Every finding on record at Rutland Healthcare & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure care plan interventions related to prevention of pressure ulcers were implemented for 2 of 6 sampled residents (Residents #62 and #32). Findings include:1. Per review of Resident #62's record, s/he has a Brief Interview of Mental Status (BIMS) of 0 (severe cognitive impairment) and diagnoses include chronic obstructive pulmonary disease (COPD), disorders of bone density and structure, spondylosis (degenerative changes in the spine), need for assistance with personal care, dementia without behaviors, depression and anxiety. The resident was admitted to the facility on [DATE] for rehabilitation services following a hip fracture. Per review of Resident #62's progress notes dated 5/1/2026, a Licensed Nursing Assistant (LNA) reported pressure areas on both heels. A nursing assessment revealed bilateral pressure areas measuring 4cm (centimeters) by 4 cm on the right heel and 0.5 cm by 0.5 cm on the left heel. The progress note states, both heels have been skin prepped, floated on a pillow, and Mepilex dressing applied. Per review of the facility's Repositioning policy, dated 01/2026, Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. Per review of Resident #62's Braden Scale (a tool used to assess a person's risk of developing pressure ulcers), s/he was categorized as moderate risk with a score of 13 on 3/10 and 3/31 and as high risk on 3/17 with a score of 11. According to the Braden Scale, a moderate to high-risk score indicates that a resident can occasionally make slight changes in body or extremity position but is unable to make frequent or significant changes independently and is dependent on staff for repositioning. Per interview with the Director of Nursing on 7/8/2026 at 11:15 AM, she confirmed that Resident #62 was identified as being at risk for pressure ulcer development due to clinical diagnoses and co-morbidities. Per review of Resident 62's care plan a nursing diagnosis of at risk for skin breakdown is noted with an intervention of assist in turning and repositioning every 2-3hrs (hours). to be initiated on 3/10/2026. Per review of Resident 62's care plan a nursing diagnosis of [resident] requires assistance with ADL care. with an intervention added on 3/13/2026 of heel protector foot cushion w/anti-internal rotation adaption wedge. Per review of Resident #62's task/intervention record and progress notes, there is no documentation of turning or repositioning ever 2-3 hrs. There is no documentation of staff placing a heel protector foot cushion w/anti-internal rotation adaption wedge. Per interview with an LNA on 7/8/2026 at 10:50 AM, he stated that they pretty much reposition residents who are in bed every 2-3 hrs. but do not document that they did it. When asked to see a task sheet with this intervention on it he stated he does not have anything like that. A second LNA stated that they have an intervention/task that they sign off on every shift (left to right rolling). Per review of the Documentation Survey Report, the resident is dependent on staff to complete left to right rolling. Documentation of staff performing this task was missing for the following shifts. 4/20/2026 evening shift 4/24/2026 evening shift 4/25/2026 evening shift 4/28/2026 day shift 4/30/2026 evening shift 4/30/2026 night shift Marked NA [not applicable] on 4/27/2026 and 4/30/2026 Per interview with the 2nd floor unit manager on 7/8/2026 at 10:50 AM, she stated that LNAs are supposed to be documenting every shift on the right to left rolling intervention record. She confirms that the above shifts are missing documentation and stated, they know they should be doing this. When asked about repositioning she stated that LNAs are supposed to be doing it every 2-3 hours on every shift, but that documentation is only completed on the night shift. She confirmed that not repositioning, along with other factors such as age and health status, could result in pressure injury. Per Interview with the DON on 7/8/2026 at 11:15 AM, she stated that the repositioning intervention is added to the care plan of all residents who are at risk for skin breakdown and they do not document the task. When asked about wheelchair repositioning, she stated that the facility cannot make the resident move from the wheelchair and that is their choice. Copies of a facility generated Turning and Repositioning document for April 12th through July 6th were provided by the 3rd floor unit manager on 7/8/2026 at approximately 11:50 AM. Each document covered 24 hrs. a day 7 days a week. According to this documentation, in the two weeks leading up to the discovery of pressure injuries on Resident #62's heels s/he was up in a wheelchair for 4-6 consecutive hours on the following dates in April: the 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 27th, and 28th with no documentation of offloading or repositioning noted. According to the National Pressure Injury Advisory Panel (NPIAP)(an organization which provides evidence-based guidelines in the prevention and treatment of pressure ulcers), common areas of pressure injury development when seated in a wheelchair are the: Occiput (back of the head) Scapula (shoulder blade) Spinous Process (upper spine) Elbow Greater Trochanter, sacrum, coccyx, ischial tuberosity (hips and buttocks) Heels The NPIAP names the heel as one of the most common sites for the development of pressure ulcers. Healthcare providers are encouraged to consider the risk of device-related heel/foot PIs [pressure injuries] associated with seating (e.g., footrests and other equipment), footwear (e.g., from ill-fitting shoes). The guidelines set forth by the NPIAP state that it is good practice to frequently reposition individuals at risk of pressure injuries who are seated out of bed and that sitting out of bed should be limited as much as possible for people who cannot reposition themselves. Per review of Resident #62's record, there is a lack of documented evidence that heel protectors were placed. Per review of documentation provided by the facility there is evidence that Resident #62 was in a wheelchair for up to 6 hrs. a day on multiple occasions with no documentation of being repositioned. Citation: National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Preventing Pressure Injuries in Seated Individuals. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. [NAME] Haesler (Ed.). 2025. [cited: 7/8/2026]. Available from: https://internationalguideline.com. 2. Per record review Resident #32's care plan revealed a focus last revised on 8/4/2025 that states that the Resident is at risk for skin breakdown related to decreased activity, limited mobility, shear/friction risks, incontinence, advanced age. Interventions initiated on 5/5/2024 include Encourage and assist with turning and Reposition every 2-3 hours when in bed, utilizing pillows to assist with positioning as needed as [s/he] will allow and tolerate. The Resident care Kardex also states Encourage and assist with turning and Reposition every 2-3 hours when in bed, utilizing pillows to assist with positioning as needed as [s/he] will allow and tolerate. Another care plan focus that was last revised on 4/30/2026 reflects that Resident #32 is incontinent of urine and stool. The care plan goal last revised on 4/15/2026 is will be free from skin irritation or breakdown due to urinary incontinence X90 days with interventions last revised on 4/28/2026 that include will have incontinence care needs met by staff to maintain dignity and comfort and to prevent incontinence related complications. The facility policy titled Repositioning last reviewed/revised 1/2026 states The purpose of this policy is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to provide comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. General Guidelines Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. . Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Upon entering Resident #32's room on 7/6/2026 at 12:35 PM there was a very strong, foul, fishy odor noted in the room. There was no evidence of any open food. Resident #32 was observed lying in bed with a blanket covering their legs. The bottom sheet, draw sheet (sheet used for moving a resident in bed), and positioning pillow under her/him were visibly soiled with what appeared to be wet with dark pinkish brown staining. Resident #32's spouse stated that Resident #32 chooses not to get out of bed and is dependent on staff for their care needs. At approximately 12:40 PM Licensed Nursing Assistant (LNA) #1 entered the room with a bag of supplies and stated that they were coming to get [Resident #32] cleaned up. The LNA left the bag on the chair and stated that they would be back. At 12:50 PM LNA #2 entered the room and set up Resident #32's lunch tray on their over bed table for her/him to eat their meal and left the room. Per interview on 7/6/2026 at 12:55 pm LNA #1 who was passing meal trays to other residents when asked when the last time Resident #32 was changed and repositioned, stated that she had not been able to get in to clean Resident #32 up for the day because the Resident had been busy and was talking with the surveyors when she came in to do so. The LNA confirmed that she had not assisted Resident #32 with care at all this day. Per phone interview on 7/7/2026 at 11:02 am LNA #3 who had been on duty on the night shift the morning of 7/6/2026 stated that she had checked on Resident #32 around 4:30- 5:00 AM, changed [her/him], and made [her/him] some tea. [Her/his] bottom has been a bit red here and there, and [s/he] had a bit of BM (bowel movement). [S/he] has moderate incontinence, and you check [her/him] every couple of hours and [s/he] is good. Per interview with LNA #2 on 7/7/2026 at 11:19 AM, Resident #32 does not get out of bed anymore. LNA #2 confirmed that Resident #32 had been incontinent in bed on 7/6/2026. She stated that she had not had a chance to get in to provide care because she had been the only LNA on the unit from 6:00 AM until 8:30 AM until LNA #1 came in. Per LNA #2, Resident #32's skin does have some soreness and staff reposition every two hours, reposition with pillows, and apply Z Guard (a zinc oxide barrier paste, used to treat or prevent moisture associated skin damage (MASD). Per interview with LNA #2 on 7/7/2026 at approximately 1:45 PM, in the presence of the DON, Administrator, Assistant DON, and Registered Nurse, the LNA stated that she had misunderstood this surveyor on 7/7/2026 at 11:19 AM when asked when Resident #32 had last had care. She stated that she had actually checked and changed the Resident at 7:30 AM on 7/7/2026, and the Resident had not gone from 5:00 AM until 1:00 PM without care. However, the Resident had not been changed and repositioned from 7:30 AM - 1:00 PM, which is 5.5 hours. Per interview with LNA #4 on 7/8/2026 at 11:30 AM Residents who are care planned for turning and repositioning have a turning and repositioning form that LNAs fill out each shift. She produced a blank form, from a file and placed it on a clipboard to be completed. The LNA stated that the Unit Manager (UM) takes the forms once they have been completed. During an interview with the DON and UM on 7/8/2026 at approximately 11:40 PM, the Um stated that the LNAs do not document turning and repositioning residents every 2-3 hours, this is done in the record once per shift. Turning and repositioning forms are not part of the medical record, and they are just something she has implemented to keep the LNAs honest. The DON and UM confirmed that there is no documented evidence that Resident #32 has been turned and repositioned every 2-3 hours. Per interview with the Director of Nursing and the Administrator on 7/8/2026 at 1:05 PM the facility is currently reviewing pressure ulcer prevention in QAPI (quality assurance, performance improvement). They are making sure that staff are monitoring skin, doing weights, encouraging fluids, and reviewing whether they are seeing more MASD or pressure ulcers. Residents who are immobile and don't get out of bed are discussed in huddle and the care plan interventions are updated, weekly skin checks are implemented.

Based upon interview and record review, the facility failed to ensure care plan interventions related to risk for skin breakdown were implemented for 1of 6 sampled residents (Resident #62). Findings include:Per review of Resident #62's record, diagnoses include chronic obstructive pulmonary disease, disorders of bone density and structure, spondylosis, need for assistance with personal care, dementia without behaviors, depression and anxiety. The resident was admitted to the facility on [DATE] for rehabilitation services following a hip fracture. The resident was then transferred to long term care services in the same facility on 4/12/2026.Per review of Resident 62's care plan a nursing diagnosis of at risk for skin breakdown is noted with an intervention of assist in turning and repositioning every 2-3hrs. to be initiated on 3/10/2026. Per review of Resident # 62's care plan a nursing diagnosis of [resident] requires assistance with ADL care. with an intervention added on 3/13/2026 of heel protector foot cushion w/anti-internal rotation adaption wedge.Per review of Resident #62's task/intervention record and progress notes there is no documentation of turning or repositioning every 2-3 hrs or the implementation of a heel protector foot cushion with anti-internal rotation adaption wedge.Per interview with 2 Licensed Nursing Assistants (LNA) on 7/8/2026 at 10:40 AM, they reported not having documentation of turning and repositioning Resident #62.Per interview with the 2 South Unit Manager (UM) on 7/8/2026 at 10:50 AM, she stated that turning/repositioning is only documented during the night shift.Per interview with the Director of Nursing (DON) on 7/8/2026 at 11:15 AM she states that the turning/repositioning intervention is assigned to all residents who are at risk for skin breakdown, but no documentation of the task is completed. When asked how she knows the task is being completed she said that when the resident is in bed they are turned and repositioned, but when they are in a wheelchair and do not want to be in the bed they are left alone stating we cannot make them move from one place to another. Copies of a facility generated Turning and Repositioning every 2 hours document was provided by the 3rd floor unit manager on 7/8/2026 at approximately 11:50 AM. She stated that the 2 hour time slots were initialed by nurses and not the LNAs. According to this documentation, Resident #62 was up in a wheelchair for 4-6 consecutive hours on the following dates in April: 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 27th, and 28th. No documentation of repositioning noted.The facility failed to provide sufficient documentation that care plan interventions of turning and repositioning of Resident #62 every 2-3 hrs. and the placement of a heel protector foot cushion w/anti-internal rotation adaption wedge were implemented.

Based on interview and record review, the facility failed to ensure 1 of 3 residents sampled [Resident #1] was free from physical abuse by facility staff. A reasonable person has the expectation that they will be safe in their home and can trust and rely on staff to keep them safe. In this case, a reasonable person would suffer psychosocial harm of fear and or anxiety related to being abused by a staff member. Findings include:Per record review, Resident #1 was admitted to the facility with diagnoses that include dementia, major depressive disorder, anxiety, hallucinations, dissociate conversion disorder, and has a BIMS [brief interview for mental status] score of 7 indicating severe cognitive impairment.Review of the facility's Abuse, Neglect, and Exploitation Prevention policy [effective 3/23/2010] reveals All residents of this facility have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property by facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals.Per review of the facility's investigation, on 7/20/25 Registered Nurse [RN] reported that [s/he] and Licensed Nursing Assistant #1 [LNA #1] heard Resident #1 yelling. LNA #1 went to Resident #1's room to see what was going on. When LNA #1 came out, [s/he] reported that Resident #1's lip was bleeding. RN reports that [s/he] assessed Resident #1's lip and relayed to LNA #1 that [s/he] would start an incident report. LNA #2 [who was in the room when Resident #1 was heard yelling] and LNA #1 then went to provide care to another resident. After that care was completed, LNA #2 went to break, and LNA #1 reported to RN that LNA #2 admitted to [h/her] that [s/he] had hit Resident #1.Per the facility 5-day investigation summary, dated 7/23/25, LNA #2 reported to the Administrator that [Resident #1] was combative during care. She reported that [Resident #1] hit her breast very hard and as a reaction, without thinking, she lashed out at [Resident #1] striking [him/her] in the face. The investigation states that the allegation that Resident #1 was physically abused by LNA #2 was verified.An interview was conducted with the facility's Administrator [ADM] on 8/5/25 at 11:30 AM.The ADM confirmed that the facility failed to ensure Resident #1 was free from abuse when LNA #2 struck the resident while providing care on 7/20/25.

Based on interviews and record reviews, the facility failed to ensure the residents' environment remained as free from accident hazards as is possible for 1 of 8 residents surveyed (Resident #29). Findings include: Per interview on 6/17/25 at 11:30 AM with Resident #29's Family Member, s/he stated that her/his parent was transferred to another room due to pest control issues. While the resident was in her/his new room, s/he got up during the night to use the bathroom and fell. S/he stated that s/he thinks the resident fell because there were no nonskid strips on the floor like there were in his/her previous room. S/he also stated his/her mother went to the hospital because s/he had a fractured hip from the fall. Per review of Resident #29's Care Plan dated 1/3/24, Resident #29 is at risk for falls related to limited mobility and cognitive impairment. Care plan interventions include nonskid strips on floor next to bed, created on 1/22/24, and nonskid strips in front of toilet, created on 4/6/25. Per interview on 6/17/2025 at 4:23 PM with the Business Office Manager and the Admissions Coordinator, they revealed that Resident #29 was relocated temporarily from her/his room to another room on a different unit on 4/28/25, due to a pest control issue in room his/her room. A nursing progress note dated 4/29/25 for Resident #29 reads, The writer heard yelling for help. upon entering the residents room, the resident was found sitting on the floor. Resident said S/he was trying to get to the bathroom and slipped and fell (his/her temporary room). Per review of progress notes dated 4/29/25, Resident #29 was sent to [NAME] Hospital for further evaluation and assessment due to fall and complains of right hip pain Per review of progress note dated 5/2/2025, Resident #29 returned from the hospital after having right hip surgery. Review of the Resident Management System (RMS) internal review of the fall revealed the facility is listing poor lighting as an environmental factor; Devices: wheelchair as a psychological factor; Recent room change, Ambulating without assistance and a history of falls as Predisposing situation factors. On 6/18/25 at 8:20 AM , the Unit Manager confirmed that Resident #29 was transferred to a different room on a different unit on 4/28/25. This Unit Manager also confirmed there were no nonskid strips on the floor next to the bed, in the new room, at the time of the fall, as is indicated in Resident #29's care plan. During the survey, it was determined that the facility had implemented actions to correct the noncompliance prior to the start of the re-certification survey. The Performance Improvement Plan included: Resident #29 returned to their original room with nonskid strips. Unit to Unit Transfers, developed by the QAPI (Quality Assurance and Performance Improvement) team. The Plan includes: a written Communication form for resident room/unit to room/unit transfers. The plan includes verbal and written elements related to all residents transferring from one room/unit to another; information is gathered and shared by Licensed Nursing Assistants (LNA) and Nurses by completing the form and communicating a verbal report. Other participants involved in room changes will be a second check to ensure process is completed. As an example: the communication form will include interventions such as nonskid strips on the floor if indicated. The education for staff was implemented for Nurses and LNA's and was completed on 4/30/25 with a completion date of 5/1/25 for the plan. Ongoing monitoring is in place for all room/unit transfers within the facility. Based on the facility submitting evidence of corrective action, the findings are cited as past noncompliance.

Based on observation and interview, it was determined that the facility failed to maintain an effective pest control program that ensures the facility is free of pests. This deficiency has the potential to impact all residents. Findings include: Per observation on 6/16/25 at approximately 11:00 AM during the initial tour of the facility kitchen area many fruit flies were observed in the dry storage room around a stainless-steel table. Across the room on top of a rack was noted to be a box of over ripe bananas with fruit flies. The Food Service Director confirmed that the fruit flies may be coming from the overripe bananas. Observation on 6/16/25 at approximately 11:15 AM revealed a large-sized moth flying and landing on clean dishes in the dishwashing room. The Food Service Director confirmed the moth was in the room and landing on the clean dishes. He confirmed the facility does have a pest control contract and is serviced regularly. During an interview on 6/16/25 at approximately 3:00 PM with the contracted Food Services District Manager (DM) providing oversight to the facility, s/he confirmed the fruit flies in the dry storage room and that the facility has a pest control contract and is serviced regularly. Fruit flies are mainly attracted to extra ripe, fermenting fruits and vegetables. However, they are also drawn to things such as drains, garbage disposals, empty bottles and cans, trash bags, cleaning rags, and mops. Essentially, they are drawn to food waste and moist environments. https://www.arrowexterminators.com/learning-center/pest-library/flies/fruit-flies#:~:text

Based on observation, interview and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility. Findings include: During observation with the Food Service Director on 6/16/25 at approximately 11:00 AM, the initial tour of the kitchen revealed a dry storage room, with a covered [NAME] mixer that was noted to have a dried yellow substance on the front of the mixer and a powdery substance on the base of the mixer. The Food Service Director stated that the mixer was ready for use in its current state and that the item is cleaned between uses. The Food Service Director observed the mixer and then confirmed the mixer was not clean in its current state. A storage rack containing pots and pans revealed a small steam pan (also known as a hotel pan or service pan, which is a rectangular or square pan used in food service for holding and serving food, particularly in steam tables or buffet-style setups where food needs to be kept warm) that was observed to be wet inside, and a small clear plastic pan was noted to have dried debris on the bottom. The Food Service Director confirmed that the rack was used for clean items and confirmed the wet and dirty pans. A plastic pitcher on top of the ice machine was observed to have gray tape on the bottom. The Food Service Director confirmed that the pitcher is used for obtaining ice and confirmed the tape on the bottom of the pitcher. S/he stated the pitcher was cracked and the tape was added as a result and could not be adequately cleaned. They stated, It should be thrown away. Storage bins were noted under a stainless-steel table, on top of the stainless-steel table was a machine with an attached soda gun (or a bar gun which is a device used by bars to serve various types of carbonated and no-carbonated drinks) that was sitting in a square metal steam pan of water. The Food Service Director stated that the soda gun was leaking and had notified maintenance to fix it. Under the stainless-steel table were 4 rectangular bins with clear covers, 3 contained food and 1 was empty. One bin contained loose flour, one contained potato chips in their original packaging, and the other contained cake mixes, also in their original packaging the clear covers to all 4 bins were wet. None of the contents within the bins were wet. The Food Service Director stated that the water was coming from the leaking soda gun. Fruit flies were observed flying around the stainless-steel table. The Food Service Director confirmed the presence of numerous fruit flies and stated they were possibly coming from overripe bananas located in the dry storage room. A clear plastic bin of individually packaged saltine crackers and a second clear plastic bin of graham crackers were observed. Neither bin had an expiration date marked on the bins or on the individual packages. The Food Service Director confirmed that the two cracker bins did not have expiration dates and the original boxes with the expiration dates had been discarded. The Dietician had joined the Food Service Director and stated that both the saltine and the graham crackers had been received this month (June). The Dietician confirmed that there was no expiration date written on the plastic bins. The Dietician wrote a date on masking tape and applied it to each bin. During observations with the Food Service Director at approximately 11:21 AM, the walk-in cooler, revealed three trays of individual pieces of sliced pie uncovered and not dated. This was confirmed by the Food Service Director at the time of this observation. The can opener in the kitchen was observed to have dried debris on the blade, which the Food Service Director confirmed. S/he stated that the can opener is processed through the dishwasher twice daily; however, it must have been missed after breakfast today. The refrigerator in the kitchen revealed (2) 8-ounce glasses of a brown liquid, revealing no date. The Food Service Director stated that these had just been poured and confirmed they had not been labeled with a date. The freezer was noted to contain a clear plastic bag of frozen patties, but the contents of the plastic bag were unknown and the bag was not dated. This was confirmed by the Food Service Director, who stated that the product was Salisbury steaks and the package was not dated. S/he stated that they needed to throw these away because they were not dated and staff know better. During observation with the Food Service Director of the stock supplies room/dry goods/canned goods, it was noted that (3) #10 cans (a specific size of metal can commonly used for food storage, especially for long-term or emergency preparedness. It is not a standard size can and is larger than typical grocery store canned goods) of Bushes Baked Beans and (1) #10 can of sliced pears were dented along the sides and bottom of all 4 cans and were on the shelves for use. The Food Service Director stated that these cans were in regular stock and would have been used for residents. They confirmed that these cans should not have been placed in stock but should have been set aside to be sent back for credit. Observation with the Food Service Director of the hallway between the dish room and the main kitchen, were 3 trays of blue coffee cups that were flipped upside down and were noted to be wet inside, on the sides and the bottom of each cup. The Food Service Director stated the coffee cups were ready for use. S/he was asked about the cups being turned upside down, directly on the trays and still wet inside, s/he stated that this is how s/he was instructed to dry them. S/he was asked how the cups would dry upside down on a tray with no air flow to dry the inside of the cups. S/he stated s/he was told to put the cups on a black plastic mesh on a tray to dry. The Food Service Director confirmed that the mesh wasn't placed under the cups, the cups were wet inside, and that they would not dry like that. The Food Service Director was noted to have facial hair and was noted to have no hair covering/hair net. S/he was asked about the policy specific to facial hair, and they stated covering was only needed when s/he was cooking. During an interview on 6/16/25 at approximately 3:00 PM with the contracted Food Services District Manager (DM), who was providing oversight to the facility, the DM confirmed the presence of fruit flies in the dry storage room. He also confirmed that the facility does have a pest control contract and is serviced regularly. The DM confirmed that facial hair must be covered in the kitchen area. This was also confirmed with the facility's policy titled Staff Attire (Revised 10/2023), which states facial hair properly restrained. During observation on 6/18/25 at approximately 11:50 AM, a revisit to the kitchen revealed 2 trays of a pudding dessert in the walk-in cooler on a food rack that were not covered or dated. The Food Service Director confirmed the items were not covered or dated. A stainless-steel multiple-shelf cart holding pots and pans that had been cleaned in the sink was noted to have built up sticky, dark debris on the racks. The Food Service Director confirmed that the cart was dirty and stated that cleaning hasn't been done in a while.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented regarding residents on enhanced barrier precautions and hand hygiene practices were completed for 1 of 4 residents sampled (Resident #25). Findings include: Per observation on 6/16/25 at approximately 11:00 AM, signage posted outside of Resident #25's room included an infection control Enhanced Barrier Precautions sign (EBPs), instructing anyone entering the room to have clean hands before and after leaving the room, and staff to wear gloves and gown during High Contact Resident Care Activities examples were provided on signage and included handling and care of a feeding tube. During record review, Resident #25's Care Plan notes intervention of EBPs was initiated on 3/11/2025 due to risk for MDRO (Multidrug-resistant Organisms) colonization/infection due to: indwelling devices: feeding tube. According to the Care Plan, EBPs are to use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing). Review of Physician Orders for Resident #25 included Enhanced barrier precautions related to feeding tube for every shift with a start date of 3/11/25. Per observation on 6/18/25 at approximately 1:30 PM, Registered Nurse (RN) completing medication administration for Resident #25 there were two missed opportunities for hand hygiene, and stethoscope wasn't cleaned before and after use with resident. Hand hygiene wasn't observed after prepping medications at bedside and again wasn't observed after listening to bowel sounds with stethoscope. During the administration of medications through the PEG tube, a gown wasn't donned to perform the task per the EBPs criteria. An interview was conducted with the facility's RN Supervisor and RN on 6/18/25 at approximately 2:30 PM. The RN was asked regarding the EBPs signage on the resident's door and if these precautions needed to be followed for the medication administration observed at 1:30 PM. S/he stated s/he was unsure and asked the RN Supervisor regarding the requirements for the precautions. The RN Supervisor confirmed for all high contact activities a gown and gloves needs to be worn. RN then asked if this included medication administration which the RN Supervisor confirmed medication administration is included because the feeding tube (PEG) is be used to administer the medications. The Centers for Disease Control and Prevention recommends the use of gown and gloves (EBPs) for high-contact resident care activities, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO (multidrug resistant organisms) colonization.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored for 1 of 7 sampled residents (Resident #42). Findings include: Per observation on 6/16/25 at 11:37 AM, Resident #42 was observed in his/her bed with two pills in a medication cup on his/her lap. Per record review, the medication left with the resident was Apriso (Mesalamine; a medication used to treat ulcerative colitis) Oral Capsule Extended Release 24 hour 0.375 GM (grams): Give 4 capsules by mouth one time a day for Colitis before lunch. Per record review of the facility's Storage of Medications policy [last revised 1/2024] states, 3. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Per interview with RN #1 on 6/16/25 at 11:38 AM, RN #1 confirmed that she left the pills at Resident #42's bedside and should not have, stating, I stepped out of the room after I gave [him/her] them.

Based on observations, staff interview, resident interview, and record review, the facility failed to ensure that each resident receives food that accommodates allergies, preferences, and intolerances for two of four sampled residents (Residents #1 and #2). Findings include: 1. Per record review, Resident #1 was admitted on [DATE] with a diagnosis of Celiac Disease (a disease that causes acute illness and long term health issues if Gluten [found in wheat and other grains] is ingested). Resident #1's allergies list also lists wheat, entered on 4/6/2023. On 4/6/23, Resident #1 had the care plan focus Risk for gastrointestinal symptoms or complications related to constipation, diverticulitis, history of colon cancer, celiac disease, and gastroesophageal reflux disease added to their care plan. The record shows that Resident #1's diet order was placed on 4/6/23. The diet order reads consistent carbohydrate diet, regular texture. There is a comment in the order that states Gluten Free. An audit of the order's revision history shows that the order was revised on 4/11/23. Per review of a grievance that Resident #1 submitted on 4/11/23, the description reads, Patient reports that [they have] a gluten free diet and is not receiving these types of meals. The immediate action taken section of the form reads, Diet order updated to Gluten Free and dietary slip sent. Per interview on 9/13/2023, the Director of Nursing confirmed that the diet order was updated on 4/11/23 following the Resident #1's complaint despite ample evidence in the chart that the Resident could not eat gluten-containing foods. 2. Per record review, Resident #2 has wheat listed as an intolerance in their medical record. This was placed on 1/8/2021. Per observation of Resident #2's meal ticket on 9/13/23 at approximately 11:30 AM, Resident #2's meal ticket for the impending lunch service did not have wheat listed as on of their allergies. Per interview at the time of the meal ticket observation, the Dietary Manager stated that allergy/intolerance information is sent from the nursing units via a diet slip to the kitchen. Kitchen staff then update meal tickets to include allergies, and this is what they reference when plating meals to avoid putting allergens on resident trays. Per interview on 9/13/23 at approximately 11:45 AM, the Unit Manager confirmed that Resident #2's medical record lists wheat as an allergen but that Resident #2 is not on a wheat or gluten-free diet. Per interview on 9/13/23 at approximately 11:50 AM, Resident #2 stated that they are aware that they have been intolerant to wheat in the past, and that it sometimes bothers them but that they continue to eat wheat at the facility.

Based on staff interview and record review, the facility failed to consult with the resident's physician when there is a need to alter treatment significantly as evidenced by a failure to follow up on consistent refusal of high-risk medications for one of 5 sampled residents (Resident #1). Findings include: Per record review, Resident #1 was admitted with Type 2 Diabetes Mellitus on 4/6/2023. An order for Insulin Aspart (short acting insulin) 20 unit injections three times a day with meals was placed on 4/7/2023. An order for Insulin Glargine (long acting insulin) 30 unit injections one time a day was also placed on 4/7/2023. Insulin is prescribed for Diabetes to help control blood sugars and prevent serious complications from chronically high blood sugar levels. Per review of Resident #1's Medication Administration Record, Resident #1 refused the Insulin Aspart injections on 4/7/23 at 5 PM, all scheduled injections on 4/8/23 through 4/10/23, on 4/11/23 at 8 AM and 5 PM, all scheduled injections on 4/12/23 through 4/13/23, and on 4/14/23 at 8 AM prior to Resident #1's discharge from the facility. Resident #1 also refused all daily Insulin Glargine injections from 4/8/23 through 4/14/23 prior to discharge from the facility. Per review of nursing progress notes, multiple daily nursing notes document Resident #1's refusal of Insulin throughout their admission. None of these notes state that the provider was notified of the refusals until 4/14/23, the morning of Resident #1's discharge. There is otherwise no evidence that the provider was notified of Resident #1's insulin refusal throughout their admission. The facility policy titled Refusal of Treatment states under the process section 3. Notify physician of refusal of treatment. 4. Staff Will: 4.1 determine and document what the patient is refusing 4.2 assess the reasons for refusal 4.3 advise patient of consequences of refusal, and 4.4 offer alternative treatments. Per interview on 9/13/23 at approximately 12:45 PM, the Director of Nursing confirmed that no evidence of provider notification could be found for Resident #1's refusal of ordered insulin.

Based on observation and staff interview, the facility failed to prepare food in accordance with professional standards for food service safety by failing to reheat previously cooked foods to a safe temperature of 165 degrees Fahrenheit. Findings include: During observation of the kitchen's lunch service on 7/25/23 at approximately 12:00 PM, a resident's meal ticket requested to substitute the seafood pasta sauce on the menu for marinara sauce. A dietary aide retrieved leftover marinara sauce from the walk-in refrigerator. The sauce was in a plastic container with a lid and not from a ready-to-serve package or sealed container. The dietary aide put a serving of marinara sauce in a steel pan and heated the sauce over a burner. After a few minutes, the aide served the sauce over a serving of pasta without measuring the temperature of the sauce and prepared the plate for the resident's tray to be sent to the unit. The Dietary Manager used an instant-read thermometer to measure the temperature of the leftover sauce. It read 115 degrees Fahrenheit. The Dietary Manager instructed the aide to discard the prepared tray and repeat the process with sauce that was heated to at least 135 degrees Fahrenheit. Per interview a few minutes after the pasta and sauce was re-plated after reaching 140 degrees Fahrenheit, the Dietary Manager re-confirmed that the kitchen's process for reheating previously cooked and cooled leftovers is to heat them to at least 135 degrees Fahrenheit. Per professional standards of food service, foods that have been previously cooked and then cooled for storage must be reheated to 165 degrees Fahrenheit for at least 15 seconds to kill all possible food borne illness. Previously cooked and cooled foods have passed through the danger zone (a temperature range of 40 to 140 degrees Fahrenheit) multiple times and are at a higher-than-average risk of being contaminated with food borne pathogens. Per interview on 7/25/23 at approximately 1:00 PM, the Dietary Manager confirmed that their training materials include education on heating previously cooked and cooled foods, but that it does not specify a temperature as high as 165 degrees Fahrenheit.

Based on observation and staff interview, the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: 1. On 03/20/23 at 2:08 PM, a staff Licensed Practical Nurse (LPN) was observed in room [ROOM NUMBER] standing approximately 4 feet from Resident # 149 who is on contact precautions for Clostridium- Difficile ( C-Diff). There was another resident in the semi-private room at the time of the observation. This other resident was being treated for chronic venous ulcers. The LPN did not don gloves or a gown as indicated by a Centers for Disease Control (CDC) sign posted on the room door. The contact precautions sign stated that anyone entering the room must don gloves and a gown. The LPN then left the room and proceeded to enter several additional resident rooms without sanitizing or washing hands. Immediately after the observation, the LPN stated that Resident # 149 had C-Diff and that gown and gloves should be worn only when providing personal care which is contrary to facility and CDC policy. CDC and facility policy states that gown and gloves must be worn before contact with the patient or patient's environment. On 3/22/23 at 10:52 AM, the Director Of Nurses (DON) agreed that staff should have been donning gloves and gowns when entering Resident # 149's room. 40258 2. During observation of the medication administration pass on 3/21/2023 at 8:55 AM the Licensed Practice Nurse (LPN) was observed administering medication to a Resident and then return to the medication cart. S/he then preceded to prepare medications for another Resident, administer them and return to the cart again. S/he then prepared medications for another resident and administered them. During this administration the LPN spilled juice on the floor, cleaned it up with a towel, and then washed her/his hands. During interview at 9:10 AM the LPN confirmed that S/he should performed hand hygiene before, after, and between residents while administering medications.

Based on staff interview and record review, the facility failed to ensure that residents who are trauma survivors receive trauma informed care that mitigates triggers that may re-traumatize residents for two of two residents (Resident #4 and Resident #49). Findings Include: 1. Per record review, Resident #4 was admitted on [DATE] with diagnoses of PTSD (Post-Traumatic Stress Disorder), Bipolar Disorder, Schizophrenia, Insomnia, and Major Depressive Disorder. Resident #4's care plan includes focuses of sexually inappropriate behavior, refusal of care, distressed/fluctuating mood symptoms, and sleep pattern disturbance. The admission note from Resident #4's Attending Physician on 3/1/2020 states, PTSD is service related. The first consult note from the Psychiatric Nurse Practitioner on 2/17/2022 states, [Resident #4] mentioned serving in Vietnam and 'agent orange'. Per review of Resident #4's record, there was no evidence found that Resident #4 was assessed for triggers that may re-traumatize the Resident. There was also no evidence found in Resident #4's plan of care regarding the Resident's triggers or how staff can provide care that avoids re-traumatizing the Resident. Per interview on 3/22/2023 at approximately 8:30 AM, an LNA (Licensed Nursing Assistant) with [AGE] years at the facility was unable to identify Resident #4's specific triggers related to their trauma experience. Per interview on 3/22/2023 at approximately 12:30 PM, the facility Administrator and Director of Nursing confirmed that Resident #4's trauma experience and associated triggers are not identified in the Resident's record. 2. Per record review, Resident #49 was admitted on [DATE] with diagnoses of PTSD (Post-Traumatic Stress Disorder), Anxiety, and Depression. Resident #49's care plan includes focuses of verbal behaviors, resistance to care, distressed/fluctuating mood symptoms, and adjustment issues. The Attending Physician admission note from 5/14/2022, the Nurse Practitioner admission note from 5/24/2022, and the Psychiatric Nurse Practitioner note from 6/2/2022 all mention that Resident #49 has PTSD but include no additional details about the trauma or associated triggers. Per review of Resident #49's care plan, a care plan intervention from 8/18/2022 states, Evaluate the nature and circumstances (i.e., triggers) of the verbal behavior with resident/patient and/or resident representative. However, there is no identification in the record of what these triggers are or how they relate to Resident #49's trauma experience. Per interview on 3/22/2023 at approximately 12:30 PM, the facility Administrator and Director of Nursing confirmed that Resident-specific triggers have not been identified or care planned for Residents with a history of trauma.

Based on staff interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan related to PICCs (peripherally inserted central catheters) for two of two residents with PICCs (Resident #73 and Resident #65). Findings include: 1. Per record review, Residents #73 and #65 both have PICCs (centrally inserted catheters that deliver fluids and medicine directly into the heart from an insertion site in the upper arm). An order was placed in Resident #73's record on 1/18/22 that reads, Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10 cm above antecubital [inner elbow]). Notify practitioner if the external length has changed since last measurement every day shift every 7 days weekly and as needed. An identical order was placed in Resident #65's record on 1/13/22. Per review of Resident #73's medication and treatment administration record, Resident #73 was scheduled for their dressing change and site assessment on 1/18/22, 1/25/22, and 2/1/22. Nurse 1 documented that the PICC dressings were changed on all 3 scheduled dates. On 1/18/22, Nurse 1 documented NA under both circumference measurement and external length measurement. On 1/25/22, Nurse 1 documented NA under circumference measurement. On 2/1/22, Nurse 1 documented NA under both circumference measurement and external length measurement. Per review of Resident #65's medication and treatment administration record, Resident #65 was scheduled for their dressing change and site assessment on 1/14/22, and 2/4/22. Nurse 1 documented that the PICC dressings were changed on both scheduled dates. On 1/14/22 and 2/4/22, Nurse 1 documented NA under both circumference measurement and external length measurement. Per review of Resident #73's care plan, under the care plan focus Central Line IV/PICC line due to antibiotic therapy initiated on 1/15/22, an intervention placed on 1/15/22 reads, sterile dressing change per policy and prn (as needed). Per review of the facility's policy Central Vascular Access Device Dressing Change, under the guidance section, the policy states, 9. Length of external catheter is obtained . 9.2 during dressing changes . 10. For PICCs, upper arm circumference (10 cm above antecubital) is obtained . 10.4 compare to baseline measurement to detect possible catheter-associated venous thrombus (blood clot). Per interview on 2/9/22 at approximately 11:30 AM, The Director of Nursing confirmed that the documentation of NA did not represent an appropriate assessment of circumference or external length, and that appropriate documentation would consist of a numeric measurement.

Based on interview and record review the facility failed to ensure that one of three residents in the sample were free from physical abuse on three occasions, (Resident #2). Findings include: Per record review Resident #1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he has a history of anxiety, aggression, and being resistive to care. Resident #1's care plan reflects a risk for resident-to-resident altercation due to cognitive deficit and wandering, and the potential to exhibit physical behaviors related to cognitive loss/dementia. Progress Notes indicate Resident #1 was becoming aggressive with other residents and staff who attempt to redirect her/him. 1. On 7/3/2021 at approximately 8:30 PM Resident #1 hit Resident #2 in the face, leaving a red mark on her/his cheek. A facility internal investigation of the incident states On Saturday, July 3rd, staff witnessed [resident #1] grab another resident's walker. In effort to get [her/him] to stop touching the resident's walker, [Resident #2] grabbed [Resident #1's} arm and pushed [her/him]. [Resident #1] turned and hit [Resident #2] in the face with [her/his] hand and [Resident #2's] glasses fell off. Staff immediately separated the residents and called the nurse for assistance. A red mark was noticed on [Resident #2's] face. During an interview on 9/1/2021 at 1:30 PM a facility LNA (Licensed Nursing Assistant) #1 who witnessed the incident stated that Resident #1 had pushed Resident #2's wheelchair and then turned and hit Resident #2 in the face. Per interview on 9/1/2021 at 3:30 PM, LNA # stated that s/he had not seen Resident #1 have behavior issues often. However, the LNA was there for the incident that occurred on 7/3/21. The LNA stated s/he did not witness the event but came to the assistance of the other LNA. Resident #2 was upset but not crying and brought back to her/his room. Staff then did checks on Resident #1 throughout the rest of the shift. 2. Per record review, on 8/21/2021 Resident #1 grabbed Resident #2's arm and repeatedly hit her/him in the head. A nurse progress note written on 8/21/2021 at 6:05 PM states The LNA reported to writer and stated [Resident #1] came up behind [Resident #2] and grabbed [her/his] arm and squeezed and with [her/his] other hand proceeded to smack the victim in the back of the head hard about five times. I ran down and removed [Resident #1's] hand from [Resident #2's] arm and escorted [Resident #1] away from the victim. Per interview at on 9/1/21 at 3:48 PM, LNA #2 stated that Resident #1 has been more agitated lately towards a few other residents. It's a day-to-day thing with his/her behavior, and there seems to be no pattern. [Resident #1] will grab other's walkers, and often grabs [Resident #2's] wheelchair. [Resident #2] gets very upset when [s/he] does this. [Resident #1] will also wander down to [Residents #2's] room and this would also upset [Resident #2]. We try to keep [Resident #1] out of others' rooms as much as possible but those behaviors kind of set off other residents too. When asked to describe the incident that took place on 8/21/2021, LNA #2 stated I was looking down the hall and [Resident #1] came up behind [Resident #2] and grabbed [her/him] very hard and then just started hitting [her/him] on the back of the head. [S/he] did not provoke him in anyway, and as soon as I saw this, I sprinted all the way down the hall and removed [Resident #1] from the situation and got someone else to come over. [S/he] just seemed to go off and just grabbed [her/him] and then proceeded to hit [her/him] in the back of the head with [her/his] other hand. I was coming out of the laundry room from getting towels and washcloths or something and then I looked up. I think the nurse might have been behind the nurse's station. [Resident #2] seemed very quiet, a little bit upset, [s/he] was stunned. [She/he] stated that [she/he] was afraid of [her/him]. There are twenty-four residents here, so you kind of just swap out kind of keeping an eye on where [s/he] is at all times making sure [s/he] isn't obviously anywhere near [Resident #2's] room. A progress note written on 8/19/2021 at 1:28 PM regarding an interdisciplinary team meeting (CAR) states that Resident #1 becomes easily agitated with direct 1:1 care when wandering, staff provides distant supervision. However, there were no staff providing direct supervision at the time of the incident. 3. Per record review on 8/23/21 while an LNA was attempting to redirect Resident #1 from Resident #2, Resident #2 swatted Resident #1 away. Resident #1 hit Resident #2 in the head twice and slammed the LNA into the wall. After this incident Resident #2 was moved to a different unit in the facility for saftey. A social services note written on 8/24/2021 states that during an interview with Resident #2 s/he stated, [S/He] really hit me pretty hard. I didn't do nothing to [her/him] to cause that. I would understand if I had. During an interview with a facility LNA #1 at 1:30 PM on 9/1/21 s/he stated that s/he was not assigned to the unit at the time of the last incident that occurred on 8/24/21, but that Resident #2 was moved over to the unit that s/he was assigned to immediately after the altercation for her/his safety. The LNA stated that Resident #2 was upset and scared. LNA #2 stated that s/he had told Resident #2 that it was for her/his own protection and states Resident #2 is doing much better on this unit. During observation of Unit Three on 9/1/2021 at 12:25 PM Resident #1 was seen in bed with his eyes closed. Staff were not visible in hallway. There were two Licensed Nursing Assistants (LNA) and an LNA in training assigned to the unit. An LNA and the LNA in training were in another resident's room towards at the other end of the hall, and the other LNA was assisting another resident with the door closed. The nurse assigned to the unit was in a residents' room which was further down hall. At 4:15 PM Resident #1 was again observed in bed with her/his eyes closed. There were no staff visible in the hallway at that time. Two activity staff members were behind the nurse's station. The two activity staff exited the nurse's station and entered the day room, the hallway is not visible from the day room, and no other visible staff were present at that time. Per interview with the Director of Nursing Services (DNS) on 9/1/21 at 4:42 PM, s/he confirms that Resident #1 has had behavioral issues and altercations with other residents on the unit. Staff have attempted one on one, but s/he does not do well with that, so they supervise her/him from a distance. However, s/he also stated they are not always able to get to [her/him] fast enough, they just don't expect it.

Based on observation and staff interview, the facility failed to provide a safe environment for residents in one area of the facility which is used by several residents. Findings include: Per observation on 11/4/19 at 1:51 PM, a handrail in a 2 South hall bathroom used by residents is very loose and pulling away from the wall. Several residents were observed using the bathroom unaccompanied by staff throughout the day. On 11/4/19 at 2:09 PM, two unit nurses confirmed the above observation and confirmed that this bathroom is used by residents. One of the nurses stated they rely on it, referring to the handrail. On 11/06/19 at 8:23 AM, the Maintenance Director confirmed that the rail had been pulled away from the wall and stated that whoever installed that rail did it improperly.

Based on staff interview and record review, the facility failed to employ a dietary service manager with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The findings include the following: Per review of the Dietary Supervisor's personnel record , the Dietary Supervisor does not have the requisite qualification to meet regulation. The Registered Dietician is contracted part-time and does not work at least 35 hours per week in the facility. On 11/04/19 during the initial kitchen tour at approximately 8:54 AM, the same Dietary Supervisor confirmed that s/he had not yet completed the certification process but has applied for the training program which has been submitted on 10/29/19. During interview on 11/06/19 at approximately 10 AM, confirmation was made by the Center Executive Director and the Regional Manager of Health Care Services, that the Dietary Supervisor has not completed the certification process for dietary managers and that the facility does not otherwise meet the regulatory requirement.

Based on staff interview and record review, the facility failed to ensure that one (1) of three (3) residents in the applicable sample (Resident #1) was treated with dignity and respect. Findings include: Per record review, on 5/13/2019 Resident #1 was exhibiting aggressive behaviors. A Licensed Nursing Assistant, (LNA) attempted to assist the resident with getting ready for bed. When other staff members entered the resident's room, the LNA was witnessed leaning over the resident with his/her face close to the resident's face. The resident swore at the LNA calling him/her a [***] . The Licensed Practical Nurse, (LPN) who was present instructed the LNA to leave the room. As the LNA was leaving the room witnesses heard him/her make an inappropriate statement to, or in the presence of Resident #1. Per review of a witness statement obtained on 5/13/2019, the LPN reported that LNA stated Well at least I'm not the one locked up in a nut house. On 10/9/2019 at 10:30 AM during an interview with the LPN, confirmation was made that the LNA stated an inappropriate comment about Resident #1 in the resident's presence. Per review of the LNA's statement given on 5/13/2019, the LNA reported that s/he said under my breath we aren't in a nut house. During an interview with the LNA on 9/30/2019 at approximately 5:45 PM, the LNA confirmed that s/he did in fact make an inappropriate statement in the presence of Resident #1.

Based on interview and record review the facility failed to develop a comprehensive care plan for 1 applicable resident (Resident #1). Findings include: Per review of a nursing progress note from 1/4/19 for Resident #1, it read, Resident wandering in other resident's rooms. Verbal redirection and tasks offered effective. On 1/11/19, Resident frequently wondering, wondering (sic) with impact, and exit seeking this morning. On 1/16/19, the resident went into another resident's room and started yelling. On 1/18/19, Resident #1 was involved in a resident to resident altercation with Resident #2. There was no evidence that a care plan had been developed to address Resident #1's wandering and/or need for supervision. Per interview on 3/7/19 at 1:38 PM with the Unit Manager, s/he confirmed that Resident #1 was not supervised at the time of the altercation with Resident #2.

Based on interview and record review the facility failed to provide transfer/discharge notices that contained the required regulatory elements for 1 applicable resident (Resident #1). Findings include: Per record review Resident #1 was transferred to the hospital on [DATE], 1/18/19, and 3/2/19. Per review of the transfer/discharge notices for Resident #1, the notices did not contain the reasons for the transfer(s)/discharge(s), the email address of the entity who receives requests for an appeal, the email address of the Office of the State Long-Term Care Ombudsman, the email address of the agency responsible for the protection and advocacy of individuals with developmental disabilities, and the email address of the agency responsible for the protection and advocacy of individuals with a mental disorder. Per interview on 3/7/19 at approximately 4:00 PM with the Administrator, s/he confirmed that the notice did not contain the required elements per regulation.

Based on staff interview and record review, the facility failed to ensure that the environment was free of accident hazards and that each resident received adequate supervision to prevent accidents for 1 of 4 residents in the sample. (Resident #4) Findings include: Per staff interview and record review, the facility failed to ensure adequate supervision to prevent accidents/falls per care plan and this failure resulted in resident injury. Per record review on 2/17/16, Resident #4 was identified as at risk for falls related to decreased safety awareness, noncompliance and a history of falls. Per review of Resident #4's 11/25/16 MDS (Minimum Data Set), s/he is listed as having severe impairment of cognitive skills for daily decision making; having short and long term memory problems; disorganized thinking; requires extensive assistance for transfers, dressing, walking and moving from seated to standing; and is not steady, only able to stabilize with staff assistance. The resident had a care plan for fall risk that was revised on 10/12/15 to include the intervention that the Resident is to be visual to staff at all times. Per review of the facility's Fall Log, Event Summary and the resident's medical record, the resident sustained [REDACTED]. Of those 19 falls, 14 were reported as unwitnessed: falls on 11/10, 12/5, 12/7, 12/8, 12/9, 12/10/15, 1/2, 1/14 (2 falls on this date), 1/21, 1/28, 1/29, 2/2 and 2/3/16. No injuries were reported for the falls except for the fall on 2/3/16. Per nurse's progress notes, on 2/3/16, at 6 PM, Resident #4 was heard calling for help and found on his/her knees in the hallway. On 2/17/16 at 1:21 PM, the staff nurse, who was on duty at the time of the 2/3/16 fall, reported that the fall occurred around dinner time when 2 of the 3 staff members were assisting residents with care needs in rooms and one staff member was providing supervision in the dining room; the nurse verified that Resident #4 was in the hallway and not within sight of staff when s/he fell . The resident's physician was notified and on 2/4/16 an x-ray of the knee revealed a nondisplaced incomplete left tibial tubercle fracture (fracture involving the lower leg bone). Per physician orders, the resident was evaluated in the Emergency Department on 2/4/16 and returned to the facility with a knee immobilizer for the fractured left tibia. On 2/17/16 commencing at 2:54 PM, the nurse and 2 LNAs (Licensed Nursing Assistants) who routinely provide care for Resident #4 reported that there are typically 13-14 residents on the Dementia unit where Resident #4 resides. Most of the residents require some assistance with meals, personal care, toileting, supervision and or redirection. At times the nurse is giving medications or treatments and the 2 LNAs are providing care to other residents in their rooms and none of the staff are available to keep eyes on Resident #4. Per interview, Resident #4 is not to transfer or walk alone; however, when other residents on the unit require care, there is not always enough staff to keep eyes on Resident #4 as per care plan. The staff reported that in most of the falls, Resident #4 had attempted to transfer or ambulate independently without requesting assistance. On 2/17/16 at 3:33 PM, the DNS (Director of Nursing) confirmed the above information related to falls and that staff have not been able to keep eyes on Resident #4 per care plan to prevent falls as other residents require care and the resident sustained [REDACTED]. (Refer F353 and F282)

Based on staff interview and record review, the facility failed to provide services in accordance with the plan of care for 1 of 4 residents who was identified as at risk for falls (Resident #4). Findings include: Per staff interview and record review, the facility failed to implement safety interventions for fall prevention per care plan and this failure resulted in resident injury. Per record review on 2/17/16, Resident #4 was identified as at risk for falls related to decreased safety awareness, noncompliance and a history of falls. Per review of Resident #4's 11/25/16 MDS (Minimum Data Set), s/he is listed as having severe impairment of cognitive skills for daily decision making; having short and long term memory problems; disorganized thinking; requires extensive assistance for transfers, dressing, walking and moving from seated to standing; and is not steady, only able to stabilize with staff assistance. The resident had a care plan for fall risk that was revised on 10/12/15 to include the intervention that the Resident is to be visual to staff at all times. Per review of the facility's Fall Log, Event Summary and the resident's medical record, the resident sustained [REDACTED]. Of those 19 falls, 14 were reported as unwitnessed falls on 11/10, 12/5, 12/7, 12/8, 12/9, 12/10/15, 1/2, 1/14 (2 falls on this date), 1/21, 1/28, 1/29, 2/2 and 2/3/16. No injuries were reported for the falls except for the fall on 2/3/16. Per nurse's progress notes, on 2/3/16, at 6 PM, Resident #4 was heard calling for help and found on his/her knees in the hallway. On 2/17/16 at 1:21 PM, the staff nurse, who was on duty at the time of the 2/3/16 fall, reported that the fall occurred around dinner time when 2 of the 3 staff members were assisting residents with care needs in rooms and one staff member was providing supervision in the dining room; Resident #4 was in the hallway and not within sight of staff when s/he fell . The resident's physician was notified and on 2/4/16 an x-ray of the knee revealed a nondisplaced incomplete left tibial tubercle fracture (fracture involving the lower leg). Per physician orders, the resident was evaluated in the Emergency Department on 2/4/16 and returned to the facility with a knee immobilizer for the fractured left tibia. On 2/17/16 at 3:33 PM, the DNS (Director of Nursing) confirmed the above information and that the care plan for Resident #4 was not followed related to the resident being visual to staff at all times and that a fracture was sustained from the unwitnessed fall on 2/3/16. (Refer F323 and F353)

Based on medical record review and staff interviews, the facility failed to assure sufficient staff to provide nursing and related services to maintain the highest practicable well-being of each resident according to residents' assessments and individual plans of care for 1 of 4 residents. (Resident #4) Findings include: Per staff interview and record review, the facility failed to ensure sufficient nursing staff to implement safety interventions for fall prevention per care plan and this failure resulted in resident injury. Per record review on 2/17/16, Resident #4 was identified as at risk for falls related to decreased safety awareness, noncompliance and a history of falls. Per review of Resident #4's 11/25/16 MDS (Minimum Data Set), s/he is listed as having severe impairment of cognitive skills for daily decision making; having short and long term memory problems; disorganized thinking; requires extensive assistance for transfers, dressing, walking and moving from seated to standing; and is not steady, only able to stabilize with staff assistance. The resident had a care plan for fall risk that was revised on 10/12/15 to include the intervention that the Resident is to be visual to staff at all times. Per review of the facility's Fall Log, Event Summary and the resident's medical record, the resident sustained [REDACTED]. Of those 19 falls, 14 were reported as unwitnessed: falls on 11/10, 12/5, 12/7, 12/8, 12/9, 12/10/15, 1/2, 1/14 (2 falls on this date), 1/21, 1/28, 1/29, 2/2 and 2/3/16. No injuries were reported for the falls except for the fall on 2/3/16. Per nurse's progress notes, on 2/3/16, at 6 PM, Resident #4 was heard calling for help and found on his/her knees in the hallway. On 2/17/16 at 1:21 PM, the staff nurse, who was on duty at the time of the 2/3/16 fall, reported that the fall occurred around dinner time when 2 of the 3 staff members were assisting residents with care needs in rooms and one staff member was providing supervision in the dining room; Resident #4 was in the hallway and not within sight of staff when s/he fell . The resident's physician was notified and on 2/4/16 an x-ray of the knee revealed a nondisplaced incomplete left tibial tubercle fracture (fracture involving the lower leg bone). Per physician orders, the resident was evaluated in the Emergency Department on 2/4/16 and returned to the facility with a knee immobilizer for the fractured left tibia. On 2/17/16 commencing at 2:54 PM, the nurse and 2 LNAs (Licensed Nursing Assistants) who routinely provide care for Resident #4 reported that there are typically 13-14 residents on the Dementia unit where Resident #4 resides. Most of the residents require some assistance with meals, personal care, toileting, supervision and or redirection. At times the nurse is giving medications or treatments and the 2 LNAs are providing care to other residents in their rooms and none of the staff are available to keep eyes on Resident #4. Per interview, Resident #4 is not to transfer or walk alone; however, when other residents on the unit require care, there is not always enough staff to keep eyes on Resident #4 as per care plan. The staff reported that in most of the falls, Resident #4 had attempted to transfer or ambulate independently without requesting assistance. On 2/17/16 at 3:33 PM, the DNS (Director of Nursing) confirmed the above information related to falls and that staff have not been able to keep eyes on Resident #4 per care plan to prevent falls as other residents require care and the resident sustained [REDACTED]. (Refer F323 and F282)

Based on record review and staff interview the facility failed to ensure that 2 of 3 residents identified (Resident #2 and 3) were free from verbal,sexual, physical, and mental abuse. The findings include: 1. Per review of the facilities internal investigation, on 10/10/12, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's internal investigation dated 5/30/12 indicates that on 5/23/12 a facility staff member (Staff #1) reported that at approximately 1:50 PM, Staff #1 overheard a Licensed Nursing Assistant (LNA), speak to Resident #3 in a harsh tone and overheard the LNA say to Resident #3, you need to get out of bed. Staff #1 then indicates that he/she witnessed the LNA grab Resident #3's lower legs just below the knee and threw them over the side of the bed. Staff #1 also indicates that he/she witnessed the LNA grab the wrists of Resident #3 and threw them onto the walker of Resident #3 and heard the LNA yell at Resident #3, you need to get up and go to the bathroom. Staff #1 indicates that he/she heard Resident #3 say twice, "stop beating me up". Staff #1 indicates that he/she then heard the LNA reply to Resident #3 "yeah, I am the one beating you up, you're the one that asked for help, now you need to get up". Per the internal investigation, Resident #3 confirmed in interview with the facility administrator on 5/23/12 that the LNA was "mean", and that the LNA "grabbed my wrist and hurt it." Resident #3 and Staff #1 re-enacted how the LNA transferred Resident #3 out of bed. Resident #3 confirmed that the LNA had "thrown (his/her) legs to the side of the bed" and Resident #3 confirmed that the LNA "yanked on (him/her)" from a lying position. Resident #3 also confirmed that he/she was "afraid of the LNA and doesn't want the LNA to take care of (him/her)." Per review of the facility's internal investigation, the investigation found that the interaction between the LNA and Resident #3 was determined to be at a minimum "abrasive, disrespectful" and that the interaction between the LNA and Resident #3 "negatively impacted the resident's emotional status as the resident stated that (he/she) was afraid of the LNA." Per interview with the facility administrator on 10/10/12, he/she confirmed that the facility felt that based on the internal investigation that Resident #3 was a victim of abuse. 2. Per review of the facility's internal investigation on 10/10/12, Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted to the facility for pain control and rehabilitation with plans to discharge to home. Per the facility's internal investigation dated 6/13/12, on 6/12/12 at approximately 2:00 AM as per an interview with Resident #2, an Licensed Nursing Assistant (LNA), came into Resident #2's room to assist the resident in transferring to the bathroom. Per Resident #2, he/she indicated that during the transfer the resident felt "hurried by the aide and I can't be hurried." The resident indicated that when the aide and Resident #2 got to the bathroom, the aide let go of the resident to "primp" herself in the mirror, Resident #2 attempted to reach for the handicap bar to sit on the toilet and missed the bar. The resident indicated she lost his/her balance and nearly fell but made it to the seat safely. The aide saw this and said "Jesus Christ!" The aide then said to Resident #2 "that's it, you are using the bed pan from now on." The resident indicated that he/she told the aide that he/she had trouble using the bed pan and the aide said "I don't care, you're going to use the bed pan from now on at night". The resident then indicated that when the aide transferred Resident #2 back to bed the resident began to cry and the aide said "Why are you crying, you are a grown adult". Per review of the internal investigation, the facility found that Resident #2 was an alert and oriented resident and reported the incident that occurred between Resident #2 and the LNA in fairly great detail. The investigation also indicates that Resident #2 was quite emotional when recalling the event on 6/12/12. The facility investigation indicates that whatever the specific elements of the interaction between the LNA and Resident #2, the LNA negatively impacted Resident #2's emotional status, and that Resident #2 requested that he/she did not want the LNA to care for him/her again. Per interview with the facility administrator on 10/10/12, he/she confirmed that the facility felt that based on the internal, investigation that Resident #2 was a victim of abuse.

Based on record review and staff interview the facility failed to promote care in a manner that maintains or enhances each resident's dignity and respect for 2 of 3 residents (Residents #2 and #3) identified. The findings include: 1. Per review of the facility's internal investigation on 10/10/12, Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted to the facility for pain control and rehabilitation with plans to discharge to home. Per the facility's internal investigation dated 6/13/12, on 6/12/12 at approximately 2:00 AM as per an interview with Resident #2, an Licensed Nursing Assistant (LNA), came into Resident #2's room to assist the resident in transferring to the bathroom. Per Resident #2, he/she indicated that during the transfer the resident felt "hurried by the aide and I can't be hurried." The resident indicated that when the aide and Resident #2 got to the bathroom, the aide let go of the resident to "primp" herself in the mirror, Resident #2 attempted to reach for the handicap bar to sit on the toilet and missed the bar. The resident indicated she lost his/her balance and nearly fell but made it to the seat safely. The aide saw this and said "Jesus Christ!" The aide then said to Resident #2 "that's it, you are using the bed pan from now on." The resident indicated that he/she told the aide that he/she had trouble using the bed pan and the aide said "I don't care, you're going to use the bed pan from now on at night". The resident then indicated that when the aide transferred Resident #2 back to bed the resident began to cry and the aide said "Why are you crying, you are a grown adult". Per review of the internal investigation, the facility found that Resident #2 was an alert and oriented resident and reported the incident that occurred between Resident #2 and the LNA in fairly great detail. The investigation also indicates that Resident #2 was quite emotional when recalling the event on 6/12/12. The facility investigation indicates that whatever the specific elements of the interaction between the LNA and Resident #2, the LNA negatively impacted Resident #2's emotional status, and that Resident #2 requested that he/she did not want the LNA to care for him/her again. Per interview with the facility administrator on 10/10/12, he/she confirmed that Resident #2's dignity had been effected by the actions of the LNA on 6/12/12. 2. Per review of the facilities internal investigation, on 10/10/12, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's internal investigation dated 5/30/12 indicates that on 5/23/12 a facility staff member (Staff #1) reported that at approximately 1:50 PM, Staff #1 overheard a Licensed Nursing Assistant (LNA), speak to Resident #3 in a harsh tone and overheard the LNA say to Resident #3, you need to get out of bed. Staff #1 then indicates that he/she witnessed the LNA grab Resident #3's lower legs just below the knee and threw them over the side of the bed. Staff #1 also indicates that he/she witnessed the LNA grab the wrists of Resident #3 and threw them onto the walker of Resident #3 and heard the LNA yell at Resident #3, you need to get up and go to the bathroom. Staff #1 indicates that he/she heard Resident #3 say twice, "stop beating me up". Staff #1 indicates that he/she then heard the LNA reply to Resident #3 "yeah, I am the one beating you up, you're the one that asked for help, now you need to get up". Per the internal investigation, Resident #3 confirmed in interview with the facility administrator on 5/23/12 that the LNA was "mean", and that the LNA "grabbed my wrist and hurt it." Resident #3 and Staff #1 re-enacted how the LNA transferred Resident #3 out of bed. Resident #3 confirmed that the LNA had "thrown (his/her) legs to the side of the bed" and Resident #3 confirmed that the LNA "yanked on (him/her)" from a lying position. Resident #3 also confirmed that he/she was "afraid of the LNA and doesn't want the LNA to take care of (him/her)." Per review of the facility's internal investigation, the investigation found that the interaction between the LNA and Resident #3 was determined to be at a minimum "abrasive, disrespectful" and that the interaction between the LNA and Resident #3 "negatively impacted the resident's emotional status as the resident stated that (he/she) was afraid of the LNA."

Based on staff interviews and record review, the services provided by the facility failed to meet professional standards of quality when facility staff failed to adequately monitor, reassess and follow the care plan for a leg wound for one resident (Resident #1) identified in a complaint. Findings include: Per record review between the dates of 6/12/12 through 6/13/12 for Resident #1, the staff nurse documented on the Resident /Patient Incident Report that on 5/22/12 this resident obtained an 'injury of unknown origin' to his/her right lower leg. The resident, who was nutritionally and medically compromised with multiple co-morbidities, had extremely fragile skin with multiple skin impairments. The nurse described the following on the incident report: ''R (right) outer leg has a 8 cm length x 3 cm wide skin tear. No one knows where it came from but pt (patient) was sitting in his chair and the pad (he was sitting on) had a zipper on that side.' On this date, 5/22/12, the nurse documented on the the Skin Integrity Report Form (which the facility utilizes to describe skin impairments) the following: Pain? 'Yes.' Appearance (of the wound): Skin Tear. Description of the Wound: 8 cm length x 3 cm width. There was no undermining or tunneling, there was no drainage, the surrounding tissue was deep purple and there was no odor associated with the wound. Per the nursing care plan for an actual skin breakdown related to 'scab on lip and skin tear to right outer leg', the care plan documents these interventions for Resident #1: 1. Evaluate the wound daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to MD as indicated 2. Provide wound treatment as ordered and 3. Weekly wound assessment to include measurements and description of wound status. Per facility policy*, staff should 'perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with any deterioration of (the) wound.' Also, document the following: For wounds that do not require a daily dressing change, monitor the status of the dressing (intact and clean) status of tissue surrounding the dressing (free of new redness or swelling), and that wound pain, if present, is being completely controlled. Between the dates of 5/22/12 (injury) and 6/6/12 (the resident's transfer to the hospital ) the Skin Integrity Report Form had only two assessments documented. The first date of wound documentation on the Skin Integrity Report was on 5/22/12 when the skin tear was discovered, and the second was on 6/6/12, the day the resident was transferred to the hospital. The Skin Integrity Report had documentation that Resident #1's wound has increased in size from 8 cm (centimeters) in length (on 5/22/12) to 22 cm in length (on 6/6/12) which is an increase of 14 cm. In addition, the wound's width went from 3 cm (5/22/12) to 9 cm (on 6/6/12) for an increase of 6 cm. in width. On 6/6/12 the surrounding tissue was described as being 'inflamed/indurated' and had an odor. On 6/12/12 at 2:15 P.M. per interview with the unit manager, s/he confirmed that although s/he had changed the (dermagel) dressing on 6/2/12, (for multiple areas per the TAR or Treatment Record) s/he had not completed an assessment of the right lower leg wound or completed any documentation on the Skin Integrity Report. S/he also confirmed that by not doing so, s/he was unable to evaluate whether the current treatment was promoting wound healing. The unit manager described the wound to this surveyor as follows: 'On 6/6/12 it (the wound) was necrotic, with sero-sanguineous drainage, the edges of the wound were inflamed and it was foul smelling.' In addition, during this same interview, another staff nurse, who, according to the TAR had changed the dressing on 5/26/12 confirmed that s/he failed to complete a wound assessment for the right lower leg wound and/or document on the Skin Integrity Report. Refer also to F282 and F309. *(Policy 14.6 Skin Integrity Management Genesis Centers Nursing Policies & Procedures 3.2, 3.3, 3.4, 12.1.1, 12.2 and 14.1.2 ) Reference: Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Based on staff interview and record review the services provided by the facility failed to be provided in accordance with the written care plan for one resident (Resident # 1) of 2 residents in the targeted sample. Findings include: Per record review between the dates of 6/12/12 through 6/13/12 for Resident #1, the staff nurse documented on the Resident /Patient Incident Report that on 5/22/12 this resident obtained an 'injury of unknown origin' to his/her right lower leg. The resident, who was nutritionally and medically compromised with multiple co-morbidities, had extremely fragile skin with multiple skin impairments. Per the nursing care plan for an actual skin breakdown related to 'scab on lip and skin tear to right outer leg ' the care plan documents these interventions for Resident #1: 1. Evaluate the wound daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to MD as indicated 2. Provide wound treatment as ordered and 3. Weekly wound assessment to include measurements and description of wound status. Between the dates of 5/22/12 (injury) and 6/6/12 (the resident's transfer to the hospital) the Skin Integrity Report Form had only two assessments documented. The first date of wound documentation on the Skin Integrity Report was on 5/22/12 when the skin tear was discovered, and the second was on 6/6/12, the day the resident was transferred to the hospital. In addition, the TAR (Treatment Record) had multiple dates when the treatment was not documented. (the dates were: 5/29/12, 5/30/12 and the dates 6/1/12 through 6/6/12) The TAR stated, 'Monitor site daily for status of dressing, surrounding tissue, s/sx of infection and wound pain.' On 6/12/12 at 2:15 P.M. per interview with the unit manager, s/he confirmed that the plan of care and agency policy* had 'not been followed' and that the TAR (Treatment Record) had multiple dates when the treatment 'Monitor site daily for status of dressing, surrounding tissue, s/sx of infection and wound pain' had not been documented. In addition, s/he confirmed the weekly skin assessments (to include measurements and the description of wound status) had not been done weekly. Refer also to F281 & F309. *(Policy 14.6 Skin Integrity Management Genesis Centers Nursing Policies & Procedures 3.3, 3.4, 12.1.1, 12.2 and 14.2)

Based on staff interviews and record review the facility failed to provide the necessary care and services for one resident (Resident # 1) to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care. Findings include: Per record review between the dates of 6/12/12 through 6/13/12 for Resident #1, the staff nurse documented on the Resident /Patient Incident Report that on 5/22/12 this resident obtained an 'injury of unknown origin' to his/her right lower leg. The resident, who was nutritionally and medically compromised with multiple co-morbidities, had extremely fragile skin with multiple skin impairments. The nurse described the following on the incident report: ''R (right) outer leg has a 8 cm length x 3 cm wide skin tear . No one knows where it came from but pt (patient) was sitting in his chair and the pad (he was sitting on) had a zipper on that side.' On this date, 5/22/12, the nurse documented on the the Skin Integrity Report Form (which the facility utilizes to describe skin impairments) the following: Pain? 'Yes.' Appearance (of the wound): Skin Tear. Description of the Wound: 8 cm length x 3 cm width. There was no undermining or tunneling, there was no drainage, the surrounding tissue was deep purple and there was no odor associated with the wound. Per facility policy,* staff should 'perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with any deterioration of (the) wound.' Also, document the following: For wounds that do not require a daily dressing change, monitor the status of the dressing (intact and clean) status of tissue surrounding the dressing (free of new redness or swelling), and that wound pain, if present, is being completely controlled. Between the dates of 5/22/12 (injury) and 6/6/12 (the resident's transfer to the hospital) the Skin Integrity Report Form had only two assessments documented. The first date of wound documentation on the Skin Integrity Report was on 5/22/12 when the skin tear was discovered, and the second was on 6/6/12, the day the resident was transferred to the hospital. The Skin Integrity Report had documentation that Resident #1's wound has increased in size from 8 cm (centimeters) in length (on 5/22/12) to 22 cm in length (on 6/6/12) which is an increase of 14 cm. In addition, the wound's width went from 3 cm (5/22/12) to 9 cm (on 6/6/12) for an increase of 6 cm. in width. On 6/6/12 the surrounding tissue was described as being 'inflamed/indurated' and had an odor. On 6/12/12 at 2:15 P.M. per interview with the unit manager, s/he confirmed that although s/he had changed the (dermagel) dressing on 6/2/12, (for multiple areas per the TAR or Treatment Record) s/he had not completed an assessment of the right lower leg wound or completed any documentation on the Skin Integrity Report. S/he also confirmed that by not doing so , s/he was unable to evaluate whether the current treatment was promoting wound healing. The unit manager described the wound to this surveyor as follows: 'On 6/6/12 it (the wound) was necrotic, with sero-sanguineous drainage, the edges of the wound were inflamed and it was foul smelling.' On 6/12/12 at 2:15 P.M. per interview with the unit manager, s/he also confirmed that the plan of care and agency policy* had 'not been followed ' and that the TAR (Treatment Record) had multiple dates when the treatment 'Monitor site daily for status of dressing, surrounding tissue, s/sx of infection and wound pain' had not been documented. In addition, s/he confirmed the weekly skin assessments (to include measurements and the description of wound status) had not been done weekly. In addition, during this same interview, another staff nurse, who, according to the TAR had changed the dressing on 5/26/12 confirmed that s/he failed to complete a wound assessment for the right lower leg wound and/or document on the Skin Integrity Report. Refer also to F281 and F282. *(Policy 14.6 Skin Integrity Management Genesis Centers Nursing Policies & Procedures 3.2, 3.3, 3.4,

Based on record review and staff interviews the facility failed to assure that one resident was free from significant medication errors. This affected one (Resident #146) of 18 stage 2 sampled residents. Findings include: Per record review, Resident #146 received his/her routine morning medications in his/her room sometime during the 8:00 A.M. medication pass on 06/01/12. After s/he received his/her medications, the medication nurse prepared to administer medications to a second resident (#77) who was in one of the unit's common areas. The nurse was a traveling nurse relatively new to the facility and asked an LNA where the resident was seated and was given a location. The nurse proceeded to the area reportedly unaware that in the interim Resident #77 had been moved out to be taken to the bathroom and Resident #146 was brought into the common area and placed in approximately the same place. Both residents have [DIAGNOSES REDACTED].#77, which included a calcium channel blocker, an antihypertensive, and an antipsychotic medication, were administered to Resident #146. The error was recognized by the administering nurse shortly after and reported to the Unit Manager. The Unit Manager assessed the Resident and requested that a Nurse Practitioner, who was in the building, come to assess the Resident. The Resident was in rapid decline, according to the progress notes, and his/her vital signs were dropping with a blood pressure of 83/57. The Medical Doctor (MD) and Emergency Medical Services (EMS) were called and the Rescue Squad arrived to stabilize and transport the Resident to Rutland Regional Medical Center (RRMC). When Resident #146 left via ambulance s/he had a blood pressure of 63/37 and was minimally responsive to sternal rub. In the progress notes, the Physician states that Resident #146 was treated with [MEDICATION NAME] (a diuretic) and intubation (mechanical ventilation) at the hospital and s/he was admitted to the hospital. The Resident was treated and returned to the facility at 2:30 PM on 06/02/12. Resident #146 was described as somnolent and more lethargic than baseline upon return. On 06/02/12 at 3:30 P.M. Resident #146 was found unresponsive with an oxygen saturation (SAO2) of 95% on oxygen at 2 liters per minute via nasal cannula, had a temperature of 101.1 degrees Fahrenheit and increased heart rate. Resident #146 was transported to RRMC via ambulance and remains hosptalized on [DATE] although the facility anticipates his return in the next day or two. These events were confirmed by interview of the Administrator and Corporate Consultant on 06/05/12 at 1:45 P.M. and 4:40 P.M. and follow up interview of the Administrator and Director of Nursing Services (DNS) on 06/06/12 at 8:45 A.M. The medication nurse was also interviewed during the survey and confirmed the events as recorded in the record.