Every finding on record at Saint Josephs Living Center Inc

Based on record review, interviews, and facility policy review, the facility failed to recognize, assess, and manage acute pain for two of three sampled residents reviewed for accidents (Residents #1 and #5), resulting in actual harm when both residents experienced prolonged unrelieved pain after emergent injuries. Resident #1 sustained a second degree burn on 3/4/26 with documented discomfort. Yet, staff did not complete a comprehensive pain assessment or administer available PRN analgesia. The ordered burn dressing was no applied until the next shift, leaving the resident to report throbbing pain for many hours without follow up from nursing. Similarly, on 3/15/26, Resident #5 experienced a witnessed fall with visible left arm deformity and severe pain, but staff failed to administer any PRN pain medication before the resident was transported to the emergency department approximately 35 minutes later, despite active orders for both acetaminophen and morphine; the resident did not receive pain relief until more than two hours after the fall. These failures to promptly assess and treat acute pain following injuries resulted in avoidable, significant suffering for both residents and occurred despite facility policies requiring immediate pain assessment and timely intervention upon onset of new pain. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, type II diabetes mellitus, muscular dystrophy (progressive muscle weakness and degeneration), lymphedema (chronic swelling of the body's tissues caused by lymphatic fluid buildup) and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was independent for eating, bed mobility, transfers and ambulation.The Resident Care Plan (RCP) dated 1/6/26 identified Resident #1 had an alteration in comfort related to the aging process and lymphedema. Interventions included interviewing the resident and observing for pain characteristics including quality, severity, location, precipitating and relieving factors, monitoring for nonverbal signs and symptoms of pain, administering medications as ordered and monitoring for effects of and side effects of the medications.An accident/incident note by RN #1 dated 3/4/26 at 2:30 PM identified while participating in a recreational activity, Resident #1 was served a cup of hot tea with a lid which he/she removed and spilled on his/her left leg. The note reported the area to the left upper inner thigh was slightly pink, with what appeared to be a popped blister and measured approximately five (5) centimeters (cm) by four (4) cm. A cool compress was applied to the area with some improvement in the discomfort, Resident #1's responsible party and the APRN were notified, and a new order was obtained to apply Xeroform gauze to the area followed by a dry protective dressing.A status post incident-accident note by RN #2 dated 3/4/26 at 10:00 PM identified the Xeroform gauze and dressing were applied to Resident #1's left inner thigh over the burn area and that discomfort was noted.Review of the clinical record failed to identify a comprehensive pain assessment was completed following a significant change in condition or when there was an onset of new pain per the facility policy.Review of the March 2026 Medication Administration Record (MAR) identified an order dated 1/23/26 directing to administer acetaminophen 325 milligrams (mg), give two (2) tablets (650 mg) by mouth every six (6) hours as needed for mild pain, but failed to identify that it had been administered on 3/4/26 for the resident's discomfort following the burn incident.A provider note by APRN #1 dated 3/5/26 at 9:45 AM identified she saw Resident #1 following the 3/4/26 incident where Resident #1 spilled a cup of hot tea on his/her left inner thigh. The note reported the left inner thigh had an erythematous superficial burn (skin injury characterized by redness, pain and dryness) exhibiting desquamation (shedding dead skin cells) and epidermal sloughing (the peeling, shedding or separation of the top layer of skin). The surrounding tissue was observed with mild inflammatory edema (swelling) consistent with a second-degree burn and Resident #1 reported discomfort at the burn site to the left inner thigh.A physician's order dated 3/5/26 and entered by APRN #1 directed to administer acetaminophen 325 mg, give 2 tablets (650 mg) by mouth two times a day for left inner thigh pain.Review of the March 2026 MAR identified Resident #1 was not administered acetaminophen or a pain relieving medication until 3/5/26 at 5:30 PM following the burn incident on 3/4/26 at 2:30 PM (more than 24-hours later) although documentation identified Resident #1 was in discomfort on 3/4/26 and 3/5/26.Interview with Resident #1 on 4/1/26 at 10:47 AM identified following the 3/4/26 burn incident, nursing applied a cool compress to the area which slightly relieved the pain but no one returned to check on him/her for several hours. Resident #1 reported nursing did not administer or offer medications for pain relief at the time of the incident or later that night and the left thigh area throbbed in pain. Additionally, Resident #1 reported the area was left open to air which was uncomfortable, and the Xeroform dressing was not applied until around 5:30 PM which was painful when applied.Review of physician's orders and the March 2026 MAR failed to identify an order for Xeroform gauze to be applied to the left inner thigh and failed to identify the treatment was administered on 3/4/26 following the burn incident until 3/5/26, when the order was entered by APRN #1.Interview with RN #1 on 4/1/26 at 12:37 PM identified following the burn to Resident #1's left inner thigh, LPN #1 and herself applied several cool compresses to the left inner thigh but Resident #1 was still in discomfort. RN #1 reported that LPN #1 should have administered acetaminophen following the incident or at least offered the acetaminophen for pain relief. RN #1 identified she obtained the Xeroform gauze dressing order verbally from APRN #1 but was unable to explain why she had not entered the order. RN #1 reported she did not apply the dressing to Resident #1 following the incident, she requested that RN #2 do so.Interview with LPN #1 on 4/1/26 at 12:54 PM identified she applied a cool compress to Resident #1's left inner thigh following the burn. She identified she should have offered acetaminophen for pain relief but Resident #1 appeared shocked and was not talking so she assumed Resident #1 was fine, left for her shift and did not offer or administer acetaminophen to Resident #1. Additionally, she identified she should have written a nurse's note regarding the care she provided and was unsure why she didn't.Interview with RN #2 on 4/1/26 at 11:22 AM identified she did not know what time it was when she applied the Xeroform gauze to Resident #1's left inner thigh burn on 3/4/26, the area was undressed and open to air and Resident #1 was in visible discomfort. RN #2 reported once she applied the dressing to the area Resident #1 appeared more comfortable but she did not offer acetaminophen for pain relief prior to or following the dressing application and was unable to explain why. She reported although she verified the dressing order for Resident #1 with RN #1, she was unaware there was no order entered for the dressing on 3/4/26 or that she did not sign it off, and she was unable to identify when she applied the dressing.Interview with APRN #1 on 4/1/26 at 1:11 PM identified any resident with acute pain or discomfort should be evaluated for pain and offered pain relief medication timely if indicated. Additionally, she identified when she saw Resident #1 on 3/5/26 following the burn incident, Resident #1 was in discomfort, so she ordered acetaminophen scheduled twice daily for three (3) days. She identified she gave RN #1 a verbal order for the Xeroform gauze treatment on 3/4/26 which was not transcribed to the clinical record so she entered the order on 3/5/26.Interview with the DON on 4/1/26 at 1:19 PM and 2:48 PM identified a pain assessment should be completed following a significant change in condition and with any identification of new acute pain. She reported if staff are documenting that a resident is in pain or discomfort, they should also be documenting follow-up and what interventions were put into place to decrease or eliminate pain. She identified that nursing staff should have offered Resident #1 pain relief medication when it was identified he/she was in pain or discomfort. She reported RN #1 should have immediately transcribed the verbal order she received from APRN #1 for the Xeroform gauze dressing so that nursing could document the application timely and accurately. Further, she identified LPN #1 should have documented her role in the incident and the care she provided as the charge nurse, and that nursing staff should ensure documentation is complete and accurate prior to leaving the shift.2. Resident #5's diagnoses included Alzheimer's disease, low back pain, encounter for palliative care, type II diabetes mellitus and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had intact cognition (Brief Interview for Mental Status (BIMS) score of 14), was independent for bed mobility and required partial assistance for transfers and supervision assistance for ambulation.The Resident Care Plan (RCP) dated 3/13/26 identified Resident #5 was admitted to hospice services as of 8/19/25, was at risk for falls due to decreased safety awareness, unsteady gait, cognitive deficits, psychotropic and narcotic drug use and was at risk for pain, complications and decline due to uterine lesion/tumor, left breast lump and breast cancer. Interventions included anticipating the resident's needs, monitoring for any signs and symptoms of pain, administering medications as ordered by the physician and monitoring their effect.An Accident/Incident note by RN #3 dated 3/15/26 at 11:24 PM identified Resident #5 tripped over his/her own feet while walking to the closet, bumped into the closet door, fell onto his/her bottom and hit both upper extremities on the floor. The incident was witnessed by the charge nurse (LPN #2) and Resident #5 did not hit his/her head but was complaining of pain to the left arm, was holding the left arm and RN #3 reported the left arm looked deformed. The note identified an assessment was completed, Resident #5 had severe pain to the left arm, Resident #5's family was notified and requested Resident #5 be sent to the ED for evaluation. Hospice services were notified at 5:00 PM, Emergency Services was called at 5:20 PM and Resident #5 was transferred to the ED.Review of the facility Reportable Event (RE) identified Resident #5's fall occurred at 4:45 PM (35 minutes prior to transfer to the ED).Review of the March 2026 MAR identified active orders dated 6/4/22 directing to administer acetaminophen 325 mg, give 2 tablets (650 mg) by mouth every four (4) hours as needed for pain or general discomfort, as well as an order dated 8/15/25 directing to administer morphine sulfate oral solution 100 mg per 5 milliliters (mL), give 0.25 mL by mouth every 4 hours as needed for pain or shortness of breath. Although as needed pain-relieving medications were in place, the MAR failed to identify Resident #5 had been administered medications for the severe pain on 3/15/26 following the fall with left arm deformity within the 35-minute timeframe from when the fall occurred until Resident #5 was transferred to the ED.The hospital documentation dated 3/15/26 identified there was suspicion for a non-displaced fracture (a bone break where the bone is cracked but remains properly aligned) of the posterior aspect of the humerus (the backside of the upper arm bone), was provided with a sling and Resident #5 would be referred to orthopedic surgery. Additionally, the documentation identified Resident #5 was administered acetaminophen 975 mg at 6:51 PM (more than two hours after the fall occurred).Interview with the DON on 4/1/26 at 1:19 PM and 2:48 PM identified that nursing staff should have offered Resident #5 pain relief medication when it was identified he/she was in pain or discomfort following the fall. Additionally, she identified that LPN #2 should have documented her role in the resident fall incident and the care she provided to Resident #5 as the charge nurse prior to leaving for her shift that night.Interview with LPN #2 on 4/1/26 at 2:24 PM identified although Resident #5 was in severe pain and was holding his/her left arm following the fall on 3/15/26, she did not administer pain relief medication to Resident #5 prior to the resident being transferred to the ED. She assumed Resident #5 would medicated in the ED and did not consider the ambulance ride to the ED. LPN #2 reported that she should have administered pain relief medication to Resident #5 before he/she was transferred to the ED. Additionally, she identified she should have written a nurse's note regarding witnessing the fall and the care she provided to Resident #5 but was unable to explain why she did not. Although attempted, an interview with RN #3 was not obtained.Review of the Pain Assessment and Management policy (undated) directed, in part, the pain management program is based on a facility-wide commitment to resident comfort. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his of her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes assessing the potential for pain, effectively recognizing the presence of pain, addressing the underlying causes of the pain and monitoring for the effectiveness of interventions. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Observe the resident for during rest and movement for physiological and non-verbal signs of pain to include verbal expressions, facial expressions and guarding, rubbing or favoring a particular part of the body. Ask the resident if he/she is experiencing pain and be aware the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, numbness or tingling. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain including musculoskeletal conditions, skin and wound conditions and end of life/hospice care. Review the resident's treatment record or recent nurse's notes to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatments for wound care or dressing changes. Pain management interventions shall reflect the sources, types and severity of pain and shall address the underlying causes of the resident's pain. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools and relevant criteria for measuring pain management. Document the resident's reported level of pain with adequate detail (enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record.Review of the Medication and Treatment Orders policy (undated) directed, in part, verbal or telephone orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials and the time and date of the order.Review of the Charting and Documentation policy (undated) directed, in part, all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #5) reviewed for accidents, the facility failed to maintain complete and accurate clinical records by failing to ensure physician orders obtained following an incident were transcribed into the medical record and failing to ensure all licensed nurses involved in the incidents documented the care and services provided. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, type II diabetes mellitus, muscular dystrophy (progressive muscle weakness and degeneration), lymphedema (chronic swelling of the body's tissues caused by lymphatic fluid buildup) and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was independent for eating, bed mobility, transfers and ambulation.The Resident Care Plan (RCP) dated 1/6/26 identified Resident #1 had an alteration in comfort related to the aging process and lymphedema. Interventions included interviewing the resident and observing for pain characteristics including quality, severity, location, precipitating and relieving factors, monitoring for nonverbal signs and symptoms of pain, administering medications as ordered and monitoring for effects of and side effects of the medications.An accident/incident note by RN #1 dated 3/4/26 at 2:30 PM identified while participating in a recreational activity, Resident #1 was served a cup of hot tea with a lid which he/she removed and spilled on his/her left leg. The note reported the area to the left upper inner thigh was slightly pink, with what appeared to be a popped blister and measured approximately five (5) centimeters (cm) by four (4) cm. A cool compress was applied to the area with some improvement in the discomfort, Resident #1's responsible party and the APRN were notified, and a new order was obtained to apply Xeroform gauze to the area followed by a dry protective dressing.Review of the facility schedule dated 3/4/26 identified LPN #1 was the charge nurse assigned to Resident #1.Review of nurse's notes dated 3/4/26 failed to identify documentation regarding the burn incident from LPN #1.A status post incident-accident note by RN #2 dated 3/4/26 at 10:00 PM identified the Xeroform gauze and dressing were applied to Resident #1's left inner thigh over the burn area and that discomfort was noted.Interview with Resident #1 on 4/1/26 at 10:47 AM identified following the 3/4/26 burn incident, nursing applied a cool compress to the area which slightly relieved the pain but no one returned to check on him/her for several hours. Resident #1 reported the area was left open to air which was uncomfortable, and the Xeroform dressing was not applied until around 5:30 PM which was painful when applied. Review of physician's orders and the March 2026 MAR failed to identify an order for Xeroform gauze to be applied to the left inner thigh and failed to identify the treatment was administered on 3/4/26 following the burn incident until 3/5/26, when the order was entered by APRN #1. Interview with RN #1 on 4/1/26 at 12:37 PM identified following the burn to Resident #1's left inner thigh, LPN #1 and herself applied several cool compresses to the left inner thigh but Resident #1 was still in discomfort. RN #1 identified she obtained the Xeroform gauze dressing order verbally from APRN #1 but was unable to explain why she had not entered the order. RN #1 reported she did not apply the dressing to Resident #1 following the incident, she requested that RN #2 do so.Interview with LPN #1 on 4/1/26 at 12:54 PM identified she applied a cool compress to Resident #1's left inner thigh following the burn. She identified she should have written a nurse's note regarding the care she provided and was unsure why she did not.Interview with RN #2 on 4/1/26 at 11:22 AM identified she did not know what time it was when she applied the Xeroform gauze to Resident #1's left inner thigh burn on 3/4/26, the area was undressed and open to air and Resident #1 was in visible discomfort. RN #2 reported once she applied the dressing to the area Resident #1 appeared more comfortable, and although she verified the dressing order for Resident #1 with RN #1, she was unaware there was no order entered for the dressing on 3/4/26 or that she did not sign it off, and she was unable to identify when she applied the dressing.Interview with APRN #1 on 4/1/26 at 1:11 PM identified when she saw Resident #1 on 3/5/26 following the burn incident, she gave RN #1 a verbal order for the Xeroform gauze treatment on 3/4/26 which was not transcribed to the clinical record so she entered the order on 3/5/26.Interview with the DON on 4/1/26 at 1:19 PM and 2:48 PM identified RN #1 should have immediately transcribed the verbal order she received from APRN #1 for the Xeroform gauze dressing following the burn incident so that nursing could document the application timely and accurately and LPN #1 should have documented her role and the care provided to Residents #1 as the charge nurse. She identified nursing staff should ensure documentation is complete and accurate prior to leaving for their shift.2. Resident #5's diagnoses included Alzheimer's disease, low back pain, encounter for palliative care, type II diabetes mellitus and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had intact cognition (Brief Interview for Mental Status (BIMS) score of 14), was independent for bed mobility and required partial assistance for transfers and supervision assistance for ambulation.The Resident Care Plan (RCP) dated 3/13/26 identified Resident #5 was admitted to hospice services as of 8/19/25, was at risk for falls due to decreased safety awareness, unsteady gait, cognitive deficits, psychotropic and narcotic drug use and was at risk for pain, complications and decline due to uterine lesion/tumor, left breast lump and breast cancer. Interventions included anticipating the resident's needs, monitoring for any signs and symptoms of pain, administering medications as ordered by the physician and monitoring their effect.An Accident/Incident note by RN #3 dated 3/15/26 at 11:24 PM identified Resident #5 tripped over his/her own feet while walking to the closet, bumped into the closet door, fell onto his/her bottom and hit both upper extremities on the floor. The incident was witnessed by the charge nurse (LPN #2) and Resident #5 did not hit his/her head but was complaining of pain to the left arm, was holding the left arm and RN #3 reported the left arm looked deformed. The note identified an assessment was completed, Resident #5 had severe pain to the left arm, Resident #5's family was notified and requested Resident #5 be sent to the ED for evaluation. Hospice services were notified at 5:00 PM, Emergency Services was called at 5:20 PM and Resident #5 was transferred to the ED.Review of nurse's notes dated 3/15/26 failed to identify documentation from LPN #2 related to Resident #2's fall or the care she provided to Resident #2.Interview with the DON on 4/1/26 at 1:19 PM and 2:48 PM identified that LPN #2 should have documented her role in the fall incident and the care she provided to Resident #5 as the charge nurse prior to leaving for her shift.Interview with LPN #2 on 4/1/26 at 2:24 PM identified she should have written a nurse's note regarding witnessing Resident #5's fall and the care she provided to Resident #5 but was unable to explain why she didn't. Review of the Charting and Documentation policy (undated) directed, in part, all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 6 of 13 residents (Resident #22, Resident #36, Resident #44, Resident #64, Resident #71 and Resident #89) reviewed for Enhanced Barrier Precautions (EBP) and 1 of 2 residents (Resident #211) reviewed for Transmission Based Precautions (TBP), the facility failed to initiate Enhanced Barrier Precautions (EBP) per Center of Disease Control (CDC) guidelines for residents with a history of Multiple Drug Resistant Organisms (MDROs) and failed to perform hand hygiene after exiting a resident room and before entering another resident room and failed to maintain Transmission Based Precautions (TBP) while assisting a resident with a positive COVID-19 diagnosis. The findings include: 1. Resident #22, Resident #36 and Resident #44 had diagnoses that included a history of Methicillin Resistant Staphylococcus Aureus (MRSA) Resident #64 had diagnoses that included a history of Clostridium Difficile (C. Diff.). Resident #71 had diagnoses that included a history Extended Spectrum Beta Lactamases (ESBL). Resident #89 had diagnoses that included a history of Methicillin Suseptible Staphylococcus Aureus. Review of the History vs Active MDRO list compared to the Enhanced Barrier Precautions list provided by the Infection Control Nurse identified Resident #22, Resident #36, Resident #44, Resident #64, Resident #71 and Resident #89 were not on EBP. Interview and review of MDRO list, EBP list and current CDC guidelines with the Director of Nursing on 12/9/24 at 2:35 PM identified that Resident #22, Resident #36, Resident #44, Resident #64, Resident #71 and Resident #89 were identified to have a history of an MDRO and should have been placed on EBP. Center for Disease Control (CDC) guidelines identified April 1, 2024: Implementation of Enhanced Barrier Precautions (EBP) in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms. Multidrug-resistant Organism (MDRO): bacteria or fungi resistant to multiple antimicrobials and colonization identifies a germ is found on or in the body but is not causing infection. Many nursing home residents are unknowingly colonized with an MDRO, especially residents with risk factors like indwelling medical devices or wounds. Residents who have an MDRO can develop serious infections, remain colonized for long time periods, and spread MDROs to others. EBP are indicated for nursing home residents with any of the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply, wounds and/or indwelling medical devices. EBP is not limited to outbreaks or specific MDROs. Review of the facility policy titled Enhanced Barrier Precautions directed, in part, to be used when caring for residents during high contact care activities for residents with an infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply. The facility will utilize the orange enhanced barrier precautions signs to be placed outside of the resident's room, to notify staff of proper PPE usage. PPE will be stored on the unit for staff availability. 2. Observation on 12/9/24 at 4:58 PM identified NA #6 was passing meal trays with gloves on. NA #6 delivered a tray to room [ROOM NUMBER] with gloves on, exited the room without the benefit of changing her gloves and performing hand hygiene, then went into room [ROOM NUMBER] to deliver another meal tray. Interview on 12/9/24 at 4:58 PM with NA #6, upon exiting room [ROOM NUMBER], indicated she was not thinking about her gloves and forgot to perform hand hygiene. NA #6 then removed her gloves and performed hand hygiene. Interview with LPN #4 on 12/9/24 at 5:18 PM identified that gloves should not be worn in the hallway or to pass meal trays and upon disposal of gloves, hands are to be sanitized prior to serving the next tray. LPN #4 did not know why NA #7 was wearing gloves to pass meal trays and did not remove the gloves and sanitize her hands before passing the next tray. A facility policy titled Standard Precautions and Other Precautions identified, in part, hand hygiene refers to handwashing with soap (antimicrobial or non-antimicrobial) or alcohol-based hand rubs (gels, foams, rinses) that do not require water. In the absence of visible soiling of hands, alcohol-based hand rubs are preferred for hand hygiene. Wash hands after removing gloves. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. 3. Resident #211 was admitted to the facility on [DATE] with diagnoses that included Covid-19 and was identified to require TBP and Contact/Droplet precautions. A Physician's order dated 12/3/24 at 3:00 PM directed to maintain strict isolation precautions and included instructions to render all care, meals, and services within Resident #211 ' s room due to Covid-19. A Physician's order dated 12/4/24 at 7:00 AM directed contact and droplet precautions for Covid-19. Observation on 12/9/24 at 5:00 PM, identified NA #7 wore only a surgical mask, without the benefit of Personal Protective Equipment (PPE), when entering Resident #211's room to deliver a meal tray. NA #7 was observed assisting Resident #211 with positioning in his/her chair and then setting up the meal tray, all within close proximity to Resdient #211. Signage was observed to be posted outside of Resident #211's room regarding precautions and required Personal Protection Equipment (PPE). Interview with NA #7 on 12/9/24 at 5:00 PM indicated NA #7 was unaware that Resident #211 was on TBP as identified by the signage posted outside of Resident #211 ' s room. NA #7 further indicated she was unaware she needed to wear an N95 mask to enter a room for a resident on TBP for Covid-19. Subsequent to surveyor identification of NA #7 rendering care without the use of PPE for Resident #211, the DNS verbally educated NA #7 regarding contact/droplet precautions and the required PPE to enter a room with TBP. Interview with LPN #4 on 12/9/24 at 5:18 PM identified that NA #7 should have been aware that Resident #211 was on TBP due to Covid-19 because NA #7 received report the start of the shift and was informed that Resident #211 was positive for Covid-19, in addition to the signage outside of the room. LPN #4 identified that meal trays for residents on isolation precautions should be served last. Interview with the DNS on 12/9/24 at 5:45 PM identified that gloves should not be worn in the hallways to pass meal trays and hands are to be washed upon the removal of gloves. A facility policy titled Standard Precautions and Other Precautions identified, in part, residents on contact and/or isolation precaution will have precautions set up and available to staff and family members including personal protection equipment. Residents, staff and visitors will be educated about the precautions as necessary and hand washing. Alcohol gel sanitizer will be available for use. Resident ' s room will show Stop or Please see the nurse sign in the room.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 8 residents (Resident #85 and Resident #98) reviewed for infection control, the facility failed to identify and document vaccination status and offer vaccinations for resdients newly admitted to the facility. The findings include: 1. Resident #85 was admitted to the facility in October of 2024, with diagnoses that included Alzheimer's Disease, Atrial Fibrillation, Asthma and Osteoporosis. The admission Minimum Data Set assessment dated [DATE] identified Resident #85 was severely cognitively impaired (Brief Interview for Metal status (BIMS) score of 3). Review of the Electronic Health Record (EHR) immunization record identified that a Moderna Covid-19 vaccine was administered on 11/18/24 and an Influenza vaccine was administered on 12/9/24 but failed to identify if a Pneumovax vaccine was offered, refused or administered. The facility failed to identify any documentation of a Vaccine Administration Consent form was completed for the Pneumovax vaccine for Resident #85. 2. Resident #98 was admitted to the facility in October of 2024 with Diagnoses that included Acute Respiratory Failure with Hypoxia and Pneumonia due to Covid- 19. The admission Minimum Data Set assessment dated [DATE] identified Resident #98 was Cognitively intact (Brief interview of Mental Status (BIMS) score of 14). Review of the Electronic Health Record (EHR) immunization record failed to identify if any immunizations had been offered, refused or administered. The facility failed to identify documentation of Vaccine Administration Consent forms were completed for any vaccinations. Interview and clinical record review with the Director of Nursing (DNS) on 12/9/24 at 2:35 PM identified that the Infection Control Nurse (ICN) interviewed residents and resident representatives and used CTWIZ (an electronic vaccine tracking system) to identify vaccination status. The DNS indicated education was provided to residents and families within the admissions packet which included immunization fact sheets. The DNS indicated that the education should have been offered upon admission to the facility and would be in the immunization tab of the EHR if it were offered. Additionally, the DNS indicated she did not know why vaccines were not offered and further identified that the ICN is new to the role. Review of the Vaccination of Residents policy directed, in part, all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education shall be documented in the resident's medical record. All new residents shall be assessed for current vaccination status upon admission. If vaccines are refused, the refusal shall be documented in the resident's medical record. If the resident receives a vaccine, the following information shall be documented in the resident's medical record: site of administration, date of administration, lot number of the vaccine, expiration date and the name of the person administering the vaccine.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #203) reviewed for nutrition and hydration, the facility failed to obtain accurate weights and failed to notify the provider of weight increases according to provider order. The findings include: Resident #203 was admitted to the facility in December of 2024 and had diagnoses that included periprosthetic fracture around the internal prosthetic right hip, diabetes, congestive heart failure (CHF) and hypertension. The Admission assessment dated [DATE] identified Resident #203 was alert and oriented to person, place and time. The Resident Care Plan dated 12/2/24 identified CHF and a risk for complications due to CHF. Interventions included to administer medications as ordered, check labs as ordered, chest x-ray as needed, daily weights for CHF, report weight gain of 3 pounds (lbs.) or more in a day to physician, diet as ordered, notify Physician of signs or symptoms of CHF exacerbation, and weigh as ordered. A Physician's order dated 12/4/24 directed to obtain daily weights for 3 days. A Physician's order dated 12/5/24 directed to obtain daily weights for CHF and directed to report a weight gain of 3 lbs. or more, within 1 day, to the physician. A Weights and Vital signs summary identified the following weight entries: 12/3/24 at 12:30 PM: 150.2 lbs. standing scale 12/4/24 at 11:06 AM: 133.4 lbs. standing scale (16.8 lb (11.2%) weight loss) 12/5/24 at 2:15 PM: 150.4 lbs. wheelchair scale (17 lb (12.7%) weight gain) 12/6/24 at 2:40 PM: 150 lbs. standing scale 12/7/24 at 1:45 PM: 134.2 lbs. wheelchair scale (15.8 lb (10.5%) weight loss) 12/7/24 at 10:01 PM: 135 lbs. sitting scale 12/8/24 at 2:39 PM: 134.6 lbs. standing scale 12/9/24 at 12:02 PM: 132.6 lbs. standing scale 12/10/24 at 11:20 AM: 137.4 lbs. standing scale (4.8 lb (3.6%) weight gain) 12/10/24 at 11:22 AM; 133.4 lbs. standing scale Review of the clinical record for December of 2024 failed to identify provider notification of the documented weight changes. Subsequent to surveyor inquiry, a handwritten Weights worksheet dated 12/7/24 was provided and identified the following weights: 12/03/24: 134.2 lbs., 12/04/24: 133.4 lbs., 12/6/24: 134.2 lbs. A Weight change note by the Dietitian dated 12/8/24 at 9:11 AM identified a significant weight change and recommended continuing daily weights and obtaining a baseline weight. A Nurse Practitioner note dated 12/9/24 at 3:00 PM identified, in part, no weight changes, no evidence of fluid overload. Interview and review of the clinical record with the Assistant Director of Nursing (ADNS) on 12/10/24 at 11:30 AM identified the physician should have been notified of the weight changes. The ADNS further identified the weights should have been obtained using the same scale. The ADNS could not determine the reason for the weight fluctuations. Subsequent to surveyor inquiry, on 12/10/24 at 11:30 AM, a standing reweight was obtained and identified a weight of 133.4 lbs. Subsequent to surveyor inquiry, on 12/10/24 at 1:30 PM the ADNS identified that he notified the provider of the weight changes and received orders for bloodwork. Review of the facility policy for Weight Assessment and Intervention, in part, directed the nursing staff will measure resident weights within a month and as scheduled by the physician, dietitian or the interdisciplinary team. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician or and Dietitian. The responsible party will also be notified. The dietitian will discuss undesired weight gain with the resident and/or family. Interventions for undesired weight gain should consider resident preferences and rights. 51183

Based on observations, review of facility documentation, facility policy, and interviews, the facility failed to ensure shift to shift controlled drug reconciliation was consistently completed and failed to maintain documentation of bi-monthly controlled drug audits. The findings include: 1. Observations on 12/9/24 at 1:50 PM of the St. [NAME]'s A medication cart with the Assistant Director of Nursing (ADNS) identified the December Change of Shift Inventory Record for Required Drugs sheet (the controlled drug reconciliation form that the on-coming and off-going nurses complete to ensure controlled drugs are counted) were missing signatures on the following dates: A. 12/3/24: 7:30 AM to 3:00 PM off-going, 3:30 PM to 11:00 PM off-going B. 12/4/24: 7:30 AM to 3:00 PM off-going, 3:30 PM to 11:00 PM off-going C. 12/6/24: 7:30 AM to 3:00 PM on-coming and off-going, 11:30 PM to 7:00 AM off-going D. 12/8/24: 7:30 AM to 3:00 PM off-going, 3:30 PM to 11:00 PM on-coming and 11:30 PM to 7:00 AM off-going Interview with LPN #1 on 12/9/24 at 1:55 PM identified she worked on the St. [NAME] unit on 12/8/24 from 7:00 AM until 7:30 PM, and she forgot to sign the change of shift controlled drug reconciliation form because she continued to work past her regular shift hours. LPN #1 indicated it was the responsibility of all the nurses to sign the controlled drug reconciliation form at the change of shift when the controlled drug count is completed. Interview with the ADNS on 12/9/24 at 2:00 PM identified that he was not aware of the missing signatures on the controlled drug reconciliation form, and it is his responsibility as the ADNS to check it, and he did not do so. The controlled drug reconciliation form should be checked weekly. 2. Observation with the ADNS on 12/9/24 at 2:15 PM identified the facility was unable to provide bi-monthly controlled drug audit sheets. Interview on 12/9/24 at 2:21 PM with the Director of Nursing (DNS) identified that she goes to each of the medication carts to review the controlled drug book and verify the counts in the cart, then matches the count to the pharmacy delivery sheets which were delivered with the controlled drugs by the pharmacy. The DNS indicated that she previously maintained a book with audit sheets but that process fell off. Review of the facility policy titled Handling and Destroying Narcotics indicated strict narcotics count should be done at the start and end of each shift. The incoming and outgoing nurses will both sign the narcotics book before handing out the key. Additionally, directed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #208) reviewed for Nutrition, the facility failed to identify preferences for meals and provide choices for food items. The findings include: Resident #208 was admitted to the facility in November of 2024 and had diagnoses that included fracture of upper end of the right humerus and diabetes. A Physician's order dated 11/21/24 at 4:36 PM directed to provide a regular diet, regular thin consistency. A Dietary admission assessment dated [DATE] at 2:11 PM identified Resident #208 wanted a diet change to a diabetic diet with limited carbohydrate portions, increased vegetables and protein. The assessment indicated the Food Service Director would updated. On 11/25/24 at 2:21 PM a Physician's order directed to provide a consistent carbohydrate diet, regular texture, regular thin consistency per resident request. The admission Minimum Data Set assessment dated [DATE] identified Resident #208 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14) and required set up assistance for eating and oral hygiene, partial moderate assistance for bed mobility, transfers and toileting. A Dietitian note dated 11/30/24 at 10:08 AM identified a 5 pound (lb) (3%) weight gain in 9 days and to continue a carbohydrate-controlled diet related to diabetes. The recommendation was to continue the current diet and monitor for new weight fluctuations. The Resident Care Plan dated 12/4/24 identified Resident #208 was at risk for alteration in nutrition due to advanced age and type 2 diabetes with a therapeutic carbohydrate-controlled diet. Interventions included to serve a consistent carbohydrate diet with regular texture and regular thin consistency, provide diet as ordered, Dietary assessment and consult as needed, labs as ordered, monitor intake of meals, and obtain weights as ordered. A Nutrition/Dietary note dated 12/6/24 at 4:45 PM by the Dietitian identified the Assistant Director of Nursing (ADNS) reported Resident #208 requested to see the Dietitian. The note indicated Resident #208 reported updated preferences related to his/her diabetes diagnosis and would continue a diabetic diet. The note indicated specific preferences were updated and she would remain available for follow-up as needed. Observation on 12/9/24 at 5:18 PM, of Resident #208 ' s saved meal tickets identified the following: 12/8/24: Breakfast: under the entree and bread sections: 1/2 cup of egg and sausage bake was noted and under the bread section: 1 slice of buttered toast was noted 12/8/24: Lunch: under the entree section: 1 cup of pork fried rice was noted, under the vegetable section 1/2 cup of oriental vegetables was noted. Handwritten instructions on the meal ticket noted: no meat, no rice, no pork and there was an X marked next to dinner roll, mashed potatoes and tropical fruit cup indicating Resident #208 should not have been served these meal items. 12/9/24 Lunch: the bottom of the meal ticket identified: no breads/pork/beef/dessert, under the entree and bread sections: substitute needed was noted, under the vegetable section: 1/2 cup of peas and carrots was noted. Interview with Resident #208 on 12/9/24 at 5:18 PM identified for breakfast on 12/8/24 he/she was served oatmeal, egg sausage bake and toast and subsequently only ate the oatmeal. Resident #208 indicated for lunch on 12/8/24 he/she was served pork fried rice, oriental vegetables, and mashed potatoes and subsequently only ate the oriental vegetables. Resident #208 identified for lunch on 12/9/24 he/she was served a breaded chicken patty, peas and carrots, and pudding and subsequently only ate the chicken after scraping off the breading and peas. Resident #208 identified he/she did not eat pork, root vegetables, breads or desserts. Observation of Resident #208's dinner meal tray on 12/09/24 5:34 PM identified he/she was served a turkey salad sandwich on white bread, a bowl of pumpkin soup with crackers, a cup of three bean salad, a cup of red Jello with whipped cream and a cup of milk. Observation of the dinner meal ticket identified: no breads/pork/beef/dessert, 8 oz of milk with each meal, and small starch portion was typed at the bottom of the meal ticket. Under the soup section: pumpkin soup was noted, under the entree section: substitute for the entree needed was noted, under the starch section: 1 oz of potato chips was noted, under the vegetable section 1/2 cup three bean salad was noted, under the dessert section: substitute needed for dessert was noted. Resident #208 ate the soup, the turkey salad inside the sandwich and the three bean salad. Interview and review of the meal tickets for Resident #208 with the Food Service Director on 12/9/24 at 5:47 PM identified that the meal tickets noted no breads/pork/beef/dessert, 8 oz of milk each meal/small starch portion. The Food Service Director indicated the dietary aides were not reading the entire ticket, and she would provide education for reading the entire ticket. Review of the Resident Menu Selection policy directed, in part, Residents are offered the ability to choose menu selections from offered choices available. Residents will be offered the availability to choose their meal options ahead of time. A staff member will be available to meet with the resident to determine their choices for meals. The resident can choose their meals up to a week in advance from menu options and always available menu. A resident can change their meal selection at any time to a different available option that does not conflict with their current physicians' orders. Review of the Resident Food Preferences policy directed, in part, a Nutritional assessment will include an evaluation of individual food preferences. After a resident's admission, the Dietitian or nursing staff will identify a resident's food preference. When possible, this will be done by direct interview with the resident. The Dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. The Food Service Department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal. The facility provides selective food items as a part of an always available menu.

Based on interviews, review of the clinical record, and facility policy for 1 of 9 residents (Resident #57) reviewed for food and nutrition, the facility failed to assist a dependent resident with menu selection. The findings include: Resident #57 was admitted to the facility in July of 2023 and had diagnoses that included legal blindness, gastro-esophageal reflux disease, and feeding difficulties A provider order dated 12/12/23 directed a regular diet, regular texture with an allergy to eggs and egg derivates. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), required set up assistance for eating, and was dependent for toileting, bathing, and transfers. The Resident Care Plan (RCP) dated 10/30/24 identified Resident #57 had impaired visual function related to legal blindness. Interventions included reviewing medications for side effects which affect vision and telling the resident where their items were placed. Additionally, the RCP identified Resident #57 was at risk for malnutrition due to varied meal intakes. Interventions included to provide diet as ordered, monitor intake of meals, offer meal alternates as needed, and provide assistance with meals as needed. Interview with Resident #57 on 12/9/24 at 3:09 PM identified he/she was not informed of the facility meal menus or given an option to select food preferences for meals but was just provided with the scheduled meal. Additionally, Resident #57 identified that he/she had informed staff that he/she would like to be informed of meal options and given the opportunity to make selections, but nothing had been done. Interview with the Food Service Director on 12/09/24 at 3:40 PM identified that the process for assisting residents with menus, food preferences and informing residents of what is on the menu is completed by the Nurse Aids (NA). Interview with NA #3 on 12/09/24 at 3:59 PM identified that NA's assist residents with filling out menus and selecting meal options. NA #3 further indicated that she did not assist Resident #57 with his/her meal selections and believed that this was completed on first shift. Interview with LPN #3 on 12/09/24 at 4:06 PM indicated that NA ' s or the recreation department help residents' complete meal selections and could not answer why it was not completed. LPN #3 stated she did not know who was overall responsible for ensuring menu selection was completed. Interview with the Director of Recreation on 12/09/24 at 5:05 PM identified that recreation helped with menu selection in the past and would help if requested, but that NA ' s were responsible for assisting residents with their menu selection. Interview with the Director of Nursing Services (DNS) on 12/09/24 at 5:40 PM identified that it was the responsibility of the NA to assist residents with menu selection and could not answer why it was not being completed for Resident #57. Additionally, the DNS stated that according to the policy, residents who were not capable of making their food selections would be assisted. Review of the Resident Menu Selections Policy identified, in part, residents would be offered the availability to choose their meal options ahead of time. A staff member would be available to meet with the resident or responsible party to determine their choices for meals. The resident could choose their meals up to one week in advance from the menu options or always available menu. A resident could change their meal selection at any time to a different available option that did not conflict with their current physician orders.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #81) reviewed for pressure injuries, the facility failed to ensure a dietician assessment was completed in a timely manner for a resident with a new facility acquired pressure injury and failed to perform preventative weekly skin assessments per provider order and facility policy and failed to perform weekly wound assessments per provider order. The findings include: Resident #81 was admitted to the facility in November of 2023 and had diagnoses that included Parkinson ' s disease, diabetes, and aphasia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #81 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), required partial/moderate assistance with bed mobility and transfers and was at risk for developing pressure injuries. The Resident Care Plan (RCP) dated 7/31/2024 identified Resident #81 had potential for impaired skin integrity related to Parkinson ' s disease, diabetes, incontinence, and stage 2 pressure injury to the right buttock identified in April of 2024. Interventions included completion of a skin evaluation weekly on shower day, provide supplements as ordered, updated provider as needed regarding pressure injury, and obtain dietician consult as needed. The RCP further identified Resident #81 was at risk for malnutrition related to variable meal intake, and Resident #81 ' s increased nutrient needs related to presence of a Stage 2 pressure injury to the right buttock. Interventions included to provide and serve supplements as ordered, obtain evaluation by the registered dietician with diet change recommendations as needed and administer liquid protein once daily. A Skin Assessment by RN #2 dated 10/17/2024 at 6:44 AM identified Resident #81 had a new right buttock stage 2 pressure injury (wound) measuring 3 centimeters (cm) by 2 cm which was cleansed with normal saline followed by a topical moisture barrier. The Skin Assessment identified the provider, dietician, and supervisor/wound nurse were notified of the new skin issue, and a treatment order was initiated. 1. A Dietician progress note by Dietician #2 on 10/24/24 at 2:09 PM identified Resident #81 was seen for a high risk assessment related to a new right buttock stage 2 pressure injury. A new order for liquid protein once a day was initiated. This assessment was conducted 7 days after the development of the new pressure injury and resulted in an added intervention of supplemental protein to aid in wound healing. A Provider order dated 10/24/2024 directed administration of liquid protein by mouth one time of day for a stage 2 wound to the right buttock. The provider order failed to identify the amount of liquid protein that was ordered for administration by the nurse. Review of the Nutritional Assessment Policy directed, in part, the dietician will conduct a nutritional assessment as indicated by a change in condition that places the resident at risk for impaired nutrition. Situations which placed the resident at increased risk for impaired nutrition included increased demand for calories and protein resulting from wounds. 2. A provider order dated 10/31/2024 directed the charge nurse to complete a weekly skin assessment and document the skin assessment (Skin Assessment-V2) under the assessments section in the electronic medical record (EMR) on Sunday ' s during the 3 PM to 11 PM shift. Review of the facility document titled Skin Checks on Shower Days identified 22 licensed nurses were provided education on 11/1/24 for a new skin assessment protocol. The education instructed nurses would receive a notification within the Electronic Medical Record (EMR), on residents scheduled shower days, directing them to complete a Skin Assessment. The nurses were instructed that when performing an Skin Assessment for a resident with a wound being treated by the wound doctor, the nurse was to document the type and location of the wound on the Skin Assessments. The education failed to instruct nurses to document wounds that were not being treated by the wound doctor on the Skin Assessment. Review of the clinical record identified weekly Skin Assessments were not completed on 10/20/24, 10/27/24, 11/3/24 (20 days with no skin assessment), and 12/1/24, despite the presence of a new facility acquired pressure injury. The Skin Assessments completed on 11/9/2024, 11/16/2024, and 11/23/2024 failed to include documentation of an existing pressure injury or the resolution of the pressure injury to the right buttock. Subsequent to surveyor inquiry a Skin Assessment was performed on 12/7/24 which identified a new dry, superficial area to the left elbow measuring 1 cm by 1 cm, but did not include documentation of an existing pressure injury or the resolution of the pressure injury to the right buttock. Interview with the ADNS on 12/10/24 at 10:20 AM identified weekly Skin Assessments should be documented by the charge nurse in the assessment section of the EMR. He identified licensed nurses should include documentation of existing skin issues within the Skin Assessments. The ADNS indicated licensed nurses received education on 11/1/24 related to the facility ' s new process for Skin Assessments. 3. A Wound-Weekly Progress Notes assessment by the Assistant Director of Nursing Services (ADNS) dated 10/25/24 at 2:16 PM identified Resident #81 had an improved facility acquired right buttock pressure injury, onset date unknown, which measured 2.4 cm by 0.4 cm. A physician ' s order dated 11/6/24 directed to measure wound(s) to the right upper and right medical buttock every Wednesday on the 7 AM to 3 PM shift. A physician ' s order clarification dated 11/20/24 directed to complete a wound assessment for buttock wounds every Wednesday on the 7 AM to 3 PM shift. Review of the clinical record for Wound-Weekly Progress Notes assessments in the assessment section of the EMR identified there were no documented wound assessments during the week of 10/27/24 through 11/2/24, and on 11/20/24, 11/27/24, and 12/4/24 according to provider order. Observation of Resident #81 ' s skin integrity with the Director of Nursing Services (DNS) and Nurse Aide (NA) #8 on 12/10/24 at 9:10 AM identified Resident #81 had 2 small superficial stage 2 pressure injuries (wounds) to the upper and lower coccyx with red wound beds and scant drainage. The DNS indicated she would have the charge nurse initiate a wound evaluation and ensure Resident #81 was added to the weekly wound rounds schedule for the wound doctor to evaluate. The DNS indicated that the observed wounds were new as the Skin Assessment performed on 12/7/24 did not identify wounds to the coccyx or buttocks, and a new treatment would be initiated. Interview with the ADNS on 12/10/24 at 10:20 AM identified he performed weekly wound rounds with the doctor and was responsible for entering subsequent wound assessments into the EMR. He further identified charge nurses were responsible for assessing and documenting all other wounds not seen by the doctor during wound rounds. The ADNS confirmed Resident #81 had stage 2 wounds to the right upper and medial buttocks as documented on 11/13/24 but was unable to identify why wound assessments were missing for 11/20/2024, 11/27/2024 and 12/4/2024. The ADNS indicated the right upper and medial buttock wounds were healed and there should have been documentation of the healed wounds in the clinical record. He was unable to provide a healed date for the wounds. The ADNS indicated he was notified by the charge nurse of 2 new stage 2 pressure injuries that morning. The ADNS identified that charge nurses were responsible for documentation of new or existing wounds, that were not followed by the wound doctor during wound rounds, during weekly skin assessments. The ADNS was unable to explain how charge nurses would identify a decline in wound status if they were not consistently assessing a wound or how they would know when to report wound status to a provider. Review of the Pressure Ulcer Prevention Policy directed, in part, the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, family and addressed and weekly Skin Assessments and documentation completed in EMR.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #210) reviewed for accidents, the facility failed to follow the plan of care to prevent an accident for a resident who was at risk of falls. The findings include: Resident #210 was admitted to the facility in October of 2022 with diagnoses that included acute and chronic respiratory failure, heart failure, long term (current) use of anticoagulants and difficulty in walking. Physician ' s order dated [DATE] directed to administer oxygen at 3 liters (L) per minute via nasal cannula. Physician's order dated [DATE] directed to place a sensor alarm to Resident #210's bed and chair every shift for safety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #210 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12) and was dependent for toileting hygiene, required moderate assistance with positioning from lying to sitting on the side of the bed and supervision assistance from sitting to standing. Additionally, the MDS identified that Resident #210 had other health conditions that caused him/her to experience shortness of breath or trouble breathing with exertion e.g. walking, bathing, transferring, when sitting at rest, and when lying flat. The MDS identified Resident #210 was receiving oxygen therapy, was prescribed an anticoagulant, and required bed alarm and chair alarm to monitor his/her movement and alert staff when movement was detected. The MDS further identified that Resident #210 had sustained a fall prior to admission to the facility. The Resident Care Plan (RCP) dated [DATE] identified Resident #210 had a history of falls related to poor safety awareness and cognitive deficits. The identified goal was a decreased risk of injury related to falls as evidenced by maximum interventions placed to provide a safe, calming environment with minimal risk of injury should a fall/incident occur. Interventions included use of bed and chair alarms and to check the function and placement every shift, provide toileting assistance at the appropriate frequency and as needed, keep bed in lowest position with brakes locked, observe Resident #210 frequently and place him/her in a supervised area when out of bed. The RCP further identified that Resident #210 had chronic respiratory failure with interstitial lung disease and hypoxia (deficiency in the amount of oxygen reaching tissues). Interventions included administering oxygen as ordered, checking for placement frequently and obtaining vital signs as ordered. The RCP further identified that Resident #210 was at potential risk for injury/bleed related to the use of anticoagulation medications for atrial fibrillation (a fib), interventions included monitoring Resident #210 for active bleeding, cyanosis and pallor and obtaining labs as ordered. The Resident Care Card (RCC) for the month of [DATE] identified that Resident #210 was alert but forgetful and required an assist of 1 with a rolling walker and gait belt for ambulation. Additionally, the RCP directed to place bed and chair sensor alarms and to check for placement and function every shift. The RCP also directed to pad oxygen cannula and check oxygen setting frequently. A Social Services note dated [DATE] at 3:07 PM written by Social Worker #1 identified that Resident #210 presented with periods of increased confusion, hallucinations and delusions particularly in the evening. The note further identified that Resident #210 had exhibited poor safety awareness with self-transfer attempts and was removing his/her oxygen despite ongoing education and oxygen saturation readings ranged from 79% to 97% while on 3L of oxygen but drops quickly with little activity including ambulating to and from the bathroom. A Nurses noted dated [DATE] at 6:20 PM written by LPN #5 identified that on 3:00 PM to 11:00 PM shift, Resident #210 was alert and forgetful with intermittent confusion and ambulated him/herself to the bathroom. The note further identified that Resident #210 was found sitting on the toilet without his/her oxygen but was brought back to his/her recliner and oxygen was applied at 3.5 L. The note identified that Resident #210 ' s oxygen saturation levels were between 81%-84% but increased to 87% when oxygen was applied. The note further identified that Resident #210 ' s oxygen increased to 93% after Morphine was administered at 5:39 PM. A Reportable Event form dated [DATE] at 3:40 AM written by LPN #6, identified that staff heard a loud thump from Resident #210's room and when they responded they found Resident #210 lying in supine position (lying on back with face and torso facing up) on the floor. The form identified that Resident #210 was unresponsive, was observed with a left eye bruise and small trickle of blood near the outer side of the left eye and LPN #6 was unable to obtain vital signs. The Registered Nurse Supervisor (RN #4) and physician were notified. The form identified LPN #4 called 911 and applied oxygen, but Resident #210 deceased within ,d+[DATE] minutes. The report identified that Resident #210 was cognitively impaired, had experienced episodes of restlessness, mood swings and agitation prior to the fall and had a bed sensor/alarm in place which was always connected. The form further identified that Resident #210 self-transferred out of bed and the bed sensor/alarm did not sound. The form identified the bed sensor/alarm was later taken apart and the alarm control unit was found to be broken. A Nurse's note dated [DATE] at 4:28 AM by RN #2, identified that at 3:40 AM she was alerted by LPN #6 that Resident #210 was on floor. RN #2 ' s note indicated he/she responded and found Resident #210 in his/her room by the bathroom door in a supine position. The note identified that Resident #210 was unresponsive and was noted to have a small amount of blood coming from the left eye. The note indicated that RN #2 was unable to obtain vital signs, called 911 and notified RN #4. The note further identified that Resident #210 was pronounced deceased at 3:45 AM. Additionally, the note indicated that EMS arrived at 3:50 AM and confirmed Resident #210's death and Resident #210's daughter was notified at 4:05 AM. A Nurses note dated [DATE] at 7:02 AM written by LPN #6, identified that prior to Resident #210 ' s fall incident on [DATE], he/she had not voided during the 11:00 PM to 7:00 AM shift. The note further identified that Resident #210 had remained asleep through the 11:00 PM to 7:00 AM shift prior to self-transferring from bed and falling. Interview with RN #4 on [DATE] at 3:37 PM identified that she responded to the fall incident on [DATE] after being called by the LPN #6. RN #4 identified that she found Resident #210 on the floor in the supine position, unresponsive and was bleeding slightly from the back of his/her head due to a small cut on the back of his/her head. RN #4 identified that Resident #210 did not have his oxygen tubing applied when he/she fell but the oxygen tubing was on the floor a few feet away. RN #4 identified that she did not check the bed alarm function at the beginning of the 11:00 PM to 7:00 AM shift because Resident #210 was asleep, and she did not want to wake him up because he would become restless, but she observed that the bed alarm/sensor was plugged in. RN #4 identified that checking the bed sensor/alarm is a routine safety task that should be done at the beginning of shift. RN #4 identified that checking for bed alarm function entails moving/rolling the resident completely off the sensor pad that is normally placed underneath the resident and then rolling the resident back. RN #4 further identified that Resident #210 was a fall risk, and the bed alarm should have sounded when Resident #210 moved out of bed alerting staff to respond timely to prevent him/her from falling and redirect him/her, but the bed alarm did not sound. RN #4 identified that both nurses and nurses assistants were responsible for checking bed alarm placement and function at the beginning of their shifts. Interview with NA #8 on [DATE] at 11:51 AM, identified that she heard a loud bang and when she responded, she found Resident #210 laying on the floor on his/her back in his/her room near the bathroom door. NA #8 further identified that Resident #210 was still and not moving. NA #8 identified that at the beginning of her shift when she did rounds, Resident #210 was sleeping, and the bed alarm was plugged in. NA #8 identified that she did not check the bed alarm's function because Resident #8 was sleeping, and she did not want to wake him/her up. NA #8 identified that she would normally check for bed alarm placement and functioning at the beginning of the shift. NA #8 further identified that checking for bed alarm function entails moving/rolling the resident completely off the sensor pad that is normally placed underneath the resident and then rolling the resident back. Rolling the Resident off the sensor pad would activate the bed alarm to sound. Interview with the DNS on [DATE] at 12:30 PM, identified that bed alarm placement was implemented as an intervention protocol to mitigate Resident #210's fall risk. The DNS identified that the bed alarm last sounded around 4:00 PM on the 3:00 PM to 11:00 PM shift when Resident #210 self-transferred to the bathroom. The DNS identified that the bed alarm control unit was found to be broken resulting in the failure to sound when Resident # 210 got out of bed. The DNS further identified that the NA's were responsible for checking the bed alarm function. Although requested, a bed alarm policy was not provided. Although requested, competencies or staff education related to bed alarm function checks by NA's was not provided. Review of facility policy titled, Fall Prevention Program, identified, in part, that the purpose of the fall preventive program is to prevent avoidable falls and injuries that result from falls. The program further identified that the plan of care will be individualized to resident.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #12) reviewed for the environment, the facility failed to ensure resident room temperatures were comfortable. The findings included: Resident #12 was admitted to the facility in April of 2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14). Observations on 12/4/24 at 11:30 AM, identified Resident #12 lying in bed, closest to the window, wearing a red jacket (fleece material), and covered in two thick plush blankets. The room temperature was observed to be cool. Interview with Resident #12 on 12/4/24 at 11:30 AM, identified the room temperature had been cold for a couple of weeks and when Resident #12 communicated feeling cold to the staff, a warm blanket would be provided. On 12/5/24 at 9:30 AM the Life Safety surveyor was notified of the cool temperature in Resident #12 ' s room and obtained room temperatures of 69 degrees Fahrenheit by the window and 71 degrees Fahrenheit near the hallway door. The Life Safety surveyor also identified the room baseboards were cold and had no heat flow. Subsequent to surveyor inquiry, the Maintenance Assistant assessed the heating system and identified the rooms heating unit was not functioning and the system needed to be bled. After bleeding the system, the heat began functioning. Maintenance Logs reviewed for the St. [NAME] wing on 12/6/24 at 11:50 AM identified there were no heating concerns noted for the month of December. There were no Maintenance Logs for the months of October and November. Interview with the Director of Nursing (DNS) on 12/9/24 at 4:18 PM identified there was a Maintenance Log, located at each unit ' s nurse's station, where the staff would log concerns or issues related to resident rooms. The DNS indicated the Maintenance Assistant would make rounds on each unit, review the logs, address logged concerns and then sign off on the log. She further identified that the Director of Maintenance keeps logs from prior months and participates in monthly environmental rounds. Interview with Nurse Aide (NA) #5 on 12/10/24 at 8:44 AM, identified she worked on 12/3/24 during the 11:00 PM to 7:00 AM shift and provided care to Resident #12. NA #5 indicated the room felt chilly, but did not check the room's thermostat. Interview with the Director of Maintenance on 12/10/24 at 10:49 AM identified there were no monthly Maintenance Logs documented for October and November, and he was not made aware of any heating issues on the units. He indicated that staff utilize the Maintenance Logs at the nurses stations and share information verbally in person. He identified an ongoing issue with a component of the heating system called a zone valve, which would get stuck and block heat flow, and indicated he should have had a system in place to monitor the zone valves. The Director of Maintenance identified he did not consistently participate in the facility monthly environmental rounds and indicated that this issue would have been identified had a member of maintenance been present during environmental rounds. The Director of Maintenance could not identify when he last attended monthly environmental rounds. The facility policy titled Homelike Environment directed, in part, the facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. Although requested, a facility policy for Environmental Rounds was not provided.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Resident #2's diagnoses included Parkinsonism, schizophrenia, and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented (no cognitive impairment). The Resident Care Plan (RCP) dated 5/17/2024 identified Resident #2 had a history of socially inappropriate behavioral symptoms. Interventions directed to provide education on what is not acceptable behavior. Review of facility Reportable Event Form dated 7/9/2024 at 10:30 AM identified Resident #2 reported to a NA that he/she did not want a certain NA to provide care because that NA asks for money. Resident #2 stated he/she gave NA #1 $80.00 and he/she wanted it back. An investigation was initiated, and NA #1 was removed from the schedule. The report identified NA #1 denied taking $80, but stated she did accept $4 that was left over from a take-out food order. NA #1 indicated she had shared personal information with Resident #2, and Resident #2 offered her money to help NA #1, and NA #1 admitted she did accept $75 from Resident #2. Facility documentation identified Resident #2 reported he/she gave the $75 to NA #1 because NA #1 had no food, and Resident #2 told NA #1 to keep the money; he/she wanted to help NA #1. The facility summary dated 7/13/2024 identified Resident #2 offered $75 to NA #1, and NA #1 accepted the money. The summary further identified Resident #2 and NA #1 both stated NA #1 kept $4 remaining from a take-out order. The DNS summary identified during the investigation, it was determined that NA #1 had kept the change of $4 from a take out order, and also had accepted $80 from Resident #2. Facility documentation review identified NA #1 was no longer employed at the facility due to violation of facility policy regarding accepting cash from residents. Interview and facility documentation review on 7/24/2024 at 10:12 AM with NA #1 identified, on an unidentified date, that she was having a rough day, stated she had not eaten for two (2) days and when Resident #2 asked her what was wrong, Resident #2 offered her money for food. NA #1 indicated that she did not ask Resident #2 for the money, but stated she did take the money. NA #1 further indicated that she initially lied about it because she was scared, but then later told the facility during a second interview that she took the money. Lastly, NA #1 identified that she should not have taken the money. Interview and record review with the DNS on 7/24/2024 at 1:30 PM identified NA #1 should not have shared personal information, and should not have accepted money from Resident #2. The DNS stated her investigation identified NA #1 kept the change of $4 from a take-out order, and also accepted $80 from Resident #1, and the facility reimbursed Resident #2. NA #1's employment was terminated as she violated facility policy regarding accepting money and discussing personal issues with residents. Review of facility Code of Conduct directed in part, employees shall follow the policies and procedures employees are responsible for safe-guarding resident's financial affairs. Review of facility Nursing Home Residents' [NAME] of Rights directed in part, Freedom from Abuse, you have the right to be free from misappropriation of property. Review of facility Abuse/Indignity/Mistreatment/Neglect Policy directed in part, misappropriation of property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Resident #2's diagnoses included Parkinsonism, schizophrenia, and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented (no cognitive impairment). The Resident Care Plan (RCP) dated 5/17/2024 identified Resident #2 had a history of socially inappropriate behavioral symptoms. Interventions directed to provide education on what is not acceptable behavior. Review of facility Reportable Event Form dated 7/9/2024 at 10:30 AM identified Resident #2 reported to a NA that he/she did not want a certain NA to provide care because that NA asks for money. Resident #2 stated he/she gave NA #1 $80.00 and he/she wanted it back. An investigation was initiated, and NA #1 was removed from the schedule. The report identified NA #1 denied taking $80, but stated she did accept $4 that was left over from a take-out food order. NA #1 indicated she had shared personal information with Resident #2, and Resident #2 offered her money to help NA #1, and NA #1 admitted she did accept $75 from Resident #2. Facility documentation identified Resident #2 reported he/she gave the $75 to NA #1 because NA #1 had no food, and Resident #2 told NA #1 to keep the money; he/she wanted to help NA #1. The facility summary dated 7/13/2024 identified Resident #2 offered $75 to NA #1, and NA #1 accepted the money. The summary further identified Resident #2 and NA #1 both stated NA #1 kept $4 remaining from a take-out order. The DNS summary identified during the investigation, it was determined that NA #1 had kept the change of $4 from a take out order, and also had accepted $80 from Resident #2. Facility documentation review identified NA #1 was no longer employed at the facility due to violation of facility policy regarding accepting cash from residents. Interview and facility documentation review on 7/24/2024 at 10:12 AM with NA #1 identified, on an unidentified date, that she was having a rough day, stated she had not eaten for two (2) days and when Resident #2 asked her what was wrong, Resident #2 offered her money for food. NA #1 indicated that she did not ask Resident #2 for the money, but stated she did take the money. NA #1 further indicated that she initially lied about it because she was scared, but then later told the facility during a second interview that she took the money. Lastly, NA #1 identified that she should not have taken the money. Interview and record review with the DNS on 7/24/2024 at 1:30 PM identified NA #1 should not have shared personal information, and should not have accepted money from Resident #2. The DNS stated her investigation identified NA #1 kept the change of $4 from a take-out order, and also accepted $80 from Resident #1, and the facility reimbursed Resident #2. NA #1's employment was terminated as she violated facility policy regarding accepting money and discussing personal issues with residents. Review of facility Code of Conduct directed in part, employees shall follow the policies and procedures employees are responsible for safe-guarding resident's financial affairs. Review of facility Nursing Home Residents' [NAME] of Rights directed in part, Freedom from Abuse, you have the right to be free from misappropriation of property. Review of facility Abuse/Indignity/Mistreatment/Neglect Policy directed in part, misappropriation of property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Resident #2's diagnoses included Parkinsonism, schizophrenia, and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented (no cognitive impairment). The Resident Care Plan (RCP) dated 5/17/2024 identified Resident #2 had a history of socially inappropriate behavioral symptoms. Interventions directed to provide education on what is not acceptable behavior. Review of facility Reportable Event Form dated 7/9/2024 at 10:30 AM identified Resident #2 reported to a NA that he/she did not want a certain NA to provide care because that NA asks for money. Resident #2 stated he/she gave NA #1 $80.00 and he/she wanted it back. An investigation was initiated, and NA #1 was removed from the schedule. The report identified NA #1 denied taking $80, but stated she did accept $4 that was left over from a take-out food order. NA #1 indicated she had shared personal information with Resident #2, and Resident #2 offered her money to help NA #1, and NA #1 admitted she did accept $75 from Resident #2. Facility documentation identified Resident #2 reported he/she gave the $75 to NA #1 because NA #1 had no food, and Resident #2 told NA #1 to keep the money; he/she wanted to help NA #1. The facility summary dated 7/13/2024 identified Resident #2 offered $75 to NA #1, and NA #1 accepted the money. The summary further identified Resident #2 and NA #1 both stated NA #1 kept $4 remaining from a take-out order. The DNS summary identified during the investigation, it was determined that NA #1 had kept the change of $4 from a take out order, and also had accepted $80 from Resident #2. Facility documentation review identified NA #1 was no longer employed at the facility due to violation of facility policy regarding accepting cash from residents. Interview and facility documentation review on 7/24/2024 at 10:12 AM with NA #1 identified, on an unidentified date, that she was having a rough day, stated she had not eaten for two (2) days and when Resident #2 asked her what was wrong, Resident #2 offered her money for food. NA #1 indicated that she did not ask Resident #2 for the money, but stated she did take the money. NA #1 further indicated that she initially lied about it because she was scared, but then later told the facility during a second interview that she took the money. Lastly, NA #1 identified that she should not have taken the money. Interview and record review with the DNS on 7/24/2024 at 1:30 PM identified NA #1 should not have shared personal information, and should not have accepted money from Resident #2. The DNS stated her investigation identified NA #1 kept the change of $4 from a take-out order, and also accepted $80 from Resident #1, and the facility reimbursed Resident #2. NA #1's employment was terminated as she violated facility policy regarding accepting money and discussing personal issues with residents. Review of facility Code of Conduct directed in part, employees shall follow the policies and procedures employees are responsible for safe-guarding resident's financial affairs. Review of facility Nursing Home Residents' [NAME] of Rights directed in part, Freedom from Abuse, you have the right to be free from misappropriation of property. Review of facility Abuse/Indignity/Mistreatment/Neglect Policy directed in part, misappropriation of property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment was completed after a resident fall. The findings include: Resident #1's diagnoses included dementia and syncope. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, required supervision or touch assistance with ambulation and toilet transfers, and had no falls since the prior assessment. The Resident Care Plan (RCP) dated 4/22/2024 identified Resident #1 had a history of falls related to poor safety awareness and cognitive deficits. Interventions directed ambulation assist of one (1) with gait belt and four-wheel walker and to keep call light in reach at all times. Review of facility incident report dated 4/29/2024 at 4:30 PM identified Resident #1 fell on the floor on his/her left side in the bathroom door entrance. Resident #1 sustained a skin tear to the left elbow and had complaints of pain to the left hip and knee when attempting to stand. The APRN was notified, and an order was obtained for x-rays of left hip, knee, elbow, and for wound care to left elbow. Review of facility Post Event Assessment Form identified Resident #1 had fall on 4/29/2024 at 4:30 PM and had a seven (7) centimeter (cm) skin tear on the left elbow. The Assessment Form further indicated Resident #1 was able to tolerate passive range of motion of the bilateral upper and lower extremities without complaints of pain, and when asked to bear weight, Resident #1 had complaints of increased pain to the left side. Additional review of the Assessment Form failed to identify an RN signature. Record review and facility documentation review failed to identify an RN assessment was completed after the fall on 4/29/2024 at 4:30 PM. Interview and record review with the ADNS on 5/28/2024 at 2:54 PM identified although he completed an RN assessment after Resident #1's fall on 4/29/2024 at 4:30 PM, he did not write a note in the clinical record to include the assessment. The ADNS stated he thought writing his assessment on the incident post event report would be documentation of the assessment and he thought the incident report was part of the clinical record. Further, the ADNS was unable to provide documentation that was included in the electronic medical record or the paper medical record that an RN assessment was completed. Interview, clinical record review and facility documentation review on 5/29/2024 at 9:49 AM with the DNS identified that the RN assessment should be completed and documented after a resident fall, and stated it is documented on the Post Event paper form and not in the electronic medical record. Although the Post Event Assessment was included with the facility incident report, the DNS indicated it was considered part of the clinical record. Further, the DNS was unable to provide documentation that was included in the electronic medical record or the paper medical record that an RN assessment was completed. Review of facility Fall Management policy in part directs residents who have a fall will be assessed by the charge nurse/RN supervisor. Review of facility Charting and Documentation policy in part directs all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. All incidents, accidents or changes in resident's condition must be recorded. Documentation of procedures shall include care-specific details and shall include at a minimum: dates and time procedure/treatment was provided; name and title of individual(s) who provided the care; assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether resident refused procedure/treatment; notification of family, physician or other staff, if indicated; signature and title of the individual documenting.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a physician order for STAT (immediate) x-rays were ordered as STAT. The findings include: Resident #1's diagnoses included dementia and syncope. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, required supervision or touch assistance with ambulation and toilet transfers, and had no falls since the prior assessment. The Resident Care Plan (RCP) dated 4/22/2024 identified Resident #1 had a history of falls related to poor safety awareness and cognitive deficits. Interventions directed ambulation assist of one (1) with gait belt and four-wheel walker and to keep call light in reach at all times. Physician order dated 3/20/2024 directed a hospice evaluation. Physician order dated 3/26/2024 directed CMO (comfort measures only), Do Not Resuscitate (DNR), Do Not Intubate (DNI), Nurse May Pronounce (NMP), Do Not Hospitalize (DNH) and no tube feedings. Review of facility incident report dated 4/29/2024 at 4:30 PM identified Resident #1 fell on the floor on his/her left side in the bathroom door entrance. Resident #1 sustained a skin tear to the left elbow and had complaints of pain to the left hip and knee when attempting to stand. The APRN was notified, and an order was obtained for x-rays of left hip, knee, elbow, and for wound care to left elbow. A physician's order dated 4/29/2024 directed non-weight bearing until after x-rays are obtained and cleared by physician. Review of facility documentation dated 4/29/2024 at 5:19 PM identified that an order was entered by the ADNS from APRN #1 to obtain x-rays: left hip unilateral with pelvis when performed, two (2) to three (3) views, left knee one (1) to two (2) views and left elbow two (2) views status post fall, pain, unable to bear weight. Further review failed to identify the order was placed as a STAT (immediate) order. Clinical record review failed to identify that x-rays were obtained prior to Resident #1's transfer to the hospital. Nursing note dated 4/30/2024 at 5:41 AM identified Resident #1 was noted to have increased pain to the left elbow, edema and leg externally rotated, RN assessment was completed, and x-ray was not obtained. The on-call APRN was notified, and a new order was obtained to transfer Resident #1 to the hospital for evaluation. The responsible party and triage nurse were notified, and 911 was called at 5:30 AM. Nursing note (health status note) dated 4/30/2024 at 4:04 PM identified Resident #1 returned to the facility on [DATE] at 1:45 PM with diagnoses of acute, moderately displaced, comminuted intertrochanteric fracture of the left femur with femoral varus deformity and comminuted olecranon fracture and a plan for admission to hospice services, and the responsible party declined surgical intervention. Interview, clinical record review and facility documentation review at 5/28/2024 at 1:18 PM with the ADNS identified he notified the APRN of the fall, and the APRN gave orders for x-rays of the left hip and elbow. The ADNS stated he called radiology and notified them of the order, and indicated he did not notify radiology the order was ordered STAT because they typically arrive within four (4) hours of notification. Interview on 5/28/2024 at 3:40 PM with Radiology Provider #1 identified that the facility ordered x-rays on 4/29/2024 at 5:19 PM, and when the x-ray technician arrived at the facility on the morning of 4/30/2024, Resident #1 had been transferred to the hospital. Radiology Provider #1 stated the facility did not order the x-rays to be completed STAT. Interview, clinical record review on 5/29/2024 with APRN #1 identified he was aware Resident #1 complained of hip pain after the fall on 4/29/2024. APRN #1 stated Resident #1 had orders that directed CMO and DNH and he did not direct to transfer Resident #1 to the hospital due to the orders for no hospitalization . APRN #1 ordered x-rays to be obtained STAT, with the plan to then discuss next steps with the responsible party. Interview, record review and facility documentation review on 5/29/2024 at 9:49 AM with the DNS identified that if x-rays were ordered STAT the orders should have been entered in the medical record as STAT and the radiology notified the orders were STAT. The DNS stated the STAT x-rays should have been done and was unable to explain why they were not obtained. Although requested, no facility policy was provided for surveyor review regarding ordering STAT x-rays.

Based on observation, interviews, and review of facility policy during the initial tour of the kitchen, the facility failed to ensure the proper concentration of sanitizing solution for one of three sanitization buckets reviewed. The findings include: Interview and observation with the Food Service Supervisor on 8/24/22 at 10:15 AM identified three buckets of sanitizing solution for cleansing kitchen surfaces, one in a sink, one on a mobile cart, and one on a shelf below a food preparation surface. The Food Service Supervisor indicated that the sanitizing solutions had been mixed on 8/24/22 between 9:30 and 10:00 AM and that the proper level of sanitization for food contact surfaces is 150-200 parts per million (PPM) for quaternary ammonia compound (QAC). Upon testing, the sanitization bucket that was in use and stored on the mobile cart indicated a level of 0 parts PPM of QAC which failed to reach the appropriate level of sanitization. The Food Service Supervisor re-tested the sanitization solution using a new package of dip sticks, but the sanitization level again indicated a level of 0 PPM. The Food Service Supervisor indicated that the sanitizer level was not at the appropriate level, the bucket should not have been in use, and subsequently, he discarded the solution. Interview with Cook/Cook's Helper on 8/24/22 at 10:55 AM identified that the three sanitizing solutions had been mixed by the automatic dispenser at the dishwashing sink earlier that morning, and that the solutions dilute due to the use of wet wiping towels. The facility Cleaning Schedule policy, directed in part, that Dietary Aids would wipe down and sanitize worktables, tray carts, and other food contact surfaces after each use.

FACILITY Kitchen Based on observations, interviews, and review of facility policy during the initial tour of the kitchen, the facility failed to ensure essential kitchen equipment was free of debris and maintained in a clean and sanitary manner, that food items were appropriately labeled, that expired food was discarded prior to the expiration date and that during meal distribution food items were appropriately covered. The findings include: 1. Observations during the initial kitchen tour on [DATE] at 10:00 AM identified the following: A. Observation of the ice machine identified a black substance on the interior back of the machine above the current supply of ice for kitchen use. Interview and review of facility policy with the Food Service Supervisor at 10:40 AM identified that the kitchen ice machine was scheduled to be cleaned every three months by maintenance. The Food Service Supervisor indicated that the interior of the ice bin currently required cleaning, that the black substance above the ice was easily removed with a paper towel and could have been mold, the current supply of ice should not be dispensed, and that he would call maintenance to empty the ice and ensure cleaning and sanitization prior to any further use. The Food Service Supervisor was unable to provide routine inspection or cleaning of the ice compartment by his staff or that maintenance had performed routine cleaning and sanitization on a three-month interval. The Food Service Supervisor subsequently placed a do not use sign on the ice machine and a maintenance log was placed into use. B. Inside the walk-in refrigerator, a fine dust like, gray debris was noted to be hanging from the running compressor fan and the ventilation grill above stored refrigerated food items. Additionally, deli turkey, American cheese, salami, cooked pancakes, and cooked waffles were noted to be wrapped in plastic wrap (secondary packaging not the original container), that failed to indicate an open date or a date that the item would expire, and a container of ricotta cheese was noted to have expired on [DATE]. C. Observations of the facility's emergency three-day supply of food identified six cans of expired fruit cocktail with a use by date of [DATE]. Interview with the Food Service Supervisor on [DATE] at 11:00 AM identified that the secondary packaging, plastic wrapped food items in the walk-in refrigerator required dating for expiration and discarding purposes, and that all expired foods should have been discarded prior to the expiration date. Review of the facility legionella policy dated [DATE] directed, in part, that internal cleaning of ice machine bin should be done via to manufacturer's recommendation and cleaning procedure of the machine. A good rule of thumb is semi-annually and that the process also needs documentation to ensure compliance and records should be maintained in the service section of this plan. Review of facility Labeling, and Dating Food policy directed, in part, that all food must be wrapped, labeled, and dated once opened. The label must include the date it was prepped and the date to discard. 2. Observation on [DATE] at 12:20 PM identified cut fruit being delivered without the benefit of being covered during distribution to residents. Observation on [DATE] at 12:20 PM noted cut fruit and salad being distributed to residents uncovered. Interview and observation with the Infection Control Nurse (ICN) on [DATE] at 12:22 PM identified facility staff passing out food items without the benefit of being covered. The ICN indicated that the facility had a recent in-service to ensure food was kept covered during distribution and that facility staff, although in-serviced, was observed failing to follow the protocol. Interview with the Food Services Manager on [DATE] at 10:40 AM identified there was a backorder of lids for the existing bowls used for fruit and soup, new bowls were ordered, and delivery is expected next week. The Food Services Manager identified that all items coming from the kitchen must be covered for distribution to residents and indicated that he would use cling wrap until the appropriate coverings were delivered. The facility did not have a policy for resident food distribution.

Resident #36 Accidents Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #36) who was reviewed for falls, the facility failed to revise the care plan. The findings include: Resident #36 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Physical Therapy Discharge Summary dated 1/25/22 recommended supervision during all functional transfers and ambulation due to decreased safety and history of fall, The quarterly MDS assessment dated [DATE] identified Resident #36 was cognitively intact and required the limited assistance of one staff for transfers and walking, and the extensive assistance of one staff for toilet use. The care plan dated 4/1/22 identified Resident #36 was at risk for falls. Interventions directed to provide two staff assist for transfers, a sensor alarm to the chair, to check the sensor alarm every shift, and to assist with transfers and ambulation as indicated. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the NA care card dated 5/5/22, 5/6/22 and 5/9/22 directed Resident #36 was to have sensors to chair, required supervision with a walker for transfers, and was independent with a rollator and ambulation for mobility. Review of the Reportable Event dated 5/7/22 at 10:35 AM identified Resident #36 turned too fast and fell . The fall review investigation form dated 5/7/22 failed to indicate if Resident #36 required the use of an alarm or if the alarm sounded. Review of the NA care card dated 5/22/22, 5/24/22, 5/25/22 and 5/26/22 directed Resident #36 was to have sensors to chair, required supervision with a walker for transfers, and was independent with a rollator and ambulation for mobility. Review off the Reportable Event dated 5/24/22 at 5:00 PM identified that Resident #36 fell , lost consciousness, and was sent to the Emergency Department. The fall review investigation dated 5/24/22 failed to indicate if Resident #36 required the use of an alarm or if the alarm sounded. Review of the hospital Discharge Summary identified that Resident #36 returned to the facility on [DATE] with a subdural hematoma and six sutures to his/her head. Interview with NA #2 on 8/30/22 at 2:10 PM identified that when Resident #36 fell on [DATE] she did not require an alarm and that if an alarm had been required, the information would have been on the resident's care card. Interview and review of fall investigation documentation on 8/31/22 at 10:24 AM with LPN #3 identified that when Resident #36 fell on [DATE] the resident's alarm had been taken off and put back on for safety many times and LPN #3 could not recall if she saw Resident #36's sensor on 5/7/22 but that no alarm was sounding when she entered. LPN #3 indicated that the alarm portion of the fall investigation should have been filled out and that she was sorry. Interview and review of fall investigation documentation on 8/31/22 at 10:31 AM with NA #1 identified that on 5/24/22 he remembered that he had toileted Resident #36 and that the resident had an alarm at one point, then it was taken away, and was unsure if there was an alarm on Resident #36's chair on 5/24/22. NA #1 indicated that Resident #36 got up independently. Interview and review of fall investigation documentation with the ADNS on 8/31/22 at 11:07 AM identified that when Resident #36 fell on [DATE] and 5/24/22 an alarm was supposed to have been in place according to the NA care card, but the fall investigations failed to document whether an alarm was present or sounding. The ADNS indicated that, according to his fall investigation documentation dated 5/25/22 when he had gone to check on Resident #36, there was no sensor alarm in place, that the resident indicated that s/he threw the alarm away, and that Resident #36 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADNS identified that this had brought to his attention by a floor nurse and a NA during a conversation, but that he was not involved in changing the care plan interventions and assumed that the care plan change for the alarm had been addressed. The ADNS indicated that the floor nurse, unit supervisor or the NA should have changed the care plan and that the facility team was responsible for reviewing the care plan changes. The ADNS identified that Resident #36 had his/her sensor subsequently discontinued on 7/22/22 (approximately 3 months after misuse of the alarm had been identified). Although the facility was aware that the use of Resident #36's sensor alarm was ineffective when Resident #36 fell on [DATE] and again on 5/24/22, they failed to revise the care plan. Review of the Care Plan Goals and Objective policy dated 4/2011 identified, in part, that goals and objectives are reviewed and/or revised when the desired outcome has not been achieved. Attempts to interview RN #1, the RN Supervisor on 5/24/22, were unsuccessful.

Resident #66 Nutrition Based on observation, clinical record review, review of facility policy and interview for 1 of 2 residents (Resident#66) reviewed for nutrition, the facility failed to ensure a reweight was obtained timely for verification, after a significant weight loss was identified. The findings include: Resident #66's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS dated [DATE] identified Resident #66 was severely cognitively impaired and was independent with eating after set up. Resident was 60 inches tall and weighed 123 pounds (lbs). The Care Plan dated 5/7/22 identified resident had an increased risk for alteration in nutrition. Interventions directed to provide diet as ordered, document the percent consumed at each meal, weight resident weekly and document and obtain nutritional consult as needed to ensure resident is meeting nutritional needs. The physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #66 ' s weights from 3/8/22 through 7/5/22 identified stable weights ranging from 123 - 126 lbs. Further review identified that on 7/17/22 a weight of 127 lbs was obtained. Documentation identified that 2 days later, on 7/19/22, resident weighed 116 lbs showing an 11 lb weight loss in 2 days, indicating a significant weight loss. No reweight could be found to verify and confirm the loss until 6 days later, on 7/24/22, with weight documented as 116.3 lbs. Review of the Nurse ' s Notes failed to reflect documentation related to Resident #66 ' s weight loss identified on 7/19/22 or that a reweight was obtained. A Dietitian note dated 7/28/22 identified Resident #66 triggered for a significant weight loss, 5% in 30 days. Resident ' s appetite varies from refusal to 75%. Dietary will add magic cup to all meals and will continue with super products. [MEDICATION(S)] was recently added on 7/26/22 and may help improve appetite. Interview with the ADNS on 8/31/22 at 10:05AM identified that Resident #66 ' s significant weight loss was reviewed at their weekly Wounds/Weights meeting on 7/21/22 with the Dietitian in attendance. ADNS identified the plan was to check the resident ' s next weight and interventions were initiated on 7/26/22 adding [MEDICATION(S)] (an antidepressant used as an appetite stimulant). Additionally, on 7/29/22, Resource 2.0 supplement was increased from 120 mls to 240 mls twice daily. ADNS identified he was unable to find a reweight documented after the 7/19/22 weight of 116 lbs, to confirm the significant weight loss. ADNS identified the charge nurses were responsible for documenting weights into the electronic medical record (EMR) and would also be responsible for ensuring a reweight was obtained. ADNS indicated it was their practice to obtain reweights the same day or at least by the following day to confirm the accuracy of the weight. Although the ADNS identified they had recently transitioned from paper documentation to electronic, he was unable to find any paper documentation to support the reweight had been obtained timely. Interview and review of the clinical record with LPN#2 on 8/31/22 at 10:30AM identified although she was Resident #66 ' s charge nurse on 7/19/22, she did not recall resident showing a significant weight loss that day indicating she only occasionally works on that unit. LPN identified that her usual practice was to always obtain a reweight on the same day the resident shows a significant change from their previous weight. Although LPN indicated she must have had the resident reweighed on 7/19/22, she could not find documentation of a reweight, and could not recall if she had ensured the reweight was done. Interview with the Dietitian on 8/31/22 at 12:00PM identified she was aware of Resident #66 ' s significant weight loss on 7/19/22 and it was discussed at their Thursday meeting. Dietitian identified she is in the facility every Tuesday and Thursday and indicated she wanted to see the resident ' s next weight for confirmation before implementing interventions. Dietitian identified she would expect a reweight to be obtained the same day on that shift, not 6 days later. Dietitian indicated that although their policy does not specify to obtain reweights when a significant weight change is identified, their practice was to obtain a reweight whenever there is a 3 lb or more weight difference from the previous weight. The Dietitian identified all the nurses were aware of this expectation and the reweight should have been obtained timelier. Review of the facility ' s Weight Loss Protocol identified a significant weight loss is considered a 5% weight loss in 30 days, a 10% weight loss in 180 days and a 3 lb weight loss/gain in 1 week. The procedure indicated to assess for causes of weight loss/gain which included, in part, improper weight obtained.

Resident #20 Urinary Catheter or [CONDITION(S)] Based on clinical record review, observations, facility policy review, and interviews for the only sampled Resident, (Resident #20) reviewed for urinary catheter use, the facility failed to position the urinary collection bag in a clean manner. The findings include: Resident #20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #20 was severely cognitively impaired and required limited assistance of one staff with transfers and required extensive assistance with locomotion and dressing and required a urinary catheter. The Resident Care Plan (RCP) dated 6/9/22 identified an indwelling catheter and failed voiding trial on 6/2/22, retention of urine. Interventions directed to position the urinary catheter bag and tubing below the level of the bladder to gravity, secure Foley catheter to avoid dislodgement, and use a privacy bag for collection bag. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Observation on 8/25/22 at 10:12 AM identified that Resident #20 was out of bed utilizing a Foley catheter bag secured and hanging from his/her wheelchair. The urinary collection bag was resting on the floor. Observation on 8/25/22 at 11:52 AM identified that Resident #26 remained in the same position with no change to the Foley catheter bag on the floor. Interview and observation with LPN #1 identified that Resident #20's Foley catheter remained on the floor. LPN #1 identified that she was busy passing medications to residents and had no time to change Resident #20's Foley catheter bag to a leg bag. LPN #1 indicated that the Foley catheter should not be left on the floor and was improperly positioned for infection control. Subsequent to surveyor inquiry, LPN #1 changed Resident #20 to a leg catheter bag and threw away the Foley catheter bag that had been resting on the floor. Review of the facility Foley Catheter policy dated 2/1/1981 directed, in part, that the catheter meatal junction is a significant portal of entry for bacteria into the urinary tract potentially causing urinary tract infections.

Based on observations, interviews, clinical record reviews, and review of facility documentation for three of four nursing units (St. Ann A and B and St. Pat's B), the facility failed to ensure staff followed manufacturer guidelines on cleaning and disinfecting a glucometer used for multiple residents to prevent the possible transmission of blood borne pathogens resulting in the finding of Immediate Jeopardy. The findings include: 1. Observation on 9/27/18 at 4:46 PM identified LPN#1 obtained Resident #42's blood sugar using a True Metrix glucometer. LPN#1 identified the glucometer was used for obtaining blood sugars of multiple residents on the unit including four residents on the 3:00PM-11:00PM shift which were already taken. The blood sugar obtained was 134 dl/mg and no insulin was administered per physician's orders [REDACTED].#1 removed an individually packaged Sani Cloth wipe (EPA Reg No: 9480-9) out of a black bag that also contained the glucometer. LPN#1 proceeded to tear the package open, wipe the glucometer down one side, then wiped the glucometer down the other side, then exited the resident's room with the glucometer. LPN#1then proceeded back to the medication cart and placed the glucometer on top of the medication cart to dry. Interview with LPN#1 at the time identified after blood glucose checks on residents, he/she uses the individually wrapped Sani-cloth wipe to wipe down the glucometer, leaving it to air dry for two (2) minutes. LPN#1 indicated that from the time he/she wiped down the glucometer in the resident's room, returned to the medication cart, and prepared the medications for the next resident, the glucometer had air dried for at least two (2) minutes. LPN#1 identified this was her usual practice to clean and sanitize the glucometer, but was not able to explain the facility policy regarding the cleaning of glucometers following blood glucose testing. 2. Demonstration of cleansing/sanitizing a True Metrix multi-use glucometer was conducted on 9/27/18 at 5:10 PM with RN#1. RN#1 used an individually packaged Sani Cloth wipe (EPA Reg No: 9480-9) to clean and sanitize the glucometer. RN#1 was observed to tear the package open, wipe the glucometer down one side, then wiped the glucometer down the other side, then placed the glucometer on the medication cart on top of the used wipe, and allowed the glucometer to air dry for two (2) minutes. Interview with RN#1 at the time identified after blood glucose checks on residents, he/she uses the individually wrapped Sani Cloth wipes to wipe down the glucometer and then allows it to air dry for two minutes. 3. Demonstration of cleansing/sanitizing a True Metrix multi-use glucometer was conducted on 9/27/18 at 5:30 PM with LPN#2. LPN#2 opened a black bag containing the glucometer and removed an individually packaged Sani-Cloth wipe (EPA Reg No: 9480-9) and tore the package open. LPN#2 then proceeded to walk down the hallway to remove a purple-topped tub containing PDI Super Sani Cloth Wipes that was affixed to the wall. LPN#2 was observed to remove a wipe from the tub, wipe the glucometer down one side, then wiped the glucometer down the other side, then placed the glucometer on the medication cart, and allowed the glucometer to dry for two (2) minutes. Although LPN #2 utilized the proper PDI wipe to clean the glucometer, the proper technique for cleaning the glucometer as directed by the manufacturer was not utilized. Interview with LPN#2 at the time identified after blood glucose checks on residents, he/she would normally use the individually wrapped wipes which are kept in the black bag along with the glucometer. LPN#2 identified he/she was not sure if the Sani-Cloth wipes (EPA Reg No: 9480-9) were the correct wipes to use on the glucometers, so he/she retrieved the purple-topped tub that contained the Super Sani Cloth wipes (EPA Reg No: 9480-4). In addition, LPN#2 indicated that he/she believed at in the past, different individually wrapped wipes were used, with different packaging that had PDI on the front of the package. LPN#2 was not certain when and why the individually wrapped wipes were changed. Review of the facility cleaning procedure after glucometer use identified glucometers must be disinfected in between each resident. The policy further directed to after use, wipe the glucometer thoroughly with the PDI wipe, do not wipe off, allow to dry, and that typically two (2) minutes is the contact time for disinfecting. The policy failed to identify instructions to follow specific manufacturer's recommendations on the cleaning and disinfecting of the glucometers. Review of the Manufacturer's Reference Manual (Owner's Booklet) for the True Metrix glucometer identified cleaning and disinfecting can be accomplished only with the Environmental Protection Agency (EPA) registered PDI Super Sani-Cloth Wipes (EPA Reg No: 9480-4). The effect of other disinfectants used interchangeably has not been tested with the meter. Use of disinfectants other than Super Sani Cloth Wipes may damage the meter. The manufacturer's recommendation for cleaning the glucometer directs to use the recommended PDI wipe to rub the entire outside of the meter using three (3) circular motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter, then to discard the used wipe. The manufacturer's recommendation for disinfecting the glucometer further directs to use fresh wipes to ensure that all outside surfaces of the meter remain wet for two (2) minutes and to ensure no liquids enter the test port or any other opening in the meter. Interview on 9/28/18 at 8:10 AM with Person #1 who is the Customer Care Representative for the manufacturer of the True Metrix glucometer (Call Reference # 579) identified for the True Metrix glucometer, only the recommended PDI wipe should be used, which is the Super Sani-Cloth wipes (EPA Reg No: 9480-4). Person #1 indicated that only the recommended wipe should be used for cleaning and disinfecting the True Metrix glucometers, because that is the only wipe that was tested by the manufacturer on the glucometers. Furthermore, Person #1 indicated Sani-cloth wipes (EPA Reg No: 9480-9) should not be used on the True Metrix glucometers as the manufacturer will not recommend a specific wipe if it has not been tested on the glucometer. In addition, Person #1 identified the proper cleaning technique, detailed in the Manufacturer's Reference Manual, and should be followed for proper cleaning and sanitizing of the glucometer. Interview with the Administrator and the DNS on 9/27/18 at 5:30 PM identified they were not aware that the Sani Cloth Wipes which were utilized by staff to clean the blood glucose monitors were not recommended by the manufacturer.

Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents, (Resident #2 and #1) who were dependent on staff for activities of daily living, the facility failed to ensure the residents were free from mistreatment. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that Resident #2 had severe cognitive impairment, difficulty focusing attention, disorganized thinking, physical behavioral symptoms directed towards others, required two person extensive assistance from with transfers and ambulating and the resident's balance during transitions and walking was not steady and the resident was only able to stabilize with staff assistance. The resident care plan dated 10/22/14 identified the resident was forgetful, wandered at times, and at risk for falls. Interventions directed nonskid foot wear when out of bed, bed in lowest position, tab and sensor alarm to bed and chair, do not leave alone in the bathroom and wanderguard. The psychiatry progress note dated 12/9/14 identified that Resident #2 was seen for increased exit seeking, agitation, yelling and striking out at the staff and the resident was sleeping during the day, day and night are reversed. The plan was a change in the medication regimen, discourage day time naps and last resort to transfer to Geri-psych facility. The nurse's note dated 12/21/14 at 6:10PM identified an allegation of abuse. The Reportable Event Form dated 12/21/14 at 5:40PM identified that Resident #2 made several attempts to walk independently and refused to sit. NA #2 pulled the resident at the waist of the pants and belt and forced Resident #2 to sit down. In a written statement Registered Nurse (RN) #2 identified that NA #2 came over to assist to redirect Resident #2. The resident resisted, NA #2 moved the wheelchair closer to Resident #2 and proceeded to grab the resident's pants by the waist as well as the belt. NA #2 then pulled the resident's pants forcing Resident #2 to sit. The statement identified that at that point Resident #2 became very angry, yelled at RN #2 not to force him and attempted to punch her. Resident #2 then grabbed both of RN #2's arms and began to squeeze them. NA #2 helped to remove Resident #2's hands. Resident #2 stated to NA #2 If you touch me again like that I will kick you're a_ _. NA #2 made a motion gesturing towards herself and stated to Resident #2 bring it on I'm not afraid of you. NA #2 was removed from the room. Review of the social service notes from 12/21/14 through 12/24/14 identified that Resident #2 had no recall of the incident. Interview with NA #3 on 6/9/15 at 1:20PM that she observed NA #2 take the back of Resident #2's pants and pull the resident back into the wheelchair. Interview with NA #5 on 6/9/15 at 1:30PM identified she witnessed NA #2 pull the resident from the back of his/her pants to sit down. Interview with RN #2 on 6/9/15 at 1:40PM identified that Resident #2 was attempting to stand and was not following directions to sit down in the wheelchair. RN #2 stated that NA #2 came over to the resident grabbed the back of the resident's pants and forcefully pulled the resident back into the chair. RN #2 identified that the resident was agitated and she heard NA #2 state to Resident #2 bring it on I'm not scared of you. RN #2 stated that NA #2 was sent home after the incident and an investigation was started. Interview with NA #6 on 6/9/15 at 1:45PM identified that he observed NA #2 pull on the resident's back of pants. NA #6 stated that he got the resident's walker and ambulate Resident #2 out of the dining room. Interview with NA #2 on 6/9/15 at 2:10PM identified that the resident was trying to stand and she put her hand in the residents belt loop and guided the resident into the chair. NA #2 stated that she was not instructed to pull a resident by the pants to sit the resident into a chair but the resident was trying to stand. Interview with the DON on 6/11/15 at 11:00AM identified that if the resident was agitated and didn't want to sit staff should have ambulated the resident. The DON stated that no resident should be pulled by the pants and after the investigation was concluded the determination was mistreatment had occurred and NA #2 was terminated. 2. Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had severe cognitive impairment, rejected care at times and required extensive two person assistance with bed mobility, personal hygiene and dressing. The resident care plan dated 3/10/15 identified the resident was dependent on for activities of daily living related to the dementia. Interventions directed assist of two for care. The Behavioral Health Follow-Up dated 5/6/15 identified that Resident #1 was seen for increased frequency of agitation and combativeness with care in the past few weeks and a change in the medication regimen was made. The Reportable Event Form dated 5/11/15 at 8:15AM identified that an allegation of abuse towards Resident #1 on 5/5/15 (six days earlier) was reported by a Nurse Aide (NA). The investigation identified the alleged incident occurred on 5/5/15 on the 11PM-7AM shift during rounds. NA #7 witnessed NA #8 lift the resident's feet up by the toes while off-loading the heels and Resident #1 yelled out. An assessment conducted on 5/11/15 identified a large blue bruise 2 centimeters (cm) under the left fifth toe and a 1cm blue bruise under the second right toe. The facility's conclusion dated 5/13/15 substantiated that the 5/5/15 incident had occurred. Interview with NA #7 on 6/9/15 at 12:10PM identified that she did not report the 5/5/15 incident for one week. NA #7 indicated that she had witnessed NA #8 grab Resident #1's toes which had gripper socks on and lift the toes in the air, and the resident yelled out. Interview with NA #8 on 6/9/15 at 11:40AM identified that he grabbed the resident's socks and placed an arm under resident's legs to lift them. Interview with the Assistant Director of Nursing (ADON) on 6/9/15 at 11:15AM identified that she was made aware of the alleged incident on 5/11/15 when a note was left for her from NA #7. The ADON stated she immediately started an investigation which included statements and suspending NA #8. The ADON identified that after the incident was reported the resident was assessed and found to have bruises near the toes. The ADON stated that NA #8 was terminated related to alleged mistreatment and that NA #7 was provided education on reporting alleged incidents per facility policy. 2.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #2) who were reviewed for elopement and/or falls, the facility failed to provide supervision and/or assistive devices to prevent a fall with an injury. The findings include: Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2 had severe cognitive impairment, required limited one person assistance with transfers and ambulating and utilized a walker for mobility. The fall risk assessment dated [DATE] identified that Resident #2 as a high fall risk with a total score of 11 (a score of 10 or above represents a high fall risk). A physician's orders [REDACTED]. The resident care plan dated 11/27/13 identified the risk for falls. Interventions directed to assist with transfers and ambulating as needed and tab alarm while in bed and on all chairs and do not leave alone in the bathroom and/or while on the commode. The nurse's note dated 12/24/13 at 5:05 PM identified Resident #2 was observed outside on the ground bleeding from the head. Subsequent to physician notification Resident #2 was transferred to the hospital for an evaluation and admitted for observation for a head injury. The Reportable Event Form and investigative report dated 12/24/13 indicated that Resident #2 was in the chapel for Mass at 4:00 PM and the walker was placed away from the resident. At the conclusion of the Mass Resident #2 was found on the pavement in front of the facility by a visitor who called for an ambulance. Resident #2 was observed to have a laceration above the left eye with a moderate amount of bleeding and bruising. The hospital discharge summary dated 12/25/13 identified Resident #2 was admitted with a left periorbital and frontal scalp hematoma status [REDACTED]. Interview with the Director of Nurses (DON) on 2/10/14 at 12:15 PM identified that Resident #2 was a fall risk and not at risk for elopement. Resident #2 got up from the activity and without the walker, walked out with the crowd. Review of facility policy identifies that a fall is defined as any unplanned resident descent to the floor. At risk residents may receive one or any combination of interventions to reduce the risk of a fall event in addition to all standard interventions. Interview with the Pastoral Care Director on 2/10/14 at 2:00 PM identified that Resident #2's walker was placed in front and on the side with the other walkers. The Mass was very crowded and dismissal at the end was very confusing. The Pastoral Care Director indicated that there was two staff in the Chapel; each staff member takes responsibility for one side. At the end of Mass the Pastoral Care Director went and picked up Resident #2's walker but could not locate the resident. The Pastoral Care Director stated that she was not aware of Resident #2's limitations and Resident #2 rarely came to Mass. Interview with Nurse Aide (NA) #1 on 2/11/14 at 10:30 AM identified that Resident #2 was very confused and was capable of walking with a walker but was "incredibly" unsteady. NA #1 continued to say that Resident #2 required a tab alarm and would often set off the alarm when the resident would rise from the chair. NA #1 indicated that he had assisted Resident #2 down to the Mass, reported to the staff that Resident #2 was a fall risk and needed to be monitored. NA #1 was directed to seat Resident #2 in the front and the resident was seated without an alarm. Interview with the Administrator and DON on 2/11/14 at 2:00 PM identified that Resident #2 was at risk for falls and was seated in the chapel without the walker and/or an alarm. The facility had addressed the need for additional personnel available to monitor residents during events in the chapel and at dismissal in order to keep them safe.

Based on clinical record review, review of facility documentation, and interviews for one of five sampled residents (Resident #132) who required two person assistance with bathing, the facility failed to ensure that the appropriate number of staff were present. The findings include: Resident #132's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #132 had memory deficits, severe cognitive impairments, required extensive two person assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing and no recent history of falls. The resident care plan dated 4/4/12 identified a potential for decline in activities of daily living related to weakness and diagnoses. Interventions directed to ambulate assist of two with gait belt, rolling walker, and wheel chair to follow closely, assist with weekly shower, use shower chair, tab alarm to bed and chair, sensor to bed, and utilize the Sara lift if not able to transfer. Review of the Reportable Event dated 4/15/12 at 11:20 AM identified that after a shower Resident #132 was seated on the shower chair, the resident reached down to pull up his/her pants and fell forward hitting his/her face on the floor. The investigation identified that only one staff member assisted with the shower, Nurse Aide (NA) #2. The resident had sustained a head injury and was transferred to the hospital for an evaluation. The Emergency Department (ED) documentation dated 4/15/12 identified that Resident #132 had sustained a laceration to the left forehead over the eyebrow, a skin tear to the bridge of the nose and a small skin tear to the right wrist. The ED note identified that the resident had a deep left face laceration six centimeters in length and six sutures were placed for closure. A physician's orders [REDACTED]. Interview with NA #2 on 7/26/12 at 3:00 PM identified that he had completed Resident #132's shower and attempted to dress the resident by himself. Resident #132 began to lean forward and fell on to the floor with the shower chair landing on top of the resident. NA #2 indicated that Resident #132 was somewhat resistive to care prior to the shower. NA #2 stated that although the resident required two person for transfer and dressing, he, (NA #2), usually showered the resident by himself. Interview with the Director of Nurses (DON) on 7/26/12 at 10:00 AM identified that Resident #132 required sutures to the forehead laceration, sustained skin tears on the both arms and required pain medication for discomfort.