Every finding on record at Saint Vincent Healthcare

Based on observation, interview, and review, the facility failed to provide care in a manner that maintained a resident's dignity and respect for three of three sampled residents (Residents 3, 57, and 65) under dignity care area by failing to ensure facility staff were at eye level while assisting the residents during meals. This deficient practice had the potential to affect Resident 3, 57, and 65's self-esteem and self-worth.1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included protein calorie malnutrition (a nutritional disorder caused by a deficiency of both protein [nutrient essential for building and repairing tissues like muscles and organs] and calories [unit of energy, and in nutrition measures the amount of energy the body gets from food and drinks] resulting in depletion of body fat and muscle mass, fatigue and increased susceptibility to illness, muscle weakness (loss of muscle strength), dementia (loss of brain function including memory, thinking and social abilities severe enough to interfere with daily life), and major depressive disorder (mood disorder characterized by feelings of sadness and loss of interest that interfere with daily life). During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 10/28/2025, the MDS indicated Resident 3 had severely impaired cognitive (ability to think, learn, remember and reason) skills for daily decision making. The MDS indicated Resident 3 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. Resident 3 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene and upper body dressing and was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, lower body dressing, and putting on/taking off footwear. During an observation in Resident 3's room on 11/18/2025 at 12:39, Certified Nurse's Aide 1 (CNA 1) was observed talking to Resident 3 who had stopped eating her food. CNA 1 was then observed feeding Resident 3 while standing. CNA 1 was not within eye level of Resident 3. 2. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included protein calorie malnutrition, dysphagia (difficulty swallowing foods or liquids easily and comfortably), dementia with psychotic disturbance (condition where a person experiencing significant cognitive decline also has symptoms of psychosis which involves losing touch with reality), and schizoaffective disorder (a mental health condition that combines symptoms of both schizophrenia [hallucinations or delusions] and a mood disorder (such as depression or mania [mood episode characterized by abnormally elevated or irritable mood, increased energy, and activity]). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 57 required partial/moderate assistance with eating. The MDS indicated Resident 57 required substantial/maximal assistance with upper body dressing and was dependent with oral, toileting and personal hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. During an observation in Resident 57's room on 11/18/2025 at 12:33 PM, CNA 1 was observed assisting Resident 57 with eating lunch while sitting on a bar stool (tall chair designed to be used at a bar or high table). Resident 57's bed was in the lowest position. CNA 1 was not within eye level with Resident 57 while assisting the resident with eating her meal. 3. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses that included vitamin D deficiency (body has inadequate levels of vitamin D which can lead to serious health problems like brittle bones and muscle weakness), dementia with mood disturbance, and major depressive disorder. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 65 required partial/moderate assistance with eating and was dependent with oral, toileting, and personal hygiene, showering/bathing self, upper and lower body dressing, and putting on/taking off footwear. During an observation in Resident 65's room on 11/18/2025 at 12:25 PM, CNA 2 was observed assisting Resident 65 with eating lunch while sitting on a bar stool. Resident 65's bed was in the lowest position. CNA 2 was not within eye level with Resident 65 while assisting the resident with eating her meal. During a concurrent observation in Residents 57 and 65's room and interview with CNA 3 on 11/18/2025 at 12:45 PM, CNA 3 confirmed CNA 1 and CNA 2 were not within eye level of Residents 57 and 65 while assisting the residents with lunch. CNA 3 stated that CNAs 1 and 2 could raise the height of the bed to be eye level with the residents. CNA 3 stated both staff should have used a chair or stool that was not high to achieve eye level while feeding the residents. CNA 3 stated that while feeding residents or providing care, staff should be within eye level with the residents to promote dignity in accordance with the facility policy. During an interview on 11/21/2025 at 2:05 PM with the Quality Assurance Nurse (QAN), the QAN stated that staff assisting residents during mealtimes should be at eye level with the residents. The QAN stated that it was important for staff to be at eye level with the residents when feeding them to promote better communication, eye contact, and dignity. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.

Based on observation, interview, and record review, the facility failed to provide the necessary care and intervention to prevent accidents or injury for three (3) of five (5) sample residents (Resident 4 and 20) under the Accidents care area in accordance with the facility's policy and procedure when: 1. The facility did not ensure Residents 4 was not in the room while the housekeeping was mopping the floor on 11/18/2025.2. The facility did not ensure Resident 20 was not in the room while housekeeping was mopping the floor on 11/18/2025 and was reoriented and redirected back to her room while wandering (to move around different places usually without having a particular purpose or direction) on 11/20/2025 and 11/21/2025. These deficient practices placed Resident 4 and 20 at risk for accident and/ or injury. Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included lack of coordination (unsteadiness) and history of fall. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 10/1/2025, the MDS indicated Resident 4 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with toileting, shower, lower body dressing and putting on/taking off footwear and required supervision (helper provides cues) oral and personal hygiene and upper body dressing. The MDS further indicated Resident 4 required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 4's Care Plan revised on 9/2025, it indicated Resident 4 was at risk for falls related to poor safety awareness and history of fall with an approach plan of ensuring to keep environment free of hazards and maintain a safe environment at all times. 2. During a review of Resident 20's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, abnormalities in gait (the manner or pattern of how someone walks, runs, or moves on foot) and mobility, and dementia (a progressive state of decline in mental abilities). During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20 had moderate impairment in cognitive skills for daily decision making. The MDS also indicated Resident 20 required partial/moderate assistance with shower and required supervision with oral, toileting, and personal hygiene, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 20 required setup assistance with eating. During a review of Resident 20's Care Plan revised on 9/2025, it indicated Resident 20 was at risk for falls related to poor safety awareness and mobility with an approach plan of ensuring to keep Resident 20's environment free of hazards and maintain a safe environment at all times. During a review of Resident 20's Care Plan revised on 9/2025, it indicated Resident 20 was at risk for wandering and elopement (the act of leaving a facility unsupervised and without prior authorization) with an approach plan to gently redirect the resident back to supervised areas. During an observation on 11/18/2025 at 9:41 AM, Facility Housekeeping was observed mopping the floor in Resident 4 and 20's room (Room A) while both residents were in bed with a wet floor precaution sign placed by the door. During an interview on 11/19/2025 at 4:21 PM, Quality Assurance Nurse (QAN) stated residents should not be in the room while housekeeping is mopping the floor/ after mopping the floor because wet floor placed the resident in that room at risk for accidents such as slip and fall. During an interview on 11/20/2025 at 11:59 AM, the Housekeeping Supervisor (HKS), the HKS stated housekeeping should ensure residents are not in the room before mopping to prevent the resident from slipping on wet floor. HKS also stated the housekeeper should not have mopped the floor when there are residents in the room to prevent fall or accident, instead the housekeeper should have skipped and went to another empty room. During an observation on 11/20/2025 at 4:15 PM, Resident 20 was seen wandering in other residents' room (Room B) without staff following and redirecting the resident. During an observation on 11/21/2025 at 1:00 PM, Resident 20 was seen going inside the DON's office where State Agency (SA) surveyors were without any facility staff close by to redirect the resident. During a concurrent interview and record review on 11/21/2025 at 1:35 PM, Resident 20's wandering assessment was reviewed. Registered Nurse Supervisor 2 (RNS 2) stated Resident 20's was high risk for elopement RNS 2 also stated the facility staff should reorient, provide diversion, and guide Resident 20 back to the resident's room for the resident's safety. During an interview on 11/21/2025 at 1:41 PM, the DON stated the facility staff should be redirecting Resident 20 when they see residents wandering around and take the resident to activities to ensure the resident is safe and not able to access exits and other residents' rooms. During an interview on 11/21/2025 at 1:44 PM, the Director of Nursing (DON), the DON stated housekeeping must make sure that residents are not within the vicinity of the areas that they are mopping to make sure the residents would not slip and fall from the wet floor. During a review of the facility's P&P titled, Safety and Supervision, revised 7/2017, the P&P indicated that the facility strives to make the environment as free from accident hazards as possible. The P&P also indicated that the residents' safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's Policy and Procedure (P&P) titled, Wandering and Elopement, revised 3/2019, the P&P indicated that the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident.

Based on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information from unauthorized disclosure without the consent of the Resident and/or the individual's surrogate or representative) for one of 18 sampled residents (Resident 48) when Resident 48's name, room number, and post-op wound care instructions were left posted outside the residents room. This deficient practice violated Resident 48's right to privacy and confidentiality. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included unspecified atrial fibrillation (irregular heart rhythm where the upper chambers of the heart beat chaotically and out of sync with the lower chambers), unspecified glaucoma (increased eye pressure that lead to permanent vision loss and blindness) and unspecified macular degeneration (damage to the center of the eye). During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool), dated 6/3/2025, it indicated Resident 48 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 48 required supervision or touching assistance with eating, oral hygiene, and upper body dressing. It indicated Resident 48 required partial/moderate assistance with toileting hygiene, personal hygiene, lower body dressing, shower/bathe self, rolling left and right sit to stand, toilet transfer, and walking 10 feet (ft-unit of measurement for length). During a review of Resident 48's Order Summary Report, dated 11/21/2025, the Order Summary Report indicated the following physician order, with a start date of 11/17/2025: Post-operative (post-op) wound care instructions for closed wound:1. Avoid strenuous exercise or activity (bending, stooping, lifting heavy objects greater than 10 pounds) that could harm to the wound for at least three weeks until (12/8/25).2. Avoid lying or sleeping on the side where surgery was performed. During an observation outside Resident 48's room, on 11/18/2025, at 9:36 AM, one sheet of paper with Resident 48's name, room number and post-op wound care instructions was observed posted outside Resident 48's room. During an interview on 11/19/2025, at 3:13 PM, with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 48 had surgery performed on the resident's left hand on 11/17/2025. RNS 1 stated Resident 48's post-op wound care instructions were confidential and should not have been posted outside Resident 48's door. RNS 1 stated Resident 48's post-op wound care instructions should have been filed in his chart. RNS 1 stated Resident 48's wound care instructions should only be given to staff providing direct care to Resident 48. RNS 1 stated posting Resident 48's wound care instructions outside the resident's door allowed everyone in the facility to have access to the resident's private information. RNS 1 stated it was Resident 48's right to have his information kept private and the resident or family member did not request to post the confidential information outside the resident's door. RNS 1 stated the facility's policy for privacy and confidentiality was not followed. During an interview on 11/21/2025, at 4:01 PM with the Director of Nursing (DON), the DON stated residents' information should be protected and kept confidential. The DON stated the facility staff should not post resident information in a place where it can be seen by visitors or staff not directly involved with the residents' care. The DON stated the residents have the right to privacy and confidentiality. During a review of the facility's policy and procedure (P&P), titled, Dignity, revised 2/2021, the P&P indicated, Staff protect confidential clinical information. Signs indicating the Resident's clinical status or care needs are not openly posted in the Resident's room unless specifically requested by the Resident or family member.

Based on interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that every resident entering a Medicaid Certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II Evaluation to ensure that the NF residence is appropriate and to identify what specialized services the resident may need) for one (1) of two (2) sampled residents (Resident 4) under PASRR care area, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 4 and had the potential for not receiving the necessary and appropriate level of treatment and evaluation in the facility.Findings: During a review of Resident 4's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 10/1/2025, the MDS indicated Resident 4 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with toileting, shower, lower body dressing and putting on/taking off footwear and required supervision (helper provides cues) oral and personal hygiene and upper body dressing. The MDS further indicated Resident 4 required setup assistance (helper sets up; resident completes activity) with eating. During an interview on 11/20/2025 at 4:16 PM, the Director of Nursing (DON) stated there should be a new PASRR 1 upon re-admission on [DATE] due to Resident 4's new diagnosis of major depressive and anxiety disorder. The DON also stated there was no PASRR 1 completed. The DON stated the admission personnel were responsible for making sure there was a file exchange from the general acute care hospital (GACH) and that the PASRR website was checked if a PASRR was downloaded. The DON further stated completing a PASRR 1 screening was important to ensure there was appropriate screening for the resident's placement, delivery of care, and to determine if further recommendations were needed. The DON stated if there was no PASRR 1, the resident might not be appropriately placed in the facility and not receive appropriate interventions. During an interview on 11/21/2025 at 9:05 AM, Registered Nurse 2 (RNS 2) stated the licensed staff should have checked Resident 4's medical records to see if there was a PASRR done from GACH for resident's mental and developmental issues and other related issues. During a concurrent interview and record review of the PASRR policy with the DON on 11/21/2025 at 9:54 AM, the DON stated that a new PASRR 1 should be done if there was a change in the residents' mental condition such as depression and anxiety and no diagnosis of that mental condition on the residents' original admission. During a review of the facility's undated policy and procedure titled, Preadmission Screening and Resident Review Reports (PASRR), revised 11/30/2023, the policy and procedure indicated that when a resident is newly admitted to the facility after a hospital stay, the facility staff will review the hospital completed PASRR. If the facility finds significant change since hospital PASRR completed, a resident review will be completed.

Based on observation, interviews, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 4) received monitoring and care for the left eye redness as indicated on the care plan and in accordance with the facility's policy. This deficient practice had the potential to negatively affect Resident 4's physical comfort and well-being caused by delay in receiving necessary treatment. Findings: During a review of Resident 4's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included cicatricial ectropion of left eye (a condition where the lower eyelid turns outward). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 10/1/2025, the MDS indicated Resident 4 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with toileting, shower, lower body dressing and putting on/taking off footwear and required supervision (helper provides cues) oral and personal hygiene and upper body dressing. The MDS further indicated Resident 4 required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 4's Care Plan revised on 10/12/2025, the Care Plan indicated Resident 4 was at risk for eye redness/irritation and infection with an approach plan to notify Medical Doctor (MD) for signs and symptoms of eye infection which included redness. During an observation in Resident 4's room on 11/18/2025 at 9:54 AM, Resident 4 was lying in bed and observed to have redness on the left lower eyelid. During an interview on 11/20/2025 at 12:35 PM, the MDS Nurse (MDSN) stated the facility staff should monitor and notify MD for Resident 4's left eye redness to prevent the condition from getting worse. During a concurrent record review and interview with Registered Nurse 2 (RNS 2) on 11/20/2025 at 12:51 PM, the nurses progress notes were reviewed. RNS 2 stated there was no documentation of monitoring for left eye redness in the nurses' progress notes. RNS 2 stated there should be monitoring on Resident 4's left eye redness to prevent complications and to ensure that the care plan interventions were being implemented. During an interview on 11/20/2025 at 3:23 PM, Assistant Activity Staff (AAS) stated he had noticed Resident 4's left eye was red a couple of days ago, on 11/18/2025, while in the activity room and had thought the resident was already getting treatment for it so he did not notify any of the staff. During an interview on 11/20/2025 at 3:36 PM, the Activity Director (AD) stated she did not notify any of the nursing staff since she had noticed Resident 4's left eye had always been red and thought the nursing staff was aware. AD also stated she should have reported her observation to the nursing staff so Resident 4's MD will be notified. During an interview on 11/21/2025 at 8:38 AM, the Director of Nursing (DON) stated the nursing staff should follow Resident 4's care plan intervention on monitoring the resident's left eye for redness to prevent development of infection. The DON also stated the facility staff should not assume that there was already treatment given to Resident 4's left eye and should report to the nursing staff their observation. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered revised 3/2022, the P&P indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to provide the necessary services to one of one sampled resident (Resident 5) who requires dialysis (the medical necessity for ongoing removal of waste and excess fluid from the blood to sustain life due to permanent kidney failure) by failing to accurately monitor the resident's fluid intake and to follow the physician's order for fluid restriction of 1000 milliliters (ml- unit of measurement for volume) a day. This deficient practice had the potential to place Resident 5 at risk for fluid overload recurrence.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included end stage renal disease (condition where the kidneys have permanently stopped working and can no longer function at a level needed to sustain life), acute respiratory failure with hypoxia (condition were the body cannot get enough oxygen in the blood), dependence on renal (kidneys) dialysis, and pleural effusion (accumulation of excess fluid in the area between the lungs and the chest wall). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 5 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 5 required setup or clean-up assistance with eating and oral hygiene. Resident 5 required supervision or touching assistance with upper body dressing and personal hygiene. Resident 5 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, lower body dressing, and putting on/taking off footwear. During a review of Resident 5's Order Summary Report, dated 11/21/2025, the Order Summary Report indicated a physician order with a start date of 9/15/2025 for: Fluid restriction: 1000 ml per 24 hoursDietary: 360 ml (breakfast=120 ml, lunch=120 ml, dinner= 120 ml)Nursing: 400 ml (7-3= 200 ml, 3-11= 100 ml, 11-7= 100 ml) andNepro (a nutritional supplement) 1 tetra pack (240 ml) at 2 PM During a review of Resident 5's care plan, titled, Hemodialysis related to: End Stage Renal Disease, At risk for complications such as weight fluctuations, fluid loss, fluid gain, weight loss, dehydration. Resident 5's care plan interventions indicated to monitor intake and output (I&O) every shift. During an observation in the Dining Room on 11/20/2025, at 12:07 PM, Resident 5 was observed sitting in his walker in front of the table where a brown drink was being poured into red plastic cups by Restorative Nurse Assistant 1 (RNA 1). RNA 1 placed a tea bag and hot water in the red plastic cup and handed the red plastic cup to Resident 5. Resident 5 sat outside the dining room and drank his tea. Resident 5 handed the empty red plastic cup to RNA 1 who placed it on the table. Resident 5 left the Dining Room and went to his room. During a concurrent observation in Resident 5's room and interview on 11/20/2025, at 12:22 PM, with Resident 5, Resident 5 was observed sitting in his room eating a sandwich. Resident 5 had a brown paper bag and a small unopened 240 ml water bottle on top of his bedside table. Resident 5 also had 1 liter (l- unit of measurement for volume) water container next to his bed with approximately 100 ml of water inside. Resident 5 stated the sandwich and water bottle was from his sack lunch (a packed meal brought by Resident to dialysis) that he did not eat during dialysis. Resident 5 drank water from the water bottle and proceeded to pour the rest of the water into the 1liter water container. Resident 5 stated there was now 300 ml of water in his water container. Resident 5 stated he always poured the leftover water from his sack lunch into his water container because he did not like wasting water. Resident 5 stated he was only allowed to drink 1000 ml of water a day. Resident 5 stated facility staff does not ask him how much water he drinks from his water container every shift. During an observation in Resident 5's room, on 11/20/2025 at 12:26 PM, an unknown Certified Nursing Assistant (CNA) placed Resident 5's lunch tray on the resident's bedside table. Resident 5's lunch tray included a cup of water. Resident 5 drank half of the water in the cup but continued to eat his sandwich from his sack lunch. During an observation in Resident 5's room, on 11/20/2025, at 12:54 PM, an unknown CNA picked up Resident 5's lunch tray including the half cup of water and returned it in the lunch cart. Resident 5 only drank half of the water in the cup. During a concurrent interview and record review on, 11/20/2025, at 3:20 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 5's Intake and Output Record form was reviewed. LVN 3 stated the Intake and Output Record form was used by licensed nurses to document Resident 5's fluid intake from medication administration and the resident's nutritional supplement. LVN 3 stated he did not know if CNAs documented Resident 5's I&O. During an interview, on 11/20/2025, at 3:26 PM with RNA 1, RNA 1 stated she gave Resident 5 tea in the dining room before lunch. RNA 1 stated she poured the tea in a 240 ml red plastic cup but only filled the cup with water halfway. RNA 1 stated Resident 5 drank approximately 120 ml of tea. RNA 1 stated Resident 5 was on fluid restriction but RNA 1 was unsure how much Resident 5 was allowed to drink per shift. RNA 1 stated she did not document how much tea/ fluid Resident 5 consumed during her shift. During an interview, on 11/20/2025, at 3:34 PM, with LVN 4, LVN 4 stated Resident 5 was on a 1000 ml a day fluid restriction. LVN 4 stated Resident 5 was allowed to drink 240 ml from 7 AM to 3 PM (120 for breakfast and 120 for lunch) and 120 ml of water for dinner. LVN 4 stated Resident 5 was also allowed to drink a 400 ml of water a day with his medications. During an interview, on 11/20/2025, at 3:59 PM, with LVN 4 and Quality Assurance Nurse (QAN), QAN stated residents on fluid restriction were not allowed to have water pitchers at the bedside. QAN stated facility staff were unaware Resident 5 poured the leftover water from the resident's sack lunch into the resident's own water container. QAN stated Resident 5 should not have had his own water container at the bedside. QAN stated RNA 1 should have reported to the Charge Nurse (CN) that Resident 5 drank tea in the dining room. QAN stated the amount of tea Resident 5 drank in the dining room should have been documented and counted as a part of the resident's fluid intake for lunch. QAN and LVN 4 were unsure if the water Resident 5 drinks from his sack lunch was being documented by facility staff. QAN stated resident 5's fluid intake was not accurately monitored and documented. During the same concurrent interview and record review on 11/20/2025, at 3:59 PM, with QAN and LVN 4, Resident 5's Self Care Log for 11/2025 was reviewed. QAN stated CNAs documented Resident 5's daily fluid intake on the Self Care Log. LVN 4 stated, according to the Self Care Log, on 11/19/2025, Resident 5 received 360 ml of fluid from 7 AM to 3 PM and another 240 ml of fluid from 3 PM to 11 PM. QAN stated the total amount of fluid documented that Resident 5 received on 11/19/2025 from 7 AM to 11 PM was over the total amount allowed/ ordered. QAN stated Resident 5's fluid intake was not being properly monitored and documented. QAN stated it was important to follow the physician's order for the fluid restriction and to monitor and accurately document Resident 5's fluid intake due to Resident 5's history of fluid overload (a buildup of excess fluid in the body, leading to symptoms like swelling in the arms, legs or abdomen, rapid weight gain, and shortness of breath). QAN stated not following Resident 5's fluid restriction order can cause Resident 5 to accumulate fluid in his lungs and his body. During an interview, on 11/21/2025, at 4:04 PM, with the Director of Nursing (DON), the DON stated Resident 5 was on fluid restriction because the resident was on dialysis and had a history of fluid overload. The DON stated the facility staff were unable to follow instructions and should not have had left a water container at Resident 5's bedside. The DON stated Resident 5's fluid intake should have been closely monitored and documented to prevent fluid overload. The DON stated it was important to avoid fluid overload because it can affect the way the heart functions, can cause fluid to enter the lungs and can cause shortness of breath and hospitalization. The DON stated the policy for fluid restriction was not followed. The DON stated the policy for fluid restriction should include the process on documenting the residents' intake and output. During a review of the facility's policy and procedure (P&P), titled, Fluid Restriction, undated, the P&P indicated following: The facility will provide a method to ensure fluid intake is restricted as ordered by the physician while maintaining optimum hydration to the extent possible. To allow for fluid intake throughout the day in accordance with fluid restriction orders. Nursing will place the resident on intake and output monitoring to ensure parameters of fluid intake are adhered to.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of six sampled residents (Resident 47) in accordance with the facility's policy and procedure (P&P) by failing to:1. Administer ferrous sulfate (a supplement used to treat or prevent iron deficiency, a condition that can lead to tiredness) every other day as ordered. 2. Administer Vitamin C (a supplement that the body needs to form collagen for skin, blood vessels, and bones, to heal wounds, and to protect cells from damage) daily as ordered. These deficient practices had the potential for Resident 47 to experience tiredness, shortness of breath, bruise or bleed easily, and poor wound healing. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anemia (condition where the blood does not carry enough oxygen to the rest of the body), moderate protein-calorie malnutrition (a nutritional deficiency characterized by symptoms like pale, dry, and easily bruised skin, hair changes, and joint pain), and dementia (a brain disorder that results in memory loss, poor judgment, and confusion). During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 9/1/2025, it indicated Resident 47 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. It indicated Resident 47 required supervision or touching assistance with eating, oral/personal hygiene, and upper body dressing. The MDS also indicated Resident 47 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, sit to lying, rolling left and right, and walking 10 feet (ft- unit of measurement in distance). During a review of Resident 47's Order Summary Report, dated 11/21/2025, the Order Summary Report indicated a physician order for the following medications:1. Ferrous Sulfate Oral Tablet, give 325 milligrams (mg- unit of measurement) by mouth one time a day every other day for anemia, with a start date of 1/21/2025.2. Vitamin C tab (ascorbic acid), give 500 mg by mouth one time a day for supplement, with a start date of 4/3/2024. During an observation of Resident 47's medication administration (med pass) on 11/20/2025, at 9:24 AM, Licensed Vocational Nurse 2 (LVN 2) administered ferrous sulfate 325 mg 1 tablet by mouth to Resident 47. LVN 2 did not administer Vitamin C 500 mg to Resident 47. During an interview on 11/20/2025, at 4:49 PM, with LVN 2, LVN 2 stated Resident 47's ferrous sulfate was ordered to be administered every other day. LVN 2 stated Resident 47 last received ferrous sulfate was on 11/19/2025. LVN 2 stated she administered ferrous sulfate to Resident 47 on 11/20/2025. LVN 2 stated Resident 47 was not due to receive the resident's next dose of ferrous sulfate until 11/21/2025. LVN 2 stated it was important to administer ferrous sulfate as ordered to help increase the red blood cells in the resident's body. LVN 2 stated too much ferrous sulfate in the body can cause constipation (a condition where a person has infrequent bowel movements and/or finds it difficult to pass hard, dry stools) and black tarry stools (usually a sign of bleeding in the stomach or esophagus) During the same interview on 11/20/2025 at 4:49 PM, with LVN 2, LVN 2 stated Resident 47 was ordered to receive Vitamin C every day. LVN 2 stated she omitted and did not administer Resident 47's Vitamin C during med pass on 11/20/2025 as ordered. LVN 2 stated it was important for Resident 47 to get Vitamin C daily to increase and improve Resident 47's immune system. During an interview, on 11/21/2025, at 3:58 PM, with the Director of Nursing (DON), the DON stated ferrous sulfate worked concurrently with Vitamin C and should be administered as ordered by the physician. The DON stated the facility's P&P for administering medication as ordered by the physician was not followed. During a review of the facility's P&P, titled, Administering Medications, revised on 4/2019, the P&P indicated the following:1. Medications are administered in a safe and timely manner, and as prescribed. 2. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to maintain a debris-free dumpster area when trash was not properly contained, uncovered, and overflowing for two of five trash bins.This failure had the potential to result in pests (an organism that causes harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to the residents.Findings:During a concurrent observation and interview on 11/18/2025 at 8:19 AM with the Kitchen [NAME] (KC) in the outdoor garbage area, there were two dumpsters, one grey trash bin, one black trash bin, and three green trash bins. The black trash bin was not completely closed. The grey trash bin beside the black trash bin did not have a lid and was overflowing with garbage. There were folded brown boxes and trash bags filled with personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) on the ground next to the grey trash bin. KC stated trash should not be left on the ground. KC stated ants, cockroaches, and flies can enter uncovered trash. KC stated pests can get inside the facility and spread disease to residents.During a concurrent observation and interview on 11/18/2025 at 8:30 AM with the Maintenance Supervisor (MS) in the outdoor garbage area, there was trash overflowing from two trash bins. MS stated trash bins should not be overfilled. MS stated garbage containers should be kept closed when not in use to prevent pests from getting inside. MS stated residents could get sick from diseases that pests spread.During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refused Disposal, dated October 2017, the P&P indicated, outside garbage containers must have tight-fitting lids that remain closed when not in use and free of surrounding litter.

Based on interview and record review, the facility failed to ensure there was documented evidence of the hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) visits and coordination in the resident's medical record for one (1) of 1 sampled resident (Resident 10) from the Hospice care area in accordance with the facility's policy and procedure ) titled, Hospice Program. This deficient practice had the potential to result in a delay or lack of coordination in the delivery of hospice care and services to Resident 10. Findings: During a review of Resident 10's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 10/9/2025, the MDS indicated Resident 10 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 10 was dependent (helper does all the effort) with shower and required substantial/maximal assistance (helper does more than half the effort) with toileting, lower body dressing and putting on/off footwear. The MDS further indicated Resident 10 required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene and upper body dressing and required supervision (helper provides cues) with eating. During a concurrent observation in Resident 10's room and interview on 11/19/2025 at 10:57 AM, Resident 10 was lying in bed and stated he was unsure whether Health Care Assistants/Nurses' Aide (HCA) came twice a week to visit the resident. Resident 10 also stated he would not know if they visited since they did not tell Resident 10 if they were from the hospice company. During a review Resident 10's plan of care dated 10/3/2025 with Registered Nurse Supervisor 2 (RNS 2), on 11/20/2025 at 10:05 AM, the plan for care update indicated certification period (a specific length of time for which a physician must certify that a resident is terminally ill with a prognosis of six months or less to live if the illness runs its normal course) from 10/3/2025 to 11/24/2025 and the ordered amount, frequency and duration of visits on the following discipline:1.) Skilled Nurse (SN) - 2x a week for 1 week, 2x a week for 9 weeks. Start October 2025. 2.) HCA - 2 x a week for 9 weeks. Start 10/5/2025 until 11/24/253.) Medical Social Worker (MSW) - 1 x per month x 3 months. Start 10/7/25 to 11/24/25. 4.) Clergy: 1x a month for 3 months. Start 10/7/25 to 11/24/25. During the concurrent interview and record review with Registered Nurse Supervisor 2 (RNS 2) on 11/20/2025 at 10:15 AM, Resident 10's hospice binder for the month of October and November 2025 was reviewed. RNS 2 stated the hospice binder had missed visits on the following discipline: 1.) SN - Registered Nurse (RN) was missing first (1st) and fourth (4th) week of October and missing 1st two (2) weeks of November. 2.) HCA - Missed 1 visit on the 1st week, third (3rd) week, and 4th week of October. HCA also Missed 1 visit on the second (2nd) week of November and none on the 3rd week of November.3.) Clergy - none for the month of October and November. RNS 2 stated the hospice staff were not following their scheduled visits, and the hospice binder did not have notes of the visits and what was provided for the month of November from SN, HCA, and MSW. RNS 2 also stated the charge nurse (lead nurse) in the morning shift should have coordinated with hospice staff to ensure they come on their scheduled visits and that Resident 10's needs were being met. RNS 2 further stated that licensed staff should ensure hospice notes are accessible and in the hospice binder to ensure the staff were updated and proper care was rendered to Resident 10. During an interview on 11/20/2025 11:24 AM, Licensed Vocational Nurse 1(LVN 1) stated the licensed staff including supervisors should have checked Resident 10's hospice binder's sign in log and ensure the hospice staff were logging in to verify they came on their scheduled visits. During an interview on 11/21/2025 at 8:45 AM, the Director of Nursing (DON) stated the hospice staff should be signing in whenever they come and visit Resident 10 to ensure that the delivery of care was provided to the resident. The facility staff (social workers and the licensed staff) should ensure hospice staff visits were based on the frequency indicated in Resident 10's plan of care dated 10/3/2025. During a review of the facility's Policy and Procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual residents needs. The P&P also indicated that the facility staff will coordinate care provided to the resident with the hospice staff.

Based on observation, interview and record review, the facility failed to ensure two (2) of 27 rooms (rooms [ROOM NUMBERS]) accommodated no more than four (4) residents in each room. rooms [ROOM NUMBERS] have five (5) beds. This deficient practice has the potential for the residents' care and services not to be adequately accommodated, have an adverse effect on the residents' safety, and place residents at risk for lack of privacy.During the initial tour of the facility on 11/18/2025 from 9 AM to 9:15 AM, there were two rooms (13 and 14) observed with five beds in a room. The residents in rooms [ROOM NUMBERS] did not complain regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. One resident who was ambulatory and three (3) residents in room [ROOM NUMBER] who were wheelchair bound were able to move in the room without difficulty. Five (5) residents in room [ROOM NUMBER] who were wheelchair bound were able to move in the room without difficulty. Residents in room [ROOM NUMBER] and 14 were observed with ample spaces for residents to move about freely inside the rooms. Nursing staff had enough space to provide care for these residents, and there was space for the beds, side tables, dressers and resident care equipment. In room [ROOM NUMBER], four beds were occupied and one was vacant. In room [ROOM NUMBER], all five beds were occupied. A review of the facility's room waiver indicated the following:Room # of Beds Square Footage Sq Ft per Bed13 5 357.19 71.4414 5 356.25 71.25 During a review of the facility's room waiver letter, dated 11/18/2025, the facility's room waiver indicated a request for the continued waivers for rooms [ROOM NUMBERS] that have five beds in a room. It also indicated the rooms were in accordance with the special needs of the residents, and do not have an adverse effect on the residents' health and safety or impedes the ability of any resident in the rooms to attain his or her highest practicable well-being. The residents can be quickly and safely evacuated in the event of an emergency. The department would be recommending the room waiver for rooms [ROOM NUMBERS].

Based on observation, interview and record review, the facility failed to provide the minimum of 80 square feet (sq.ft. - unit of measurement) per resident bed in 25 of 27 resident rooms in the facility. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.During an observation of the residents' rooms one (1) to nine (9) and 11 to 26 on 10/18/2025 from 9 AM to 3:48 PM, 25 of 27 resident rooms did not meet the minimum 80 sq ft per resident in each room. The residents did not complain regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. All the Residents including the ones who were ambulatory and wheelchair bound were able to move in and out of the room without difficulty. During a concurrent observation in Resident 39's room (room [ROOM NUMBER]) and interview on 11/20/2025 at 1 PM, Resident 39 was observed resting in bed then walking to her closet then back to bed. Resident 39 stated she can move about the room without difficulty and that there is no furniture blocking her way. Resident 39 stated she has her own bed, table and closet inside the room and still has enough space. Resident 39 stated the nurses were able to help her without any problems.During an interview on 11/21/2025 at 2 PM with Certified Nurse Aide 3 (CNA 3), CNA 3 stated there was enough space in the residents' rooms to provide care to the residents. CNA 3 stated staff can move a recliner chair in and out of room [ROOM NUMBER] without issues. During a review of the Client Accommodations Analysis Form, Client Accommodations Analysis Form indicated the following:Room Beds Total Sq Ft Sq ft per Resident1 3 213.75 71.252 2 145.55 72.783 3 213.09 71.034 2 146.11 73.055 3 213.09 71.036 3 213.89 71.307 3 213.89 71.30 8 3 213.10 71.039 3 213.10 71.0310 2 215.33 107.6711 3 213.10 71.0312 3 218.82 72.9413 5 357.19 71.4414 5 356.25 71.2515 3 213.10 71.0316 2 138.93 69.4717 3 216.28 72.0918 3 214.69 71.5619 2 145.56 72.7820 2 143.99 71.9921 3 213.10 71.0322 3 213.10 71.0323 3 215.63 71.8824 3 214.04 71.3425 3 212.63 70.8826 3 213.89 71.2927 2 219.29 109.65 During a review of the facility's Room Waiver request, dated 11/18/2025, the Room Waiver request indicated Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26 measured less than the minimum requirement for room size. It also indicated that Resident rooms [ROOM NUMBERS] are in compliance with the minimum 80 sq ft per resident. The Request Waiver indicated a request for the continued waiver for square footage per resident. Room Beds Total Sq Ft 1 3 213.75 2 2 145.55 3 3 213.09 4 2 146.11 5 3 213.09 6 3 213.89 7 3 213.89 8 3 213.10 9 3 213.10 10 2 215.33 11 3 213.10 12 3 218.82 13 5 357.19 14 5 356.25 15 3 213.10 16 2 138.93 17 3 216.28 18 3 214.69 19 2 145.56 20 2 143.99 21 3 213.10 22 3 213.10 23 3 215.63 24 3 214.04 25 3 212.63 26 3 213.89 27 2 219.29 During this re-certification survey from 11/18/2025 to 11/21/2025, the above listed rooms had sufficient space for the residents' freedom of movement. The rooms had adequate space to provide nursing care, privacy during care, and the ability to maneuver resident care equipment in the rooms. The room size did not present any adverse effect on the residents' personal space, nursing care, and comfort. The Department would be recommending the room waiver for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Properly store frozen food items in the kitchen freezer. 2. Properly store and label dry pasta in sealed containers. 3. Ensure there were no expired foods in the kitchen. These deficient practices had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 67 residents consuming food by mouth. Findings: 1. During a concurrent observation in the facility kitchen with [NAME] 1 on [DATE] at 8:02 AM, a box of sliced bacon and a box of frozen meat were observed in the freezer. Both boxes were observed opened, with the top box flaps folded and the contained meats were not in an airtight moisture resistant wrapper. During an interview on [DATE] at 8:50 AM with Dietary Service Supervisor (DSS), DSS stated the kitchen staff do not remove frozen meats from the original box to store in a sealed bag for the freezer, instead the kitchen staff only need to close [fold] the flaps of the original box because sealed storage is not necessary for the frozen meats. During a review of the facility's Policy and Procedure (P&P) titled Procedure for Freezer Storage, dated 2023, indicated facility is to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. 2. During a concurrent observation in the kitchen's dry storage room and interview with [NAME] 1 on [DATE] at 8:10 AM, a ripped clear bag of dry twisted pasta noodles and a bag of unlabeled and undated dry egg noodles were observed. [NAME] 1 stated the bag of twisted pasta was opened and not sealed because of the rip in the bag and should have been placed in a Ziploc bag to be sealed properly. [NAME] 1 also stated the bag of egg noodles should have been labeled and dated with an open and use by date. During a review of the facility's P&P titled, Storage of Food and Supplies, Procedures for Dry Storage, dated 2023, the P&P indicated: 1. Food and supplies will be stored properly and in a safe manner. 2. Dry bulk foods should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. 3. Dry food items which have been opened such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. 4. Liquid foods such as syrup oils, vinegar, honey, corn syrup, Worcestershire sauce, and molasses which have been opened will be closed, labeled, and dated. 3. During a concurrent observation in the kitchen and interview with [NAME] 1 on [DATE] at 8:18 AM, the following expired items were observed: a. Bottle of Worchester sauce labeled with an expiration date of [DATE]. b. Container of peanut butter labeled with an expiration date of [DATE]. c. Baking Soda labeled with an expiration date of [DATE]. d. Package of Seasoning (Red shade) labeled with unreadable expiration date. Cook 1 stated the food items that have already expired should have been discarded. [NAME] 1 stated the peanut butter was only good for 30 days after it has been opened so it should have been discarded. [NAME] 1 stated he was unable to identify the expiration date of the seasoning so it should have been discarded and replaced. During an interview on [DATE] at 8:50 AM with Dietary Service Supervisor (DSS), DSS stated once any food items were opened, there should be a label with the date the item was opened and a use by date. DSS also stated the use by date indicates the date the item expires and needs to be discarded. During a review of the facility's P&P titled, Labeled and Dating Foods, dated 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P also indicated opened food items need to be used by the date that follows storage guidelines. During an interview on [DATE] at 12:21 PM with DSS, DSS stated it is important to follow the facility protocol with the storage of frozen to prevent freezer burn, which would damage the food. DSS stated it is important to store opened dry foods in a tight closed manner to prevent contamination. DSS stated it is important to label all foods because if food is mislabeled, not labeled, or expired, the food can be given to the residents, and they can experience illnesses.

Based on observation, interview and record review, the facility failed to ensure two (2) of 2 garbage container (dumpster) lids remained closed and were not overflowing with trash in accordance with the facility's policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g. rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During a concurrent observation and interview on 10/16/2024 at 8:32 AM, with Maintenance Supervisor (MS) and Maintenance Assistant (MA), in the facility's parking lot dumpster area, two dumpsters were observed with trash overflowing out of the sides and top of both dumpsters, with the dumpster lids opened due to overflowing trash. MA stated, The trash is overflowing, and the dumpster lids are not closed. Facility may need bigger trashcans. MS stated per facility policy, the dumpster lids should not be open and are to stay closed to make sure rodents, flies and insects [pests] do not go to dumpsters and possibly the facility. MS stated if pests entered the facility, that would be a danger to the everyone, including residents and staff. During a review of the facility's Policy and Procedure (P&P) titled, Exterior Maintenance: Grounds, Sidewalks, Patios, and Parking Lots, dated 1/1/2018, the P&P indicated facility is to make sure garbage and trash containers are maintained in a clean and pest free condition. Trash must be packed down, boxes folded, and container lids must stay closed when not in use.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - an infection control practice that involves wearing gloves and gowns during high-contact patient care activities to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms that are resistant to multiple classes of antibiotics and antifungals]) for 11 of 11 sampled residents on EBP (Residents 27, 3, 7, 21, 23, 42, 69, 225, 28, 1, and 24) as indicated in the facility policy, by failing to ensure: 1. Licensed Vocational Nurse 3 (LVN 3) wore indicated personal protective equipment (PPE- protective clothing or equipment designed to protect the body from injury or infection) of a gown while administering medications through Resident 27's gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications) on 10/18/2024. Facility also failed to implement signage posted and PPE cart at the resident's door per policy. 2. - 8. Facility implemented posted signage in the door or wall outside the rooms of Residents 3, 7, 21, 23, 42, 69 and 225, that indicated EBP, and specific PPE required. The facility also failed to ensure PPE is available outside Residents 3, 7, 21, 23, 42, 69 and 225 room per policy. 9. Certified Nurse Assistant 3 (CNA 3) wore a gown while providing diaper change for Resident 28 on 10/18/2024. Facility also failed to implement posted signage and have available PPE for Resident 28's room. 10. Ensure LVN 2 observed infection control measures for Resident 1 by not donning (wear) a gown before administering medications for Resident 1 who had a GT. 11. Ensure Treatment Nurse 1 (TN 1) observed infection control measures for Resident 24 by not donning a gown before providing wound care. TN 2 also failed to ensure the wound bandage scissor was disinfected with the appropriate disinfectant solution before returning it to the treatment cart after providing wound treatment to Resident 24. These deficient practices placed the residents at a higher risk for cross-contamination and increased spread of infection in the facility. Findings: 1. During a review of Resident 27's Admission Record, the Admission Record indicated Resident 27 was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs). During a review of Resident 27's Minimum Data Set (MDS- a federally mandated assessment tool), dated 8/5/2024, the MDS indicated Resident 27 was severely impaired with cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 27 was partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral and personal hygiene, and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with toileting. The MDS also indicated Resident 27 had a feeding tube (nasogastric or abdominal) while a resident in the facility. During a review of Resident 27's Initial History and Physical (H&P), dated 4/30/2024, the H&P indicated Resident 27 does not have the capacity to understand and make decisions and had an abdominal GT in place. During a concurrent observation and interview on 10/18/2024 at 10:16 AM with LVN 3, at Resident 27's bedside, LVN 3 was observed checking the GT placement, flushing the GT with water, and administering medications into the GT without a gown. LVN 3 stated she only needs to perform hand hygiene and apply gloves while caring for Resident 27's GT and medication administration. LVN 3 also stated EBP is only utilized for residents with foley catheter (a medical device that drains urine from the bladder) or GT when the resident has a current infection. During an observation and interview on 10/18/2024 AT 11:10 AM with IPN outside of Resident 27's room was observed with no EBP signage and PPE [NAME] outside the doorway. IPN stated per policy, it should be an EBP sign and PPE cart outside of Resident 27's room. 2. During a review of Resident 3's Admission Record, the Admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), dementia and urinary retention (inability to completely empty the bladder). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was severely impaired with cognitive skills for daily decision making. Resident 3 was dependent (helper does all effort needed to complete activity) for toileting, bathing, and lower body dressing. The MDS also indicated Resident 3 had an indwelling catheter (Foley catheter). 3. During a review of Resident 7's Admission Record, the Admission record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, heart failure and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 was severely impaired with cognitive skills for daily decision making. Resident 7 was dependent with oral and personal hygiene, toileting, and dressing. The MDS also indicated Resident 7 with an indwelling catheter and a feeding tube. During a review of Resident 7's H&P, dated 9/15/2024, the H&P indicated Resident 7 does not have the capacity to understand and make decisions and had an abdominal GT. 4. During a review of Resident 21's Admission Record, the Admission record indicated Resident 21 was readmitted to the facility on [DATE] with diagnoses that included gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), adult failure to thrive (AFTT - a condition that describes a gradual decline in a person's physical and mental health) and dementia. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was moderately impaired with cognitive skills for daily decision making. Resident 21 was dependent with toileting and bathing and partial/moderate assistance with oral and personal hygiene. The MDS also indicated Resident 21 had a feeding tube. During a review of Resident 21's H&P, dated 9/30/2024, the H&P indicated Resident 21 does not have the capacity to understand and make decisions and had an abdominal GT in place. 5. During a review of Resident 23's Admission Record, the Admission record indicated Resident 23 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), AFTT, and type 2 diabetes mellitus (DM2 - a chronic metabolic disease that occurs when the body doesn't produce enough insulin or cannot use it properly). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 was severely impaired with cognitive skills for daily decision making. Resident 23 was dependent with toileting and bathing. The MDS also indicated Resident 23 had a feeding tube. During a review of Resident 23's H&P, dated 8/6/2024, the H&P indicated Resident 23 does not have the capacity to understand and make decisions and had an abdominal GT. 6. During a review of Resident 42's Admission Record, the Admission record indicated Resident 42 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, DM2, and dementia. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was severely impaired with cognitive skills for daily decision making. Resident 42 was dependent with toileting, lower body dressing and bathing and substantial/maximal assistance with oral and personal hygiene. The MDS also indicated Resident 42 had a feeding tube. During a review of Resident 42's H&P, dated 6/6/2024, the H&P indicated Resident 42 does not have the capacity to understand and make decisions. 7. During a review of Resident 69's Admission Record, the Admission record indicated Resident 69 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in any part of the urinary system), obstructive uropathy (occurs when urine cannot drain or flows backwards through a ureter [a tube that carries urine from the kidneys to the bladder]) and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin to carry oxygen all through the body). During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 was severely impaired with cognitive skills for daily decision making. Resident 69 required substantial/maximal assistance with eating and oral hygiene and dependent with toileting, bathing, and lower body dressing. The MDS also indicated Resident 69 with an indwelling catheter. During a review of Resident 69's H&P, dated 9/25/2024, the H&P indicated Resident 69 had a fluctuating (changing) capacity to understand and make decisions. 8. During a review of Resident 225's Admission Record, the Admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included muscle wasting (deterioration of muscle tissue), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and atrophy (deterioration of a part of the body). During a review of Resident 225's MDS, dated [DATE], the MDS indicated Resident 225 was moderately impaired with cognitive skills for daily decision making. Resident 225 required substantial/maximal assistance with eating, oral and personal hygiene and dependent with toileting. The MDS also indicated Resident 225 had an indwelling catheter. During a review of Resident 225's H&P, dated 10/12/2024, the H&P indicated Resident 225 has the capacity to understand and make decisions. During an observation on 10/16/2024 at 8:30 AM, there were no facility rooms observed to have EBP signage on the door or walls. There were also no PPE carts outside the rooms. During an interview on 10/16/2024 at 8:59 AM with IPN, IPN stated there were no rooms with EBP in the facility. IPN stated EBP was not implemented because the EBP only needed to be implemented with residents who have wounds, GTs, and indwelling catheters in addition to an MDRO. During an interview on 10/18/2024 at 10:56 AM with IPN, IPN stated per the facility policy, EBP should have been implemented and followed throughout the facility for residents with wounds, indwelling catheters and/or feeding tubes regardless of their MDRO status or history to prevent the spread of infections within the facility to everyone [residents, staff, and visitors]. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated: a. EBPs are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. b. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. c. Gloves and gown are applied prior to performing the high contact care activity. d. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (urinary catheter, feeding tube, etc.) and wound care. e. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. f. Signs are posted in the door or wall outside the resident's room indicating the type of precautions and PPE required. g. PPE is available outside of the resident rooms. 45099 9. During a review of Resident 28's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 28's History and Physical (H&P), dated 8/28/2024, the H&P indicated Resident 28 does not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 28 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 28 was dependent (helper does all the effort) with oral, personal and toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. During an observation on 10/18/2024 at 8:49 AM, Resident 28 was receiving gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding of Glucerna (tube feeding formula) at 55 cubic centimeters (cc - units of volume on liquids) per hour. During a concurrent observation and interview with Certified Nursing Assistant 3 (CNA 3) on 10/18/2024 at 9:11 AM, there was no isolation cart for Personal Protective Equipment (PPE - Personal Protective Equipment (PPE - is a specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) and no signage to indicate Enhanced Barrier Precaution (EBP - an infection control intervention designed to reduce transmission of resistant organism by using PPE's during high contact resident care activities) was needed outside Resident 28's room. CNA 3 stated she cleaned and changed Resident 28's diaper using gloves and did not wore any gowns. During an interview on 10/18/2024 at 9:14 AM, Licensed Vocational Nurse 1 (LVN 1) stated he only wears a mask and gloves when giving medications via GT to Resident 28. LVN 1 also stated he believed an isolation gown was not required when providing care to Resident 28. During an interview on 10/18/2024 at 10:16 AM, CNA 3 stated she should have worn an isolation gown when providing care to Resident 28 to protect the resident from getting infections from the staff and prevent the resident prevent the resident from getting sick. During an interview on 10/18/2024 at 10:22 AM, LVN 1 stated the staff should use EBP for residents that had open wounds, indwelling catheter (a flexible tube that passes through the urethra [a tube through which the urine leaves the body] and into the bladder to drain urine) and GT to prevent transmission of any infections to the resident. LVN 1 also stated EBP should be used to prevent facility acquired infections that could be transmitted from one resident to another. During an interview on 10/18/2024 at 10:39 AM, the Director of Nursing (DON) stated the staff should use PPE when providing care to residents with open wounds, GT, and indwelling catheters to prevent transmission of infections to other residents. The DON also stated the facility should have a small cart for PPEs and signage posted outside the rooms for all residents that required EBP's. During an interview on 10/18/2024 at 10:47 AM, the Infection Prevention Nurse (IPN) stated the facility only uses EBP for residents with indwelling catheters, GT, and those with wounds that had multidrug - resistant organism (MDRO, bacteria that resist treatment with more than one antibiotic) to prevent the spread of infection. 46919 10. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included bladder-neck obstruction (a condition that occurs when the bladder neck doesn't open properly, which can slow or stop urine flow), encounter for attention to gastrostomy, and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was assessed having severely impaired cognitive skills for daily decision making. Resident 1 was dependent with oral/toileting hygiene, upper/lower body dressing, sit to lying, and toilet transfer. Resident 1 had a feeding tube. During a review of Resident 1's Physician Order, dated 8/22/2024, Resident 1 had an enteral (Gtube) feed order to check tube placement every shift. During an observation of Resident 1's medication administration on 10/17/2024, at 8:26 AM, LVN 2 disconnected Resident 1's Gtube feeding and administered Resident 1's medications thru the Gtube. LVN 2 did not wear a gown prior to Resident 1's medication administration. 11. During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 24's H&P, dated, 9/25/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 required substantial/maximal assistance with oral/personal hygiene, upper/lower body dressing, putting on/taking off footwear, and sit to lying. Resident 24 was dependent with toileting hygiene, shower/bathe self, and sit to stand. Resident 24 had one or more unhealed pressure ulcers/injuries. During a review of Resident 24's Order Summary Report, dated 10/18/2024, the Order Summary report indicated a physician order, with a start date of 10/1/2024, for treatment on right heel stage 3 pressure injury (full-thickness loss of skin, dead and black tissue may be visible), cleanse with normal saline (NS-a saltwater solution), pat dry, apply collagen powder (a powder used to absorb wound drainage), cover with dry dressing, wrap with Kerlix roll every day shift for 30 days. During an observation of Resident 24's wound treatment on 10/18/2024, at 9AM, TN 1 cut Resident 24's old wound dressing with bandage scissors and provided wound care to Resident 24. TN 2 was observed not wearing a gown while providing wound treatment. TN 1 did not clean the bandage scissor with sanitizing wipes before placing it back in the treatment cart. During an interview with TN 1 on 10/18/2024, at 9:09 AM, TN 1 stated she only needed to wash her hands and wear gloves before providing wound treatment to Resident 24. TN 1 stated a gown was only worn for wound treatment if a resident was in isolation (process of separating sick residents with contagious disease from residents who are not sick). TN 1 stated she washed the bandage scissors with soap and water before placing it back in the treatment cart. TN 1 stated she did not follow the facility's policy to clean and disinfect the bandage scissor with a disinfectant wipe before placing it back in the treatment cart. During an interview with the Infection Preventionist Nurse (IPN), on 10/18/2024, at 11:54 AM, the IPN stated drainage from wounds can get on bandage scissors during wound dressing change. The IPN stated bandage scissors should be cleaned and disinfected with disinfectant wipe and not soap and water. The IPN stated disinfectant wipes have the proper chemicals to kill and remove microorganisms that cause infection. The IPN stated infection can get transferred from one resident to another if a bandage scissor was not cleaned and disinfected properly before placing it back in the treatment cart. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised on 9/2022, the P&P indicated the following: 1. Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 2. Non-critical items are those that come in contact with intact skin but not mucous membranes. 3. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal). a. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with an HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment. b. Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used. 4. Intermediate and low-level disinfectants for non-critical items include: a. Ethyl or isopropyl alcohol; b. Sodium hypochlorite (5.25-6.15% diluted 1:500 or per manufacturer's instructions); c. Phenolic germicidal detergents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only).

Based on observation, interview, and record review, the facility failed to ensure the foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside of the body) was covered with a dignity bag (a bag that covers and holds a foley catheter drainage bag to keep it out of sight) for one of 18 residents (Resident 225). This deficient practice had the potential to result in Resident 225 having decreased feelings of self-worth and/or self-esteem. Findings: During a review of Resident 225's Admission Record, the Admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), muscle wasting (deterioration of muscle tissue) and atrophy (deterioration of a part of the body) and polyneuropathy (damage to multiple nerves outside of the brain and central nervous system). During a review of Resident 225's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/15/2024, the MDS indicated Resident 225 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. Resident 225 required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating, oral and personal hygiene, and dependent (helper does all effort needed to complete activity) with toileting. During a review of Resident 225's Initial History & Physical (H&P), dated 10/12/2024, the H&P indicated Resident 225 has the capacity to understand and make decisions. During a review of Resident 225's Order Summary Report, dated 10/17/2024, the Order Summary Report indicated foley catheter 18 French (F- a measurement of the foley catheter's diameter) for benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty). During on observation on 10/15/2024 at 10:12 AM at Resident 225's bedside, Resident 225's urinary catheter bag was observed uncovered without a dignity bag. During an interview on 10/17/2024 at 9:07 AM with Treatment Nurse 1 (TN1), TN1 stated facility policy is to have a dignity bag on every foley catheter bag. During an interview on 10/17/2024 at 10:11 AM with Director of Nursing (DON), the DON stated the dignity bags are to be used according to the facility policy and are important because they keep the dignity and privacy for Resident 225. The DON stated the dignity bags are a way to maintain Resident 225's self-esteem in a positive way and not having it could cause his self esteem to be low if he or other residents were to see the urinary catheter bag without a dignity bag to cover. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated each resident will be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem, residents are always treated with dignity and respect. The P&P also stated demeaning practices and standards of care that compromise dignity are prohibited and staff are expected to promote dignity and assist residents with keeping the urinary catheter bag covered.

Based on observation, interview, and record review, the facility failed to accommodate the needs of one (1) of three (3) sampled residents (Resident 63) by failing to provide a pad call light (a device for residents who have difficulty using a call light cord). This failure had the potential for Resident 63's needs to not be met, resulting in a lowered quality of care and quality of life. Findings: During a review of Resident 63's Admission Record, the Admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), pain in right shoulder, weakness (lack of strength), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 63's Minimum Data Set (MDS- a federally mandated assessment tool), dated 9/2/2024, the MDS indicated Resident with clear speech, usually having the ability to express her ideas and wants when prompted or given time and moderately impaired cognitive skills (ability to understand and make decisions) with daily decision making. The MDS indicated Resident 63 had a functional limitation in range of motion (ROM- the distance and direction a joint or muscle can move) that interfered with daily functions to both left and right upper extremities (shoulder, elbow, wrist, hand). The MDS also indicated Resident 63 dependent (helper does all the effort needed to complete the activity) with toileting, bathing, upper and lower body dressing, personal hygiene and rolling left and right and substantial/maximal assistance (helper does more than half the effort needed to complete the activity by lifting, holding, or supporting the trunk or limbs) with eating (the ability to use the utensils to bring food/liquids to the mouth and swallow) and oral hygiene (the ability to use items to clean teeth). During a review of Resident 63's Initial History & Physical (H&P), dated 4/21/2024, the H&P indicated Resident 63 has deformity (condition when a part of the body is not developed in the normal way or with the normal shape) to the extremities. During a concurrent observation in Resident 63's room and interview on 10/15/2024 at 8:45 AM with Resident 63, Resident 63 was observed with a call cord (a string that allows residents in healthcare settings to remotely call for help from a nurse or other medical staff) attached to a silver clip, clipped to the bedsheet on the left side of Resident 63's head. Resident 63 stated she was not aware of a cord she could use to call for assistance and stated she normally will wait for staff to come into her room to ask for assistance. During a concurrent observation in Resident 63's room and interview on 10/15/2024 at 8:55 AM with Resident 63, Resident 63 was informed of the cord on the left side of her head and attempted to reach and pull the call cord but was unable to see and reach it. Resident 63 stated she cannot see the clip and is unable to reach it. Resident 63 stated, I'd love to be able to have a button to push for when I need help just to make sure I get to the bathroom and back safely. During an interview on 10/15/204 9:08 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 63 has restricted movement in her arms and Resident 63 does not use the call cord for assistance but will verbally call for assistance. CNA 1 stated Resident 63 should have a call button for the contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of her hands, not her current call cord. During an interview on 10/17/2024 at 3:52 PM with CNA 2, CNA 2 stated Resident 63 has limited mobility in both her hands, and when Resident 63 needs assistance from staff she will yell or let staff know during rounding. CNA 2 also stated he has not seen Resident 63 use her call cord due to the limitation of her hand movement and the pulling, I believe there is not enough energy in her hands to pull it. During an interview on 10/18/2024 at 9:16 AM with Registered Nurse 3 (RN3), RN 3 stated Resident 63 has limitation with her upper extremities due to her left and right-hand contractures in her fingers. RN 3 stated Resident 63 cannot use the call cord [due to her hand contractures] so staff round every two hours to check if any assistance was needed. RN 3 stated if resident needs assistance between the rounds or has an emergency, she will yell for assistance. During a concurrent observation in Resident 63's room and interview on 10/18/2024 at 9:22 AM with RN 3, Resident 63 was observed trying to pull the call cord to see if accessible with Resident 63's contractures. Resident 63 was observed unable to grasp the call cord in her hand. Resident 63 stated I guess I can't get to it. RN 3 stated Resident 63 was unable to use her call cord. RN 3 stated if Resident 63 needed help at this time It would be impossible to call for help using her string [call cord]. RN 3 stated Resident 63 has not been evaluated for a different type of call light device like the pad call light (a device for residents who have difficulty using a call light cord) and could benefit from the padded call light. RN 3 also stated it was important for Resident 63 to have a call light that accommodates her limitations to ensure her needs were met including during emergencies. RN 3 stated if Resident 63 does not have an accessible call light, she may fall and/or be neglected. During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P also indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. During a review of the undated P&P titled,Call Lights, indicated the purpose is to assure that residents receive prompt service.

Based on interview and record review, the facility failed to ensure the care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) interventions for one (1) of 18 residents (Resident 3), were applicable and resident-centered. This failure had the potential for Resident 3 to receive inappropriate and/or inadequate services which could harm the resident. Findings: During a review of Resident 3's Admission Record, the Admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), retention of urine (inability to completely empty the bladder), dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and gross hematuria (a condition where blood is visibly present in the urine). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated assessment tool), dated 7/19/2024, the MDS indicated Resident 3 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 3 was dependent (helper does all effort needed to complete activity) with toileting, bathing, and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral and personal hygiene. During a concurrent interview and review on 10/17/2024 at 8:38 AM with Registered Nurse 1 (RN1), Resident 3's Indwelling Foley Catheter, care plan, dated 9/13/2024 was reviewed. The care plan indicated to provide adequate fluid via percutaneous endoscopic gastrostomy tube (PEG- a feeding tube that is surgically inserted through the abdominal wall and into the stomach to allow access for food, fluids, and medications) as ordered. RN 1 stated this intervention was not appropriate because Resident 3 does not have a PEG tube and eats foods and liquids by mouth only. RN 1 stated this intervention should have not been included in the care plan. During a concurrent interview and review on 10/17/2024 at 9:43 AM with RN 1, Resident 3's Hematuria on Foley Catheter, care plan, dated 9/1/2024 and Order Summary Report, dated 10/17/2024, were reviewed. The care plan indicated cranberry as ordered for urinary tract infection (UTI) prophylaxis. Registered Nurse 1 (RN 1) stated the summary report failed to indicate any order for cranberry. RN 1 stated Resident 3 has never had an order for cranberry and the intervention was not implemented. RN 1 stated a resident's care plan needs to be applicable to the resident's current needs. RN 1 stated it was important to make sure the care plan was applicable to the resident to ensure the interventions will be effective or beneficial to the resident. A review of the facility's Policy and Procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated: 1. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. Care plan interventions are chosen only after data gathering. proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, interview, and record review, the licensed nursing staff failed to meet professional standards of quality for assessing one (1) of five sampled residents (Resident 72) by failing to ensure Resident 72 was assessed and evaluated by Medical Doctor (MD) before adding a new diagnosis of schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others ) according to accepted standards of clinical practice. This deficient practice had the potential to result in provision of unnecessary care for Resident 72. Findings: During a review of Resident 72's Admission Record, the Admission record indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). During a review of Resident 72's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 72 did not have the capacity to understand and make decisions. During a review of Resident 72's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/24/2023, the MDS indicated Resident 72 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 72 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, and toilet transfer. Resident 72 required supervision or touching assistance with eating. Resident 72 did not have a diagnosis of schizophrenia. During a review of Resident 72's Order Summary Report, dated 2/29/2024, the Order Summary Report indicated a physician order, with a start date of 10/23/2023 for Seroquel Oral Tablet give 25 milligrams (mg- unit of measurement) by mouth (po) two times a day (bid) for dementia with behavioral disturbances manifested by (m/b) being aggressive towards other people which impedes own self health and performing activities of daily living (ADLs). During a review of Resident 72's Physician Order, dated 3/7/2024, the Physician's Order indicated an order to continue Seroquel oral tab (Quetiapine Fumarate) give 25 mg by mouth every (q) twelve hours for schizophrenia m/b being aggressive towards other people which impedes own self health and performing ADLs. During a review of Resident 72's Psychiatric Follow Up Note, signed by the Certified Nurse Practitioner 1 (CNP 1), dated, 3/7/2024, the Psychiatric Follow Up Note indicated that Resident 72's case was reviewed and discussed with Interdisciplinary Team (IDT- a group of healthcare professionals who work together to help residents receive the care they need). Resident 72 was presently stable without any new symptoms and no need for any medication adjustment at this time. Resident 72's Mental Status Examination on the Psychiatric Follow Up Note did not indicate any paranoid interactions, delusions (an unshakable belief in something untrue), or hallucinations (an experience in which you see, hear, feel, or smell something that does not exist). The Psychiatric Follow Up Note assessment indicated Resident 72's psychiatric condition was generally unchanged and Resident 72's weaknesses were impaired insight and judgment, inability to function in less structured setting, and significantly impaired coping skills. The Psychiatric Follow Up Note indicated Resident 72's diagnosis was Major Depressive Disorder (MDD, mental condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable. During an observation of Resident 72 on 10/15/2024, at 9:08 AM, Resident 72 was sitting in bed eating breakfast. Resident 72 was quiet and folded tissues while chewing her food. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 10/17/2024, at 12 PM, Resident 72's Admission Record and H&P were reviewed. RN 2 stated the Admission Record and H&P did not indicate Resident had a diagnosis of schizophrenia. RN 2 stated CNP 1 added the schizophrenia diagnosis on 3/7/2024. RN 2 stated she did not know why CNP 1 diagnosed Resident 72 with schizophrenia. During an interview with CNP 1 on 10/17/2024, at 3:18 PM, the CNP 1 stated Resident 72 was diagnosed with Alzheimer's Disease on admission. The CNP 1 stated he diagnosed Resident 72 with schizophrenia on 3/7/2024 because Resident 72 had delusions and disorganized thoughts based on his evaluation and reports from the facility staff. The CNP 1 stated the delusions could be from Alzheimer's Disease but Resident 72 was misdiagnosed . The CNP 1 stated he did not document Resident 72's delusions on the Psychiatric Follow Up Note but he will write a late entry psychiatry note on 10/17/2024. During an observation of Resident 72 on 10/17/2024, Resident 72 was observed sitting on her wheelchair in the Activity Room. Resident 72 did not have any outbursts or demonstrated aggressive behavior towards other residents in the Activity Room. During an interview with the Director of Nursing (DON), on 10/18/2024, at 4:55 PM, the DON stated there was no documentation that CNP 1 spoke to Resident 72's family to confirm her mental history or schizophrenia diagnosis. The DON stated schizophrenia develops at a younger age. The DON stated there was no indication from Resident 72's admission records and H&P that Resident 72 was diagnosed with schizophrenia. The DON stated Resident 72's family never mentioned to facility staff that Resident 72 had schizophrenia. The DON stated CNP 1 should have assessed Resident 72 according to standard practice. During a review of the American Psychiatric Association's website, reviewed on 3/2024, titled, What is Schizophrenia, the website indicated the following: Schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions (when a person has strong beliefs that are not true and may seem irrational to others), hallucinations (when a person sees, hears, smells, tastes or feels things that are not actually there), disorganized speech, trouble with thinking and lack of motivation. When the disease is active, it can be characterized by episodes in which the person is unable to distinguish between real and unreal experiences. As with any illness, duration and frequency of symptoms can vary; however, in persons with schizophrenia, the incidence of severe psychotic symptoms often decreases as the person becomes older. Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made. Men often experience initial symptoms in their late teens or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More subtle signs may be present earlier, including troubled relationships, poor school performance and reduced motivation. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms may mimic schizophrenia. https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

Based on observation, interview, and record review, the facility failed to ensure one (1) of 18 sampled residents (Resident 2) with limitations in mobility was provided assistance while eating as indicated in the care plan and facility policy. This deficient practice had the potential for decline and not to maximize Resident 2's functional ability to perform activities of daily living (ADL), which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 2's nutritional needs which could lead to malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization . Findings: During a review of Resident 2's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included reduced mobility and Parkinson's disease (a progressive disease of the nervous system marked by rhythmic movement in one or more parts of the body, inability of the muscles to relax normally, and slow, non-precise movement affecting middle aged and elderly people). During a review of Resident 2's Care Plan initiated on 9/26/2024, the Care Plan indicated a problem with Resident 2's right hand contracture and an approach plan to assist Resident 2 in attending to activities of daily living (ADL, basic tasks that people need to do to live independently). During a review of Resident 2's History and Physical (H&P), dated 9/27/2024, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Occupational Therapy Daily notes with a service date of 10/3/2024, the Occupational Therapy Daily notes indicated Resident 2 preferred assistance when presented with plate guard (a dining aid that fits around the rim of a plate to help prevent food from falling off and to make it easier to eat with one hand) option to maximize independence in self-feeding. During a review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/4/2024, the MDS indicated Resident 2 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 2 required substantial assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene and required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. The MDS also indicated Resident 2 had a functional limitation in range of motion (ROM- how far one can move or stretch a part of the body, such as a joint or a muscle) that interfered with daily functions that involved impairment on 1 side of Resident 2's upper extremity (shoulder, elbow, wrist, and hand). During a dining observation on 10/15/2024 at 12:26 PM, Resident 2 was observed with contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) left hand and was only able to use his right hand while trying to get food from his plate onto the spoon. Resident 2 was also observed spilling some of the food from his plate to his clothes and onto the floor. There were no staff providing assistance to Resident 2. During another dining observation on 10/17/2024 at 12:20 PM, Resident 2 was observed eating at the dining room area using his right hand to spoon food from his plate. A plate guard recommended by occupational therapy (OT) was not observed being used by Resident 2. Resident 2 was observed with food particles on the front of the residents' clothes. There were no staff providing assistance to Resident 2 while eating. During an interview on 10/17/2024 at 4:09 PM, Registered Nurse 3 (RN 3) stated if Resident 2 refused the plate guard, the staff should have assisted the resident with eating to ensure Resident 2's nutritional needs were met. During an interview on 10/18/2024 at 9:15 AM, Resident 2 stated he prefers to be assisted by staff as opposed to using the plate guard when eating. Resident 2 stated it made him upset when food gets all over his clothes and floor when eating and stated, I could do better than that. Resident 2 further stated that he does need help with eating. During an interview with the Director of Nursing (DON) on 10/18/2024 at 9:22 AM, the DON stated Resident 2 does tend to spill food and stated staff should be assisting the resident since Resident 2 only had 1 hand to use and to accommodate his needs and adequate food intake provided. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living, revised March 2018, indicated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy also indicated that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining. During a review of the facility's P&P titled, Accommodation of Needs, revised March 2021, indicated that the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The policy also indicated that the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

Based on interview and record review the facility failed to provide the necessary treatment and services for one of one sampled residents (Resident 24) by failing to ensure Resident 24 received treatment for right heel (ankle) stage 3 (full-thickness loss of skin, dead and black tissue may be visible) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from 10/1/2024 to 10/7/2024 as indicated in Resident 24's wound treatment plan. This deficiency had the potential for Resident 24's right heel stage 3 pressure injury to worsen and had the potential to develop an infection. Findings: During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 24's History and Physical Examination (H&P), dated, 9/25/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/4/2024, the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 required substantial/maximal assistance (helper does more than half the effort) with oral/personal hygiene, upper/lower body dressing, putting on/taking off footwear, and sit to lying. Resident 24 was dependent with toileting hygiene, shower/bathe self, and sit to stand. Resident 24 had one or more unhealed pressure ulcers/injuries. During a review of Resident 24's Order Summary Report, dated 10/18/2024, the Order Summary report indicated an order with a start date of 10/1/2024, for the resident's treatment on right heel stage 3 pressure injury (full-thickness loss of skin, dead and black tissue may be visible), cleanse with normal saline (NS-a saltwater solution), pat dry, apply collagen powder (a powder used to absorb wound drainage), cover with dry dressing (a wound dressing that absorbs but does not retain moisture), wrap with Kerlix roll (a bandage made of 100% woven gauze that's used to protect wound areas) every day shift for 30 days. During a concurrent interview and record review on 10/18/2024, at 9:30 AM, with Registered Nurse 2 (RN 2), Resident 24's Wound Care Physician (WCP) Progress Note, dated 10/1/2024 was reviewed. RN 2 stated WCP comes to the facility to assess and treat Resident 24's right heel pressure injury every Tuesday. RN 2 stated Resident 24's treatment plan from the WCP Progress Note, dated 10/1/2024, indicated to cleanse with wound cleanser, pat dry with gauze pad, apply collagen to the size of the wound bed, cover with calcium alginate (a highly absorbent wound dressing that is a combination of alginic acid and calcium ions, ideal for wounds with moderate to heavy drainage) and bordered gauze dressing, wrap with rolled gauze and secure with tape. RN 2 also stated, the WCP progress note indicated dressing change frequency: every 3 days and as needed (PRN) for loss of integrity/soiling. RN 2 stated the treatment plan did not match what was in the physician's order dated 10/1/2024. During a concurrent interview and record review on 10/18/2024 at 9:56 AM, with Treatment Nurse 1 (TN 1), Resident 24's WCP Preliminary Wound Report, dated 10/2/2024 was reviewed. TN 1 stated she followed the Preliminary Wound Report which indicated under post debridement (removal of damaged tissue or foreign objects from a wound)/procedure to irrigate/cleanse with NS, pat dry, apply collagen, cover/wrap with border gauze daily. TN 1 stated she did not read or follow the treatment plan on the WCP Progress Note after it was sent to the facility. TN 1 stated it was important to follow the treatment plan on the WCP Progress Note to prevent infection and prevent the wound from getting worse. TN 1 stated she did not follow the treatment plan from 10/1/2024 to 10/7/2024. During an interview with the Director of Nursing (DON), on 10/18/2024 at 4:47 PM, the DON stated TN 1 should have confirmed that the treatment plan on the WCP was correct before filing and implementing. The DON stated Resident 24's WCP treatment plan should have been followed to provide proper wound treatment and promote wound healing. During a review of the facility's policy and procedure (P&P), titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised on 4/2018, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents.

Based on observations, interviews and record reviews, the facility failed to provide treatment and services for a recurrent pressure ulcer (area of damaged skin caused by staying in one position for too long) for a resident who had a history of [REDACTED]. As a result Resident 5 was not provided with treatment to promote healing of the pressure ulcer (open wound) for 4 days, that can lead to worsening and/or non healing of the pressure ulcer and other complications, such as infection. Findings: A review of Resident 5's admission face sheet revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident 5's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated March 21, 2013, indicated the resident was able to understand and be understood, required extensive assistance to reposition self in bed, extensive assistance for staff for transfer, was always incontinent, and had one stage II pressure ulcer. A review of the pressure ulcer care plan last reevaluated on March 21, 2013, indicated to conduct weekly skin checks. However, the care plan did not include the treatments to provide for an actual pressure ulcer. A review of the resident's last documented wound care progress note dated April 25, 2013, indicated the wound care primary care provider described the pressure ulcer as being healed. The plan was to re-evaluate the resident on the next visit. On May 31, 2013 at 8:07 a.m., a body check was conducted on Resident 5 by the treatment nurse in the presence of the certified nursing assistant (CNA) and the surveyor. The body check revealed that the resident's stage II pressure ulcer had reopened. The open wound had not been assessed or identified by the licensed nurse during the weekly skin assessments. The pressure ulcer of the mid upper back was described by the treatment nurse as a superficial wound (a stage II pressure ulcer) with the wound bed that measured 0.5 centimeter (cm) in length by 0.5 cm in width. A review of the certified nursing assistants (CNA) daily body check report dated May 22, 2013 and May 24, 2013 for the 11 p.m. -7 a.m. shift, indicated the residents had redness to the mid upper back, (a stage I pressure ulcer is an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body ). On May 28, 2013, for the 3 p.m.-11 p.m. shift, the report indicated the resident had an abrasion (a stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. ) to the mid upper back. On May 30, 2013 for the 3 p.m. - 11 p.m., shift, the report indicated a skin abrasion to the mid upper back. On May 30, 2013 for the 11 p.m. -7 a.m. shift, the report indicated a skin abrasion to the mid upper back. Although the resident had an open wound on her upper back from May 28, 2013, through May 31, 2013, that was identified by the CNAs, the open skin abrasion was not reported to the licensed nurses. During a review of Resident 5's clinical record with the treatment nurse on May 31, 2013 at 8:29 a.m., she stated that she was unable to find an a recent skin assessment that documented the open wound by the licensed nurses, or a note that it was reported by the CNAs nor that the physician was notified of the open wound. In addition, she stated that no treatment had been given to the resident for the open wound to the mid upper back, since it was identified by the CNA on May 28, 2013. The resident had the open wound to the mid upper back for four days however, no treatment was obtained or provided. During an interview with the CNA on May 31, 2013 at 3:30 p.m., he stated that he did not report the resident had the open wound to the mid upper back to the licensed nurse because he thought it was already reported, since it was documented on the prior daily body check report. The undated facility's policy and procedure titled "Weekly Body Checks," indicated that CNAs shall report any reddened areas, skin rashes, bruises, or changes to the charge nurse.

Based on observation, interview and record review, the facility failed to ensure that three residents (Residents 2, 6 and 15) of 15 sample residents, received adequate supervision to prevent accidents. Resident 15, who did not have the capacity to understand and make his own decisions, was not supervised and eloped from the facility. Resident 2 was unsupervised in his room and fell out of his wheelchair, while wearing a lap belt (a safety belt), that can lead to chest compression and suffocation. Resident 6 while he was in his room unsupervised, fell when he transferred himself (unassisted) from his wheelchair to the bed, this had a potential to result in injury. Findings: a. On May 30, 2013, at 8:45 a.m., a review of Resident 15's medical record indicated the resident was admitted to the facility, on March 11, 2013, with [DIAGNOSES REDACTED]. On March 12, 2013, the primary physician completed a history and physical, and determined that the resident did not have the capacity to understand and make his own decisions. The community discharge potential care plan dated March 14, 2013, indicated that the resident will remain in the facility and requires 24-hour care. According to the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated March 18, 2013, the resident had poor recall, needed extensive assistance for activities of daily living, and had a current [DIAGNOSES REDACTED]. On March 18, 2013, the following care plans were initiated: 1) cognitive impairment due to dementia and depression, and 2) extensive assistance in activities of daily living due to dementia. The care plan intervention indicated that nursing was to maintain a safe environment at all times, however the care plan did not include a method for monitoring or supervising the resident to ensure safety. According to the licensed progress notes on May 24, 2013, at 11:10 p.m., during the change of shift, the nursing staff were conducting their head count and noticed that Resident 15 was not in his room. Staff conducted a search inside the facility, but the resident could not be found. At 11:15 p.m., staff searched outside of the facility and found the resident's wheelchair, with his belongings on the seat, at the south-east corner of the rear parking lot. Staff also saw a long wooden board propped up against the fence, which was probably used as an incline. Staff did a perimeter search of the neighborhood and the local law enforcement was notified. Staff were unable to locate the resident. The local law enforcement arrived, reviewed the security camera videotape and took a report. The local law enforcement initiated an investigation to search for the resident. On May 30, 2013, at 2:05 p.m., a review of the security camera videotape was conducted by the surveyor and the administrator, who validated the finding. On May 24, 2013, at 9:42 p.m., Resident 15 was seen looking at the top of the south-facing fence, as he walked next to it. The resident was seen walking back and forth at the south-east corner of the parking lot. At 9:59 p.m., a shadow was seen moving around at the rear area of the neighboring board and care facility. (The board and care facility's rear area was elevated higher than the facility's rear parking area.) It appeared that the shadow may have tossed a wooden board over the fence. At 10:03 p.m., Resident 15 could be seen climbing the fence and walking in an east direction, away from the facility. On May 30, 2013, at 3:45 p.m., an interview was conducted with the 3 p.m. - 11 p.m. licensed vocational nurse (LVN) who was working the same shift when Resident 15 eloped from the facility. The LVN stated that around 9 p.m., she saw Resident 15 in his room, when she gave the resident's roommate his medication. At around 11 p.m., the nursing staff noticed that the resident was not in his room and so began to search for him. When staff checked the rear parking lot, the LVN saw the resident's wheelchair next to a wooden board that was propped against the fence. Staff called the police, physician, and the family to inform them of the resident's elopement. The LVN further stated that the facility does not lock the facility fire exit doors at any time. On May 31, 2013, at 10:50 a.m., a review of the facility's undated security management plan policy and procedure indicated that security issues are addressed as evidenced by exit doors are locked by 8 p.m. to 8 a.m., and parking lot security ensured through proper lighting and nightly rounds. On June 3, 2013, at 4:05 p.m., after the director of nurses submitted by fax, the police report to the surveyor, a review of the police report revealed that the police department had contacted Resident 15's daughter, who stated that the resident left another long-term care facility, on January 23, 2013. Two months later, Resident 15 was found in a hospital, 21 miles away from that other facility. There was no evidence (prior to May 24, 2013, at 9:42 p.m., when Resident 15 eloped from the facility) that the staff ensured the facility's exit doors were locked by 8 p.m., or that the parking lot was secured, as indicated in the facility's security management plan policy and procedure. As a result Resident 15 eloped from the facility and grounds into an unsecured, unprotected and unknown environment. b. Record review of an Admission and Discharge Summary indicated Resident 2 was admitted to the facility on [DATE], and was readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated February 27, 2013, indicated the resident was usually understood and usually able to understand others. The resident required extensive assistance from staff with two or more persons physical assistance for transfers. Locomotion on the unit while in wheelchair (locations in his/her room and adjacent corridor) required extensive assistance from staff with one person physical assistance. The MDS indicated the resident had a fall prior to admission to the facility. Review of a quarterly MDS dated [DATE], indicated the resident had a fall within the last month of the MDS assessment date. Review of a "Fall Risk Assessment", dated December 28, 2012, which reviewed certain parameters including level of consciousness, history of falls, vision, and medications, indicated the resident had a total score of 17. A second assessment dated [DATE], indicated the resident had a score of 18. According to the "Fall Risk Assessment", a total score above 10 indicated the resident was at high risk for falls. A care plan dated December 28, 2012, indicated the resident was at high risk for falls due to cognitive impairment, poor safety awareness, and a history of falls. The care plan interventions included to apply a lap buddy (a wheelchair lap tray, positioning pad, and wandering patient system designed for use by individuals with mobility disabilities) while in the wheelchair. A second care plan dated January 1, 2013, indicated the resident had a fall in his room. The care plan interventions included to assess causative factor of the fall and intervene accordingly. Another care plan dated April 10, 2013, titled, "Falls Care Plan", indicated the resident had a fall risk assessment of 16. The care plan interventions included to apply a non-self release seat belt. However, none of the care plans addressed the need for monitoring the resident while using a restrictive device to prevent further falls and did not include a method for supervising the resident as a means of diminishing the fall risk. In addition, the care plans were not updated or revised after the resident's fall on May 24, 2013. Review of nursing notes dated January 1, 2013, revealed the resident was found on the floor in his room next to his wheelchair, the lap buddy was on the floor next to him. The resident was noted with redness to the neck and was complaining of headache. Another nursing note dated May 24, 2013 indicated the resident was found on the floor, with the wheelchair tipped over and his bottom still on the wheelchair seat. The resident had redness to the forehead and complained of pain 5/10 (on a scale of 1 to 10, ten being the most painful) to the left wrist. The resident was transferred to the general acute care hospital (GACH), on the same day. Review of a History and Physical from the GACH dated May 24, 2013, indicated the resident was complaining of syncope (dizziness) following the fall at the facility. A computerized tomography scan (CT scan a procedure that assists in diagnosing tumors, fractures (broken bones), bony structures, and infections in the organs and tissues of the body) was performed, the result of the CT scan was negative. The resident was admitted to the GACH for observation and was discharged to the skilled nursing facility four days later. In an interview on May 31, 2013 at 9:05 a.m., the activities director stated she had walked by the resident's room on May 24, 2013 (date of the most recent fall), when she observed the resident with his forehead on the floor and his bottom still in the wheel chair. The activities director stated she called for assistance. On May 31, 2013 at 9:15 a.m., licensed vocational nurse 2 (LVN 2) stated she was called by the activities director on May 24, 2013, to assist her with Resident 2 after a fall from his wheelchair. According to LVN 2 the resident had redness to his forehead from the fall, the non-self release belt was secured and in place. During an interview on May 31, 2013 at 10:40 a.m., registered nurse 1 (RN 1) stated the resident had two falls from his wheelchair while in the facility, both times the resident was in his room unsupervised. An application instruction sheet dated 2007, for the use of lap belts includes the following: " Patients in restrictive products require appropriate monitoring per facility policy. In addition the instruction sheet indicated Warning: After applying a restrictive product, always monitor appropriately per facility policy to make sure the patient is not able to ... fall off the chair seat. ... if their body weight becomes suspended off the chair, chest compression and suffocation could result." According to the policy "Falls and Fall Risk, Managing", revised April 2006, staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. c. A review of Resident 6's admission face sheet revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 6's Minimum Data Set (MDS/ a standardized assessment and care planning tool) dated March 15, 2013, indicated the resident was able to usually understand and usually be understood, required limited assistance with a one person physical assist for transfer to and from the bed to wheelchair. During a review of the clinical record for Resident 6, the "Fall Risk Assessment" dated May 29, 2013, indicated a score of 24 (a total score above 10 represents high risk for falls). Furthermore, under the parameter of history of falls it indicated the resident had 1-2 falls in the last 30 days. A care plan dated September 17, 2012, indicated the resident was at high risk for falls due to psychotropic (exerting an effect on the mind; capable of modifying mental activity) medication use and had a fall risk assessment score of 22. The care plan interventions included to encourage and remind the resident to ask for help, provide assistance in transfer and mobility, and anticipate needs in a timely manner. The care plan did not include a method for supervising the resident as a means of diminishing the fall risk. Review of nursing notes dated May 29, 2013 at 4:50 p.m., revealed the resident was found on the floor lying on his back. Although the resident did not sustain an injury, the resident stated that he was attempting to go back to bed from his wheelchair. During an interview with the registered nurse supervisor on May 31, 2013 at 8 a.m., she stated that the incident on May 29, 2013 was the resident's second fall from his wheelchair while in the facility, both times the resident was in his room unsupervised. According to the policy "Falls and Fall Risk, Managing", revised April 2006, staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.