Every finding on record at Pomperaug Woods Health Center

Based on a tour of the Dietary Department, observations, review of facility policy and interviews, the facility failed to ensure stored food was labeled and dated when opened, expired food was discarded and failed to ensure dietary staff wore a beard guard when preparing food. The findings included: A tour of the Dietary Department on 5/18/26 at 7:10 AM with [NAME] #1 identified the following:1.The refrigerator was observed to have the following items:a. One large serving tray with a small amount of coleslaw covering the complete bottom of serving container not labeled or dated.b. One 5-quart container with 1 quart of apple sauce dated 5/11.c. One 6-quart container with 4 quarts of three bean salad not labeled or datedd. One open container containing a thick orange creamy liquid-like texture (Cook #4 indicated it was a red pepper dipping sauce that is no longer used) dated 5/13/26.e. One 5-pound plastic tub of sour cream with a small portion used dated 5/7/26.f. One container of apple sauce (1/2 full) not labeled or dated.g. One half of a cherry pie not labeled or dated.h. One piece of lemon meringue pie not labeled or dated.i. One half of an apple pie not labeled or dated.Interview with [NAME] #4 on 5/18/26 at 7:30 AM identified all opened and used food items are to be labeled and dated when placed in the refrigerator. [NAME] #4 initially stated that food is good for 5 days after opening, then corrected himself and stated 4 days, and later stated he believed the correct timeframe was 3 days but was unsure. [NAME] #4 indicated all kitchen staff are responsible for discarding food items once they exceed the allowable storage timeframe. [NAME] #4 indicated the identified undated food items would be discarded immediately.Interview with Director of Dietary on 5/18/26 at 7:50 AM identified all food items in the kitchen that have been opened are to be labeled and dated. The Director of Dietary indicated after 3 days all food items are to be discarded.Subsequent to surveyor inquiry, the Director of Dietary indicated all the expired food items and foods not labeled and dated were discarded.2. Tour of the large walk-in refrigerator on 5/18/26 at 8:00 AM identified the following:a. One 2-quart container of egg salad 1/2 full dated 5/13/26.b. One 2-quart container of cut up onions and peppers dated 5/11/26.c. One 2-quart container with tuna salad dated 5/11/26.d. One 3-quart container with 2 quarts of opened canned tangerines in syrup was not labeled or dated.e. One 3-quart container with 2 quarts of cut-up celery was not labeled or dated.f. One 4-quart container with 1 quart of cut-up celery was not labeled or dated.Interview with the Director of Dietary on 5/18/26 at 8:10 AM indicated an employee had recently gone through the walk-in refrigerator; however, the Director of Dietary stated he believed dietary staff were confused regarding proper labeling and dating procedures for food items.Review of the facility Leftover Foods Policy identified that all leftover foods shall be covered, labeled, and dated when refrigerated. The cooks and prep cooks shall check dates daily and dispose of leftover food more than 72 hours (3 days) old.3. Observation on 5/19/26 at 12:20 PM noted Dietary Aide (DA) #1 exiting the kitchen carrying food without the benefit of a beard guard. DA #1 was observed with facial hair longer than an inch without the benefit of a beard guard. Interview with Dietary Aide (DA) #1 on 5/19/26 at 12:21 PM identified he was not informed he was required to wear a beard guard while working in the kitchen or handling food items. DA #1 indicated he did not think the facility had beard guards available.4. Observation of [NAME] #1 on 5/19/26 at 12:24 PM noted [NAME] #1 was leaning directly over the food preparation area mixing food by hand in a large mixing bowl. [NAME] #1 was observed with a full beard and mustache measuring approximately 1/2 to 1 inch in length without the benefit of a beard guard.Interview with [NAME] #1 on 5/19/26 at 12:25 PM identified he was preparing shrimp salad at the time of observation. [NAME] #1 identified he should have been wearing a beard guard while preparing food. [NAME] #1 stated the kitchen did not have beard guards available. [NAME] #1 indicated he considered using a hair net over his beard and mustache but was unsure if it would be effective.5. Observation of [NAME] #3 on 5/19/26 at 12:27 PM noted [NAME] #3 was preparing a tray of chicken and placing prosciutto (ham) on top of the chicken. [NAME] #3 was observed with a beard and mustache, including chin hair measuring greater than one inch in length, without the benefit of a beard guard.Interview with [NAME] #3 on 5/19/26 at 12:28 PM identified he was preparing chicken prosciutto at the time of observation. [NAME] #3 indicated no one had informed him that he was required to wear a beard guard while handling or preparing food for residents.6. Observation of the Director of Dietary on 5/19/26 at 12:28 PM noted he was assisting the cooks in the kitchen carrying a tray containing food items from one preparation area to another. The Director of Dietary was observed with a thick goatee measuring greater than 1/2 inch in length and was not wearing a beard guard while handling food items in the kitchen.7. Observation of [NAME] #2 on 5/19/26 at 12:30 PM noted [NAME] #2 cutting pies and plating portions for service. [NAME] #2 was observed with a goatee measuring greater than 1/2 inch in length and was not wearing a beard guard while handling and preparing food items.Interview with [NAME] #2 on 5/19/26 at 12:35 PM identified he could not explain why he was not wearing a beard guard.Interview with the Director of Dietary on 5/19/26 at 12:40 PM identified all male kitchen staff are expected to wear a beard guard when they have facial hair. The Director of Dietary indicated he was unsure of the specific length of facial hair that requires use of a beard guard. The Director of Dietary indicated that he would review the facility policy and follow up with the surveyor for clarification regarding requirements. Follow-up interview with the Director of Dietary on 5/19/26 at 1:15 PM identified the facility policy does not specifically address beard guard requirements; however, after conducting additional research, the Director of Dietary stated male staff with facial hair greater than 1 centimeter are required to wear a beard guard in the kitchen. The Director of Dietary identified that all cooks, including himself, should have been wearing beard guards while preparing and handling food. The Director of Dietary indicated that he would update the facility policy and provide education to staff regarding proper beard guard use and facial hair requirements in the kitchen.Review of the facility Employee Personal Cleanliness Policy identified the food and beverage department will have a comprehensive sanitation program to prevent the spread of infection and food borne illness throughout all areas of the operation. Bacteria can be present on hands, skin, breath, and hair: therefore, proper cleanliness practices are a vital link in the prevention of food-borne illnesses. Hair nets or caps should always be worn in food preparation areas and during food preparation. Facil hair must be clean and trimmed or shaved.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #21) reviewed for Advance Directives, the facility failed to ensure the clinical record was complete and accurate to include signed Advance Directives by the resident or resident's representative upon admission. The findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and COVID-19 infection.The nurses note written by RN #1 dated 1/8/26 at 7:21 PM identified Resident #21 was admitted via stretcher. Resident #21 was alert and oriented to person, place, and time.The Advanced Directive and Treatment Decisions form dated 1/8/26, with Resident #21's name printed at the top, identified initials from two nurses next to a Do Not Resuscitate (DNR) code status. The signature page included signatures from RN #1 and LPN #3 dated 1/8/26 and APRN #1 dated 1/12/26. The form did not contain the signature of Resident #21 or the resident's representative to indicate the resident's wishes.A physician's order dated 1/8/26 directed DNR. The admission MDS dated [DATE] identified Resident #21 had intact cognition.The physician's order dated 5/19/26 directed DNR, RN may pronounce (RNP), transfer to hospital for evaluation of acute injury only, and intravenous fluids and/or nutrition and tube feeding acceptable.Interview and clinical record review with the Director of Nursing Services (DNS) on 5/19/26 at 11:35 AM identified on admission the code status form should be signed within 24 hours by the resident or the resident's representative. The DNS indicated if a resident was cognitively intact, the resident would sign the form at admission if able. The DNS further indicated if a resident was unable to make decisions, two nurses would obtain a telephone order from the resident's representative regarding the code status until the representative could sign the form in person. The DNS identified the nurses were expected to document the telephone order, the name of the representative contacted, and the date and time of the conversation on the form. The DNS identified RN #1 and LPN # 3 completed Resident #21's Advance Directive and Treatment Decision form; however, the form did not identify whether staff spoke with Resident #21 or his/her representatives regarding code status wishes. The DNS further identified the nurses did not document a telephone order, the name of the individual contacted, or supporting progress notes regarding the code status discussion. The DNS indicated Resident #21 was admitted from the hospital with DNR status; however, the DNS could not identify whether Resident #21 or the representatives authorized the DNR status. The DNS identified Resident #21 was cognitively intact and could have signed the advance directive form. The DNS indicated Resident #21's representatives attended care conferences, and the advance directive form should have been presented for signature while the representatives were present in the facility.Interview and clinical record review with LPN #3 on 5/19/26 at 11:55 AM, with the DNS present, identified the nursing supervisor was responsible for obtaining signatures on the advance directive form. LPN #3 identified during telephone discussions with the resident representative, the supervisor was responsible for completing the form, documenting the telephone order, and identifying the representative contacted. LPN #3 indicated that the resident or representative was required to physically sign the form. LPN #3 indicated on 1/8/26 she could not recall who she and RN #1 spoke to regarding Resident #21's code status. Interview and clinical record review with APRN #1 on 5/19/26 at 1:40 PM identified the supervisors were responsible for obtaining code status wishes upon admission and having the form signed. APRN #1 identified if a resident lacked decision-making capacity, two nurses were required to contact the representative and document the telephone order, including the name of the representative contacted. APRN #1 stated he should not have signed Resident #21's Advanced Directive and Treatment Decision form because it lacked the signature of Resident #21 or the resident's representative and did not identify who nursing staff contacted regarding code status wishes.The nurse's note written by the DNS on 5/19/26 at 4:14 PM identified advance directives were reviewed with Resident #21 at bedside. Resident #21 selected his/her advance directive preferences after education was provided. APRN #1 was notified of Resident #21's wishes and he will sign the form. Subsequent to surveyor inquiry, Resident #21 signed the Advanced Directive and Treatment Decisions form dated 5/19/26 (133 days later) indicating DNR status.Although attempted, an interview with RN #1 was not obtained.Review of facility Advanced Directive Policy dated February 2020 identified upon admission of a resident, the social worker or designee, inquiries with the resident or the resident's legal representative, about the existence of any written advanced directives. The resident or representative is provided with written information concerning the right to refuse or accept medical and surgical treatment and formulate an advanced directive if he or she chooses to. Upon admission copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The DNS or designee notifies the attending physician so the appropriate orders can be documented in the resident's medical record and plan of care.Review of the facility Advanced Directive and Treatment Decisions Form identified this is to acknowledge that you have been informed in writing, in a language that you understands, of your rights, to make decisions concerning your medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue Advanced Directives to be followed should you become incapacitated. The resident or healthcare representative must initial one item in each section below for cardiopulmonary resuscitation or DNR, hospitalization, artificial hydration and nutrition.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #8) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include:Resident #8 had diagnoses that included major depressive disorder, right femur fracture, difficulty walking, fracture of the first lumbar vertebrae, bilateral sacral fractures, and sacral insufficiency fracture. The Resident Care Plan (RCP) dated 3/5/26 identified Resident #8 had a functional ADL decline related to fractures and recent surgery with interventions that directed to provide the assistance of one with ADLs and toileting. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition, was always continent of bowel and bladder, required moderate assistance with personal hygiene, and touching assistance for toileting and toileting hygiene. A change in condition evaluation dated 4/1/26 at 1:00 PM, completed by Registered Nurse (RN) #5, identified Resident #8 had a change in condition related to an allegation of abuse. The assessment indicated an investigation was initiated and the alleged perpetrator, Nurse Aide (NA) #6, was placed on administrative leave pending the outcome of the investigation. The assessment indicated Resident #8 had a skin assessment completed, and vital signs were obtained. RN #5 indicated an interview with Resident #8 was conducted with his/her daughter present at the bedside and Resident #8 declined police involvement. Interviews with additional residents and staff members were initiated. The assessment indicated that the Medical Director, APRN, and Administrator were notified, and no new orders were received. Facility reportable event form dated 4/1/26 at 1:00 PM, identified, Resident #8 reported on 4/1/26 at approximately 2:00 AM, while being toileted by NA #6, NA #6 was sharp with him/her and usually had a bad attitude. Resident #8 stated he/she was afraid to use the call button afterward due to NA #6's attitude. Investigation was initiated and NA #6 was placed on administrative leave pending the outcome of the investigation. Review of RN #6's written statement dated 4/2/26 at 10:29 PM identified Resident #8 was alert and oriented x's 4 and able to verbalize all needs. RN #6 identified he had concerns regarding NA #6's interactions with residents. RN #6 further identified that he had previously reported two additional allegations involving NA #6 to the nursing team. RN #6 indicated he had educated NA #6 on multiple occasions regarding the importance of choosing appropriate words and refraining from expressing frustration while in residents' rooms.Facility reportable event summary dated 4/2/26 identified Resident #8, who is alert and oriented reported, a staff member woke him/her up during the overnight hours to provide toileting care and subsequently Resident #8 felt hesitant to request assistance due to the staff member's perceived attitude. Resident #8 did not provide specific statements or language indicative of verbal abuse but expressed general concerns regarding the staff member's demeanor. NA #6 was placed on administrative leave pending investigation. NA #6 denied the allegation of abuse. Following a thorough investigation, the allegation of abuse was unsubstantiated. Education was provided to staff regarding resident rights, including the right to request assistance without hesitation or fear of reprisal.Interview on 5/20/26 at 9:35 AM with Resident #8 identified a month or so ago when NA #6 went into his/her room in the middle of the night to assist him/her with the bed pan, NA #6 was not happy to help, NA #6 seemed annoyed, and NA #6 had a bad attitude. Resident #8 indicated NA #6 was not the nicest girl, but after the incident he/she was nervous to use the call bell again. Resident #8 identified he/she never felt that way before, so he/she reported what happened to the Director of Nursing (DNS) and never seen NA #6 again. Resident #8 could not recall exactly when it happened or when he/she reported it to the DNS. Interview with the DNS on 5/20/26 at 11:00 AM identified on 4/1/26 at 1:00 PM, Resident #8 reported at approximately 2:00 AM when NA #6 entered the room to assist him/her with toileting, NA #6 made him/her feel hesitant to call for assistance again due to NA #6's attitude. The DNS indicated he asked Resident #8 what NA #6 said to him/her and Resident #8 did not provide any specifics on language used towards him/her, but felt NA #6's attitude towards him/her was not positive. The DNS indicated the allegation of staff to resident abuse was unsubstantiated. The DNS identified NA #6 had prior customer service complaints made against her that were addressed. The DNS further identified NA #6 did not provide Resident #8 with good customer service, therefore, NA #6 was terminated. Although attempted, interviews with RN #6 and NA #6 were not obtained. Review of the facility Resident Rights policy dated February 2001, directed in part, employees shall treat all residents with kindness, respect, and dignity. These rights include the resident's right to be treated with respect, kindness, and dignity Review of the facility Hospitality Services Standard policy dated 2/2022, directed in part, to anticipate the needs of each resident and respond positively and promptly to their requests, respond timely with empathy and concern.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #28) reviewed for abuse, the facility neglected to provide a resident with incontinent care during the 11 PM to 7 AM shift per the plan of care. The findings include:Resident #28's had diagnoses that included Alzheimer's dementia, heart failure, and anxiety.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had severely impaired cognition, was frequently incontinent of bowel and always incontinent of bladder, required substantial assistance with bed mobility, non-ambulatory, and dependent on staff for personal hygiene, toileting hygiene, transfers, and mobility in the wheelchair. The Resident Care Plan (RCP) dated 4/28/26, identified Resident #28 had ADL self-care deficit and required assistance with bed mobility, transfers, hygiene, dressing, grooming, feeding, toileting and locomotion off unit. Interventions directed to provide incontinent care and skin care every 2-3 hours and as needed, apply barrier cream with incontinent care, and turning and repositioning every 2 hours.The nurse's aide care card dated 4/28/26 directed to incontinent care every 2-3 hours and as needed and assist the private duty aide (PDA) with turning and repositioning every 1-2 hours while in the chair and every 1 hour when in bed.The physician's order dated 5/7/26 directed the use of 1/4 side rails x's 2 as a mobility enabler on every shift and admit to hospice. Facility reportable event dated 5/17/26 at 6:00 PM identified Resident #28 was noted with purple discoloration and swelling to the lateral right eye with no recent trauma. The private duty aide reported that the resident may have been lying on the call bell. The nurse during the previous shift noted an indentation to the right side of the resident's upper face after the private duty aide reported it. The family had initiated video monitoring in the resident's room on 5/6/26. Investigation initiated for injury of unknown origin.A change in Condition assessment dated [DATE] at 8:30 PM conducted by Registered Nurse (RN) #2 identified Resident #28 had sustained an in-house injury of unknown origin. RN #2 identified Resident #28 was observed with discoloration and a change in skin color to the right temple area.The physician's order dated 5/17/26 directed to apply a cold compress to the right periorbital (eye socket) area for 20 minutes, off for 20 minutes, and as needed for pain for 24-48 hours to reduce swelling, and monitor closely for progression for swelling, increased pain, any vision changes, or signs of orbital movement.The nurses note dated 5/18/26 at 11:11 AM written by RN #5, identified the DNS and RN #5 spoke with Person #1 who reported Resident #28 had been leaning on the side rail of the bed which caused the discoloration and swelling around his/her eye. RN #5 identified Resident #28's right lateral eye was noted with discoloration, minimal swelling, and without open areas. RN #5 indicated staff will turn and position Resident #28 every hour. Observation on 5/18/26 at 12:18 PM identified Resident #28 had swelling around the periorbital area of the right eye with light purple discoloration. Resident #28 nodded yes when asked if the area was painful.Interview with Person #1 on 5/19/26 at 9:24 AM identified approximately 2 weeks prior, video monitoring system was installed in Resident #28's room. Person #1 indicated the facility notified him/her that Resident #28 had a bruise on the right eye. Person #1 indicated he/she reviewed the video footage from 7:00 PM on 5/16/26 to 7:00 AM on 5/17/26. Person #1 indicated the video footage showed no movement or sound, and the facility staff did not enter Resident #28's room to provide care or reposition the resident on 5/17/26 between 1:15 AM to 5:32 AM. Person #1 indicated the video footage showed at approximately 5:32 AM on 5/17/26, the private duty aide appeared to observe something on the right side of Resident #28's face or head and repositioned Resident #28 away from the left side rail. Review of Resident #28's Detailed Patient Activity (a call light system that staff are expected to utilized by pressing the corresponding light when entering a resident's room to indicate their presence and turn it off upon exiting to signal the resident was checked and needs were met) dated 5/17/26 indicated staff did not activate the call light system between 1:15 AM and 5:30 AM to document entry into or exit from Resident #28's room to indicate care was provided.Interview and clinical record review with the DNS on 5/20/26 at 9:55 AM identified the facility nurse aides are expected to check in with private duty caregivers to determine if the resident requires assistance. The DNS indicated if the private duty caregiver is not a nurse aide, facility staff provide all required care. The DNS identified he had not personally reviewed Resident #28's video footage for the overnight shift on 5/17/26 and was unsure whether staff checked in with the caregiver or resident. The DNS indicated staff routinely check on residents and have received education on providing care even when a resident has a private caregiver. The DNS identified nurse aides are expected to check on residents every 1-2 hours. The DNS indicated staff recently received education on the call light system and staff are expected to press the corresponding light when entering a resident's room to indicate their presence and turn it off upon exiting to signal the resident was checked and needs were met. The DNS identified on 5/17/26, the nurse aides should have checked on Resident #28 every 1-2 hours during the overnight hours per the resident's plan of care. Interview with Registered Nurse (RN) #2 on 5/20/26 at 10:25 AM identified on 5/17/26 during the 11:00 PM to 7:00 AM shift she was the nursing supervisor. RN#2 indicated Resident #28's private duty aide notified her of a mark and indentation on Resident #28's right temple. RN #2 identified she assessed Resident #28 and observed a linear-shaped indentation near the resident's right eye area. RN #2 indicated Resident #28 favored his/her right side and the indentation appeared to have resulted from the resident leaning against either the call bell or the side rail. RN #2 identified all residents should be checked on every 2 hours, even when they have a privately hired caregiver. Interview on 5/20/26 at 11:05 AM with Nurse Aide (NA) #5 identified her shift began on 5/16/26 at 11:00 PM and ended on 5/17/26 at 7:00 AM. NA #5 identified she was assigned to care for Resident #28. NA #5 reported she completed walking round at 11:00 PM and did not observe any bruising to Resident #28's right eye. NA #5 indicated she became aware of Resident #28's right eye injury on the morning of 5/17/26. NA #5 identified on 5/17/26 she completed resident rounds between 12:30 AM and 1:00 AM and again between 4:30 AM and 5:00 AM. In addition, NA #5 indicated she checked on residents hourly, including Resident #28, to ensure they were safe, comfortable, and did not require assistance. NA #5 identified she did not always turn the light on during hourly checks because she did not want to wake residents. NA #5 identified instead she peeked into resident rooms to ensure residents were safe and the call light was within reach. NA #5 identified at approximately 1:30 AM, she observed Resident #28 asleep in bed and did not provide care or reposition the resident because she did not want to wake him/her. Subsequent to surveyor inquiry, the DNS provided facility documentation dated 5/20/26 indicating the interdisciplinary team conducted an AdHoc (unplanned meeting) QAPI meeting. The documentation identified Resident #28 was not assisted with activities of daily living (ADLs) according to his/her plan of care during the 11:00 PM to 7:00 AM shift on 5/16/26.Review of the facility Abuse and Neglect policy dated March 2018, directed in part, neglect means the failure of the facility, it's employees to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Along with staff and management the physician will help identify situations might constitute or be construed as neglect, for example failure to provide incontinent care. Review of the facility Activities of Daily Living policy dated April 2025, directed in part, that appropriate care be provided for residents who are unable to carry out ADL's independently, with the consent of the resident, and in accordance with the plan of care.Review of facility In-Service education for the New Call Bell System Answer, Respond and Assist resident's, dated 11/6/25, identified answering the call bell within 5 minutes of it going off. To deactivate the call bell when you enter the room and then hit your color button (nurse-green, nurse's aide-orange, and all other staff-yellow) to show that you have responded to the resident call bell and were in the room.

Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #7 and Resident #39) reviewed for hospitalizations and discharge, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when residents were transferred to the hospital and when a resident was transferred and discharged to the hospital. The findings include: 1.Resident #7 had diagnoses that included heart failure, anxiety, pneumonia, acute and chronic respiratory failure with hypoxia. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #7 had intact cognition. a.The nurse's note dated 1/7/26 at 6:36 AM identified Resident #7 was noted with shortness of breath, using accessory muscles to breathe, and had wheezing with exertion. Resident #7 was placed on 4 liters of oxygen, and oxygen saturation levels ranged between 86% and 88%. The APRN and responsible party were notified and Resident #7 was transferred to the hospital for further evaluation. Review of the census report identified Resident #7 was transferred and admitted to the hospital on [DATE]. A nurse's note dated 1/29/26 at 2:45 AM identified Resident #7 returned to the facility from the hospital. b. The nurse's note dated 1/26/26 at 8:25 AM identified at approximately 7:45 AM, during morning care, Resident #7 exhibited respiratory distress. Resident #7 was struggling to breathe, and oxygen saturation level was 82% on room air. Resident #7 was placed on oxygen at 4 liters via nasal cannula; however, oxygen saturation remained between 86% and 87%. The oxygen was increased to 8 liters via nasal cannula with no improvement. The APRN and responsible party were notified, 911 was called, and Resident #7 was transferred to the emergency room. Review of the census report identified Resident #7 was transferred and admitted to the hospital on [DATE]. A nurse's note dated 1/29/26 at 2:45 AM identified Resident #7 returned to the facility from the hospital. 3. Resident #39 had diagnoses that included adjustment disorder, anxiety, hypertension, urinary tract infection, left hip strain, lumbar radiculopathy, and acute respiratory failure with hypoxia. The admission MDS dated [DATE] identified Resident #39 had moderately impaired cognition. The SNF/NF to hospital transfer form dated 3/13/26 at 11:52 PM, completed by RN #6, identified Resident #39 was transferred to the hospital for altered mental status. Review of the census report identified Resident #39 was discharged to the hospital on 3/14/26. Interview with the Director of Nursing Services (DNS) on 5/19/26 at 8:27 AM identified the Social Worker was responsible for notifying the Ombudsman of routine discharges during weekdays. The DNS indicated nurses were responsible for notifications during off-shifts and weekends. The DNS further indicated nurses do not notify the Ombudsman of hospital transfers or discharges to the hospital. The DNS indicated that the Social Worker submits monthly reports to the Ombudsman for hospital transfers. The DNS identified the Social Worker was on a two-week vacation and unavailable. Interview with Ombudsman #1 on 5/19/26 at 9:23 AM identified the facility did not notify the Office of the State Long-Term Care Ombudsman when Resident #7 was transferred and admitted to the hospital on [DATE] and 1/26/26. Ombudsman #1 further identified the facility did not notify the Office of the State Long-Term Care Ombudsman Resident #39 was transferred and discharged to the hospital on 3/13/26. Interview with the DNS on 5/19/26 at 12:06 PM identified he was aware the facility was not notifying the Ombudsman of all hospital transfers and admissions. The DNS indicated he was working on correcting the issue. Subsequent to surveyor inquiry, the DNS notified the Office of the State Long-Term Care Ombudsman of Resident #39's hospital transfer and discharge. Review of the facility Emergency Acute Care Transfer Policy dated 2001 directed, in part, residents sent to acute care settings due to an emergency are considered transfers, not discharges. When a resident is temporarily transferred to acute care facility, a notice of transfer is provided to the resident and resident representative as soon as possible before the transfer. Copies of notices for emergency transfers are also sent to the representative of the Office of the State Long Term Care Ombudsman, but may be sent when practicable, such as in a list of residents monthly. Review of the facility Transfer or Discharge Notices policy dated 2001 directed, in part, if a discharge is initiated by the facility after an emergency transfer to the hospital the facility will send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman and the notice to the Office of the State Long Term Care Ombudsman will occur at the same time as the notice of discharge is provided to the resident and resident representative.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #4) reviewed for medication administration, the facility failed to ensure physician's orders were accurately transcribed resulting in a medication administration error. The findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included hypertension, diabetes mellitus, and hyponatremia.The Hospital Discharge Summary and W-10 (communication between the hospital and the receiving facility) dated 3/3/26 directed to continue Lisinopril 40 milligram (medication used to lower blood pressure), one tablet daily.The physician's order dated 3/3/26 directed to administer Lisinopril 40 mg, give 2 tablets (80 mg) daily, Sodium Chloride (medication used to treat low sodium levels) 1000 mg daily, and obtain a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) one time after admission. An electronic order alert dated 3/3/26 at 10:54 PM identified RN #1's entered dose of Lisinopril 80 mg exceeded the recommended dose.A nurse's note dated 3/4/26 at 12:02 AM written by RN #1 identified Resident #4's medications were reconciled with APRN #1 and no changes were made.Review of the Medication Administration Record (MAR) identified from 3/3/26 through 3/20/26 at 8:00 AM Lisinopril 40 mg 2 tablets (80 mg) was signed off indicating it was administered to Resident #4 ( Resident #4 received the wrong dose for 17 days).The Resident Care Plan (RCP) dated 3/4/26 identified Resident #4 required medication management. Interventions included confirming all orders with the physician and reviewing pharmacist medication with recommendations as applicable. APRN #1's note dated 3/6/26 at 10:30 AM identified Resident #4 was admitted with a potassium level of 4.9 mmol/L within normal range. APRN #1 identified per the discharge summary continue Lisinopril 40 mg daily for hypertension and repeat labs for CBC and BMP.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #4 had intact cognition.laboratory results dated [DATE] identified Resident #4 potassium level was 5.4 mmol/L (normal range 3.3 to 5.1 mmol/L), and sodium level was 131 mmol/L (normal range 133 to 145 mmol/L).The physician's order dated 3/9/26 at 11:54 PM directed to administer Kayexalate (sodium polystyrene sulfonate combination suspension) 15 grams/60 milliliters one time for hyperkalemia (high potassium level).Laboratory result report dated 3/10/26 identified Resident #4's potassium level was 5.1 mmol/L (normal range 3.3 to 5.1 mmol/L).APRN #1's noted dated 3/10/26 at 10:30 AM identified Resident #4's potassium level was elevated on 3/9/26 and Kayexalate was given as ordered. APRN #1 identified on 3/10/26, Resident #4's potassium level was 5.1, and now normal. APRN #1 indicated Resident #4 appeared asymptomatic, the blood pressures were reviewed: on 3/6/26 blood pressure was 132/64, on 3/7/26 blood pressure was 160/80, and on 3/8/26 blood pressure was 148/88. APRN #1 identified Kayexalate was discontinued and the plan was to continue to monitor periodic BMP labs.A physician's order dated 3/16/26 directed to obtain a BMP on the next lab day.laboratory results dated [DATE] identified Resident #4's potassium level was 5.2 mmol/L (normal range 3.3 to 5.1 mmol/L), and sodium level was 131 mmol/L (normal range 133 to 145 mmol/L).A nurse's note dated 3/19/26 at 1:15 PM identified Resident #4 had a BMP drawn today results showed an elevated potassium level of 5.2, and low sodium level of 131, the results were reported to APRN #1 with no new orders at this time.APRN #1's note dated 3/20/2026 at 10:30 AM identified Resident #4 was seen for evaluation of abnormal labs showing mild hyperkalemia and mild hyponatremia. APRN #1 identified on 3/19/26 Resident #4 was diagnosed with hyperkalemia due to a potassium level of 5.2 mmol/L. APRN #1 identified in error Resident #4 received Lisinopril 80 mg daily instead of Lisinopril 40 mg daily which may have contributed to the hyperkalemia. APRN #1 indicated he reviewed the hospital paperwork and noted Resident #4 was previously ordered Lisinopril 40 mg daily. APRN #1 indicated Resident #4's blood pressures were stable, and potassium levels are normal. APRN #1 identified Lisinopril 80 mg was discontinued, will start Lisinopril 40 mg once daily on 3/21/26, and on the next lab day repeat BMP.The physician's order dated 3/20/26 directed to discontinue Lisinopril 80 mg daily and start Lisinopril 40 mg daily on 3/21/26. (17 days after receiving the wrong dose) and obtain BMP on the next lab day.laboratory results dated [DATE] identified Resident #4's potassium level was 5.1 mmol/L (normal range 3.3 to 5.1 mmol/L) and sodium level was 131 mmol/L (normal range 133 to 145 mmol/L).APRN #1's note dated 3/31/26 at 4:26 PM identified Resident #4 was seen for recent hyperkalemia and dose adjustment of Lisinopril. APRN #1 identified Resident #4's repeat labs showed potassium level had normalized, and sodium level had improved. APRN #1 indicated will continue Sodium Chloride supplement, monitor periodic BMP labs, continue Lisinopril 40 mg once a day, and monitor blood pressures.APRN #1's note dated 4/10/26 at 10:45 AM identified on 3/20/26 a Lisinopril dosing error was identified Resident #4 was given Lisinopril 80 mg instead of 40 mg daily. APRN # 1 indicated Resident #4's blood pressures were stable with a few isolated low readings, but he/she is asymptomatic. APRN #1 identified he added hold parameters to Lisinopril if blood pressure is less than 100/80 hold medication. Interview with the Director of Nursing Services (DNS) on 5/19/26 at 7:03 AM identified the nursing supervisors are responsible for transcribing orders from the hospital's W-10 and discharge summary after verifying orders with the provider. The DNS indicated medications are reconciled with the APRN prior to being ordered. The DNS further indicated that the nursing supervisor contacts the APRN, reviews the hospital orders one at a time, and then enters the orders into the electronic medical record. The DNS identified all medication errors are investigated, and the pharmacy, physician, and family are notified of the med error. The DNS indicated medication error forms are utilized and include documentation of the investigation/findings, interventions implemented, and the identified root cause of the error. The DNS indicated he is responsible for conducting the investigation. The DNS identified he was aware of Resident #4's medication error involving Lisinopril. The DNS further identified RN #1 incorrectly transcribed Resident #4's hospital order and ordered Lisinopril 40 mg, two tablets (80 mg), instead of one tablet. The DNS indicated a medication error form was not completed in accordance with facility policy because RN #1 had already been terminated by the time the error was identified. The DNS identified RN #1 had previously made additional medication transcription errors prior to discovery of this incident and was subsequently terminated.Interview with APRN #1 on 5/19/26 at 1:39 PM identified when a new admission arrives at the facility, the nursing supervisor contacts him to verbally review the hospital discharge instructions and medication orders for approval. APRN #1 stated upon admission, Resident #4 was prescribed Lisinopril 40 mg; however, the nursing supervisor (RN #1) incorrectly transcribed the order as two tablets, resulting in Resident #4 being administered 80 mg instead of the 40 mg dose. APRN #1 identified on 3/9/26 Resident #4 was noted to have an elevated potassium level. APRN #1 indicated Kayexalate was administered and repeat laboratory testing on 3/10/26 indicated the potassium level had returned to normal. APRN #1 identified on 3/19/26, Resident #4 potassium level again was noted with an elevated potassium level. APRN indicated he conducted a review of Resident #4's medications to identify potential contributing factors. APRN #1 identified during the review, he identified Resident #4 had been receiving Lisinopril at twice the prescribed dose for approximately 17 days. APRN #1 indicated elevated potassium levels are a know potential side effect associated with higher doses of Lisinopril. APRN #1 identified he determined the medication error may have contributed to Resident #4's elevated potassium levels. APRN #1 identified he immediately reduced the dosage of Lisinopril to the prescribed amount of 40 mg and ordered a repeat laboratory testing. APRN #1 indicated Resident #4 remained asymptomatic, potassium levels returned to normal after correction of the Lisinopril dose. APRN #1 indicated although Resident #4 was administered twice the ordered dose of Lisinopril for 17 days there were no adverse outcomes.Interview with Pharmacist Consultant #2 on 5/19/26 at 2:05 PM identified she is responsible for conducting monthly medication regimen reviews for residents at the facility. Pharmacist Consultant #2 identified administration of a high dose of Lisinopril to Resident #4 could result in side effects such as hyperkalemia or hypotension. She indicated that the admission medication review for Resident #4 had been completed by Pharmacist Consultant #1.Subsequent to surveyor inquiry on 5/19/26 at 2:20 PM, the DNS identified a medication error report should have been completed regarding Resident #4's Lisinopril medication error. The DNS further indicated he would conduct a retrospective review of the previous 90 days to identify any medication errors and initiate medication error reports for any identified findings, including the error involving Resident #4.Although attempted, an interview with RN #1 was not obtained.Review of the facility Admissions Policy identified when a resident arrives to the facility ensure the nursing staff conducts a comprehensive assessment and if verbally or by telephone orders are received the nurse receiving the orders will enter it in thee electronic medical record and have it confirmed by a second nurse directly in the electronic medical record at the time of order entry.Review of the facility Medication Therapy Policy identified upon admission or shortly thereafter and periodically thereafter, the staff and practitioner assisted by the consultant pharmacist will review an individual's current medication regimen, to identify whether medication doses are appropriate.Review of the facility Medication and Treatment Orders policy identified orders for medications will be consistent with principles of safe and effective order writing. Medications shall be administered only upon written orders by a person authorized to prescribe in this state.Review of the facility Medication Error Policy identified a medication error report is completed immediately after an error is discovered to ensure proper resident follow up. Medication error reports are reviewed by the DNS and the physician. All errors related to medications are reported to the charge nurse and attending physician. If the situation is potentially life threatening the error and the resident assessment data are communicated to the attending immediately. If the error has no serious effect on the resident, the physician is notified as soon as possible. The DNS is responsible for investigating the error to determine the cause. The DNS completes a monthly summation of medication errors and reports information at QAPI.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for misappropriation, the facility failed to ensure a resident was free from misappropriation of property when an iPad was taken from the facility. The findings include: Resident #1 had diagnoses that included dementia, anxiety, generalized muscle weakness, and chronic obstructive pulmonary disease. The care plan dated [DATE] identified Resident #1 needed to feel comfortable in h/her new placement with interventions that directed to inform the resident of other available areas to explore a change of scenery such as the library, living rooms, or recreation room, provide in room visits for simple conversation, provide the resident with a monthly recreation calendar, and provide in room activities as needed to keep the resident busy in the morning and at bedtime. The quarterly [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), was frequently incontinent of bowel and bladder, and required substantial assistance with ADLs. A Concern/Grievance form dated [DATE] by RN #2 identified Resident #1's children reported that Resident #1's iPad with a blue cover was missing. RN #2 indicated that a search was conducted and all departments were notified. The summary identified Resident #1's iPad was not found, the facility offered to reimburse for the missing item, Family Member #1 contacted the Director of Nursing Services (DNS) to inform him that the item was located outside of the facility, and an investigation and police report were filed on [DATE]. The facility's accident and incident report dated [DATE] at 1:45 P.M. identified Family Member #1, of recently deceased Resident #1, reported that Resident #1 had h/her iPad in h/her possession at the time of h/her death, and h/she was unable to locate the iPad. Family Member #1 identified that today h/she used Resident #1's iCloud account to remotely track the location of the device which pinged at a middle school and h/she was able to remotely lock the device. An investigation was initiated, Family Member #1 was interviewed for further information, and the police were notified. The facility's summary dated [DATE] identified during follow up phone call to Family Member #1 h/she identified h/she pinged the location of the device on [DATE] and [DATE] and both times the location continued to be reported at a middle school, a police report was filed, residents on the unit were interviewed to determine if they have had any loss of property or missing items and no missing items were reported. A list of staff members was provided to the police officer and the police stated to allow them to investigate the matter as a crime, and they would perform all questioning with staff. This is an ongoing police investigation. Review of an Administrative Leave Form dated [DATE] identified NA #4 was placed on an immediate administrative leave while investigating a serious matter that pertained to her and the facility would contact her following a review of the matter with information regarding her status. Interview with the DNS on [DATE] at 9:45 A.M. identified on [DATE] he was notified by RN #2 that when Resident #1's family member arrived to pick up Resident #1's belongings h/she reported that Resident #1's iPad was missing, RN #2 searched for the iPad, it was not located, so RN #2 offered to reimburse the family for the missing iPad, but Resident #1's family member declined asking that the facility keep looking for it. The DNS indicated that on [DATE] Family Member #1 reported that the iPad was still missing, but h/she was able to sign into the iCloud account and pinged the location of the iPad. The DNS identified an investigation was initiated and he notified the police. The DNS indicated that when the Police Officer arrived, he provided a list of all staff who cared for Resident #1, the addresses of staff, and the bus routes in the area where the iPad location had pinged. The DNS indicated the Police Officer stated to allow the police to investigate and question staff because it was a criminal matter. The DNS indicated that on [DATE] the Police Officer identified that the iPad was returned to Family Member #1, the suspect was NA #4, it was still an ongoing investigation, not to share any information, and that a judge would be signing a warrant for arrest. The DNS identified on [DATE] NA #4 was placed on administrative leave and remained out of work. The DNS indicated that there were no other residents with missing items and that NA #4 had no prior disciplinary action or any other allegations. Subsequent to surveyor inquiry, the DNS provided a letter dated [DATE] written by Human Resource Assistant #1 titled witness statement indicating that the facility was terminating NA #4's employment effective on [DATE]. Review of facility Abuse, Neglect, Exploitation, and Misappropriation policy dated [DATE] identified residents have a right to be free from abuse, neglect, and misappropriation of resident property.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure a controlled medication, Oxycodone, and the controlled disposition sheet were not removed from the facility. The findings include: Resident #1's diagnoses included osteoporosis, spondylosis of cervical region, cervicalgia, and polyosteoarthritis. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits and received a scheduled pain medication. The Resident Care Plan dated 10/18/24 identified Resident #1 was at risk for pain related to the history of chronic back pain. Interventions directed to complete pain evaluation, discuss with the resident what causes and alleviates pain, medications per physician's order, monitor pain scale every shift, notify physician if medication is not alleviating pain to an acceptable level and provide non-pharmacological measures prior to administering pain medication if acceptable. A physician's order dated 11/5/24 directed to give the narcotic pain medication, Oxycodone HCL 5 milligram (mg) by mouth every six (6) hours as needed for severe pain. The Facility Reportable Incident form dated 11/26/24 at 6:15 PM identified during the routine twice monthly narcotic audit conducted by the Director of Nursing (DON), it was determined that one (1) blister pack of Oxycodone and the corresponding controlled substance record were unaccounted for. The summary report dated 12/1/24 24 identified the pharmacy delivered one (1) blister pack of Oxycodone 5 mg tablets (28 tablets) for Resident #1 at 6:33 PM on 11/7/24 which was signed in by two (2) nurses and then placed in the medication cart in the locked narcotic drawer. The report identified on 11/9/24 at 2:50 PM, Resident #1 required a dose of Oxycodone which was not found in the medication cart locked drawer and had to be obtained from the emergency box of medications. Interview with the Director of Nursing (DON), on 1/7/25 at 2:36 PM identified while doing his bimonthly audit of narcotic medications on 11/26/24, it was discovered that one (1) blister pack of Resident #1's Oxycodone (28 tablets) and the corresponding narcotic medication disposition sheet was missing. The DON identified at that time he initiated an investigation, called the pharmacy, the police and the drug enforcement agency (DEA). The DON identified he searched all medication rooms, medication carts, the emergency box as well as interviews of all staff who worked during the period of 11/7/24 through 11/9/24, the time from when the Oxycodone was delivered to the time it was discovered missing, and he could not locate the medication. The DON identified the facility policy for narcotic medication was that two (2) licensed staff members sign for the medication when it was delivered from the pharmacy, then put the blister pack in the locked narcotic drawer on the medication cart and put the narcotic medication disposition sheet in the corresponding medication count binder and a narcotic count of medication was done at the beginning and end of each shift by the outgoing and oncoming nurse. The DON identified he was unable to conclude where the medication went. Review of the facility policy titled Controlled Drugs/Control Drug Audits directed, in part, the facility is responsible to ensure that proper accounting and documentation of use of all control drugs is performed. Review of the facility policy titled Abuse Prevention Policy, identified misappropriate defined as the misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further directed, in part, the facility will have proper measures implemented to prevent and maintain an abuse free (misappropriation) environment in accordance with state and federal law. Review of the facility policy titled Resident Rights, directed, in part the resident has the right to be free from misappropriation of property.

Based on clinical record reviews, facility documentation, facility policy and interviews for 3 of 5 sampled residents (Resident #26, Resident #2 and Resident #10) reviewed for accidents, the facility failed to follow the plan of care resulting in a fall with major injury (Resident #26) and failed to ensure a transfer was provided according to physician order (Resident #2) and failed to implement interventions according to the plan of care resulting in falls (Resident #10). The findings include: 1. Resident #26's diagnoses included dementia, cognitive communication deficit, history of falls, and traumatic subdural hemorrhage. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3) and required moderate assistance with transfers, bed mobility and sitting to standing. The MDS further identified Resident #26 required moderate assistance with dressing and supervision with toileting, had two or more previous falls and was always incontinent of bowel and bladder. The facility Morse Fall Scale evaluation dated 11/15/23 identified Resident #26 as a high fall risk. The Resident Care Plan dated 11/22/23 identified Resident #26 as at risk for falls, at risk for incontinence and at risk for impaired communication related to dementia and a hearing deficit. The RCP included interventions of applying gripper socks at bedtime, placing a call light within reach, offering toileting every 2 hours, and checking Resident #26 every 2 to 3 hours and as needed for toileting needs. Review of the facility Event Report dated 11/22/23 by RN #2 identified that on 11/22/23 at 9:30 PM, Resident #26 was found on the floor in front of his/her bathroom, sitting upright, with both lower extremities curled towards his/her back. The Event Report identified Resident #26 stated he/she hit his/her head on the floor and Resident #26 was transferred to the hospital for further evaluation. The Event Report further identified Resident #26 was barefoot when discovered and his/her shoes were located at the bed side. The Event Report indicated Resident #26 did not put his/her shoes on prior to getting out of bed and did not request assistance for toileting. Review of a statement dated 11/22/23 by NA #8, who was assigned to provide care for Resident #26 during the 3 PM to 11 PM shift on 11/22/23, identified NA #8 changed (referring to incontinent care) Resident #26 at around 2 PM then further identified Resident #26 was in his/her bed at around 7:30 PM to 8 PM, wearing pajamas, and indicated Resident #26 changed into pajamas by his/herself. The statement did not indicate toileting was provided every 2-3 hours according to the plan of care or indicate if footwear was on prior to or at the time of the incident. Review of a statement dated 11/22/23 by LPN #1, who was assigned to provide care for Resident #26 during the 3 PM to 11 PM shift on 11/22/23, identified no indication of Resident #26's status prior to the fall incident. The statement did not identify the last time Resident #26 was toileted or if footwear was on at the time of the incident. Review of a statement dated 11/22/23 by NA #1 who worked during the 3 PM to 11 PM shift on 11/22/23 identified no indication of Resident #26's status prior to the fall incident and no indication of care or toileting provided to Resident #26 prior to the fall incident. Review of an email correspondence on 11/23/23 between the Director of Nursing (DNS) and RN #2 indicated RN #2 interviewed NA #1, who also worked during the 3 PM to 11 PM shift on 11/22/23, regarding the fall incident, and that NA #1 stated she did not toilet Resident #26 at all during the 3 PM to 11 PM shift on 11/22/23 and that Resident #26 frequently toilets him/herself and does not require assistance. Review of the hospital discharge summary dated 11/27/23 identified a 5-day hospital admission with a transfer to the surgical intensive care unit for hourly neuro monitoring from 11/22/23 to 11/24/23. Resident #26 was then transferred to the hospital floor for further monitoring until discharge back to the facility on [DATE]. Hospital diagnoses related to the fall incident on 11/22/23 are as follows: a primary diagnosis of trauma secondary to a ground level fall with multiple subarachnoid hemorrhages (SAH) and several other diagnoses to include Bifrontal SAH anteriorly/inferiorly extending superiorly along the left, subtle right parietal SAH, subtle right temporal/occipital SAH, small anterior falx subdural hematoma extending to the right frontal convexity, nondisplaced occipital bone fracture extending to foramen magnum, right occipital hematoma. Interview with NA #8 on 10/11/24 at 11:48 AM identified Resident #26 often exhibited wandering behaviors and once awake would begin to walk. NA #8 identified Resident #26 dressed him/herself at bedtime on 11/22/23. NA #8 identified she saw Resident #26 in bed with pajamas on and did not provide any further care for Resident #26 once he/she was observed in bed. NA #8 identified she did not pull the blankets back to check that gripper socks were in place as directed in the plan of care. 2. Resident #2 had diagnoses that included dementia and osteoarthritis. The Minimum Data Set assessment dated [DATE] identified Resident #2 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12) and required a 2 person assist with bed mobility, transfers and toileting. The Resident Care Plan dated 5/20/24 identified Resident #2 had impaired cognition, an ADL deficit and was at risk for falls. Interventions directed to explain procedures prior to beginning and to provide an assist of 2 with transfers and toileting. Physician orders dated 5/21/24 directed an assist of 2 with toileting at wheelchair level during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and to provide transfers using a Hoyer lift (mechanical device used to move residents with limited mobility) during the 11:00 PM to 7:00 AM shift. A Nurse's note dated 7/10/24 at 11:03 PM identified Resident #2 was assisted to the floor in the bathroom by his/her assigned Nurse Aide (NA #1). Resident #2 was unable to hold weight in a panic and was assisted to the floor. The assessment further identified Resident #2 had no change in mobility status, did not hit his/her head, was stable, and cognition was at baseline. A facility Reportable Event Investigation Statement dated 7/10/24 completed by NA #1 identified that at 10:45 PM, Resident #2 was being transferred from the toilet to his/her wheelchair when he/she started to panic and fell . An interview with the Director of Rehabilitation (DOR) on 10/15/24 at 11:18 AM identified prior to the incident, Resident #2 required an assist of 2 for transfers to the toilet during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and Hoyer lift transfers during the 11:00 PM to 7:00 AM shift. The DOR further identified Resident #2 should have been transferred from the toilet to his/her wheelchair with an assist of 2. Resident #2 was provided an elevated toilet seat after the incident. An interview with NA #1 on 10/15/24 at 1:44 PM identified she was assigned to provide care for Resident #2 during the 3:00 PM to 11:00 PM shift on 7/10/24. NA #1 identified she knew Resident #2 required an assist of 2 with transfers, however, demonstrated that Resident #2 could stand with an assist of 1 while utilizing the grab bar to perform duties and then transfer back to the wheelchair. NA #1 identified that on 7/10/24, she began independently transferring Resident #2 to his/her wheelchair. NA #1 identified Resident #2 panicked, and NA #1 placed her foot behind Resident #2's body, pushed the wheelchair out of the way and eased him/her to the floor. An interview with NA #3 on 10/15/24 at 2:02 PM identified she was also assigned to provide care for Resident #2 during the 3:00 PM to 11:00 PM shift on 7/10/24. NA #3 identified she was aware Resident #2 required an assist of 2 with transfers. NA #3 further identified that there was no request for assistance with Resident #2 on 7/10/24 and that she was only made aware that Resident #2 had fallen when she heard NA #1 call for help. An interview with the Director of Nursing on 10/15/24 at 3:09 PM identified Resident #2 required an assist of 2 at the time of the fall and that Resident #2's transfer status was reviewed after the fall with no changes. 3. Resident #10 had diagnoses that included left femur fracture, dementia, repeated falls and restlessness and agitation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), required partial/moderate assistance with toileting, personal hygiene and transfers. The MDS identified Resident #10 occasionally experienced urinary incontinence. The Resident Care Plan (RCP) dated 5/24/24 identified Resident #10 as a fall risk related to cognition, diagnosis of dementia, ADL decline, history of repeated falls, incontinence and attempts to get up on his/her own. Interventions included offering toileting every hour while awake and to remain with Resident #10 near the bathroom while toileting. The RCP identified Resident #10 had urinary incontinence and included an intervention to check Resident #10 every 2 to 3 hours for toileting needs. The Resident Care Card (RCC) identified Resident #10 as a high fall risk with a history of a hip fracture and directed incontinence care every 2-3 hours, to offer toileting every half hour while awake and not to leave Resident #10 alone in the bathroom. a. Review of the Reportable Event form dated 6/3/24 identified Resident #10 was observed sitting on the bathroom floor at 7:40 PM. Review of a written statement by LPN #2 dated 6/3/24 identified Resident #10 was incontinent of stool at the time he/she was found on the bathroom floor. Review of a written statement by NA #1 dated 6/3/24 identified she was the NA assigned to care for Resident #10 during the 3 PM to 11 PM shift on 6/3/24. The statement written by NA #1 did not include information about toileting or any care provided for Resident #10 throughout the shift. During an interview with NA #1 on 10/16/24 at 11:11 AM, NA #1 indicated she remembered the fall incident that occurred on 6/3/24 and she remembered writing her statement. NA #1 identified she did not toilet Resident #10 prior to the fall in the bathroom and stated her reason for not toileting Resident #10 was because most of the time he/she goes to the toilet on his/her own. NA #1 further identified Resident #10 forgets to use the call bell when he/she needs help and indicated it is difficult to keep an eye on Resident #10 because there are other residents who need tending to. NA #1 indicated that even if Resident #10 is brought to the bathroom, he/she will still go on his/her own and further stated this is not someone you can keep tabs on, even if you toilet him/her every 2 hours, he/she will still go by himself/herself. b. Review of the facility Post Fall Evaluation by RN #2 dated 10/14/24 identified Resident #10 fell in the bathroom at 8:52 PM while attempting to self-transfer to the toilet and was incontinent at the time of the fall. Review of the Reportable Event Investigation Statement form by NA #5 dated 10/14/24 identified the last time care was provided to Resident #10 prior to the incident was at 3:30PM and further down the form identified Resident #10 was last toileted at 7:30 PM. Interview with NA #5 on 10/15/24 at 9:32 AM identified she was assigned to provide care for Resident #10 on 10/14/24 during the 3 PM to 11 PM shift. NA #5 indicated Resident #10 was more anxious and agitated than usual. NA #5 further identified Resident #10 was hyper focused on having his/her wanderguard bracelet (wearable alert device for residents who are at risk for wandering) removed and was arguing with another resident at the nurse's station for most of the shift. NA #5 identified that prior to the fall in the bathroom at 8:52 PM, she last brought Resident #10 to the bathroom at 3:30 PM. NA#5 identified she did not bring Resident #10 to the bathroom at 7:30 PM but, instead, asked Resident #10 if she needed to go to the bathroom. Interview with the Director of Nursing (DNS) on 10/15/24 at 11:47 AM indicated that although Resident #10 is severely cognitively impaired, at times Resident #10 knows when he/she needs use the bathroom. The DNS further identified that Resident #10 may not always answer questions appropriately or be able to make decisions based on his/her severe cognitive impairment and Resident #10 should be toileted according to a schedule. The facility Fall Prevention and Management policy states, in part, residents who are identified as a fall risk will be care planned and individualized interventions and precautions will be noted to avoid falls. The policy directed a safe environment with the least restrictive measures while promoting the highest possible independence. The Facility policy titled Urinary Incontinence - Clinical Protocol states, in part, based on assessment, staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence patterns. The facility Accidents and Incidents - Reporting and Investigating policy states, in part, all accidents, incidents, or events involving residents shall be reported and investigated.

Based on review of facility documentation, facility policy and interviews the facility failed to implement appropriate plans of action to correct quality deficiencies once identified through Quality Assurance and Performance Improvement (QAPI). The findings include: A review of the facility QAPI program identified the following: 1.QAPI Committee Minutes dated 3/21/24 identified a bed safety program was being initiated for entrapment checks prior to bed changes for residents who choose to use bed rails as a mobility enabler. QAPI Committee Minutes dated 6/19/24 identified a bed safety program was completed and that bed checks were being performed by maintenance. A review of facility documentation failed to reflect documentation of measurable goals, step by step interventions to correct the problem or how the facility was to monitor progress over time. 2.QAPI Meeting Minutes dated 3/21/24, beginning February 2024, identified a plan for mechanical lifts and sling quality control was being initiated to ensure all slings were safe for use and sizing appropriate according to manufacturer guidelines. A review of the QAPI meeting Minutes dated 7/17/24 identified the mechanical lift sling and quality control project was completed and that all residents had (2) slings in rotation and inspection as part of a daily practice. A review of facility documentation failed to reflect documentation of measurable goals, step by step interventions to correct the problem or how the facility was to monitor progress over time. An interview with the Director of Nursing identified he was unable to provide an explanation for lack of documentation related to the QAPI initiatives. A review of the facility policy for QAPI Plan dated 2/3/2019 directed Performance Improvement Projects take a systemic approach to improve care and services that identify problems, document performance improvement/trends and conduct periodic measurement and review to ensure new action is adopted and performed consistently.

Based on observation and interview, the facility failed to ensure staff were provided Personal Protective Equipment (PPE) gowns while sorting and washing soiled linens. On 10/15/2024 at 11:00 AM interview and observation with Laundry Aide (LA) #1 identified PPE gowns had never been used to handle soiled linen. An interview on 10/16/24 at 9:35 AM with the Director of Laundry (DOL) identified she/he was new to the position and did not know when PPE gowns should be utilized while processing laundry. An observation and interview with LA #1 and the DOL on 10/16/24 at 9:35 AM identified PPE gowns were never used with the handling of soiled linens. Observation with the DOL identified no PPE gowns were stored in the laundry area. Further observation identified contamination of LA #1's clothing with the handling of soiled linens and subsequent handling of clean linens. On 10/17/2024 at 11:30 AM the facility Administrator indicated laundry staff should utilize PPE gowns when handling soiled linen. Subsequent to surveyor inquiry, PPE gowns were stocked in the laundry area and staff were educated regarding the use of PPE gowns. The facility policy labeled Departmental (Environmental Services)-Laundry and Linen indicated, in part, employees sorting and washing linen must wear a gown and gloves and a mask may be worn if aerosolization is expected.

Based on observations, review of facility policy, and interviews, the facility failed to store personal care items in a clean and sanitary manner in rooms with a shared bathroom. The findings include: Observation on 10/10/24 at 9:43 AM identified unlabeled personal care items on the left side of the bathroom countertop, shared by Resident #16 and Resident #24, to include a hairbrush, comb, used disposable razor, open 1/2 full shampoo bottle, blue soap dish containing a yellow used bar of soap, kidney shaped basin containing a used toothbrush, and a plastic cup laying on its side containing 2 used toothbrushes (1 white and 1 blue). Observed on the right side of the countertop were unlabeled items to include a denture cup, barrier cream and 2 electric razors. Also on the right side of the countertop was a kidney shaped basin, labeled with the last name of Resident #16, containing a used white toothbrush, toothpaste and comb. Observation on 10/10/24 at 10:01 AM identified unlabeled personal care items on the left side of the bathroom countertop, shared by Resident #27 and Resident #336, to include a kidney shaped basin containing a used toothbrush, toothpaste, hairbrush and comb. Interview with NA #6 on 10/10/24 at 10:07 AM in the shared bathroom belonging to Resident #16 and Resident #24 indicated she would not know what personal care items belonged to the residents so she would throw the items away. She further indicated both Resident #16 and Resident #24 were confused and would use whatever items were on the countertop without giving it a second thought. Interview with NA #7 on 10/10/24 at 10:23 AM identified both Resident #16 and Resident #24 used the shared bathroom and when asked how someone would know what items belonged to each resident, she indicated the items should be labeled. Observations on 10/15/24 at 10:02 AM identified unlabeled personal care items remained on the bathroom countertop belonging to Resident #16 and Resident #24. Unlabeled items observed on the left side of the countertop included 1 electric razor and a kidney shaped basin containing a used white toothbrush, comb and denture cup. Unlabeled items observed on the right side of the countertop included a comb, blue soap dish containing a yellow used bar of soap and 2 used toothbrushes (1 white and 1 blue), 1 electric razor and a comb. Observation on 10/15/24 at 10:04 AM identified unlabeled personal care items remained on the bathroom countertop belonging to Resident #27 and Resident #336. A kidney shaped basin was observed upside down on the left side of the countertop, when picked up, unlabeled items to include a used toothbrush, toothpaste, hairbrush and comb were observed laying directly on the countertop. Interview and observation with RN #1 on 10/15/24 at 10:17 AM identified the personal care items in the bathrooms shared by Resident #16 and Resident #24 and Resident #27 and Resident #336 should be labeled with resident identifiers and stored in the facility provided shelving units that hang in the bathrooms and are labeled with either door or window. Subsequent to surveyor inquiry, RN #1 used a label maker to label all personal care items in the shared bathrooms observed. Interview with the Director of Nursing (DNS) on 10/15/24 at 11:15 AM identified the facility did not have staff competencies or in-services related to storage and labeling of personal care items and further identified he was working on creating one. The DNS indicated personal care items in shared resident bathrooms should be kept separated and labeled with resident identifiers. The facility policy titled, Homelike Environment, states, in part, the facility staff maximizes facility characteristics to reflect a personalized, homelike setting to include a clean, sanitary and orderly environment.

Based on observation, staff interviews, and facility documentation, the facility failed to maintain refrigerator and dishwasher temperature logs and failed to ensure storage containers were clean. The findings include, Tour and observation of the kitchen on 10/10/24 at 9:40 AM with the Culinary Director identified the following: 1. Temperature logs for the refrigerators, freezers and dishwasher were completed through 9/30/24, however none were completed for 10/1/24 to 10/10/24. Subsequent to surveyor inquiry, on 10/10/24 at 10:16 AM, temperature logs were produced for the month of October, however the log was postdated with temperatures through 10/10/24 at 5 PM. 2. Four 50-pound storage containers used for flour, sugar, oatmeal and rice had a brown sticky substance around the outside of the tops of the containers. Subsequent to surveyor inquiry, the containers were cleaned. Interview on 10/10/24 at 9:40 AM with the Culinary Director identified the storage containers were not clean and that he does not have a cleaning schedule or log. Interview on 10/10/24 at 10:16 AM with the Culinary Director confirmed that the temperature logs were postdated through 5PM on 10/10/24. He identified that the manager logs both daily temperatures at 10:30 AM and then checks the temperature at 5 PM to ensure the documented temperatures are accurate. Although requested, policies for temperature maintenance and cleaning equipment were not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #2) reviewed for accidents, the facility failed to report an injury of unknown origin to the overseeing state agency. The findings include: Resident #2 had diagnoses that included dementia and osteoarthritis. The Minimum Data Set assessment dated [DATE] identified Resident #2 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14) and required a 2 person assist with bed mobility, transfers and toileting. The Resident Care Plan dated 8/30/23 identified Resident #2 had impaired cognition and an activity of daily living (ADL) deficit. Interventions directed to explain procedures prior to beginning and provide an assist of 2 with transfers and toileting. A facility Event Report dated 11/3/23 at 9:00 AM identified a 6.5cm by 4cm bruise was observed, on Resident #2's left upper thigh, during care. An Investigation Summary/Root Cause Analysis and Final Action Plan form dated 11/7/24 identified Resident #2 had a bruise to the left upper thigh. The form identified Resident #2 denied any mistreatment, used a mechanical lift during nighttime hours due to fatigue, and complained of discomfort with use of the mechanical lift. The mechanical lift was evaluated by nursing and deemed the appropriate size. The mechanical lift company provided onsite education for staff to prevent further injury. An interview with the Director of Nursing (DNS) on 10/15/24 at 3:09 PM identified he was responsible for overseeing abuse allegations. The DNS identified the resident and staff would be interviewed, for any injury of unknown origin, to determine what may have occurred. The DNS indicated, if abuse was suspected, he would report to the overseeing state agency. Despite the bruise location of the left upper thigh, the DNS identified he did not report the injury as he did not feel it met criteria for reporting. A review of the facility Abuse Prevention Policy dated 4/20/23 directed all alleged violations of abuse including injuries of an unknown source are to be reported immediately, not to exceed (2) hours after discovery, to members of the community and other officials in accordance with state and federal laws through established procedures. Injuries of unknown source are when the following conditions are not met: The source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury, location (the injury is not located in an area generally vulnerable to trauma), the number of injuries at one point in time or incidence of injuries over time.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 sampled resident (Resident #22) reviewed for resident rights, the facility failed to honor a resident's food preference. The findings include: Resident #22 had diagnoses that included type II diabetes and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was cognitively intact and independent with eating. The Resident Care Plan dated 8/13/24 identified Resident #22 had impaired cognition or thought process related to dementia with confusion. Interventions directed to implement an approach to maximize involvement with daily decision making. Physician orders dated 8/30/24 directed a regular, diabetic, low potassium renal diet. An interview with Resident #22 on 10/11/24 at 12:30 PM identified she/he was supposed to receive fresh potatoes at mealtimes, but the facility repeatedly provided instant potatoes. Resident #22 further identified she/he discussed the matter with the Director of Nursing (DNS) who ensured it would not happen again. An interview and observation with Nurse Aide (NA) #4 on 10/11/24 at 12:30 PM identified she was delivering a bowl of fresh mashed potatoes to Resident #22's room. NA #4 identified Resident #22 preferred fresh mashed potatoes but at times was served instant mashed potatoes instead. NA #4 further identified that Resident #22 was initially served instant mashed potatoes with lunch, and she was delivering fresh mashed potatoes as a replacement. An interview with Dietary Aide (DA) #1 on 10/11/24 at 12:50 PM identified he was aware Resident #22 should receive fresh potatoes and that Resident #22 was served instant potatoes with lunch by another dietary staff member. An interview with DA #2 on 10/11/24 at 12:57 PM identified residents complete menus that include daily preferences which are then transcribed onto meal tickets. DA #2 indicated he was aware Resident #22 preferred fresh potatoes rather than instant potatoes and excluded his/her preference for fresh potatoes. Additionally, DA #2 plated Resident #22's meal at lunchtime and did not serve Resident #22 fresh potatoes as an oversight. An interview with the DNS on 10/11/24 at 1:08 PM identified he did not recall any conversations regarding fresh potatoes as a preference, but efforts were made to ensure Resident #22 was comfortable. An interview with the Food Service Director on 10/11/24 at 2:30 PM identified staff were responsible for checking meal tickets when plating meals and Resident #22 should have been served fresh potatoes according to preference. A review of the Resident [NAME] of Rights directed a resident has the right to self-determination and to make choices about all aspects of life in the facility that are significant to the resident.

Based on record review and staff interviews for 1 of 5 residents reviewed for unnecessary medications (Resident #16), the facility failed to ensure accurate transcription of a physician's order for a newly ordered psychotropic medication. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses that included a history of fainting, falls, and a cervical fracture. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was cognitively intact and had not exhibited behaviors directed toward others. A Psychiatrist note dated 10/2/24 identified Resident #16 exhibited delusions, hallucinations, and behaviors of yelling. The Psychiatrist note indicated that Risperdal (an antipsychotic medication) would be started. The note further indicated that the dose and frequency for Risperdal was 0.25 milligrams (mg) every evening at 8:00 PM. A facility Physician's Order dated 10/2/24 by the psychiatric provider, Medical Doctor (MD) #2, identified a handwritten order directing to administer Risperdal 0.25 mg by mouth every evening at 8:00 PM. An electronic Physician's order dated 10/2/24 directed the administration of Risperdal 0.25 mg by mouth every 8 hours. A review of the Electronic Medication Administration Record (EMAR) identified that Resident #16 was administered Risperdal 0.25 mg by mouth every 8 hours from 10/3/24 to 10/15/24 (a total of 13 days). A Nursing note dated 10/15/24 indicated that a new order for Risperdal was received from MD #2 on 10/2/24 and was transcribed as Risperdal 0.25 mg every 8 hours rather than Risperdal 0.25 mg every evening at 8:00 PM. On 10/16/24 at 11:36 AM, an interview with RN #2 indicated that providers usually input orders directly into the EMAR, but MD #2 handwrites orders which then require transcription into the EMAR by the nursing supervisor. RN #2 indicated that the handwritten Risperdal order looked unclear, but he thought the order was written as Risperdal 0.25 mg every 8 hours as needed. RN #2 indicated that he did not contact any staff member or providers for order clarification. On 10/16/24 at 12:25 PM, an interview with the Director of Nursing (DNS) identified that RN #2 brought the order discrepancy to his attention on 10/15/24. The DNS indicated that the facility was still investigating the incident, but that Resident #16 did not have an adverse effect from the medication error. The DNS indicated that staff do a 24-hour chart review every day to look for new orders and ensure orders look okay. The DNS further indicated that the 24-hour chart review does not serve as a check for the order transcription process. On 10/16/24 at 12:35 PM, an interview with MD #2 identified on 10/2/24 she ordered Risperdal 0.25 mg every evening at 8:00 PM, she did not order Risperdal 0.25mg every 8 hours. MD #2 indicated that she found discrepancies between what she ordered and what was being administered when she reviewed Resident #16's medications on 10/15/24. MD #2 identified that Risperdal was a new medication for Resident #16. MD #2 indicated that potential adverse effects of a higher dose or frequency of Risperdal included oversedation, falls, and low blood pressure. MD #2 identified that Resident #16 had a history of falls prior to starting Risperdal and was not aware of any falls or other adverse effects while receiving Risperdal. MD #2 further indicated that she would expect to be called or emailed if orders needed clarification. The facility policy titled Physician Order Transcription states, in part, orders written on the physician's order sheet by a prescriber will be entered in the electronic health record (EHR) after verification by a licensed nurse.

Based on clinical record reviews, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred with the assistance of two staff in accordance with the Resident Care Plan and as a result, the resident was not positioned safely in the chair and when staff directed the resident to reposition him/herself, the resident slid out of the wheelchair and sustained a femur fracture. The finding includes: Resident #1's diagnoses included osteoarthritis, dementia and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating moderate impaired cognition and required substantial/maximal assistance with toileting and transfers. The Resident Care Plan dated 8/7/24 identified Resident #1 had limited mobility. Interventions directed to provide assistance of two (2) staff for toilet transfers. Review of the facility incident report dated 8/26/24 at 10:50 PM identified two (2) NAs were preparing to transfer Resident #1 from the wheelchair into bed and identified Resident #1 was not seated back far enough in the chair to initiate a safe transfer. Resident #1 was instructed by the NA to move him/herself back in the wheelchair, and when the resident leaned forward, and Resident #1 fell . Resident #1 complained of pain with a deformity noted of the left thigh, 9-1-1 was called, Resident #1 was transferred to the hospital and diagnosed with a left femur fracture. Review of the hospital's discharge summary dated 8/30/24 identified Resident #1 had a midshaft displaced femur fracture of the left leg and required an Open Reduction and Internal Fixation (ORIF). Record review identified Resident #1 was readmitted to the facility on [DATE]. Facility documentation review identified NA #2 and NA #3 completed competency assessments using a mechanical lift prior to this incident in 2024. Interview with NA #3 on 9/18/24 at 12:30 PM identified she and NA #2 were preparing to transfer Resident #1 into bed. NA #3 stated when she entered the room with the Hoyer lift, Resident #1's buttocks was on the edge of the wheelchair with his/her shoulders against the back part of the wheelchair. NA #2 and NA #3 directed Resident #1 to scooch back in the wheelchair. NA #2 was standing behind the wheelchair and NA #3 was on the side of the wheelchair, and when Resident #1 attempted to move, he/she slid out of his/her wheelchair and onto the floor. NA #3 stated she and NA #2 did not lock the wheelchair before Resident #1 attempted to reposition him/herself in the wheelchair. NA #3 further indicated that she had transferred Resident #1 with a Hoyer prior to the incident. Interview and record review with Physical Therapist #1 on 9/18/24 at 12:58 PM identified Resident #1 had an order for assistance of two via the Hoyer lift to get the resident in and out of the bed and chair and the assistance of two staff when transferring Resident #1 on and off the toilet. The Hoyer lift and toilet transfer order was in place since 4/15/24. Interview with NA #2 on 9/18/24 at 1:42 PM identified she transferred Resident #1 off the toilet and into the wheelchair by herself. When NA #3 came into the room they identified Resident #1 was not properly positioned in the wheelchair and needed the resident to move back further before using the Hoyer lift. Resident #1's buttocks was observed on the edge of the wheelchair when NA #2 and #3 directed Resident #1 to scooch back. NA #2 was standing behind the wheelchair and NA #3 was on the side of the wheelchair with the wheelchair unlocked, and when Resident #1 attempted to reposition in the wheelchair, he/she slid out of his/her wheelchair and onto the floor. NA #2 stated she doesn't usually care for the resident and believed Resident #1 only required one person assistance for toileting. Interview with the Director of Nursing (DON) on 9/18/24 at 1:10 PM identified Resident #1 required two (2) staff for transfers, and on 8/26/24 NA #2 transferred Resident #1 from the toilet into the wheelchair alone, and Resident #1 was not properly positioned in the chair. NA #2 and NA #3 then directed Resident #1 to reposition in the chair, and Resident #1 slid out of the wheelchair onto the floor. The DON stated NA #2 should have had a second staff member present for the transfer off the toilet and was unable to identify why NA #2 performed the transfer without the benefit of a second staff member assisting. Although requested the facility stated they do not have a policy on transferring residents.

Based on clinical record review, facility documentation, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was transferred in accordance with physician orders. The findings include: Resident #2's diagnoses included difficulty in walking, and muscle weakness with a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderately impaired cognition and required partial/moderate assistance with transferring from sitting to standing and from transferring from chair to bed. The Resident Care Plan (RCP) dated 7/25/2024 identified that Resident #2 was at risk for falls and required assistance with ADLs. Interventions directed to provide an assist of two (2) with transfers, and to ensure the residents call light and personal items are within reach. A physician's order dated 8/26/2024 directed to provide an assistance of two (2) when toileting and transferring with the Maximove lift. Facility reportable event form dated 9/5/2024 at 11:15 AM identified Resident #2 alleged NA #1 was rough when providing care and threw him/her into the chair and yelled lousy words and was unable to recall what was allegedly said. NA #1 was suspended, and an investigation initiated. Resident #2 had no injuries. Facility incident summary dated 9/5/2024 identified the roommate did not witness the alleged incident. The summary further identified Resident #2 had a history of directing staff to perform unsafe transfers and investigation identified NA #1 performed the transfer without a second staff member present. Although attempted, an interview with NA #1 but was not obtained during survey. Interview with the Director of Nursing (DON) on 9/18/2024 at 2:12 PM identified Resident #2 required two (2) staff for transfers, and NA #1 performed the transfer alone, without a second staff assistance. The DON stated NA #1's employment was terminated due to not transferring the resident in accordance with physician orders.

Based on clinical record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include transfer status orders. The findings include: Resident #1's diagnoses included osteoarthritis, dementia and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderately impaired cognition, required substantial/maximal assistance with toileting, and required substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 8/7/2024 identified Resident #1 had limited mobility. nterventions directed to provide an assistance of 2 staff for toilet transfers and for Hoyer lift at night for all transfers. Although requested the facility did not provide physician orders for Resident #1. Review of the facility incident report dated 8/26/2024 at 10:50 PM identified 2 NAs were preparing to transfer Resident #1 from the wheelchair into bed and identified Resident #1 was not seated far back enough in the chair to initiate a safe transfer. Resident #1 was instructed by the NA to move back in the wheelchair and the resident abruptly leaned forward in the wheelchair. The NA attempted to intercept the resident to prevent the fall, but the NA was unable to prevent Resident #1 from falling out of the wheelchair. Resident #1 complained of pain with a deformity noted of the left thigh. 9-1-1 was called, Resident #1 was transferred to the hospital and diagnosed with a left femur fracture. Interview with NA #3 on 9/18/2024 at 12:30 PM identified she and NA #2 were preparing to transfer Resident #1 into bed. NA #3 stated when she entered the room with the Hoyer lift, Resident #1's buttocks was on the edge of the wheelchair with his/her shoulders against the back part of the wheelchair. NA #2 and NA #3 directed Resident #1 to scooch back in the wheelchair. NA #2 was standing behind the wheelchair and NA #3 was on the side of the wheelchair, and when Resident #1 attempted to move, he/she slid out of his/her wheelchair and onto the floor. NA #3 stated she and NA #2 did not lock wheelchair before attempting to reposition Resident #1 in his/her wheelchair. Interview with NA #2 on 9/18/2024 at 1:42 PM identified Resident #1 was on the toilet when she entered the room. NA #2 stated she transferred Resident #1 by herself off the toilet and into his/her wheelchair, placing Resident #1 on top of the Hoyer pad. NA #3 came into the room and NA #3 said Resident #1 needed to move further back in the wheelchair before using the lift, and they directed Resident #1 to scooch back in the wheelchair. NA #2 was standing behind the wheelchair and NA #3 was on the side of the wheelchair, and when Resident #1 attempted to move, he/she slid out of his/her wheelchair and onto the floor. Interview identified NA #2 did not properly position Resident #1 in the wheelchair when she transferred Resident #1 off the toilet by herself. NA #2 was unable to explain why she did the transfer without a second staff present. Interview with the Director of Nursing (DON) on 9/18/2024 at 1:10 PM identified the facility was unable to provide physician orders for Resident #1's transfer status prior to the fall. Although records were requested, they were not provided prior exiting the facility, and were not received as of 10/2/2024.

Based on tour of the Dietary Department and staff interview, the facility failed to ensure adequate staffing to carry out the functions for cleaning the kitchen. Tour of the Dietary Department on 4/13/23 at 11:30 AM with the Food and Beverage Director identified the following: a. The cart to transport dirty dishes was noted with a heavy accumulation of dirt, dust, and grime on the handles, lower shelf, and sides and was located by the food area, just outside of the dishroom. b. The cart behind the vegetable prep sink was noted with an accumulation of dirt and grime. c. The back of the food prep area had visible dust accumulation. d. The chemical dispensers above the 3 bay sink were noted with a heavy accumulation of dirt and grime, especially on the outer front face that dispenses the chemical when hand pumped. e. The tile areas surrounding the 3 bay sink, surrounding the dishwasher, and behind the hand washing sink had a blackened substance accumulated in the grout sections of the tiles. f. The rack containing approximately six clear plastic bins (that were turned upside down and stored within one another) located near the soda area had visible dust, and debris in the crevices of the outer lip. g. The wire rack by the clock on the wall, that contained clean clearing trays with lids had visible dirt, dust, and debris. j. A rack located in the dry storage area was noted to contain an accumulation of dirt and debris. k. The shelves in the freezer were noted to contain an accumulation of dirt, dust and debris. (The Director Food and Beverage Director stated that area definitely needed to be cleaned). l. The Robot Coupe Food Processor was noted with a heavy accumulation of soiling, dust and debris. The Food and Beverage Director identified that this machine was operational and used in the Dietary Department. m. The vent near the prep sink was noted to contain a black substance, and dust. n. The Dessert refrigerator was noted with a white, sticky substance splattered on the walls inside and lacked a thermometer on the inside or outside. Interview with Dietary Manager at that time identified that although there was a cleaning schedule for the kitchen, the kitchen was short a utility staff who would be responsible for cleaning, and the kitchen was not as clean as it should be due to being short staffed.

Based on clinical record review, facility documentation, interviews, and observations, for one of three residents reviewed for accidents, (Resident #80), the facility failed to ensure side rails were installed/maintained in accordance with manufacturers guidelines and/or that interventions for prevention of skin tears were in place to prevent an accident with a major injury. The findings include: Resident #80 had [DIAGNOSES REDACTED]. Review of a device safety plan dated 3/7/18 identified that the resident's Power of Attorney requested the use of side rails to assist with the resident's positioning and mobility. A minimum (MDS) data set [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living. A care plan dated 9/1/18 identified that the resident was at risk for impaired skin integrity related to a disorder of the skin and subcutaneous tissue with interventions that included to have the right side rail padded. Review of a reportable event and investigation dated 10/13/18 at 8:45 AM identified that the resident was noted with a 15 centimeter (cm) by 6.5 cm by 0.3 cm laceration with 5 cm of bone exposed in the center of the right shin. There was blood noted on the right side rail, and it was determined that the injury occurred by the resident dragging his/her right leg across the right side rail. Review of a nurse's note dated 10/13/18 identified that the resident was noted with a skin tear to the right shin, with a large amount of bleeding, the resident was medicated with [MEDICATION NAME] for discomfort, and sent to the emergency department for an evaluation. After the incident, the resident's side rails were fully padded and alternative side rails were ordered for the resident. Review of emergency room documentation dated 10/13/18 identified that the resident received 4 sutures to pull together the subcutaneous tissue, then 3 sutures to loosely approximate the skin on the right shin area. Review of a nurse's note dated 10/13/18 identified that the resident returned to the facility at 3:45 PM with orders for wound care and antibiotic therapy for 10 days. Interview with Nurse Aide (NA) #4 on 4/15/19 at 10:3 AM identified that she had provide incontinent care and positioning for Resident #80 at 6:00 AM on 10/13/18, and there was no apparent injury and/or blood noted during care. Interview with NA# 3 on 4/16/19 at 10:24 AM identified that she had entered Resident # 80's room at the beginning of her shift (approximately 7:30 AM), to gather supplies for care, but was called away for an emergency. The resident at the time was sleeping in bed. When she returned at approximately 8:45 AM she noted that the resident's right leg was hanging over the right side rail, with her right shin in contact with the right side rail, with blood noted at the gap in the plastic on the side rail. She then immediately notified her nurse. Interview with Registered Nurse (RN) #5 on 4/15/19 at 12:33 PM identified that when she entered Resident #80's room she identified that it was apparent that the resident had gotten her leg caught on the right side rail because the blood was dripping off of it, the fitted sheet was also soaked in blood. She immediately summoned another nurse to call 911, and the physician while she assessed the resident and dressed the wound. Additionally RN #3 identified that there was no padding on the right side rail at the time of the injury. Resident #80 no longer resides at the facility. Interview and observation with the Director of Nurses (DON) on 4/15/19 at 1:30 PM of a side rail that was identical to the one Resident #80's side rail identified a gap in the plastic of the side rail measuring 8 cm by ½ cm, at the far end of the side rail (towards the foot of the bed). The DON identified that the area is not entirely smooth and the resident could have caught his/her leg on that area. Review of the manufacturer's directions for use for the side rail identified that the gap in the side rail's plastic should be facing the wall at the head of the bed (not towards the inside of the bed). Interview with the maintenance director on 4/16/19 at 9:00 AM identified that after reviewing the manufacturer's directions for use on 4/15/19 it was identified that Resident #80's side rail was placed on the bed backwards, the gap in the side rails plastic should be at the head of the bed facing the wall, and it was facing the foot of the bed at the time of the incident. He further stated that subsequent to surveyor inquiry on 4/15/19, all side rails in the facility were checked, and 11 of the 35 beds had the side rails on backwards. The facility immediately fixed the side rails. Interview with the manufacturer on 4/16/19 at 2:00 PM identified that the gap in the plastic should be at the head of the bed facing the wall, the gap in the plastic is there to cradle the leg of the side rail when placed in a downward position. The area with the gap could be identified as a rougher surface, and placing it towards the wall would lessen resident contact with that surface. Further interview with the DON on 4/16/19 at 12:30 PM identified that according to the plan of care for Resident #80, the right side rail should have been padded. She further identified that if a resident requires a padded side rail it should be on the NA care card and/or the Treatment Administration Record so staff can ensure the padding is in place. The DON stated that she was unaware at the time of the injury that the side rail was not padded, and further identified that the NA care card and TAR lacked information on the padded side rail. Review of the side rail policy identified the facility goal is to prevent injuries from bed and related equipment (including side rails), by having maintenance inspect the beds and related equipment as part of the regular bed safety program to identify risks and problems.

Based on clinical record review and staff interview for 1 of 3 sampled residents (R#10), requiring mechanical devices for transfers, the facility failed to ensure appropriate assistance/supervision to prevent a fall with fracture. The findings include: Resident #10's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had severe cognitive impairment, required extensive to total assistance with transfers and locomotion on and off the unit, required assistance with stabilizing self while moving on and off the toilet, and had a fall since the prior assessment. The resident care plan dated 11/7/11 identified fall risk related to poor safety awareness and decreased mobility. Interventions included a toileting program, assist of 2 persons for all transfers using the sara-lift, and carefully observe and maintain correct placement while on lift. Nurse's notes dated 11/19/11 identified that during morning care, R#10 was placed onto the toilet still attached to the mechanical lift, and fell to the floor. The resident was assessed and at the time found to have no injury. Nurse's notes dated 11/20/11 at 6 AM identified R#10 complained of ankle pain, the area was assessed and found to have no areas of swelling. Nurse's notes dated 11/21/11 at 1:45 PM identified R#10 was yelling and in discomfort when the right foot and lower leg were touched. The area was assessed, the Physician was notified and ordered and x-rays of the right tibia, fibula and right ankle. The results of the x-rays were negative. Nurses notes dated 11/26/11 at 7:55 PM noted R#10 complained of pain in the right ankle, the area was assessed and found to have swelling, the physician was notified and a repeat x-ray was obtained and identified an acute medial malleolar avulsion fracture. Facility documentation dated 11/19/11 and 11/30/11 identified a nurse aide placed the resident onto the toilet using a Sara-lift, and found the resident on the floor still attached to the lift. Additionally, the investigation identified that NA's lowered the resident to the floor and then notified the nurse. Interview with the RN #1 on 5/9/12 at 10:15 am stated that the NA ' s made her aware that the resident was on the floor. Upon assessment R # 10 was observed to be sitting with the legs crossed, denied pain and was able to move legs. The resident was transferred to a chair. RN #1 stated that the NA left the resident unattended on the toilet, while still attached to the lift and that the facility policy is to not leave a resident unattended on the toilet. Interview with NA#2 on 5/9/12 at 1:55 PM noted that she heard R#10 yelling and saw the aide down the hall so she responded to the resident and found the resident hanging off the toilet still attached to the lift. Interview with NA#3 on 5/9/12 at 2:20 PM noted she saw R # 10 hanging from the lift with the leg straps still in place and that she assisted NA#2 to lower the resident to the floor. Interview with the DNS on 5/9/12 at 10:30 am noted that the policy of the facility for the use of lifts is that residents are not left unattended and that through the investigation, NA #1 stated she left the resident alone on the toilet still attached to the lift.