Every finding on record at Portland Care & Rehab Centre, INC

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Residents #3, 33 and 12) reviewed for unnecessary medications, for Resident #3 and 33, the facility failed to ensure monthly pharmacy medication regimen reviews were completed for 5 of the 12 months reviewed and for 1 of 5 residents Resident #12 the facility failed to ensure monthly pharmacy medication reviews were completed 11 of 12 months. The findings include: 1. Resident #3 was admitted to the facility in December 2023 with diagnoses that included thrombophilia, severe dementia with mood disturbance, and hypothyroidism. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and was receiving antipsychotic, hypnotic, and anticoagulant medications. The care plan dated 3/10/26 identified Resident #3 was taking an anticoagulant medication, with interventions that included reviewing the medication list for adverse interactions and was taking an antipsychotic medication, with interventions that included monitoring, recording, and reporting to the physician side effects and adverse reactions of the psychoactive medications. Review of Resident #3's clinical record failed to identify a monthly medication regimen review was completed by the Consultant Pharmacist in 9/2025, 11/2025, 12/2025, 1/2026, and 2/2026. 2. Resident #33 was admitted to the facility in December 2022 with diagnoses that included hypertensive heart and chronic kidney disease with heart failure, schizophrenia, and anxiety. The annual MDS dated [DATE] identified Resident #33 had intact cognition and was receiving antipsychotic, antidepressant, anticoagulant, diuretic, and antiplatelet medications. The care plan dated 12/9/25 identified Resident #33 was taking an anticoagulant medication, with interventions that included reviewing the medication list for adverse interactions and was taking psychotropic medications and antipsychotic medications, with interventions that included monitoring, recording, and reporting to the physician side effects and adverse reactions of psychoactive medications. Review of Resident #33's clinical record failed to identify a monthly medication regimen review was completed by the Consultant Pharmacist in 9/2025, 11/2025, 12/2025, 1/2026, and 2/2026. Interview with the DNS on 3/10/26 at 6:29 AM identified that the medication regimen reviews were received from the Consultant Pharmacist via encrypted email, monthly; she was unable to find the Consultant Pharmacist's monthly recommendations, for Residents #3 and #33, from 9/2025, 11/2025, 12/2025, 1/2026, and 2/2026. The DNS indicated that she had not been getting the monthly pharmacy medication regimen reviews for the long-term care residents and had only been receiving the reviews for the newly admitted residents, which were completed by a different Consultant Pharmacist, from the same company. The DNS further indicated that she had called the Consultant Pharmacist #1, in December, and notified him that she had not been receiving the monthly reviews for the long-term residents, and she verbally followed up with the Supervising Pharmacy Consultant at the end of January; he said he was looking into it. The DNS further indicated that the Consultant Pharmacist #1 sent her the medication regimen review that was completed in 10/2025, but she was missing the reviews from 9/2025, 11/2025, 12/2025, 1/2026, and 2/2026, for the long-term care residents. Although attempted an interview with the Consultant Pharmacist #1 was not obtained. Interview with Supervising Pharmacy Consultant #1 on 3/11/26 at 2:59 PM identified the Consultant Pharmacist was responsible for completing monthly pharmacy medication reviews and sending them electronically following their review. Supervising Pharmacy Consultant #1 identified sometime in December 2025, Pharmacy Consultant #1 reported experiencing computer issues when, during repair, the hard drive was cleared of work-related information. Supervising Pharmacy Consultant #1 directed Pharmacy Consultant #1 to retrieve previously completed medication reviews from past emails. Supervising Pharmacy Consultant #1 periodically followed up on the status of the lost files and was informed the matter was being addressed. Supervising Pharmacy Consultant #1 indicated while he was not made aware the issue remained unresolved until after surveyor inquiry, there were no reports of irregularities not being addressed and was attempting to recover lost data. Pharmacy Consultant #1 was terminated. The Consultant Pharmacist Services Provider Requirements policy directs that regular and reliable consultant pharmacist services are provided to residents; specific activities that the consultant pharmacist performs include, but is not limited to: reviewing the medication regimen of each resident at least monthly, or more frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review and the findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation, communicating to the responsible prescriber and the facility leadership potential or actual problems detected in other findings related to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues at least monthly. The policy further directs the consultant pharmacist to document activities performed and services provided on behalf of the residents and the facility, a written or electronic report of findings and recommendations resulting from the activities as described above is given to the attending physician, director of nursing, and others as may be appropriate at least monthly, and the facility has a process to ensure that the findings are acted upon. Resident specific recommendations are documented in the resident's active medical record. 3. Resident #12 was admitted to the facility in December 2024 with diagnoses that included chronic obstructive pulmonary disease, type II diabetes and chronic kidney disease. The quarterly MDS dated [DATE] identified Resident #12 was cognitively intact and received medications daily to manage multiple comorbidities. The care plan dated 9/23/25 identified Resident #12 had an alteration in endocrine status, received an anticoagulant and was prescribed antidepressant medication. Interventions included to administer medications as ordered and monitor for effectiveness and side effects consider gradual dose reductions if indicated. Resident #12 was a long-term resident. Pharmacy medication review dated 10/1/25 identified no irregularities with no other documented review. Review of the clinical record identified no other documented pharmacy medication reviews from 3/20/25 to 9/2025 and 11/2025 to 2/2026. Interview and clinical documentation review with the DNS on 3/10/26 6:29 AM identified Pharmacy Consultant #1 completed medication reviews for all long-term care residents monthly. Once complete, the reviews were sent to the DNS electronically for review and dissemination to the appropriate units for provider review. The DNS identified in 12/2025, she noticed she had not received any pharmacy reviews from 9/2025. The DNS contacted the Pharmacy Consultant #1 who indicated he would investigate the matter and subsequently received one pharmacy medication review dated 10/1/2025. The DNS followed up with Pharmacy Consultant #1 in 1/2026 and was told he was still looking into the matter. The DNS had not addressed the matter any further, was unable to provide any documentation of her efforts to address the problem and had no explanation of documentation regarding the status of any other pharmacy medication reviews prior to 9/2025 for Resident #12. Interview with Supervising Pharmacy Consultant #1 on 3/11/26 at 2:59 PM identified the pharmacy consultant was responsible for completing monthly pharmacy medication reviews and sending them electronically following their review. Supervising Pharmacy Consultant #1 identified sometime in December 2025, Pharmacy Consultant #1 reported experiencing computer issues when, during repair, the hard drive was cleared of work-related information. Supervising Pharmacy Consultant #1 directed Pharmacy Consultant #1 to retrieve previously completed medication reviews from past emails. Supervising Pharmacy Consultant #1 periodically followed up on the status of the lost files and was informed the matter was being addressed. Supervising Pharmacy Consultant #1 indicated while he was not made aware the issue remained unresolved until after surveyor inquiry, there were no reports of irregularities not being addressed and was attempting to recover lost data. The Consultant Pharmacist Services Provider Requirements policy directs that regular and reliable consultant pharmacist services are provided to residents; specific activities that the consultant pharmacist performs include, but is not limited to: reviewing the medication regimen of each resident at least monthly, or more frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review and the findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation, communicating to the responsible prescriber and the facility leadership potential or actual problems detected in other findings related to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues at least monthly. The policy further directs the consultant pharmacist to document activities performed and services provided on behalf of the residents and the facility, a written or electronic report of findings and recommendations resulting from the activities as described above is given to the attending physician, director of nursing, and others as may be appropriate at least monthly, and the facility has a process to ensure that the findings are acted upon. Resident specific recommendations are documented in the resident's active medical record. Efforts to interview Pharmacy Consultant #1 were unsuccessful.

Based on observation, review of facility documentation, facility policies, and interviews, the facility failed to ensure food service staff were wearing hair restraints while preparing food and failed to ensure a low temperature dishwasher was operating in accordance with the manufacturer's recommendation. The findings include: 1. [NAME] #1 was hired in October 2012.Dietary Aide #1 was hired in November 2023.Observation on 3/8/26 at 9:00 AM, in the first-floor dining room, identified Dietary Aide #1, serving breakfast from the steam table, without the benefit of a hair guard.Interview with Dietary Aide #1 on 3/8/26 at 9:08 AM identified that she was aware that she should be wearing a hair net while serving food, but today she had arrived late and they were short staffed, so she forgot to put it on. Dietary Aide #1 indicated that she always wears a hair net.Observation on 3/9/26 at 11:40 AM identified [NAME] #1, in the kitchen, temping food on the steam table, without the benefit of a beard guard.Interview with [NAME] #1 on 3/9/26 at 11:40 AM identified that he always puts on a beard guard right after he puts on his hair net, but today the bag for the beard guards was not available and he needed to grab a new bag, therefore he forgot to put on a beard guard before starting work.Interview with the Dietary Director on 3/10/26 at 10:30 AM identified that it was his expectation that food service staff wear hair restraints while in the kitchen and while preparing, cooking, and plating food. The Dietary Director further identified that he had reeducated food service staff on the hair restraint policy. Interview with the Administrator on 3/10/26 at 10:00 AM identified that he would expect the food service staff to follow the hair restraint policy and wear the appropriate hair restraints while in the kitchen and preparing and serving food.The Hair Restraints policy directs hair restraints will be put on when entering the kitchen and when preparing, cooking and plating food. All staff preparing, cooking, and plating food will wear hair restraints or a head cover. All facial hair will be covered using a hair restraint, all staff entering the kitchen will put on a hair restraint to cover head and facial hair as provided at the entrance of the kitchen, any time kitchen staff needs to manage their hair restraint, head covering or facial hair they will step away from the food area and remove and discard their gloves and hair restraints period. Prior to returning to the food area the employee will wash their hands with soap and water or hand disinfectant, apply a new hair restraint and new gloves. 2. Dietary Aide #2 was hired in March 2023.Review of the Dietary Aide Orientation dated 3/14/23 identified Dietary Aide #2 had been educated on the use and care of the dishwasher, which included proper temperature, use of detergents, and sanitation.Observation on 3/9/26 at 1:40 PM identified Dietary Aide #2 washing the dirty dishes and utensils in the low temperature dishwasher, with a sanitizer reading within normal limits (WNL), but a maximum temperature of 90 degrees Fahrenheit, (low temperature dishwashers should operate at a minimum temperature 120 degrees Fahrenheit and also use chemical sanitizer to ensure food safety). Three additional observations from 1:45 PM through 2:00 PM identified the maximum dishwasher temperature achieved was 90 degrees F (temperature confirmation obtained with a digital thermometer).Interview with the Dietary Director on 3/9/26 at 2:05 PM identified that the low temperature dishwasher should be operating at a minimum of 120 degrees F, and that he notified the Administrator and the Director of Maintenance that the dishwasher temperature was reading at 90 F. The Dietary Director further identified that until the dishwasher was operating at a proper temperature, all food and drink services would be served using disposable plates, cutlery, cups, napkins, and lids. The Dietary Director further indicated that all dishes and utensils would be rewashed once the dishwasher was running at the appropriate temperature.Review of the March 2026 Dish Machine Temperature and Sanitizing Record directed to run the wash and rinse cycle empty twice prior to use, upon completion of this process, record below for the appropriate meals, do no wash any dishes before the required temperature and sanitizer levels were met. The Record failed to identify documentation that a temperature and sanitizer level were obtained before the breakfast dishes were washed and before the lunch dishes were washed, on 3/9/26.Interview with Dietary Aide #2 on 3/9/26 at 2:30 PM identified that he checked the dishwasher temperature before washing the breakfast dishes and that the reading was 90 degrees he planned on rechecking the temperature after the lunch dishes were washed, and if it was still 90 degrees, he was going to tell someone.Interview with the Administrator on 3/9/26 at 3:20 PM identified he was getting a reading of 117 degrees F, after adjusting the mixer valve, and he placed a call for the plumber to evaluate the system. The Administrator further indicated that until the dishwasher was functioning at the appropriate temperature, all food and drink services would be served on disposable plates and cups.Observation with the Dietary Director on 3/10/26 at 10:30 AM identified the low temperature dishwasher was operating at 123 F, all meal and drink services had been served using disposable items, and that the plumber was on his way to look at the system; disposable cups and plates would remain in place until the plumber looked at the system. The Dietary Director indicated that Dietary Aide #2 had received a written warning for not notifying him of the low dishwasher temperature, and all food service staff had been reeducated on the dishwasher temperatures and timely reporting when the temperature was out of range. The Dietary Director identified that for the next 5 days, he would check the dishwasher temperature every 15 minutes, while in use, to ensure temperature stability.Interview with the Administrator on 3/10/26 at 10:00 AM indicated that adjusting the mixer valve resolved the low water temperature issue, but the plumber would be on-site within the hour to evaluate the system. The Administrator indicated that, according to the guidance written on top of the Dish Machine Temperature and Sanitizing Record, he would expect that any temperature reading below 120 F would be immediately reported to the Dietary Director and dishwashing would not be resumed until the temperature was 120 F or greater.Interview with the Administrator and the plumber from an outside service on 3/10/26 at 11:40 AM identified that there were no mechanical issues identified with the low temperature dishwasher, and that the mixer valve adjustment had corrected the issue; the water temperature was now measuring 125 F.The Low Temperature Dishwasher Machine Operational Requirements directed the wash temperature to be 120 F minimum and required 50 ppm available chlorine rinse.

Based on observation, review of facility documentation and interviews the facility failed to ensure a clean and homelike environment. The findings include:Observation on 3/10/26 11:37 AM with the facility Administrator/Owner identified 3 of 4 upholstered chairs in the solarium (sitting room) and 5 of 10 upholstered chairs in the dining room were marked with heavy brown/black staining on the seat, and back of chairs.Interview with the Administrator on 3/10/26 11:37 AM identified he was aware the chairs were heavily soiled and had recently been researching replacements indicating they were costly. The Administrator further identified although his efforts were ongoing, he was unable to provide any documentation regarding progress towards replacement.Although requested, a policy on maintaining a clean homelike environment was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #12) reviewed for accidents, the facility failed to ensure a resident with a customized wheelchair was re-assessed for safe transfers after implementing a new standing mechanical lift and sling harness resulting in staff having to lower the resident on a firm surface near the floor. The findings include:Resident #12 was admitted to the facility in December 2024 with diagnoses that included morbid obesity and osteoarthritisPhysical Therapy Evaluation dated 6/24/25 identified Resident #12 was assessed with the use of a mechanical stand lift assist and was able to stand 1-3 minutes with total dependence.The quarterly MDS dated [DATE] identified Resident #12 was cognitively intact and required two person assist with transfers, utilized a motorized wheelchair for mobility and had not experienced any falls since admission.The care plan dated 9/23/25 identified Resident #12 was non ambulatory, at risk for falls and required assistance with mobility and transfers. Interventions included providing transfers as ordered a custom power wheelchair, tilt in space motorized with adjustable head rest, pelvic positioning belt, Roho cushion and elevating split foot plates.Physical Therapy Progress Report and Updated Therapy plan dated 11/21/25 identified skills services were recommended, in part due to balance deficits, decreased functional capacity and the need to maintain the ability to stand while in the stand assist lift was being repaired. The report further identified on 11/21/25, Resident #12 stood at a standing table for up to 22 minutes.Physician's order dated 11/22/25 (original 7/9/25) directed stand assist lift bed to/from the wheelchair. May use total mechanical lift as needed.Invoice dated 12/10/25 identified two new (different manufacturer and model) electric mechanical stand lifts were purchased and delivered on 12/12/25.Inservice Report dated 12/16/25 at 2:50 PM to 3:05 PM identified nursing staff were educated on the use of the new stand lift, specifically, sling, power button, hand controls and charge indicator.Nurse's note dated 12/16/25 at 5:45 PM identified while transferring Resident #12 to the wheelchair, his/her lower back and buttock were hitting the wheelchair seat rather than rising above with the mechanical lift at maximum height, then the resident slowly sliped out of the lift's (upper body) sling harness after no longer being able to hold his/her own weight. NA #1 applied a gait belt and Resident #12 was lowered slowly onto the footrests of the chair. Upon assessment resident denied any pain or discomfort, A body audit was performed, small flat 1cm x 1cm bruise was noted at right gluteal fold, range of motion was present in all extremities. A Hoyer pad was applied following assessment and Resident #12 was transferred into his/her wheelchair. The APRN was notified and the mechanical stand lift was removed from service until assessed by physical therapy.Rehabilitation progress note dated 12/17/25 at 10:45 AM identified an assessment of mechanical stand assist lift determined that a smaller sling was needed or trial of different connecting point and order a smaller sling harness.Physician orders dated 12/22/25 directed the use of a mechanical Hoyer lift for all transfers.Interview with the Director of Rehabilitation on 3/9/26 at 8:55 AM identified nursing staff were previously responsible for determining the appropriate sling harness size used during resident transfers. The Director of Rehabilitation indicated two new mechanical stand lifts from a different manufacturer were ordered and staff received in-service training prior to implementation, with Resident #12 being the first resident the lift was used with. The Director of Rehabilitation identified he did not re-assess the use of the lift and sling harness with Resident #12 following the incident. However, determined the sling harness provided with the mechanical stand lift as one unit was too long and not appropriate to safely secure the resident and subsequently ordered shorter sling harnesses.Interview with NA #1 on 3/09/2026 at 10:42 AM identified she was working during the 3:00 PM to 11:00 PM shift on 12/16/25 at the time of the incident. NA #1 indicated while she was not the assigned nurse aide, she assisted NA #2 by standing behind and securing the wheelchair during the transfer while NA #2 operated the lift. NA #1 identified she noticed there was insufficient clearance between the top of the wheelchair seat and the bottom of the harness where Resident #12 was being supported to allow him/ her to be lowered safely onto the wheelchair seat while the lift was at maximum height. Resident #12 was unable to stand and began sliding out of the sling harness. NA #1 grabbed a nearby gait belt, secured it around Resident #12's waist to assist with lowering where he/she came to rest on the footrests of the wheelchair. NA #1 further identified the lift and sling harness were new but looked different than what she was used to using. NA #1 was not included in the list of staff who were in-service.Interview with NA #2 on 3/09/26 at 11:57 AM identified she was the assigned nurse aide for Resident #12 during the 3:00 PM to 11:00 PM shift on 12/16/25. NA #2 indicated she used the new mechanical stand lift for the first time with Resident #12 after receiving in servicing. NA #2 indicated Resident #12 was on sitting the bed, dressed, wearing his/her orthotic footwear with both feet planted on the floor and secured in the sling harness. NA #2 enabled the lifting mechanism of the mechanical stand lift to raise Resident #12 to assist in transferring him/her from the bed to the wheelchair. NA #2 noticed at its maximum height, the lift was unable to clear the top of Resident #12's wheelchair seat. Resident #12 was unable to stand and began slipping out of the harness. NA #2 further identified a gait belt was used to lower Resident #12 who came to rest on the footrests of the wheelchair.Interview with the DNS on 03/10/26 at 7:49 AM identified she initially speculated the batteries stopped functioning when the chair was in the elevated position and purchased new batteries. The DNS later had to consider that the lift could not fully extend because the customized wheelchair for Resident #12 was too high to clear the seat to allow Resident #12 to be safely lowered onto the seat of the wheelchair. The DNS later was later informed by the Director of Rehabilitation that the sling harness for the new lift was too long. Shorter slings had since been purchased and the Director of Rehabilitation was responsible for ensuring the proper size and fit of the sling harness prior to use.Subsequent interview with the Director of Rehabilitation on 3/10/26 at 7:59 AM identified residents were evaluated by OT/PT for functional level and transfer status, with recommendations provided to nursing staff. Residents using a mechanical stand lift were assessed to ensure safe use of the equipment. Resident #12 had previously been assessed using his/her customized wheelchair and mechanical stand lift in part, to ensure adequate clearance between the wheelchair seat and resident while in the harness during a transfer. Nursing staff were then responsible for making adjustments to the sling harness up or down using a loop mechanism located on the side of the harness to accommodate the individual size of the resident and secure placement before transfer. The Director of Rehabilitation further identified he did not re-assess Resident #12's ability to complete a safe transfer using the new model and sling harness prior to its implementation lift, nor did he require staff to demonstrate competency during the in-service. Additionally, no further in servicing was provided to staff after the incident with the implementation of the new, shorter slings.The facility policy for Fall Management and Standards for Fall Reduction direct, in part to assess a resident's risk fir fall, implement interventions to reduce falls and periodically reassess effectiveness.Review of the facility policy for Total Mechanical Lifts and Sit to Stand Lifts directed all residents will be sized for the proper sling pad for sit to stand lifts by the rehabilitation department. Orders will be placed in the electronic clinical record and nurse aide care card.

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 3 sampled residents (Resident #18) who were reviewed for falls, the facility failed to utilize a gait belt during a transfer resulting in a major injury from a fall. The findings include: Resident #18's diagnosis included chronic obstructive pulmonary disease, heart failure, and history of falling. Review of the Resident Transfer Policy dated 6/14/22 directed that gait belts are used with all transfers unless contraindicated. A Fall Risk assessment dated [DATE] identified Resident #18 was at a moderate risk of falling. Review of the Reportable Event dated 6/23/23 identified Resident #18 fell while being transferred back to bed with the assistance of Nursing Assistant #1 (NA#1). Review of the submitted conclusion summary, written by the DNS, dated 6/28/23 identified that the investigation led to conflicting information from staff, however, after all staff were interviewed it was determined that NA #1 had not followed the care card for Resident #18's transfer status (had failed to utilize a gait belt). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #18 was cognitively intact and required partial/moderate assistance from staff with toileting, bathing, transfers, and dressing. The Resident Care Plan dated 5/4/23 identified Resident #18 was at risk of falling. Interventions directed to transfer as ordered, encourage/remind the resident to call for assistance when needed, and to report any difficulties or changes in transfers or ambulation. The physician's orders dated 5/26/23 directed the assistance of 1 staff for transfers, including toileting using a 2 wheeled walker. A nurse's note dated 6/23/23 at 7:53 PM identified Resident #18 lost his/her balance and had a witnessed fall. Resident #18 complained of pain in his/her right hip along with a skin tear to his/her right elbow. Resident #18 was unable to move his/her legs and the Advanced Practice Nurse directed that the resident be sent to the emergency room for an evaluation. The nurse's note dated 6/23/23 at 11:29 PM identified that the hospital called the facility stating that Resident #18 had a right hip spiral fracture of the proximal right femur which required surgery. Interview with NA #1 on 6/12/24 at 10:16 AM identified that she did not use a gait belt on 6/23/23 when she transferred Resident #18 to bed. NA#1 stated she did not use a gait belt because it was a quick transfer and was not a long distance. NA#1 identified that although the facility policy directed that all NA were to use a gait belt when transferring residents, she did not utilize a gait belt during this transfer. NA#1 stated that she did not try to prevent the fall because she was afraid of hurting herself. Interview and review of facility documentation with Physical Therapist #1 (PT #1) on 6/12/24 at 11:18 AM identified an Interdisciplinary Screening Form (PT/OT/ST) dated 4/20/23 directed Resident #18 required the assistance of 1 for transfers up to 100 feet using a 2 wheeled walker. PT #1, after reading and reviewing the reportable event, indicated that NA#1 should have used a gait belt and a 2 wheeled walker while transferring Resident #18, but NA #1 had utilized a wheelchair for the transfer instead of the 2 wheeled walker and failed to use a gait belt. PT#1 stated that a gait belt would not prevent a fall but is used to assist/lower a resident to the floor, preventing a hard impact should the resident fall. PT#1 identified that all staff are trained on the policy of transfers utilizing a gait belt and NA #1 was trained on 5/8/23 which directed that gait belts will be used on all residents during transfers and ambulation unless contraindicated (which was not the case for Resident #18). PT #1 indicated that if NA #1 had utilized a gait belt, Resident #18 may have had a fall with a less severe injury. Interview with the Director of Nurses (DNS) on 6/13/24 at 10:08 AM identified during the facility investigation that NA#1 stated that she utilized a gait belt while transferring Resident #18, however, the DNS indicated that through interviews with other staff, a gait belt had not been used during Resident #18's transfer. The DNS indicated that the NA Care Card (care plan) for Resident #18, had not been followed. The DNS indicated that the facility policy was to use a gait belt with all residents and that NA #1 did not follow the facility policy. Additionally, NA#1 had been educated on 5/8/23 on the gait belt policy with transfers.

Based on the tour of the Dietary Department, staff interview, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure canned foods in the emergency stock were not expired, and failed to ensure food was served under sanitary conditions. The findings included: During a tour of the Dietary Department on [DATE] 10:31 AM with the Dietary Director the following was identified: a. 2 ceiling fans directly over the prep area were noted to be oscillating with a heavy accumulation of dust. A dietary worker was cutting a cake directly under one of the fans. In addition, the ceiling fan in the dish room was noted with a heavy accumulation of dust. b. An uncovered pan of gravy and flour mixture was observed to be on top of the preparation (prep) table. The side and underneath area of the prep table were noted to have a heavy accumulation of dirt and debris. c. The pipes behind the conventional convection oven and the flooring behind the oven was observed with a heavy accumulation of dust, grime, and dirt. The top of the convection oven was observed with a heavy accumulation of dirt, debris, and grime. d. The hood vent area was noted to have heavy accumulation of dirt and dust. e. The eye wash station adjacent to the prep area was noted to have dirt, debris, and stains on the stainless sink and the area behind the sink. f. The microwave was noted with a heavy accumulation of stains and finger prints on the outside. Interview and observations with the cook on [DATE] at 10:56 AM identified that he cleaned the microwave on the previous day, and he only removed some and not all of the debris. g. The refrigerator door and handles were noted to have a heavy accumulation of dirt, debris, drip marks, and accumulation of finger prints. Interview and observations with the Dietary Director at [DATE] at 10:57 AM indicated that he cleaned the top of the stove a few days ago. He further identified that he didn't know the reason the convection oven was still soiled. h. The beverage cooler which contained milk and health shakes had a 5-foot gasket section under the door that was noted to have a heavy accumulation of black like substance/material. i. The walk-in freezer was noted to contain a 2-pound bag of broccoli that was half full and 7 individually wrapped pieces of cake that were not labeled/dated when opened. j. The dry storage room had the following food items with no open dates and time: 10 lbs. (half full) bag of pasta, ,d+[DATE] lbs. of orzo that was open to air, ,d+[DATE] full box of gluten free pasta and flour in a 10-gallon container that was ,d+[DATE] full and the lid and handle had heavy accumulation of dried on white substance. k. A 3-day emergency supply of food was noted to have expired expiration dates and included: 12 (28 oz) boxes of cream of wheat with an expiration of [DATE], 6 (108 oz) cans of Beef Ravioli with an exp of [DATE], 4 cans of 6 lbs. 10 oz, 4 (10 oz) cans of mandarin oranges with an exp of ,d+[DATE], 12(10 oz) cans of tomato soup with an exp of (,d+[DATE]), 6 (4 lbs. 2.5 oz) cans of Tuna fish with no expiration date. Interview and observation with Dietary Director on [DATE] at 11:35 AM indicated that he was responsible for checking the 3-day emergency food supply and expiration dates. Additionally, he noted that food items in the 3 day supply were also used whenever needed for in-house stock, were rotated whenever they are low, and were discarded when expired and replaced. l. The steam table which contained roasted chicken, baked fish, macaroni and cheese, green beans, peas, mashed potatoes, cream of chicken soup and pasta fagioli, on [DATE] at 12:20 PM was noted to have a heavy accumulation of dirt and debris on the bottom drawer and the front of the steam table. In addition, the steam table was observed being transported from the Dining Room to room [ROOM NUMBER] (approximately 80 feet in distance) without the benefit of covering the catering pans. The meals were plated from the steam table for residents who were eating in their rooms. After residents who ate in their rooms were served, the steam table was brought from room [ROOM NUMBER] to 201 (approximately 22 feet) without the benefit of covering the catering pans, however the lids were noted to be on the bottom shelf of the steam table. Interview and observations with the cook on [DATE] at 1:07 PM identified that food should be covered with lids while being transported in the hallway. He further stated that he forgot to cover the food. Interview with the Maintenance Manager on [DATE] at 2:00 PM identified that distance from the dining room to room [ROOM NUMBER] as 80 feet and from room [ROOM NUMBER] to room [ROOM NUMBER] as 22 feet. The facility was unable to provide a policy regarding labeling and dating of foods, however, an interview with the Dietary Director on [DATE] at 12:30 PM stated that opened food should be dated when opened and discarded by the expiration date on the container.

Based on observations and interviews for 1 of 2 shower rooms, the facility failed to provide a homelike, sanitary, and safe environment for the first-floor shower. The findings included: Observation during the initial facility tour on 6/10/24 at 12:30 PM on the first floor in the shower room identified the following: 1 broken ceiling tile, A black substance on the floor, walls, and ceiling, Lack of a drain cover over the floor drain, 3 unlabeled wash basins, A dirty linen cart, An empty bucket, A baseball cap, and The top of a spray bottle with no bottle. Interview with Registered Nurse #1 (RN #1 the Infection Prevention nurse) on 6/10/23 at 12:30 PM identified that the shower room was the only shower for the first floor residents. RN #1 indicated that the black substance was mildew on the floor, chipping was noted on the wall, the ceiling was falling apart, and the dirty laundry cart should not be stored in the shower room. RN #1 further stated that there was a brown/black coloring on wall but was unable to identify the type of substance noted. Subsequent to surveyor inquiry, RN#1 removed the dirty linen cart from the shower room. RN#1 stated her last environmental rounds for checking the shower room were performed on 3/20/23 and that rounds were performed quarterly. Interview with Nursing Assistant #3 (NA#3), on 6/10/24 at 2:55 PM identified that she utilized the shower on the first floor that day, but she stated that it was a quick shower and did not notice anything concerning the shower room. When she looked at the ceiling tiles, she stated that she reported the problem by placing the information in the maintenance book. Following NA #3's interview the maintenance request log was reviewed from 5/11/24 through 6/10/25 but failed to indicate that the first floor shower room required repairs. No other maintenance logs were available for review. Interview with NA#4 on 6/10/24 at 3:00 PM identified that the first-floor shower room was not homelike, was not maintained in a clean manner, and that the shower room was old. NA #4 indicated that the 11:00 PM to 7:00 AM shift was responsible to maintain and clean the shower room. Interview with Housekeeper #3 on 6/12/24 at 12:10 PM identified that she was unsure of what the buildup on the wall was and although she sprayed the area daily, she had not scrubbed the unknown substance to try to eliminate the debris. Interview with Director of Maintenance on 6/12/24 at 2:20PM identified that the first-floor shower did not have a drain cover and the opening measured 5 round and 1.5 in depth. Subsequent to surveyor inquiry, the Director of Maintenance indicated that he would be covering the open drain. Although requested a policy for shower room cleaning and maintenance was not provided, however, according to the DNS, the housekeeping staff was overseen by the Director of Nurses, Infection Control Nurse, and Human Resources.

Based on observations, interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #5) reviewed for oxygen use, the facility failed to ensure oxygen tubing was connected to the concentrator providing oxygen on 2 occasions. The findings include: Resident #5's diagnoses included chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, obstructive sleep apnea, and chronic pain syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was severely cognitively impaired and required total assistance with bathing and dressing, set up assistance with eating, partial moderate assistance with bed mobility, and total assistance with transfers and mobility. The Resident Care Plan dated 5/3/24 identified oxygen therapy since 2019, chronic respiratory failure with long term oxygen use, choosing to remove oxygen and Chronic Obstructive Pulmonary Disease (COPD). Interventions included to remind to keep oxygen on, monitor for signs or symptoms of respiratory distress and report to the physician as needed, oxygen as ordered, position to facilitate ventilation upright position whenever possible. A nurse practitioner's note dated 6/12/24 identified a diagnosis of obstructive sleep apnea, asthma, and chronic respiratory failure with hypoxia or hypercapnia and that Resident #5 was dependent on the use of oxygen noting an oxygen saturation of 94% on 6/11/24. Interview and observation on 6/12/24 at 1:47 PM with NA #4 identified Resident #5 lying in bed and complaining of pain. The nasal cannula oxygen tubing providing oxygen was found disconnected from the oxygen concentrator which prevented the delivery of oxygen to Resident #5. NA #4 reconnected the oxygen tubing at the concentrator and notified LPN #2. Interview and observation on 6/12/24 at 1:48 PM with LPN #2 identified that Resident #5 had taken her oxygen tubing off at times out of her nose. Additionally, the oxygen tubing had been disconnected from the oxygen concentrator to the humidifier bottle, however the nasal cannula was in place. LPN #2 obtained Resident #5's oxygen saturation of 93% which LPN #2 identified as Resident #5's baseline. A physician's order dated 6/13/24 directed to administer oxygen at 3 liters per minute via nasal cannula and attach humidifier filled with distilled water to the compressor. Observation on 6/13/24 at 10:02 AM identified Resident #5 was lying in bed with his/her oxygen nasal cannula in place and complaining of nausea. Additionally, the oxygen tubing was found disconnected from the oxygen concentrator to the humidifier bottle preventing Resident #5 from receiving his/her prescribed oxygen. Interview and observation on 6/13/24 at 10:07 AM with LPN #2 identified the oxygen tubing was disconnected from the oxygen concentrator to the humidifier bottle. LPN #2 identified she did not know how the oxygen tubing became disconnected, but suspected it was getting bumped when Resident #5 was being transferred via mechanical lift into bed. Additionally, LPN #2 identified that she would start education with the staff to ensure that the oxygen connection was secure after mechanical lift transfers. Review of the Oxygen policy for nasal cannula oxygen administration identified, in part, attach the cannula to the nipple adapter of the oxygen device and or humidifier bottle as needed. Humidifier bottle use directed, in part, to attach oxygen delivery device to the outlet nipple of the humidifier bottle and confirm that oxygen is flowing through the bottle by observing bubbling in the bottle.

Based on clinical record review, interviews, and facility policy for 1 of 5 sampled residents (Resident #14) reviewed for unnecessary medications, the facility failed to attempt a Gradual Dose Reduction (GDR) for a psychotropic medication. The findings include: Resident #14 was admitted on [DATE] with diagnoses of major depressive disorder and personal history of other mental and behavioral disorders. A physician order dated 1/25/23 directed the administration of Lexapro (an antidepressant medication) 20 milligrams daily. An admission MDS dated [DATE] identified Resident #14 had intact cognition, was independent with eating, required supervision with oral hygiene, and partial to moderate staff assistance with transfers. Additionally, Resident #14 had a diagnosis of depression and received an antidepressant. The Resident Care Plan dated 5/1/23 identified Resident #14 was on an antidepressant, interventions included monitoring ongoing signs and symptoms of depression and monitoring side effects and effectiveness of the medication. An Advanced Practice Registered Nurse (APRN) progress note dated 3/6/24 at 6:18 PM identified Resident #14 sometimes having sad days but overall did not feel depressed. Review of the clinical record from 1/25/23 through 6/12/24 failed to indicate a change in the dose of Resident #14's Lexapro or an attempt to complete a GDR. An interview with the psychiatric APRN, (APRN #1) on 6/12/24 at 11:05 AM identified that a GDR should be considered for a resident taking antidepressants. If a GDR was not indicated, then the reason for not attempting the GDR should be documented in the clinical record. APRN #1 further identified that psychiatry did not follow Resident #14 so she could not explain why a GDR was not attempted for the resident. Interview and clinical record review with the DNS on 6/12/24 at 3:12 PM failed to provide information that a GDR was ever attempted for Resident #14's Lexapro. The DNS was unable to explain the reason a GDR was never attempted but indicated that the pharmacist and facility providers who follow Resident #14 were responsible to ensure GDRs were recommended and attempted. The DNS further identified she was unaware that a GDR needed to be attempted for antidepressant medications and did not know the facility policy. Interview with the primary care APRN (APRN #2) on 6/13/24 at 10:59 AM identified that the psychiatric practitioner normally handles the GDR but if they are not following the resident, then the primary care provider would be responsible to address any required GDR attempts. APRN #2 further stated that she did not attempt a GDR because no one brought it to her attention. APRN #2 identified that a GDR attempt should be made 1 or 2 times in a calendar year. Review of facility policy for Psychotropic Medication Management identified review of psychotropic medication management should include verification that adequate indications for use of the psychotropic medication exist, the medications are not being used for extended duration, and residents are free of duplicate therapy and being monitored for adverse consequences, per current professional standards of practice and in accordance with federal and state guidelines.

Based on observation and interviews for 1 of 5 sampled residents (Resident #1) reviewed for the environment, the facility failed to maintain adequate temperatures for a resident refrigerator on the 2nd floor. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses of anxiety, dysphagia, and gastro-esophageal reflux disease. Observation of resident rooms on 6/13/24 identified Resident #1's refrigerator tempeature guage read 50 degrees and the following foods were stored in the refrigerator, yogurt and leftover food from dining service. Additionally, the temperatures recorded on a log for June 2024 ranged between 48 and 50 degrees Fahrenheit (F) (normal at or below 41 degrees F). Interview with the Director of Maintenance on 6/13/24 at 11:00 AM identified the refrigerators belonged to the facility and that housekeeping was responsible to check the temperatures of the refrigerators. If the temperatures were out of range, the facility would replace the malfunctioning refrigerator with a new one. The Director of Maintenance further identified that refrigerator temperatures were supposed to be between 36 to 42 degrees F. The Director of Maintenance could not recall if the abnormal temperature of Resident #1's refrigerator had been reported for maintenance during the month of June. Interview with Housekeeper #1 on 6/13/24 at 11:25 AM identified housekeepers checked the refrigerator temperatures daily for all the rooms on the 2nd floor that had a refrigerator, and if the temperature was out of range, they reported it to their supervisor who then informed maintenance. Housekeeper #1 also identified that they would report temperatures that were below 50 or 60 degrees F but was unaware of what the acceptable refrigerator temperatures ranges should have been. Interview with the Director of Housekeeping on 6/13/24 at 11:40 AM identified that housekeeping was supposed to check the refrigerator temperatures in resident rooms and if the temperatures were out of range, they were supposed to tell him or maintenance. The Director of Housekeeping identified that temperatures were supposed to be between 36 to 46 degrees and was unable to explain why the out of range temperatures in Resident #1's room were not reported. The Director of Housekeeping further identified that each new hire for housekeeping was shown the temperature log indicating what to do if temperatures were out of range. Review of the facility Refrigerator/Freezer policy identified the temperature readings would be entered daily in the appropriate box on the calendar log. If a housekeeping staff member notices a temperature outside the range, they were to adjust the coolness dial and recheck the temperature in 1 or 2 hours. Food should be labeled and moved to the pantry until the temperature resolves. If the temperature remains outside of range, housekeeping would contact maintenance for service.

Based on observations, clinical record review, facility documentation review, and interviews for one of two dining rooms observed, the facility failed to ensure that adaptive dining equipment was in place for one observed resident (Resident #12) during a meal in accordance with the resident plan of care. The findings include: Resident #12's diagnoses included Alzheimer's Dementia, failure to thrive, [CONDITION(S)] and bilateral [CONDITION(S)]. Occupational Therapy treatment note dated 7/22/2021 directed use of a non-slip mat under dishes, a lip plate, and Nosey Cup for drinks, and noted orders were written for staff to provide feeding equipment at all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 had moderate cognitive impairment and required supervision (oversight, encouragement, or cueing) with eating. The Resident Care Plan (RCP) dated 1/18/2022 identified Resident #12 was at risk for weight loss due to dementia. Interventions directed use of a Nosey Cup or a cup with lid and straw, use of a lip plate and a non-slip table mat under dishes during meals. Review of facility dietary information sheet for facility residents from the Green dietary book dated 4/7/2022 identified Resident #12 required appliances of a Nosey Cup or a cup with lid and straw, lip plate and non-slip mat with meals. Observations on 4/11/2022 at 12:23 PM identified Resident #12 was in the East/West dining room with a meal placed on the table in front of him/her. The meal was on a circular flat plate directly on the table. There was no non-slip pad or lip plate observed to be in place. Interview on 4/11/2022 at 12:37 PM with NA #3 identified that she was unsure why the adaptive equipment was not in place and indicated that the non-slip pad and lip plate should be used. NA #3 indicated that the information that directed what Resident #12 needed for meals was located in the Green book and that the book should be checked by whoever brings a meal to the resident. Interview and observation on 4/11/22 at 12:42 PM with Dietary Aide #1/Cook identified he was plating food to be served to residents in the East West dining room. Dietary Aide #1/Cook indicated he did not know why Resident #12 did not have a lip plate and non-slip mat. He indicated there were a lot of staff in the dining room, and he did not know if he had a lip plate available on the serving table for use. Review of the undated facility Feeding Equipment Policy directed in part, that the facility was to provide feeding equipment such as utensils, cups, bowls, plates, and other tools to allow for highest level of independence with eating and or drinking. Procedures directed some specialized equipment/utensils may be issued/provided by therapy upon screening or evaluation, otherwise feeding equipment would be provided by the dietary department.

Based on observations, interviews, and facility policy review, the facility failed to ensure the laundry room and linens were maintained in a clean manner. The findings include: Observations with RN #2 on 4/13/2022 at 2:03 PM in the facility laundry area, identified a heavy accumulation of white, fluffy debris on the laundry room walls, tops of the laundry machines, tops of the soap dispenser, water pipes, door hinges, ceiling, and on the top of a wall mounted heater. Strands of the white, fluffy debris were observed hanging downward approximately three (3) to six (6) inches from the ceiling and door closure arm. A large industrial-sized fan was observed located on a green plastic chair. The fan was observed to have a large accumulation of white, fluffy debris on the grill cover in front of the fan blades. The fan was turned on and blowing toward a hanging rack with clean clothing and linens and toward folded, clean laundry located on a multi-level linen cart with the protective cover left open, and clean blankets on a table next to the linen cart. Additional linens were observed on top of the clean linen, including multiple non-slip socks, a lamp shade, a small and black wrap-style brace. Interview completed with RN #2 on 4/13/2022 at the time of the observation identified she was unsure what the policy was regarding clean linen storage, use of the fan with the described debris, and the cleanliness of the laundry area. RN #2 also identified that maintenance was responsible for cleaning any debris in the laundry room, and the staff working in the laundry room were responsible for notifying maintenance of any needs. Interview completed with the Maintenance Director on 4/13/2022 at 2:11 PM identified that he was responsible to maintaining the laundry area. The Maintenance Director identified that the area was difficult to address due to the type of cleaning needed to remove the debris, and indicated the debris was caused by use of the dryers. He identified that we have to blow it off. He indicated that he would schedule the cleaning, the cleaning should be completed weekly, and that it was completed the week prior. An additional interview completed with the Maintenance director and Maintenance Assistant on 4/13/2022 at 2:25 PM identified that the laundry area and dryer vent had not been cleaned in the prior two weeks. The Maintenance Director identified the cleaning should have been done and he did not know why it was not completed. No facility policy was provided for surveyor review.

Based on clinical record reviews review of facility policy, review of facility documentation and interviews for one of three sampled residents (Resident#22) reviewed for assistance with Activities of Daily Living (ADL), the facility failed to ensure the resident received incontinent care in respectful manner that enhanced the resident's quality of life and/or for one of three sampled resident reviewed for mistreatment ( Resident # 35), the facility failed to treat the resident in a respectful and dignified manner . The findings included: 1.Resident # 22's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance of one person for physical assistance for bed mobility, transfers, locomotion on and off the unit and personal hygiene. The assessment further indicated the resident required extensive assistance two people for toileting. The Resident Care Plan (RCP) for needs assistance with toileting and ADL due to dementia and [CONDITION(S)]. Interventions included to provide assistance with ADL, toileting /incontinent care approximately every two hours and when needed. Observation 9/17/19 from 2:15 P.M. to 2:45 P.M. identified Resident # 22 out of bed in the wheelchair in the hallway. NA #4 was noted bringing Resident # 22 into the room. NA #2 was noted operating the stand to sit lift and speaking to the resident in calm, gentle and soft manner prior to providing care to the resident. Resident # 22 was transferred by NA # 2 and NA#4 from the wheelchair to the bed without difficulty. Resident # 22 was noted at 2:35 P.M. with moderate amount of strong saturated urine in his/her brief, skin was noted with minimal wrinkles, pink and intact. NA # 4 and NA # 2 was noted on 9/17/19 at 2:38 P.M. pulling Resident# 22's sweat pants 3/4 quarters down the resident's leg in bed. NA # 4 then proceeded to provide incontinent care to the resident with the resident's sweat pants 3/4 down the resident's leg. Surveyor intervened and NA #4 stated I am sorry and immediately pull the resident's off. Interview with NA # 4 on 9/17/19 at 2:40 P.M. identified she/he was unaware the resident's sweat pants were pulled 3/4 down during incontinent care and indicated she /he was just trying to complete the incontinent care. Interview with the DNS on 9/17/19 at 2:50 P.M. identified she/he was unaware that NA # 4 and NA # 2 provided incontinent care while the resident was in bed with sweat pants 3/4 down the resident's leg. The DNS on 9/19/19 further indicated she/he believed it was fine for NA #2 and NA # 4 to provide incontinent in room with Resident # 22's sweat pants 3/4 down his/her leg as long as the door was closed, curtain pull and the resident was out of public view. 2. Resident #35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change MDS assessment dated [DATE] identified Resident #35 had severe cognitive impairment, required extensive assistance of one person for bed mobility, transfers toileting and personal hygiene and ambulation in the corridor. Additionally, the MDS assessment identified Resident #35 had verbal behavioral symptoms directed toward others. The RCP dated 9/17/19 identified Resident #35 had ineffective coping (verbal and physical aggression) related to the problematic manner in which the resident acts, secondary to cognitive impairment, sun-downing, forgetfulness and agitation with care, swearing at staff and making racial comments. An observation on 9/17/19 at 9:45 A.M. identified Resident #35 was sitting in the sit to stand lift yelling at NA #2 and NA #6. NA #6 was kneeling beside the stand lift with what appear to be frustration on his/her face. Resident #35 requested NA #6 smile and he/she continued to appear frustrated. NA #2 calmed Resident #35 and NA #2 and NA #6 completed the toilet transfer. An observation on 9/17/19 at 10:05 A.M. identified NA #6 standing by Resident #35 in the hallway across from the nurse's station near the dining room. NA #6 was discussing Resident #35 in a frustrated tone with the Occupational Therapist (OT) #1 in the presence of Resident #35. NA #6 told OT #1 that Resident #35 had slapped a nurse aide, was using inappropriate language and indicated that NA #6 hoped Resident # 35 would be good for OT #1. OT # 1 proceeded to wheel Resident #35 away in his/her wheelchair. Interview with NA #6 on 9/17/19 at 10:10.A.M. identified NA #6 had reported Resident #35's behavior to OT #1 prior to his/her therapy session. NA #6 identified Resident #35 exhibiting behaviors of fighting with staff during the day, speaking inappropriately to staff and made attempts to kiss and /or touch staff. NA #6 also indicated he/she should have pulled OT #1 aside and discussed the behavior away from Resident #35. Interviewed DNS on 9/17/19 at 10:45 A.M. identified NA #6 was likely busy due to the no call no show of staff on his/her unit and indicated NA # 6 was probably trying to get everything done. Additionally, the DNS identified NA #6 could have involved Resident #35 in the conversation rather than speaking about Resident #35 in front of him/her. Interview with OT #1 on 9/17/19 11:45 A.M. identified NA #6 was giving report to him/her ( OT #1) in the hallway in front of Resident #35 prior to the resident's therapy session. Additionally, OT #1 indicated NA #6 informed OT #1 that Resident # 35 had smashed a nurse aide hand, had used inappropriate language and that NA #6 hoped Resident #35 would be good for him/her. Additionally, OT # 1 identified that he /she usually speak with staff on the side, however, she/he did not speak to the staff out of the resident's presence because it was busy day. Interview with the DNS on 9/17/19 at 12:00 P.M. identified the DNS sent NA #6 home and initiated the investigative protocol. Interview with the DNS on 9/18/19 at 11:30 A.M. identified NA #6 returned to work after the investigation was completed and indicated he/she would educate staff not to give report in front of the resident unless the resident was alert and oriented and could be a part of the conversation. Review of an in-service bulletin for all staff dated 9/18/19 identified NA # 6 was educated on showing and expressing interest in resident care and directed staff to engage residents in conversation during care. Review of the Resident's Bill of Rights identified residents have the right to be treated with consideration, respect and full recognition of dignity and individuality.

Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of three residents reviewed for abuse/ mistreatment (Resident # 41), the facility failed to report an allegation of inappropriate physical interaction in a timely manner to the state agency. The findings include: Resident#41's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 7/15/19 identified need assistance with ADLs as the focus. Interventions included assist with ADL as needed and encourage the resident to do as much as able. An annual MDS assessment dated [DATE] identified the resident as moderately impaired for decision-making skills, requiring extensive assistance from staff for most activities of ADL, noted utilization of a walker and wheelchair for mobility, and as having an unsteady balance during transition and walking. On 9/18/19 at 9:35 A.M. during an observation of medication administration pass with Resident #41 and the unit charge nurse (RN#2) identified that when Resident # 41 is transferred from the wheelchair to a recliner it does not go well when the person (staff and/or nurse aide) who is assisting Resident #41 becomes frustrated with the resident. Staff becomes frustrated because Resident # 41 is moving too slow and has not had the chance to stretch his/her legs after sitting for a long period of time. Subsequent to RN#2's inquiry in the presence of the surveyor, Resident #41 indicated on the previous day (9/17/19 in the late morning) a staff member and/or nurse aide, became frustrated with him/her( Resident #41) because the resident moved too slow during the transfer. Resident #41 further indicated and demonstrated how the staff member and/or nurse aide touched him/her on the left upper arm to get him/her (Resident # 41) to move and when the resident asked the nurse aide to wait a minute, the staff member would not listen to the resident and began to exhibit increase frustration while helping the resident transfer into his/her chair. Although Resident #41 indicated the person who had assisted him/her had blonde hair and indicated he/she didn't know the person's name. Resident # 41 also indicated he/she refused to identify the person and/or the name of the staff so the staff would not get into trouble. On 9/18/19 at 9:46 A.M. an interview with the DNS regarding Resident #41's reported allegation of staff becoming frustrated and inappropriately touching him/her during the assistance of care. The DNS further indicated he/she would speak with the resident regarding the allegation and would get back to the surveyor with the outcome. On 9/18/19 at 3:40 P.M interview with the DNS regarding his/her follow up with Resident #41 identified Resident # 41 didn't want to share the nurse aide name, could not remember much about the incident and was not able to tell him/her (DNS) when the event occurred yesterday or today. The DNS also indicated the facility's response to the resident's allegation was to initiate staff educational training. On 9/19/19 at 3:10 P.M. an interview and review of the clinical record, facility documentation and the facility policy and/or procedures for abuse with the DNS in the presence of the Administrator and survey team members indicated the DNS did not report to the state agency Resident #41's allegation of staff inappropriate touching (Resident # 41 to get the resident to move' during a transfer), because he/she was able to substantiate that the resident had not been abused immediately. On 9/19/19 at 3:10 P.M. an interview and review of the clinical record, facility documentation, the facility policy and/or procedure and the Federal interpretive guidelines for reporting abuse timeframe with the Administrator indicated that based on the resident's dementia, the facility's investigation and the facility's inability to substantiate the resident's allegation of abuse, the facility was not obligated to report the resident's allegation to a state agency. According to the facility's policy and/or procedure for abuse which noted in part, report all allegations and all substantiated incidents immediately to the following person: Nurse Supervisor, DNS or designee, the Administrator, physician, family, social worker, police if indicated and state agency and all other agencies required within 2 hours. The policy also directed to take necessary action depending on the result of the investigation. Subsequent to surveyor inquiry, on 9/19/19 at 8:34 P.M. an email was sent to the state agency with attachment for a Reportable Event regarding Resident # 41's allegation.

Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of three residents reviewed for potential abuse/ mistreatment (Resident # 41), the facility failed to provide evidence that the facility followed their policy and procedure for investigating an allegation of inappropriate touching. The findings include: Resident#41's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 7/15/19 identified need assistance with ADLs as the focus. Interventions included assist with ADL as needed and encourage the resident to do as much as able. An annual MDS assessment dated [DATE] identified the resident as moderately impaired for decision-making skills, requiring extensive assistance from staff for most activities of ADL, noted utilization of a walker and wheelchair for mobility, and as having an unsteady balance during transition and walking. On 9/18/19 at 9:35 A.M. during an observation of medication administration pass with Resident #41 and the unit charge nurse (RN#2) identified that when Resident # 41 is transferred from the wheelchair to a recliner it does not go well when the person (staff and/or nurse aide) who is assisting Resident #41 becomes frustrated with the resident. Staff becomes frustrated because Resident # 41 is moving too slow and has not had the chance to stretch his/her legs after sitting for a long period of time. Subsequent to RN#2's inquiry in the presence of the surveyor, Resident #41 indicated on the previous day (9/17/19 in the late morning) a staff member and/or nurse aide, became frustrated with him/her( Resident #41) because the resident moved too slow during the transfer. Resident #41 further indicated and demonstrated how the staff member and/or nurse aide touched him/her on the left upper arm to get him/her (Resident # 41) to move and when the resident asked the nurse aide to wait a minute, the staff member would not listen to the resident and began to exhibit increase frustration while helping the resident transfer into his/her chair. Although Resident #41 indicated the person who had assisted him/her had blonde hair and indicated he/she didn't know the person's name. Resident # 41 also indicated he/she refused to identify the person and/or the name of the staff so the staff would not get into trouble. On 9/18/19 at 9:46 A.M. an interview with the DNS regarding Resident #41's reported allegation of staff becoming frustrated and inappropriately touching him/her during the assistance of care. The DNS further indicated he/she would speak with the resident regarding the allegation and would get back to the surveyor with the outcome. On 9/18/19 at 3:40 P.M interview with the DNS regarding his/her follow up with Resident #41 identified Resident # 41 didn't want to share the nurse aide name, could not remember much about the incident and was not able to tell him/her (DNS) when the event occurred yesterday or today. The DNS also indicated the facility's response to the resident's allegation was to initiate staff educational training. On 9/19/19 at 3:10 P.M. an interview and review of the clinical record, facility documentation and the facility policy and/or procedures for abuse with the DNS in the presence of the Administrator and survey team members indicated the DNS did not report to the state agency Resident #41's allegation of staff inappropriate touching (Resident # 41 to get the resident to move' during a transfer), because he/she was able to substantiate that the resident had not been abused immediately. Subsequent to surveyor's inquiry regarding the facility's investigation and a review of facility documentation dated 9/18/19 regarding Resident #41's allegation identified 3 pages of handwritten notes transcribed by the DNS on a small note pad, with excerpts of Resident #41's stating, he/she was unable to really remember conversation with the surveyor. The facility documentation further noted the DNS providing instructions to resident to feel free to contact the DNS at any time, if this happens again however, no statements were provided by the facility staff within the investigation to reflect whether or not the staff had any knowledge of the incident and/ or to substantiate that the facility could rule out abuse / mistreatment within 2 hours. On 9/19/19 at 3:10 P.M. an interview and review of the clinical record, facility documentation, the facility policy and/or procedure and the Federal interpretive guidelines for reporting abuse with the Administrator in the presence of the DNS indicated that based on the facility's investigation which was conducted within the time frame of 2 hours and based on the resident's dementia, the facility was unable to substantiate the resident's allegation of abuse. The facility policy for Abuse Policy and Procedure notes the facility investigate different types of incidents, and identify the staff member responsible for the initial reporting, investigate all alleged violations and directs that any findings of potential abuse, neglect, mistreatment are immediately investigated.

Based on clinical record review, review of facility documentation and staff interview for one of three residents (Resident # 22) reviewed for accidents, the facility failed to revise and/or re-evaluate the resident's mechanical lift to ensure the lift was appropriate for a resident with increased agitation after an injury occurred. The findings include: Resident # 22's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance of one person physical assistance for bed mobility, transfers, locomotion on and off the unit and personal hygiene and indicated the resident required extensive assistance two people for toileting. The RCP for striking out, agitation sadness, and refusal of care related to dementia dated 4/26/19. Intervention included: to modify environment, reduce noise, dim lights as needed, observe behavior and attempted interventions in the behavior log and directed staff to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk away calmly and re-approach later. The RCP at risk for falls due to dementia, history of falls and on medications that may increase fall risk for falls. Interventions included: ant tippers as ordered, bed in low position, mats next to bed on both sides when in bed and to report any difficulties with transfer status. The nurse's progress note dated 5/14/19 at 11:10 P.M. identified the resident was in the room when a nurse aides called the licensed staff around 10:30 P.M. and said there was something wrong with Resident # 22's shoulder. Vital signs noted blood pressure and was 200/100. An assessment of Resident # 22's shoulder identified the left shoulder was in pain and Resident # 22 could not squeeze the licensed staff hand hard. Resident # 22 complained of pain in the left shoulder upon movement. The Medical Doctor (MD) was notified and directed staff to transport the resident to an acute care facility for an evaluation. Additionally, the nurse's progress note dated 5/14/19 identified Resident # 22's POA and family were notified. The Reportable Event dated 5/14/19 at 10:30 P.M. identified while Resident # 22 was being transferred in a Sara lift to bed by NA # 2, NA# 3, and NA#1, Resident # 22 moved his/her left arm and the resident's left arm appeared abnormal. Resident # 22 was noted with left arm pain upon movement and was sent to the emergency room for an evaluation. The facility investigation dated 5/14/19 identified the resident was being transferred to bed via sit to stand mechanical lift with NA #3 and NA#1 when the resident became agitated , swinging her/his arms and kicking. The resident's arm landed under the sling pad of the sit to stand mechanical lift. Subsequently, NA # 1, NA#2 and NA #3 transferred the resident to bed and noticed the resident's left shoulder was injured and immediately notified the nurse. A statement from NA # 1 identified while Resident #22 was in the sit and stand Sara lift the resident became agitated and moved her/his hand out of the sling which causing the resident to sustain an abnormality to the left shoulder area. The emergency room Discharge Instructions dated 5/14/19 identified the resident was diagnosed with a dislocated left shoulder and noted the utilization of a sling, directed to apply an ice pack over the injured area for 20 minutes every 1-2 hours the first day and to continue the ice packs 3-4 times a day for the next two days. Recommended Tylenol and Motrin/Advil to control pain. Interview with NA # 3 on 9/16/19 at 4:30 P.M. identified while she/he was in the process of doing charting she/he overheard NA #1 and Resident # 22 who appeared to be very agitated. NA #3 indicated she/he went into the room to see if she/he could assist NA # 1 with Resident # 22. When she/he (NA # 3) entered the room Resident # 22 was already in the Johnny coat and the sit to stand pad was buckled on the resident. The resident appeared calm at the time. NA # 3 then asked NA # 1 if she/he wanted to proceed to get Resident # 22 in the bed and hook the resident to the Sara sit to stand lift, NA # 1 said yes, the resident was calm. Resident # 22 indicated she/he wanted to go to bed therefore NA #1 and NA # 3 proceed to hook the resident up to the sit to stand mechanical lift properly. However, once Resident # 22 was transferred from the wheelchair and lifted up in the air, Resident # 22 became agitated when she/he stood up. Resident # 22 was calm when NA #3 and NA # 1 moved the wheelchair out of the room, NA # 3 further indicated when she/he and NA #1 started to provided incontinent care while the resident was in the sit to stand lift, Resident # 22 became very agitated. NA # 3 further indicated because the resident was agitated she/he (NA# 3) and NA #1 did not get a change to pull the resident's pants down before Resident # 22 became agitate. NA # 3 further indicated we do not know how it happen but Resident # 22's arm slipped through the pad. Interview with NA # 2 on 9/16/19 at 5: 15 P.M. identified she/he was walking in the hall overhead NA #1 and NA #3 with the resident who was already hook to Sara sit stand lift. NA # 2 indicated that she/he was informed by NA #1 before she/he came to assist NA #1 and NA #3 that Resident # 22 was agitated prior to her/him (NA#2) arrival. NA # 2 further indicated and indicated once they left the resident up in the air Resident # 22 became agitated swinging his/her arm outside the lift at which time NA #1, NA # 3 and NA # 1 safely transferred the resident to the bed and noticed something was abnormal about the resident's shoulder . NA # 2 indicated they immediately notified the charge nurse of the resident's abnormal shoulder and indicated they did not have time to call and/or notify the licensed staff when Resident # 22 first became agitated. Interview with the RN 2 on 9/16/19 at 4:09 P.M. identified she/he was called to Resident # 22's room to assess the resident's shoulder because the nurse aides told her/him something was wrong. When she/he arrived to assess Resident # 22 the resident's shoulder look abnormal but the resident did not express any pain, RN # 2 immediately notified the MD who directed staff to send the resident to emergency room for an evaluation. Interview with the DNS on 9/17/19 at 2:50 P.M. and 9/19/19 at 2:30 P.M. identified while NA #1 and NA #3 was in the process of getting Resident # 22 ready to transfer the resident with the Sara Sit to Stand lift, NA # 2 came in to offer to assistance NA #1 and NA #3 with the transfer because she /he ( NA # 2) was outside Resident # 22 's room and thought they could use some help. During the transfer NA # 2 operated the Sit to Stand lift and NA #1 and NA # 3 provided support on each side of the resident. However, once the resident was in the air Resident # 22 became agitated and began moving his/her arms about causing Resident # 22's left arm to be caught in the lift sling device. Additionally, the DNS indicated the root cause analysis of the accident was due to Resident # 22 agitation which can be unpredictable secondary to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Several attempts made to reach NA #1 were unsuccessful. A review of Resident # 22's care plans on 9/19/19 at 3:00 P.M. identified no revision and/or re- evaluation of the resident's lift device to ensure the Sara Sit to stand lift was still appropriate for a resident with agitation.

Based on observations interviews and review of the facility policy, the facility failed to store medications in a safe manner to ensure only authorized personnel have access. The findings include: Observation of the second floor medication room on 9/18/19 at 6:10 [NAME]M. identified the medication room door was opened with a garbage can holding the door place. Additionally, an open shelf on the wall of the medication room was visible from the hallway. The opened medication room contained multiple bottles of medications that was not in a locked cabinet. Further, the medication cart was sitting in the entrance of the medication room and the medication room was unattended by a licensed staff. Interview with RN # 1 on 9/18/19 at 6:15 [NAME]M. identified he/she had left the door open when she/he left to attend to Resident # 52 who was yelling and had a history of [REDACTED].#2 identified it is not her/his usual practice to leave the medication room door open and unattended. RN #1 also indicated the medication bottles on the shelf of the medication room were over the counter medication. Interview with the ADNS on 9/18/19 at 6:35[NAME]M. identified RN #1 should have closed the medication room door when he/she left the room to attend to Resident # 52. Review of the medication storage in the medication room policy identified it is the policy of the facility to store medication safely and medication room doors will be locked when unattended.

Based on a review of clinical records, review of facility documentation, review of facility policies and procedures, and interviews for one of three residents (R #1) reviewed for therapeutic diets, the facility failed to ensure that the resident's food was cut up in accordance with physician's orders [REDACTED].#1 choked and required hospitalization which resulted in immediate jeopardy. Immediate Jeopardy was verified as corrected during the onsite visit on 6/13/19. The finding includes: R #1's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that R #1 had a BIMS score of 11 (moderate cognitive loss), required supervision with eating and needed assistance with cutting up food. A physician's orders [REDACTED]. The Resident Care Plan (RCP) dated 4/18/19 identified R #1 had a history of [REDACTED]. Review of a nurse's note dated 5/16/19 at 7:00 PM identified that LPN #1 was notified by NA #1 that R #1 was having difficulty breathing. R #1 was observed with a red complexion, making wheezing sounds, and was unable to speak. Further review identified that back blows were unsuccessful and R #1 ceased making noises. R #1 was returned to his/her room, lowered to the floor and abdominal thrusts were administered with several pieces of pierogies expelled. R #1 regained the ability to speak, had shallow respirations, color remained dusky, and the resident vomited. R #1 was transferred to the hospital for evaluation. Review of the hospital record dated 5/16/19 identified that when EMS arrived on scene, R #1 was not breathing on his/her own, was pale, diaphoretic, and warm with cyanosis in fingers and mouth. The resident was started on 3 liters of oxygen for saturation of 87% and then a nonrebreather. The resident was admitted with [MEDICAL CONDITION] after choking, new onset [MEDICAL CONDITION] perhaps incited by the stressful event of choking and becoming severely hypoxic, lactic acidosis due to acute hypoxic event, and tropoinemia secondary to demand ischemia due to [MEDICAL CONDITION] and aspiration pneumonia. Review of facility documentation dated 5/16/19 at 6:15 PM identified that R #1 experienced respiratory distress while eating. Review of the facility investigation identified that staff in the dining room did not follow the diet texture direction to cut all food written in the green diet binder and staff thought because the food was soft in texture that the resident was capable of chewing food with out difficulty as his/her diet was mechanical soft. Review of the clinical record and facility documentation during interview with LPN #1 on 6/13/19 at 10:55 AM identified R #1 ate his/her meals in the dining room with supervision due to aspiration precautions. LPN #1 indicated that the meal served on 5/16/19 was kielbasa and pierogies and the resident required assistance to cut up food. LPN #1 indicated that dietary staff would serve food from a steam table, and based on resident needs, they would alter the texture/consistency of the diet at the steam table prior to the food being served to a resident. LPN #1 stated although he remembered the kielbasa was cut appropriately, he could not remember if the resident's pierogies were cut up. LPN #1 further stated he was in the dining room when alerted by a staff member that R #1 was unable to speak and back blows were administered without success. LPN #1 moved R #1 into the hallway outside the dining room, administered additional back blows with no results and stated R #1's color deteriorated. LPN #1 and RN #1 moved R #1 to his/her room (two rooms away), called 911, lowered R #1 to the floor and administered abdominal thrusts with expulsion of food. R #1 was then able to speak, vomited, and his/her color improved and R #1 was transferred to the hospital. Further interview with LPN #1 on 6/13/19 at 1:44 PM identified although he thought the pierogies were included in a mechanical soft diet, it was not clear to him who should cut the food - dietary staff at the steam table, the nurse, or the person serving the food to the resident. LPN #1 identified the pierogies were not cut when they left the steam table and he did not know if they were cut when they were served to R #1. Interview with R #1 on 6/13/19 at 1:15 PM identified he/she remembered the incident. R#1 indicated that s/he had been served a meal of kielbasa and pierogies. R #1 stated the staff did not cut the pierogies, and that he/she could not cut the food. R #1 stated he/she ate a large pierogi and choked. R #1 further stated that staff were supposed to cut food for him/her and they did not cut the pierogies. Interview and review of facility documentation with Cook #1 on 6/13/19 at 1:30 PM identified that LPN #1 had directed her not to cut up the pierogies, and stated that R #1's food should have been cut up into dime size pieces. Interview, review of the clinical record and facility documentation with the DON and ADON on 6/13/19 at 1:56 PM identified that the cook on the steam table was the first line of defense to make sure the resident's diet was correct, the nurse was the second line of defense, and the person serving the food to the resident was the third line of defense. Further interview identified that the meal was served to R #1 by LPN #1, the kielbasa was cut up, but the pierogies were not cut, and they should have been cut in accordance with physician's orders [REDACTED]. The facility failed to ensure that the resident's food was cut up before being served in accordance with physician's orders [REDACTED].#1 choked and required hospitalization . Subsequent to this incident, staff were re-educated on 5/17/19 and included following orders and special instructions for diets, referencing the green book in the dining room for diet orders, different diet textures and consistencies, resident safety, crash cart, and specific review of diet textures and consistencies. Audits were initiated on 6/17/19 and are on-going. Review of facility Dining Room Policy and Procedure directed in part, the unit diet orders in the Green Binder will be used to guide all meals for residents. The policy further directed if there is a question regarding the diet, the nurse will reference the diet order and/or speech therapy notes and dietician notes in Point Click Care.

Based on observations, review of facility policy, and staff interview, the facility failed to ensure staff donned a beard covering/restraint when preparing and/or serving food. The findings include: Observation of Cook #1 on 7/26/18 at 10:00 AM identified he/she had facial hair (a beard/mustache) and was in the first floor dining room, in front of the grill, cooking eggs and/or serving food from the steam table without the benefit of a beard restraint/covering. On 7/24/18 at 11:21 AM while touring the kitchen, Cook #1 was noted to be in front of the preparation area with food open and on the table in front of him/her, without the benefit of a beard restraint/covering. Interview with the Director of the kitchen at that time identified he/she was unsure about the policy for beard restraint/covering. Observation of the first floor dining room on 7/23/18 at 12:40 PM identified Cook #1 who had facial hair (a beard/mustache) was in front of the steam table serving food without the benefit of a beard restraint/covering. Observation of the second floor dining room on 7/25/18 at 8:30 AM identified Cook #1 who had facial hair (a beard/mustache) was in front of the grill preparing breakfast without the benefit of a beard restraint/covering. Interview with Cook #1 on 7/25/18 at 10:51 AM identified he/she had been employed since 3/2018 and was not aware that a beard restraint/covering was needed during food preparation and/or serving from the steam table. Cook #1 further indicated he/she had never worn a beard restraint while serving food. Interview with the Director of Dietary on 7/25/18 at 10:55 AM identified he/she was not aware that staff needed to wear a beard restraint/covering in the kitchen and/or while serving food, when facial hair (a beard/mustache) was present. Further observation of the second floor dining room on 7/25/18 at 12:26 PM identified Cook #1 who had facial hair (a beard/mustache) was noted to be in front of the steam table, serving food without the benefit of a beard restraint. Interview with the Infection Control Nurse (ICN) on 7/26/18 at 10:51 AM identified he/she was not aware if staff in the kitchen with facial hair were required to wear a beard restraint/covering and therefore had not inserviced staff regarding donning beard coverings. The facility policy for hair nets/head covering failed to identify that dietary staff with a beard were to wear a beard restraint/covering to prevent hair from coming in contact with food.

Based on clinical record review and interview for one sampled resident reviewed for preadmission screening and resident review (PASRR) (R#18), the facility failed to accurately assess/code the resident's level II related condition on the Minimum Data Set (MDS). The findings include: Resident #18's [DIAGNOSES REDACTED]. Interview with Social Worker #1 (SW) on 07/24/18 at 11:46 AM indicated that Resident #18 had met Level II criteria in (MONTH) of (YEAR) and was granted short term approval for 120 days. SW #1 further indicated that Resident #18 was granted long term stay approval on 07/03/2017. On 7/24/18 at 1:45PM, interview with RN #1 and review of Significant Change MDS' dated 11/27/2017 and 5/21/2018 failed to reflect that Resident #18 was coded correctly regarding being considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Further interview at that time with RN #1 indicated that the two MDS' were inaccurate and a MDS correction would be completed and submitted.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the physician's orders [REDACTED]. Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 never or rarely made decisions regarding tasks of daily living, was totally dependent on one (1) to two (2) staff members for personal hygiene and eating and received scheduled and when needed pain medication, and had indicators of pain and/or possible pain three (3) to four (4) days in the past five (5) days as evidenced by non-verbal sounds, facial expressions and protective body movements or postures. A physician's orders [REDACTED]. needed for mild pain and/or shortness of breath or [MEDICATION NAME] Solution 0.5 ml sublingually every one hour as needed for severe pain and/or shortness of breath. The Resident Care Plan dated 2/14/18 identified the resident had a potential for pain related to occasional pain at the nephrostomy site. Interventions directed to monitor for verbal and non-verbal signs of pain and administer pain medication as ordered. The nurse's note dated 4/21/18 at 5:41 AM identified that at 3:30 AM the charge nurse administered [MEDICATION NAME] 2.5 cc instead of the 0.25 cc as ordered by the physician. The note identified the nurse immediately realized that she had administered the wrong dose and notified the physician and the resident's responsible party, Resident #1 was then transferred to the hospital for an evaluation. The Hospital Discharge Summary dated 4/22/18 identified Resident #1 was seen for an unintentional overdose on [MEDICATION NAME], the resident developed [MEDICAL CONDITION], received three (3) boluses of intravenous fluids and developed acute [MEDICAL CONDITION] for which oxygen therapy was initiated at twelve (12) liters via venti mask, and intravenous [MEDICATION NAME] 40 mg was administered. The record indicted after the diuresis, the oxygen was weaned down to four (4) liters and Resident #1 did not require immediate reversal with [MEDICATION NAME] as there was no signs of acute intoxication. The nurse's note dated 4/22/18 at 2:46 PM identified Resident #1 returned to the facility at 12:00 PM with [DIAGNOSES REDACTED]. Interview and review of the clinical record on 6/5/18 at 11:35 AM with the 11PM-7AM charge nurse, Registered Nurse (RN) #1, identified that she had been rushing, administered the [MEDICATION NAME] and then realized after that the syringe was larger than usual. RN #1 stated she knew then that she had administered 2.5 cc instead of the 0.25 cc as ordered. Interview and review of the clinical record and facility documentation with the Director of Nursing on 6/5/18 at 9:15 AM identified subsequent to the incident RN #1 received education on the prevention of medication errors and was evaluated on liquid narcotic med-pass competencies.

Based on clinical record review, observation and intervention for 2 of 3 sampled residents (Resident #116 & Resident #111) reviewed for pressure ulcers, the facility failed to ensure that interventions were in place to prevent and/or promote the healing of a pressure ulcer. The findings include 1. Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission body audit identified bilateral [MEDICAL CONDITION] of the lower extremities, 18 bruises on the body (not including the feet) and intact skin to the feet and heels. The Braden scale dated 07/14/15 identified a score of 13 representing a moderate risk for the development of a pressure ulcer. The Braden Assessment contains protocols identifying interventions related to the level of risk that should be considered. The form indicates that for a score of 13-14 the following interventions should be considered; turning schedule, use foam wedges for 30 degree lateral positioning, pressure reduction support surface, maximal remobilization, protect heels and manage moisture. The interventions checked for Resident #116 were turning schedule and maximal remobilization. The physician's order [REDACTED]. The orders also noted that the resident was not to be ambulated. Review of the Resident Flow Sheet identified that from the admission date of [DATE] to 07/23/15 the resident was totally dependent for bed mobility and required the assistance of two staff members for movements that include; lying to sitting position, positioning in bed, turning side to side, moving legs in and out of bed including boosting up in bed. The flow sheet further identified for the same time period that the resident ' s meal intake varied between 25% to 50%. A nurse ' s note dated 07/20/15, 11:00PM-7:00AM identified a dark area on the left heel that measured 3.5cm by 3.3cm. The physician was notified and a new order was obtained to offload heels and apply skin prep every shift. Review of the Weekly Wound Audit identified a stage 1 pressure ulcer to the left heel with the above mentioned measurements and with depth unable to be determined. Observation on 07/23/15 at 12:05PM with LPN #1 identified the resident seated in a wheelchair with foot rests and socks to the feet. LPN #1 removed the sock to the left foot and a dark brown crescent shaped area was observed. Interview with LPN #1 at the time identified Resident #116 required help to turn and further identified Resident #116 did not have the cognitive ability to make positional changes to the feet. Interview with nurse aide #1 on 07/23/15 at 12:30PM identified Resident #116 required staff members to reposition his/ her lower extremities. Interview and review of the clinical record with the Infection Control Nurse and the DNS on 07/23/15 at 1:00PM identified the clinical record lacked documentation that Resident #116's heels were off loaded from 7/14/15 through 7/20/15. The INC and DNS further identified they utilize the Braden scale to determine risk but that the interventions utilized are left up to the individual licensed staff members to implement as the facility did not have a specific protocol for pressure ulcers prevention. The Infection Control Nurse did not offer an explanation as to the reason the left heel pressure area was documented as a stage 1 and not a deep tissue injury. He/she further identified although he/she was present when the nurse assessed the area he/ she did not assess the area him/herself. 2. Resident #111 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The acute care discharge summary dated 5/27/15 identified the presence of multiple wounds during Resident #111 in patient stay, including a healing stage 2 pressure ulcer from a compression stocking. The nursing admission assessment dated [DATE] identified the absence of pressure ulcers. A Braden scale completed on 5/27/15 identified the resident was at a high risk for pressure ulcer development. The Braden Assessment contains protocols identifying interventions related to the level of risk that should be considered for a high risk score of 12 or less: increase frequency of turning, supplement with small shifts, pressure reduction support surface, foam wedges for 30 degree lateral positioning and pressure relieving surface. The admission MDS assessment dated [DATE] identified severely impaired cognitive skills, required total dependence for all activities of daily living and was always incontinent of bowel and bladder. The care plan dated 6/4/15 identified a risk for skin breakdown with interventions which included treat skin as ordered, provide with pressure reducing devices to bed and wheelchair and encourage good food and fluid intake. The nurse's note dated 7/20/15 identified the presence of pressure ulcers on the left and right buttock. A weekly wound audit initiated on 7/20/15 identified a Stage II pressure ulcer on the right inner buttock that measured 0.7cm x 0.5cm x 0.2 cm without drainage. The physician directed to apply [MEDICATION NAME] gauze after cleansing with normal saline followed by padded foam dressing twice a day. Further clinical record review identified an unstageable pressure ulcer on the left inner buttock that measured 2cm x 0.6cm with 100% yellow slough on the wound bed. The physician directed to apply Santyl after cleansing with normal saline then apply [MEDICATION NAME] gauze followed by foam padded dressing twice a day. Observation on 7/22/15 at 10:25AM identified a static air mattress overlay on the resident's bed. Clinical record review and interview with the Infection Control Nurse on 7/23/15 at 11:18AM identified the facility did not have specific protocols in place to guide the staff in the use of appropriate supportive mattresses and the Group one air mattress was initiated following the development of the two pressure ulcers on 7/20/15. The ICN identified that although turning and repositioning was completed, the clinical record lacked documentation that the care plan had been revised to reflect that additional interventions were implemented between 5/27/15 and 7/20/15 to prevent the development of a pressure ulcer.

Based on clinical record review and interviews for 1 of 3 sampled residents reviewed for pressure ulcers (R#110) the facility failed to ensure that the resident received the appropriate care and services to treat and/or prevent the development of a pressure ulcer. The findings include: Resident #110's [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] identified the resident with a pink area on the coccyx. A Braden Scale (skin assessment for risk of developing pressure ulcers) dated 8/22/13 identified the resident was at moderate risk for the development of pressure ulcers, it further indicated that that interventions included a turning schedule. Physician's admission orders [REDACTED]. An admission MDS assessment dated [DATE] identified the resident as cognitively intact, was totally dependent on staff for bed mobility and extensive assistance for transfers, toilet use and personal hygiene. Review of the treatment kardex for the month of August, 2013 failed to reflect documentation to indicate that the resident was placed on a turning schedule and/or that the turning and repositioning was completed. Review of facility's protocol for pressure ulcers identified that when a stage 1 pressure area is identified it is to be monitored on a pressure ulcer weekly assessment form. The form notes the stage of the area, the size (measurements) and location. A nurse's note dated 9/03/13 (3-11 PM) identified increased redness to the coccyx sacral area with a 2 cm open area. It further noted that the area was cleansed and a protective dressing was applied and the physician was notified of the change in the skin condition. A weekly wound audit noted that on 9/04/13 the resident had an area on the coccyx that measured 7.0 cm in length and 3.0 cm in width with a depth of less than 0.2 cm and notes the wound bed is 50% pink and 50% red. Measurements on 9/09/13 identified the area as 3.0 cm by 2.0 cm with a depth of less than 0.3 cm and is 10% red and has 90 % slough with some serosanguinous drainage. The wound documentation failed to reflect the stage of the pressure ulcer. Interview with the charge nurse on 9/23/13 identified that the resident had a stage 2 to the coccyx. Further review of the weekly wound sheet noted the area was assessed on 9/17/13, and 9/24/13 but none of the documentation reflected the stage of the pressure ulcer. Review of the clinical record with the charge nurse on 9/05/13 at 2:05 PM and with the MDS coordinator on 9/25/13 at 2:21 PM failed to identify what the stage of the pressure ulcer was and/or a care plan to address the pressure ulcer/skin integrity. Interview with the MDS Coordinator on 9/25/13 at 2:30 PM identified that although she indicated that she had developed a care plan to address the resident's skin integrity, she could locate the care plan anywhere on the unit. Subsequently the MDS Coordinator developed a care plan dated 9/25/13 that identified a problem of alteration in skin integrity secondary to pressure sore and the pressure ulcer stage was noted as unstageable. Interview with the infection control nurse on 9/26/13 at 11:30 AM and review of the pressure ulcer list failed to identify the tracking of the stage 1 pressure ulcer when the resident was first admitted to the facility and failed to identify the stage of the pressure ulcer once it opened and its progression to an unstageable area. The infection control nurse and the DNS noted that the area should have been staged and the appropriate documentation reflected on the weekly wound documentation.

Based on review of the clinical record, review of facility documentation, and interview for two of five sampled residents with a history of falls (R#28, #82 ), the facility failed to implement the plan of care and/or failed to ensure resident equipment were properly affixed to prevent an incident with injury. The findings include: 1. Resident #28 [DIAGNOSES REDACTED]. An MDS dated 6/24/13 identified the resident as moderately cognitively impaired, with a BIMS score of 12 and required extensive assistance with the assist of one for transfers from the wheelchair onto the toilet. A RCP dated 9/25/13 identified the resident at risk for falls. Interventions included call bell within reach, bathroom light on at night, and attempt to anticipate needs. A review of a facility A/I dated 9/1/13 identified the resident slipped out of his/her wheelchair. Intervention subsequent to the incident identified anti-slip pad (dycem) was to be applied to the wheelchair to prevent a reoccurrence of the accident. Observation on 9/25/13 at 10:00 AM and on 9/26/13 at 10:30 AM with NA#1 and LPN#1 identified R#28 in his/her wheelchair and without the benefit of a dycem pad. A review of the nurse aide care card on 9/26/13 indicated that the resident required a wheelchair however, the care card failed to reflect the use of a dycem in the wheelchair. Interview with NA#1 on 9/26/13 at 11:00 AM identified that he/she was not aware that the resident should have a dycem pad on the wheelchair. Subsequent to surveyor inquiry on 9/26/13 at 11:00 AM LPN#1 obtained a dycem from the PT department and placed it on the resident's wheelchair. 2. Resident #82's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely cognitively impaired, and requiring extensive assistance with ADL's including toilet use, with unsteady balance during transitions and only able to stabilize with staff assistance. Nurse's note dated 6/02/13 identified that at 7:00 AM, NA#1 reported that the resident was sitting on the toilet and fell to the floor. A thorough assessment was conducted and 3 skin tears were noted on the resident's right arm. Although the resident was able to move all extremities without complaints of pain, during the transfer back onto the toilet the resident complained of right hip pain. The physician was notified and the resident was transferred to the ED for evaluation. A nurse's note dated 6/09/13 identified the resident was admitted to the hospital with [REDACTED]. A hospital discharge summary dated 6/11/13 identified that although x-rays of the right leg where negative for fracture, an MRI identified a non-displaced fracture of the right femoral neck extending into the intertrochanteric region with an associated effusion. The resident returned to the facility on [DATE]. Interview and review of facility documentation on 9/25/13 at 11:00 AM with NA #1, who was assigned to the resident at the time of the incident, identified that the resident was seated on a raised toilet seat. The NA was assisting the resident with morning care, the resident leaned to the side, and tipped the raised seat and slid to the floor. Further interview and reenactment of the incident on 9/25/13 at 1:45 AM with NA#1 identified that the NA left the room to get the resident's wheelchair. She placed the wheelchair in front of the resident who was ready to transfer off the toilet. The resident leaned to his/her right, the raised seat tipped and the resident landed on the floor. NA#1 indicated that she was not able to get around the wheelchair in time to prevent the incident. Interview with RN#1 on 9/25/13 at 11:45 AM and review of facility documentation identified that the physician was notified and the resident was transferred to the ED. Additionally, it was noted that there was a possibility that the raised seat was not placed on the toilet correctly causing it to slip off the toilet. Subsequently RN#1 provided the NA's on duty with preventive instructions to ensure that in the future, raised toilet seats were appropriately placed on the toilet seat prior to transferring residents. Interview with the DNS on 9/25/13 at 1:45 PM and review of the clinical record and facility documentation, identified that subsequent to the incident, all raised toilet seats were replaced with a model that has legs on either side to prevent tipping.

Based on clinical record review, observation and interview for three of four sampled residents reviewed for pressure ulcers, (R#7, R#27, R#57), the facility failed to provide care and services for the prevention and treatment of [REDACTED]. The findings include: 1. Resident #7's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as severely cognitively impaired, requiring extensive assistance with bed mobility and transfers, requiring total assistance with personal hygiene, at risk for developing pressure ulcers, and currently having a Stage III pressure ulcer. Review of the clinical record and weekly wound audit sheets identified a left buttock stage III pressure ulcer which originally developed on 6/11, and a right buttock stage II pressure ulcer which developed 11/15/12. A RCP dated 8/12 identified an alteration in skin integrity with interventions that included to avoid pressure to the area and off-load pressure. a. Observation on 12/07/12 at 1:00 PM with the Director of Maintenance (DM) identified an improperly inflated static air mattress on R#7's bed. The Director of Maintenance indicated he is responsible to inflate the mattress initially, and nursing staff is responsible to inform him if the mattress appears to be under inflated. The DM further indicated he would provide additional information on the mattress. Interview with RN#3 on 12/7/12 at 3:00 PM and testing to ensure proper inflation, the mattress was tested and R#7's buttocks bottomed out, indicating under inflation. b. Observation of Resident #7 on 12/7/12 at 1:00 PM identified R#7 sitting in the dining room with a cushion on the wheelchair. Review of physician's orders [REDACTED]. Interdisciplinary rehabilitation screening form dated 11/28/12, 12/8/12, (13 days after the new stage II pressure sore developed), indicated no change in skin integrity with no indication for occupational therapy needed. Interview with OT#2 on 12/7/12 at 3:15 PM indicated that the expectation is that when a new pressure ulcer develops, nursing staff is to inform OT in order to screen for new interventions and/or make changes to the treatment plan. Review of the clinical record and observations of R#7 on 12/10/12, indicated that there was no documentation of an OT screen and/or changes regarding the use of the cushion. 2. Resident #27 was admitted to the facility with a [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely cognitively impaired and required extensive assistance with bed mobility, transfers, toilet use and personal hygiene, at risk for pressure ulcers and with a stage four pressure ulcer. A care plan dated 10/11/12 identified a modified custom wheelchair, and to be out of bed for meals only, with a pressure relieving device to bed and chair. Observation with RN #3, on 12/06/12 at 10:00 AM, during a recreational program, identified R#27 sitting in an adaptive custom wheelchair and chambers of the RoHo cushion deflated. Interview with the Infection Control Nurse on 12/06/12 at 2:25 PM identified it is the responsibility of the unit nurse to ensure proper inflation of the cushion and report issues to maintenance. Interview with the OT on 12/06/12 at 2:45 PM identified that the nurse should report problems with proper inflation to the Rehabilitation Department or request a pump to re-inflate the RoHo cushion. Additionally, the OT identified that if the chamber does not re-inflate within 1-5 second, it would need to be filled with more air. To test the cushion, OT sat on the RoHo cushion and noted that the cushion bottomed out, and did not re-inflate after 5 seconds. A second observation with RN #3 on 12/10/12 at 8:30 AM identified R#27 being transferred via Hoyer to the adaptive custom wheelchair. The RoHo cushion again failed to re-inflate after being compressed. Interview with the Maintenance Director on 12/10/12 at 2:00 PM. identified he had never filled a RoHo cushion, nor was he responsible to check or fill the RoHo cushions. 3. Resident #57's MDS dated [DATE] identified the resident as total care with all ADL's and a history of pressure ulcers. A RCP dated 11/06/12 identified the resident with an alteration in skin integrity secondary to pressure (right ankle) with interventions that included to provide a therapeutic mattress and cushion for chair. Observation on 12/10/2012 at 9:00 AM identified the resident in bed with the mattress setting at 8. Interview with the ICN identified the mattress setting should be at medium (4). Review of manufacturers guidelines noted on the mattress controls identified; to adjust setting to maximum (8) and place 2 fingers under mattress to ensure maximum benefit. Mattress testing with ICN at 11:30 AM identified the mattress setting at 8, with the resident's bottom to the mattress indicating improper inflation for the resident in order to provide maximum benefit to resident.

Based on clinical record review, review of facility documentation and interview for one of three sampled residents who required the assitance of two for transfers (R#105) the facility failed to transfer the resident as per the plan of care to ensure the safety of the resident. The findings included: Resident #105's [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] identified resident as severely cognitively impaired and required two nursing staff to provide assistance for transfers. A RCP dated 1/26/11 identified the resident at risk for falls related to Parkinson's Disease. Interventions included nurse aides to follow the resident's plan of care for safe transfer, and to transfer the resident via mechanical lift with the assistance of two staff. A nurse's note dated 4/21/11 identified that at 7:55 PM, LPN #1 was called to R# 105's room by NA#2 who reported that while the resident was sitting in the shower chair he turned to move the Sara Lift and R#105 slid out of the shower chair on to the floor. Additionally, the nurse's note indicated that the resident complained of pain. Interview with NA#1 on 10/26/11 at 1:50 PM identified that on 4/21/11 (3-11 shift) he assisted NA#2 pick R# 105 off the floor and back into bed. NA#1 further indicated that approximately 30 minutes later, Resident # 105's call bell was noted to be on and upon entering the resident's room with another staff member the resident was observed lying on the floor. Interview with LPN#1 identified that when she was called to R#105's room the resident was found lying on floor with the resident's head by foot of bed. LPN#1 indicated that during an interview, NA#2 indicated that he transfered the resident into the shower chair and the resident fell out. LPN#1 further indicated that she was unaware that the resident had a fall earlier that day and then was transferred back to bed until after an investigation was initiated. Review of police report dated 5/02/11 indicated that NA#2 indicated that at approximately 7:45 PM he transfered R#105 from wheelchair to shower chair and then left the room and upon return he noticed that R# 105 was on the floor. The report also indicated that NA#2 asked NA#1 for assistance in transferring the resident back into bed and indicated that NA # 2 did not inform the nurse of the resident's fall. Additionally, the report indicated that about ten minutes after placing the resident back into bed, NA # 2 lifted the resident off the bed and placed the resident back onto the floor, fifteen minutes later he told the nurse that resident was on the floor. Police report further indicated that NA#2 indicated he put the resident back on the floor to justify the original fall. Review of the facility investigation and the police report identified R# 105 was transferred to the hospital and was diagnosed with [REDACTED].