferred to eat meals in his/her room and the facility wanted to honor the resident's rights. The DNS identified the facility's policy related to assistance with meals directed [NAME] residents who required distant supervision required meals in the dining room. The DNS could not identify how distant supervision was completed for Resident #24 who elected to dine in his/her room. Interview with SLP #1 on 12/15/25 at 1:58 PM identified that while she was not the Speech Therapist who previously treated Resident #24, in general any resident who required distant supervision needed supervision by facility staff which included occasional cueing and feeding with meals, ensuring the resident was not taking in too much food, and that the resident was able to break down food with chewing and getting adequate nutritional intake. SLP #1 indicated that distant supervision was specifically to be utilized in the dining room area. SLP #1 further identified she had never been asked to evaluate Resident #24 and was not aware of the distant supervision or aspiration precaution orders. SLP #1 identified that if Resident #24 refused to eat meals in the dining room, he/she should have been placed on 1:1 feeding supervision with a staff member in his/her room during meals to ensure the resident's safety, and that it was not appropriate for the resident to eat without a staff member present for the entire meal. Although requested, the facility failed to provide a policy on aspiration precautions. The facility policy on assistance with meals directed that the purpose of the policy was to ensure that residents of the facility would receive assistance with meals in a manner that met the individual needs of each resident. The policy further directed all residents were encouraged to eat in the dining room, and any resident who required distant supervision related to swallowing should be eating in the dining room and might require occasional cues or feeding. The facility policy on dysphasia directed the purpose of the policy was to help identify individuals with a history of swallowing difficulties or related diagnosis such as dysphasia. The policy further directed that the staff and physician would collaborate to define the nature of any swallowing difficulties which included if the resident was coughing, weather difficulties happened with all meals, selectively, or at other times as well, or if the problem was new or there had been previous complications, etc. The policy also directed that the attending physician and staff would review all pertinent findings including the resident's overall condition, prognosis, nutritional status, and wishes, and identify simple interventions to manage the situation.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #3) reviewed for unnecessary medications, the facility failed to ensure the provider adequately addressed pharmacy recommendations for a resident receiving a medication that should be administered before meals. The findings include:Resident #3 was admitted to the facility in February 2025 with diagnosis that included diabetes type ll. The care plan dated 2/26/25 identified Resident #3 was at risk for low/high blood sugars related to diabetes type II. Interventions included administering hypo/hyperglycemic (low/high blood sugar level) agents according to physician orders.Physician's order dated 3/1/25 directed to administer Glipizide 5mg (medication that aids in lowering blood sugar) tablet daily at 9:00 AM.Pharmacy consult dated 3/5/25 identified Glipizide was best administered 30 minutes before a meal to ensure maximum reduction of postprandial hyperglycemia (increase in blood glucose levels following a meal). Recommendations were made to adjust the administration time from 9:00 AM to improve efficacy and reduce the potential for any adverse effects.The admission MDS dated [DATE] identified Resident #3 had severe cognitive impairment and required one person assist with locomotion using a wheelchair, set up assistance with eating, had a metabolic disorder and received blood sugar lowing medication.Prescriber response dated 3/25/25, to the pharmacy consult dated 3/5/25, identified the provider agreed with the recommendation and noted that the time was changed.Physician's order dated 3/25/25 directed to administer Glipizide 5 mg daily at 8:00 AM. The physician's order failed to reflect direction to administer Glipizide 5 mg 30 minutes prior to a meal.Pharmacy consult dated 9/18/25 identified Glipizide was best administered 30 minutes before a meal to ensure maximum reduction of postprandial hyperglycemia. Recommendations were made to adjust the administration time from 8:00 AM to improve efficacy and reduce the potential for any adverse effects unless it was before breakfast. The consultation did not include a provider response and there were no changes made to the physician order.Interview and review of the clinical record with the DNS on 12/16/25 at 6:02 AM identified pharmacy recommendations were mailed from the pharmacy and distributed to nursing units. Providers were responsible for reviewing, responding, and returning completed consultations. The DNS identified the second pharmacy consult dated 9/18/25 was not addressed due to oversight. The DNS further indicated that, although nursing staff were allowed one hour flexibility with medication administration times before and after 8:00 AM for breakfast, the absence of instructions to administer 30 minutes before meals likely resulted in inconsistent administration prior to breakfast.Interview with LPN #1 on 12/16/25 at 7:29 AM identified breakfast trays normally arrive at 7:40 AM daily. LPN #1 indicated Resident #3 was prescribed Glipizide at 8:00 AM, however LPN #1 was not aware the medication was to be administered before breakfast and indicated it was not a requirement.Interview with APRN #1 on 12/16/25 at 9:09 AM identified when she receives pharmacy consultations from nursing staff for review responses are documented on the consultation form and in the clinical record. APRN #1 further identified she did originally change the administration time to 8:00 AM, however, regardless of the time, the medication was to be given 30 minutes prior to a meal.Review of the policy for Consult Pharmacist Services directs a monthly medication regimen review (MRR) for each skilled resident to identify and communicate actual or potential medication-related issues and make recommendations. Completed recommendations are provided to prescribers, the medical director, and the director of nursing.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #2 had diagnoses that included anxiety, depression, fracture of the 7th rib, and hypertension. The quarterly [NAME] Data Set (MDS) assessement dated 1/31/2025 identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of thirteen (13) indicative of intact cognition, was occasionally incontinent of bowel and bladder, required moderate assistance with ADLs, bed mobility, and transfers. The nurse's note dated 4/13/2025 at 3:47 P.M. written by Licensed Practical Nurse (LPN) #1 identified Resident #2 presented a complaint about disrespectful comments from Nurse Aide (NA) #1 and indicated Registered Nurse (RN) #1 spoke with Resident #2. The facility's reportable event form dated 4/14/2025 at 10:06 A.M. identified Resident #2 alleged on 4/13/2025 at 1:30 A.M. NA #1 was rude to h/her. The facility's summary dated 4/16/2025 identified that after performing a thorough investigation, the findings of the allegation of verbal abuse were unsubstantiated. The investigation identified that NA #1 did not conduct herself with the professional standards of the facility, NA #1 was terminated, and facility staff were re-educated on the abuse policy and professional conduct, which includes joking with the resident. The social workers' note dated 4/14/2025 at 4:22 P.M. written by Social Worker (SW) #1 identified she followed up with Resident #2 regarding a care concern over the weekend. SW #1 identified Resident #2 was alert and oriented and reported over the weekend NA #1 had rude behavior. Interview with Resident #2 on 5/1/2025 at 9:50 A.M. identified on 4/13/2025 when h/she was done using the bedpan h/she put the call light on. Resident #2 identified that NA #1 responded to h/her call light and when she entered the room NA #1 stated why don't you get off your lazy butt and go to the bathroom. Resident #2 identified h/she said, 'excuse me' and NA #1 replied I talk to my grandmother like that. Resident #2 identified h/she replied I am not your grandmother I am a resident here. Resident #2 identified NA #1 finished caring for h/her without any issues and left the room. Resident #2 indicated shortly after the incident she told NA #2 what happened, but did not want to make a big deal about it. Resident #2 identified that the staff at the facility did an investigation, notified the police, and h/she never saw NA #1 again. Resident #2 identified h/she felt NA #1 was rude and disrespectful. Interview with the Director of Nursing on 5/1/2025 at 10:06 A.M. identified on 4/13/2025 NA #1 did not treat Resident #2 in a respectful dignified manner. The DNS indicated that when staff respond to a call light they should always provide good customer service and treat the residents with respect and dignity. Although attempted, an interview with NA #1 wa not obtained. Review of the facility Resident Rights policy dated February 2021; in part, identified employees shall treat all residents with kindness, respect, and dignity.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to report an allegation of abuse to the state agency. The findings include: Resident #1 had diagnoses that included dementia with severe anxiety, depression, adult failure to thrive, weakness, difficulty walking, and unsteadiness on feet. The quarterly [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was always incontinent of bowel and bladder, and dependent on staff for ADLs including bed mobility, transfers, was non ambulatory and dependent on staff for mobility in the wheelchair. The Resident Care Plan dated 2/20/2025 identified at times Resident #1 refused or was combative with care, refused medications with interventions that directed to notify the provider and family of refusals of care and showers and educate the resident on the importance of getting out of bed to reduce the risk of pneumonia, skin breakdown, and weakness. APRN #1's note dated 4/8/2025 at 9:14 A.M. indicated it was a late entry note for an encounter date of 4/7/2025. APRN #1 identified Resident #1 had an unwitnessed fall, was found on the floor between the bed and window, and it was unknown if h/she hit h/her head. APRN #1 identified Resident #1 had refused nursing care and would be sent to the hospital for evaluation to rule out head injuries. Review of the emergency department notes dated 4/7/2025 at 3:01 P.M. identified Resident #1's family member was at the bedside and was not happy with the treatment by staff at Resident #1's current facility. Review of hospital history of present illness note dated 4/7/2025 at 9:15 P.M. by MD #2 (hospital provider) identified Resident #1 remembered the events of the night before, h/she confirmed that h/she slid out of bed because h/she was attempting to leave, and the reason h/she wanted to leave was not just due to inattention from staff, but Resident #1 said they were guilty of assault. Review of the hospital social worker consult note dated 4/8/2025 at 2:23 P.M. by Social Worker (SW) #2 identified she attempted to speak with Resident #1; however, h/she was resting. SW #2 identified she spoke with Family Member #1 who reported Resident #1 had been making comments for some time and indicated Family Member #1 was aware that a mandated reporter form for long term care facilities was completed. A nurse's note dated 4/10/2025 at 6:25 P.M. by Registered Nurse (RN) #2 identified Resident #1 was re-admitted to the facility from the hospital, per report from the hospital nurse Resident #1 required 2 persons for all care due to accusations. RN #2 identified that Resident #1 would have 2 persons with care. A nurse's note dated 4/10/2025 at 9:47 P.M. by Licensed Practical Nurse (LPN) #2 identified Resident #1 was provided with care by 2 staff at all times due to accusatory behavior. The social worker's note dated 4/11/2025 at 2:20 P.M. by SW #1 identified Resident #1 was re-admitted to the facility on [DATE]. SW #1 indicated she and RN #2 met with Resident #1 who was very alert, talkative, and answered questions appropriately. SW #1 identified that while Resident #1 was in the hospital he/she reported concerns and made allegations. SW #1 indicated that she discussed with Resident #1 that during care there would be 2 staff and Resident #1 agreed. Interview with SW #1 on 5/1/2025 at 10:31 A.M. identified on 4/11/2025 while reviewing Resident #1's hospital referral documents she became aware that Resident #1 reported to the staff at the hospital that h/she had been assaulted and/or mistreated by the staff at the facility. SW #1 indicated on 4/11/2025 she and RN #2 went to meet with Resident #1 and ask if h/she felt safe or had any concerns. SW #1 indicated that Resident #1 stated h/she felt safe and had no concerns. SW #1 identified that she did not call to ask Resident #1's Power of Attorney if h/she had any concerns that Resident #1 had been mistreated. Interview with the Director of Nursing (DNS) and Administrator on 5/1/2025 at 12:59 P.M. identified on 4/11/2025 while reviewing Resident #1's hospital discharge summary and referral documents they became aware that Resident #1 reported to hospital staff that h/she had been assaulted and mistreated by staff at the facility. The DNS and Administrator identified they did not notify the state agency that Resident #1 alleged h/she was abused by staff at the facility because the hospital documentation indicated that they already completed the mandated reporter form for long term care facilities (W-410) and notified the Department of Public Health. Review of facility abuse, neglect, exploitation, or misappropriation policy dated April 2021, in part; identified all alleged violations must be reported but not later than: 2 hours if the alleged violation involves abuse and should be reported immediately to the State Agency.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to conduct a complete and thorough investigation for an allegation of abuse. The findings include: Resident #1 had diagnoses that included dementia with severe anxiety, depression, adult failure to thrive, weakness, difficulty walking, and unsteadiness on feet. The quarterly [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was always incontinent of bowel and bladder, and dependent on staff for ADLs including bed mobility, transfers, was non ambulatory and dependent on staff for mobility in the wheelchair. The Resident Care Plan dated 2/20/2025 identified at times Resident #1 refused or was combative with care, refused medications with interventions that directed to notify the provider and family of refusals of care and showers and educate the resident on the importance of getting out of bed to reduce the risk of pneumonia, skin breakdown, and weakness. APRN #1's note dated 4/8/2025 at 9:14 A.M. indicated it was a late entry note for an encounter date of 4/7/2025. APRN #1 identified Resident #1 had an unwitnessed fall, was found on the floor between the bed and window, and it was unknown if h/she hit h/her head. APRN #1 identified Resident #1 had refused nursing care and would be sent to the hospital for evaluation to rule out head injuries. Review of the emergency department notes dated 4/7/2025 at 3:01 P.M. identified Resident #1's family member was at the bedside and was not happy with the treatment by staff at Resident #1's current facility. Review of hospital history of present illness note dated 4/7/2025 at 9:15 P.M. by MD #2 (hospital provider) identified Resident #1 remembered the events of the night before, h/she confirmed that h/she slid out of bed because h/she was attempting to leave, and the reason h/she wanted to leave was not just due to inattention from staff, but Resident #1 said they were guilty of assault. Review of the hospital social worker consult note dated 4/8/2025 at 2:23 P.M. by Social Worker (SW) #2 identified she attempted to speak with Resident #1; however, h/she was resting. SW #2 identified she spoke with Family Member #1 who reported Resident #1 had been making comments for some time and indicated Family Member #1 was aware that a mandated reporter form for long term care facilities was completed. A nurse's note dated 4/10/2025 at 6:25 P.M. by Registered Nurse (RN) #2 identified Resident #1 was re-admitted to the facility from the hospital, per report from the hospital nurse Resident #1 required 2 persons for all care due to accusations. RN #2 identified that Resident #1 would have 2 persons with care. A nurse's note dated 4/10/2025 at 9:47 P.M. by Licensed Practical Nurse (LPN) #2 identified Resident #1 was provided with care by 2 staff at all times due to accusatory behavior. The social worker's note dated 4/11/2025 at 2:20 P.M. by SW #1 identified Resident #1 was re-admitted to the facility on [DATE]. SW #1 indicated she and RN #2 met with Resident #1 who was very alert, talkative, and answered questions appropriately. SW #1 identified that while Resident #1 was in the hospital he/she reported concerns and made allegations. SW #1 indicated that she discussed with Resident #1 that during care there would be 2 staff and Resident #1 agreed. Interview with SW #1 on 5/1/2025 at 10:31 A.M. identified on 4/11/2025 while reviewing Resident #1's hospital referral documents she became aware that Resident #1 reported to the staff at the hospital that h/she had been assaulted and/or mistreated by the staff at the facility. SW #1 indicated on 4/11/2025 she and RN #2 went to meet with Resident #1 and ask if h/she felt safe or had any concerns. SW #1 indicated that Resident #1 stated h/she felt safe and had no concerns. SW #1 identified that she did not call to ask Resident #1's Power of Attorney if h/she had any concerns that Resident #1 had been mistreated. Interview with the Director of Nursing (DNS) and Administrator on 5/1/2025 at 12:59 P.M. identified on 4/11/2025 while reviewing Resident #1's hospital discharge summary and referral documents they became aware that Resident #1 reported to hospital staff that h/she had been assaulted and mistreated by staff at the facility. They identified an investigation was not initiated. The DNS and Administrator indicated that since there was no verbal communication of the allegations of abuse or mistreatment, they were unaware that they needed to conduct a complete and thorough investigation. The DNS indicated that on 4/11/2025 she asked Resident #1 if h/she had any care concerns and Resident #1 denied care concerns. The DNS indicated that based on the hospital record which identified Resident #1 exhibited accusatory behaviors, Resident #1's care plan was updated and directed 2 staff with all care. Review of facility abuse, neglect, exploitation, or misappropriation policy dated April 2021, in part; upon receiving any allegations of abuse the administrator is responsible for determining what actions if any are needed for the protection of the residents, all allegations are thoroughly investigated, and the administrator initiates investigations.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for abuse, the facility failed to ensure appropriate interventions were implemented following an allegation of staff-to-resident verbal abuse. The findings include: Resident #2 had diagnoses that included anxiety, depression, fracture of the 7th rib, and hypertension. The quarterly [NAME] Data Set (MDS) assessement dated 1/31/2025 identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of thirteen (13) indicative of intact cognition, was occasionally incontinent of bowel and bladder, required moderate assistance with ADLs, bed mobility, and transfers. The nurse's note dated 4/13/2025 at 3:47 P.M. written by Licensed Practical Nurse (LPN) #1 identified Resident #2 presented a complaint about disrespectful comments from Nurse Aide (NA) #1 and indicated Registered Nurse (RN) #1 spoke with Resident #2. The facility's reportable event form dated 4/14/2025 at 10:06 A.M. identified Resident #2 alleged on 4/13/2025 at 1:30 A.M. NA #1 was rude to h/her. The facility's summary dated 4/16/2025 identified that after performing a thorough investigation, the findings of the allegation of verbal abuse were unsubstantiated. The investigation identified that NA #1 did not conduct herself with the professional standards of the facility, NA #1 was terminated, and facility staff were re-educated on the abuse policy and professional conduct, which includes joking with the resident. The social workers' note dated 4/14/2025 at 4:22 P.M. written by Social Worker (SW) #1 identified she followed up with Resident #2 regarding a care concern over the weekend. SW #1 identified Resident #2 was alert and oriented and reported over the weekend NA #1 had rude behavior. Interview with Resident #2 on 5/1/2025 at 9:50 A.M. identified on 4/13/2025 when h/she was done using the bedpan h/she put the call light on. Resident #2 identified that NA #1 responded to h/her call light and when she entered the room NA #1 stated why don't you get off your lazy butt and go to the bathroom. Resident #2 identified h/she said, 'excuse me' and NA #1 replied I talk to my grandmother like that. Resident #2 identified h/she replied I am not your grandmother I am a resident here. Resident #2 identified NA #1 finished caring for h/her without any issues and left the room. Resident #2 indicated shortly after the incident she told NA #2 what happened, but did not want to make a big deal about it. Resident #2 identified that the staff at the facility did an investigation, notified the police, and h/she never saw NA #1 again. Resident #2 identified h/she felt NA #1 was rude and disrespectful. Review of Resident #2's care plan on 5/1/2025 failed to identify revisions to the care plan to include interventions after the allegation of verbal abuse on 4/14/2025. Interview and clinical record review with the Director of Nursing on 5/1/2025 at 10:06 A.M. identified that after an allegation of staff to resident abuse, a comprehensive care plan should be implemented with appropriate interventions. The DNS was unable to provide documentation to reflect Resident #2 had a comprehensive care plan implemented following the allegation of verbal abuse on 4/14/2025. The DNS identified Resident #2 should have had a care plan implemented with appropriate interventions to identify and address the negative interaction Resident #2 had with NA #1. Review of the facility care plan comprehensive person-centered policy dated March 2022; in part, the care plan interventions are chosen only after data gathering, proper sequencing of events, care consideration of the relationship between the residents' problem areas and their causes, and relevant clinical information. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition changes.

Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who was a re-admission and had a foot ulcer, the facility failed to develop a care plan that addressed a diabetic ulcer to ensure interventions were implemented for the prevention and treatment of wounds. The findings include: Resident #1 diagnoses included kidney failure, chronic heart failure, open wound right ankle, and type 2 diabetes mellitus with polyneuropathy. The admission physician's order dated 3/8/24 directed for wound treatments however, the orders failed to address the use of pressure relieving devices or protective boots to the feet. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, was at risk of developing pressure ulcers, had an unhealed pressure ulcer Stage I or higher, a diabetic foot ulcer, and skin and ulcer treatments noted were pressure reducing device for chair and bed, nutrition intervention, pressure ulcer care, applications of medications, and applications of dressings to feet. The physician's wound care progress notes dated 3/11/24, 3/18/24, and 3/25/24 directed to follow the facility pressure ulcer prevention protocol, to utilize a pressure redistribution mattress and off-load the heels. The Resident Care Plan dated 3/20/24 failed to address the current right foot ulcer wound and prevention or treatment interventions. Review of the nurse's note from 3/12/24 through 3/31/24 failed to reflect documentation of the use of pressure relieving devices to the bed or chair, off-loading heels, or protective boots as in the previous admission of 2/3/24 through 2/26/24. Review of the March 2024 Medication Administration Record and Treatment Administration Record failed to show documentation of pressure relieving devices, off-loading of heels, or use of protective boots. Although requested, the facility failed to provide a copy of the Nurse Aide Care Card. Interview with the Director of Nursing (DON) on 5/24/24 at 12:20 PM identified the expectation for wound care treatment and interventions was to address the diabetic ulcer on the individual resident's care plan. The DON identified physician orders for wound care prevention should have been obtained. Review of the facility policy Care Plans, Comprehensive Person-Centered identified the care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The facility Wound care Policy identified to review the resident's care plan for any special needs of the resident and to use supportive devices as instructed.

Based on review of the clinical record, review of facility documentation, and interviews for 4 of 5 residents (Resident #304) reviewed for accidents, the facility failed to appropriately supervise a resident resulting in a fall with a major injury. The findings include: Resident #304 's diagnoses included dementia, anxiety, history of a transient cerebral ischemic attack (TIA), atrial fibrillation, and blindness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #304 was severely cognitively impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Additionally, Resident #304 had balance issues during transitions when moving from a seated to standing position and surface to surface transfers between the bed and chair or wheelchair. Review of the Resident Care Plan (RCP) in effect from 5/1/23 through 5/31/23 identified that Resident #304 was at risk for falls and required assistance with Activities of Daily Living (ADL's). Interventions included arranging personal items within reach, monitoring for safety, placing a floor mat to the right side of the bed, and providing the assistance of 1 staff for bed mobility, bathing, dressing, hygiene, and toileting. Review of physician's orders in effect from 5/1/23 through 5/31/23, identified Resident #304 had been on Eliquis (a blood thinner) 5 milligrams (mg) twice daily and was at increased risk for bleeding. A nursing progress note dated 5/31/23 at 2:13 PM identified Resident #304 was in bed, receiving incontinent care from NA #1, and had rolled out of the bed. Resident #304 sustained a head laceration to the right back of his/her head, was bleeding, and complained of back pain. Pressure was applied to the area of bleeding, the APRN was notified, and the resident was transferred to the emergency room for an evaluation on 5/31/23 at 11:51 AM. Review of the hospital Discharge Summary dated 5/31/24 identified Resident #304 was on an anticoagulant (blood thinner) and was complaining of a fall out of bed while being changed. Resident #304 indicated that s/he struck the back of his/her head, reported a mild headache, and had pain between his/her shoulder blades. Resident #304 had a 2 centimeter laceration on the right back side of his/her head, received 3 staples, and underwent Computer Aided Tomography (CT) scans of the head, chest, and cervical and thoracic spine. The resident was given Tylenol 650mg (a pain reliever) with good effect. A nursing progress note dated 5/31/23 at 5:26 PM identified Resident #304 returned from the hospital, had 2 staples placed to the back right of his/her head, and had a hematoma (an area of blood pooling below the surface of the skin) noted. Review of the staff education sheet dated 5/31/23 identified that staff were to ensure all supplies were on hand and never to leave residents unattended, but if staff must leave, to ensure the resident was in a safe position with the call bell in reach. Review of Resident #304's NA care card (care plan), updated 6/1/23, directed the assistance of 2 staff when providing care and for bed mobility. Interview and review of facility documentation on 4/17/24 at 11:46 AM with the DNS identified that NA #1 had left Resident #304 unattended. According to facility documentation, NA #1 was performing incontinent care on Resident #304, placed him/her on their side unsecured. NA #1 then left the resident on their side, unattended to obtain water from the resident's bathroom. While NA #1 was in the bathroom, Resident #304 verbalized s/he was sliding and was going to fall, but NA #1 was unable to reach the resident in time to prevent him/her from falling to the floor. NA #1 was educated to have supplies ready to perform care and not to leave resident's unattended on their side in the bed. Additionally Resident #304 should have been rolled onto his/her back prior to NA #1 leaving to obtain water from the resident's bathroom. Interview and clinical record review with PT #1 on 4/17/24 at 1:22 PM identified that Resident #304 had last been seen prior to his/her fall in June of 2022. At that time, Resident #304 had been made an assist of 1 for bed mobility and personal care, with a second staff to assist with transfers, the resident was non-ambulatory, used a specialized wheelchair, and had remained at the same functional status since the previous screening. Following Resident #304's fall on 5/31/23 PT received a request to screen the resident. Resident #304 was screened on 6/5/23 but was not not picked up for services as there had been no change from the previous screen in June 2022. Additionally, PT #1 identified that Resident #304 required partial to moderate assistance of 25-50% and anyone requiring any level of assistance with care is hands on and should not be left alone during care. She identified that staff leaving the resident in a side lying position to go the bathroom for water was not acceptable for safety reasons. She also indicated that Resident #304 had a balance deficit for sitting and standing. Resident #304 had not been assessed during the screen for bed mobility and PT #1 was unsure how capable Resident #304 would have been to stop him/herself from falling using the bed frame or mattress as Resident #304 did not have siderails on his/her bed to utilize for repositioning. PT #1 was unable to identify if Resident #304 required siderails for bed mobility as she had not assessed the resident for siderail use. Further review of the clinical record failed to identify if Resident #304 had his/her fall care plan intervention, a fall mat on the right side of the bed, in place as no post fall assessment had been conducted. Attempts to contact NA #1 were unsuccessful. Although requested, a facility policy for accidents and resident supervision and safety was not provided. Review of the facility Falls policy dated 3/2018 directed, in part, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

50177 Based on interviews, review of the clinical record and facility policy for 1 of 4 residents (Resident #454) reviewed for accidents, the facility failed to include in the Resident Baseline Care Plan interventions to prevent falls for a resident who sustained a fall with injury prior to admission and for 1 of 3 residents (Resident #554) reviewed for pressure ulcers, failed to initiate a Resident Baseline Care Plan for a resident admitted with an unstageable pressure ulcer. The findings include: 1. Resident #454 was admitted to the facility on [DATE] with diagnoses that included a displaced fracture of the anterior wall of the left acetabular (broken hip), dementia, and difficulty walking. A physician's order dated 3/25/24 directed no ambulation and to transfer using a mechanical lift with a two person assist. The Resident, Baseline Care Plan dated 3/25/24 identified that Resident #454 was a fall risk and had weight bearing restrictions with goals to maintain safety and to be free from falls/injury, however, did not identify any interventions to prevent falls. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #454 was severely cognitively impaired and required total dependence with all mobility utilizing his/her wheelchair. Walking was not attempted due to Resident #454's medical condition or safety concerns. Additionally, the MDS identified that Resident #454 had a fall within the last month and a fracture related to a fall within the last 6 months prior to admission. A nurse's note dated 3/29/24 at 10:34 PM identified that Resident #454 was found on the floor at 8:35 PM with an open, bleeding laceration on the back of his/her head and was sent to the hospital for further evaluation. A computed tomography (CT) scan of the pelvis completed at the hospital and dated 3/29/24 identified that the previous fractures (from Resident #454's fall prior to admission) demonstrated increased displacement when compared with the previous scan. A CT scan of the head dated 3/29/24 identified no acute intracranial hemorrhage (brain bleed). Interview and clinical record review with the Director of Nursing Services (DNS) on 4/22/24 at 11:25 AM identified that the admitting nurse supervisor at the time of admission was responsible for completing the Baseline Care Plan and if it was not completed, the DNS was responsible to ensure completion. Further, the DNS indicated that the Baseline Care Plan was to be completed within 48 hours and should have included interventions to prevent falls. The DNS stated that the facility was working with their Quality Assurance and Performance Improvement program to improve care plans. 2. Resident #554's diagnoses included hemarthrosis (bleeding into the joint cavity) of the right hip, unsteadiness on feet, and intervertebral disc disorder with radiculopathy (pinching of a nerve in the spinal column). Review of the Resident #554's care card (care plan) signed by nursing on 4/8/24 at 6:50 PM failed to identify any directives regarding a wound or a pressure relieving mattress (care card is blank). Physician's orders dated 4/9/24 directed the use of a pressure relieving mattress on the bed, and to cleanse the coccyx wound with normal saline, apply Medi honey and cover with foam dressing daily and as needed, and to monitor dressing to coccyx every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #554 was cognitively intact and was dependent on staff for bed mobility and toileting. Additionally, the MDS indicated the resident was admitted to the facility on [DATE] with an unstageable community acquired pressure ulcer. Interview and clinical record review with RN #4 (MDS Coordinator) on 4/23/24 at 11:38 AM identified that Resident #554 did not have a baseline or comprehensive person-centered care plan developed for his/her community acquired pressure ulcer. RN #4 identified that she was new to her role and that she worked with the DNS to develop the care plans, but that ultimately it was her job to initiate and review/revise care plans. She reported the care plan was missed and that she would initiate one. Subsequent to surveyor inquiry, a care plan was added for Resident #554 on 4/23/24 to identify an unstageable coccyx pressure ulcer. Review of the Baseline Care Plan policy dated 3/2022 directed, in part, that a baseline care plan is developed for each resident within 48 hours of admission to meet the resident's immediate health and safety needs. Additionally, the Baseline Care Plan includes instructions needed to provide effective, person-centered care of the resident that meets the professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #304) reviewed for accidents, the facility failed to assess the resident's neurological status and failed to complete a fall assessment following a fall with head injury per the facility policy. The findings include: Resident #304 's diagnoses included dementia, anxiety, history of a transient cerebral ischemic attack (TIA), atrial fibrillation, and blindness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #304 was severely cognitively impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Additionally, Resident #304 had balance issues during transitions when moving from a seated to standing position, and surface to surface transfers between the bed and chair or wheelchair. Review of the Resident Care Plan (RCP) in effect from 5/1/23 through 5/31/23 identified that Resident #304 was at risk for falls and required assistance with Activities of Daily Living (ADL's). Interventions included arranging personal items within reach, monitoring for safety, placing a floor mat to the right side of the bed, and providing the assistance of 1 staff for bed mobility, bathing, dressing, hygiene, and toileting. A nurse's note dated 5/31/23 at 2:13 PM identified that Resident #304 was receiving incontinent care by a NA and rolled off the side of the bed and sustaining a bleeding laceration to the right backside of his/her head and which required a pressure dressing. The note identified that vital signs were obtained but failed to indicate any neurological or fall assessments. Review of the facility's Accident and Incident (A&I), investigation information, and clinical record identified Resident #304 had fallen on 5/31/23. A Neurological Checks form was with the documentation which read: To be done following a head injury, TIA, active seizure, unwitnessed fall, or any other situation which may alter neurological status and that neurological checks were to be completed every 15 minutes for the first hour. The first line of the table on the form was time stamped on 5/31/23 at 11:45 AM but failed to document the level of consciousness, right and left pupil reactions, or the strength and sensation of both the right and left extremity (indicating neurological checks). Additional review of the clinical record (paper or electronic) failed to indicate a nurse's note indicating neurological signs or that a post fall assessment had been completed prior to Resident #304's transfer to the hospital on 5/31/23 at 11:51 AM. Interview with RN #3 (RN Supervisor) on 4/22/24 at 8:59 AM identified that according to the facility policy, after either an unwitnessed fall or a fall with a head injury, both neurological and fall assessments were to be conducted by the RN Supervisor. RN #3 indicated that previously the electronic health record had a Fall Assessment section, but due to a computer issue, the section was no longer available and both the neurological and fall assessments were to be conducted on paper and a nurse's note written. RN #3 was unable to locate assessments that Neurological Checks and a Fall Assessment had been completed following Resident #304's fall and she was unable to explain the lack of assessments. Interview with the DNS on 4/22/24 at 10:30AM identified that no fall assessment was conducted (paper or the EHR) following Resident #304's fall with injury on 5/31/23, but that fall assessments should be conducted following any resident fall. Review of the Neurological Assessment policy dated 10/2010 directed, in part, that neurological assessments are indicated following a fall or other accident/injury involving head trauma and the nurse should check vital signs (temperature, pulse, respirations, and blood pressure), pupil reaction, determine motor ability, determine sensation in extremities, assess the gag reflex, and check eye opening, verbal and motor responses using the Glasgow Coma Scale. All assessment data obtained should be documented in the resident's medical record. Review of the Falls- Clinical Protocol policy dated 3/2018 directed, in part, that the nurse shall document/report on a change in cognition or level of consciousness, neurological status, and the frequency and number of falls since last physician visit. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls.

Based on review of the clinical record, and interviews for the only sampled resident (Resident #19) reviewed for a change in condition, the facility failed to correctly transcribe physician's orders for a medication, Synthroid. The findings include: Resident #19 's diagnoses included hypothyroidism, metabolic encephalopathy, and Vascular Dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #19 was moderately cognitively impaired and required, maximal assistance with bed mobility, moderate assistance with eating and was dependent with toileting hygiene. The Resident Care Plan dated 4/6/22 identified issues with Activities of daily living. Interventions included providing all nourishment and medication through the G-Tube. Interview with Person #3 on 4/17/24 at 1:40 PM indicated that in 2022 Resident #19 had been receiving Synthroid 125 mcg, however, should have received Synthroid 62.2 mcg (one half of the 125 mcg dose). Person #3 reported the facility had requested to change the time of administration, to which they consented. After receiving Resident #19's laboratory result in November 2022 (5 months following the change in time of administration) Resident #19's blood level was noted to be abnormally low. Person #3 indicated that s/he believed Resident #19's Synthroid dosage had been doubled. A readmission hospital W10 dated 4/30/22 directed Resident #19 was to receive Synthroid, 125mcg (62.5 mcg total) tablet via PEG tube daily on empty stomach. A nurse's note dated 4/30/22 at 11:23 PM identified Resident #19 returned to the facility from the hospital, the APRN was notified, and verified the readmission orders. A physician's order dated 5/2/22 directed to give 125 mcg of Synthroid once daily, give one half tablet. Review of the Medication Administration Records (MAR) from 5/3/22 through 6/10/22 directed that Synthroid 125 micrograms (mcg) one half tablet (62.5 mcg) had been given every morning. On 6/10/22 the MAR indicated Synthroid 125 mcg (give 1/2 tab) had been discontinued. A time of administration change was noted on the MAR and the order for Synthroid 125 mcg was rewritten but lacked the indication that one half tablet (62.5 mcg) should be administered. A physician's order sheet dated 11/30/22 directed to discontinue the Synthroid. A Quality Assurance reporting form dated 3/15/23 indicated that a mediation administration and documentation error had occurred. Further, the form indicated the staff who had changed the time of administration had been reeducated on the 5 rights of medication administration (right route, right dose, right resident, right time, right medication). Although requested, the facility failed to provide a policy. 50250

Based on review of the clinical record, facility policy, facility documentation, and interviews for 3 of 3 residents (Resident #554) reviewed for pressure ulcers, the facility failed to ensure a low air loss mattress was set at the appropriate setting for Resident #554's weight, and failed to assess and measure a community acquired pressure ulcer on admission. The findings include: Resident #554's diagnoses included hemarthrosis (bleeding into the joint cavity) of the right hip, unsteadiness on feet, and intervertebral disc disorder with radiculopathy (pinching of a nerve in the spinal column). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #554 was cognitively intact and was dependent on staff for bed mobility and toileting. Additionally, the MDS indicated the resident was admitted to the facility on [DATE] with an unstageable community acquired pressure ulcer. Review of discharge summary paperwork from Hartford Hospital dated 4/8/24 identified that resident was followed by wound care, but did not indicate where the wound was located, the measurement, or the treatment to the wound. Review of the Nursing Admission Evaluation dated 4/8/24 identified that Resident #554 was admitted with a wound but did not include an assessment of the wound or provide measurements of the wound on admission. Review of nursing progress notes dated 4/8/24 failed to identify a wound. Physician's orders dated 4/9/24 directed to monitor the dressing to the coccyx every shift, and cleanse the coccyx wound with normal saline, then apply Medihoney and cover with foam dressing daily and as needed. Review of nursing progress notes from 4/9/24 through 4/17/24 identified a wound to the coccyx but failed to identify wound measurements. A physician's note dated 4/10/24 failed to mention a wound on Resident #554. A wound physician note dated 4/15/24 identified Resident #554 with an unstageable pressure wound to the coccyx and included a wound evaluation and measurements of 6 cm x 3 cm x 0.1 cm. Interview with LPN #1 on 4/18/24 at 9:32 AM identified that the facility was aware prior to admission on 4/8/24 that Resident #554 had a wound to her coccyx and stated they were also alerted when they received report by phone from Hartford Hospital. A late entry nursing progress note on 4/18/24 at 12:35 PM identified that Resident #554 was seen by the wound physician on 4/15/24. The note included the measurements, assessment of the wound, and the treatment that was ordered and administered. Interview and clinical record review with RN #1 on 4/22/24 at 12:22 PM identified that no wound evaluation or measurements were done on admission for Resident #554. She indicated that it is facility policy that a community acquired wound is assessed and documented on admission by an RN in the Nursing Admission Evaluation, and identified the wound was not measured until she saw the resident with the wound physician on 4/15/24. She was unable to identify if the coccyx wound had increased in size or changed in appearance from 4/8/24 through 4/15/24. Review of the Prevention of Pressure Injuries policy dated 4/2020 directed, in part, to conduct a comprehensive skin assessment upon admission. During the skin assessment inspect for the presence of erythema, temperature of the skin and soft tissue, and edema. Evaluate, report, and document potential changes in the skin.

Based on observation, interviews, review of the clinical record and facility policy for the only sampled resident (Resident #13) reviewed for respiratory care, the facility failed to provide oxygen therapy consistent with professional standards of practice. The findings include: Resident #13's diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, and shortness of breath. A physician's order dated 3/19/24 directed to administer oxygen at 6 liters (L) via nasal cannula. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was without cognitive impairment and required partial/moderate assistance with toileting, showering, dressing, and personal hygiene. Walking was not attempted due to Resident #13's medical condition or safety concerns. Additionally, the MDS identified that Resident #13 received oxygen therapy. The Resident Care Plan dated 3/27/24 identified a problem with respiratory status. Interventions included to assess and monitor respiratory status and signs/symptoms of complications, medications and vital signs as ordered, and oxygen to maintain therapeutic oxygen level. Observation and interview with Resident #13 on 4/18/24 at 1:55 PM identified that he/she had returned to the unit after his/her portable oxygen tank was noted to be empty while attending a lunch group with recreation in an area of the complex requiring transportation via a wheelchair van. Resident #13 identified that he/she was without oxygen for approximately 2 minutes and he/she still felt shaky. Interview with LPN #1 on 4/18/24 at 2:14 PM identified that Resident #13 received 6 L of oxygen and that a portable oxygen tank would last about 1 hour for someone receiving 6 L of oxygen, therefore 2 tanks were typically supplied when Resident #13 left the unit. Additionally, LPN #1 identified that she did not administer or set the portable oxygen on Resident #13 when the resident left the unit and Resident #13 left the unit with only 1 tank. Interview with the Recreation Director (Life Enrichment Supervisor) on 4/18/24 at 2:19 PM identified that she had applied and set the portable oxygen on Resident #13. Additionally, the Recreation Director identified that she confirmed the oxygen setting of 6 L with LPN #1. The Recreation Director identified that she was unaware Resident #13 typically brought 2 portable oxygen tanks with him/her off the unit and connected only 1 tank. An additional interview with LPN #1 on 4/18/24 at 2:25 PM identified that she was in the hallway when the Recreation Director inquired on the liter flow of Resident #13's oxygen, however was not aware that the Recreation Director was applying oxygen to Resident #13. A nurse's note dated 4/18/24 at 3:36 PM identified Resident #13 went to a luncheon with recreation via wheelchair van, the portable oxygen tank was low and a Nurse Aide brought a new portable oxygen tank to Resident #13. Resident #13 then returned to the unit with the Nurse Aide in no distress. Interview with the Director of Nursing Services (DNS) on 4/22/24 at 11:25 AM identified that only nurses are allowed to administer and set oxygen. Additionally, the DNS advised that staff would be retrained on who can apply oxygen to a resident. Review of the Oxygen Administration policy identified the steps to complete safe oxygen administration, including review of the physician's orders, completion of assessments before and during administration, and documentation. The Oxygen Administration policy was retrieved from the Nursing Services Policy and Procedure Manual for Long-Term Care. Subsequent to surveyor inquiry, a retraining dated 4/23/24 was provided identifying that only nurses can perform oxygen administration.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who required supervision with all meals, the facility failed to ensure the resident was supervised when eating in accordance with the plan of care. The findings include: Resident #1's diagnoses included dysphagia and dementia. The Speech Therapy discharge summary dated 4/12/22 identified Resident #1 had made fair progress towards goals from time of evaluation to time of discharge. Resident #1 was being discharged from skilled speech therapy services at this time as maximum rehabilitation potential had been met and Resident #1 was tolerating the safest and least restrictive diet. The discharge recommendation included close supervision and to facilitate safety and efficiency, it was recommended Resident #1 use the following strategies and maneuvers during oral intake: lingual sweep and re-swallow, alternation of liquids and solids, rate modification, bolus size modification and general swallow techniques and precautions upright posture during meals and upright posture for more than thirty (30) minutes after meals. The Resident Care Plan dated 2/1/23 identified Resident #1 had diagnosis of dysphagia. Interventions directed to provide supervision with meals and snacks, to assist Resident #1 into an upright position for meals and snacks, and to eat all meals in the dining room as tolerated. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had long and short-term memory problem, poor making skills regarding tasks of daily life, required supervision when eating after set up, was on a mechanically altered diet and had no teeth. A monthly physician order dated 5/1/23 directed do not resuscitate, do not intubate, registered nurse may pronounce, and regular mechanical soft diet, small portions, and thin liquids diet. The Facility Reported Incident form dated 5/7/23 at 6:15 PM identified Resident #1 was eating dinner and began to choke on ground chicken. The nurse's note dated 5/7/23 at 10:28 PM identified at 6:00 PM the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, went to check on Resident #1 to see how he/she was doing with supper, Resident #1 was sitting in bed with the head of bed at ninety (90) degrees eating the meal. The note indicated at approximately 6:15 PM the 3-11PM nurse aide, Nurse Aide (NA) #1, was calling out for LPN #1 to come to Resident #1's room, Resident #1 was found to have some food in his/her oral cavity, and Resident #1's face was dusky in color. The note identified NA #1 was instructed to call the Nursing Supervisor and have the Nursing Supervisor call 911, the bed was immediately put in flat position, LPN #1 started to perform abdominal compressions (Heimlich Maneuver), two (2) small pieces of chicken salad were visualized in the oral cavity and removed. The note indicated Resident #1's mouth and lips were noted to be blue in color within five (5) to ten (10) minutes after the Heimlich Maneuver and chest thrusts were started. The note identified the first responders arrived in Resident #1's room at approximately 6:25 PM, the Automated External Defibrillator (AED) was applied and no shock was advised, Resident #1 had no heart rate at this time and was pronounced at 6:45 PM. Interview with the 3-11PM charge nurse, LPN #1, on 5/22/23 at 11:01 AM identified Resident #1 was sitting in an upright, ninety (90) degree position in his/her room eating dinner. LPN #1 indicated Resident #1 required general supervision with meals, NA #1 and herself would go in and out of Resident #1's room to check on Resident #1 to make sure he/she was eating and was okay. LPN #1 identified Resident #1 liked to feed him/herself. LPN #1 indicated she saw Resident #1 fifteen (15) minutes prior to the incident, and Resident #1 was eating dinner, did not have any difficulty swallowing, and was not coughing while she was in the room. LPN #1 identified fifteen (15) minutes later NA #1 went into Resident #1's room and called for her to come into Resident #1's room. LPN #1 indicated once she entered the room, Resident #1's face was dusky, purplish in color, Resident #1 was not trying to clear his/her throat, was not coughing, Resident #1 was just staring. LPN #1 identified she instructed NA #1 to call the Nursing Supervisor and call 911. Interview with the Speech Therapist on 5/22/23 at 11:40 AM identified Resident #1 required supervision with meals which meant a nurse aide or nurse was to sit with Resident #1 in the room while Resident #1 was eating dinner providing feeding assistance or cueing. Interview with the Nurse Practitioner (NP) #1 on 5/22/23 at 11:54 AM identified talking with the Medical Director and the events of the incident, no signs or symptoms of choking evidenced by gagging, coughing, they decided the cause of death was cardiac arrest, which was denoted on the death certificate. Interview with the 3-11PM nurse aide, NA #1, on 5/22/23 at 1:40 PM identified she would check on Resident #1 while Resident #1 was eating dinner in the room to make sure Resident #1 was okay. NA #1 identified if a resident was a feed, then she needed to stay with a resident until the resident finished eating and supervision with meals meant to check on a resident, pop in and out to make sure the resident was eating and okay. Interview with the Director of Nursing (DON) on 5/22/23 at 12:05 PM identified Resident #1 required close supervision with meals and snacks. The DON indicated NA #1 or LPN #1 were to provide supervision during dinner which meant for one (1) of them to stay with Resident #1 in his/her room while Resident #1 was eating dinner. The DON identified NA #1 and LPN #1 told her they were taking turns going in and out of Resident #1's room. The DON indicated there was no policy that differentiated what close and direct supervision meant.

Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three residents (R #1) reviewed for accidents, the facility failed to ensure assistance was provided in accordance with the plan of care to prevent a fall with an injury. The findings include: R #1's diagnoses included [CONDITION(S)], muscle weakness, and lumbar vertebra compression fracture. A physician's order dated 8/10/20 directed to ambulate R #1 two times a day, fifty to seventy feet with contact guard with one assist and a rolling walker, to use a gait belt and a wheelchair to follow. The quarterly Minimum Data Set assessment dated [DATE] identified R #1 had cognitive impairment, required extensive assistance of one person to ambulate in the room, and was not steady (was only able to stabilize with staff assistance). The Resident Care Plan (RCP) dated 10/26/20 identified R #1 was at risk for falls. Interventions directed to ambulate R #1 with contact guard assist of one person, and to utilize a rolling walker, a gait belt and a wheelchair to follow. Review of the facility incident report dated 11/16/2020 at 5:45 AM identified when Nurse's Aide (NA) #1 walked R #1 to the bathroom, R #1 stumbled and fell backwards onto NA #1 and then fell to the floor. Facility investigation further identified that NA #1 did not use a gait belt when ambulating R #1 to the bathroom. The nurse's note dated 11/16/20 at 11:15 PM identified R #1 complained of severe right hip pain. The APRN was notified and a new order for a right hip x-ray was obtained. The x-ray was completed at 10:30 PM and the technician confirmed an obvious fracture of the right hip. The APRN was notified and R #1 was transferred to the hospital. Review of facility x-ray report dated 11/16/20 at 10:31 identified an acute fracture of the right hip. Hospital discharge summary dated 11/20/20 identified R #1 underwent a surgical repair or his/her right hip fracture; R #1 had a right hip intertan surgical procedure for a right intertrochanteric proximal femoral fracture while at the hospital. Review of the nurse's note dated 11/20/20 at 8:28 PM identified R #1 was readmitted to the facility, status post right hip pinning. During an interview on 2/5/21 at 11:30 AM with LPN #1, LPN #1 stated that R #1 required the use of a gait belt for ambulation. She further indicated that gait belts are used for all residents who require staff assistance with ambulation. Interview with Certified Occupational Therapy Assistant (COTA) #1 on 2/5/21 at 11:55 AM identified R #1 required contact guard and a rolling walker with a gait belt for ambulation. He further identified that staff should have used a gait belt on 11/16/20 when the incident occurred. During an interview on 2/5/21 at 11:36 PM with NA #1, NA #1 stated that on 11/16/20 she ambulated R #1 from his/her bed to the bathroom using a walker. R #1's legs gave out R #1 fell on to the floor, sitting on his/her buttocks. NA #1 stated that she did not use the wheelchair or the gait belt while ambulating R #1 to the bathroom. NA#1 further stated that although she was aware that she should have used a gait belt when ambulating R #1, she did not use a gait belt on 11/16/20. NA#1 further stated that she was aware that R #1 should be ambulated with the assistance of a gait belt but she was unable to find the gait belt that was assigned to R #1. In an interview with the Director of Nursing on 2/8/21 at 12:10 PM, she indicated that NA #1 did not follow facility policy and physician's orders when she ambulated R #1 on 11/16/20, and she should have used a gait belt. Review of the facility gait belt policy indicated that staff who are responsible for assisting patients with ambulation, transfer and transport procedures must utilize a transfer belt at all times, unless the patient's condition contraindicates such use.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (R #2) reviewed for accidents, the facility failed to ensure a brace was applied in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] R #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan dated 8/17/20 identified R #2 required assistance with ADLS, and was at risk for falls related to difficulty walking and poor standing balance. Interventions directed to assist R #2 to put on his/her TLSO brace when sitting up or out of bed, provide assist of one for transfers and ambulation, and keep call bell within reach. The Physician's history and physical dated 8/19/20 identified a plan to continue with cervical neck brace and TLSO brace as ordered. The admission Minimum Data Set assessment dated [DATE] identified R #2 had moderate cognitive impairment, required extensive assistance of one person for toilet use and personal hygiene, and R #2's balance was not steady (was only able to stabilize with staff assistance with transfers and/or moving from seated to standing position). The nurse's note dated 8/30/20 at 4:23PM identified that staff heard noise coming from R #2's bathroom and R #2 was found sitting on floor. The resident stated he/she fell while attempting to pull the string for the call light. R #2 complained of severe right hip pain and stated he/she hit head on the wall. R #2 was transferred to the hospital for evaluation. Review of the hospital discharge summary dated 9/2/20 identified that R #2 had a separation of his/her right greater trochanter from the main shaft femur, and R #2 was not a surgical candidate. The nurse's note dated 9/2/20 at 8:54 PM identified R #2 was readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 2/5/21 at 1:36 PM, NA #2 stated that she assisted R #2 to the bathroom, R #2 asked for privacy and she instructed the resident to call for help before she left R #2 in the bathroom. NA #2 stated that shortly after exiting the room, she was a few doors down the hall when she heard a loud noise and upon entering the bathroom she observed R #2 on the floor. NA #2 indicated that R #2 was a new patient to her, and she was not aware that R #2 was at risk for falling. NA #2 further indicated that R #2 did not have the TLSO brace on when she ambulated R #2 to the bathroom or while sitting on the toilet. Interview with RN #1 on 2/5/21 at 2 PM identified she directed the NA to not leave R #2 alone in the bathroom. She further indicated that after the fall she asked NA #2 why R #2 was left alone in the bathroom, but NA #2 did not provide an answer. In an interview on 2/8/21 at 9:50 AM, Certified Occupational Therapy Assistant (COTA) #1 indicated that R #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . COTA#1 further indicated that R #2 had limited range of motion to left upper extremity and required the use of the TLSO brace when out of bed. COTA #1 stated that not wearing the TLSO brace when on the toilet could affect R #2's balance, and R #2 could fall. In an interview on 2/8/21 at 12:10 PM, the Director of Nursing (DON) indicated that although R #2's plan of care directed use of the TLSO brace when out of bed, the TLSO brace was not on R #2 when R #2 was in the bathroom at the time of the fall. A review of the facility fall and fall prevention policy indicated in part, that the resident's environment will remain free from accident hazards as possible and each resident will receive adequate supervision and assistive devices to prevent accidents.

Based on clinical record reviews, observations, review of facility documentation, and interviews for one sampled resident (Resident #1) who was reviewed for infection control practices, the facility failed to ensure that face shields were cleaned appropriately. The finding includes: Resident (R) #1's [DIAGNOSES REDACTED]. The admission data collection and documentation form dated 9/21/20 identified R #1 with cognitive impairment. The Resident Care Plan dated 9/21/20 identified R#1 was at risk for respiratory exchange as related to being a person under investigation (PUI) for COVID-19. Interventions directed to place R#1 under contact and droplet precaution and isolation. A physician's orders [REDACTED]. The nurse's note dated 9/28/20 at 11:43AM indicated R#1 remained on droplet precautions related to transfer from another state and his/her COVID assessment negative for signs and symptoms. During interview and review of facility Personal Protective Equipment (PPE) on 9/29/20 at 10:10AM, the administrator indicated that facility have one thousand two hundred and seven (1207) face shields. An observation on 9/29/20 at 10:20 AM with the Director of Nursing (DON) identified a clear plastic bin with Personal Protective Equipment (PPE) was located in-front of R#1's door. The top complartment of the bin contained blue surgical masks, several clear plastic bags and three face shields. The face shields had a soft sponge area approximately one inch thick that rested directly on staff foreheads. The face shields were noted to have a smudged appearing coating and the shield elastic was worn. During an interview with the DON on 9/29/20 at 10:20 AM she indicated that smudge resulted from staff cleaning the face shield with Clorox wipes. The DON indicated that the identified face shields were assigned to R#1 and it is the nursing staff responsibility to ensure that shields are wiped after use and return to the PPE cart. During an interview with Nursing Assistant (NA) #1 on 9/29/20 at 10:25 AM she indicated that facility staff does not have individual face shield and one face shield is used by several staff on different shifts. NA#1 further indicated that she often tries to clean the sponge area on the face shield with an alcohol wipe after using. During an interview with Registered Nurse (RN) #1 (Infection Preventionist) on 9/29/20 at 10:30 AM she indicated that R#1 was newly admitted to the facility and will be on quarantine for 14 days. During the 14 days staff entering room are required to use full PPE which included face shield and gown. RN#1 also indicated that three (3) face shields were assigned for staff to utilize when entering R#1's room. During further interview with RN#1 she indicated that although the facility had an adequate supply of face shields, the facility did not provide individual face shield to staff. RN#1 further stated that face shields are assigned to the resident and are utilized by different staff on all three shifts. Review of the facility re-usable PPE policy instructed staff to wipe the inside and outside of the face shield using a clean cloth saturated with neutral detergent solution or cleaning wipes. Although the facility re-usable PPE policy instructed staff on how to wipe the face shield, the policy did not address or direct staff on how to clean the sponge area of the face shield. Subsequent to surveyor's inquiry RN#1 indicated that a face shield will be assign to each individual employee.

Based on a review of the clinical record, a review of facility documentation, staff interviews and a review of the facility policy for two of two sampled residents, (Resident #8 and #364), reviewed for abuse, the facility failed to report an alleged violation of abuse and misappropriation of resident property and failed to report the results of the investigation to the proper authorities within prescribed timeframe's. The findings include: a. Resident # 8's diagnoses included dysphagia, muscle weakness, difficulty walking and dysphagia. Physician's orders dated 7/2/19 directed the assistance of one staff for care. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, absence of behavioral problems, extensive assistance of two staff for bed mobility, and assistance of one staff for dressing. The care plan dated 8/22/19 identified Resident # 8 required assistance for activities of daily living related to his/her advanced age. Interventions included the assistance of one staff for toileting and dressing. Review of the nurses note dated 9/9/19 identified Resident #8 had shower and a light discoloration was noted to his/her bilateral forearms. While the resident had a visitor at the facility he/she voiced care complaints from the weekend. The nursing supervisor and the Director of Nursing (DNS) were notified. Further review of the nurses notes dated 9/1/19 through 9/15/19 failed to identify any information regarding forearm discolorations, care concerns, or follow up regarding these allegations. Review of social services notes for the month of September 2019 failed to identify any issues related to allegations of abuse. Review of facility grievance form dated 9/9/19 identified Resident #8 voiced concerns that he/she was afraid of a staff member. The grievance form written and signed by the DNS identified LPN #3 informed the DNS that Resident # 8 stated a female Nurses aide (NA) raped her and beat her up. The documentation further identified that the RN supervisor had completed a body audit and found a bruise on the back of his/her right hand and some bruising on his/her forearm. The document further identified the staff in question was believed to be NA #4. The grievance form identified that NA #4 would no longer be caring for the resident. Psychiatric consultations reviewed from 8/1/19 to 10/1/19 reflected one psychiatric consult dated 9/12/19, which identified the consultation was a follow up for problematic behavior, and did not reflect an evaluation related to allegations of abuse. Interview and review of the grievance form with the DNS on 1/30/20 at 12:25 PM identified he/she was aware of a grievance concern but missed that it was an allegation of abuse. The DNS indicated he/she should have identified this as an allegation of abuse and reported to the state agency and did not. The facility policy for Abuse Prevention Program identified the facility would report an allegation of abuse within two hours to the state agency. b. Resident #364 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of the lateral malleolus, osteoarthritis, and major depressive disorder. The discharge care plan dated 1/13/20 identified Resident #364 was alert and oriented and had been admitted for short term rehab. Interventions included social service would meet with Resident #364 one to one. During visits, social service would orient him/her to the unit and the facility routine. Resident #364 would have opportunities to verbalize feelings and an assessment for psychosocial concerns would be conducted. The admission MDS dated on 1/16/2020 identified Resident #364 was cognitively intact, and required extensive assistance with one person physical assist for dressing and personal hygiene. Review of the clinical record with RN #3 on 1/30/2020 at 11:25 AM indicated a nursing note dated 1/18/2020 identified Resident #364 reported a grievance related to $40.00 dollars that was missing from his/her handbag/purse to LPN #4. LPN #4 reported the allegation to RN #3. Interview with RN#3 on 1/30/2020 at 11:30 AM identified she completed a grievance report and investigation but was unable to locate the missing funds. RN #3 submitted the report to the social worker and DNS. Review of the grievance form on 1/30/20 at 12:15 PM identified on 1/18/20, Resident #364 reported an allegation of misappropriation of money. On 1/23/20, the facility located a single $20.00 bill in the laundry, but not the remaining funds. Interview with the DNS on 1/30/20 at 11:40 AM identified he/she was aware of the allegation, but did not formally submit the reportable event to the local state agency. The DNS identified it was his/her responsible to submit and complete all reportable events to the state agency and in this case he/she did not. Review of facilities abuse policy identified if there was a specific written or verbal allegation of resident abuse, neglect, or misappropriation of resident property the facility would report the incident within 2 hours to the state agency and in addition report the findings to the state agency within 5 days. 41682

Based on a review of facility documentation, a review of the clinical record and staff interviews, for one of two residents reviewed for abuse, Resident # 8, the facility failed to ensure a complete and thorough investigation of an allegation of abuse, and failed to protect residents by removing staff pending the outcome of an investigation. The findings include: Resident # 8's diagnoses included dysphagia, muscle weakness, difficulty walking and dysphagia. Physician's orders dated 7/2/19 directed the assistance of one staff member for care. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, absence of behavior problems, required extensive assistance of two staff for bed mobility, and the assistance of one staff member for dressing. The care plan dated 8/22/19 identified the need for assistance with activities of daily living related to advanced age. Interventions included assistance of one staff member for toileting and dressing. Review of the nurses notes dated 9/9/19 identified Resident #8 had shower and a light discoloration was noted to his/her bilateral forearms. While Resident #8 had a visitor, the resident voiced care complaints from the weekend. The nursing supervisor and Director of Nursing (DNS) were updated. Further review of the nurses notes dated 9/1/19 through 9/15/19 failed to identify any information regarding forearm discolorations, care concerns, or follow up regarding the discoloration of the resident's skin. Social services notes from the month of September 2019 failed to reflect any concerns or allegations of abuse. Review of facility grievance form dated 9/9/19 identified Resident #8 voiced concerns that he/she was afraid of a staff member. The grievance form identified LPN #3 informed the DNS that Resident # 8, stated that a female nurses aide (NA) raped and beat him/her up. The documentation further identified the nursing supervisor had completed a body audit and found a bruise on back of the resident's right hand and bruises on the forearm. The document identified the staff in question was believed to be NA #4. The grievance form identified that NA #4 would no longer care for Resident #8. Psychiatric consultations reviewed from 8/1/19 to 10/1/19 reflected one psychiatric consult dated 9/12/19, which identified the consultation was a follow up for problematic behavior, and did not reflect an evaluation related to any incident of concern or allegation of abuse. Interview with the DNS on 1/31/20 at 11:28 AM identified he/she was not looking at the incident as an allegation of abuse, and should have. The DNS identified she/he should have followed the abuse policy and removed the staff from work pending the outcome of an comprehensive investigation and did not as he/she was not thinking of this as an allegation of abuse. The facility policy for Abuse Prevention Program directed in part that the facility would protect the resident or residents from potential harm during an investigation. If an employee was the alleged perpetrator, administration would take appropriate action, including suspending the employee pending the investigation.

Based on observation, clinical record review, staff interviews, review of facility documentation, and a review of facility policy and procedures for two of four residents (Resident #22 and Resident #60) reviewed for accidents, the facility failed to provide care in a manner to prevent an accident. The findings include: a. Resident #22's [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] identified Resident #22 had a Brief Interview for Mental Status( BIMS) score of five out of fifteen, indicating severe cognitive impairment and required extensive assistance of 2 person with transfers, dressing, and toilet use. Fall risk assessment dated [DATE] identified fall risk of 15 indicating Resident #22 was a high risk for falls. The Resident Care Plan (RCP) dated 6/30/16 identified Resident #22 as a risk for falls related to poor safety awareness, decreased strength, decreased endurance and vascular dementia with interventions that included fall risk assessments as indicated, provide toileting upon request, and call bell within reach. A physician's orders [REDACTED]. Review of Resident #22's care flow sheet dated 7/29/16 to 8/3/16 indicated that Resident #22 required extensive assistance of 2 for toilet use 5 of 12 times. The Nurse's notes dated 8/3/16 at 9:37 PM identified that Resident #22 was found lying on floor in bathroom on left side with laceration to left eyebrow. Nurse's notes also indicated Resident #22 was transferred to emergency room for evaluation. The Nurse's notes dated 8/4/16 at 1:07 AM indicated that Resident #22 received six (6) sutures to the left eyebrow area. The facility reportable event form dated 8/5/16 indicated that at approximately 6:30 PM on 8/3/16, Resident #22 was seated on the toilet and the nurse aide turned to dispose of a brief in the garbage and the resident fell on to the floor. In an interview with NA#1 on 5/2/17 at 2:45 PM, he/she indicated that on 8/3/16 Resident #22 was seated on the toilet and was leaning forward as if attempting to pick something up from the floor. NA#1 turned his/her back to Resident #22 and placed the soiled diaper into the garbage can and Resident #22 bent forward and fell on to the floor. During further interview with NA#1, he/she indicated that Resident #22 always had a tendency to lean forward when sitting on the toilet. In an interview with LPN#1 on 5/2/17 at 3:20 PM, LPN#1 indicated that on 8/3/16 he/she was summoned to the bathroom and upon arrival Resident #22 was observed lying on the floor with feet next to the front of the toilet, head next to bathroom door and with the resident's face looking out the door. LPN#1 also indicated that on observation, blood was noted on Resident #22's left forehead. In an interview with NA#2 on 5/3/17 at 12:25 PM, he/she indicated that on 8/3/16 he/she heard a loud noise in Resident #22's room and then heard NA#1 yelling. Upon entering Resident #22's room, he/she was laying on the bathroom floor. NA#2 further indicated that Resident #22 did not have good balance while seated and should not be left alone on the toilet. Review of acute care hospital documentation dated 8/3/16 indicated that Resident #22 had a stellate laceration to the left lateral eyebrow extending inferiorly and laterally with subcutaneous fat exposing. Acute care documentation further indicated that the laceration was repaired with six (6) sutures with recommendation to follow up with ophthalmology within 2-3 days. The facility failed to ensure measures were in place to prevent an accident. b. Resident #60 [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified that Resident #60 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In addition, the MDS identified Resident #60 as totally dependendent with two plus person physical assist for bathing, and extensive assistance with two plus person physical assist for transfers. The care plan reviewed on 3/9/17 identified that Resident #60 was at risk for falls and injury related to a seizure disorder with interventions to assist as needed and clear environment of obstacles. Also Resident #60 had impaired ADLs/mobility and required assist of 2 for transfers, 2 for toileting, 2 for ambulation, 2 for dressing/bathing, 2 for mobility, and 1 for grooming. A review of the Nurse Aide Care Card/Resident Summary identified that Resident #60's bathing preference was to take showers, but did not identify the level of assistance the resident required for bathing. A physician's orders [REDACTED]. A review of facility documentation identified that on 4/30/17 at 9:00 AM, Resident #60 was being wheeled out of the shower room stall by Nurse Aide #4 (NA #4). The nurse aide was positioned facing Resident #60 as he/she was pulling the shower chair. NA #4 indicated that he/she noticed that Resident #60 began jerking his/her upper body. NA #4 continued to move the shower chair. The nurse aide then noticed that Resident #60 beginning to shake again and looked down to ensure there was enough room to pull the chair out of the stall (doorframe). NA #4 indicated that he/she heard a bang and noticed that Resident #60 was bleeding from the right side of her head. NA #4 indicated that Resident #60 hit his/her head on the marbled surface of the shower stall. Resident #60 was sent out to the Emergency Department and returned with four sutures. The physician's orders [REDACTED]. An interview (and reenactment of the incident) with NA #4 on 5/4/17 at 9:30 AM indicated that on 4/30/17 at 9:00 AM, he/she had completed giving Resident #60 a shower and was pulling the resident's shower chair through the shower stall doorframe. The resident began to make jerking motions while under the doorframe. NA #4 indicated that Resident #60 often made jerking motions, especially if he/she had not yet been administered his/her scheduled medications (including anti-seizure medications). NA #4 further indicated that at the time of the shower on 4/30/17, the resident had not gotten his/her morning medications yet. NA #4 indicated that as he/she looked down to pull the shower chair through the door frame when he/she heard a bang and looked up to see the resident bleeding above the right eyebrow. An interview and review of the clinical record with the Director of Therapy on 5/4/17 at 12:15 PM identified that on 4/28/17 an order was placed for Resident #60 to be transferred via mechanical lift. An additional interview with NA #4 on 5/4/17 at 12:30 PM indicated that prior to Resident #60's shower on 4/30/17, the resident was transferred to the shower chair in the resident's room with the assistance of another nurse aide and the use of a gait belt. NA #4 indicated that he/she was not aware that Resident #60's activity orders had changed on 4/28/17, requiring a mechanical lift for transfers. NA #4 indicated that he/she was informed by nursing staff on 5/4/17 that Resident #60 was a mechanical lift for transfers, and two assist for all ADLs, including bathing. An interview with the Director of Nursing (DNS) on 5/4/17 at 10:00 AM indicated that the level of assistance required for bathing should be included on the Nurse Aide Care Card/Resident Summary under the Add Other Preferences tab. The DNS further indicated that for Resident #60, the assistance required for bathing was omitted. Subsequent to surveyor inquiry, the DNS indicated that he/she would edit the Nurse Aide Care Card/Resident Summary to ensure that the assistance needed for bathing would be featured more prominently for nursing staff to identify assistance needs. In addition, the DNS indicated that bathing times for Resident #60 could be adjusted so showers are given after the resident has received scheduled medications.

Based on review of the clinical record, review of facility documentation, and staff interviews for one of five sampled residents (Resident #2) reviewed for the provision of care after a change in condition was noted, the facility failed to ensure a thorough assessment was completed which delayed care to promote the residents highest practicable well-being. The findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified the resident had impaired cognition, (BIMS of 9), required extensive assistance of two staff for bed mobility, transfers, walking, and toilet use, and had no falls. The corresponding care plan identified the resident required assistance of one staff to transfer and ambulate with the rolling walker. physician's orders [REDACTED]. Additionally, physician's orders [REDACTED]. Nurses note dated 12/28/15 at 2:16PM reflected that the resident had complaints of pain to the right lower extremity, required two staff assist for transfers and toileting, and was unable to sit steady on the toilet. Additionally, the note reflected that the RN Supervisor (RN#2) was made aware and the above was noted in the APRN book. [MEDICATION NAME] was administered. Nurses note written by RN#2 (late entry for the morning of 12/28/15) dated 12/30/15 at 5:17PM reflected that a NA reported that Resident #2 complained of right upper leg pain the morning of 12/28/15. RN#2 went in to see the resident and he/she did not appear to be in severe pain. RN#2 notified the unit nurse who medicated the resident with [MEDICATION NAME]. Approximately 1 - 2 hours later the resident reported some relief. At 1:45PM PT#1 advised RN#2 that the resident was unable to ambulate and was having difficulty with transfers. RN#2 completed an assessment of the right hip which identified no redness/swelling/bruising or internal/external rotation. The APRN was updated and ordered a right hip x ray. Additionally, the APRN assessed Resident #2 20 minutes after RN#2 and ordered additional x rays of the right femur. A nurses note dated 12/28/15 identified the x-ray was completed at 10:45PM, 9 hours after RN#2 and the APRN assessment. A nurses note dated 12/28/15 at 11:35PM reflected the x ray identified a right [MEDICAL CONDITION] and after APRN notification, the resident was transported to the hospital for an evaluation. Review of a physical therapy discharge summary dated 12/28/15 reflected Resident #2 began demonstrating signs and symptoms of increased pain and decreased mobility with therapy. The resident had refused morning therapy but agreed to assistance with bathroom needs and bed mobility therapy during the afternoon. The resident ' s level of function prior to 12/28/15 was documented as a Contact Guard Assist (CGA) for bed mobility and minimum CGA with sit to stand and ambulation up to 75 feet with the rolling walker and CGA. On 12/28/15 the resident's level of function declined and it was documented that the resident required assist of two for transfers and bed mobility, was unable to bear weight on the right lower extremity and was unable to maintain sitting balance on the toilet. Therapy was discontinued unexpectedly due to an x ray finding of right [MEDICAL CONDITION] and the resident's subsequent admission to the hospital. Interview with RN#2 on 6/9/16 at 1:10PM identified that he/she could not remember what time staff notified him/her of Resident #2's hip pain but it was sometime in the morning. RN#2 indicated that he/she went in to see the resident that morning, and the resident did not appear to be in much pain and an assessment was not completed at that time. RN#2 was not aware that the resident had been having pain since 7:15AM and was not aware that the resident could not bear weight on the right leg. RN#2 indicated if he/she had been made aware of that information, a thorough assessment would have been immediately done. Interview with PT#1 on 6/9/16 at 2:30PM identified that the resident refused therapy in the morning on 12/28/15 but agreed to have therapy that afternoon. At that time, the resident was unable to maintain a sitting position and could not bear weight on the right leg. This was a clear change in condition/function as the resident could previously ambulate 75 feet with the rolling walker. PT#1 indicated he/she notified nursing and RN#2 came in to assess the resident. Accident/incident report dated 12/28/15 identified that NA#3 reported that when he/she got Resident #2 out of bed and put him/her in the wheelchair at 7:15AM the resident complained of pain in the right leg. NA#3's statement reflected that when the resident put his/her foot on the floor, he/she complained of pain to the right leg. The resident was brought to the bathroom and assisted to the toilet. After the resident was cleaned, he/she could not stand back up due to right leg pain. NA#3 went and got NA#4 to assist the resident off the toilet and back into the wheelchair. The charge nurse and supervisor were then updated. A statement by NA#4 reflected that at 7:40AM the nurse requested that he/she assist the resident. Resident #2 indicated to NA#4 that he/she could not move his/her leg. RN#2 walked in at that time. A statement by NA#5 reflected that at 8:20AM he/she went to get Resident #2 for breakfast and upon pushing the wheelchair the resident grabbed his/her leg and indicated he/she was in a lot of pain. NA#5 indicated he/she went to get the supervisor, who took over from there. A statement by RN#2 reflected that on 12/28/15 a NA reported that Resident #2 complained of right hip/leg pain. RN#2 went into visit Resident #2 and he/she did not appear to be in severe pain. RN#2 advised the unit nurse of the pain and [MEDICATION NAME] was administered. At approximately 1:45PM PT#1 advised RN#2 the resident was unable to ambulate and had difficulty transferring. After assessment and APRN notification, an x ray was ordered. The facility's investigation conclusion reflected that the fracture occured during the positioning/transfer out of bed between 7:15 - 7:30AM. Review of the hospital emergency department assessment dated [DATE] reflected the resident's right lower extremity was shortened and externally rotated. Additionally, any internal and/or external rotation caused significant discomfort. The hospital radiology report dated 12/29/15 reflected a multipartite intertrochanteric [MEDICAL CONDITION] femur with angulation and mild displacement of the lesser trochanter. A nurses note dated 1/1/16 reflected Resident #2 returned from the hospital status [REDACTED]. The facility policy on change in condition directed that the physician will be made aware of a significant change in the resident ' s physical/emotional/mental condition. Although requested, a facility policy on assessment by a RN after a change in condition policy was not provided. Based on the above investigation, the facility failed to complete a thorough assessment the morning of 12/28/15 when the resident experienced pain in the right hip and could not bear weight. Additionally, the facility failed to ensure timely interventions to address the residents change in condition, as the resident was not transported to the emergency department for 16 hours after a exhibiting a change in condition in the right hip.

Based on clinical record review, review of facility documentation, observations, and interviews for 2 of 4 residents (Resident #20 and #58) reviewed for accidents and/or for 2 sampled residents (Resident #33 and Resident #40) observed during tour and/or for review of the hot water temperatures, the facility failed to maintain appropriate supervision to prevent a fall with injury and/or ensure that the resident's mattress safely fit the resident's bed frame and/or ensure measures were in place to ensure a safe environment for the residents. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 9/3/15 identified that Resident #20 was at risk for falls related to decreased strength with an intervention to utilize a bed and chair alarm for safety. physician's orders [REDACTED].#20 was to have a bed and chair alarm in place and for staff to check the function every shift. physician's orders [REDACTED].#20 required an assist of 1 staff person for transfers and for Resident #20 to ambulate 50-100 feet with a rolling walker and assist of 1 daily. The MDS dated [DATE] identified Resident #20 as severely cognitively impaired and required extensive assistance of one staff person for ADLs including transfers, ambulation, and locomotion. The MDS further identified that Resident #20 normally used a walker and wheelchair and had a history of [REDACTED]. Review of the October 2015 Treatment Administration Record (TAR) identified that for all the shifts from October 1 to October 4 day shift, staff had checked the functioning of the bed and chair alarm. The TAR failed to reflect documentation that there was a problem with the alarms. Facility documentation dated 10/4/15 identified that at 9:45 am Resident #20 was found face down on the floor, bleeding from the nose. Resident #20's right forehead was swelling. Resident #20 was sent to the hospital for evaluation. Further documentation identified that NA #2 identified in a statement that he/she last saw Resident #20 when he/she offered Resident #20 if she need to use the bathroom. Additionally, the resident was found on the floor the bed/chair alarm were not sounding. Documentation of a statement from RN #1 identified that he/he did not see an alarm on Resident #20 on 10/4 and there was not an alarm sounding when she entered the room when Resident #20 was found on the floor. Nurses' notes dated 10/4/15 at 10:56am identified that Resident #20 was found face down on the floor, bleeding from the nose and head. Pressure was applied and 911 was called. Resident #29 was transferred to the Emergency Department for evaluation. A subsequent note at 1:50pm identified that Resident #20 was being admitted to the hospital. Further facility documentation identified that Resident #20 was treated in the hospital for a head laceration and subarachnoid hemorrhage. Interview on 6/9/16 at 1:15pm with NA #2 identified that he/she does not recall if the bed alarm was sounding at the time. Interview on 6/9/16 at 1:20pm with RN #1 identified the he/she was called to the room by the NA and Resident #20 was on the floor face down near the roommates bed and Resident #20 was sent to the hospital. RN #1 further identified that Resident #20 did not ambulate independently and was pretty sure alarms were in place. RN #1 did not recall if the alarm was sounding at the time of the incident. An attempt to interview LPN #2 was unsuccessful. The facility failed to ensure measures were in place to ensure Resident #20's safety. 2. Resident #58's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#58 to transfer and ambulate with rolling walker and assist of one. The Quarterly Assessment ((MDS) dated [DATE] identified Resident #58 was severely cognitively impaired (BIMS 3) and required extensive assistance of 1 staff with bed mobility, transfers, toileting, bathing, and dressing. Additionally, Resident #58 was not steady and only able to stabilize with staff assistance when moving on and off toilet. The Care Plan dated 5/26/16 identified risk for falls related to dementia, decreased strength, endurance, and coordination, and psychoactive drug use. Interventions included to keep resident where staff can visualize when out of bed, pressure alarm in bed and chair and to assist with all transfers. Review of Resident #58's care card identified not to leave resident unattended in the bathroom. Review of the facility's reportable event dated 5/27/16 identified that on 5/26/16 at 8:10PM NA #2 found Resident #58 sitting on the floor in his/her room bleeding from the back of the head. The facility investigation identified that NA #2 had assisted the resident to the bathroom and transferred him/her onto toilet at 8:05PM. It further identified that the resident closed the door to the bathroom indicating he/she wanted privacy. While the resident was in the bathroom, NA #2 left the room to answer another call bell and upon return to Resident #58's room, found the resident on the floor bleeding from the back of head and that blood was also noted on the bathroom sink. Additionally, it was identified that the resident fell in the bathroom while attempting to get up unassisted and then scooted self on his/her bottom on the floor out of bathroom and into room. Review of the nurses notes from 5/26/16 - 5/27/16 identified that Resident #58 was sent to the hospital emergency room for evaluation and treatment. It was further identified that resident's wound to the occipital area was closed with 2 staples and tetanus was updated. Interview with LPN #1 on 6/8/16 at 9:00AM identified that because Resident #58 was confused and had a sensor alarm for both bed and chair, he/she was not to be left unsupervised when in the bathroom. Interview with the DNS on 6/8/16 at 10:00AM identified that the resident was not to be left alone, unsupervised while in the bathroom. Additionally, although residents' bathroom privacy was important, it was his/her expectation that all staff be able to visualize a confused resident who is identified as at risk for falls. Interview with NA#1 on 6/9/16 at 1:15 PM identified that he/she was aware that Resident #58 was at risk for falls and required assistance and supervision with toilet use. Additionally, even though NA #1 instructed the resident to use call light upon completion of toilet use, he/she should not have left the resident in the bathroom unsupervised. The facility failed to implement measures to ensure Resident #58's safety. 3a. Resident #33's [DIAGNOSES REDACTED]. The Resident's significant change MDS dated [DATE] identified a BIM score of four indicative of severely impaired cognition and that Resident #33 required extensive assistance of two people for all bed mobility and transfers. The physician's orders [REDACTED].#33 with a hoyer lift with the assist of two persons and the resident was non ambulatory. b. Resident #40's [DIAGNOSES REDACTED]. The Resident's Quarterly MDS dated [DATE] identified that the resident was severely impaired with cognitive skills for daily decision making and required extensive assistance of two people for all bed mobility and transfers. The physician's orders [REDACTED].#40 with a hoyer lift for all transfers. c. Observation on 6/7/16 at 11:00 AM identified Resident #33 in bed dressed. The mattress on Resident #33's bed did not fit the bed frame properly. The mattress was observed to be too small to fit the bed frame and was measured to be ten inches from the head board to the top of the resident's mattress. The resident's bed frame was observed to have a metal frame. Interview with LPN #1 at the time of the observation identified that the bed frame should not be exposed that way and that if a mattress does not fit a bed frame from the head of the bed and/or the base of the resident's feet, the facility has base board wedges that are secured in the gap that is exposed. She/he further stated that Resident #33's bed should have something in place between the mattress and the headboard. LPN#1 immediately checked all of the other beds on the unit and did identify a similar situation with Resident #40's mattress not fitting the bed properly, and an identified six inch gap was observed from the end of the bed (foot board) to the mattress with the bed frame exposed. Subsequent to surveyor inquiry, LPN#1 immediately had the base board wedges placed in both Resident #33 and Resident #40's beds. Interview with NA#1 on 6/7/16 at 11:20 AM identified that Resident #33 had a new bed in his/her room about a month ago and that there has never been any base board wedges in place. NA#1 further stated that he/she has been placing rolled blankets and sheets between the mattress and the base board since the resident has been in that bed. Interview with Maintenance Person #1 on 6/7/16 at 1:00 PM identified that Resident #33 had a bed frame that was previously for a tall resident who required a special bed. He/she further stated that Resident #33 was given that bed approximately a month ago because there were no other regular beds available for Resident #33. Maintenance Person #1 further stated that a special mattress should be ordered for that bed but one was not ordered and that the resident has a normal size mattress for a tall resident bed frame. He/she further stated that the Maintenance department would usually place something such as a base board wedge in between the mattress and the head/foot board but this was not done on Resident #33's bed. Resident #40's bed had a specialty pressure relieving mattress and required a small wedge on the bottom (foot board) to be placed and was placed subsequent to surveyor inquiry. Interview with The Administrator on 6/9/16 at 9:30 AM identified that Resident #33's bed should not have been left without a base board wedge immediately placed by the maintenance department and that the nursing assistants should not have been using rolled sheets and/or blankets to bridge the gap. He/she further stated that an appropriate mattress that fits a specialty bed such as Resident #33's should have been ordered and since the observation has been ordered by the facility for the resident's bed. 4. On 6/6/16 between 11:30AM and11:50AM hot water temperatures tested by 3 surveyors in 9 resident rooms were identified to be in the range of 130.6-138.0 degrees Fahrenheit (F). The Administrator and Director of Maintenance were notified immediately. The Maintenance Director and surveyor tested hot water temperatures in 2 resident rooms to confirm accuracy using surveyor and facility thermometers. Both rooms were found to have hot water temperatures of 134.5 and 138.6 degrees F. Review of the facility's hot water temperature policy identified that hot water temperatures are checked weekly as part of the preventive maintenance program. Additionally, that the water temperatures should be in the range between 105-118 degrees F. A plan to correct hot water temperatures was submitted by the Administrator and Director of Maintenance prior to surveyors leaving the building on 6/6/16. The plan included testing hot water temperatures every 30 minutes until temperatures stabilized and were within the desired range, in-servicing of all staff involved in direct patient care, and posting signs in all resident bathrooms to warn residents about the hot water concern. Additionally, a plumber was contacted and scheduled to change the mixing valve on 6/7/16. Observations of resident bathrooms on 6/7/16 identified that although signs were posted in all resident bathrooms indicating concern for hot water temperatures, the signs were posted on the top portion of bathroom mirrors, making it difficult for residents who were seated in wheelchairs to visualize the signs. Review of the facility documentation of hot water temperature monitoring for 6/6/15 between approximately of 3:55pm and 4:00pm, identified that temperatures ranged between 123.8 and 130.2 degrees F. Documentation was lacking that temperatures were monitored again until 5:47pm on the Gardenview Unit (115 degrees F) and 6:36pm on the Laurelview unit (120 degrees F). Temperatures were again monitored throughout the day and then from 12:13am -4:55am temperatures were noted to be 122 degrees F to 128 degrees F. Documentation was lacking that temperatures were monitored again until 6:25am. On 6/7/16 at 12:50PM a surveyor tested and identified hot water temperatures of 126.9 and 127 degrees F in 2 resident rooms. Review of the facility's temperature logs failed to reflect that any water temperatures were checked after 10:00AM that morning, almost 3 hours prior. Interview and review of facility documentation with the Administrator on 6/7/16 at 1:00PM identified that he/she was not aware that the hot water temperatures were high again and/or that temperatures had not been documented since 10:00AM and/or that the signs were posted too high in resident bathrooms. Interview with Maintenance Person #1 on 6/7/16 at 1:10PM identified that he/she had stopped documenting the temperatures after 10:00AM because the temperatures were all over the place as they were adjusting the mixing valve. Subsequent to surveyor inquiry temperature monitoring was restarted at 1:45PM, testing and documenting hot water temperatures every 30 minutes per facility plan, and resident signs were all lowered to a more appropriate height near the sinks.