Every finding on record at Premier Rehab and Healthcare at Burlington

Based on observation, interview, and record review the facility failed to ensure that the call light was within reach and secured for 1 (Resident #2) of 3 sampled residents while in bed. Findings include:Per record review Resident #2 has a diagnosis history of hemiplegia (A paralysis or severe weakness affecting one side of the body, usually caused by brain or spinal cord damage.) and hemiparesis (A partial weakness or reduced strength on one side of the body.) following cerebral infarction affecting right dominant side, Morbid (severe) obesity due to excess calories, Contracture (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility.) of right hand, and muscle weakness. It also states in the resident's care plan that they are at risk for decreased ability to perform activities of daily living in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility. Per interview and observation on 7/8/26 at approximately 12:15 PM, Resident #2's call bell was well out of their reach hanging on the side of the bed. Resident #2 reported that they can't reach to call bell during most of the day shift. Resident #1 (Resident #2's roommate) rang their call bell to alert the staff that Resident #2 needed incontinence care. During this interview, a Licensed Nursing Assistant (LNA) came in to help Resident #2. Per interview on 7/8/26 at approximately 12:30 PM, Resident #2 verbalized that the LNA that came in during the interview changed their briefs and shirt but has since then had another accident and does not have the call bell close by to get help. The call bell was observed to be tucked in on the side of the bed rails, out of their reach. Per observation on 7/8/26 at approximately 1:49 PM, Resident #2's call bell was tucked in on the side of the bed rail again, out of their reach for the 3rd time in three hours. Per interview with Registered Nurse when showed this, he stated that the call bell was tucked in a way that was out of reach for the resident and could not have just fallen there on its own. The nurse confirmed that the call bell was out of the residents reach and should be clipped to the residents' sheet where they can reach it. Per interview with the Director of Nursing on 7/8/26 at approximately 3:15 PM, she confirmed that the call bells should be within the residents reach if they need help and not on the floor or behind the bed rails. Per Call Lights Accessibility and Timely Response Policy Revised 5/2026 Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interview and record review, the facility failed to ensure adequate supervision and the implementation of care planned interventions for 1 of 3 sampled residents (Resident #1). The facility did not ensure staff followed the resident's individualized transfer requirements, including the use of a Hoyer lift with two staff members as outlined in the care plan and facility policy. A Licensed Nursing Assistant (LNA) independently conducted a manual transfer of Resident #1 and as a result, Resident #1 experienced pain and subsequently sustained a fractured scapula (shoulder blade). Findings include:Per record review, Resident #1 was admitted to the facility on [DATE] and has diagnoses that include Osteogenesis Imperfecta (a genetic disorder causing fragile bones that break easily due to defective or insufficient collagen) and Osteoporosis (bone disease where decreased bone mass and density make bones weak, brittle, and prone to fractures). The facility reported incident was reviewed, which described a Licensed Nursing Assistant (LNA) who independently transferred the resident from their wheelchair to their bed and sustained an injury. A review of the resident's care plan revealed an intervention to transfer the resident with two staff members using a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility), but the LNA neglected to follow it. Review of the hospital report after the incident noted a diagnosis of a broken scapula (shoulder blade) sustained by the resident after the incident of repositioning completed by the LNA. Per interview with Resident #1, s/he confirmed the LNA moved them without using a mechanical lift, and shared the LNA picked them up by lifting them under their arms. S/he attempted to stop the LNA by telling them to use the mechanical lift to move them from the wheelchair to the bed, but the LNA continued with the transfer without the mechanical lift assistance or another colleague. S/he stated that once in bed, they felt a pop and experienced discomfort, which they reported to the LNA. The following statements collected by facility leadership with staff revealed that the LNA reported transferring Resident #1 without using the mechanical lift and that the resident screamed, along with the resident reporting pain. The LNA confirmed she was aware and didn't follow the resident's care plan, which has an intervention of transferring with a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) with two staff members. The following statements collected by facility leadership with staff revealed that the Licensed Practical Nurse (LPN) on duty for the unit was informed by the LNA regarding Resident #1 needing pain medications. When they asked for further information, the LNA stated that Resident #1 complained of pain in the upper back and shoulder area on the right side after assisting the resident with removing their sweater. The LPN assessed Resident #1 and found a limited range of motion, with the resident grimacing when movement was attempted. The LPN asked the resident what had occurred. Resident #1 informed the LPN that the LNA had transferred them into bed by lifting them. The LPN confirmed with the LNA that they had lifted them into bed. Per interview with the Administrator at 12:56 PM, she confirmed the LNA didn't follow the facility's policies and procedures or Resident #1's care plan, which states the resident is to be transferred using a Hoyer lift with two staff, and this led to Resident #1 sustaining an injury. Per interview with the Director Of Nursing (DON) at 1:15 PM, she confirmed the LNA failed to comply with Resident #1's care plan, which states the resident is to be transferred using a Hoyer lift with two staff, and that the resident sustained an injury during the transfer. Review of the facility's Safe Resident Handling/Transfers policy, last reviewed 10/2025, includes Staff members are expected to maintain compliance with safe handling/transfer practices.Resident lifting and transferring will be performed according to the resident's individual plan of care. References:https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteogenesis-imperfecta#:~:text=Symptoms%20of%20OI%20include:%20*%20Easily%20broken,Physical%20and%20occupational%20therapy%20*%20Assistive%20deviceshttps://my.clevelandclinic.org/health/diseases/4443-osteoporosis

Based on record review and interview, the facility failed to provide necessary education and ensure staff were competent to provide care to a resident with a wound vac (wound vacuum; a negative pressure pump that helps a wound heal faster by removing fluid and infection-causing bacteria with suction) for 3 of 3 sampled licensed nurses providing care to Resident #14 . As a result, Resident #14 developed an infection requiring hospitalization and two surgical interventions. Findings include:Per record review, Resident #14 was admitted to the facility on [DATE] for rehabilitation services after a left hip replacement. Resident #14's cognition was assessed on 11/29/25 with a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitive intactness.Per interview on 12/16/25 at 8:55 AM, Resident #14 explained that s/he really wants to go back home and is very frustrated that s/he can't because s/he has to go back for another revision to his/her hip due to an infection. S/he explained that s/he had a wound vac (wound vacuum; a negative pressure pump that helps a wound heal faster by removing fluid and infection-causing bacteria with suction) on the surgical hip and here was a period of time that it wasn't on when it should have been. S/He stated that it got full and stopped working. S/He said that there was an issue with the wound vac supplies, and the staff didn't know what to do with it, so they stopped using it.Per record review and interview, Resident #14 had a wound vac placed on his/her left hip surgical site on 11/4/25 due to drainage. Resident #14 required hip revision surgery on 11/19/25 due to an infection. Resident #14 did not have a care plan or physician orders and evidence of monitoring in accordance with facility policy for the wound vac until 11/27/25, 22 days later. See F684 for more information.Per interview on 12/16/25 at 3:04 PM, the Unit Manager explained that Resident #14 had multiple wound vacs placed since s/he was first admitted and she was not familiar with the type of wound vacs that s/he had. Education files for 3 licensed nursing staff that cared for Resident #14 while s/he had a wound vac were reviewed. 3 of 3 licensed nursing staff did not have wound vac training or competencies.Per interview on 12/17/25 at 11:24 AM, the Director of Nursing confirmed that education and competencies were not provided to staff for wound vacs.Review of the Facility Assessment, dated 10/6/25, reveals that the facility has determined it can care for residents who have major joint replacements and wounds. A section titled Information About Our Staff Training/Education and Competencies describes the skills and competencies required to meet resident needs and reads, We identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations, and technical/hands-on skills. Refer to the worksheet 'Facility Education/Staff Competencies Necessary to Care for Resident Population.' The worksheet identifies which staff require certain competencies and skill sets, and the frequency of education. See also 'Staff Development Training Plan.'Per interview on 12/17/25 at 1:20 PM, the Nurse Educator confirmed that there had been no education provided to staff for wound vacs. During this interview, the facility assessment was reviewed with the Nurse Educator. She was unfamiliar with the education and competency worksheet and the staff development training plan that the facility assessment referred to.

Based on record review and interview, the facility failed to provide care to a resident with a wound vac (wound vacuum; a negative pressure pump that helps a wound heal faster by removing fluid and infection-causing bacteria with suction) in accordance with their facility policy for 1 of 1 sampled residents (Resident #14). The facility did not have a care plan or physician orders and evidence of monitoring in accordance with facility policy for the wound vac until 11/27/25, 22 days later, did not maintain a wound vac or following wound treatment orders after wound vac was removed on 11/13/25, and did not provide necessary education and ensure staff were competent to provide care to a resident with a wound vac. As a result, Resident #14 developed an infection requiring hospitalization and two surgical interventions. Findings include:Per record review, Resident #14 was admitted to the facility on [DATE] for rehabilitation services after a left hip replacement. A Transition of Care report from the sending hospital dated 10/21/25 reads, Patient is at high risk for developing post-operative infection. Resident #14's cognition was assessed on 11/29/25 with a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitive intactness. Resident #14 has the following care plans: [Resident #14] is at risk for an infection related to: recent hospitalization, post surgery, SAR [sub acute rehab] placement, created on 10/21/25, and [Resident #14] has actual non-pressure skin impairment/s present R/T [related to] Surgical site, created on 10/22/25, with an intervention for Treatment as ordered to the wound, created on 10/22/25.Per interview on 12/16/25 at 8:55 AM, Resident #14 explained that s/he really wants to go back home and is very frustrated that s/he can't because s/he has to go back for another hip surgery- a revision to his/her hip due to an infection. S/He explained that s/he had a wound vac on the surgical hip and there was a period of time that it wasn't on when it should have been. S/He stated that it got full and stopped working. S/He said that there was an issue with the wound vac supplies, and the staff didn't know what to do with it, so they stopped using it.Facility policy titled Negative Pressure Wound Therapy [NPWT], revised 2/2025, reads, 1. Negative pressure wound therapy will be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing change. 7. Use and application of the therapy shall be accordance with manufacturer's recommendations. 9. Monitoring throughout the use of NPWT shall include, but is not limited to, the following: a. pain associated with the therapy; b. device setting is functioning properly; c. settings are prescribed; d. troubleshooting of any alarms, in accordance with pump/product specifications; e. response of the therapy, including wound characteristics and progress towards healing.Per record review a change in condition form dated 11/4/25 reads Increased drainage to L hip surgical incision site. Resident #14 was sent to the Emergency Department (ED).A 11/4/25 orthopedic survey consultation note reveals that Resident #14 presents with incisional drainage from his/her left hip. A Prevena wound vacuum was placed with intent for it to remain until scheduled outpatient follow up [11/10].Per record review, on return from the hospital on [DATE], Resident #14's care plan was not revised to include interventions related to the wound vac or wound vac monitoring, and did not have physician orders for the wound vac. There is no evidence that his/her wound vac was monitored in accordance with facility policy.Per interview on 12/16/25 at 3:04 PM, the Unit Manager explained that Resident #14 had multiple wound vacs placed since s/he was first admitted and she was not familiar with the type of wound vacs that s/he had. She was unable to find physician orders or care plan for the wound vac placed on 11/4/25.A 11/10/25 orthopedic note regarding a scheduled outpatient follow up reads overall incision healing well with 2 very small areas with ongoing serous draining, centrally and superiorly. Prevena wound vacuum sponger was replaced in clinic, well-tolerated. We stressed the importance of keeping the incision dry. I reviewed a prosthetic joint infection would require multiple surgeries including possible an explant and another revision. Plan: Maintain Prevena wound VAC for 5 days, then 3 times daily dry dressing changes.A 11/10/25 nursing note states Resident came back from Ortho appt with new orders as followed: wound vac for 5 days then TID [three times a day] dry dressing changes.A physician order starting 11/10/25 reads Keep wound vac in place for 5 days every shift until 11/15/2025, but does not include desired pressure settings. Resident #14's care plan was not revised to include interventions related to the wound vac or wound vac monitoring, and there is no evidence that his/her wound vac was monitored in accordance with facility policy.A 11/11/25 Advance Practice Registered Nurse (APRN) note reveals that Resident #14's hip wound incision was cultured and found to have MRSA (methicillin resistant staph aureus). The resident did not show signs of infection. A wound vac was applied and is to stay in place until 11/15/25 then will get 3 times a day dry due to [sic] dressing changes and instructed to keep wound dry.Review of the Treatment Administration Record (TAR), the wound vac was marked as administered only for three days, on 11/10/25 through 11/12/25.A 11/13/25 nursing note reads Wound vac removed due to the cartridge being full and not having a replacement cartridge and leaking on the bed from the wound. Wet to dry dressing applied.A 11/13/25 progress note reads, advised by day shift nurse that the wound vac clogged on the prior night shift and was removed, wet to dry dressing was put in place.Per review of the TAR, Resident #14 only received once a day dressing changes on 11/14/25 until 11/16/25.A 11/18/25 UM note reads Wound noted to have increased drainage which is more thick. Dressing are needed to be changed more frequently than daily. Resident #14 was sent to the ED.A 11/25/25 Transition of Care report reveals that Resident #14 had both a surgical site and joint infection and had hip revision surgery on 11/19/15. Resident #14 was discharged back to the facility on [DATE] with another wound vac.Per record review, on return to the facility, Resident #14's care plan was revised to include information regarding the wound vac and physician orders were placed with the desired settings, 22 days after the resident had first had a wound vac at the facility.A 12/12/25 Hospital Nurse Practitioner note reveals that Resident #14 is scheduled for another hip revision surgery on 12/17/25 due to persistent drainage and s/he is discouraged about this.There was no evidence that staff had the required training and competencies to care for Resident #14's wound vac at any point of his/her stay. Per employee education file review, 3 of 3 licensed nursing staff that cared for Resident #14 while s/he had a wound vac did not have wound vac training or competencies. See F726 for more information.Per interview on12/17/25 at 11:24 AM, the Director of Nursing confirmed that Resident #14's care plan did not include wound vac until later in November, s/he did not have physician orders for the wound vac when s/he first got it, did not have orders or interventions to monitor the wound vac until later in November. She stated that the wound vac supplies were not available when it was removed on 11/13/25 and that the order for a dry dressing three times a day was not put in place. She confirmed that education and competencies were not provided to staff for wound vacs.

Based on observations and interviews, the facility failed to store food in a safe, sanitary condition. This has the potential to impact all residents. Findings include: 1. On 12/15/2025 at 10:55 AM, a tour of the kitchen as conducted with the Kitchen Manager (KM) and Registered Dietician. The following observation was made: The walk-in freezer had multiple boxes stacked directly on the floor of the cooler, blocking access to most of the food on the shelves. The KM explained that the boxes should be put on crates and should not be on the freezer floor directly.Per observation on 12/16/2025 at 8:12 AM, the walk-in freezer had multiple boxes stacked directly on the floor of the cooler.Per interview on 12/16/2025 at 8:14 AM, the Kitchen Manager stated that the freezer was organized yesterday after our initial observation and boxes shouldn't be on the freezer floor.2. On 12/15/25, starting at 11:27 AM, the following observations were made of all four unit kitchenettes:Second floor The microwave was covered in a large white smear; The cabinets were lined with what looked like cracker crumbs and contained a hot chocolate bag open to the air, a loaf of gluten free bread with no date, an open bag of chips with no date, and a regular loaf of bread with no date; The refrigerator had two undated take out containers, a jar of brown celery, chicken stock dated 10/15/25, and the inside doors were lined with a yellow substance; The freezer had two loaves of undated bread with a brown substance on the bags; The coffee station had a bag of brown sugar, open to air with no date.Third floor The cabinets contained three loaves of bread with significant green mold and five additional undated loaves of bread, an open jar of grape jelly 48 oz that read refrigerate after open, an open bag of chips with no date; The refrigerator had an unlabeled container of soup, a large bag of hot dogs open to air with no date, a greasy undated subway bag, an undated take out bag, a container of raviolis with a use by date of 12/8/25, prune juice with a use by date of 10/16/25. Per interview with the Unit Manager, she said that it is not good about the moldy bread, and explained that all food in the refrigerator should be marked with names and dates and it wasn't. Fourth floor The cabinets contained one loaf of undated bread; The refrigerator had two unlabeled take out containers.Fifth floor The cabinets contained five undated loaves of bread; The freezer had an unlabeled bag of ground beef; The refrigerator had eight take out containers with no dates or names and two Ziploc bag containing soup like food with no labels.Per interview with the Director of Nursing, she explained that the policy was to have all food items labeled and dated and confirmed that none of the food listed above should be in the refrigerator. Per interview on 12/17/2025 at 9:55 AM, the Kitchen Manager confirmed that all food in the kitchenettes, including bread, should be labeled with the resident's name (if applicable) and the dates that the food was open and expires.

Based on record review, observations, and interviews, the facility failed to provide substantial snacks at bedtime when there is more than14 hours between a substantial evening meal and breakfast the following day. This has the potential to impact all residents. Findings include: 1. Per review of the medical record for Resident #106, it revealed the resident has medical diagnosis that include end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, anemia in chronic kidney disease, pulmonary hypertension, generalized edema, chronic obstructive pulmonary disease, insomnia, and chronic diastolic heart failure. Per review of Resident #106's physician orders, the resident is scheduled for dialysis treatments on Tuesdays, Thursdays, and Saturdays. Per record review of Resident #106's meal intake, from the dates of 11/1/25 through 12/17/25, there are six dates where Resident #106 either had no documentation for their dinner consumption, or the documentation stated RX resident not available. Per interview with Resident #106 on 12/15/25 at 3:18 PM, s/he revealed that when they get back from their dialysis appointments at 9:30 PM at night, s/he doesn't always get dinner because they take his/her tray away and throw it out. Resident #106 reports this having happened three to four times. Resident #106 also reported that the always available menu the facility offers is not available after 7 or 8 PM. Resident #106 has asked for snacks when they get back, and staff have made statements like you just want me to run around for you to the Resident when they request a drink or food. Per interview with Resident #106 on 12/17/25 at 8:26 AM, s/he stated that they had something to eat after their dialysis appointment on 12/16/25, but that it wasn't enough. S/he also reported the food was a turkey sandwich which was saturated. They reported that they ordered out more food as the kitchen was closed and they don't have snacks available for him/her. Per observation with the Unit Manager of the snacks on Floor 2 on 12/17/25 at 10:50 AM, she revealed that there are no sandwiches in the refrigerator and that if they have them the kitchen is supposed to bring them up. The Unit Manager confirmed that there should be more snacks in the cupboard like goldfish, peanut butter sandwich crackers, pretzels, and that it was missing these items. She revealed that dietary is supposed to fill the fridge when empty and that nursing staff should be calling down if they are missing snack items. When asked about what residents have to eat at night if they are hungry, she stated that she thinks nursing staff can go into the kitchen downstairs. Per observation of the floor 3 snacks, she confirmed that there should be sandwiches in the fridge available for residents. She confirmed that there was no peanut butter crackers or jelly in the cupboards. Per interview with the Kitchen Manager on 12/17/25 at 11:19 AM, they reported that the kitchen closes at around 7:45 PM to 8 PM and that there isn't an option for residents to have hot food at night. The Kitchen Manager stated that the units have peanut butter and jelly all the time and that they are working on getting sandwich fillings up there so they can make the resident a sandwich on the floor. The Kitchen Manager also revealed that it is the kitchens responsibility to keep the snacks stocked and that the evening cook is supposed to check all the snacking supplies or that nursing is supposed to call them. He confirmed that they do not keep track of what is stocked upstairs for snacks. The Kitchen Manager also stated after 7:45 PM, whatever is on the units for snacks are the options that residents have like pudding, fudge rounds, and saltines. When asked if those items constitute a meal, he confirmed that those are not dinner meals and that the kitchen is closed so there are no meal options for residents overnight. Additionally, he confirmed that the menu does say always available, but it is not always available once the kitchen is closed. Per interview with the kitchen manager on 12/17/25 at 12:21 PM, he reported that nursing staff have access to the kitchen but he doesn't know if they are allowed to go into the kitchen. Per interview with an LNA on 12/17/25 at 1:53 PM, she reported that she frequently cares for Resident #106. The LNA confirmed that they don't bring sandwiches and put them in the refrigerator and she confirmed that there are no meal alternatives after 8 PM. When asked if she could go into the kitchen if a resident wanted something different after the kitchen is closed, she reported that she has never done that before and wasn't sure if she was allowed to. The LNA also confirmed that nursing staff aren't consistently documenting Resident #106's meal intake on the evening shifts and that they should be documenting Resident #106's meal intake after they get back from dialysis. Per interview with LNA #2 on 12/17/25 at 1:47 PM, she confirmed that they don't have a meal replacement option for residents who want a meal after 8 PM and that they never have sandwiches stocked on the unit. When asked if she has ever gone to the kitchen to get a resident food, she stated that she has never had to. Per interview with the Director of Nursing on 12/17/25 at 2:37 PM, she confirmed that the staff should be documenting how much Resident #106 eats when they get back from their dialysis appointments and that they weren't always doing that. She confirmed that nursing staff should not be coding RX (Resident not Available) for dinner on the days Resident #106 goes out for dialysis and then comes back. 2. An interview was conducted with four residents (Resident #59, #104, #83, and #99) on 12/17/25 at 10:27 AM during a resident council task. Resident #59 has a BIMS [Brief Interview of Mental Status] score of 14 as of 12/2/25, indicated s/he is cognitively intact. Resident #104 has a BIMS of 15 as of 10/23/25 indicating they are cognitively intact. Resident #83 has a BIMS of 15 as of 10/13/25 indicating s/he is cognitively intact. Resident # 99 has a BIMS of 14 as of 10/24/25 indicating they are cognitively intact. At 10:45 AM all four residents discussed that they get snacks only if the kitchenettes have the food. They discussed that kitchenettes do not always have food stocked for snacks. 3. Per observation on 12/15/25, starting at 11:27, the kitchenettes on each unit were observed. There were no salads (chicken, egg, or tuna salad) on any unit, and the kitchenettes were minimally stocked with snack food including bread, potato chips, and a small number of crackers. Per interview on 12/17/2025 at 12:03 PM, the Kitchen Manager stated that meals are served between 8 AM and 5 PM on the first unit, and 9 AM and 6 PM on the last unit (making it 15 hours between dinner and breakfast). He explained that the kitchen staff are responsible for stocking the snacks on the units. When asked what should be available to residents as a substantial snack, he said that each unit should have a minimum of two salad options, like chicken salad or egg salad to make sandwiches, and other snack options.

Per interview and record review, the facility failed to have a qualified food service director or a full-time qualified dietician. This has the potential to impact all residents. Findings include:Per interview on 12/16/25 at 8:14 AM, the Kitchen Manager explained that he was new to the position and does not have his certification as a dietary manager or food service manager yet.Per interview on 12/17/25 at 12:15 PM, the Administrator explained that the Registered Dietician (RD) works full time between two facilities. Per review of the RD's timecard for the previous week, the RD worked 25 hours at the facility.Per interview on 12/17/25 at 12:32 PM, the RD explained that she works at the facility 3 times a week and confirmed that she does not work full-time at this facility.

Based on observation, record review, and interview, the facility failed to implement infection control practices designed to provide a safe and sanitary environment for 1 of 4 units (Second floor) and ensure infection control measures were followed to prevent the transmission of diseases and infections for one randomly sampled resident (Resident #14). Findings include: 1. Per observation on 12/15/2025 at approximately 2:10 PM, a white/grey powder like substance was on the code cart, wound care/treatment cart, and the precaution supply carts. Per interview on 12/15/2025 at approximately 2:30 PM with the LPN on the Second floor, they confirmed the code cart, wound care cart, and precaution supply carts were dusty with white/grey powder and needed to be cleaned. Per interview with 12/15/2025 at 3:09 PM with the Director of Nursing (DON), she confirmed there was dust on the code cart, suction machine, precaution supply carts, and treatment cart containing construction dust and that they all needed to be cleaned. During observation of the Second floor on 12/17/25 at 9:41 AM, Hoyer lifts, a mechanical device used to lift and transfer residents with limited mobility safely, were observed with dust-like material that had a white powder look on the base of the equipment. Per interview on 12/17/2025 at 9:57 AM with the Infection Preventionist, Director of Nursing (DON), and the Regional Nurse Consultant, they confirmed the debris seen on the Second floor. During the observation of the Second floor on 12/17/25 at 11:28 AM, the Regional Nurse Consultant acknowledged that the Hoyer lifts required cleaning due to construction dust and reported that housekeeping was working on it. During an interview on 12/17/25 at 12:19 PM with the Assistant Administrator and the DON, the Assistant Administrator described the debris as construction particles and dust produced during sanding and wall preparation for wallpaper. During an interview on 12/17/25 at 1:40 PM with a maintenance person and the Second floor LPN, both confirmed that the kitchenette hood had a buildup of debris and had not been cleaned. According to the Centers for Disease Control and Prevention (2023, CDC) when the environment is disturbed such as by producing dust airborne infections can be released into the air which can cause healthcare associated infections. 2. Per observation on 12/15/2025 at 11:07 AM, a resident in room [ROOM NUMBER] had been discharged earlier that morning. The mattress was noted to have had a brown discoloration in the middle. The protective lining in the center of the mattress was a lighter blue than the rest of the mattress with the edges appearing chipped. There were two pillows observed with holes in the protective/plastic covering. Per interview on 12/15/2025 at 1:09 PM with a Licensed Practical Nurse (LPN) on the Second floor, s/he confirmed the mattress was compromised as noted above, and that there was a brown stain to the mattress where the top layer was worn, and that both pillows had holes in them. Per observation on 12/15/2025 at approximately 2:32 PM, room [ROOM NUMBER] appeared to have been cleaned and the bed containing the identified compromised mattress was noted to be made and ready for use. The bed linens were removed from one side of the mattress revealing the compromised mattress observed earlier in the day as noted above. The pillows noted above were on the bed with pillow cased in place. Per interview with a Housekeeping Staff who was finishing up in room [ROOM NUMBER], they confirmed the room had been terminally cleaned and the mattress/bed was ready for a new resident. The Housekeeping Staff was shown the mattress/bed and asked if the mattress was safe to use for a new resident and the Housekeeping Staff said she didn't know but it was re-made and ready for a new resident. Per interview on 12/15/2025 at 2:43 PM with the Administrator (ADM), she confirmed that the mattress was not appropriate for resident use in the above noted condition, it was compromised and could not properly be cleaned in that condition and needed to be thrown away. Per interview on 12/17/2025 at 8:11 AM with the Housekeeping Manager, he confirmed if a mattress cover is compromised it should be reported and removed from use and stated he was mortified by the condition of the mattress found in one of the resident rooms that was being terminally cleaned, thorough cleaning of a room after use in healthcare environments to control the spread of infections, and he wouldn't put a resident on a mattress I wouldn't sleep on myself. He confirmed that staff should contact the Administrator or Assistant Administrator for a replacement when equipment is worn out, damaged, or broken. Per interview on 12/17/2025 at 9:57 AM with the Infection Preventionist, Director of Nursing (DON), and the Regional Nurse Consultant, they confirmed that equipment that cannot be disinfected shouldn't remain in use for residents. When there are worn-out, damaged, or broken items, staff are expected to use TELS (the online platform for building maintenance) or contact the Assistant Administrator to request a replacement. Review of facility policy titled Care, Cleaning and Storage of Equipment, last reviewed 2/2025, states Equipment found to be in disrepair.should be reported to the supervisor on the day it is noted. 3. Per interview on 12/17/25 at 1:30 PM with the Second floor LPN, confirmed that an out-of-service medication cart was missing a sharps container, a special puncture-proof container used for the safe disposal of needles, syringes, and other sharp medical items. In the designated location for the sharps container, there was a used butterfly needle, a device with a small needle attached to flexible wings, used for drawing blood or administering fluids. Additionally, she noted dust-like debris was present on the suspension wires for the partitions at the nurses' station and on the activity cart. During a 12/17/25 interview at 1:46 PM, the Unit Manager for the Second floor confirmed that an out-of-service medication cart contained a used needle and lancet that had not been disposed of in the required sharps container. 4. Per observation on 12/16/2025 at approximately 11:30 AM of the second-floor kitchenette, two ice packs were identified in the freezer. Each ice pack had a resident's first and last name written on them. Per interview on 12/16/2025 at 1:20 PM with the Licensed Practical Nurse (LPN) on the Second floor, they confirmed the two ice packs observed in the kitchenette refrigerator freezer are used for a resident who recently had surgery to address topical pain relief. The LPN confirmed the topical ice packs are specific to one resident and should not be stored in a refrigerator/freezer that is used for food storage. Per interview with the DON on 12/16/2025 at 1:24 PM, she stated they did not know where the ice packs came from or why they were in the freezer. S/he confirmed that the ice packs identified in the freezer should not be stored in a refrigerator/freezer where food is kept. 5. On 12/16/25 at 1:39 PM, wound care was observed for Resident #14. Resident #14's left hip surgical dressing did not have a date to indicate the day it was last changed. Resident #14 was observed to have a PICC line (Peripherally Inserted Central Catheter; a long term IV site) on his/her right arm. This dressing also did not have a date to indicate the day it was last changed. Per interview with the Licensed Practical Nurse performing the dressing change, she confirmed that Resident #14's surgical dressing and PICC line dressing were not labeled with dates and should be. Reference: Centers for Disease Control and Prevention (CDC). (2023, December 21). C. Air. https://www.cdc.gov/infection-control/hcp/environmental-control/air.html

Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment regarding construction debris and resident room equipment maintenance and repair on 1 of 4 units (Second Floor).Findings include:1. Per observation on 12/15/2025 at approximately 2:10 PM, a white/grey powder like substance was on the code cart, wound care/treatment cart, and the precaution supply carts. Per interview on 12/15/2025 at approximately 2:30 PM with the LPN on the Second floor, they confirmed the code cart, wound care cart, and precaution supply carts were dusty with white/grey powder and needed to be cleaned. Per interview with 12/15/2025 at 3:09 PM with the Director of Nursing (DON), she confirmed there was dust on the code cart, suction machine, precaution supply carts, and treatment cart containing construction dust and that they all needed to be cleaned. During observation of the Second floor on 12/17/25 at 9:41 AM, Hoyer lifts, a mechanical device used to lift and transfer residents with limited mobility safely, were observed with dust-like material that had a white powder look on the base of the equipment. Per interview on 12/17/2025 at 9:57 AM with the Infection Preventionist, Director of Nursing (DON), and the Regional Nurse Consultant, they confirmed the debris seen on the Second floor. During the observation of the Second floor on 12/17/25 at 11:28 AM, the Regional Nurse Consultant acknowledged that the Hoyer lifts required cleaning due to construction dust and reported that housekeeping was working on it. During an interview on 12/17/25 at 12:19 PM with the Assistant Administrator and the DON, the Assistant Administrator described the debris as construction particles and dust produced during sanding and wall preparation for wallpaper. During an interview on 12/17/25 at 1:40 PM with a maintenance person and the Second floor LPN, both confirmed that the kitchenette hood had a buildup of debris and had not been cleaned. According to the Centers for Disease Control and Prevention (2023, CDC) when the environment is disturbed such as by producing dust airborne infections can be released into the air which can cause healthcare associated infections. 2. Per observation on 12/15/2025 at 11:07 AM, a resident in room [ROOM NUMBER] had been discharged earlier that morning. The mattress was noted to have had a brown discoloration in the middle. The protective lining in the center of the mattress was a lighter blue than the rest of the mattress with the edges appearing chipped. There were two pillows observed with holes in the protective/plastic covering. Per interview on 12/15/2025 at 1:09 PM with a Licensed Practical Nurse (LPN) on the Second floor, s/he confirmed the mattress was compromised as noted above, and that there was a brown stain to the mattress where the top layer was worn, and that both pillows had holes in them. Per observation on 12/15/2025 at approximately 2:32 PM, room [ROOM NUMBER] appeared to have been cleaned and the bed containing the identified compromised mattress was noted to be made and ready for use. The bed linens were removed from one side of the mattress revealing the compromised mattress observed earlier in the day as noted above. The pillows noted above were on the bed with pillow cased in place. Per interview with a Housekeeping Staff who was finishing up in room [ROOM NUMBER], they confirmed the room had been terminally cleaned and the mattress/bed was ready for a new resident. The Housekeeping Staff was shown the mattress/bed and asked if the mattress was safe to use for a new resident and the Housekeeping Staff said she didn't know but it was re-made and ready for a new resident. Per interview on 12/15/2025 at 2:43 PM with the Administrator (ADM), she confirmed that the mattress was not appropriate for resident use in the above noted condition, it was compromised and could not properly be cleaned in that condition and needed to be thrown away. Per interview on 12/17/2025 at 8:11 AM with the Housekeeping Manager, he confirmed if a mattress cover is compromised it should be reported and removed from use and stated he was mortified by the condition of the mattress found in one of the resident rooms that was being terminally cleaned, thorough cleaning of a room after use in healthcare environments to control the spread of infections, and he wouldn't put a resident on a mattress I wouldn't sleep on myself. He confirmed that staff should contact the Administrator or Assistant Administrator for a replacement when equipment is worn out, damaged, or broken. Per interview on 12/17/2025 at 9:57 AM with the Infection Preventionist, Director of Nursing (DON), and the Regional Nurse Consultant, they confirmed that equipment that cannot be disinfected shouldn't remain in use for residents. When there are worn-out, damaged, or broken items, staff are expected to use TELS (the online platform for building maintenance) or contact the Assistant Administrator to request a replacement. Review of facility policy titled Care, Cleaning and Storage of Equipment, last reviewed 2/2025, states Equipment found to be in disrepair.should be reported to the supervisor on the day it is noted.

Based on interview and record review, the facility failed to ensure a resident who required dialysis received services consistent with professional standards of practice for one of two residents (Resident #106). Findings include:Facility policy titled Hemodialysis revised on 9/25, states The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility . ongoing assessment and oversight of the resident before, during and after dialysis treatments . Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Per review of the medical record for Resident #106, it revealed the resident has medical diagnosis that include end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, anemia in chronic kidney disease, pulmonary hypertension, generalized edema, chronic obstructive pulmonary disease, insomnia, and chronic diastolic heart failure. Per review of Resident #106's physician orders, the resident is scheduled for dialysis treatments on Tuesdays, Thursdays, and Saturdays. Per record review of Resident #106's Hemodialysis Communication Record, there are 23 dates where the communication log is not filled out completely by either the facility, the dialysis center, or both since 8/19/25. Per interview with a nurse on 12/17/25 at approximately 2:10 PM, she confirmed that the facility staff should be completing the before and after dialysis treatment assessments which include assessing for bruit, thrill, blood pressure, temperature, pulse, time of last meal, diet, and the patient's general condition and that this wasn't completed for 12/16/25. She also confirmed that the dialysis center should complete the middle section of the Hemodialysis Communication Record. Per interview on 12/17/25 at 2:27 PM, the Director of Nursing (DON) confirmed that the Hemodialysis Communication Record was not being filled out completely by the facility and by the dialysis center and that they should be filled out completely. The DON confirmed that the nursing staff should be assessing Resident #106's condition before they leave the facility, ensuring that the dialysis center completes their portion of the documentation on return to the facility, and that on Resident #106's return to the facility, nursing staff assesses their condition and documents that in the Hemodialysis Communication Record. The DON revealed the Unit Manager should be ensuring the Hemodialysis Communication Record is filled out by the facility, and dialysis center, and the dialysis center should be contacted when the documentation is incomplete.

Based on record review and interview the facility failed to put effective measures in place to ensure that further potential abuse does not occur while investigating an allegation of abuse for one of three sampled residents (Resident #73). Findings include:Per review of Resident #73's medical record, s/he had a BIMS [Brief Interview of Mental Status] score of 13 as of 9/26/25, indicating s/he is not cognitively impaired. S/he has medical diagnoses of COPD [Chronic Obstructive Pulmonary Disease], anxiety disorder, MDD [Major Depressive Disorder], and Wernicke's encephalopathy [a disease that is caused from a low level of thiamine]. Resident #73 is independent with ADLs [Activities of Daily Living] and hygiene.Per record review of a progress note written on 10/21/25 at 2:39 PM states, Resident is being monitor on accusation of abuse from staff. No interaction with accused staff noted in this shift. Resident is pleasant to work with today. No c/o [complaints of] of accusation from staff reported today. POC [plan of care] continued.Per record review, the alleged incident occurred on 10/20/25. The final investigation was submitted on 10/24/25.Per the facility's initial report dated 10/21/25 states, [Resident #73] says [s/he] was walking in the hallway on [his/her] unit late in the evening last night when [LNA#1] yelled at [him/her] and told [him/her] to go back to [his/her] room. When [Resident #73] told [LNA#1] no [Resident #73] says that [LNA#1] walked up behind [him/his] and made [him/her] fall onto [his/her] face in the hallway. [S/he] says [s/he] then walked into [his/her] room and [LNA#1] told [him/her] to go to bed. [Resident #73] got into bed and [LNA#1] told [him/her] to roll over. [Resident #73] told him no and [LNA#1] put his hands on the mattress and started bouncing [him/her] like a child [Resident #73] continues on to say that [LNA#2] does this as well. An interview was conducted with Resident #73 on 12/15/25 at 11:11 AM. Per Resident #73, LNA [Licensed Nursing Assistant] #1 stated, Get back to your room as the resident was in the hall. S/he stated the LNA pushed me because I wasn't go[ing] fast enough. Resident #73 stated s/he landed face down in the hallway. Resident #73 stated LNA#1 then grabbed him/her and started bouncing him/her off the bed. Resident #73 stated s/he kicked the staff member in the face. Resident #73 stated s/he has not seen the LNA lately, stating, I asked for that. He's not on this floor anyway.Per record review of the facility's internal investigation states, Both male caregivers have been moved to work on other units to prevent any further concerns. Per record review of the schedules during the investigation from 10/20/25 to 10/24/25, LNA#1 worked 10/20/25, 10/21/25, 10/23/25 and 10/24/25. LNA#2 worked on 10/21/25, 10/22/25, 10/23/25, and 10/24/25. Per record review of the facility's Abuse, Neglect, and Exploitation policy [last revised 9/2024] states, VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:.D .Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.An interview was conducted with the Administrator on 12/16/25 at 4:09 PM. The Administrator confirmed LNA#1 and LNA#2 were not removed from the facility during the investigation.

Based on interview, record review, and observation, the facility failed to safely store locked medications for 1 of 7 medication carts. Findings include: During observations on the second floor on 12/15/25 at 10:54 AM till 11:04 AM, the medication treatment cart was observed to be unlocked. There was one Resident walking up and down the hallway. Per interview with a nurse on 12/15/25 at 11:04 AM, she confirmed that the medication treatment cart should be locked and then locked the cart. Per review of the facility's Medication Storage policy reviewed 9/24, it states . All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).

Based on interview and record review, the facility failed to create and implement a baseline care plan for 2 of 3 sampled residents related to communication (Residents #1 and #2). Findings include:1. Per record review, Resident #1 was admitted to the facility on [DATE]. Per his/her MDS dated [DATE], his/her preferred language is not English, and s/he needs an interpreter to communicate with doctors and health care staff.Per phone interview on 9/23/25 at 2:05 PM, Resident #1's Representative explained that the facility was unable to get Resident # an interpreter so the facility made a communication board in English, which s/he could not understand. As a result, staff were not able to meet his/her needs. Once the staff gave Resident # pain medication when s/he was trying to let staff know s/he was cold.Per record review, Resident #1 did not have a baseline care plan for communication or interventions for interpreter services within 48 hours of admission. A care plan was created on 9/6/25, with a focus that Resident #1 has impaired communication r/t [related to] . speaks a language that the facility staff do not speak., 10 days after admission. There are no interventions for interpreter services.Per interview on 9/23/25 at 2:20 PM with a Licensed Nurse that worked with Resident #1, she explained that she was never able to directly communicate with the resident interpreter services in his/her language were not available.2. Per record review, Resident #2 was admitted to the facility on [DATE]. Per his/her MDS dated [DATE], his/her preferred language is not English, and s/he needs an interpreter to communicate with doctors and health care staff. Per record review, Resident #2 did not have a baseline care plan for communication or interventions for interpreter services within 48 hours of admission. As of 9/23/25, Resident #2 did not have a care plan related to communication or interventions for interpreter services.Per interview on 9/23/25 at approximately 4:00 PM, with the Administrator and Director of Nursing, they confirmed that residents should have a baseline care plan in place to meet their communication needs and were unable to provide evidence that Resident #1 or Resident #2 did.

Based on record review and interview, the facility failed to assure that 2 of 4 residents reviewed were free from physical abuse (Resident #1 and Resident #3). 1. Per record review, Resident #1 was the victim of a physical assault on 5/18/25 at 9:30 AM. A progress note dated 5/18/25 says, Resident noted to have verbal altercation with [Resident #2], resulting in [Resident #2] hitting resident on the side of the face. Per interview with Resident #1 on 5/20/25 at 11:43 AM, s/he reported that Resident #2 was touching his/her belongings and when s/he tried to get Resident #2 to stop, it resulted in him/her getting hit in the head by Resident #2. A review of the facilities policy titled Abuse, Neglect and Exploitation dated 4/2025 states Abuse means the willful infliction of injury .with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Per interview with the [NAME] President of Clinical Operations, the Administrator, and the Assistant Director of Nursing on 5/20/25 at 3:29 PM, they confirmed that this incident occurred between Resident #1 and Resident #2. 2. Per record review, Resident #3 was the victim of a physical assault on 5/16/25 at 10:29 AM from Resident #4. A progress note dated 5/16/25 says, Resident was standing in the doorway, and another resident came up to [him/her] and punched [him/her] in the left side of the chest. Skin assessment completed. No bruising noted. Per interview with the [NAME] President of Clinical Operations, the Administrator, and the Assistant Director of Nursing on 5/20/25 at 3:35 PM, they confirmed that this incident occurred between Resident #3 and Resident #4.

Based on interview and record review, the facility failed to ensure that an allegation of abuse was reported to the licensing agency for 1 of 5 sampled residents (Resident #5). Per record review, the facility was unable to provide evidence that they submitted a report to the state licensing agency after Resident #5 reported an allegation of abuse; being hit with a wet towel by a staff member. Additionally, there is no evidence of an investigation in Resident #5's medical record. Per interview with Resident #5's nurse on 5/20/25 at 11:54 AM, she reported that she sent a message using the electronic health record (EHR) reporting this incident on 4/29/25 and that Resident #5's hospice nurse also communicated with the Assistant Director of Nursing and the former Director of Nursing about this allegation of abuse. She reported that the Director of Nursing and Administration were aware of the allegation of abuse. A review of the facilities policy titled Abuse, Neglect and Exploitation dated 4/2025 states that an Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visor or others but has not yet been investigated and, if verified, could be indication of noncompliance. Additionally, the section titled Policy Explanation and Compliance Guidelines marked number 2 states The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law and that an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The section of this policy titled Reporting/Response states The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies . within specified timeframes . Per interview with the [NAME] President of Clinical Operations, the Assistant Director of Nursing, and the Administrator on 5/20/25 at 3:49 PM, they reported that the hospice nurse informed them of the allegation of abuse, but they didn't report the allegation to the state because they didn't believe abuse had occurred based on Resident #5 having hallucinations.

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.71 regarding 13 residents [Res.#44, #145, #88, #73, #8, #1, #70, #87, #90, #295, #89, #21 and #6] of 44 sampled residents. Findings include: 1). Per record review, Res.#44 was admitted to the facility with diagnoses that included Right leg below knee amputation, anxiety disorder, and major depressive disorder. Res.#44's Care Plan identifies the resident as at risk for decreased ability to perform Activities of Daily Living [ADLs] requiring extensive assist of 2 with sit to stand for transfers. Per interview with Res.#44 on 12/02/24 at 12:01 PM, the resident reported s/he is unable to transfer out of bed into a wheelchair or onto a bedside commode without the assistance of 2 staff members for safety. The resident stated that unless s/he is transferred out of bed, s/he is unable to attend the group activities which are located on a different floor in the facility. Further review of Res.#44's Care Plan reveals the resident states that it is important that he has the opportunity to engage in daily routines that are meaningful relative to [h/her] preferences including I like to participate in bingo and music with groups of people. The Care Plan also identifies the resident as at risk for distressed/fluctuating mood symptoms related to: anxiety & depression, with interventions that include participation in activity preferences, Provide [Res.#44] with opportunities for choice during care/activities to provide a sense of control and Encourage [Res.#44] to attend activities that maximize [h/her] full potential while meeting [h/her]need to socialize. Review of Res.#44's quarterly Recreation Evaluation dated 10/4/24 identifies the resident has the following needs for special adaptation in order to participate in desired engagement opportunities: use of adaptive equipment- electric wheelchair for physical limitations. Per interview with Res.#44 on 12/02/24 at 12:01 PM, the resident stated, I miss activities because staff don't get here to get me out of bed in time. Sometimes my lunch doesn't get delivered until 2:00 o'clock, and Bingo is at 2:00. I have to choose: do I go [to activities] or do I eat? Sometimes they save me my lunch, other times I come back to my room and there is nothing there. An observation and interview were conducted with Res.#44 on 12/4/24 at 10:46 AM. Per observation, 2 staff were in the room with the resident, with the resident being transferred out of bed at 10:45 AM. The resident reported that staff transferring h/her out of bed happens a lot of times later than it is now. Per review of the facility's Activities Calendar for December 2024, Bingo is offered as an activity at 2:00 PM on Wednesdays and 10:30 AM on Saturdays. 2). Per record review, Res.#145 was admitted to the facility with diagnoses that included a fracture of the right tibia and fibula [The lower leg is made up of two bones: the tibia and fibula. The tibia is the larger of the two bones]. Res.#145's Care Plan identified the resident as exhibits or is at risk for alterations in comfort related to fracture of right tibia, fibula. An interview was conducted with Res.#145 and a friend visiting the resident on 12/03/24 at 2:25 PM. The resident's friend stated s/he was present on 12/2/24 at approx. 4:00 PM when the resident requested a muscle relaxant medication from nursing staff and stated that the resident had not received it when the friend left at 5:00 PM. An observation and interview were conducted with Res.#145 at 5:49 PM on 12/2/24, shortly after the friend had left. Res.#145 was observed yelling in h/her room stating that s/he had been waiting 2 1/2 hours for the muscle relaxant medication. Per interview, the resident stated that s/he had yet to receive the medication s/he had requested at 4:00 PM. A follow up interview on 12/3/24 with the resident revealed the resident reported s/he received the muscle relaxant medication at approximately 6:00 PM on 12/2/24, approximately 2 hours after requesting it. An interview was conducted with the Unit Manager [UM] of Res.#145's unit on 12/03/24 at 2:35 PM. The UM confirmed a wait time of approx. 2 hours for medication to relieve a resident's discomfort was too long. The UM stated staffing level was enough but could not explain why with enough staffing a resident would have to wait 2 hours for a medication. 40258 3. During Resident interviews conducted throughout the initial survey screening process, Residents #88, #73, #8, #1, #18, #70, #87, #90, #145, #295, #89, #309, and Resident #6's family member expressed concerns related to insufficient staffing leading to long wait times for care, and excessive call light times up to 45 minutes. Review of the facility call bell history for 11/26/24 - 12/3/2024 revealed call wait times for the above Residents and multiple other Residents on all open units up to an excess of 7 hours and 46 minutes making this a wide spread concern. Extended wait times of over 30 minutes after a call light was activated by the specific Residents in the sample are as follows: 11/26/24: room [ROOM NUMBER](Resident #89) activated at 6:29 PM - 111 minutes room [ROOM NUMBER] (Resident #70) activated at 8:05 PM - 62 minutes 11/27/2024: room [ROOM NUMBER] (Resident #70) activated at 5:32 AM - 68 minutes room [ROOM NUMBER] (Resident #88) activated at 5:32 AM - 69 minutes room [ROOM NUMBER] W (Resident #18) activated at 8:12 AM - 75 minutes room [ROOM NUMBER] (Resident #70) activated at 12:33 PM - 44 minutes room [ROOM NUMBER](Resident #295) activated at 12:54 PM - 36 minutes room [ROOM NUMBER] (Resident #70) activated at 2:15 PM - 43 minutes room [ROOM NUMBER] (Resident #8) activated at 3:45 PM - 41 minutes room [ROOM NUMBER] (Resident # 73) activated at 7:13 PM - 81 minutes room [ROOM NUMBER] (Resident #145) activated at 9:32 PM - 38 minutes 11/28/24: room [ROOM NUMBER] (Resident #89) activated at 4:15 AM - 90 minutes room [ROOM NUMBER] (Resident #70) activated at 5:07 AM - 94 minutes room [ROOM NUMBER] (Resident #88) activated at 9:34 AM - 42 minutes room [ROOM NUMBER](Resident #18) activated at 10:12 AM - 56 minutes room [ROOM NUMBER] (Resident #70) activated at 1:06 PM - 40 minutes room [ROOM NUMBER] (Resident #18) activated at 3:13 PM - 40 minutes room [ROOM NUMBER] (Resident #89) activated at 4:41 PM - 55 minutes room [ROOM NUMBER] (Resident #3) activated at 7:24 PM - 45 minutes room [ROOM NUMBER] (Resident #145) activated at 8:24 PM - 49 minutes 11/29/24: room [ROOM NUMBER] (Resident #70) activated at 5:23 AM - 56 minutes room [ROOM NUMBER] (Resident #5) activated at 6:58 AM - 48 minutes room [ROOM NUMBER] (Resident #44) activated at 9:01 AM - 316 minutes room [ROOM NUMBER] (Resident #70) activated at 9:02 AM - 44 minutes room [ROOM NUMBER] (Resident #89) activated at 12:26 PM - 51 minutes room [ROOM NUMBER] (Resident #77) activated at 1:48 PM - 47 minutes room [ROOM NUMBER] (Resident # 89) activated at 6:07 PM -103 minutes room [ROOM NUMBER] (Resident # 89) activated at 7:50 PM - 131 minutes 11/30/24: room [ROOM NUMBER] (Resident #89) activated at 6:05 AM - 149 minutes room [ROOM NUMBER] (Resident #89) activated at 8:36 AM - 466 minutes room [ROOM NUMBER] (Resident #18) activated at 8:56 AM - 52 minutes room [ROOM NUMBER] (Resident #44) activated at 10:26 AM - 37 minutes room [ROOM NUMBER] (Resident #73) activated at 10:49 AM - 36 minutes room [ROOM NUMBER] (Resident #8) activated at 12:22 PM - 42 minutes room [ROOM NUMBER] (Resident #44) activated at 12:25 PM - 66 minutes room [ROOM NUMBER] (Resident #89) activated at 12:42 PM - 106 minutes room [ROOM NUMBER] (Resident #88) activated at 1:25 PM - 42 minutes room [ROOM NUMBER] (Resident #18) activated at 1:31 PM - 44 minutes room [ROOM NUMBER] (Resident #70) activated at 3:33 PM - 73 minutes room [ROOM NUMBER] (Resident #44) activated at 6:08 PM - 44 minutes room [ROOM NUMBER] (Resident #70) activated at 6:35 PM - 42 minutes room [ROOM NUMBER] (Resident #89) activated at 6:35 PM - 83 minutes room [ROOM NUMBER] (Resident #77) activated at 7:33 PM - 58 minutes room [ROOM NUMBER] (Resident #37) activated at 8:14 PM - 41 minutes 12/1/24: room [ROOM NUMBER] (Resident #18) activated at 4:51 AM - 48 minutes room [ROOM NUMBER] (Resident #70) activated at 6:41 AM - 52 minutes room [ROOM NUMBER] (Resident #88) activated at 6:58 AM - 41 minutes room [ROOM NUMBER](Resident #18) activated at 7:32 AM - 45 minutes room [ROOM NUMBER] (Resident #5) activated at 8:17 AM - 43 minutes room [ROOM NUMBER] (Resident #44) activated at 9:21 AM - 69 minutes room [ROOM NUMBER] (Resident #70) activated at 10:28 AM - 42 minutes room [ROOM NUMBER] (Resident #70) activated at 12:47 PM - 44 minutes room [ROOM NUMBER] (Resident #70) activated at 1:55 PM - 70 minutes room [ROOM NUMBER] (Resident #18) activated at 2:35 PM - 77 minutes room [ROOM NUMBER] (Resident #88) activated at 5:49 PM - 90 minutes room [ROOM NUMBER] (Resident #88) activated at 7:25 PM - 56 minutes 12/2/24: room [ROOM NUMBER] (Resident #89) activated at 6:10 AM - 41 minutes room [ROOM NUMBER] (Resident #3) activated at 6:35 AM - 66 minutes room [ROOM NUMBER] (Resident #89) activated at 12:44 PM - 41 minutes room [ROOM NUMBER] (Resident #8) activated at 2:29 PM - 126 minutes 12/3/24: room [ROOM NUMBER] (Resident #44) activated at 10:02 AM - 38 minutes room [ROOM NUMBER] (Resident #89) activated at 12:47 PM - 35 minutes Review of the facility policy titled NSG101 Call Lights states: Policy All Genesis HealthCare patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. Purpose To ensure safety and communication between staff and patients. During an interview on 12/4/24 2:00 PM the Market Clinical Advisor confirmed that the call light log reflected excessively long wait times. 46135 4. Per record review, Resident #18's care plan reads, [Resident #18] has an ADL Self Care Performance Deficit [related to] Activity Intolerance/weakness, Spondylopathy Lumbar [degeneration of the vertebrae and disks of the lower back], Morbid Obesity and Intervertebral Disc Degeneration Lumbar [condition that occurs when discs in lower back break down causing pain and stiffness], revised on 7/18/23, with interventions that include staff assistance for transferring and toileting. On 11/27/24, the residents was assessed as having a BIMS of 14, indicating the resident is cognitively intact. Per interview on 12/3/24 at 9:29 AM, Resident #18 explained that when s/he uses the commode, s/he sometimes has to wait an hour or longer to have a staff help him/her off the commode if it is during meals. Staff report to him/her that s/he will have to wait until after meals are served because it is unsanitary to provide care while passing meal trays. S/he explained that this makes him/her upset because it begins to hurt when s/he sits for so long, and s/he also has to look at his/her food that was delivered get cold. S/He explained that it happens often enough for it to be a problem. Review of the facility call bell history for 11/26/24 - 12/3/2024 revealed the following excessive wait times after the call light was activated in Resident #18's room: 11/27/24 - wait times of 75 minutes, 81 minutes, and 25 minutes. 11/28/24 - wait times of 36 minutes 56 minutes, and 25 minutes. 11/29/24 - wait times of 40 minutes and 32 minutes. 11/30/24 - wait times of 38 minutes and 36 minutes. 12/1/24 - wait times of 48 minutes, 45 minutes, 25 minutes, and 77 minutes. 12/2/24 - wait time of 97 minutes. 5. Per record review, Resident #73's care plan reads, [Resident #73] has an ADL Self Care Performance Deficit r/t [related to] Spinal Stenosis [condition putting pressure on spinal cord and nerves], C5-6 Myelopathy [compression of spinal cord], last revised on 4/10/23, and includes interventions revealing s/he requires assistance of 2 staff for transferring and toileting. Resident #73's care plan also states they are sometimes incontinent of bladder and bowel and has an intervention to encourage [Resident #73] to toilet upon awakening, after meals, nightly, and PRN [as needed], revised on 4/10/23. Resident #73 has a BIMS score of 13 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness) dated 11/5/24. Per interview with Resident #73 and Resident #73's family member on 12/3/124 at 2:30 PM, Resident #73 stated that s/he is not being assisted with toileting as frequently as s/he needs. I ring the bell and sometimes it takes a very long time to get someone to help me. When asked to clarify what a long time is, Resident #73 stated sometimes an hour or more. Resident #73 stated that many times when they call for help toileting, help does not arrive until long after they have soiled themselves causing them distress. Resident #73 also stated that if they could get the help they need in a timely manner, they would not have so many episodes of incontinence. Resident #73's family member stated that they visit Resident #73 almost daily and confirmed that they have witnessed wait times of 1-2 hours for Resident #73's call bell to be answered. Record review of facility call bell wait times for Resident #73 from 11/27/24-12/2/24, there are wait times including 81 minutes on 11/27/24, 36 minutes on 11/30/24 and 97 minutes on 12/2/24. 6. Per record review, Resident #21 has a diagnosis of Parkinson's disease. Resident #21 has physician orders for the following Parkinson's medications: Carbidopa-Levodopa Oral Tablet 25-100 milligram (mg), to be given at 6:00 AM, 9:00 AM, 12:00 PM, 3:00 PM, 6:00 PM, and 9:00 PM daily; Carbidopa-Levodopa ER ,d+[DATE] mg Tablet extended release, to be given at 6:00 AM, 9:00 AM, 12:00 PM, 3:00 PM, 6:00 PM, and 9:00 PM daily; and Entacapone Oral Tablet 200 mg, to be given at 6:00 AM, 9:00 AM, 12:00 PM, 3:00 PM, and 6:00 PM daily. Per interview on 12/2/24 at 2:16 PM, Resident #21 explained that s/he is frustrated because s/he often does not get his/her Parkinson's medications when they are scheduled. S/He stated that it is important for him/her to get them when they are scheduled because the medication wears off and s/he starts to have more symptoms including tremors and difficulty speaking, which makes it difficult to do things. Per review of Resident #21's Medication Administration Audit Report from 11/1/24 through 12/4/24, Resident #21 had 8 of their Parkinson's medications administered an hour or more before or after the physician order scheduled time on the following dates: 11/15/24 (Carbidopa-Levodopa Oral Tablet 25-100 mg and Carbidopa-Levodopa ER ,d+[DATE] mg Tablet extended release), 11/18/24 (Carbidopa-Levodopa Oral Tablet 25-100 mg, Carbidopa-Levodopa ER ,d+[DATE] mg Tablet extended release, and Entacapone Oral Tablet 200 mg), and 11/25/24 (Carbidopa-Levodopa Oral Tablet 25-100 mg, Carbidopa-Levodopa ER ,d+[DATE] mg Tablet extended release, and Entacapone Oral Tablet 200 mg). 7. Per interview on 12/2/24 at 11:46 AM, Resident #90 stated that s/he is upset that his/her Parkinson's medications are not always on time. S/He explained that it is important to have his/her medications on time so his/her symptoms do not get worse. Per record review, Resident #90 has a diagnosis of Parkinson's disease. Resident #90 has physician orders for the following Parkinson's medications: Carbidopa-Levodopa ER ,d+[DATE] mg Tablet extended release, to be given at 8:00 AM and 8:00 PM. Resident had a physician order for Carbidopa-Levodopa Oral Tablet 25-250 mg, to be given at 4:00 AM, 8:00 AM, 1:00 PM, 6:00 PM, and 11:00 PM, which ended 11/8/24. Per review of Resident #90's Medication Administration Audit Report from 11/1/24 through 12/4/24, Resident #90 had 7 of their Parkinson's medications administered an hour or more before or after the physician order scheduled time on the following dates: 11/1/24 (Carbidopa-Levodopa Oral Tablet 25-250 mg), three times on 11/2/24 (Carbidopa-Levodopa Oral Tablet 25-250 mg), 11/3/24 (Carbidopa-Levodopa Oral Tablet 25-250 mg), 11/6/24 (Carbidopa-Levodopa Oral Tablet 25-250 mg), and 11/15/24 (Carbidopa-Levodopa ER ,d+[DATE] mg Tablet extended release). Facility policy titled Medication Administration and Documentation- General Policy #PHNE69, which is not dated, reads, Medication Administration and Documentation occurs in a timely and accurate manner. 2. Medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time. Per interview on 12/4/24 at 9:00 AM, the Unit Manager explained that Parkinson's medications should be administered as close to the administration time as possible.

Based on interview and record review, the facility failed to treat and care for each resident in a manner that maintains their dignity and respect for 8 out of 29 Residents in the sample (Residents #3, #88, #19, #1, #81, #17, #39, and #8) Findings include: Per interview with Resident #88 on 12/3/24 at approximately 10:05 AM, they stated that when they ring their call bell for assistance it takes over an hour most often before someone responds, and by then they have either wet or soiled themselves. Resident #88 stated it is very upsetting when this happens. Review of Resident #88's call bell log for the week of 11/26/24 - 12/2/24 revealed 16 times when the resident rang their call bell and the response time was 20 minutes or more. Of those calls, there were 8 times when the call bell was not responded to for greater than 30 minutes, and 3 times when the response time was greater than 1 hour. Review of Resident #88's current care plan, revealed they have an incontinence care plan that states the following: .is incontinent of urine at times and is unable to physically participate in a retraining program . The goal listed in this care plan is as follows: .will have incontinence care needs met by staff to maintain dignity and comfort and to prevent incontinence related complications. This care plan was last revised on 11/22/2024. Review of Resident #88's ADL (Activities of Daily Living) flow sheets for 11/26/24 - 12/2/24 revealed the resident was incontinent on all these days. 50336 2. Per observation on 12/2/2024 at 1:00 PM, Resident #3 was at his/her door with the call light on. The Licensed Nursing Assistant (LNA ) answered the call light, and Resident #3 requested to use the bathroom. The LNA told Resident #3 in front of this surveyor that s/he could not take him/her to the bathroom and that his/her LNA was on break and would take the resident to the bathroom when s/he returned. Per further observation at 1:30 PM, Resident #3 remained sitting at the door in his/her wheelchair waiting to use the bathroom. Resident #3 put his/her call light on and requested the LNA take him or her to the bathroom. The same LNA approached the resident and told him/her that s/he would need to wait until his/her LNA returned. Resident #3 began yelling out that s/he needed to use the bathroom, across the common area of the unit with other residents present. The Unit Manager responded to the room, approached the LNA and directed him/her to bring Resident #3 to the bathroom. Per record review of Resident #3's care plan dated 3/7/2024, s/he has stress incontinence (incontinence is the loss of bladder control resulting in loss of urine). The following interventions were implemented on 3/7/2024 -Resident to use toilet upon awakening, after meals, nightly and as needed - respond promptly to the resident's request to use the toilet. Per Interview on 12/2/2024 at 1:45 PM with the Unit Manager, s/he confirmed that the LNA was responsible for the resident's care while the assigned LNA was on break and should have provided care to Resident #3 as requested by the resident. 46135 3. A Resident Council meeting with the survey team occurred on 12/4/24 at 10:27 AM, and there were six attendees, Residents #19, #1, #81, #17, #39, and #8. Per record review, Resident #19's has a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness) dated 11/12/24, Resident #1 has a BIMS of 14 (indicating cognitive intactness) dated 11/9/24, Resident # 81 has a BIMS of 15 dated 11/13/24, Resident #17 has a BIMS of 15 dated 10/8/24, Resident #39 has a BIMS of 15 dated 10/24/24, and Resident #8 has a BIMS of 15 dated 10/4/24. A collaborative conversation involving all six residents revealed that they do not feel that they are treated with dignity and respect by all staff. Resident #1 stated that a lot of staff don't treat him/her like s/he is in his/her own home. Not all staff treat him/her with dignity. Foe example, not all staff knock on his/her door before coming in and a lot of staff give him/her an attitude. There are some staff that do all his/her personal care, even though s/he is able to wash up parts of his/her own body. S/He explained that s/he likes to wash the front of him/herself up and they won't let her which makes him/her upset because it would be faster and s/he would feel better to be able to participate in his/her own care. S/He has had aides yell at him/her and tell him/her to shut up. Sometimes staff won't put his/her call bell within reach and s/he ends up having to yell for help. S/He stated that s/he should be treated with dignity and respect in his/her own house but it doesn't feel like his/her home. Resident #17 explained that she was told by the LNA that they would not help him/her to bed because she could do it herself. S/he stated that s/he can see some staff pass his/her room when s/he has his/her call bell on and don't stop and if they do, they say they will be right back but end up coming back much later or with an attitude. Resident #8 stated that staff often rush his/her care. S/he explained that sometimes staff tell him/her s/he has to take a shower before dinner but that is not his/her preference; s/he would like to take a shower after dinner. They don't listen to him/her and staff have screamed at him/her for taking too long in the shower. Resident #19 said that staff never ask him/her what they need and don't help him/her at times and tell him/her it is because s/he is independent. All six residents individually confirmed that they did not believe that all staff treated them with dignity and respect and this sentiment was brought up multiple times during the conversation.

Per interview and facility policy review, the facility failed to establish a grievance reporting system that supports the resident's right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal for 6 of 29 sampled residents (Residents # 1, #19, #1, #81, #17, #39, and #8). Findings include: Facility policy titled, OPS204 Grievance/Concern, last revised on 10/15/24, reads, The patient/resident (hereinafter patient) has the right to voice grievances to the Center or any other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. A Resident Council meeting with the survey team occurred on 12/4/24 at 10:27 AM, and there were six attendees, Residents #19, #1, #81, #17, #39, and #8. Per record review, Resident #19's has a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness) dated 11/12/24, Resident #1 has a BIMS of 14 (indicating cognitive intactness) dated 11/9/24, Resident # 81 has a BIMS of 15 dated 11/13/24, Resident #17 has a BIMS of 15 dated 10/8/24, Resident #39 has a BIMS of 15 dated 10/24/24, and Resident #8 has a BIMS of 15 dated 10/4/24. A collaborative conversation involving all six residents revealed that they do not feel that they are treated with dignity and respect by all staff. See F550 for more information. They relayed that they all know how to file a grievance and the process is successful for issues like missing personal property. However, when asked if they have reported their concerns about not being treated with dignity or respect to the facility, all six residents explained that they did not feel comfortable reporting how they are treated to anyone because they are afraid of repercussions. Resident #81 reported that if residents report rude, disrespectful, or rough behavior from the staff, they will get yelled at or ignored. All six residents individually confirmed that this was true for them and this sentiment was brought up multiple times during the conversation.

Based on interview and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) without assistance receives the proper level of assistance for 3 of 29 sampled residents (Residents #18, #145, and #73) related to transferring and toileting. Findings include: 1. Per record review, Res.#145 was admitted to the facility with diagnoses that included a fracture of the right tibia and fibula [The lower leg is made up of two bones: the tibia and fibula. The tibia is the larger of the two bones]. Res.#145's Care Plan identified the resident as requires assistance/is dependent for ADL [Activities of Daily Living] care in personal transfer, toileting with interventions that include Provide with assist of one using the bedside commode with walker and gait belt for toileting. An interview was conducted with Res.#145 on 12/2/24 at 5:49 PM. The resident stated that I have been left sitting on the bedpan for 45 minutes, balling my [expletive] eyes out. The resident reported that due to h/her fracture, she needed assistance with toileting, and despite using the call bell and staff having placed h/her on the bedpan in the first place, s/he was left on the bedpan for an extended period of time which was painful. 46135 2. Per record review, Resident #18's care plan reads, [Resident #18] has an ADL Self Care Performance Deficit [related to] Activity Intolerance/weakness, Spondylopathy Lumbar [degeneration of the vertebrae and disks of the lower back], Morbid Obesity and Intervertebral Disc Degeneration Lumbar [condition that occurs when discs in lower back break down causing pain and stiffness], revised on 7/18/23, with interventions that include staff assistance for transferring and toileting. Resident #18 has a BIMS of 14 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness) dated 11/27/24. Per interview on 12/3/24 at 9:29 AM, Resident #18 explained that when s/he uses the commode, s/he sometimes has to wait an hour or longer to have a staff help him/her off the commode if it is during meals. Staff report to him/her that s/he will have to wait until after meals are served because it is unsanitary to provide care while passing meal trays, S/he explained that this makes him/her upset because it begins to hurt when s/he sits for so long, and s/he also has to look at his/her food that was delivered get cold. S/He explained that it happens often enough for it to be a problem. Per interview on 12/4/24 at approximately 11:00 AM, a Licensed Nursing Assistant explained that s/he does not provide patient care, like toileting, while s/he is passing meal trays because it is unsanitary. 51586 3. Per record review, Resident #73's care plan reads, [Resident #73] has an ADL Self Care Performance Deficit r/t [related to] Spinal Stenosis [condition putting pressure on spinal cord and nerves], C5-6 Myelopathy [compression of spinal cord], last revised on 4/10/23, and includes interventions revealing s/he requires assistance of 2 staff for transferring and toileting. Resident #73's care plan also states they are sometimes incontinent of bladder and bowel and has an intervention to encourage [Resident #73] to toilet upon awakening, after meals, nightly, and PRN [as needed], revised on 4/10/23. Resident #73 has a BIMS score of 13 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness) dated 11/5/24. Per interview with Resident #73 and Resident #73's family member on 12/3/24 at 2:30 PM, Resident #73 stated that s/he is not being assisted with toileting as frequently as s/he needs. I ring the bell and sometimes it takes a very long time to get someone to help me. When asked to clarify what a long time is, Resident #73 stated sometimes an hour or more. Resident #73 stated that many times when they call for help toileting, help does not arrive until long after they have soiled themselves, causing them distress. Resident #73 also stated that if they could get the help they need in a timely manner, they would not have so many episodes of incontinence. Resident #73's family member stated that they visit Resident #73 almost daily and confirmed that they have witnessed wait times of 1-2 hours for Resident #73's call bell to be answered.

Based on observation, interview, and record review, the facility failed to provide activities that support the physical, mental, and psychosocial well-being of each resident for 1 of 29 sampled residents (Resident #29). Findings include: Per record review, Resident #21 has a diagnosis of Parkinson's disease. Per a 10/5/24 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool), Resident #21 has a BIMS of 14 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness) and expressed for activity preferences that it is very important for him/her to do his/her favorite activities and go outside. Resident #21's care plan reads, While in the facility, [Resident #21] states that it is important that [s/he] has the opportunity to engage in daily routines that are meaningful relative to [his/her] preferences, created 10/3/23, and an intervention reads, It is important for me to go outside when the weather is good, staff, family and friends to assist outdoors weather permitting. I have my rock collection on the patio, revised on 1/3/24. Per interview on 12/2/24 at 2:16 PM, Resident #21 stated that s/he wants to go outside every day and the staff won't let him/her go out every day because there are not enough staff and s/he needs to be supervised when s/he goes outside. S/He explained that staff also tell him/her that it is too cold to go outside. Resident #21 explained that it is very important to him/her to go outside as much as possible and said that if s/he's going to be stuck here s/he wants to enjoy his/her time and go out into nature because it is very important. Resident #21 was not observed outside at any time during the recertification survey on 12/2/24 through 12/4/24. Activity logs dated 11/1/24 through 12/3/24 reveal that Resident #21 spent time outdoors on just 11/1/24; only once in 33 days. An 8/30/24 Advanced Practice Registered Nurse note reads, The patient says, 'I feel like I'm trapped in prison'. 'I can't get anyone to bring me outside'. Per interview on 12/4/24 at 3:14 PM an Activity Aide explained that s/he was aware of how important it is for Resident #21 to go outside as much as possible but is not sure there are enough staff to make that happen. S/He stated that Resident #21 should be able to go outside when s/he wants to but doesn't think there is anything in place to ensure that it happens.

Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one applicable resident (Resident #1) by neglecting to provide services that are necessary to avoid physical harm and emotional distress related to providing care to a port (port-a-cath; a device, typically implanted in the chest, used to access the central vein to deliver medications or obtain blood samples) for 1 applicable resident (Resident #1). As a result, Resident #1's port became infected and had to be removed which delayed Resident #1's chemotherapy. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] and has diagnoses that include ovarian cancer, congestive heart failure, and depression. A 4/3/24 facility nurse Practitioner note indicates that Resident #1 was admitted for sub-acute rehabilitation from the hospital following 3 rounds of chemotherapy and surgery to remove her uterus, ovaries, and tumors related to ovarian cancer. The note indicates that she will need additional rounds of chemotherapy in the future. A 4/29/24 hospital oncology physician visit note reveals that Resident #1's treatment plan is to receive her fourth dose of chemotherapy on 5/10/24. Per phone interview on 5/29/24 at 10:35 AM, Resident #1's Representative explained that when Resident #1 went to their appointment on 5/10/24 to receive their fourth round of chemotherapy, the staff identified that her port was infected. Resident #1 had their port removed, was admitted to the hospital and was unable to receive their fourth round of chemotherapy. The Representative explained that s/he was there at the chemotherapy appointment and stated the staff removed a blue .moldy or fungus looking bandage and described the site as red and inflamed and described the port site as black. The Representative stated that Resident #1 is still in the hospital, has not had her port replaced, and has not been able to receive her fourth dose of chemotherapy which has made her upset and very anxious. A hospital outpatient chemotherapy Registered Nurse note dated 5/10/24 states that I went to remove the gauze and Tegaderm [adhesive dressing which can be used for up to seven days] over the patient's port site and I found the gauze to be dried [with a] blackish colored substance. Her port site itself appeared ecchymotic [discolored skin resulting from ruptured blood vessels], tender, swollen and a black scab was present. [Patient] reports that it has 'itched.' She denies any fevers. Her [white blood count] is elevated. She is unsure if this dressing has ever been changed to the site assessed since her admission to Rehab [facility]. Plan to hold chemo today, have [radiology] assess the port site and admit patient for observation and antibiotics and likely port removal. Patient is upset/anxious but able to reassure patient. Included in the above notes are two photos of Resident #1's port site. The first photo reveals Resident #1's port site which appears to be approximately 1.5 cm x 1.5 cm, raised, and very red with a pinhole open black spot. The second photo shows the gauze that was removed from the port site being approximately 2.5 cm x 2.5 cm and covered in a black-ish substance. A hospital physician history and physical note dated 5/10/24 explains that Resident #1's chemotherapy was deferred today and she reports feeling like her whole body is achy, and say the port has been tender for 'awhile.' Physical exam findings reveal the chest is erythematous port site with pinhole at 6 o'clock. No active drainage, mildly tender to palpation. A hospital Physician progress note dated 5/14/24 reveals that [Resident #1] presents as a direct admit from the chemotherapy infusion suite, where she was found to have an infected port prior to her fourth cycle of chemotherapy. Infected port removed, now [status post] vancomycin (5/10-5/13) [antibiotic]. Decided to hold on port replacement yesterday given patient's fragility and pending chemotherapy break. Per phone interview on 5/29/24 at 11:01 AM, the hospital outpatient chemotherapy Registered Nurse (HRN #1), who wrote the above note, confirmed that the above nursing note was accurate. Per phone interview on 5/29/24 at 4:38 PM, a second hospital outpatient chemotherapy Registered Nurse (HRN #2) explained that on 5/10/24 Resident #1's port appeared to be infected. HRN #2 reviewed Resident #1's hospital medical record and confirmed that the port was not accessed at the hospital, including the two outpatient visits she had on 4/11/24 and 4/29/24, since 4/3/24. HRN #2 explained that the dressing that Resident #1 had covering her port was not intended to be on for an extended period of time. S/He explained that since Resident #1's port was over 2 weeks old when she arrived at the nursing facility on 4/3/24, the expectation would be for the dressing to be removed on admission to the facility so the port could be assessed and not cover the port again. S/He explained that the expectation of the facility would be to monitor the port site regularly without a dressing to notice any potential complications. Per interview on 5/28/24 at approximately 9:10 AM, the Director of Nursing (DON) explained that the hospital contacted the facility on 5/10/24 to let them know Resident #1 would not be returning to the facility because she was being admitted to the hospital. The DON explained that the facility initiated an investigation and discovered that Resident #1 had an infected port. There is no evidence that Resident #1's port was identified on admission to the facility on [DATE]. While the Transfer of Care (hospital discharge summary) dated 4/3/24 does not reveal that Resident #1 has a port or any physician orders to care for Resident #1's port, the facility did not identify the port on the admission nursing assessment. Per the initial admission nursing assessment completed on 4/3/24, Resident #1's port is not identified, including the section that assesses for a port, device/treatment, and skin status, Integumentary. Per interview on 5/28/24 at 8:55 AM, a Unit Manger explained that on admission, a floor nurse will do the initial nursing assessment using an admission checklist. The facility tries to get the wound nurse to do the skin assessment with the floor nurse to identify any possible skin issues, including those that are not on the transfer of care document. The admission check list provided to this surveyor by the Unit Manager shows a section for IVs, PICC lines, and ports (devices inserted into the body used to deliver medications) with a checklist to obtain batch provider orders (dressing change, measurements, etc.) and a care plan. Per interview on 5/28/24 at 8:50 AM, Licensed Practical Nurse (LPN) #4 explained that if a resident had a port, nursing staff would need physician orders to remove or change a dressing, provide port care, and would also have an order to monitor the port site. A review of the facility investigation reveals the following transcripts of interviews conducted by facility leadership with staff. On 5/13/24 at 2:30 PM, the Licensed Practical Nurse (LPN #1) who documented and signed as preforming Resident #1 admission nursing assessment, including a comprehensive skin check, explained that s/he did not see the dressing on Resident #1's chest on admission because the only contact s/he had with Resident #1 was to give her medications and RN #1 did the skin assessment. LPN #1 states that s/he does recall Resident #1 having a dressing on her chest, but not until 5/7/24. On 5/14/24 at 4:15 PM, Registered Nurse (RN #1) who is the facility's lead skin nurse explains that s/he does not remember seeing gauze dressing or a port when s/he assessed Resident #1 on admission. Because the port was not identified on admission, Resident #1 did not receive physician orders to care for the port, including orders for dressing changes, and a care plan focus related to risk of infection related to a port, with interventions that include monitoring the port. After admission, there is no evidence that direct care staff provided Resident #1's services to prevent complications of her port at any time between 4/3/24 and 5/10/24. The staff neglected to complete comprehensive skin assessments, document the port, obtain care orders for the port, develop a plan of care for the port, provide care to the port, and monitor the port site for complications. Per review of weekly skin assessments completed by RN #2 on 4/17/24 and 5/1/24 and review of all Resident #1's nursing notes, there is no evidence that RN #2 was aware of Resident #1's port. Per a transcript of an interview conducted by facility leadership with RN #2 on 5/13/24 at 3:52 PM, RN #2 explained that s/he did not know Resident #1 had a port because s/he did not look at Resident #1's entire skin during skin assessments. Per interview on 5/28/2024 at 11:43 AM, RN #2 explained Resident #1's port should have been discovered and documented during weekly skin assessments and confirmed that skin assessments are to be a head to toe inspection of a resident's body. The following transcripts of interviews conducted by facility leadership with staff reveal that multiple licensed nurses were aware that Resident #1 did have a port. On 5/13/24 at 2:20 PM, LPN #4, who completed Resident #1's skin checks on 4/10/24 and 4/24/24, said s/he was aware that Resident #1 had a port under her dressing but was told by the skin lead nurse that oncology was addressing it. On 5/13/24 at 2:48 PM, LPN #2, said s/he was aware that Resident #1 had a dressing and figured people knew about it. On 5/13/24 at 2:54 PM, LPN #3, who completed Resident #1's skin check on 5/1/24, explained that Resident #1 had a chemo port under a dressing on her chest and didn't take off the dressing to look at the port. LPNs #2, #3, and #4 do not indicate in these interviews that they removed the dressing in order to monitor Resident #1's port site. Along with the weekly skin checks completed by licensed nursing staff on 4/10/24, 4/17/24, 4/24/24, 5/1/24, and 5/8/24, care documented in the POC (point of care; electronic documentation system for Licensed Nursing Assistants) shows that Licensed Nursing Assistants (LNAs) had multiple opportunities to observe Resident #1's entire skin, including the dressing covering Resident #1's port. Showers are documented as given on 4/10/24, 4/19/24, 4/22/24, 4/26/24, 4/30/24, and 5/7/24 and bed baths are documented as given on 4/3/24, 4/4/24, 4/7/24, 4/8/24, 4/13/24, 4/18/24, 4/20/24, 4/21/24, 4/25/24, and 5/2/24. The following transcripts of interviews conducted by facility leadership with staff reveal that the LNAs were aware of the bandage on Resident #1's chest and had discussed it with nursing staff. On 5/13/24 at 1:15 PM LNA #1 stated that s/he had given Resident #1 approximately 3 showers and remembers seeing a dressing on her chest and nursing staff had told him/her that it as ok to shower the resident as long as they covered the dressing. On 5/13/24 at 2:05 PM LNA #2 stated that s/he had given Resident #1 a shower shortly after she was admitted to the facility and remembers seeing a dressing on Resident #1's chest and being told by nursing staff that s/he could cover up the dressing for the shower. While interviews reveal that multiple direct care staff were aware that Resident #1 had a port there is no evidence that anyone provided any care to the port. Per review of Resident #1's medical record, including nursing assessments, skin assessments, nursing notes, provider notes, physician orders, care plan, Medication Administration Records, and Treatment Administration Records, Resident #1's port was not documented and there is no evidence that their port was cared for or monitored for 38 days, the entirety of their stay at the facility. Per a transcript of an interview conducted by facility leadership with the Unit Manager (UM) on 5/13/24 at 2:54 PM, the UM confirmed that staff did not make him/her aware that Resident #1 had a port. Per interview on 5/28/24 at 1:25 PM with the DON and the Market Clinical Lead, the Market Clinical Lead confirmed that there was no documentation that the staff monitored the port site or that staff had contacted the DON or a provider to obtain care orders for the port at any time during Resident #1's stay at the facility. The DON explained that no staff had come to him/her to address that Resident #1 did not have any care orders or a care plan for their port and confirmed that s/he did not know that Resident #1 had a port until she was admitted to the hospital following her chemotherapy appointment on 5/10/24 and stated that s/he should have been aware. Per review of the facility investigation, a document titled Plan of Action states Based on the investigation the facility noted the following: 1) Admission assessment should have included removing the protective dressing over the port site and identify the port on admission 2) The facility should have initiated orders for care of the port 3) The facility should have a [care plan] for care of the port The above was confirmed by the Market Clinical Director on 5/28/2024 at 1:25 PM. ************** Per review of a facility Plan of Action and interview on 5/28/24 at 1:25 PM, the Director of Nursing (DON) and the Market Clinical Lead revealed that the facility implemented corrective action for the above deficiency. The facility completed a house wide audit of skin on 5/11/24 to ensure all ports were identified and no residents were identified to have ports. Education related to skin assessments, wound dressings, port dressing changes, and obtaining care orders for the port, and care planning for the port, completed on 5/15/24. The DON or designee will audit all new admissions for ports and audits will be reviewed at monthly QAPI meetings. Based on corrective actions completed by 5/15/24, prior to the onsite investigation, this citation is designated as past non-compliance. Reference regarding Tegaderm: https://multimedia.3m.com/mws/media/2243525O/nexcare-tegaderm-transparent-dressing.pdf

Based on interview and record review, the facility failed to provide care to a port [A port protects your veins during cancer treatment. An implanted port is a type of central venous catheter .[that] lets the medication go into your bloodstream through your vein. It can be used to give you medication for several days in a row.1.] for 1 applicable resident (Resident #1) as evidenced by staff not conducting comprehensive skin assessments, obtaining and implementing orders for port care, and care planning for the care of a port. As a result, Resident #1's port became infected and had to be removed which delayed Resident #1's chemotherapy. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] for sub-acute rehabilitation following abdominal surgery and has diagnoses that include ovarian cancer, congestive heart failure, and depression. A 4/3/2024 facility nurse practitioner note indicates that Resident #1 was admitted for sub-acute rehabilitation from the hospital following three rounds of chemotherapy, surgery to remove her uterus, ovaries, and tumors related to ovarian cancer. The note indicates that she will need additional rounds of chemotherapy in the future. A 4/29/24 hospital oncology physician visit note reveals that Resident #1's treatment plan is to receive her fourth dose of chemotherapy on 5/10/24. A telephone interview was conducted 05/29/2024 at 10:35 AM with Resident #1's family representative who was present at the chemotherapy infusion appointment. The family representative discussed that when Resident #1 went to their appointment on 5/10/24 to receive their fourth round of chemotherapy, she instead was admitted to the hospital because of an infected port and was unable to receive their fourth round of chemotherapy. The family representative stated the staff removed a blue .moldy or fungus looking bandage. The family representative described the site as red and inflamed and described the port site as black. The medical team consulted with Oncology and admitted Resident #1 to the hospital that day [05/10/2024]. She did not have chemotherapy that day. IR (Interventional Radiology) removed the old port. The family representative discussed but they have not put a new port in yet and have thus not received any chemotherapy. The family representative discussed that Resident #1 is upset and anxious about her delayed chemotherapy. A hospital outpatient chemotherapy Registered Nurse note dated 5/10/24 states that I went to remove the gauze and Tegaderm [adhesive dressing which can be used for up to seven days] over the patient's port site and I found the gauze to be dried [with a] blackish colored substance. Her port site itself appeared ecchymotic [discolored skin resulting from ruptured blood vessels], tender, swollen and a black scab was present. [Patient] reports that it has 'itched.' She denies any fevers. [His/Her] [white blood count] is elevated. She is unsure if this dressing has ever been changed to the site assessed since her admission to Rehab [facility]. Plan to hold chemo today, have [radiology] assess the port site and admit patient for observation and antibiotics and likely port removal. Patient is upset/anxious but able to reassure patient. Included in the above notes are two photos of Resident #1's port site. The first photo reveals Resident #1's port site which appears to be approximately 1.5 cm x 1.5 cm, raised, and very red with a pinhole open black spot. The second photo shows the gauze that was removed from the port site being approximately 2.5 cm x 2.5 cm and covered in a black-ish substance. A hospital physician history and physical note dated 5/10/24 explains that Resident #1's chemotherapy was deferred today and she reports feeling like her whole body is achy, and say the port has been tender for 'awhile.' Physical exam findings reveal the chest is erythematous port site with pinhole at 6 o'clock. No active drainage, mildly tender to palpation. A hospital Physician progress note dated 5/14/24 reveals that [Resident #1] presents as a direct admit from the chemotherapy infusion suite, where she was found to have an infected port prior to her fourth cycle of chemotherapy. Infected port removed, now [status post] vancomycin (5/10-5/13) [antibiotic]. Decided to hold on port replacement yesterday given patient's fragility and pending chemotherapy break. Per phone interview on 5/29/24 at 4:38 PM, a hospital outpatient chemotherapy Registered Nurse (HRN #2) explained that on 5/10/24 Resident #1's port appeared to be infected. HRN #2 reviewed Resident #1's hospital medical record and confirmed that the port was not accessed at the hospital, including the two outpatient visits she had on 4/11/24 and 4/29/24, since 4/3/24. HRN #2 explained that the dressing that Resident #1 had covering her port was not intended to be on for an extended period of time. S/He explained that since Resident #1's port was over 2 weeks old when she arrived at the facility on 4/3/24, the expectation would be for the dressing to be removed on admission to the facility so the port could be assessed and not cover the port again. S/He explained that the expectation of the facility would be to monitor the port site regularly without a dressing to notice any potential complications. While the Transfer of Care (hospital discharge summary) dated 4/3/24 does not reveal that Resident #1 has a port or any physician orders to care for Resident #1's port, the facility did not identify the port on the admission nursing assessment. Per the initial admission nursing assessment completed on 4/3/24, Resident #1's port is not identified, including the section that assesses for a port, device/treatment, and skin status, Integumentary. Per record review the DON and Market Clinical Lead investigated the concern of resident #1's port. The investigation included transcripts of interviews conducted with staff involved with Resident #1's care from 4/3/24 to 5/10/24. Some interviews reveal that staff did not perform complete skin assessments to identify Resident #1's port. A majority of the interviews conducted with multiple direct care staff reveal that they were aware that Resident #1 had a port but did not provide any care to the port, including dressing changes or monitoring the port site under the bandage. Per review of Resident #1's medical record, including nursing assessments, skin assessments, nursing notes, provider notes, physician orders, care plan, Medication Administration Records, and Treatment Administration Records, Resident #1's port was not documented and there is no evidence that their port was cared for or monitored for 38 days, the entirety of their stay at the facility. Per a comprehensive record review revealing zero evidence that port care was performed, including comprehensive skin assessments, obtaining and implementing orders for port care, and care planning for the care of a port, in combination with review of the facility investigation related to Resident #1's port care, the facility neglected to provide care for Resident #1's port. See F600 for more information. Per interview on 5/28/24 at 1:25 PM with the DON and the Market Clinical Lead, the Market Clinical Lead confirmed that there was no documentation that the staff monitored the port site or that staff had contacted the DON or a provider to obtain care orders for the port at any time during Resident #1's stay at the facility. The DON explained that no staff had come to him/her to address that Resident #1 did not have any care orders or a care plan for their port and confirmed that s/he did not know that Resident #1 had a port until she was admitted to the hospital following her chemotherapy appointment on 5/10/24 and stated that s/he should have been aware. A facility investigation Plan of Action states Based on the investigation the facility noted the following: 1) Admission assessment should have included removing the protective dressing over the port site and identify the port on admission 2) The facility should have initiated orders for care of the port 3) The facility should have a [care plan] for care of the port The above was confirmed by the Market Clinical Director on 5/28/2024 at 1:25 PM. **************** Per review of a facility Plan of Action and interview on 5/28/24 at 1:25 PM, the Director of Nursing (DON) and the Market Clinical Lead revealed that the facility implemented corrective action for the above deficiency. The facility completed a house wide audit of skin on 5/11/24 to ensure all ports were identified and no residents were identified to have ports. Education related to skin assessments, wound dressings, port dressing changes, and obtaining care orders for the port, and care planning for the port, completed on 5/15/24. Based on corrective actions completed by 5/15/24, prior to the onsite investigation, this citation is designated as past non-compliance. 1. Reference: About Your Implanted Port. Memorial [NAME] Cancer Center. https://www.mskcc.org/cancer-care/patient-education/your-implanted-port

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for three applicable residents (Resident #1, #3, and #5). Findings include: 1. Record review reveals that Resident #1 has diagnoses that include personality disorder, depression, and dementia. On 7/11/23, Resident #1 is assessed to have a BIMS of 4 (brief interview for mental status; a cognitive assessment score indicating severe cognitive impairment). Resident #2 has diagnoses that include schizophrenia, depression, and post-traumatic stress disorder. On 8/14/23, Resident #2 is assessed to have a BIMS of 14 (indicating cognitive intactness). Review of facility resident to resident incident reports dated 9/15/23 for Residents #1 and #2 reveal that Resident #1 was found by nursing staff on the floor in the dining room at approximately 4:30 PM complaining of left arm and hand pain. Resident #2 was standing over Resident #1. A 9/15/23 progress note reveals that Resident #1 was sent to the emergency room after the incident and returned to the facility with a fracture to his/her left wrist. A 9/18/23 skin assessment reveals that Resident #1 has bruising on his/her left arm, left hip and coccyx. Per interview on 9/19/23 at 8:55 AM Resident #2 confirmed that s/he had swung at Resident #1 on 9/15/23. S/he stated it was because [Resident #1] was touching my walker and told me to go [explicit word] my mother. Resident #2 reported that s/he had previously been touched by Resident #1. On 9/19/23 at 9:03 AM, the Administrator reported that an incident had occurred between Resident #1 and #2 the previous month. Review of the facility's investigation dated 9/1/23 reveals that Resident #2 reported that Resident #1 had entered their room and grabbed their genitals while they were in their bed on 8/29/23. The facility investigation summary substantiated the event occurred without harm. Review of surveillance footage of the dining area on 9/15/23 at approximately 4:45 PM reveals Resident #2 sitting at a table with a few other residents when Resident #1 begins to move Resident #2's walker away from Resident #2. Resident #2 pulls the walker closer to themselves and Resident #1 immediately moves Resident #2's walker away again. This happens a couple more times before Resident #2 stands up from the table and strikes Resident #1, who then falls backwards onto the floor. No interventions by staff were observed in the footage until staff responded to Resident #1 being on the floor. Review of a facility investigation report summary dated 9/20/23 substantiates the event did occur and resulted in harm for Resident #1. 2. Record review reveals that Resident #3 has diagnoses that include dementia with behavioral disturbances, communication deficit, anxiety, and depression. On 7/19/23, Resident #3 is assessed to have a BIMS of 3 (indicating severe cognitive impairment). Resident #4 has diagnoses that include dementia with behavioral disturbances and depression. On 9/20/23, Resident #4 is assessed to have a BIMS of 6 (indicating severe cognitive impairment). Review of facility resident to resident incident reports dated 9/27/23 for Residents #3 and #4 reveal that Residents #3 and #4 were seen having a verbal disagreement at Resident #4's doorway. Resident #3 spit on Resident #4. Resident #4 then raised his/her cane and hit Resident #3 on their left shoulder. Witness statements indicate that this event occurred at approximately 5:00 PM. A 10/9/23 skin assessment reveals that Resident #4 has bruising on his/her left shoulder. A facility investigation summary dated 10/3/2023 substantiates the event did occur. This report reveals that Residents #3 and #4 had not had prior aggression with each other, however, Resident #3's medical record reveals a history of resident to resident altercations. Resident #3's care plan states that s/he wanders, exhibits physical behaviors and is at risk for resident to resident altercation related to: Cognitive Loss/Dementia, Poor impulse control, created on 3/24/23, and has multiple interventions to prevent being harmed or harming others including, Redirect [Resident #3] if wandering, entering other rooms, created on 7/10/23, and Monitor [Resident #3]'s whereabouts and redirect to staff supervised area as needed, created on 7/10/23. Review of facility resident to resident altercation investigation summaries reveal the following substantiated events: A 6/13/23 facility investigation summary reveals that on 6/8/23 Resident #3 entered Resident #6's room, yelled profanities, and hit Resident #6 on their right cheek. A 7/10/23 facility investigation summary reveals that on 7/6/23 Resident #3 entered Resident #6's room and Resident #6 struck Resident #3 on the back of their head. An 8/11/23 facility investigation summary reveals that on 7/6/23 Resident #3 entered Resident #6's room, grabbed, kicked, and struck Resident #6 in the face. 3. Record review reveals that Resident #5 has diagnoses that include severe dementia with agitation and psychotic disturbances, anxiety, cognitive communication deficit, and depression. On 8/1/23, Resident #5 is assessed to have a BIMS of 5 (indicating severe cognitive impairment). Resident #6 has diagnoses that include osteogenesis imperfecta (brittle bone disease) and cognitive communication deficit. On 8/17/23, Resident #6 is assessed to have a BIMS of 15 (indicating cognitive intactness) and uses a wheelchair for independent locomotion. Review of facility resident to resident incident reports dated 10/1/23 for Residents #5 and #6 reveal that Resident #6 was seen in the dining room approaching Resident #5 around a table, then punching Resident #5 in the jaw. Witness statements indicate that this event occurred at approximately 5:00 PM. A facility investigation summary dated 10/6/2023 substantiates the event did occur. Per interview on 10/9/23 at 3:50 PM, Resident #6 indicated that on 10/1/23 s/he was provoked by Resident #5 pulling on the tablecloth while waiting for dinner, almost spilling his/her drink. S/He confirmed that s/he did hit Resident #6 and revealed that s/he has been involved in altercations with other residents before. S/He explained that Resident #3 used to come into his/her room and it had been physical. Review of Resident #6's medical record and facility reported resident to resident altercations reveal that Resident #6 has a history of physical behaviors. Resident #6's care plan states that s/he exhibits, or has the potential to exhibit physical behaviors related to: Poor impulse control, hit another resident created on 7/9/23. A 7/10/23 facility resident to resident altercation investigation summary reveals that on 7/6/23 Resident #3 entered Resident #6's room and Resident #6 struck Resident #3 on the back of their head.

Based on record review and interview, the facility failed to provide care to an existing non-pressure related injury for 2 of 2 sampled residents [Residents #2 and #8] and preventative skin care to residents at risk for development of non-pressure related injuries for 5 of 6 sampled residents [Residents #1, #2, #3, #6, and #8] consistent with facility policy and professional standards of practice. Findings include: Record review and interview reveal the facility had multiple systemic failures in its prevention and management of non-pressure injuries in accordance with facility policy and professional standard of practice. These included failure to: Complete an accurate comprehensive skin evaluation on admission for Residents #1 and #2; Complete skin risk evaluations per facility schedule for Residents #1, #2, #3, #6, and #8; Document newly identified non-pressure ulcer skin impairments as a change of condition for Resident #2; Accurately and regularly perform and document skin inspections (skin checks) per facility schedule for Residents #1, #3, #6, and #8; Accurately and regularly perform non-pressure ulcer wound evaluations per facility schedule for Residents #2 and #8; Perform and document daily monitoring of non-pressure ulcer wounds or dressings for Resident #8; Revise care plans to reflect actual skin status for Resident #2; Create care plans to monitor diabetic residents' feet for Residents #1, #3, and #8; and Monitor diabetic residents' feet for Residents #1, #2, and #3. These failures contributed to the amputation of Resident #2's 5th toe, and put Residents #1, #2, #3, #6, and #8 at increased risk for new or additional non-pressure ulcer related skin impairments, creating an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. Facility policy titled NSG236 Skin Integrity and Wound Management, last reviewed 9/1/22, states: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influences skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Practice Standards include: 3. Complete risk evaluation on admission, re-admission, weekly for the first month, quarterly, and with significant change in condition. 5. The nursing assistant will observe skin daily and report any changes or concern to the nurse. 6. A licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds 6.2 Document newly identified skin/wound impairments as a change in condition 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. 6.6 Perform daily monitoring of wounds or dressings for presence of complications or declines. 6.6.1 Document daily monitoring of ulcer/wound site with or without dressing. 8. Review care plan and revise as indicated. Facility policy titled Wound Dressing: Aseptic No Touch, last reviewed 12/1/2021, states staff are to verify the wound dressing order before changing dressings and document wound evaluation with unanticipated wound decline and/or weekly if assessment is due. The American Diabetes Association Standards of Care in Diabetes-2023 reveals on page S209 the recommendation for diabetics to perform daily examination of the feet to identify early foot problems. 1. Resident #2 Record review and interview reveal that a diabetic foot ulcer was discovered on Resident #2's left foot on 12/9/22. The facility failed to provide accurate and regular skin and wound assessments, initiate a change of condition in the electronic medical record (EMR), implement care plan interventions for daily diabetic foot monitoring, and revise his/her care plan to reflect his/her clinical condition and needs placing him/her at increased risk for wound complications and other non-pressure ulcer skin impairments. The deterioration of Resident #2's diabetic ulcer resulted in an amputation of his/her 5th toe on 1/4/23. Record Review: Resident #2 was initially admitted to the facility on [DATE] and readmitted to the facility from the hospital on 9/1/22 with diagnoses that include type 2 diabetes mellitus, chronic respiratory failure, hypertension, chronic pain syndrome, chronic kidney disease, arthritis, anemia, congestive heart failure, legal blindness, and depression. Resident #2's care plan dated 8/9/22 reveals s/he needs staff assistance for transferring and toileting. These clinical conditions and comorbidities are risk factors for developing skin injuries. A 9/1/22 transition of care note [discharge summary] from the hospital reveals on pages 5-8 that Resident #2 had multiple assessed wounds and dressings including: a right heel wound described as red, with a small open area and boggy with a foam dressing; a left heel wound described as red and boggy with a foam dressing; and a left planter foot wound, described as black, brown, and open to air. Upon return to the facility, the 9/1/22 nursing skin assessment does not document the above wounds noted in the 9/1/22 transition of care. Resident #2's care plan includes the following care plan focuses: Resident is at risk of skin breakdown r/t [related to] Seborrheic Dermatitis [skin condition affecting the scalp] < DM [diabetes] and alterations in mobility, created on 8/9/22. Interventions include: Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, created on 8/9/22, and Weekly skin check by license nurse, created on 8/9/22. The resident has a diagnosis of diabetes: Insulin Dependent, created on 8/3/22. Interventions include: Diabetic foot checks daily. Observe feet/toes/ankles/soles/heels noting alteration in skin integrity, color, temperature, and cleanliness, created on 8/3/22. A Nurse Practitioner (NP) note dated 12/9/22 reveals in a physical exam that Resident #2 has a L [left] planter 5th mtp [Metatarsophalangeal; where the bones of the toe and foot meet] diabetic ulcer pale white lifting of dermis [middle layer of skin] beefy protrusion dime size. The provider notes There is this open area dorsal 5th mtp that no one was aware of. Severe neuropathy. The treatment plan indicates a referral to the wound nurse. The NP also notes a non-pressure chronic ulcer of other part of right foot with fat layer exposed. A skin check dated 12/9/22 reveals a new skin wound described as a .5 x .5 hard, blanchable, white area to bottom of left foot. There is no mention of a non-pressure chronic ulcer of the right foot as indicated in the NP's note from an hour earlier. Resident #2's care plan was updated on 12/10/22 to include Blanchable areas to heels. The care plan does not acknowledge Resident #2's left foot wound. No interventions were added to the care plan for wound care or wound evaluations. A Wound Nurse note dated 12/28/22 reveals an initial evaluation of Resident #2's diabetic foot wound measuring 1.1 x 1.1 x 4.3 cm. A 12/30/22 nursing home to hospital transfer form reveals that Resident #2 was transferred to the hospital on 12/30/22 due to pain in his/her left lateral foot. Review of Resident #2's medical record reveals that s/he does not have: An accurate comprehensive readmission skin evaluation on 9/1/22; A Braden Scale risk assessment [score predicting the risk of developing pressure sores] from 8/8/22 through 12/20/22; A change of condition documentation for the wound identified on 12/9/22; Weekly wound evaluations from 12/10/22 through 12/28/22; Documentation of daily diabetic foot checks from 9/1/22 through 12/30/22; or A care plan focus that reflects actual wounds. The facility was unable to produce evidence of missing risk assessments, change of condition documentation, wound evaluations, or documentation of diabetic foot checks for Resident #2 when requested on 1/10/23 at 10:20 AM by the surveyor. A 1/9/23 hospital progress note reveals that Resident #2 was admitted to the hospital on 12/30/22 for a left planter foot ulcer with osteomyelitis [bone infection] and MRSA [Methicillin-resistant Staphylococcus aureus; bacterial infection]. As a result, Resident #2 had a left 5th partial ray resection [amputation of 5th toe] on 1/4/23. Interview: On 1/5/23 at 2:48 PM the Medical Director confirmed that nursing orders for daily foot checks for diabetic residents is a standard of care and should be a standard nursing order for all diabetic residents. On 1/6/22 at 11:55 AM, the Director of Nursing confirmed that the facility policy titled Skin Integrity and Wound Management should be followed by nursing staff for all residents. On 1/6/22 at 12:30 PM, the Regional Clinical Consultant stated that it is up to nursing judgment to add diabetic foot checks into nursing orders or care plans as it is not something standard the facility does for all diabetics. S/He confirmed that there is not written policy or procedure in place to ensure that a residents transfer of care information for wounds is entered into [the electronic medical record system]. On 1/9/23 at 9:20 AM, the Unit Manager stated that there is a diabetic protocol that should be implemented for every resident with diabetes and once triggered, it will add orders for daily diabetic foot checks. S/He stated that a lot of the nurses are working to the order [only doing what there is an order for] and might not do daily diabetic foot checks if there is not an order on a resident's MAR. S/He stated that there is not a facility procedure on how to enter in orders and staff need something to refer to about the process. On 1/9/23 at 12:15 AM, a Licensed Practical Nurse (LPN) stated that s/he will do daily diabetic foot checks when they pop up on the medication administration record (MAR) or treatment administration record (TAR). On 1/9/23 at 1:22 PM, the Director of Nursing stated that when a change of condition form is filled out for new wounds, weekly skin and wound evaluations will auto populate in the EMR. S/He confirmed that a change of condition form is not being done all the time per facility policy and it might be due to a training issue. On 1/9/23 at 3:19 PM, an LPN stated that s/he will do a diabetic foot check when there is an order on the TAR to do one. On 10/10/23 at 10:20 AM, the Director of Nursing confirmed that the skin risk evaluation used by the facility was the Braden Scale for Predicting Pressure Sore Risk Assessment. On 1/10/23 at 11:55 AM, the Wound Nurse stated that if a provider plans for a resident to see the wound nurse, the referral should happen immediately. S/He confirmed that s/he did not get a referral to see Resident #2 until the end of December. On 1/18/23 at 9:40 AM, the Director of Nursing and the Market President confirmed that the failures to implement the skin and wound policies and procedures were due to a mix of staff not having the enough training on the policies and procedures and staff not having the competencies to implement them. 2. Resident #8 Record review and interview reveal that Resident #8 has venous ulcers on both legs since his/her initial admission. The facility failed to provide accurate and regular skin and wound assessments and create a care plan intervention for daily diabetic foot monitoring, placing Resident #8 at increased risk for wound complications and other non-pressure ulcer skin impairments. Record Review: Resident #8 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, hypertension, peripheral vascular disease, chronic kidney disease, obesity, and coronary artery disease. Resident #8's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 11/14/22 reveals that s/he is at risk for developing pressure ulcers and needs staff assistance for transferring and toileting. These clinical conditions and comorbidities are risk factors for developing skin injuries. Resident #8's care plan includes the following care plan focus: [Resident #8] is at risk for skin break down related to osteoarthritis, PVD [peripheral vascular disease], bilateral mastectomy. Resident currently has venous ulcers to right and left posterior legs and abrasion to left calf, created on 11/27/20. Interventions include: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs and symptoms] of infection, maceration [moist skin] etc. to MD, created on 11/27/20, and skin/wounds will be checked weekly by licensed professional, created on 10/18/22. The care plan does not include daily diabetic foot checks. Resident #8's medication administration record (MAR) reveals an order to Cleanse BLE [bilateral lower extremities] with wound cleaner. Pat dry. Apply moisturizing cream to intact skin. For RLE [right lower extremity] only iodosorb cream. Apply iodine cadexomer gel to open areas and cover with foam [cover with Ag/silver foam if iodine not available]. Wrap with roller gauze (kerlix) and adhesive wrap (Coban) every evening shift, every 2 day(s) for venous ulcers. This order was documented as completed throughout October. Skin checks from 10/1/22 and 10/11/22 indicate that Resident #8 does not have any skin injuries or wounds. This information contradicts the dressing changes for wounds documented as performed in the MAR. Review of Resident #8's medical record reveals that s/he does not have: A Braden Scale risk assessment from 2/12/21 through 1/11/23; Weekly skin checks from 8/28/22 through 9/30/22; Accurate skin checks from 10/1/22 through 10/17/22; Weekly skin checks from 12/13/22 through 1/5/23; Documentation of daily monitoring for wound/dressing on days that Resident #8's dressing was not changed; Weekly wound evaluations from 9/9/22 through 9/28/22; A weekly wound evaluation from 10/7/22 through 10/19/22; or A care plan intervention for daily diabetic foot checks from 11/27/20 through 1/5/23. Interview: On 1/9/23 at 4:03 PM, the Regional Clinical Consultant stated that there is an expectation for staff to document any irregularities of the skin, not just wounds, whether they are new or not. S/he confirmed that skin checks are a full body assessment of a resident's skin. On 1/18/23 at 9:15 AM, the Unit Manager stated that traveling nursing staff do not get enough education when they are hired and that some staff do not document wounds on skin checks if the wound is not new. S/He confirmed that Resident #3 had venous ulcers on both legs during October 2022 and if skin checks stated that Resident #3 did not have any wounds on 10/1/22 or 10/11/22, the skin checks would not be accurate. On 1/18/23 at 11:00 AM, the Director of Nursing confirmed that there is no evidence that skin checks or wound evaluations were completed for the above dates per facility policy and Resident #8's care plan. 3. Resident #1 Record review and interview reveal that the facility failed to provide timely and regular skin and wound assessments, initiate a change of condition in the electronic medical record, and create and implement care plan interventions for daily diabetic foot monitoring, placing Resident #1 at increased risk for non-pressure ulcer skin impairments. Record Review: Resident #1 was readmitted to the facility on [DATE] following a hospital stay with diagnoses that included: type 2 diabetes mellitus, altered cardiac status, obesity, frequent incontinence, renal insufficiency, chronic obstructive pulmonary disease, chronic respiratory failure, severe chronic kidney disease, congestive heart failure, atrial fibrillation, amputation of the right toe, anemia, osteoporosis, hypertension, rheumatoid arthritis, muscle weakness, chronic pain, and history of urinary tract infections, seizures, and stroke. Resident #1's MDS dated [DATE] reveals that s/he requires two-person assist for bed mobility, toileting, and transfers. These clinical conditions and comorbidities are risk factors for developing skin injuries. Resident #1's care plan includes the following care plan focus: Resident is at risk of skin breakdown r/t [related to] DM [diabetes], incontinence (B&B) [bowel and bladder]. Has redness to grain and abdominal folds. Has absence of right toes created on 2/16/22. Interventions include assess for changed in skin condition each shift, created on 2/16/22, and complete skin risk assessment as per facility policy, created on 2/16/22. The care plan does not include daily diabetic foot checks. Review of Resident #1's medical record reveals that s/he does not have: A Braden Scale risk assessment from 3/13/22 through 1/3/23; A comprehensive skin assessment on 9/14/22 readmission; Weekly skin checks from 9/14/22 through 9/26/22; Weekly skin checks from 11/25/22 through 12/13/22; A care plan intervention for daily diabetic foot checks from 9/14/22 through 10/14/22; or Documentation of daily diabetic foot checks from 9/14/22 through 12/13/22. The facility was unable to produce evidence of missing risk assessments, change of condition documentation, wound evaluations, or documentation of diabetic foot checks for Resident #1 when requested on 1/10/23 at 10:20 AM by the surveyor. Interview: On 1/4/23 at 2:55 PM, the Unit Manager stated that there is a glitch with putting in orders for readmissions. When a resident is out of the facility for three or more days, orders are deleted, and the nurse must start from scratch to put orders in. There is no way of knowing what the previous orders were for a readmission but standard nursing orders, like skin assessments, should be in the electronic medical record system. On 1/5/23 at 2:48 PM the Medical Director confirmed that head to toe skin checks are to be done for all residents on return from the hospital. On 1/6/23 at 10:52 AM, the Administrator confirmed that there was no evidence of a readmission skin assessment on 9/14/22. On 1/10/23 at 9:50 AM, an LPN stated that skin checks and diabetic foot checks will pop up on the TAR if they are due. When asked if the diabetic residents on his assignment that day need their feet checked every day, s/he stated he was unaware that they did. On 1/10/23 at 4:10 PM, Resident #1 stated that staff did not look at his/her feet every day. 4. Resident #3 Record review and interview reveal that the facility failed to provide regular skin assessments and create and implement care plan interventions for daily diabetic foot monitoring, placing Resident #3 at increased risk for non-pressure ulcer skin impairments. Record Review: Resident #3 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, hypertension, left foot drop, muscle weakness, dementia, depression, and history of stroke. Resident #3's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers and totally dependent on staff, requiring a two person assist for bed mobility, transferring, and toileting. These clinical conditions and comorbidities are risk factors for developing skin injuries. Resident #3's care plan includes the following care plan focus: Patient is at risk for skin breakdown related to Advanced age (greater than [AGE] years), decreased activity, impaired Cognition, incontinence, limited mobility, nutritional concerns and or has actual skin integrity impairments-admitted with bruises to abdomen and bilateral arms, created on 12/21/22. Interventions include: Weekly skin check by license nurse created on 12/21/22. The care plan does not include daily diabetic foot checks. Review of Resident #3's medical record reveals that s/he does not have: A Braden Scale risk assessment from 12/20/22 through 1/8/23; A weekly skin check from 12/21/22 through 1/5/23; A care plan intervention for daily diabetic foot checks from 12/20/22 through 1/5/23; or Documentation of daily diabetic foot checks from 12/20/22 through 1/5/23. The facility was unable to produce evidence of missing risk assessments, skin checks, or documentation of diabetic foot checks for Resident # 3 when requested on 1/10/23 at 10:20 AM by the surveyor. 5. Resident #6 Record review and interview reveal that the facility failed to provide timely and regular skin and wound assessments placing Resident #6 at increased risk for non-pressure ulcer skin impairments. Record Review: Resident #6 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, muscle weakness, and dementia. Resident #3's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers and needs extensive or full assistance, requiring a two person assist for bed mobility, transferring, and toileting. These clinical conditions and comorbidities are risk factors for developing skin injuries. Resident #6's care plan includes the following care plan focuses: Resident at risk for skin breakdown related to impaired mobility, advanced age, poor safety awareness, frail/fragile skin, incontinence, created on 8/18/22. Interventions include: Weekly skin check by license nurse, created on 8/18/22 and Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, created 8/18/22. The resident has potential for pressure ulcer development r/t [related to] decreased mobility, created on 2/15/21. Interventions include: Follow facility protocols for the prevention/treatment of skin breakdown, created on 2/15/21 and, Document/report to MD PRN [as needed] changes in skin status: appearance, color, wound healing, s/sx [signs and symptoms] of infection, wound size and stage, created on 2/15/21. A physician's order dated 7/27/22 states to Check skin condition to bilateral lower extremities daily every shift for fragile skin document in nurses note any new skin concerns. Review of Resident #6's medical record reveals that s/he does not have: A Braden Scale risk assessment from 2/26/22 through 1/11/23; or Weekly skin checks from 11/24/22 through 1/5/23. Interview: On 1/17/23 at 11:03 AM, the Director of Nursing confirmed there is no evidence that skin checks were done as care planned and ordered in December 2022.

Based on record review and interview, the facility failed to provide treatment to an existing pressure injury for 2 of 2 sampled residents [Residents #1 and #6] and preventative skin care to residents at risk for development of pressure injuries for 5 of 6 sampled residents [Residents #1, #2, #3, #6, and #8] consistent with facility policy and professional standards of practice. Findings include: Record review and interview reveal the facility had multiple systemic failures in its prevention and management of pressure injuries in accordance with facility policy and professional standard of practice. These included failure to: Complete an accurate comprehensive skin evaluation on admission for Residents #1 and #2; Complete skin risk evaluations per facility schedule for Residents #1, #2, #3, #6, and #8; Document newly identified pressure injuries as a change of condition for Resident #1; Accurately and regularly perform and document skin inspections (skin checks) per facility schedule for Residents #1, #3, #6, and #8; Accurately and regularly perform wound evaluations for pressure injuries per facility schedule for Resident #1; Provide pressure ulcer dressing changes or treatment for Resident #1; Perform and document daily monitoring of pressure injuries or dressings for Resident #1; Revise care plans to reflect actual skin status for Resident #1; Create care plans to monitor diabetic residents' feet for Residents #1, #3, and #8; and Monitor diabetic residents' feet for Residents #1, #2, and #3. These failures contributed to a below the knee amputation for Resident #'1, a delay in pressure ulcer treatment for Resident #6, and put Residents #1, #2, #3, #6, and #8 at risk for developing new or additional pressure ulcers, creating an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. Facility policy titled NSG236 Skin Integrity and Wound Management, last reviewed 9/1/22, states: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influences skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Practice Standards include: 3. Complete risk evaluation on admission, re-admission, weekly for the first month, quarterly, and with significant change in condition. 5. The nursing assistant will observe skin daily and report any changes or concern to the nurse. 6. A licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds 6.2 Document newly identified skin/wound impairments as a change in condition 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. 6.6 Perform daily monitoring of wounds or dressings for presence of complications or declines. 6.6.1 Document daily monitoring of ulcer/wound site with or without dressing. 8. Review care plan and revise as indicated. Facility policy titled Wound Dressing: Aseptic No Touch, last reviewed 12/1/2021, states staff are to verify the wound dressing order before changing dressings and document wound evaluation with unanticipated wound decline and/or weekly if assessment is due. The American Diabetes Association Standards of Care in Diabetes-2023 reveals on page S209 the recommendation for diabetics to perform daily examination of the feet to identify early foot problems. 1. Resident #1 Record review and interview reveal that Resident #1 was readmitted to the facility from the hospital on 9/14/22 with a deep tissue pressure injury. The facility failed to provide timely and regular skin and wound assessments, provide pressure ulcer treatment and dressing changes, initiate a change of condition in the electronic medical record, revise his/her care plan to reflect his/her clinical condition and needs, and create and implement care plan interventions for daily diabetic foot monitoring, placing Resident #1 at increased risk for wound complications and developing additional pressure ulcers. The deep tissue injury progressed to an unstageable pressure wound by 9/29/22, fifteen days after readmission to the facility. Once the wound was documented as discovered, the facility continued to fail to implement skin integrity and wound management interventions. The deterioration of Resident #1's pressure injury resulted in a below the knee left leg amputation on 12/20/22. Record Review: Resident #1 was initially admitted to the facility on [DATE]. Since then, Resident #1 has had extended hospital stays of three or more days on 6/6/22-6/21/22, 6/22/22-6/30/22, 7/1/22-8/1/22, 8/14/22-8/25/22, 9/5/22-9/14/22, and 12/13/22-1/4/23. Resident #1 was readmitted to the facility on [DATE] following a hospital stay with diagnoses that included: type 2 diabetes mellitus, altered cardiac status, obesity, frequent incontinence, renal insufficiency, chronic obstructive pulmonary disease, chronic respiratory failure, severe chronic kidney disease, congestive heart failure, atrial fibrillation, amputation of the right toe, anemia, osteoporosis, hypertension, rheumatoid arthritis, muscle weakness, chronic pain, and history of urinary tract infections, seizures, and stroke. Resident #1's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 9/14/22 reveals that s/he requires two-person assist for bed mobility, toileting, and transfers. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. The transition of care (discharge summary) from the hospital on 9/14/22 reveals on page 3 that Resident #1 needed follow up with the podiatry clinic for a left heel ulcer. Page 6 indicates that Resident #1 had a left heel deep tissue pressure injury. It is documented on page 7 that on 9/14/22 at 9:30 am, the heel wound had a clean, dry, and intact foam dressing. There is no evidence that the facility completed a skin risk evaluation, skin inspection, wound evaluation, or monitoring of wound and/or dressing when Resident #1 was readmitted on [DATE]'s. Resident #1's care plan on 9/14/22 includes the following care plan focus: Resident is at risk of skin breakdown r/t [related to] DM [diabetes], incontinence (B&B) [bowel and bladder]. Has redness to groin and abdominal folds. Has absence of right toes initiated on 2/16/22. Interventions include assess for changed in skin condition each shift, initiated 2/16/22, and complete skin risk assessment as per facility policy, initiated 2/16/22. The care plan does not address his/her deep tissue injury or include interventions to care for the wound present on 9/14/22. Also, the care plan does not include daily diabetic foot checks or reflect Resident #1's actual wound. A progress note signed and dated on 9/27/22 2:47 PM, thirteen days after readmission by the Unit Manager, reveals Evaluated left heel area found wrapped with kling [gauze bandage] covered with foam dressing noted to have circular necrotic center with yellow slough surrounding edges. Foul odor noted. Notified [physician]. awaiting return call. Foam dressing applied with kling. Will place resident on list for wound nurse on Thursday. Review of Resident #1's medication administration record (MAR), treatment administration record (TAR), Licensed Nurse Aide (LNA) documentation, physician's orders, progress notes, provider notes, and assessment tools does not reveal any of the following for Resident #1 between the time s/he was readmitted on [DATE] and the time the wound was first documented on 9/27/22: a comprehensive skin assessment, skin risk assessments, skin checks, nursing assistants reporting skin concerns to the nurse, wound evaluations, a change in condition form, orders for dressing changes or treatments, daily diabetic foot checks, or daily monitoring of wounds and/or dressings. A Wound Nurse note dated 9/29/22 documented the visit as the initial encounter and recorded that Resident #1's pressure ulcer appears infected. A Nurse Practitioner note dated 9/30/22 indicated that Resident #1's wound was approximately 3x2 inches in size and is described as eschar [dark, crusty tissue]. A Wound Nurse progress note from 10/6/22 indicates that the wound is 3.5 x 2.8 x 0.5 cm, unstageable, and improving. Resident #1's care plan was revised on 10/13/22 to include actual L [left] heel wound inner aspect, as a skin breakdown focus. An intervention for diabetic foot checks was added on 10/25/22. A Nurse Practitioner (NP) note dated 10/19/22 reveals that symptoms related to the injury [pressure ulcer] have worsened. The note discloses entire heel back eschar. Dressing removed was from 10/13. Foul smell. Redness around eschar. Reported to the DON [Director of Nursing] that the daily dsg [dressing] ordered is not being followed. Wound Nurse noted dated 10/20/22 reveals that the wound has increased in size to 5.5 x 6.1 x 0.2 cm, unstageable, and deteriorating. S/He writes that Resident #1's wound has worsened this week d/t [due to] issue with dressing changes. Resident #1's MAR or TAR does not reveal dressing orders or documentation that the dressing was changed from 10/7/22 through 10/19/22. Review of Resident #1's medical record reveals that s/he does not have: A comprehensive skin assessment on 9/14/22 readmission; A Braden Scale risk assessment [score predicting the risk of developing pressure sores] from 3/13/22 through 1/3/23; Physician orders for wound dressing changes or treatment from 9/14/22 through 9/28/22; Daily documentation of wound monitoring from 9/14/22 through 9/26/22; Weekly skin checks from 9/14/22 through 9/26/22; Weekly wound evaluations from 9/14/22 through 9/28/22; Change of condition documentation for a new skin impairment identified on 9/27/22; A care plan focus reflective of actual wound from 9/14/22 through 10/12/22; Documentation of dressing changes from 10/7/22 through 10/19/22; A weekly wound evaluation from 10/7/22 through 10/19/22; Weekly skin checks from 11/25/22 through 12/13/22; A care plan intervention for daily diabetic foot checks from 9/14/22 through 10/14/22; or Documentation of daily diabetic foot checks from 9/14/22 through 12/13/22. The facility was unable to produce evidence of missing skin and wound assessments/evaluations, dressing and treatment orders, dressing changes, change of condition documentation, or diabetic foot checks for Resident #1 when requested on 1/10/23 at 10:20 AM by the surveyor. A 12/14/22 hospital orthopedic progress note reveals that Resident #1 was transferred to the emergency department on 12/13/22 and orthopedic surgery was consulted for his/her left heel ulcer. The note reveals: On exam left heel ulcer probes to bone with thin eschar, which with removal has substantial fibrinous and necrotic tissue. A hospital operative report from 12/20/22 states Given the extent and location of the wound, presence of peripheral artery insufficiency, and the infectious burden related to the left heel wound, multiple providers had discussed with the patient that a left transtibial amputation would be appropriate, and Resident #1 had his/her left leg amputated below the knee on that day. Interview: Per interview on 1/4/23 at 12:36 PM, the Unit Manager confirmed that there was a dressing on Resident #1's heel when s/he first discovered the wound. S/He was unable to determine how long the pressure ulcer had been present and how long the dressing had been in place for. Per interview on 1/4/23 at 1:01 PM, the Administrator (ADM) confirmed that there had not been an initial nursing assessment, including a skin assessment for Resident #1's readmission on 9/14/22. The ADM confirmed that there was not a weekly skin check documented between 9/14/22 and the initial documentation of Resident #1's pressure ulcer by the facility. On 1/4/23 at 2:55 PM, the Unit Manager stated that there is a glitch with putting in orders for readmissions. When a resident is out of the facility for three or more days, orders are deleted, and the nurse must start from scratch to put orders in. There is no way of knowing what the previous orders were for a readmission but standard nursing orders, like skin assessments, should be there [in the EMR]. This could be one of the reasons Resident #1 did not have skin checks or diabetic foot checks as a nursing order. Per interview on 1/5/23 at 2:48 PM the Medical Director confirmed that nursing orders for daily foot checks for diabetic residents is a standard of care and should be a standard nursing order for all diabetics. S/He also confirmed that head to toe skin checks are to be done for all residents on return from the hospital. Per interview on 1/6/23 at 8:21 AM, Resident #1, stated that staff could have been more preventative with his/her care. S/He had noticed the spot on his/her foot months before staff started treating it and had told staff about his/her concern. S/He stated that by the time the Wound Nurse saw his/her heel, it was big and orange. S/He said that sometimes the dressing wouldn't be changed for 5-6 days. A later interview with Resident #1 on 1/10/23 at 4:10 pm reiterated the above and expanded to explain that staff did not look at his/her feet every day. [Resident #1's 1/10/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15.] On 1/6/22 at 11:55 AM, the Director of Nursing confirmed that the facility policy titled Skin Integrity and Wound Management should be followed by nursing staff for all residents. On 1/6/22 at 12:30 PM, the Regional Clinical Consultant stated that it is up to nursing judgment to add diabetic foot checks into nursing orders or care plans as it is not something standard the facility does for all diabetics. S/He confirmed that there is not written policy or procedure in place to ensure that a residents transfer of care information for wounds is entered into [the electronic medical record system]. On 1/9/23 at 9:20 AM, the Unit Manager stated that there is a diabetic protocol that should be implemented for every resident with diabetes. Once triggered, it will add orders for daily diabetic foot checks. S/He stated that nurses are working to the order and might not do daily diabetic foot checks if there is not an order for it. S/He stated that there is not a facility procedure on how to enter in orders and staff need something to refer to about the process. On 1/9/23 at 12:15 PM, a Licensed Practical Nurse (LPN) stated that s/he will do daily diabetic foot checks when they pop up on the medication administration record (MAR) or treatment administration record (TAR). On 1/9/23 at 1:22 PM, the Director of Nursing stated that when a change of condition form is filled out for new wounds, weekly skin and wound evaluations will auto populate in the EMR. S/He confirmed that a change of condition form is not being done all the time and it might be due to a training issue. On 1/9/23 at 3:19 PM, an LPN stated that s/he will do diabetic foot checks if they are on the TAR. On 1/10/23 at 9:50 AM, an LPN stated that skin checks and diabetic foot checks will pop up on the TAR if they are due. When asked if the diabetic residents on his/her assignment that day needed their feet checked every day, s/he stated that s/he was unaware that they did. On 10/10/23 at 10:20 AM, the Director of Nursing confirmed that the skin risk evaluation used by the facility was the Braden Scale for Predicting Pressure Sore Risk Assessment. Per interview on 1/10/23 at 11:55 AM, the Wound Nurse stated that Resident #1's wound was severe when s/he first cared for it. S/He said there have been issues around dressings not being changed at the facility and she had made management aware. Sometimes staff cannot answer question about residents' wound management, and s/he encounters situations where wound evaluations were not correct. S/He has done informal education sessions with staff and has offered to do a formal educational session for staff, but management has not taken him/her up on the offer. On 1/18/23 at 9:40 AM, the Director of Nursing and the Market President confirmed that the failures to implement the skin and wound policies and procedures were due to a mix of staff not having the enough training on the policies and procedures and staff not having the competencies to implement them. 2. Resident #6 Record review and interview reveal that the facility failed to provide timely and regular skin and wound assessments placing Resident #6 at increased risk for developing pressure ulcers. This failure resulted in the discovery of three unstageable pressure ulcers and two deep tissue injuries 43 days after his/her last skin check. Record Review Resident #6 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, muscle weakness, and dementia. Resident #3's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers and needs extensive or full assistance, requiring a two person assist for bed mobility, transferring, and toileting. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. Resident #6's care plan includes the following care plan focuses: Resident at risk for skin breakdown related to impaired mobility, advanced age, poor safety awareness, frail/fragile skin, incontinence, created on 8/18/22. Interventions include: Weekly skin check by license nurse, created on 8/18/22 and Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, created 8/18/22. The resident has potential for pressure ulcer development r/t [related to] decreased mobility, created on 2/15/21. Interventions include: Follow facility protocols for the prevention/treatment of skin breakdown, created on 2/15/21 and, Document/report to MD PRN [as needed] changes in skin status: appearance, color, wound healing, s/sx [signs and symptoms] of infection, wound size and stage, created on 2/15/21. A physician's order dated 7/27/22 states to Check skin condition to bilateral lower extremities daily every shift for fragile skin document in nurses note any new skin concerns. A skin check was done on 11/9/2022. No skin injury/wound(s) were noted. A skin check on 1/6/22 reveals the following wounds were identified: Unstageable pressure ulcer on left buttock (lateral). Unstageable pressure ulcer on left buttock (medial). Unstageable pressure ulcer on right heel. Deep tissue injury on left lateral foot. Deep tissue injury on left medial ankle. Review of Resident #6's medical record reveals that s/he does not have: A Braden Scale risk assessment from 2/26/22 through 1/11/23; or Weekly skin checks from 11/24/22 through 1/5/23. Interview On 1/17/23 at 11:03 AM, the Director of Nursing confirmed there is no evidence that skin checks were done as care planned and ordered in December 2022. 3. Resident #3 Record review and interview reveal that the facility failed to provide regular skin assessments and create and implement care plan interventions for daily diabetic foot monitoring, placing Resident #3 at increased risk for developing pressure ulcers. Record Review: Resident #3 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, hypertension, left foot drop, muscle weakness, dementia, depression, and history of stroke. Resident #3's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers and totally dependent on staff, requiring a two person assist for bed mobility, transferring, and toileting. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. Resident #3's care plan includes the following care plan focus: Patient is at risk for skin breakdown related to Advanced age (greater than [AGE] years), decreased activity, impaired Cognition, incontinence, limited mobility, nutritional concerns and or has actual skin integrity impairments-admitted with bruises to abdomen and bilateral arms, created on 12/21/22. Interventions include: Weekly skin check by license nurse created on 12/21/22. The care plan does not include daily diabetic foot checks. Review of Resident #3's medical record reveals that s/he does not have: A Braden Scale risk assessment from 12/20/22 through 1/8/23; A weekly skin check from 12/21/22 through 1/5/23; A care plan intervention for daily diabetic foot checks from 12/20/22 through 1/5/23; or Documentation of daily diabetic foot checks from 12/20/22 through 1/5/23. The facility was unable to produce evidence of missing risk assessments, skin checks, or documentation of diabetic foot checks for Resident #3 when requested on 1/10/23 at 10:20 AM by the surveyor. 4. Resident #8 Record review and interview reveal the facility failed to provide accurate and regular skin assessments and create a care plan intervention for daily diabetic foot monitoring, placing Resident #8 increased risk for developing pressure ulcers. Record Review: Resident #8 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, hypertension, peripheral vascular disease, chronic kidney disease, obesity, and coronary artery disease. Resident #8's MDS dated [DATE] reveals that s/he is at risk for developing pressure ulcers and needs staff assistance for transferring and toileting. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. Resident #8's care plan includes the following care plan focus: [Resident #8] is at risk for skin break down related to osteoarthritis, PVD [peripheral vascular disease], bilateral mastectomy. Resident currently has venous ulcers to right and left posterior legs and abrasion to left calf, created on 11/27/20. Interventions include: skin/wounds will be checked weekly by licensed professional, created on 10/18/22. The care plan does not include daily diabetic foot checks. Resident #8's medication administration record (MAR) reveals an order to Cleanse BLE [bilateral lower extremities] with wound cleaner. Pat dry. Apply moisturizing cream to intact skin. For RLE [right lower extremitiy] only iodosorb cream. Apply iodine cadexomer gel to open areas and cover with foam [cover with Ag/silver foam if iodine not available]. Wrap with roller gauze (kerlix) and adhesive wrap (Coban) every evening shift, every 2 day(s) for venous ulcers. This order was documented as completed throughout October. Skin checks from 10/1/22 and 10/11/22 indicate that Resident #8 does not have any skin injuries or wounds. This information contradicts the dressing changes for wounds documented as performed in the MAR. Review of Resident #8's medical record reveals that s/he does not have: A Braden Scale risk assessment from 2/12/21 through 1/11/23; Weekly skin checks from 8/28/22 through 9/30/22; Accurate skin checks from 10/1/22 through 10/17/22; Weekly skin checks from 12/13/22 through 1/5/23; or A care plan intervention for daily diabetic foot checks from 11/27/20 through 1/5/23. Interview: On 1/18/23 at 9:15 AM, the Unit Manager stated that traveling nursing staff do not get enough education when they are hired and that some staff do not document wounds on skin checks if the wound is not new. S/He confirmed that Resident #3 had venous ulcers on both legs during October 2022 and if skin checks on 10/1/22 or 10/11/22 stated that Resident #3 did not have any wounds on 10/1/22 or 10/11/22, the skin checks would not be accurate. On 1/18/23 at 11:00 AM, the Director of Nursing confirmed that there is no evidence that skin checks were completed for the above dates per facility policy and care plan. 5. Resident #2 Record review and interview reveal that the facility failed to provide an accurate comprehensive skin assessment on readmission and implement care plan interventions for daily diabetic foot monitoring, placing Resident #2 at increased risk for developing pressure ulcers. Record Review: Resident #2 was initially admitted to the facility on [DATE] and readmitted to the facility from the hospital on 9/1/22 with diagnoses that include type 2 diabetes mellitus, chronic respiratory failure, hypertension, chronic pain syndrome, chronic kidney disease, arthritis, anemia, congestive heart failure, legal blindness, and depression. Resident #2's care plan dated 8/9/22 reveals s/he needs staff assistance for transferring and toileting. These clinical conditions and comorbidities are risk factors for developing pressure ulcers. A 9/1/22 transition of care note [discharge summary] from the hospital reveals on pages 5-8 that Resident #2 had multiple assessed wounds and dressings including: a right heel wound described as red, with a small open area and boggy with a foam dressing; a left heel wound described as red and boggy with a foam dressing; and a left planter foot wound, described as black, brown, and open to air. A 9/1/22 nursing skin assessment does not document the above wounds noted in the 9/1/22 transition of care. Resident #2's care plan includes the following care plan focuses: Resident is at risk of skin breakdown r/t [related to] Seborrheic Dermatitis [skin condition affecting the scalp] < DM [diabetes] and alterations in mobility, created on 8/9/22. Interventions include: Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily, created on 8/9/22 and Weekly skin check by license nurse, created 8/9/22. The resident has a diagnosis of diabetes: Insulin Dependent, created on 8/3/22. Interventions include: Diabetic foot checks daily. Observe feet/toes/ankles/soles/heels noting alteration in skin integrity, color, temperature, and cleanliness, created on 8/3/22. Review of Resident #2's medical record reveals that s/he does not have: An accurate comprehensive readmission skin evaluation on 9/1/22; A Braden Scale risk assessment [score predicting the risk of developing pressure sores] from 8/8/22 through 12/20/22; or Documentation of daily diabetic foot checks from 9/1/22 through 12/30/22. The facility was unable to produce evidence of missing risk assessments or documentation of diabetic foot checks for Resident #2 when requested on 1/10/23 at 10:20 AM by the surveyor.

Per record review and interview, the facility failed to ensure that licensed nurses and other nursing personnel have the knowledge and competencies to provide skin and diabetic foot care for 5 of 6 sampled residents at risk for skin break down. Findings include: The facility's Facility Assessment, last updated 7/27/22, indicates that the facility is able to provide care and services related to skin integrity and management of medical conditions related to diabetes. Part 2: Services and Care We Offer Based on our Residents' Needs a. Skin integrity: Pressure injury prevention and care, wound care (surgical, pressure, other skin wounds) b. Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, . Record review and interview reveals the facility had systemic failures in ensuring staff were trained and competent in skin integrity and wound management per facility policies and professional standards of care by failing to ensure nursing staff were competent in: skin and wound assessment and skin and wound assessment documentation; wound dressing changes. These failures put 5 of the 6 sampled residents [Residents #1, #2, #3, #6, and #8] at increased risk for developing new pressure ulcer and non-pressure ulcer skin impairments, and increased risk for pressure ulcer and non-pressure ulcer skin impairments complications for 4 of the 6 samples residents [Residents #1, #2, #6, and #8]. Resident #1 had a below the knee amputation as a result of pressure ulcer complications, Resident #2 had a 5th toe amputation as a result of diabetic ulcer complications, and Resident #6 had a delayed treatment for 5 pressure ulcers creating an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. 1. It was established that training and competencies in skin assessment and wound care were not completed for all staff. Record Review: Review of 5 licensed nursing education records reveals the following: 4 of 5 licensed nurses did not have skin assessment training. 5 of 5 licensed nurses were not assessed for skin assessment competencies. 4 of 5 licensed nurses did not have wound care training. 3 of 5 licensed nurses were not assessed wound care competencies. 5 of 5 licensed nurses did not have change of condition training. Interview: Per interview on 1/4/23 at approximately 11:00 AM, the Administer revealed that the Nurse Educator, Director of Nursing (DON), and Assistant Director of Nursing had all recently stopped working at the facility. A temporary DON, who had been working at the facility less than a week when the complaint investigation started, was going to be taking on all these roles until replacements were hired. Per interview on 1/9/23 at approximately 9:00 AM, a Licensed Practical Nurse (LPN) stated that s/he did have some competencies when hired in October, but skin assessment was not one of them. On 1/9/23 at 12:25, an LPN stated that the facility did not do skin assessment competencies with him/her. On 1/9/23 at 1:22 PM, the DON confirmed that a change of condition form is not being done all the time and it might be due to a training issue. S/He confirmed that nurse training does not include skin assessment competencies, but s/he has a plan to do so. S/He handed this surveyor a Skin Assessment Clinical Competency Validation worksheet and stated that this is what should be used to evaluate skin assessment competencies with staff. Review of this competency worksheet reveal critical elements of competency include evaluating skin on all parts of the body and documenting results, including: changes in temperature, color, moisture, turgor, and integrity in the medical record. On 1/10/23 at 9:50 AM, an LPN stated that s/he did not have any skin assessment competencies since s/he was hired. On 1/10/23 between 2:59 PM and 4:30 PM, 3 licensed nursing assistants (LNA), 3 LPNs, and 1 registered nurse (RN) could not locate the skin integrity and wound management policy when asked. When showed the policy, the above staff confirmed that they had never seen it before. 2. It was established that staff are not implementing skin risk assessment, skin checks, wound evaluations, or diabetic foot checks unless there is a UDA [user defined assessment; assessment due to complete], or a treatment order to do so. Facility policy titled NSG236 Skin Integrity and Wound Management, last reviewed 9/1/22, states: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influences skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Practice Standards include: 3. Complete risk evaluation on admission, re-admission, weekly for the first month, quarterly, and with significant change in condition. 6. A licensed nurse will: 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. The American Diabetes Association Standards of Care in Diabetes-2023 reveals on page S209 the recommendation for diabetics to perform daily examination of the feet to identify early foot problems. Record Review: Record review reveals the facility failed to perform: Skin risk evaluations per facility schedule for Residents #1, #2, #3, #6, and #8; Skin inspections (skin checks) per facility schedule for Residents #1, #3, #6, and #8; Pressure injury and non-pressure injury wound evaluations per facility schedule for Residents #1, #2 and #8; Daily diabetic foot checks for Residents #1, #2, and #3. See F684 and F686 for additional information regarding residents #1, #2, #3, #6, and #8. Interview: On 1/5/23 at 2:48 PM the Medical Director confirmed that nursing orders for daily foot checks for diabetic residents is a standard of care and should be a standard nursing order for all diabetic residents. On 1/9/23 at 9:20 AM, the Unit Manager stated that there is a diabetic protocol that should be implemented for every resident with diabetes. Once triggered, it will add orders for daily diabetic foot checks. S/He stated that a lot of the nurses are working to the order [only doing what there is an order for] and might not do daily diabetic foot checks if there is not an order on a resident's MAR. On 1/10/23 at 9:50 AM, an LPN stated that skin checks and diabetic foot checks will pop up on the TAR if they are due. When asked if the diabetic residents on his/her assignment that day need their feet checked every day, s/he stated s/he was unaware that they did. On 1/10/23 at 9:50 AM, an LPN stated that s/he will do weekly skin assessments if they come up on the TAR. S/He has never had to do a head-to-toe skin assessment because those are only done on admission, and s/he has never had to do a new admission skin assessment since s/he has started working at the facility a few months ago. S/He is not aware of daily foot checks for the two residents with diabetes on the unit. S/He stated that foot checks would pop up on the TAR if they were needed. On 1/10/23 at 3:09 PM, a RN explained that s/he will perform skin risk assessments, skin checks, and wound evaluations when they pop up as an alert in the electronic medical record. On 1/10/23 at 3:25 PM, an LPN, when showed the skin integrity policy, s/he stated s/he had never seen it before. S/he revealed that s/he only knows that a resident needs skin checks or foot checks by what is due on the UDA or MAR/TAR. On 1/18/23 at 9:40 AM, the Director of Nursing and the Market President confirmed that the failures to implement the skin and wound policies and procedures were due to a mix of staff not having the enough training on the policies and procedures and staff not having the competencies to implement them. 3. It was established that not all skin assessments are accurate; some staff are not doing a full body skin assessment during skin checks and some staff are only documenting new skin injuries on skin checks. Record Review: Resident #2 was readmitted to the facility from the hospital on 9/1/22. A 9/1/22 transition of care note [discharge summary] from the hospital reveals on pages 5-8 that Resident #2 had multiple assessed wounds and dressings including: a right heel wound described as red, with a small open area and boggy with a foam dressing; a left heel wound described as red and boggy with a foam dressing; and a left planter foot wound, described as black, brown, and open to air. A 9/1/22 readmission nursing skin assessment by the facility does not document the above wounds noted in the 9/1/22 transition of care. Resident #8 was admitted to the facility on [DATE]. Skin checks and wound care notes indicate that Resident #8 had chronic venous ulcers to right and left posterior legs since admission. Resident #8 has physician's orders for treatment and dressing changes of these wounds. Skin checks from 10/1/22 and 10/11/22 reveals that Resident #8 does not have any skin injuries or wounds which contradicts the information in progress notes, the medication administration record (MAR), and treatment administration record (TAR). Interview: On 1/9/22 at 10:48 AM, Resident #4 stated that s/he does not recall having full body skin assessments regularly. It might have happened a couple times. They look at my skin but not head to toe. I feel like I'd remember staff looking at my skin head-to-toe. On 1/9/23 at 1:22 PM, the DON confirmed that skin checks are a head-to-toe assessment of all parts of the resident's body. On 1/9/23 at 4:03 PM, the Regional Clinical Consultant stated that there is an expectation for staff to document any irregularities of the skin, not just wounds, whether they are new or not. S/He confirmed that skin checks are a full body assessment of a resident's skin. On 1/10/23 at 9:50 AM, an LPN stated that s/he will do weekly skin assessments if they come up on the TAR. S/He has never had to do a head-to-toe skin assessment because those are only done on admission, and s/he has never had to do a new admission skin assessment since s/he has started working at the facility a few months ago. S/He is not aware of daily foot checks for the two residents with diabetes on the unit. S/He stated that foot checks would pop up on the TAR if they were needed. Per interview on 1/10/23 at 10:55 AM, the Wound Nurse stated s/he had made management aware that there have been issues with dressing changes for residents. S/He has encountered situations where the facility's assessment of a wound is not consistent with her/his own. S/He has offered to do formal educational sessions with facility staff, but the facility has never taken up the offer. On 1/18/23 at 9:15 AM, the Unit Manager stated that traveling nursing staff do not get enough education when they are hired and that some staff do not document wounds on skin checks if the wound is not new.

Based on interview and record review, the facility was not administered in a manner that enables it to maintain the physical well-being of each resident, whereby actions and decisions by the facility's leadership team directly contributed to deficient practices at F684 and F686. Findings include: Findings of deficient practices at F684 and F686 establish that 5 of 6 sampled residents were not provided effective care to promote optimal skin health, prevent pressure injuries and non-pressure injury skin impairments, and promote healing. As a result, these 5 residents were put at increased risk for developing pressure ulcer and non-pressure ulcer skin impairments. Failure to provide care per facility policy and professional standards of practice contributed to Resident #1 receiving a below the knee amputation due to a pressure ulcer complication, Resident #2 receiving a left toe amputation due to a diabetic ulcer complication, and Resident #6 having five unidentified pressure injuries. Per interview on 1/4/23 at 3:15 PM, the Administrator stated that leadership was aware of issues related to skin assessment not being completed. S/he stated that skin assessments were addressed during the 11/11/22 QAPI (quality assurance & performance improvement) meeting. Per interview on 1/10/23 at 11:55 AM, the Wound Nurse stated that there have been issues around dressings not being changed at the facility and she had made management aware. Sometimes staff cannot answer question about residents' wound management, and s/he encounters situations where wound evaluations were not correct. S/He has done informal education sessions with staff and has offered to do a formal educational session for staff, but management has not taken him/her up on the offer. On 1/10/23 at 12:20 PM, the Administrator and Market President confirmed that they were aware of the issues with skin care and have been working on it since the QAPI meeting in November. When asked what the facility has done to ensure residents were receiving the appropriate skin care since the November QAPI meeting, the Administrator said that they completed facility wide skin checks, updated care plans, and have done staff education starting 1/6/23. When asked if these actions were planned or if they were initiated because of the complaint investigations, the Administrator responded that the process took time. On 1/19/23 the Market President of Special Projects confirmed in an email that the facility was not able to find significant evidence of improvement activities related to the QAPI plan in place for skin care.

Based on interview and record review, the facility failed to ensure pain medication was administered per physician order for 1 of 31 sampled residents (Resident #368). Findings include: Per record review, Resident #368 was admitted to the facility on [DATE] for pain management and therapy following back surgery. Resident #368 had an order for HYDROmorphone HCl Tablet 2 MG Give 1 tablet by mouth every 3 hours as needed for Pain -Start Date- 09/12/2022 [Dilaudid, used to treat severe pain]. Per interview on 09/19/22 at 01:09 PM, Resident #368 stated that s/he didn't have his/her pain medication for almost 15 hours after admission. S/he said s/he was admitted to the facility around 5 PM in the evening and his/her pain was okay at first but became increasingly worse after arrival. S/he informed the nurse repeatedly of his/her pain. S/he was finally offered Tylenol and Robaxin [methocarbamol; a muscle relaxant] around 2:00 AM which didn't help manage the pain completely. S/he stated the nurse told her/him that the Dilaudid wasn't available because the pharmacy was closed, and the day shift would have to work on getting it. S/he reemphasized that it was the worst pain s/he had felt since surgery, s/he constantly asked for pain medication, and didn't get any relief until the following morning around 8:00 AM when s/he received her first dose of Dilaudid since being admitted to the facility. Per review of Resident #368's Medication Administration Record, Hydromorphone was not administered until 7:50 AM on 09/13/2022. Per interview on 9/20/22 at 11:05 AM, the Director of Nursing stated that Resident #368's Dilaudid was not available because the pharmacy did not have the faxed physician's orders. A faxed order is required to gain access to the CubeX [medication dispenser holding emergency medications], which is where the nurse would get the Dilaudid from at that time. Per interview on 9/20/22 at 2:16 PM, the Admission's Licensed Nurse Aide (ALNA) confirmed that Resident #368's order for Dilaudid was not faxed to the pharmacy until the following morning and it was the responsibility of the nurse that admitted Resident #368 to fax the order to the pharmacy on admission. S/he later revealed the order was faxed to the pharmacy at 7:30 AM on 9/13/22.

Based on observation, interview, and record review it was revealed that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 residents in a survey sample of 3. (Resident #1) 1.) Per record revew, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply in the AM Remove in the PM one time a day and remove per schedule. Review of Resident #1's comprehensive person-centered care plan, revealed the following current care plan: The resident has fluid overload or potential fluid volume overload r/t [related to] BLE [Bilateral Lower [CONDITION(S)]]. The goal specific to this care plan was as follows: The resident will remain free of s/sx [signs and symptoms] of fluid overload through review date as evidenced by decrease in or absence of [CONDITION(S)], anxiety, agitation, restlessness, confusion, changes in mood or behavior, nausea/vomiting, dypsnea, congestion, orthopnea, easily fatigued, jugular distentions. One of the interventions to this goal read, Compression stockings to BLE, apply in AM remove in PM. The date this goal was initiated was on 10/18/21 and the target date is documented as 02/22/22. Observation of Resident #1 in her/his room on 12/20/21 at 12:15 PM, revealed that s/he was wearing black shorts, a white shirt, and white socks and she/he was not wearing compression stockings. Interview on 12/20/21 at approximately 1:30 PM with Resident #1's assigned LNA (Licensed Nurses Aide) who confirmed the resident was not wearing her/his compression stockings. The LNA explained that a couple of days earlier, when s/he was providing care to the resident and the resident had a pair of black compression stockings on. The LNA removed these compression stockings and sent them to the laundry because they were covered in feces. The LNA stated to his/her knowledge the resident only had the one pair of compression stockings and the black ones have not yet come back from the laundry. Interview on 12/20/21 at approximately 12:16 PM with the LPN (Licensed Practical Nurse) who was assigned to this resident, s/he confirmed that Resident #1 was not wearing compression stockings as ordered. 2.) Per record review, Resident #1 had a current care plan that read, The resident will be able to express thoughts/feelings regarding current situation through next review. This goal was initiated on 05/17/2021 and was revised on 12/20/2021 with a target date of 02/22/2022. One of the interventions read, Stop sign across room door to deter other residents from entering room, 15 minutes [sic] check to provide for safety. Date initiated was 12/19/2021. Observation on 12/20/21 at 12:15 revealed a cloth stop sign was hung on the left side of the residents room doorway and on the right side of the doorway was a piece of velcro that the sign was noted to attach to. The cloth sign was hanging on the left side of the door and was not across the door. Interview with Resident #1, who stated that the cloth stop sign was put up to stop the lady with dementia from coming into my room - she comes in and drinks the coffee off my table, she goes through my things, and when I tell staff they do nothing about it. Time spent with the resident was from 12:15 PM to 1:00 PM and at no time did the staff come to put the cloth stop sign up and across the residents doorway and at no time during that 45 minutes did a staff member come and check in on the resident to meet the goal of 15 minute checks to provide safety. Interview with the assigned LNA who explained that the cloth sign should be across the residents doorway as some of the residents with dementia tend to wander into his room and this is upsetting to him. The LNA was not aware of 15 minute checks to provide safety. 3.) Per record review, Resident #1 had a current care plan that read, Alteration in musculoskeletal status r/t [related to] [CONDITION(S)] with an initiation date of 05/17/2021, there was no revision date. The goal read, The resident will remain free of complications through review date, the target date was documented as 02/22/2022. One of the interventions read, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Observation of Resident #1 on 12/20/21 at 12:15 PM revealed s/he was sitting in a wheelchair, leaning to the far left side, with the left side of her/his head resting on her/his left shoulder. The resident was wearing a pair of black shorts, a white shirt, and white mid shin high socks. S/he had a white towel wrapped around her/his waist, above the umbilicus and her/his mid and lower abdomen were exposed. The bottom of a [CONDITION(S)] bag was noted below the towel that was wrapped around the resident. The white towel was noted to have some light brown to yellow substance and particles covering much of the exposed surface. Under the resident in her/his wheelchair was a large white pad with writing on the underside, that covered the seat of the wheelchair and draped down in front of the wheelchair to approximately 2 inches above the front wheels of the wheelchair. Along the right side of this pad, from the seat of the wheelchair down to the bottom of the pad where it hung to approximately 2 inches above the front wheels of the wheelchair was a strip approximately 2 inches wide, where more of the light brown to yellow substance and particles were noted. The residents hands were noted to have this light brown and yellow substance on both her/his hands as well as on the right leg of her/his shorts. Introductions were made and the resident stated, I asked over an hour ago for someone to come in and help me, as you can see I am covered in feces. This is my life, everyday and they don't seem to care. I sit like this for hours until someone decides I am deserving of their help. She/he went on to say, I use to be able to care for myself, but my vision is so bad all I can see are shadows. When asked about the substance noted on the towel, her/his shorts, her/his hands and the pad they were sitting on, she/he stated this is all feces, they do not use the right supplies for my [CONDITION(S)]. During this interaction with this resident a person who identified themselves as the residents therapist, came into the room and greeted the resident. This person stated, this is unexceptable, I've suggested he call and file a complaint. S/he is on a hunger strike and I'm very concerned about his nutrition. The surveyor asked the resident why s/he was on a hunger strike and the resident stated, Because the staff here don't listen to me, they don't really seem to care about me and I worry about those that can't speak for themselves, I feel like doing this hunger strike, well, it might bring awareness to how we are treated. I came here because I wanted to but I didn't know the care was going to be so bad. It's not right for old people like me to be left sitting in feces for hours and then to be told we are difficult, argumentative, and hard to care for because we speak out. I am speaking out for all the residents here, because we pay good money and should get good care. This surveyor explained that they would bring to the staffs attention the residents current situation. The resident asked that this surveyor come back while the staff provide the care I want you to see for yourself the chemical [CONDITION(S)] I have on my skin from being left in my own feces for hours at a time. Interview on 12/20/21 at approximately 12:45 PM with the LPN who was assigned to this resident, s/he explained that they were aware of the residents needs but it takes 2 staff members to clean this resident up. S/he pointed to the LNA that was assigned to this resident and stated, she/he has been busy providing care to other residents while I've been busy passing medications to the residents and I have several Covid positive patients on my side so I have to put gloves on, mask, face shield, and a gown before I go into the room, then I provide the care and have to ungarb to go to the next residents room and then do the same thing with putting on new gloves, masks, face shield and gown. The surveyor asked her/him to come and see the resident to which the LPN put her/his arms out to the side and said, What? Do you want me to go clean him/her up now? The nurse and surveyor arrived in the residents room at approximately 12:55 PM, the nurse confirmed that the resident was covered in her/his own feces and referred to the [CONDITION(S)] stating that it must have let loose and, yup, this is a typical day. The nurse explained that the process of cleaning the resident up after this type of situation is quite time consuming so he is usually done once everyone has received their care for the morning. The nurse stated she would gather the supplies and she/he and the assigned LNA would come back and get her/him cleaned up. Interview with the DON on 12/20/21 at approximately 1:10 PM who agreed to go to the unit and see the resident. Upon approaching the residents room with the DON, the resident was out in her/his wheelchair in the hallway just outside of her/his room. The assigned LPN and LNA met us with the resident, who had not been cleaned up at this point. The DON greeted the resident who stated to the DON, This is new, all this attention all of a sudden, too bad it took a visit from the state to get the care I need. The DON acknowledged the residents condition and that she/he had feces on her/his clothes, hands, down the front of the pad she/he was sitting on in the wheelchair and the towel wrapped around the resident that was also covered in feces. The DON stated she/he was not aware of this being a frequent occurance. The LPN requested the resident to come into her/his room so she/he could change the residents catheter and ostomy. The resident asked the LPN to please use the ostomy supplies that were in the box at the end of her/his bed. The LPN brought out into the hallway, 5 different ostomy bags and supplies and asked the resident which one she/he wanted to use. The resident explained to the LPN which supplies work the best but she/he was not sure if there were any left. The resident explained that the supplies she/he had at home are the ones that she/he has used for a long time and they work very well. The resident stated that a while ago a staff member went to the residents home and brought back one box of the supplies the resident used prior to her/his admission to this facility. The resident asked why the facility couldn't just order the supplies that worked and stated, I told them if my insurance wouldn't cover them then I would pay for them and they still use whatever they want. The resident stated that the facility uses whatever they happen to have available instead of the proven supplies that really work. At 1:45 PM the resident was in her/his bed and the LPN pulled the front of the residents incontinence brief forward which revealed a large amount of dried feces on the residents lower abdomen. The LNA brought to the residents bedside a basin of warm soapy water. The LPN attempted to wash the feces off with a warm wet wash cloth with soap and the resident cried out and stated, Oh my god that hurts so bad, please, what are you doing? The LPN explained, I just tried washing the feces off but it is dried in place. I will need to soak your tummy for a bit to clean it all off. The LPN put the washcloth in the basin and then pulled it out and squeezed the water onto the residents abdomen. S/he then patted and wiped the residents abdomen until the abdomen was clean exposing red, raw skin. The LPN then lifted the bottom of the residents shirt up above the [CONDITION(S)] bag and then lifted the bottom of the [CONDITION(S)] bag where she/he noted red, raw skin where the bottom of the [CONDITION(S)] bag was. White tape that was discolored with a brownish yellow substance, was noted around where the opening of the ostomy bag is. The LPN stated s/he was going to remove the entire ostomy device and replace with all new as well as changing the resident catheter and clothes. At 2:15 PM the LPN and LNA were still working to get the resident cleaned up. An interview on 12/20/21 at proximately 2:30 PM with the Regional Director of Clinical Services regarding the observation and interviews that took place earlier in the day specific to observations made of this resident at 12:15 PM and an hour and a half later, at 1:45 PM staff had started to provide care to the resident. S/he did explain that this resident does refuse care at times and most recently was found in a similar way by the Administrator. S/he stated that the Administrator offered to get staff to come clean her/him up and she/he stated they wanted to eat their breakfast first. Review of Resident #1's medical record revealed an active order that read, Complete Weekly Skin Review every day shift every Mon. The following Weekly Skin Review were noted 11/06/2021 at 21:46 revealed redness and pre-existing skin tears. A note states, Skin tear to L [left] shin, tx is place, scattered small open areas surrounding stoma, tx in place.; 11/15/2021 at 13:30 that reports the same areas and the same note; 11/22/2021 at 13:35 that reports the same areas with a note that states, Stoma site present on abdomen, tx in place. L shin wound tx in place.; 11/29/2021 at 13:35 revealed Skin Tears pre-existing and a note that states, skin tear in healing stages; 12/06/2021 at 13:35 revealed Skin Tears pre-existing and Open Area. A note stated, Left shin skin tear Stoma to right abdomen; and 12/13/2021 at 14:21 revealed Skin Tears pre-exisiting and Open Area. A note stated, Skin tear to L shin, tx in place, scattered small open areas surrounding stoma, tx in place. A review of the residents MAR (Medication Administration Record) revealed that the resident had not had any behaviors for the month of the November 2021 and December of 2021 and there was no documentation to support that the resident refused care or services. Review of the last 30 days of nurses notes revealed resident refused a shower on 11/16/21 stating, I'm not in the mood for it and its too cold.; a nursing note dated 12/14/21 reveals, Patient became agitated and verbally aggressive during meal pass this evening .Patient proceeded to move down to dining room to yell and be verbally aggressive with staff .Patient returned to room agitated, unable to redirect.; and on 12/20/21 at 08:21 a Behavior Note was entered stating, This writer spoke to [proper name omitted] on or about 12/16/21 about [pronoun omitted] taking over the day room with all of [pronoun omitted] gadgets and IT type equipment Also on Saturday 12/18/21 when this writer was serving breakfast I noticed [proper name omitted] to be soiled from his [CONDITION(S)] bag. I told [pronoun omitted] I would get an LNA to help. [Pronoun omitted] refused saying [proper name omitted] wanted to eat breakfast first. After [pronoun omitted] finished breakfast [pronoun omitted] consented to and received care., this was signed by the facility Administrator. There were no other notes or documentations available to support frequent refusals of care. There is a PA's (Physician Assistant) note dated 12/20/2021 at 10:17 AM, Review of Systems does not include any skin assessment or documentation specific to the residents complaints about her/his skin having chemical [CONDITION(S)]. A previous assessment completed on 12/02/2021 at 04:22 PM by the PA did include an assessment of the residents integumentary (skin) system and reveals the resident had a rash, there were no recommendations made specific to this rash.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents are treated with respect and dignity for 1 resident. ( Resident #1). Findings include: Observation of Resident #1 on 12/20/21 at 12:15 PM revealed she/he was sitting in a wheelchair, leaning to the far left side, with the left side of her/his head resting on her/his left shoulder. The resident was wearing a pair of black shorts, a white shirt, and white mid shin high socks. She/he had a white towel wrapped around her/his waist, above the umbilicus and her/his mid and lower abdomen were exposed. The bottom of a [CONDITION(S)] bag was noted below the towel that was wrapped around the resident. The white towel was noted to have some light brown to yellow substance and particles covering much of the exposed surface. Under the resident in her/his wheelchair was a large white pad with writing on the underside, that covered the seat of the wheelchair and draped down in front of the wheelchair to approximately 2 inches above the front wheels of the wheelchair. Along the right side of this pad, from the seat of the wheelchair down to the bottom of the pad where it hung to approximately 2 inches above the front wheels of the wheelchair was a strip approximately 2 inches wide, where more of the light brown to yellow substance and particles were noted. The residents hands were noted to have this light brown and yellow substance on both her/his hands as well as on the right leg of her/his shorts at the thigh area. Introductions were made and the resident stated, I asked over an hour ago for someone to come in and help me, as you can see I am covered in feces. This is my life, everyday and they don't seem to care. I sit like this for hours until someone decides I am deserving of their help. S/he went on to say, I use to be able to care for myself, but my vision is so bad all I can see are shadows. When asked about the substance noted on the towel, her/his shorts, her/his hands and the pad s/he were sitting on, s/he stated this is all feces, they do not use the right supplies for my [CONDITION(S)]. During this interaction with this resident a person who identified themselves as the residents therapist, came into the residents room and greeted the resident. This person stated, this is unacceptable, I've suggested s/he call and file a complaint. S/he is on a hunger strike and I'm very concerned about her/his nutrition. The surveyor asked the resident why s/he was on a hunger strike and the resident stated, Because the staff here don't listen to me, they don't really seem to care about me and I worry about those that can't speak for themselves, I feel like doing this hunger strike, well, it might bring awareness to how we are treated. I came here because I wanted to but I didn't know the care was going to be so bad. It's not right for old people like me to be left sitting in feces for hours and then to be told we are difficult, argumentative, and hard to care for because we speak out. I am speaking out for all the residents here, because we pay good money and should get good care. This surveyor stated that they would bring to the staffs attention the residents current situation. The resident asked that this surveyor come back while the staff provide the care I want you to see for yourself the chemical [CONDITION(S)] I have on my skin from being left in my own feces for hours at a time. Interview on 12/20/21 at approximately 12:45 PM with the LPN who was assigned to this resident, s/he explained that they were aware of the residents needs but it takes 2 staff members to clean this resident up. S/he pointed to the LNA that was assigned to this resident and stated, s/he has been busy providing care to other residents while I've been busy passing medications to the residents and I have several Covid positive patients on my side so I have to put gloves on, mask, face shield, and a gown before I go into the room, then I provide the care and have to ungarb to go to the next residents room and then do the same thing with putting on new gloves, masks, face shield and gown. The surveyor asked her/him to come and see the resident to which the LPN put her/his arms out to the side and said, What? Do you want me to go clean [pronoun omitted] up now? The nurse and surveyor arrived in the residents room at approximately 12:55 PM, the nurse confirmed that the resident was covered in his/her own feces and that the [CONDITION(S)] bag must have let loose, s/he stated, yup, this is a typical day for [pronoun omitted]. The nurse explained that the process of cleaning the resident up after this type of situation is quite time consuming so s/he is usually assisted once everyone else has received their care for the morning. The nurse stated s/he would gather the supplies, get the assigned LNA and they would come back and get her/him cleaned up. Interview with the DON on 12/20/21 at approximately 1:10 PM who agreed to go to the unit with the surveyor and see the resident. Upon approaching the residents room with the DON, the resident was out in her/his wheelchair in the hallway just outside of her/his room. The assigned LPN and LNA met us with the resident, who had not been cleaned up at this point. The DON greeted the resident who stated to the DON, This is new, all this attention all of a sudden, too bad it took a visit from the state to get the care I need. The DON acknowledged the residents condition and that s/he had feces on her/his clothes, hands, down the front of the pad s/he was sitting on in the wheelchair and the towel wrapped around the residents waist that was also covered in feces. The DON stated s/he was not aware of this being a frequent occurrence. The LPN requested the resident to come into her/his room so s/he could change the resident's catheter and ostomy and get h/him cleaned up and in some clean clothes. The resident asked the LPN to please use the ostomy supplies that were in the box at the end of her/his bed. The LPN brought out into the hallway, 5 different ostomy bags and supplies and asked the resident which one s/he wanted to use. The resident explained to the LPN which supplies work the best but s/he was not sure if there were any left. The resident explained that the supplies s/he had at home are the ones that s/he had used for a long time and they work very well. The resident stated that a while ago a staff member went to the residents home and brought back one box of the supplies the resident used prior to her/his admission to this facility. The resident asked why the facility couldn't just order the supplies that worked and stated, I told them if my insurance wouldn't cover them then I would pay for them and they still use whatever they want. The resident stated that the facility uses whatever they happen to have available instead of the proven supplies that really work. At 1:45 PM the resident was in her/his bed and the LPN pulled the front of the residents incontinence brief forward which revealed a large amount of dried feces on the residents lower abdomen. The LNA brought to the residents bedside a basin of warm soapy water. The LPN attempted to wash the feces off with a warm wet wash cloth with soap and the resident cried out and stated, Oh my god that hurts so bad, please, what are you doing? The LPN explained, I just tried washing the feces off but it is dried in place. I will need to soak your tummy for a bit to clean it all off. The LPN put the washcloth in the basin and then pulled it out and squeezed the water onto the residents abdomen. S/he then patted and wiped the residents abdomen until the abdomen was clean exposing red, raw skin. The LPN then lifted the bottom of the residents shirt up above the [CONDITION(S)] bag and then lifted the bottom of the [CONDITION(S)] bag where s/he noted red, raw skin where the bottom of the [CONDITION(S)] bag was. White tape that was discolored with a brownish yellow substance, was noted around where the opening of the ostomy bag was. The LPN stated s/he was going to remove the entire ostomy device and replace with all new as well as changing the residents catheter. At 2:15 PM the LPN and LNA were still working to get the resident cleaned up. On four occasions during this time while care was being provided by the LPN, s/he said, I know that hurts baby, I'm sorry. On 12/20/21 at approximately 2:30 PM an interview with the Regional Director of Clinical Services regarding the interviews that took place earlier, specific to the observations that were made of this resident at 12:15 PM and an hour and a half later, at 1:45 PM staff had started to provide care to the resident. S/he stated that this resident does refuse care at times and most recently was found in a similar way by the Administrator. S/he stated that the Administrator offered to get staff to come clean her/him up and s/he stated they wanted to eat their breakfast first. A review of the residents MAR (Medication Administration Record) revealed that the resident had not had any behaviors for the month of the November 2021 and December of 2021 and there was no documentation to support that the resident refused care or services. Review of the last 30 days of nurses notes revealed resident refused a shower on 11/16/21 stating, I'm not in the mood for it and its too cold.; a nursing note dated 12/14/21 reveals, Patient became agitated and verbally aggressive during meal pass this evening .Patient proceeded to move down to dining room to yell and be verbally aggressive with staff .Patient returned to room agitated, unable to redirect.; and on 12/20/21 at 08:21 a Behavior Note was entered stating, This writer spoke to [proper name omitted] on or about 12/16/21 about [pronoun omitted] taking over the day room with all of [pronoun omitted] gadgets and IT type equipment .Also on Saturday 12/18/21 when this writer was serving breakfast I noticed [proper name omitted] to be soiled from his [CONDITION(S)] bag. I told [pronoun omitted] I would get an LNA to help. [Pronoun omitted] refused saying [proper name omitted] wanted to eat breakfast first. After [pronoun omitted] finished breakfast [pronoun omitted] consented to and received care., this was signed by the facility Administrator. There were no other notes or documentations available to support frequent refusals of care. There is a PA's (Physician Assistant) note dated 12/20/2021 at 10:17 AM, Review of Systems which does not include any skin assessment or documentation specific to the residents complaints about her/his skin having chemical [CONDITION(S)]. A previous assessment completed on 12/02/2021 at 04:22 PM by the PA did include an assessment of the residents integumentary (skin) system and reveals the resident had a rash, there were no recommendations made specific to this rash and no treatment for this rash listed in the current doctors orders.

Based upon observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality regarding a Do Not Resuscitate [DNR] order, for 1 resident [Res. #37] of 31 residents with DNR orders. This citation is at the immediate jeopardy level due to significant risk of serious harm to this resident and the 30 other residents with DNR orders, as a result of the noncompliance. Findings include: Per review of the [NAME] Department of Health Do Not Resuscitate/ Clinician Orders for Life Sustaining Treatment [DNR/COLST] form - Instructions for Clinicians Completing [NAME] DNR/COLST: Health care professionals, health care facilities, and residential care facilities must honor a DNR order or a DNR identification unless the professional or facility believes in good faith, after consultation with the patient, agent, or guardian, where possible and appropriate: - That the patient wishes to have the DNR Order revoked, or - That the patient with the DNR indemnification or order is not the individual for whom the DNR order was issued. Documentation of basis for belief in medical record is required. Review of Res. #37's Care Plan reveals the resident identified as The resident has an advanced directive of DNR, with the goal listed as The resident's advanced directives will be honored. Review of the facility's policy and procedure titled 'Cardiac and/or Respiratory Arrest', Section 2.2 reads If there is a DNR order: Do not initiate CPR/AED. Per record review, Res. #37's medical records included both a paper chart in a binder, located at the Nurses' Station on Res. #37's unit, and an electronic medical record, also accessible at the Nurses' Station. Per observation, Res. #37's printed DNR order dated [DATE] was located immediately inside the binder cover in a clear plastic sleeve. The orders read (If patient/resident has no pulse and/or no respirations)-an 'X' is marked next to DNR/Do Not Attempt Resuscitation (Allow Natural Death). Further record review revealed a printed copy of Res. #37's face sheet located in the binder, with the entry DNR located under Advance Directives. Review of Res. #37's electronic medical record also contained a scanned photographic copy of the resident's DNR order and the face sheet listing the resident as DNR. A list was requested and provided by the facility of all residents with DNR status, and among the 31 residents listed was Res. #37. Review of Res. #37's medical record dated [DATE] reveals an entry by the Nurse Practioner [NP] who was on Res. #37's unit. The entry reads: Sitting writing notes when an LNA [Licensed Nursing Assistant] notified me at approx. 4:25 that the resident was difficult to arouse and breathing funny. Found unconscious and breathing in an irregular [NAME]-stokes pattern*. Call placed to 911. Deep sternal rubbing, loud verbal stimulus without response, repositioned, back board place no change. Apneic periods [moments without any breath], loss of pulse. AED applied [Automated External Defibrillator- a portable medical device that analyzes the heart rhythm of a person in sudden [CONDITION(S)]] analyzed directed chest compressions [part of CPR: Cardiopulmonary Resuscitation]. [MEDICATION(S)] IM administer approx. 4:40. Compressions for approx. 5 mins between 4:,d+[DATE]:45 when analyzer started clear. Police arrived and then EMT arrived around 4:50. [Res. #37] then started to arouse. *['In addition to heart failure and stroke .[NAME]-Stokes respirations are also a clinical sign seen in people who are in the process of dying'* https://www.sleepfoundation.org/sleep-apnea/[NAME]-stokes-respirations] Nurses Notes dated the next day, [DATE] record [Res. #37] returned from ER last night at 10:45 PM via ambulance stretcher . [Res. # 37] is very upset that s/he received CPR. States his/her chest and back hurt, and s/he did not want to go through this again, and that is why s/he has a DNR order. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR initiated .UDS [Urine Drug Screen] negative. Labs negative. Returned to facility. Met with patient. Denies drug ingestion .Patient alert, oriented, complains of chest pain from CPR.'I'M A DNR' .significant pain from CPR . An interview was conducted with Res. #37 on [DATE] at 4:19 PM. The resident reported that on [DATE] his/her heart stopped and s/he had stopped breathing. S/he stated that s/he wanted nothing done to him/her, that s/he had obtained a DNR order in [DATE] that was signed by him/her, the doctor, and was notarized. The resident stated the DNR status is reviewed with him/her weekly. S/he stated that s/he was mad when s/he realized s/he had been brought back. S/he stated when his/her heart stops, I am done. The resident further stated that even if his/her heart stopped or breathing stopped due to a drug overdose, s/he did not want to be given life-saving measures, including chest compressions. During the interview, the resident pointed to a bracelet on his/her right wrist. The clear plastic bracelet contained a strip of pink/orange paper, upon which was printed in black capital letters Do Not Resuscitate.

Based upon observation, interview, and record review, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment was implemented, as indicated in a Do Not Resuscitate [DNR] order, for 1 resident [Res. #37] of 31 residents with DNR orders. This citation is at the immediate jeopardy level due to significant risk of serious harm as a result of the noncompliance to this resident and the 30 other residents with DNR orders. Findings include: A review of Res. #37's medical record reveals the resident has complex medical issues and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Res. #37 on [DATE] at 4:19 PM. The resident reported that on [DATE] his/her heart stopped and s/he had stopped breathing. S/he stated that s/he wanted nothing done to him/her, that s/he had obtained a DNR [Do Not Resuscitate] order in [DATE] that was signed by him/her, the doctor, and was notarized. The resident stated the DNR status is reviewed with him/her weekly. S/he stated that s/he was mad when s/he realized s/he had been brought back. S/he stated when his/her heart stops, I am done. The resident further stated that even if his/her heart stopped or breathing stopped due to a drug overdose, s/he did not want to be given life-saving measures, including chest compressions. During the interview, the resident pointed to a bracelet on his/her right wrist. The clear plastic bracelet contained a strip of pink/orange paper, upon which was printed in black capital letters Do Not Resuscitate. A review of Res. #37's Minimum Data Sheet, dated 6 days after Res. #37 signed his/her DNR directive on [DATE], contains a Brief Interview for Mental Status [BIMS], which is used to assess a resident for cognitive impairment. The BIMS assessed Res. #37 as cognitively intact, rating the resident with a score of '15', the highest score possible. Per record review, Res. #37's medical records included both a paper chart in a binder, located at the Nurses' Station on Res. #37's unit, and an electronic medical record, also accessible at the Nurses' Station. Per observation, Res. #37's printed DNR order dated [DATE] was located immediately inside the binder cover in a clear plastic sleeve. The orders read (If patient/resident has no pulse and/or no respirations)-an 'X' is marked next to DNR/Do Not Attempt Resuscitation (Allow Natural Death). Further record review revealed a printed copy of Res. #37's face sheet located in the binder, with the entry DNR located under Advance Directives. Review of Res. #37's electronic medical record also contained a scanned photographic copy of the resident's DNR order and the face sheet listing the resident as DNR. A list was requested and provided by the facility of all residents with DNR status, and among the 31 residents listed was Res. #37. Review of the facility's policy and procedure titled 'Cardiac and/or Respiratory Arrest', Section 2.2 reads If there is a DNR order: Do not initiate CPR/AED. Review of Res. #37's medical record dated [DATE] reveals an entry by the Nurse Practioner [NP] who was on Res. #37's unit. The entry reads: Sitting writing notes when an LNA [Licensed Nursing Assistant] notified me at approx. 4:25 that the resident was difficult to arouse and breathing funny. Found unconscious and breathing in an irregular [NAME]-stokes pattern*. Call placed to 911. Deep sternal rubbing, loud verbal stimulus without response, repositioned, back board place no change. Apneic periods [moments without any breath], loss of pulse. AED applied [Automated External Defibrillator- a portable medical device that analyzes the heart rhythm of a person in sudden [CONDITION(S)]] analyzed directed chest compressions [part of CPR: Cardiopulmonary Resuscitation]. [MEDICATION(S)] IM administered approx. 4:40. Compressions for approx. 5 mins between 4:,d+[DATE]:45 when analyzer stated clear. Police arrived and then EMT arrived around 4:50. [Res. #37] then started to arouse. *['In addition to heart failure and stroke .[NAME]-Stokes respirations are also a clinical sign seen in people who are in the process of dying' https://www.sleepfoundation.org/sleep-apnea/[NAME]-stokes-respirations] Nurses Notes dated the next day, [DATE] record [Res. #37] returned from ER last night at 10:45 PM via ambulance stretcher . [Res. # 37] is very upset that [s/he] received CPR. States [his/her] chest and back hurt, and [s/he] did not want to go through this again, and that is why [s/he] has a DNR order. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR initiated .UDS [Urine Drug Screen] negative. Labs negative. Returned to facility. Met with patient. Denies drug ingestion .Patient alert, oriented, complains of chest pain from CPR. 'I'M A DNR' .significant pain from CPR . An interview was conducted with the facility's Staff Educator on [DATE] at 8:09 AM. The Staff Educator stated that after the incident, all staff were sent an email stating where to find DNR information on a resident's chart and to check a resident's chart prior to initiating CPR. The Staff Educator provided a list of all the staff who received the email, and the NP who initiated the CPR on Res. #37 was not included on the list. The Staff Educator stated the facility's Administrator [ADM] and Director of Nursing Services [DNS] at the time of the incident both spoke with the NP after the incident. An interview was conducted with the facility's ADM on [DATE] at 9:06 AM. The ADM stated he was out of state at a company function on [DATE] and upon his return he spoke with the NP about the incident. He also stated that he did not provide education related to DNR status and that he was unaware if the DNS at the time had done so. An interview was conducted with the DNS at the time of incident on [DATE] at 9:20 AM. The DNS stated that the NP was not specifically educated by the DNS, and the DNS did not realize the Medical Director overseeing the NP and NP were not part of email group who received the DNR education. An interview was conducted with the NP on [DATE] at 8:48 AM. The NP stated she received education regarding where DNR information is located on a resident's chart and to check for DNR information. The NP stated that she received the education from the Staff Educator. [As noted above, the Staff Educator stated that she educated staff via an email, which the NP was not included on. The Staff Educator also stated the NP was spoken to by the ADM and the DNS at the time, who both stated they did not educate the NP on DNR status.] An interview was conducted with the facility's Medical Director who oversees the NP on [DATE] at 9:38 AM. The Medical Director stated that he did not give any education to the NP regarding DNR status and procedures at the facility. Per interview with the ADM, the current DNS, the Medical Director, and the Staff Educator, and per record review, there was no documentation that the NP received any education regarding DNR status, procedures, and resident rights after the incident with Res. #37 on [DATE].

Based on observations, interviews, and record review, the facility failed to prevent accidents by providing an environment that is free from hazards over which the facility has control for 1 of 15 residents (Resident #14). This citation is at the immediate jeopardy level due to significant risk of serious harm or death as a result of the noncompliance. Findings include: Resident # 14 was found making suicidal gestures on two documented occasions. The facility failed to take adequate measures to ensure resident safety, resulting in ongoing risk of serious harm and/or death, due to lack of assessment of the resident's mental status and lack of assessment of the safety of the resident's environment Resident #14 has a history of [CONDITION(S)], major depressive disorder, muscle weakness (generalized), and unsteadiness on feet. Resident #14 was admitted in January 2020 and had two significant falls on 06/17/20 and 7/25/20 that required hospital evaluation. The Minimum Data Set (MDS) on 12/21/20 indicates that Resident #14 requires a 2 person assist for bed mobility, is non-ambulatory, and has a Brief Interview for Mental Status (BIMS) of 2, indicating severe cognitive impairment. Per review of nursing progress notes dated 12/25/20, Resident #14 was found by a Licensed Nursing Assistant (LNA) in bed, with a call light cord wrapped around his/her neck. The Licensed Practical Nurse (LPN) documented that would continue rounding q 2 hours and that there was no further attempt by resident to harm self-noted for remainder of shift. A progress note dated 12/30/20 stated that Resident #14 was found by an LNA in bed with a call light cord wrapped around his/her neck. The call light cord was removed at this time and replaced with hand bell for safety purposes. LPN reported that resident was last checked on approximately 1.5H ago. There is no indication in the clinical record that management was notified or that additional precautions were put into place. On 02/02/21 at 1:01 PM, the Center Nursing Executive stated that the policy for suicidal ideations and self-harm includes an assessment for significant change in condition. S/he stated that the resident needs to be assessed and cleared by a physician, and staff should then follow provider recommendations. On 02/02/21 at 01:41 PM, the Social Services Director stated that facility policy for self-harming behaviors includes removing harmful objects from resident and placing the resident on a one-to-one observation until seen by a physician. S/he confirmed that Resident #14 was not placed on one-to-one observation, per facility policy, after either incident on 12/25/20 and 12/30/20. On 02/02/21 at 2:10 PM, Resident #14's roommate stated during interview that in December 2020, Resident #14 wrapped a call light cord around his/her neck 4 times and wrapped a phone cord around his/her neck 1 time. S/he stated that the cord was wrapped several times around Resident #14's neck, and that on all the 5 occasions, s/he went to get help from staff. Resident #14's roommate was alert and oriented, with a BIMS score of 15, indicating little to no cognitive impairment. On 02/03/21, facility policy on Suicide Threats was reviewed. The policy stated that in the event that there is a resident threat of suicide, the resident will be placed on 1:1 observation until the acute episode has been resolved if the resident is physically capable of self-injury. On all three survey days, Resident #14 was observed in bed with a long phone cord within arm's reach. On 02/03/21 at 10:54 AM, Resident #14's family was contacted to discuss the events of 12/25/20 and 12/30/20. Resident #14's family confirmed that the facility never contacted family after either event. The family member stated that he/she was told by Resident # 14's roommate that Resident #14 had wrapped a cord around his/her neck. On 2/3/21 at 12:09 PM, the Center Executive Director (CED) confirmed that the resident should have been placed on 1:1 supervision immediately after each incident and that management, the physician and the family should have been notified. The CED also confirmed that this had not been done per facility policy. Refer also to F580.

Based on observations, interviews, and record review, the facility failed to consult with the resident's physician and notify the resident representative when there is a significant change in health, mental, or psychosocial status for 1 of 15 residents (Resident #14). This citation is at the immediate jeopardy level due to significant risk of serious harm or death as a result of the noncompliance. Findings include: Resident #14 was found making suicidal gestures on two documented occasions. The facility failed to notify the physician and the resident representative of a significant change in the resident's mental status, resulting in ongoing risk of serious harm and/or death, due to lack of assessment of the resident's mental status and lack of assessment of the safety of the resident's environment. Resident #14 has a history of [CONDITION(S)], major depressive disorder, muscle weakness (generalized), and unsteadiness on feet. Resident #14 was admitted in January 2020 and had two significant falls on 06/17/20 and 7/25/20 that required hospital evaluation. The Minimum Data Set (MDS) on 12/21/20 displays that Resident #14 requires a 2 person assist for bed mobility, is non-ambulatory, and has a Brief Interview for Mental Status (BIMS) of 2, indicating severe cognitive impairment. Per review of nursing progress notes dated 12/25/20, Resident #14 was found by a Licensed Nursing Assistant (LNA) in bed, with a call light cord wrapped around his/her neck. The Licensed Practical Nurse (LPN) documented they would continue rounding q 2 hours and that there was no further attempt by resident to harm self noted for remainder of shift. Another progress note dated 12/30/20 stated that Resident #14 was found by an LNA in bed with a call light cord wrapped around his/her neck. The call light cord was removed at this time and replaced with hand bell for safety purposes. There is no indication in the clinical record that the LPN notified the management team. On all three survey days, Resident #14 was observed in bed with a long phone cord within arm's reach. On 02/02/21 at 1:01 PM, the Center Nursing Executive stated that the policy for suicidal ideations and self-harm includes an assessment for significant change in condition. S/he stated that the resident needs to be assessed and cleared by a physician, and staff should then follow provider recommendations. On 02/02/21 at 01:41 PM, the Social Services Director confirmed that staff did not notify social services of Resident 14#'s incidents per facility policy. S/he stated that s/he was unaware that the incidents were suicidal gestures until today, and s/he confirmed that Resident #14 was not assessed by a physician after either event on 12/25/20 and 12/30/20. On 02/02/21 at 2:10 PM, Resident #14's roommate stated during interview that in December 2020, Resident #14 wrapped a call light cord around his/her neck 4 times and wrapped a phone cord around his/her neck 1 time. S/he stated that the cord was wrapped several times around Resident #14's neck, and that on all the 5 occasions, s/he went to get help from staff. Resident #14's roommate was alert and oriented, with a BIMS score of 15, indicating little to no cognitive impairment. On 2/02/21, Genesis Health Care Skilled Nursing Centers policy on NSG115 Physician/Advanced Practice Provider (APP) Notification was reviewed. The policy stated that upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations, collect pertinent patient information .and data collection and report to physician/ advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. Review of policy identifies suicidal gestures as an immediate notification to provider. Per record review on 02/02/21, Resident #14 had no Significant Change of Condition assessment after incident on 12/25/20 and after incident on 12/30/20. There is no documentation that a physician was notified of either event or that the medical director was contacted. On 02/03/21, facility policy on Suicide Threats was reviewed. The policy stated that any resident threats of suicide must be reported immediately to nurse supervisor/charge nurse, the resident's attending physician, the resident's responsible party, the Director of Nursing Services and/or Administration, and social services staff. Per record review on 02/03/21, resident's physician, Center Nursing Executive, social services staff, and Resident #14's family was not notified after either incident on 12/25/20 and on 12/30/20. On 02/03/21 at 10:54 AM, Resident #14's family was contacted to discuss the events of 12/25/20 and 12/30/20. Resident #14's family confirmed that the facility never contacted family after either event. The family member stated that s/he was told by Resident # 14's roommate that Resident #14 had wrapped a cord around his/her neck. On 2/3/21 at 12:09 PM, the Center Executive Director (CED) confirmed that management, the physician, and the family should have been notified after each incident. The CED also confirmed that this had not been done per facility policy.

Based on observation, interviews and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: 1. Per interview and confirmed via staff interview, Resident # 7 received her medications 2.5 hours late on 2/1/21. During interview on 2/3/21, Resident # 7 that all his/her medications were late on 2/1/21, including pain medications. The resident stated that s/he was in terrible pain due to the late medications. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also stated that s/he is a 1 assist for toileting, but staff don't come so s/he goes by him/herself. States s/he is supposed to get a weekly shower but hasn't had one for over 2 weeks due to lack of staff. States food is always cold and that s/he doesn't even bother with asking staff to heat it because they are too busy with other things. States s/he often runs out of clean washcloths and towels. States bed linens have not been changed for 3 weeks. On 2/1/21 at 11:35 AM, the Unit Nurse stated that it is impossible to administer resident medications on time with one nurse on the unit. S/he also stated that resident care is really suffering and it's not ok. States this is the second time s/he's worked alone on the unit. The nurse confirmed that the 8:00 AM medications were given at least 2 hours late on 2/1/21. Facility reports indicate that administration of the 8:00 AM med's was documented at 11:14 AM. 2. Per interview, Resident # 12 was left sitting in feces for over 1 hour. During interview on 2/1/21 at 2:21 PM, Resident # 12 stated that this had occurred several times and that it was very upsetting to him/her. The resident resides on the 4th floor. Minimum Data Set (MDS) dated [DATE] indicates that Resident # 12 requires extensive assist of 1 staff for activities of daily living (ADLs). Per interview with the Center Executive Director (CED), the 4th floor has 3 residents that use mechanical lifts and that there are 5 residents that require assist of 2 staff for ADLs. On the morning of 2/1/21, per observation there was only 1 nurse and 3 Licensed Nursing Assistants (LNA's) working on the 4th floor. 3. During interview on 2/1/21 at 11:00 AM, fourth floor residents # 10 and 11 stated that the food is generally cold when delivered because they need more help to deliver meals. 4. During an interview on 2/1/21 at 12:00 PM, Resident # 1 reported concerns for his/her safety and health. Stated that s/he waited up to an hour and a half for the call light to be answered and has been left lying in his/her feces for an extended period. Stated that s/he uses the Hoyer mechanical lift to get out of bed but has only been able to get up for 10-minute intervals. Resident #1 identified working on a bowel management program before being admitted to the facility, but with the lack of staff, his/her bowel regimen is gone. Stated that his/her hair has not been cleaned during his/her whole stay. Stated that staff are grossly overworked and horrifically understaffed. Stated that the food always comes cold, so he/she has been ordering chef's salads. 5. Per interview, Resident #13 received medications 1.75 hours late on 12/24/20, 1.5 hours late on 1/11/21, 1.75 hours late on 12/27/20, 1.5 hours late on 12/31/20, and 2.5 hours late on 1/16/21. During interview on 02/01/21 at 14:32, Resident #13 stated that his/her medications were late on 12/24/20, 12/27/20, 12/31/20, 1/11/21, and 1/16/21. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also stated that in December, his/her head was not washed for 3 weeks, and that in January, there were multiple occasions where s/he waited 30 to 40 minutes for staff to use the bed pan. Resident #13 stated fear to have a bowel movement because s/he was worried to be left on the bed pan for an extended period in pain. Resident #13 stated the unit did not have enough linen, especially washcloths, and that staffing was so low, that the lady who helps with her finances has also been helping to pass out meal trays. Resident #13 cried and stated, this place is so bad for me; it's so bad for my mental health. 6. During an interview on 02/01/21 at 11:51 AM, Resident #12 stated that unit residents are not getting help at a reasonable time. S/he identifies that the facility is understaffed, and that his/her bed linen hasn't been changed in three weeks. Resident #12 stated that the food was always cold on arrival to the room. 7. During an interview on 02/02/21 at 02:02 PM, Resident #15 stated that his/her stay at the facility has not been a good experience. Stated that s/he fell , broke his/her nose, and laid there. Stated that staff at the facility are spread too thin, and that help is desperately needed. Resident #15 stated that the food is always cold and stated, it sucks to eat cold food, three times a day, 7 days a week. 8. During an interview on 02/01/21 at 11:15 AM, Resident #2 stated that there is just not enough staff, some days and shifts are worse than others. S/he reported that just that morning s/he put on her/his call light after breakfast to request her pain patch be placed on her knee, and it still had not be done. While we continued our interview, I asked her/him to again put on the call light and ask for the patch, 6 minutes later a Licensed Nursing Aide (LNA) responded and stated, I will tell the nurse. After completing the interview at 11:45 AM, I went out and told the nurse that the resident was in pain and wanted the patch placed. S/he responded, I'll get to it. Upon reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In reviewing the (MAR) for 02/01/21 for this resident the documentation indicates that the [MEDICATION(S)] Patch was documented as being placed at 1:38 PM. The same resident reported that there are times in which her/his finger stick for diabetes is not done before s/he eats, because there is not enough staff to do so and they will come either when s/he is eating or after s/he is finished. 9. During an interview on 02/01/21 at 2:00 PM, Resident #8 reported that they are short staffed, that s/he has had to wait over an hour for someone to respond to her call light and that there have been times that medications have arrived late, even hours late. S/he feels that weekends are worse and stated, it is kind of frightening that I might need help, and no one will come. S/he also reports that there are times s/he has had to ask staff to change her/his bedding, because there does not seem to be a specific time when this occurs. Per observation of the 5th floor on 2/1/21 at 11:35 AM, 4 staff members were present on the unit. During an interview on 2/1/21 at 11:40 AM with the 5th floor Unit Manager, s/he stated that the unit currently had 35 long term care residents; and that there was 1 Licensed Practical Nurse (LPN) and 3 Licensed Nursing Assistants (LNA's) working today. S/he stated that 18 of the 35 residents needed to have total care with their Activities of Daily Living (ADL's); and that 10 of the 35 residents used mechanical lifts which required 2 staff members. Per interview at approximately 12:15 PM with 2 LNAs on the 5th floor, they stated that at times they only run 2 staff and that this was not enough. And that when this happens, they can't get the work done. They also stated that they don't ever stop and that it's hard and they have learned how to manage. On 02/02/2021 at 08:37 AM, the Dietary Services Manager, stated that he/she was aware of residents' complaints of cold entrees. Stated that s/he keeps food temperature logs and knows that residents' meals are warm when they are delivered to the floors. Stated that resident complaints of cold food trays have become a heightened issue since COVID-19, as residents are confined to their room during mealtimes, instead of using the communal dining area. Stated that s/he believes that once arriving to the floor, trays are not getting dispersed to resident rooms in a timely manner.

Based on interview and record review, the facility failed to ensure 2 of 15 applicable residents (Resident #6 and #13) are free of any significant medication errors. Findings include: 1. Resident #6 received his/her medications 2.5 hours late on 2/1/21. During interview on 2/3/21, Resident # 6 that all his/her medications were late on 2/1/21, including pain medications. The resident stated that s/he was in terrible pain due to the late medications. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/21 at 11:35 AM, the Unit Nurse stated that it is impossible to administer resident medications on time with one nurse on the unit. S/he also stated that resident care is really suffering and it's not ok. S/he states this is the second time s/he has worked alone on the unit. The nurse confirmed that the 8:00 AM medications were given at least 2 hours late on 2/1/21. Facility reports indicate that administration of the 8:00 AM medications were documented at 11:14 AM. 2. During an interview on 02/01/21 at 11:15 AM, resident #2 stated that s/he has been waiting all morning for her pain patch to be placed on her knee and at this point s/he was experiencing significant pain. Upon reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The (MAR) indicates 8:00 AM as the time it should be placed. In reviewing the (MAR) for 02/01/21 for this resident the documentation indicates that the [MEDICATION(S)] Patch was documented as being placed at 1:38 PM.

Based on staff interview and record review, the facility failed to ensure that 1 of 4 sampled residents (Resident #1) was free from any significant medication errors. Findings include: Per review of Resident #1's medical record, Resident # 1 was given 10 times the physician-ordered dosage of [MEDICATION NAME] on 3 occasions, March 4, 5 and 6 which led to his/her hospitalization on [DATE]. Resident #1 was admitted to the facility on [DATE] from an acute care hospital. The discharge summary from the hospital stated that Resident #1 tolerated the [MEDICATION NAME] well. The summary also included an order for [REDACTED]. The care plan for Resident #1 stated that Resident is at risk for respiratory complications related to Chronic [MEDICAL CONDITION] with [MEDICAL CONDITIONS] hypertension, interstitial [MEDICAL CONDITION] disease. Review of the March 2020 Medication Administration Record [REDACTED]. This is confirmed by nursing notes. Review of the narcotics record shows that [MEDICATION NAME] 20 milligrams per 1 milliliter was pulled from facility stock. This record indicates that Resident #1 was administered 1 ml of the 20 mg per ml solution on 3/4/20 at 6:30 PM, 3/5/20 at 11:00 AM and 3/6/20 at 11:30 AM, which would be equivalent to a dose of 20 mg. Resident #1 should have received 2 mg of [MEDICATION NAME] each dose but rather received 20 mg of [MEDICATION NAME] at each dose. On 8/10/20 at 12:45 PM, the Director of Nurses confirmed that the MAR indicated [REDACTED].

Based on record review and resident interview, the facility failed to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 of 4 residents sampled (Resident #1). Findings include: Per medical record review 4/29-5/1/19, Resident #1 is paraplegic (paralyzed in the lower body) due to a (YEAR) trauma, with other [DIAGNOSES REDACTED]. S/he was assessed and care planned to require staff assistance of 1-2 for bed mobility, transfers from bed to chair, personal hygiene, and catheter care. S/he could eat a regular diet with provision and setup by staff. Leading up to an unsafe discharge on 4/24/19, Resident #1 had known psychosocial and mental health needs that were not addressed by the facility. The facility failed to ensure that the resident received appropriate treatment and services to address his/her alcohol dependence, risk of isolation, feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and/or professional, medically-related social services to address these issues of trauma, loss, addiction, and adjustment, from admission through discharge on 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described only having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM, the Director of Nursing and Administrator related difficulty finding an alternate placement closer to home. Per interview with the Nurse Practitioner (NP), 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. During the above interviews, the Administrator, DNS, and NP referred to Resident #1 as non-compliant with various aspects of care and services. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement (leaving the building without signing out) on 4/19/19 to assert his/her right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. There is no facility policy that requires residents to sign out AMA when they wish to go on a therapeutic leave. The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. The facility discharged the resident and ordered a maintenence staff person to transport him/her to a local hotel, paying for a one-night stay, on 4/24/19. The facility knew at that time that the family did not intend to care for him/her that evening. The facility knew that the resident could not get from wheelchair to bed, had difficulty dialing a phone, and needed help with catheter care, stool incontinence, all personal hygiene, and could not acquire food, drink, medications or future housing without assistance. The resident was known to have a history of serious UTI [MEDICAL CONDITION], and a current deep tissue pressure sore on the buttocks which could become infected without regular hygiene and care. The facility did not notify the family until some time on 4/25/19 of the hotel location. The facility did not do a Visiting Nurse Association referral by fax until midday, 4/25/19, per copy of fax transmission. This was confirmed by the Administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM. Significant harm and risk of death resulted from this discharge, per review of hospital documents. Per interview of 2 maintenance staff, on 4/29/19 at 11:25 AM, Resident #1 was moved into a hotel room with belongings and medications, and 911 was called from the hotel room at approximately 6:30 PM on 4/24/19. The maintenance person who did the transport was not a caregiver and noted that s/he needed to dial the phone for the resident because Resident #1 gets shaky when tries to zero in with hands. Per hospital records, dated 4/25/19, Resident #1 reported to the physician that his/her hand tremors increased previously as a heralding (warning symptom) to UTI. Resident #1 had a history of [REDACTED]. Per interview of Resident #1 on 4/29/19 at about 3:30 PM, the rescue squad summoned by the maintenance person transferred the resident to bed, removed a soiled brief, and emptied the catheter bag, which had leaked on the resident's clothing. On 4/25/19, at approximately noon, an anonymous concerned facility staff person, per interview on 4/29/19, called the resident at the hotel. The resident did not know how to use the phone to reach hotel staff, so the staff person called the police and asked for a welfare check. It was later on 4/25/19 that hotel staff called 911 and ambulance response transported the resident to University of Vermont Medical Center (UVMMC) at approximately 6:12 PM, arriving 6: 34 PM, per dispatch records. Per review of hospital records of 4/25/19, upon emergency department assessment, Resident #1 was not oriented to time, saying s/he had been at the hotel for three days vs the actual 24 hours. The exam revealed the following: Mildly tremulous, unstageable ulcer of coccyx, covered in feces, arrives unable to care for self at motel, ruptured foley (catheter) bag, leukocytosis (high white blood cell count) and fever (100.5 F), abnormal urine dipstick with urine brown and cloudy. Given 1 gram Tylenol for reported headache, and hydrated with intravenous (IV) bolus 1 Liter [MEDICATION NAME] ringers. Attending (physician) attests to failure to thrive after sudden discharge from rehab, associated AKI (acute kidney infection) in addition to leukocytosis and fever, with UA (urinalysis) consistent with complicated UTI (urinary tract infection). Attending notes that patient reports similar heralding of increased hand tremors with previous UTI. admitted to hospitable for further UTI care and placement/housing. Per observation of Resident #1 by this surveyor, on 4/29/19 at 3:30 PM at UVMMC, the resident was receiving IV (Intra-venous) treatment for [REDACTED]. The resident therefore is confirmed to have declined to a level of serious harm and potentially life-threatening status of septic UTI during the 24 hour hotel stay, subsequent to sudden discharge by the facility, with no care rendered after 1:00 PM on 4/24/19, despite the resident returning to the facility twice during the afternoon of 4/24/19 clearly in need of care/assistance and indicating to the DNS that s/he made a mistake. The facility did not make any attempt to contact the resident at the hotel or secure caregivers except to fax a VNA referral at 1:30 PM on 4/25/19, with no check of follow through by the VNA. Per interview on 4/30/19 at 9:00 AM, the Administrator and DNS confirmed that the resident was considered discharged after the AMA was signed, 1:00 PM on 4/24/19, and that they had arranged the transport and paid for a one night hotel stay. See also F0561, F0622, F0626, F0656, F0660, F0742 and F0745.

Based on record review, staff and resident interview, the facility failed to permit 1 of 4 residents sampled (Resident #1) to remain in the facility, and not transfer or discharge. Findings include: Per record review and staff interviews on 4/29-30/19, the facility alleged that there was a resident initiated AMA (against medical advice) discharge on 4/24/19. This was confirmed by the administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM, based on the signature of Resident #1 on an AMA document, signed at 1:00 PM on 4/24/19, and verbal expression of desire to leave the facility during an Interdisciplinary Team (IDT) meeting just prior (per Social Services notes of 4/24/19 and interview on 4/29/19 at 12:30 PM). On 4/29/19 at 2:15 PM, the Recreation Assistant, who was present at the IDT meeting of 4/24/19, stated that Resident #1 had described that s/he simply wanted to go downtown that day. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. Based on the behavior of Resident #1, returning to the facility twice on the afternoon of 4/24/19 and verbalizing that s/he made a mistake, this could also be viewed as a therapeutic leave on the part of the resident, and an unsafe decision related to potential cognitive changes caused by brewing bacterial urinary tract infection [MEDICAL CONDITIONS]. The unit manager witnessed Resident #1 in the building at approximately 3:30 PM on 4/24/19 on 4th floor unit, per interview on 4/29/19 at 12:05 PM. The Administrator and DNS stated on 4/30/19 at 9 AM, that on 4/24/19 around 3:30-4 PM they brought Resident #1 into the conference room and allowed phone use to call the daughter and others. It was stated that a staff person had to dial the phone related to hand tremors of Resident #1. Per review of the comprehensive care plan regarding discharge planning, it is clear that a discharge to the community was not the plan. Per Occupational Therapy assessment dated [DATE], the resident required supervision outside of the building and per interview on 4/29/19 at 12:45 PM, the OT stated that the resident had poor judgement and safety awareness. The health status was declining at the time of discharge 4/24/19 (diagnosed [DATE] as septic with UTI, requiring hospital admission and intravenous antibiotics). In hospital documents of 4/25/19, Resident #1 reported having been at the hotel for 3 days, when in fact it had been approximately 24 hours from entry to the hotel 4/24/19 6:30 PM, per statement of maintenance person who did the transport in facility van, 4/29/19 at 11:25 AM. This statement of 3 days in the hotel represents evidence of lost orientation to time. Both the maintenance person, who called 911 from the hotel, and the DNS, mentioned that on 4/24/19 Resident #1 needed assistance to dial the phone related to hand tremors. Per hospital records, dated 4/25/19, Resident #1 reported to the physician that his/her hand tremors increased previously as a heralding (warning symptom) to UTI. Resident #1 had a history of [REDACTED]. An additional factor is that Resident #1 had a recent history of going off the premises on 4/19/19, per record review and confirmed by the administrator, DNS, and social worker during interviews on 4/29/19. The facility called the police and sent a staff person to bring Resident #1 back to the facility, and re-entry was permitted on 4/19/19. Resident #1 had been in discussions regarding autonomy and choices from January, 2019 through 4/24/19, and disagreed with restrictions the facility put in place regarding independence. There is no written evidence that the facility notified the ombudsman or issued a 30 day notice of discharge during the period prior to the 4/24/19 alleged AMA discharge. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility had never contacted him/her about this resident's issues surrounding independence or desire to leave the facility AMA until 4/25/19, the day after discharge.

Based on record review and staff interviews, the facility failed to provide professional, medically related social services to ensure 1 of 4 residents sampled (Resident #1) attained their highest practicable physical, mental and psychosocial well-being related to trauma, new [MEDICAL CONDITION] with loss of independence, adjustment problems, and a history of [MEDICAL CONDITION]. Findings include: Per record review, the facility failed to ensure that the resident received appropriate treatment and services to correct his/her alcohol dependence, risk of isolation, feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and/or professional, medically-related social services to address these issues of trauma, loss, addiction, and adjustment from admission through discharge 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM the Director of Nursing and Administrator related difficulty finding an alternate placement closer to home. Per interview with the Nurse Practitioner (NP), 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. During the above interviews, the Administrator, DNS, and NP referred to Resident #1 as non-compliant with various aspects of care and services. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence to suggest that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement on 4/19/19 to assert his/her right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Despite leaving and returning to the facility that afternoon at least twice, indicating s/he had made a mistake, the facility moved forward with a less than orderly discharge to a hotel, alone and without care. This culminated in emergency services and transport to hospital for treatment of [REDACTED].

Based on observation, record review and staff interviews, the facility failed to ensure 1 of 4 residents sampled (Resident #1) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being, related to trauma, new [MEDICAL CONDITION] with loss of independence, adjustment problems, and a history of [MEDICAL CONDITION]. Findings include: Per record review, the facility failed to ensure that the resident received appropriate treatment and services to correct his/her alcohol dependence, risk of isolation, and feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and treatment to address these issues of trauma, loss, addiction, and adjustment from admission through discharge 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM the Director of Nursing and administrator related difficulty finding an alternate placement. Per interview with the nurse practitioner, 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence to suggest that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement on 4/19/19 to assert the right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. Despite leaving and returning to the facility that afternoon at least twice, the facility moved forward with a less than orderly discharge to a hotel, alone and without care. This culminated in emergency services and transport to hospital for treatment of [REDACTED].

Based on record review, and confirmed by interviews, the facility failed to consider need for care and capacity, and to inform and consult the office of the State Long Term Care Ombudsman, regarding the desire of 1 of 4 residents sampled (Resident #1) to discharge. Findings include: Resident #1 was admitted for care on 6/27/18 after [MEDICAL CONDITION], caused by trauma and complicated by [MEDICAL CONDITION]. The facility developed a plan of care which included discharge planning for a desire to move to a facility closer to family on the New Hampshire border, and indicated the resident is dependent on staff for care, assistance with a urinary catheter, a pressure ulcer, adjustment concerns, and other issues. At the time of alleged discharge against medical advice (AMA), 4/24/19, the facility failed to consider the caregiver/support person availability, capacity, and capability to perform required care unassisted in the community. Resident #1 was also assessed and care planned as needing staff support for fecal incontinence, lower body [MEDICAL CONDITION] with inability to transfer without 1-2 person assistance, and hand tremors which impaired ability to dial a telephone. The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility failed to contact the ombudsman and involve him/her in exploration of alternative options for placements, transfers or discharges. The facility made a hasty discharge arrangement 4/24/19, to transport the resident to a hotel and paid for one night, knowing that the family did not intend to care for him/her. This was confirmed by Administrator interview of 4/30/19 at 9 AM. Per hospital documents dated 4/25/19, the resident required Emergency Medical Services for transport to hospital from the hotel. [DIAGNOSES REDACTED]. The resident was admitted for UTI hospital care and homeless status. Per review of the comprehensive care plan regarding discharge planning, it is clear that a discharge to the community was not the plan. Per Occupational Therapy assessment dated [DATE], the resident required supervision outside of the building and per interview on 4/29/19 at 12:45 PM, the OT stated that the resident had poor judgement and safety awareness.

Based on record review and staff interviews, the facility failed to implement the written plan of care for 1 of 4 residents in the sample (Resident #1). Findings include: After admission 6/27/18 with [MEDICAL CONDITION] due to trauma, and a history of [MEDICAL CONDITION], the facility developed a care plan based on the assessed needs and preferences of Resident #1. This included a preference to go outside, weather permitting, and risk of social isolation related to change in customary lifestyle, difficulty accepting placement in the center, loss of status and/or freedom, loss of support network, and coping with decline in overall health and functional decline. Staff were directed in the written plan of care to: evaluate mood state or behavioral symptoms impacting social isolation; encourage to make decisions independently and provide positive feedback; encourage expression of thoughts and feelings associated with the change or loss of customary lifestyle/routines; encourage to participate in activity preferences; family and staff to assist outdoors, weather permitting. On 4/18/19, a care plan was also developed for risk of elopement related to history of leaving grounds without signing out. This directed staff to notify the physician, observe location when out of bed, remind to sign out/in when leaving. Additionally the care plan included risk for [MEDICAL CONDITION] activity related to tremors. Monitor for signs/symptoms of impending [MEDICAL CONDITION]. Resident #1 stated during interview on 4/29/19 at 3:30 PM that s/he expressed to facility staff that s/he had not been out of the building all year, that rehab means getting out and mingling with people.Contrary to the care plan which states that staff or family will support the resident to go outside, Resident #1 was allowed to go outside and off the premises a few times alone. On 4/19/19 when Resident #1 left the premises, the facility called police. During the care plan meeting of 4/24/19, Resident #1 asserted the desire to go downtown that afternoon. This was confirmed by a staff witness during interview at 2:15 PM on 4/29/19. The facility did not implement care strategies to safely allow such community activity.The facility instead initiated an Against Medical Advice (AMA) discharge on 4/24/19. Per record review, staff and resident interviews, the resident left the facility and returned on 4/24/19 at least twice after having been considered discharged against medical advice (AMA) by the facility (signature on 4/24/19, 1:00 PM, per AMA document). First the resident was documented as leaving the building to go to a friend's to live. Later, Resident #1 was observed in the building and on the 4th floor at 3:30-4 PM, per interviews with the nurse unit manager (4/29/19 at 12:05 PM) and by the Nurse Practitioner (4/30/19 9:35 AM), as well as by both the administrator and Director of Nursing/DNS (4/30/19 at 9:00 AM). Per facility records, and these interviews, Resident #1 again left the premises, allegedly going to the hospital (where he presented as homeless in need of housing and was turned away) and returned at approximately 5:00 PM. During the above interviews, witnesses placed Resident #1 in the building again, meeting in the ground floor conference room with administrator, DNS, Assistant DNS, and Business Manager regarding funds. The Assistant DNS was confirmed having dialed the phone for Resident #1 to talk with his/her family and others due to hand tremors preventing the resident from dialing the phone independently. At approximately 5:30 PM on 4/24/19, the Occupational Therapist (OT) confirmed having talked to Resident #1 from a window, as s/he was outside near the rear of the building, and asked Resident #1 to meet him/her at the entrance. Confirmed during this interview on 4/29/19 at 12:45 PM, the OT described that Resident #1 said they would not let him/her back in the building and s/he had no place to go. The resident stated I made a mistake. The OT went to the DNS and advised that Resident #1 was not safe and capable of living alone in the community. The DNS stated clearly to the OT, per this interview, that Resident #1 was AMA and that's too bad; I'll get him/her a hotel. When interviewed at the hospital on [DATE] at 3:30 PM, the resident said the DNS told me you've got to get out of here; we'll call the cops. The facility had called police on 4/19/19 and allowed return to the facility after Resident #1 left the premises in a perceived elopement (notes of 4/19/19, confirmed by administrator and DNS 4/30/19 at 9:00 AM). The facility then arranged for the one-night stay at a hotel for the night of 4/24/19, and had a maintenance person transport the resident, with plastic bags of clothing, belongings, and medications, and a list of area healthcare providers, along with the electric wheelchair. The facility did not permit the resident to re-admit to the facility after a therapeutic leave due to possible altered mental status and brewing infection. After spending approximately 24 hours in the hotel, and having 3 emergency 911 responses for care and welfare checks, Resident #1 was admitted to hospital on [DATE]. Hospital records showed a multi-drug resistant urinary tract infection which represented substantial health risk to Resident #1. The facility not only did not permit return, but failed also to provide community services to a vulnerable person who could not, by their assessment and care plan, transfer him/herself from chair to bed, had an indwelling urinary catheter, and had trouble using a telephone. A fax was sent by the facility to the Visiting Nurse Association at 1:30 PM on 4/25/19, with no evidence of any effort to check on Resident #1, and knowing the family was not coming promptly to assist (per interview administrator and DNS, 4/30/19 at 9:00 AM). Refer to F561.

Based on record review, staff and resident interviews, the facility failed to permit return to the facility after a therapeutic leave for 1 of 4 residents in the sample (Resident #1). Findings include: Per record review, staff and resident interviews, Resident #1 returned to the facility 4/24/19 at least twice after having been considered discharged against medical advice (AMA) by the facility (signature on 4/24/19 at 1:00 PM, per AMA document). The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. At 3:30-4 PM, Resident #1 was observed in the building on the 4th floor, per interviews with the nurse unit manager (4/29/19 at 12:05 PM), the Nurse Practitioner (4/30/19 9:35 AM), as well as by both the Administrator and Director of Nursing/DNS (4/30/19 at 9:00 AM). Per facility records, and these interviews, Resident #1 again left the premises, allegedly going to the hospital (where he presented as homeless needing housing and was turned away) and returned again to the facility at approximately 5:00 PM, clearly in need of care, indicating to the DNS s/he made a mistake. During the above interviews, witnesses placed Resident #1 in the building again, meeting in the ground floor conference room with administrator, DNS, Assistant DNS, and Business Manager regarding funds. The Assistant DNS was confirmed having dialed the phone for Resident #1 to talk with his/her daughter and others because the resident could not independently dial the phone due to hand tremors. At approximately 5:30 PM on 4/24/19, the Occupational Therapist (OT) confirmed having talked to Resident #1 from a window, as s/he was outside near the rear of the building, and asked Resident #1 to meet him/her at the entrance. Confirmed during this interview on 4/29/19 at 12:45 PM, the OT described that s/he went to the DNS and advised that Resident #1 was not safe and capable of living alone in the community. The DNS stated clearly to the OT, per this interview, that Resident #1 was AMA and not to receive medical care nor allowed to stay at the facility that night. S/he stated that when the resident returned, the facility DNS (Director of Nursing Services) asserted the AMA status to the resident and refused re-admission to the facility. When interviewed at the hospital on [DATE] at 3:30 PM, the resident said s/he did not specifically ask for re-admission because the DNS told me (s/he) would call the cops; they did that before so I knew they would. The facility had called the police on 4/19/19 and allowed return to the facility after Resident #1 left the premises in a perceived elopement (notes of 4/19/19, confirmed by administrator and DNS 4/30/19 at 9:00 AM). The facility then arranged for the one-night stay at a hotel for the night of 4/24/19 instead of readmitting the resident who had extensive care needs, and had a maintenance person transport the resident, with plastic bags of clothing, belongings, and medications, and a list of area healthcare providers, along with the electric wheelchair. The facility did not permit the resident to re-admit to the facility after a therapeutic leave and mis-understanding of the AMA discharge due to possible altered mental status and brewing infection. After spending approximately 24 hours in the hotel, and having 3 emergency 911 responses for care and welfare checks, Resident #1 was admitted to the hospital on [DATE]. Hospital records showed a multi-drug resistant urinary tract infection which represented substantial health risk to Resident #1. The facility not only did not permit return, but failed also to provide community services to a vulnerable person who could not, by their assessment and care plan, transfer him/herself from chair to bed, had an indwelling urinary catheter, was dependent on caregivers for hygiene, and had trouble using a telephone. A fax was sent by the facility to the Visiting Nurse Association at 1:30 PM on 4/25/19, with no evidence of any effort to check on Resident #1, and knowing the family was not coming promptly to assist (per interview administrator and DNS, 4/30/19 at 9:00 AM).

Based on record review and interviews with the resident and facility staff, the facility failed to promote and support the resident's choice (1 of 4 sampled, Resident #1) to participate in preferred activities and interact with members of the community, both inside and outside the facility, leading to an unsafe discharge. Findings include: Per record review, Resident #1 entered the facility on 6/27/18, following [MEDICAL CONDITION] (paralyzed in the lower body), caused by trauma. There was also a clear history of [MEDICAL CONDITION] among the admitting diagnoses. Resident #1 had a medical order allowing 1 beer per day. A note on 1/21/19 relates that Resident #1 was non-compliant with the 1 beer per day order, and thus the order was discontinued. Resident #1 had a written plan of care which outlined risk of adjustment issues related to isolation, difficulty accepting placement in center, loss of status and/or freedom associated with transition, loss of support network, coping with decline in overall health status, including functional decline. Additionally the care plan stated, It is important for me to go outside when the weather is good. Family and staff to assist outdoors, weather permitting. The facility could show no evidence that mental health or medically-related social services were engaged to assist Resident #1 with adjustment issues, or with abrupt withdrawal of alcohol use. On 4/18/19, the facility held a meeting with Resident #1 and informed him/her of their intent to enforce their requirement that all residents sign out and back in whenever leaving the facility. The facility had been allowing Resident #1 to leave and go off site to visit friends down the street. When Resident #1 went off premises on 4/19/19 without signing out, the facility called the police. This experience resulted in Resident #1 exhibiting increased efforts to assert independence and a right to autonomy. When questioned on 4/29/19 at 3:30 PM, Resident #1 stated, they let me go out and took it back; I can have a beer and a cheeseburger. In the wake of this further restriction, Resident #1 verbalized intent to leave the facility whenever s/he wanted, per Interdisciplinary Team (IDT) notes of 4/24/19. Resident #1 had been in discussions regarding autonomy and choices from January, 2019 through 4/24/19, and disagreed with restrictions the facility put in place regarding independence. There is no written evidence that the facility notified the ombudsman or issued a 30 day notice of discharge during the period prior to the 4/24/19 alleged AMA (against medical advice) discharge. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility had never contacted him/her about this resident's issues surrounding independence or desire to leave the facility AMA until 4/25/19, the day after discharge. Due to the disagreement regarding rights to engage in activities outside the facility, the Administrator and other facility staff had Resident #1 sign an AMA document at 1:00 PM on 4/24/19. That afternoon, Resident #1 left the premises twice, and subsequently returned both times, indicating to the DNS s/he made a mistake. Per interview with a facility staff member who was a witness to the events during the second return to the facility, s/he stated that when the resident returned, the facility DNS (Director of Nursing Services) asserted the AMA status and refused re-admission to the facility. After asserting the AMA status and refusing re-entry to the resident despite clear needs surrounding care, the administration ordered a maintenance staff person to transport the resident to a hotel and paid for one night. Per observation at hospital at 3:30 PM on 4/29/19, and confirmed by hospital documents dated 4/25/19, Resident #1 deteriorated during the hotel stay and required emergency transport to hospital for treatment of [REDACTED].

Based on medical record review, direct observation, staff and resident interviews between 4/2-3/2018, the facility failed to ensure that the environment was free of accident hazards for 1 of 7 residents (Resident # 1). The specifics are detailed below: Per medical record review on 4/2/2018, Resident # 1 suffered second [MEDICAL CONDITION] 01/31/2018 on his/ her abdomen, chest and upper left thigh after spilling a cup of coffee. Wounds on the abdomen and chest healed quickly. Wound assessments of the left thigh by both the physician and nursing staff resulted in daily dressing protocols being changed 3 different times, before the area healed on 4/3/2018. Resident # 1 is observed in bed on 4/2/2018 with a dressing in place over the left thigh, denying any pain or discomfort. Resident # 1 is able to articulate that it happened from coffee. Resident # 1 requires assistance and supervision with meals and eats all meals in the main dining room. Unit staff confirm during interview on 4/2 and 4/3/2018 that Resident # 1 was having breakfast in the dining room on 1/31/2018 when the injury occurred. Interview with the food service director on 4/3/2018 in the late afternoon confirms that liquid temps were not being taken before the coffee urn was taken to the unit dining room, but that after being notified that an incident happened, the coffee temperatures were checked and ranged between 170 and 190 degrees. As a result of this incident, temperatures of hot liquids are now taken prior to serving the residents. The food service director further states that Resident #1's meal ticket indicates that a cup with lid is to be used for liquids. This is confirmed by unit staff and on the care plan. The cup with the lid is a sturdy, hard plastic cup with a secure lid and large handle for residents to hold. Protocols were put in place after the injury that include taking temperatures of hot liquids, providing covered cups to residents to minimize injuries if cups are dropped and directions to not leave residents unsupervised who are at risk for spilling liquids/food. There have been no further injuries of this nature throughout the facility since (MONTH) (YEAR). This tag is cited as past non-compliance.

Based on interviews and record review, the facility failed to ensure that 1 applicable resident (Resident # 1) received their physicia-ordered therapeutic diet and adequate dining assistance. Findings include: Per interview and record review, Resident #1 was given the wrong meal on [DATE] and left unattended. Per review of internal investigation information and per interviews, Resident #1 choked on whole grapes and subsequently expired at the facility on [DATE]. Resident #1 had a [DIAGNOSES REDACTED]. There is a physician's orders [REDACTED]. There is a care plan for risk for impaired swallowing that includes an intervention to provide a dysphagia pureed diet as ordered. The care plan for Activities of daily living (ADLs) stated that Resident #1 required extensive assist of 1 person for eating. Per interview with the Center Nurse Executive (CNE) on [DATE] at 12:57 PM, a staff member brought another resident's tray to Resident #1's room on [DATE]. Resident #1's roommate stated that this person was a tall woman later identified by staff as a facility Registered Nurse (RN). A staff Licensed Nursing Assistant (LNA) brought the correct meal tray to Resident #1 a while later as described by Resident #1's roommate. This LNA discovered Resident #1 in distress and alerted nursing staff. In a written statement by the RN that delivered the incorrect tray to Resident #1, the RN stated Resident #1 refused the potatoes and asked for fruit so I placed the cup of grapes on (his/her) lap so (s/he) could reach them better. The RN then wrote that h/she left the room. The CNE confirmed that this RN was the person that delivered the incorrect meal tray to the Resident #1 and that Resident #1 was an extensive assist of 1 for eating and should not have been left alone with grapes. In a [DATE] interview at 3:03 PM, a facility LNA stated that h/she set up the regular diet tray that was delivered to Resident #1 that was meant for a resident 5 doors down from Resident #1's room. The LNA confirmed that h/she observed whole grapes on the table in front of Resident #1 on [DATE]. The LNA also confirmed that the aforementioned RN said that h/she gave Resident #1 the grapes. This citation will be considered past non-compliance. The facility has taken significant steps to correct the issues. Staff have been educated, management has audited meal tickets and resident photographs are now on meal tickets. Per observation of the noon meal on [DATE], staff were observed following proper procedures regarding meal trays.

Based on interviews and record review, the facility failed to ensure that 1 applicable resident (Resident # 1) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan regarding implementation of diet orders. Findings include: Per interview and record review, Resident #1 was given the wrong meal on [DATE] and left unattended. Per review of internal investigation information and per interviews, Resident #1 choked on whole grapes and subsequently expired at the facility on [DATE]. Resident #1 had a [DIAGNOSES REDACTED]. There is a physician's orders [REDACTED]. There is a care plan for risk for impaired swallowing that includes an intervention to provide a dysphagia pureed diet as ordered. The care plan for Activities of daily living (ADLs) stated that Resident #1 required extensive assist of 1 person for eating. Per interview with the Center Nurse Executive (CNE) on [DATE] at 12:57 PM, a staff member brought another resident's tray to Resident #1's room on [DATE]. Resident #1's roommate stated that this person was a tall woman later identified by staff as a facility Registered Nurse (RN). A staff Licensed Nursing Assistant (LNA) brought the correct meal tray to Resident #1 a while later as described by Resident #1's roommate. This LNA discovered Resident #1 in distress and alerted nursing staff. In a written statement by the RN that delivered the incorrect tray to Resident #1, the RN stated Resident #1 refused the potatoes and asked for fruit so I placed the cup of grapes on (his/her) lap so (s/he) could reach them better. The RN then wrote that h/she left the room. The CNE confirmed that this RN was the person that delivered the incorrect meal tray to the Resident #1 and that Resident #1 was an extensive assist of 1 for eating and should not have been left alone with grapes. In a [DATE] interview at 3:03 PM, a facility LNA stated that h/she set up the regular diet tray that was delivered to Resident #1 that was meant for a resident 5 doors down from Resident #1's room. The LNA confirmed that h/she observed whole grapes on the table in front of Resident #1 on [DATE]. The LNA also confirmed that the aforementioned RN said that h/she gave Resident #1 the grapes. This citation will be considered past non-compliance. The facility has taken significant steps to correct the issues. Staff have been educated, management has audited meal tickets and resident photographs are now on meal tickets. Per observation of the noon meal on [DATE], staff were observed following proper procedures regarding meal trays.