Every finding on record at Skyview Rehab and Nursing

Based on a review of clinical records, facility documentation and facility policies, and interviews for one of two Residents (Resident #2) reviewed for a change in condition, the facility failed to ensure medications were administered in accordance with physician orders, and after an unplanned transfer, the facility failed to ensure the hospital was notified the ordered medications were not administered prior to transfer. The findings include: Resident #2 was admitted to the facility with diagnoses that included seizures and malignant cancer of the bladder. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderate cognitive impairment, had an indwelling catheter to drain urine and a feeding tube, had a seizure disorder, and received an anticonvulsant (used to prevent seizures) medication. The Resident Care Plan (RCP) dated 6/10/2026 identified Resident #2 had pain, was nonverbal and was on anticoagulation therapy (blood thinner). Interventions directed to administer medications as per physician orders. A physician order dated 5/15/2026 directed Levetiracetam (Keppra, anticonvulsant medication) oral solution 500 milligrams (mgs)/milliliter (ml), give 5 ml via g-tube every 12 hours for seizure. A physician order dated 6/18/2026 directed Tylenol oral tablet 325 mg, give three (3) tablets via g-tube every twelve (12) hours for leg and arm pain. Review of the Medication Administration Record (MAR) identified Tylenol 325 mg three (3) tablets were scheduled for administration at 8 AM and 8 PM, and the Levetiracetam was scheduled to be administered at 8 AM and 8 PM. Review of the MAR identified Tylenol 325 mg three (3) tablets and the Levetiracetam were not signed to indicate it was administered on 6/22/2026 at 8 AM; the box for the nurse's signature to indicate medication was administered was blank. Interview and record review with LPN # 5 on 7/14/2026 at 11:07 AM identified she was the charge nurse on 6/22/2026 during the 7:00 AM to 3:00 PM shift and the MAR indicated the Tylenol and Levetiracetam were both scheduled per the MAR for administration on 6/22/2026 at 8 AM. LPN #5 stated the facility used a liberalized medication administration policy that allowed for morning medications scheduled between 7:00 AM to 12:00 PM to be given any time between those hours. LPN #5 stated Resident #2 did not miss any ordered medications because although the Tylenol and Levetiracetam that were ordered to be administered at 8 AM, she had until 12 noon to administer the medications. Further, Resident #2 was transferred to the hospital about 11:30 AM. Interview and record review with the DON on 7/14/2026 at 12:40 PM identified that he was aware of a liberalized medication policy. The DON stated when orders entered into the electronic medical record (EMR), the nurse selects the appropriate time for the administration to occur and the EMR would reflect the time on the MAR. The DON stated although daily medications had an administration time from 7:00 AM to 12:00 PM, medications ordered for every twelve (12) hours were required to be administered at the scheduled time; Resident #2's Tylenol and Levetiracetam were ordered every twelve (12) hours and should have been administered at 8 AM in accordance with the MAR directions. The DON stated he did not know why LPN # 5 did not administer the medications at 8:00 AM as per the physician orders, and stated they should have been administered timely. Interview with the facility Pharmacy Services Director (PSD) on 7/15/2026 at 9:05 AM identified that the PSD was unaware of the facility's liberalized medication administration policy and stated that was not an industry standard. The PSD stated the standard to be considered timely administration; medications can be administered one (1) hour before or after the ordered/scheduled time. Further, anti-seizure medications are an example of a medication that would need consistent time intervals to meet treatment recommendations. The facility policy Medication Administration: Liberalized dated 11/2021 directed in part, that adjustment of medication timed to meet the individual's needs and preferences but must still consider the physician's/nurse practitioner/physician assistant's prescription. Medication administration guidelines directed medications prescribed as every 12 hours would be timed for administration at 8:00 AM and 8:00 PM. The facility did not provide a policy regarding timely medication administration for one (1) hour before or after the ordered/scheduled time. a. Nursing note Change in Condition Evaluation dated 6/22/2026 identified Resident #2 had a fever, abnormal vital signs at 11:42 AM; Resident #2 had an abrupt onset of increased lethargy, decreased alertness and gross hematuria (blood in the urine). Blood pressure was 130/64, temperature was 100, pulse 106, respirations 20, blood oxygen level 91% (normal 90% and above). The APRN assessed Resident #2 and ordered transfer to the hospital. Transfer for dated 6/22/2026 at 11:44 identified transfer to the hospital for evaluation of possible sepsis, hematuria and abnormal vitals (vital signs). Record review failed to identify the hospital was notified the Levetiracetam and Tylenol were not administered at 8 AM, in accordance with physician orders. Interview and record review with the DON on 7/14/2026 at 12:40 PM identified he had completed the transfer documentation on 6/22/2026 for Resident #2. Review of the transfer packet provided by the DON, there was not a listing of when the last dose of Resident #2's medications were administered prior to the hospital transfer. Further, the documentation did not identify Resident #2 did not receive the scheduled Tylenol and Levetiracetam as ordered on 6/22/2026. The DON stated he could not recall if he had reported any missed medications to the hospital when Resident #2's was transferred on 6/22/2026. The DON stated the transfer documentation information should have included the last time medications were administered, and the hospital should have been notified that the 8 AM scheduled doses of Tylenol and Levetiracetam were not administered on 6/22/2026. Although requested, the facility did not provide a policy for surveyor review regarding resident transfers.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for facility discharges, the facility failed to document the resident's discharge in the clinical record and notify the Office of the State Long-Term Care Ombudsman of the resident's discharge. The findings include:Resident #1's diagnoses included bipolar disorder (a mental health condition characterized by intense and fluctuating mood shifts including extreme highs and lows), dementia without behavioral disturbances and anxiety disorder.The Court of Probate document identified Resident #1 was appointed a conservator of person (Person #1), in part, to ensure personal care, comfort, safety and maintenance, and medical or other professional care effective 2/17/26.The Nursing Evaluation dated 3/16/26 identified Resident #1 was admitted to the facility and was alert and oriented to person, place, time and situation, was verbally appropriate and was independent with all Activities of Daily Living (ADLs), bed mobility, transfers and ambulation.A physician's order dated 3/16/26 directed Resident #1 may go on LOA with someone. The Resident Care Plan (RCP) dated 3/20/26 identified Resident #1 was an elopement risk related to impaired safety awareness and exit seeking behaviors. Interventions included observing for and reporting verbalizations of wanting to leave the facility and placing a Wanderguard to the resident's left ankle and checking it every shift for placement and function daily on the 11:00 PM to 7:00 PM shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility, transfers and ambulation and Resident #1 did not exhibit any behaviors, including wandering behaviors. A late entry nurse's note by RN #1 dated 3/30/26 at 10:15 AM (created on 3/31/26 at 7:14 AM) identified he called Person #1 to discuss Resident #1 going out on a LOA with a friend and Person #1 consented to Resident #1 going on a LOA.A late entry nurse's note by RN #1 dated 3/30/26 at 12:10 PM (created on 3/31/26 at 7:15 AM) identified Resident #1's friend came to the facility to take Resident #1 on LOA and stated they would return around 6:00 PM and the LOA book was signed.A late entry nurse's note by RN #2 dated 3/31/26 at 12:32 AM (created on 3/31/26 at 10:08 AM) identified at 10:15 PM, Resident #1 had not returned from LOA after leaving at 12:05 PM. Resident #1's friend was contacted and three (3) voicemails were left without return call. Resident #1 was contacted and the voicemail was full. Resident #1's son was contacted and reported not knowing anything about Resident #1. Person #1 was contacted and a voicemail and email were left, the police were notified, the APRN was notified and the DON was notified. It was later identified that most of Resident #1's belongings were gone from the room. The police later followed up and reported being unable to contact the friend that took Resident out on LOA but they would continue their search. Review of the facility census identified Resident #1 was discharged from the facility on 3/31/26Review of the clinical record failed to identify documentation from the Director of Social Services on the outcome of the LOA or Resident #1 being discharged from the facility.Interview with Person #2 (ombudsman) on 4/24/26 at 1:28 PM identified he/she was not made aware of Resident #1's discharge from the facility or LOA situation. Person #2 reported he/she reviewed the portal and there was no discharge notice submitted for Resident #1. Person #2 identified all discharge notices were required to be sent through the portal to include residents who leave the facility AMA.Interview and review of the Nursing Facility Discharge Notifications on the Long-Term Care Ombudsman portal with the Director of Social Services on 4/24/26 at 1:39 PM, failed to identify Resident #1's 3/31/26 discharge per the facility census was reported via the Long-Term Care Ombudsman portal as required. The Director of Social Services identified although she discharged Resident #1 from the electronic health record, she was unaware that Resident #1 not returning from the LOA was considered a discharge so she did not document on the LOA or the discharge from the facility or send notification to the Long-Term Care Ombudsman via the portal. She identified she never encountered this scenario before.Interview with the DON on 4/24/26 at 12:05PM identified the Director of Social Services should have documented that Resident #1 was discharged once not returning from the LOA and should have reported Resident #1's discharge on [DATE] via the Long-Term Care Ombudsman portal as required.Review of the Discharge of Resident policy dated 6/2023 directed, in part, to record all pertinent documentation in the resident's medical record and describe in detail the sequence of events including specified timed notations.Although requested a policy on reporting discharges to the Long-Term Care Ombudsman was unavailable.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for elopement risk, the facility failed to ensure the clinical record was complete and accurate to include communication with the resident's conservator prior to a Leave of Absence (LOA) and the anticipated return time of the resident resulting in the preceding nurse being unaware of the resident's anticipated return and delaying notification when the resident did not return from the LOA. The findings include:Resident #1's diagnoses included bipolar disorder (a mental health condition characterized by intense and fluctuating mood shifts including extreme highs and lows), dementia without behavioral disturbances and anxiety disorder.The Court of Probate document identified Resident #1 was appointed a conservator of person (Person #1), in part, to ensure personal care, comfort, safety and maintenance, and medical or other professional care effective 2/17/26.The Nursing Evaluation dated 3/16/26 identified Resident #1 was admitted to the facility and was alert and oriented to person, place, time and situation, was verbally appropriate and was independent with all Activities of Daily Living (ADLs), bed mobility, transfers and ambulation.A physician's order dated 3/16/26 directed Resident #1 may go on LOA with someone.The Resident Care Plan (RCP) dated 3/20/26 identified Resident #1 was an elopement risk related to impaired safety awareness and exit seeking behaviors. Interventions included observing for and reporting verbalizations of wanting to leave the facility and placing a Wanderguard to the resident's left ankle and checking it every shift for placement and function daily on the 11:00 PM to 7:00 PM shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility, transfers and ambulation and Resident #1 did not exhibit any behaviors, including wandering behaviors.A late entry nurse's note by RN #1 dated 3/30/26 at 10:15 AM (created on 3/31/26 at 7:14 AM) identified he called Person #1 to discuss Resident #1 going out on a LOA with a friend and Person #1 consented to Resident #1 going on a LOA.A late entry nurse's note by RN #1 dated 3/30/26 at 12:10 PM (created on 3/31/26 at 7:15 AM) identified Resident #1's friend came to the facility to take Resident #1 on LOA and stated they would return around 6:00 PM and the LOA book was signed.A late entry nurse's note by RN #2 dated 3/31/26 at 12:32 AM (created on 3/31/26 at 10:08 AM) identified at 10:15 PM, Resident #1 had not returned from LOA after leaving at 12:05 PM. Resident #1's friend was contacted and three (3) voicemails were left without return call. Resident #1 was contacted and the voicemail was full. Resident #1's son was contacted and reported not knowing anything about Resident #1. Person #1 was contacted and a voicemail and email were left, the police were notified, the APRN was notified and the DON was notified. It was later identified that most of Resident #1's belongings were gone from the room. The police later followed up and reported being unable to contact the friend that took Resident out on LOA but they would continue their search.Interview with Person #1 on 4/24/26 at 10:33 AM identified he/she was first notified at 10:00 PM that Resident #1 did not return from the LOA. Person #1 reported she would have liked to have been notified immediately.Interview with RN #1 on 4/24/26 at 11:32 AM identified he spoke with Person #1 for LOA approval on 3/30/26 and confirmed the return time of 6:00 PM on 3/30/26 with Resident #1's friend. RN #1 identified he should have documented the communications in the clinical record prior to the end of his shift. RN #1 was unable to recall if he communicated Resident #1's anticipated return time with RN #2 (3:00 PM to 11:00 PM nursing supervisor) but reported that he should have.Interview with the DON on 4/24/26 at 12:05 PM identified all licensed nurses should complete documentation timely, prior to leaving for their shift. She reported RN #1 was orienting with her on 3/19/26 and identified communication with Person #1 as well as communication with Resident #1. The anticipated LOA return time should have been documented in the clinical record prior to RN #1 leaving for his shift on 3/30/26. Additionally, RN #2 should have been made aware of Resident #1's anticipated return time during shift change. Interview with RN #2 on 4/24/26 at 1:48 PM identified she was not notified by RN #1 or any other staff of the time Resident #1 was expected to return from the LOA on 3/30/26, there was no nurse's note written regarding the LOA, the LOA log did not include an anticipated return time, therefore, she was unaware of when Resident #1 was scheduled to return. She identified many residents return from LOA's as late as 10:00 PM. At 10:00 PM when Resident #1 did not return, she contacted Resident #1's friend, but after calling three (3) times and leaving messages with no return call, she called Resident #1 who's phone went to voicemail. Person #1 and Resident #1's son were unable to locate Resident #1. RN #2 identified if she knew Resident #1 was anticipated to return at 6:00 PM, she would have started making calls to locate Resident #1 after 6:00 PM and would not have waited until 10:00 PM.Review of the LOA Log identified Resident #1 was signed out for the 3/30/26 LOA at 12:05 PM. The log did not identity a column for the anticipated return time, only the time a resident was signed back in.Review of the Leave of Absence (LOA) policy dated 4/2016 directed, in part, the resident must be signed out by the responsible party when leaving and sign in upon return in the LOA log book. Staff will inquire if there is an anticipated duration for the LOA.Review of the Charting and Documentation policy dated 6/2023 directed, in part, services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition shall be documented in the resident's medical record an indicated. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for elopement risk, the facility failed to ensure a resident, who was alert and oriented and had no previous documented exit seeking behaviors while in the facility, was free from restraint when a Wanderguard device (a bracelet which is a part of a wander management system designed to prevent those at risk for wandering from leaving a protected area) was applied to the resident prior to receiving consent from the conservator, restricting the resident's freedom of movement. Following the placement of the Wanderguard, Resident #1 was granted a Leave of Absence (LOA) with a friend and did not return to the facility as planned. The findings include:Resident #1's diagnoses included bipolar disorder (a mental health condition characterized by intense and fluctuating mood shifts including extreme highs and lows), dementia without behavioral disturbances and anxiety disorder.The Court of Probate document identified Resident #1 was appointed a conservator of person (Person #1), in part, to ensure personal care, comfort, safety and maintenance, and medical or other professional care effective 2/17/26.The Nursing Evaluation dated 3/16/26 identified Resident #1 was admitted to the facility and was alert and oriented to person, place, time and situation, was verbally appropriate and was independent with all Activities of Daily Living (ADLs), bed mobility, transfers and ambulation.A physician's order dated 3/16/26 directed Resident #1 may go on LOA with someone.An Elopement Risk Scale dated 3/16/26 identified Resident #1 was not at risk for elopement.Review of nurse's notes dated 3/16/26 through 3/18/26 failed to identify disorientation, verbalization of wanting to leave the facility or exit seeking behaviors.A nurse's note by LPN #1 dated 3/19/26 at 2:22 PM identified a Wanderguard was placed on Resident #1's left ankle due to exit seeking and an elopement assessment was completed. The note failed to identify that Person #1 was contacted for approval prior to the placement of the Wanderguard.An Elopement Evaluation dated 3/19/26 identified Resident #1 was at risk for elopement.A physician's order dated 3/19/26 directed a Wanderguard was placed to Resident #1's left ankle and placement was to be checked every shift.Review of the March 2026 Medication Administration Record (MAR) failed to identify Resident #1 exhibited any behaviors from 3/16/26 through 3/19/26.The Resident Care Plan (RCP) dated 3/20/26 identified Resident #1 was an elopement risk related to impaired safety awareness and exit seeking behaviors. Interventions included observing for and reporting verbalizations of wanting to leave the facility and placing a Wanderguard to the resident's left ankle and checking it every shift for placement and function daily on the 11:00 PM to 7:00 PM shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility, transfers and ambulation and Resident #1 did not exhibit any behaviors, including wandering behaviors.Review of nurse's notes dated 3/20/26 through 3/28/26 failed to identify disorientation, verbalization of wanting to leave the facility or exit seeking behaviors.A nurse's note by RN #2 dated 3/29/26 at 11:38 AM identified Resident #1 requested to go LOA with a friend but Resident #1 nor herself (RN #2) were able to contact Person #1 despite messages left, so Resident #1 was notified he/she could not go on a LOA and stayed in the facility with the friend.Review of the March 2026 MAR and TAR failed to identify Resident #1 was being monitored for wandering or exit seeking behaviors although a Wanderguard was placed on 3/19/26.A late entry nurse's note by RN #1 dated 3/30/26 at 10:15 AM (created on 3/31/26 at 7:14 AM) identified he called Person #1 to discuss Resident #1 going out on a LOA with a friend and Person #1 consented to Resident #1 going on a LOA.A late entry nurse's note by RN #1 dated 3/30/26 at 12:10 PM (created on 3/31/26 at 7:15 AM) identified Resident #1's friend came to the facility to take Resident #1 on LOA and stated they would return around 6:00 PM and the LOA book was signed.A late entry nurse's note by RN #2 dated 3/31/26 at 12:32 AM (created on 3/31/26 at 10:08 AM) identified at 10:15 PM, Resident #1 had not returned from LOA after leaving at 12:05 PM. Resident #1's friend was contacted and three (3) voicemails were left without return call. Resident #1 was contacted and the voicemail was full. Resident #1's son was contacted and reported not knowing anything about Resident #1. Person #1 was contacted and a voicemail and email were left, the police were notified, the APRN was notified and the DON was notified. It was later identified that most of Resident #1's belongings were gone from the room. The police later followed up and reported being unable to contact the friend that took Resident out on LOA but they would continue their search.A nurse's note by RN #1 dated 4/1/26 at 12:03 PM identified a call was received at 10:00 AM from Resident #1's brother stating Resident #1 called him/her at 9:50 AM reporting he/she (Resident #1) was fine and would call Person #1.Review of the facility census on 4/24/26 identified Resident #1 had not returned to the facility.Interview with Person #1 on 4/24/26 at 10:33 AM identified the facility notified him/her that a Wanderguard was placed on Resident #1 but was unsure of what time and stated they had not reported previous exit seeking or wandering behaviors and did not receive consent prior to the placement of the Wanderguard. Person #1 identified when he/she spoke to RN #1 on 3/30/26 in regards to the LOA, Person #1 reported not being notified of any additional exit seeking behavior and identified he/she knew Resident #1's friend and thought a LOA would be least restrictive, so approved it. Person #1 identified at around 10:00 PM, the facility called and notified him/her Resident #1 never returned, and they could not reach the friend, so they called the police. Person #1 reported he/she had contact with Resident #1 and explained housing options, but Resident #1 stated he/she did not want to return to the facility because it felt like a jail. On 4/3/26, Person #1 reported Resident #1 contacted him/her and wanted to go back to the hospital. The police were called and Resident #1 was transported to the hospital where he/she was admitted and remained on the geriatric psychiatry unit due to the facility refusing to accept Resident #1 back into the facility.Interview with LPN #1 on 4/24/26 at 11:48 AM identified on 3/19/26 Resident #1 was exit seeking and tried to leave the facility. She identified she did not know Resident #1 prior to 3/19/26 and was unaware Resident #1 was conserved. She identified she placed a Wanderguard on Resident #1 without contacting Person #1 for approval and then completed the Elopement Evaluation indicating Resident #1 was at risk for elopement. LPN #1 identified she explained the Wanderguard to Resident #1 and he/she did not resist, and then she notified the nursing supervisor of the behaviors and subsequent placement of the Wanderguard.Interview with the DON on 4/24/26 at 12:05 PM identified on 3/19/26 she was the 7:00 AM to 3:00 PM nursing supervisor and reported she was aware Resident #1 wanted to leave and that LPN #1 placed a Wanderguard on Resident #1. She was unable to recall if she notified Person #1 but identified the communication should have been documented if it occurred. The DON identified she was unsure if it was appropriate to place a Wanderguard on an alert and oriented resident, but Person #1 should have been contacted for approval prior to placement of the Wanderguard. She reported a Wanderguard should not have been placed to Resident #1 following the first episode of exit seeking and that other interventions should have been attempted and documented first. Additionally, she identified once the Wanderguard was placed, wandering/exit seeking behaviors should have been monitored every shift and she was unsure why that had not occurred.Review of the Wanderguard Security System policy dated 7/2023 directed, in part, that a Wanderguard Security Device will be placed on any resident that the resident care team decides is at risk for wandering away from the facility. When the Wanderguard door alarm sounds, the nearest employees shall immediately respond to that door.Although requested, facility policies on conservator notification and behavior monitoring were not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for elopement risk, the facility failed to ensure a resident, who was alert and oriented and had no previous documented exit seeking behaviors while in the facility, was free from restraint when a Wanderguard device (a bracelet which is a part of a wander management system designed to prevent those at risk for wandering from leaving a protected area) was applied to the resident prior to receiving consent from the conservator, restricting the resident's freedom of movement. Following the placement of the Wanderguard, Resident #1 was granted a Leave of Absence (LOA) with a friend and did not return to the facility as planned. The findings include:Resident #1's diagnoses included bipolar disorder (a mental health condition characterized by intense and fluctuating mood shifts including extreme highs and lows), dementia without behavioral disturbances and anxiety disorder.The Court of Probate document identified Resident #1 was appointed a conservator of person (Person #1), in part, to ensure personal care, comfort, safety and maintenance, and medical or other professional care effective 2/17/26.The Nursing Evaluation dated 3/16/26 identified Resident #1 was admitted to the facility and was alert and oriented to person, place, time and situation, was verbally appropriate and was independent with all Activities of Daily Living (ADLs), bed mobility, transfers and ambulation.A physician's order dated 3/16/26 directed Resident #1 may go on LOA with someone.An Elopement Risk Scale dated 3/16/26 identified Resident #1 was not at risk for elopement.Review of nurse's notes dated 3/16/26 through 3/18/26 failed to identify disorientation, verbalization of wanting to leave the facility or exit seeking behaviors.A nurse's note by LPN #1 dated 3/19/26 at 2:22 PM identified a Wanderguard was placed on Resident #1's left ankle due to exit seeking and an elopement assessment was completed. The note failed to identify that Person #1 was contacted for approval prior to the placement of the Wanderguard.An Elopement Evaluation dated 3/19/26 identified Resident #1 was at risk for elopement.A physician's order dated 3/19/26 directed a Wanderguard was placed to Resident #1's left ankle and placement was to be checked every shift.Review of the March 2026 Medication Administration Record (MAR) failed to identify Resident #1 exhibited any behaviors from 3/16/26 through 3/19/26.The Resident Care Plan (RCP) dated 3/20/26 identified Resident #1 was an elopement risk related to impaired safety awareness and exit seeking behaviors. Interventions included observing for and reporting verbalizations of wanting to leave the facility and placing a Wanderguard to the resident's left ankle and checking it every shift for placement and function daily on the 11:00 PM to 7:00 PM shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility, transfers and ambulation and Resident #1 did not exhibit any behaviors, including wandering behaviors.Review of nurse's notes dated 3/20/26 through 3/28/26 failed to identify disorientation, verbalization of wanting to leave the facility or exit seeking behaviors.A nurse's note by RN #2 dated 3/29/26 at 11:38 AM identified Resident #1 requested to go LOA with a friend but Resident #1 nor herself (RN #2) were able to contact Person #1 despite messages left, so Resident #1 was notified he/she could not go on a LOA and stayed in the facility with the friend.Review of the March 2026 MAR and TAR failed to identify Resident #1 was being monitored for wandering or exit seeking behaviors although a Wanderguard was placed on 3/19/26.A late entry nurse's note by RN #1 dated 3/30/26 at 10:15 AM (created on 3/31/26 at 7:14 AM) identified he called Person #1 to discuss Resident #1 going out on a LOA with a friend and Person #1 consented to Resident #1 going on a LOA.A late entry nurse's note by RN #1 dated 3/30/26 at 12:10 PM (created on 3/31/26 at 7:15 AM) identified Resident #1's friend came to the facility to take Resident #1 on LOA and stated they would return around 6:00 PM and the LOA book was signed.A late entry nurse's note by RN #2 dated 3/31/26 at 12:32 AM (created on 3/31/26 at 10:08 AM) identified at 10:15 PM, Resident #1 had not returned from LOA after leaving at 12:05 PM. Resident #1's friend was contacted and three (3) voicemails were left without return call. Resident #1 was contacted and the voicemail was full. Resident #1's son was contacted and reported not knowing anything about Resident #1. Person #1 was contacted and a voicemail and email were left, the police were notified, the APRN was notified and the DON was notified. It was later identified that most of Resident #1's belongings were gone from the room. The police later followed up and reported being unable to contact the friend that took Resident out on LOA but they would continue their search.A nurse's note by RN #1 dated 4/1/26 at 12:03 PM identified a call was received at 10:00 AM from Resident #1's brother stating Resident #1 called him/her at 9:50 AM reporting he/she (Resident #1) was fine and would call Person #1.Review of the facility census on 4/24/26 identified Resident #1 had not returned to the facility.Interview with Person #1 on 4/24/26 at 10:33 AM identified the facility notified him/her that a Wanderguard was placed on Resident #1 but was unsure of what time and stated they had not reported previous exit seeking or wandering behaviors and did not receive consent prior to the placement of the Wanderguard. Person #1 identified when he/she spoke to RN #1 on 3/30/26 in regards to the LOA, Person #1 reported not being notified of any additional exit seeking behavior and identified he/she knew Resident #1's friend and thought a LOA would be least restrictive, so approved it. Person #1 identified at around 10:00 PM, the facility called and notified him/her Resident #1 never returned, and they could not reach the friend, so they called the police. Person #1 reported he/she had contact with Resident #1 and explained housing options, but Resident #1 stated he/she did not want to return to the facility because it felt like a jail. On 4/3/26, Person #1 reported Resident #1 contacted him/her and wanted to go back to the hospital. The police were called and Resident #1 was transported to the hospital where he/she was admitted and remained on the geriatric psychiatry unit due to the facility refusing to accept Resident #1 back into the facility.Interview with LPN #1 on 4/24/26 at 11:48 AM identified on 3/19/26 Resident #1 was exit seeking and tried to leave the facility. She identified she did not know Resident #1 prior to 3/19/26 and was unaware Resident #1 was conserved. She identified she placed a Wanderguard on Resident #1 without contacting Person #1 for approval and then completed the Elopement Evaluation indicating Resident #1 was at risk for elopement. LPN #1 identified she explained the Wanderguard to Resident #1 and he/she did not resist, and then she notified the nursing supervisor of the behaviors and subsequent placement of the Wanderguard.Interview with the DON on 4/24/26 at 12:05 PM identified on 3/19/26 she was the 7:00 AM to 3:00 PM nursing supervisor and reported she was aware Resident #1 wanted to leave and that LPN #1 placed a Wanderguard on Resident #1. She was unable to recall if she notified Person #1 but identified the communication should have been documented if it occurred. The DON identified she was unsure if it was appropriate to place a Wanderguard on an alert and oriented resident, but Person #1 should have been contacted for approval prior to placement of the Wanderguard. She reported a Wanderguard should not have been placed to Resident #1 following the first episode of exit seeking and that other interventions should have been attempted and documented first. Additionally, she identified once the Wanderguard was placed, wandering/exit seeking behaviors should have been monitored every shift and she was unsure why that had not occurred.Review of the Wanderguard Security System policy dated 7/2023 directed, in part, that a Wanderguard Security Device will be placed on any resident that the resident care team decides is at risk for wandering away from the facility. When the Wanderguard door alarm sounds, the nearest employees shall immediately respond to that door.Although requested, facility policies on conservator notification and behavior monitoring were not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for facility discharges, the facility failed to permit Resident #1 to return to the facility following a Leave of Absence (LOA) when the resident did not return as planned and subsequently required hospitalization, despite the facility having available beds and lacking documentation to support an Against Medical Advice (AMA) discharge or that readmission would endanger the health or safety of other residents. The findings include: Resident #1's diagnoses included bipolar disorder (a mental health condition characterized by intense and fluctuating mood shifts including extreme highs and lows), dementia without behavioral disturbances and anxiety disorder.The Court of Probate document identified Resident #1 was appointed a conservator of person (Person #1), in part, to ensure personal care, comfort, safety and maintenance, and medical or other professional care effective 2/17/26.The Nursing Evaluation dated 3/16/26 identified Resident #1 was admitted to the facility and was alert and oriented to person, place, time and situation, was verbally appropriate and was independent with all Activities of Daily Living (ADLs), bed mobility, transfers and ambulation.A physician's order dated 3/16/26 directed Resident #1 may go on LOA with someone. The Resident Care Plan (RCP) dated 3/20/26 identified Resident #1 was an elopement risk related to impaired safety awareness and exit seeking behaviors. Interventions included observing for and reporting verbalizations of wanting to leave the facility and placing a Wanderguard to the resident's left ankle and checking it every shift for placement and function daily on the 11:00 PM to 7:00 PM shift.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility, transfers and ambulation and Resident #1 did not exhibit any behaviors, including wandering behaviors. A late entry nurse's note by RN #1 dated 3/30/26 at 10:15 AM (created on 3/31/26 at 7:14 AM) identified he called Person #1 to discuss Resident #1 going out on a LOA with a friend and Person #1 consented to Resident #1 going on a LOA.A late entry nurse's note by RN #1 dated 3/30/26 at 12:10 PM (created on 3/31/26 at 7:15 AM) identified Resident #1's friend came to the facility to take Resident #1 on LOA and stated they would return around 6:00 PM and the LOA book was signed.A late entry nurse's note by RN #2 dated 3/31/26 at 12:32 AM (created on 3/31/26 at 10:08 AM) identified at 10:15 PM, Resident #1 had not returned from LOA after leaving at 12:05 PM. Resident #1's friend was contacted and three (3) voicemails were left without return call. Resident #1 was contacted and the voicemail was full. Resident #1's son was contacted and reported not knowing anything about Resident #1. Person #1 was contacted and a voicemail and email were left, the police were notified, the APRN was notified and the DON was notified. It was later identified that most of Resident #1's belongings were gone from the room. The police later followed up and reported being unable to contact the friend that took Resident out on LOA but they would continue their search. Review of the facility census identified Resident #1 was discharged from the facility on 3/31/26 Interview with Person #1 on 4/24/26 at 10:33 AM identified the facility would no readmit Resident #1 following the extended LOA, despite Resident #1 returning to the hospital on 4/3/26. The facility communicated Resident #1 required a locked unit which they did not have. Person #1 reported Resident #1 remained on the geriatric psychiatry unit until placement could be found.Interview with the Admissions Director on 4/24/26 at 12:50 PM identified she received hospital referrals for Resident #1 on 4/3/26 and 4/14/26, and although the facility had open female beds on those dates, Resident #1 left against medical advice and refused to return which put the facility at risk for future incidents. She identified Resident #1 was placed on a Corporate denial list from all of their facilities.Interview with the Administrator on 4/24/26 at 1:23 PM identified although Resident #1 returning to the facility would not endanger other residents, Resident #1 was ambulatory without an assistive device and had the ability to cut off a Wanderguard which puts Resident #1 at risk if he/she were to elope from the facility. She reported she was unaware of the requirements of readmissions for extended LOA's or residents leaving AMA and was unsure if the facility was required to take Resident #1 back.Review of the clinical record failed to identify documentation identifying Resident #1 left AMA or was considered an AMA discharge.Review of the Discharge of Resident policy dated 6/2023 directed, in part, residents will be discharged from the facility as per physician's order. If against medical advice then the resident or responsible party must sign, a release of responsibility form, notify the supervisor immediately and the physician as soon as possible. Record all pertinent documentation in the resident's medical record and describe in detail the sequence of events including specified timed notations.Although requested, facility policies for residents not returning from an LOA and the anticipated time or readmitting discharged residents were unavailable.

Based on facility documentation review, facility policy review, and interviews for 5 of 5 residents (Resident #17, #29, #40, #52, and #70) reviewed for grievances, the facility failed to ensure residents were provided information on how to file a grievance. The findings include: Review of the Resident Council Monthly Meeting Minutes dated 1/27/25 through 2/10/26 failed to reflect residents were educated or provided information on the grievance policy, the location of the grievance forms, how to file a grievance, or the resolution process. A Resident Council Meeting was held on 3/9/26 at 12:56 PM, and Residents #17, #29, #40, #52, and #77 indicated they were not aware of the grievance process, policy, or how to file a grievance. The residents further indicated they did not know who the Grievance official was or where the grievance forms were located. Interview with NA #7 on 3/16/26 at 10:07 AM identified that she does not know where the grievance forms are located. Interview with NA #6 on 3/16/26 at 10:08 AM identified that she does not know how grievances are handled or where the forms are located.Interview with Housekeeper #1 on 3/16/26 at 10:11 AM identified she has worked at the facility for 5 years and had never filled out a grievance form for a resident. Housekeeper #1 identified that if a resident asked her to fill out a grievance form, she did not know where they were located, so she would just Interview with RN #2 (day supervisor) on 3/16/26 at 10:15 AM, identified when a resident or resident's representative wishes to file a grievance, she writes it on a blank piece of paper because there are no grievance forms. RN #2 indicated she does not know who the Grievance Official is, but thinks it is the Director of Nurses (DNS). Observation on 3/16/26 at 10:18 AM identified an unlabeled smoke colored bin approximately 4 feet 3 inches off the floor/ground, not visible or reachable for a resident in a wheelchair. The 2 folders in the bin had a small label with grievance handwritten on them that is not visible from the wheelchair level. Interview with Social Worker (SW) SW #1 on 3/16/26 at 10:19 AM identified that she, the Administrator, and DNS are responsible for the grievance book. SW #1 indicated that if a resident has a grievance, the staff can give the completed grievance form to any of them. SW #1 indicated that if she receives the grievance form, she will read it, give it to the department that is involved, start the investigation, and include the DNS and Administrator. SW #1 indicated a grievance must be resolved in 5-7 days. SW #1 indicated that someone would inform the resident or resident representative of the outcome and then the grievance form is filed. SW #1 indicated that there is a folder outside of her office with the grievance forms. SW #1 identified grievance forms are not kept at the nurse's stations. SW #1 identified at the time of admission residents and resident representatives are educated on the grievance form and policy. SW #1 was unable to explain why information on how to file a grievance or complaint was not available to the residents. Interview with the Administrator on 3/16/26 at 9:45 AM identified grievance forms are outside of SW #1's office. The Administrator identified SW #1 was responsible for the grievance forms. Interview with RN #7 (charge nurse and fill in supervisor) on 3/16/26 at 10:28 AM identified if a resident or residents' representative had a complaint and wanted to file a grievance he would tell them to speak with SW #1 but if it was a weekend he would tell them to wait and talk to SW #1 on Monday. Review of facility Grievance policy identified the policy is designed to ensure that all residents residing at the facility, their families, and other interested parties, are given a fair and proper procedure to voice complaints, grievances, or suggestions. The objective is to ensure that all residents receive the following: confidentiality, fair and equal treatment, and the ability to resolve problems without prejudice, threat of discharge or other reprisals. If the assistant director of nursing, the DNS, or the Director of social services cannot resolve the problem, they will refer the problem to the administrator. The administrator will make every effort to resolve the questions, problems, or grievances. The policy does not identify the timeframes for the resolution process. Review of the Resident Rights Policy identified that federal and state laws guarantee certain basic rights to residents in the facility which include the right to voice a grievance to the facility without discrimination or reprisal and without fear of discrimination or reprisal. The residents have the right to receive a response to his/her grievances from the facility.

Based on review of the clinical record, facility documentation, observations, and interviews for 1 of 3 sampled residents (Resident #70) reviewed for medication administration, the facility failed to ensure parameters were followed prior to administering a blood pressure medication. The findings include:Resident #70's diagnoses included congestive heart failure, coronary artery disease, and hypertension.The physician's order dated 9/16/25 directed to administer Amlodipine besylate ( medication used to treat high blood pressure) oral tablet 2.5 milligrams, give 1 tablet by mouth one time a day for hypertension, hold for systolic blood pressure less than 110 or heart rate less than 50 beats per minute.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 was moderately cognitively impaired. The Resident Care Plan dated 2/18/26 identified Resident #70 had an altered cardiovascular status. Interventions included monitoring vital signs, notifying the physician of any significant abnormalities, report changes in lung sounds on auscultation, edema, and changes in weight.Observation and interview on 3/5/26 at 9:55 AM with Licensed Practical Nurse (LPN) #2 identified she administered Amlodipine Besylate 2.5 mg (one tablet by mouth) to Resident #70 without first obtaining a blood pressure or pulse, as directed on the medication label and per the physician's orders. LPN #2 stated Resident #70 did not have any specific parameters required prior to medication administration. Subsequent to surveyor inquiry, LPN #2 stated she reread the label on Resident #70's Amlodipine Besylate label after administration and identified instructions to hold the medication for a systolic blood pressure less than 110 or a heart rate less than 50 beats per minute. LPN #2 returned to Resident #70's room, obtained his/her blood pressure and pulse and recorded the blood pressure as 128/63 and a pulse of 66 beats per minute. Interview on 3/5/26 at 1:28 PM with the Director of Nursing Services (DNS) identified LPN #2 should have checked Resident #70's blood pressure and pulse before she administered Amlodipine Besylate oral tablet 2.5 milligrams. The DNS stated LPN #2 should have followed the physician orders.Review of the facility Physician Order policy dated 7/2023 directed to provide residents with prompt accurate treatment and orders must be documented in the resident's legal electronic medical record.Although requested, a facility policy for medication administration with perimeters was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #22) reviewed for Activities of Daily Living, the facility failed to ensure showers were provided. The findings include:Resident #22 was admitted to the facility in July 2025 with diagnoses that included diabetes and heart disease.The Resident Care Plan dated 10/15/25 identified that Resident #22 was at risk for falling with interventions that directed to keep personal items and the call light within reach.The quarterly MDS dated [DATE] identified Resident #22 had moderately impaired cognition, and required supervision or touching assistance for showers, transfers, bathing, and dressing the lower body.The physician's orders dated 1/1/26 directed weekly showers with the assistance of 1 staff member, every Wednesday on the 3:00 PM - 11:00 PM shift.Review of Resident #22's nurse aide flow sheets dated 1/14/26, 1/21/26, 1/28/26, and 2/25/26 identified NA #4 documented N/A for showers, indicating showers were not applicable.Review of Resident #22's nurse aide flow sheet dated 2/25/26 identified NA #7 documented N/A for shower, indicating shower was not applicable.Interview with Resident #22 on 3/5/26 at 11:00 AM identified that he/she had not received a weekly shower for at least the last 3 weeks. Resident #22 further indicated he/she had only received maybe 2 showers in the last few months. Resident #22 identified for several months that he/she has been requesting additional showers for several months from the nurse aides and nurses, as he/she prefers to shower daily. Resident #22 indicated his/her requests were ignored. Resident #22 indicated he/she would like to receive two showers at least twice per week.Interview with NA #3 for Resident #22 on 3/10/26 at 9:31 AM identified that she works full-time and is assigned to care for Resident #22. NA #3 identified Resident #22 required maximum assistance with showers and could not be left alone. NA #3 identified that she provided Resident #22 with only one shower on 2/4/26.Interview with LPN #3 on 3/10/26 at 11:30 AM identified she works full-time on the 3:00 PM to 11:00 PM shift and is assigned to care for Resident #22. LPN #3 indicated the nurse aides have not reported any refusals of showers by Resident #22 within the past few months. LPN #3 identified that although she had not seen Resident #22 being brought into the shower room, there was no reason why Resident #22 should not have been given his/her weekly shower.Interview and clinical record review with NA #4 on 3/10/26 at 1:53 PM identified that she did not give Resident #22 any showers despite documenting that showers were given. NA #4 indicated that although she was assigned to provide showers to Resident #22, she did not do so because she is pregnant and found it physically difficult. NA #4 identified had not seen Resident #22 being brought into the shower room.Interview with NA #5 on 3/10/26 at 2:11 PM identified that showers are provided to Resident #22 upon request. NA #5 indicated Resident #22 was independent with showering. NA #5 identified that she could not recall whether Resident #22 received showers in February 2026.Interview and clinical record review with the DNS on 3/10/26 at 2:20 PM identified that shower assignments are based on room number, and Resident #22 is scheduled for showers on Wednesday evenings during the 3:00 PM to 11:00 PM shift. The DNS identified there was no documentation indicating that Resident #22 had refused showers. The DNS indicated that if a resident refuses a scheduled shower, the nurse aide is expected to re-approach the resident two to three times during the shift, and if the resident continues to refuse, the nurse aide is to notify the nurse, who will re-approach the resident and document the refusal in a progress note. The DNS indicated she was not aware that Resident #22 was not provided with his/her weekly showers or that Resident #22 requested showers more frequently. The DNS identified that her expectation is the charge nurse ensures nurse aides complete resident showers according to the established schedule. The DNS further identified that if a resident asks for a shower, it should be done, and if a resident wants a shower twice a week, it should be scheduled.Review of the Activities of Daily Living Policy identified residents will be provided with care, treatment and services as appropriate to maintain or improve as able, their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #25) reviewed for personal property, the facility failed to ensure a resident had access to personal property timely. The findings include:Resident #25 had diagnoses that included congestive heart failure, Type 2 Diabetes, and major depression.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had a Brief Interview for Mental Status (BIMS) score of 11 indicative of moderately impaired cognition, did not experience delusions, was dependent with transfers, and required maximal assistance with bed mobility. The Resident Care Plan (RCP) dated 2/11/2026 identified Resident #25 was at risk of falling with interventions that directed to keep personal items within reach and anticipate the resident's needs.Interview with Resident #25 on 3/5/2026 at 11:43 AM identified he/she was missing multiple personal items including a phone. Resident #25 indicated he/she reported the missing items to several staff members, and the Administrator was aware of the missing items.Interview SW #1 on 3/10/2026 at 10:29 AM identified Resident #25 notified her on 3/9/2026 that he/she was missing multiple items, including a cell phone. SW #1 indicated the facility was still searching for the missing items.Interviews with NA #8 and NA #9 on 3/10/2026 at 1:53 PM identified Resident #25's phone was not in his/her room because the phone was sitting on the nurse's station counter for several days. NA #9 identified Resident #25's phone was moved from the nurse station into the supervisor's office because the phone was not holding a charge. Interview and observation with the Director of Nursing Services (DNS) on 3/10/2026 at 2:09 PM identified Resident #25's phone was not in the locked cabinet in the supervisor's office. The DNS identified she thought the phone was given back to Resident #25 a few days ago but was going to check with the nurse managers to inquire when the phone was returned to Resident #25.On 3/10/2026 at 2:22 PM, the DNS indicated she was informed by the supervisor Resident #25's phone had not been returned. Interview with the DNS on 3/11/2026 at 9:45 AM identified Resident #25's phone was located and given to SW #1.Interviews with Resident #25, the DNS, and SW #1 on 3/11/2026 at 1:32 PM identified Resident #25's phone had not been returned to him/her. SW #1 identified the phone was still in her office, and she had not returned it to Resident #25 because the phone needed to be charged.Interview with SW #1 on 3/16/2026 at 9:12 AM identified Resident #25's phone had not been returned to him/her. SW #1 indicated the reason the phone had not been returned to Resident #25 was because she didn't want the phone to be misplaced and the phone had not been charged.Subsequent to surveyor inquiry, on 3/16/2026 at 9:43 AM, Resident #25's phone was returned to him/her, and it was charging in his/her room.Review of the facility's Resident Rights policy identified, in part, that the residents have a right to self-determination, to have the facility respond to his or her grievances and shall retain and use personal possessions to the maximum extent that space and safety permit.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #4) reviewed for Advance Directives, the facility failed to implement Advance Directives according to the resident's expressed wishes. The findings include:Resident #4 had diagnoses that included cardiac arrythmia, end-stage renal disease, and type 2 diabetes.Review of the clinical record identified Resident #4 signed an Advance Directives form on 4/6/2025 indicating he/she wished to be a Full Code (all life-saving measures).A physician's order dated 2/21/2026 directed Do not resuscitate (DNR) and Do not Intubate (DNI).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.Interview and clinical record review with Licensed Practical Nurse (LPN) #4 on 3/11/2026 at 10:14 AM identified Resident #4's code status did not match the signed Advance Directives form dated 4/6/2025 indicating Full Code. LPN #4 indicated that in an emergency, she would first check the signed hard copy and then the electronic health record to verify the physician ordered code status. LPN #4 identified nurses are responsible for placing signed Advance Directives in the paper chart and entering the order into the electronic health record.Interview and clinical record review with Register Nurse (RN) #5 on 3/11/2026 at 10:25 AM identified supervisors are responsible for ensuring a resident's code status order matches their signed Advance Directives form. RN #5 identified Resident #4's signed Advance Directives form did not match the code status order placing Resident #4 at risk of not receiving cardiopulmonary resuscitation in an emergency. RN #5 further identified that this risk existed within the facility and at the dialysis center, which relies on the facility's electronic health record for Resident #4's code status.Interview with the Director of Nursing Services (DNS) on 3/11/2026 at 10:31 AM identified nurses are responsible for reviewing Advance Directives with upon admission, placing the signed Advance Directives form in the paper chart, and entering the order into the electronic health record. The DNS stated supervisors are responsible for ensuring the signed Advance Directive form matches the physician- ordered code status. The DNS identified, although, Resident #4 was recently re-admitted to the facility rather than newly admitted , the process to verify the correct Advance Directives is the same. The DNS identified Resident #4's code status did not match his/her signed Advance Directives form.Subsequent to surveyor inquiry, on 3/11/2026 at 10:57 AM RN #5 entered a physician's order dated 3/11/2026 into Resident #4's electronic health record that directed a Full Code. RN #5 also notified the dialysis center of Resident #4's correct code status.Review of the facility policy titled Advanced Directives undated identified in part that all residents will be asked upon admission if they have Advanced Directives and a copy of the Advanced Directives will be placed in the resident chart.

Based on observation, review of the clinical record, facility documentation, facility policy, and staff interviews, for 1 sampled resident (Resident #8) reviewed for physical restraints, the facility failed to conduct elopement risk assessments for a resident with a Wander Guard alarm to indicate if continued use was appropriate. The findings include:Resident #8 had diagnoses that included depression, anxiety, and stroke. The physician's order dated 5/15/25 directed to place a Wander Guard (wearable bracelet alerts staff by setting off audible alarms) to the right ankle, check placement on every shift, and check function every day on the night shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had intact cognition, had no behaviors, and required use of a wander/elopement alarm less than daily.The Resident Care Plan (RCP) dated 5/26/25 identified Resident #8 was at risk for elopement, due to a history of attempts to leave the facility unattended, impaired safety, and awareness. Interventions included a Wander Guard to the right ankle, check functioning every shift, and providing structured activities, including walking inside and outside the facility.The physician's order dated 5/15/26 directed to check Wander Guard placement every shift. The annual MDS assessment dated [DATE] identified Resident #8 had moderately impaired cognition, had no behaviors, and required use of a wander/elopement alarm daily. Observation and interview on 3/11/26 at 10:48 AM identified Resident #8 was ambulating independently throughout the facility with a Wander Guard bracelet in place on the right ankle. Resident #8 stated he/she attempted to leave the facility approximately one year ago and had not attempted to leave since that time. Resident #8 stated he/she could not recall how long the Wander Guard bracelet had been in place. Resident #8 stated he/she ambulated throughout the facility daily but avoided the front entrance doors to prevent activation of the alarm. Resident #8 stated he/she wanted the Wander Guard bracelet removed.Interview with RN #2 on 3/11/26 at 11:21 AM identified Resident #8 was identified at risk for elopement upon admission, and staff applied a Wander Guard bracelet at that time. RN #2 stated she had not observed any exit-seeking behaviors by Resident #8. RN #2 identified because Resident #8 ambulated independently throughout the facility, the Wander Guard was used for his/safety. Interview and clinical record review with the DNS on 3/11/26 at 12:36 PM identified Resident #8's last elopement assessment was completed on 2/26/25. The DNS identified elopement assessments were required to be completed at least quarterly to indicate if a resident required the use of a Wander Guard. The DNS was unable to explain why the quarterly elopement assessments were not conducted on Resident #8 to determine if he/she still required a Wander Guard. The DNS identified she had not observed any exit seeking behaviors from Resident #8. The DNS identified Resident #8's elopement assessment should had been done quarterly. Subsequent to surveyor inquiry on 3/11/26, the DNS conducted an Elopement Risk Scale assessment for Resident #8, and Resident #8's Wander Guard was discontinued by the physician. The Elopement Risk Scale assessment dated [DATE] at 1:13 PM completed by the DNS identified Resident #8 was not at risk for elopement. Review of the Elopement Prevention policy dated 6/23, identified the facility shall complete a wandering/elopement risk assessment on every resident. Assessments will be conducted upon admission, quarterly and after elopement incidents. It also identified the quarterly elopement assessments would be conducted at the same time that the quarterly Minimum Data Sets (MDS) were completed.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for personal property, the facility failed to report an allegation of misappropriation of property to the State Agency within the required time frame. The findings include:Resident #7 had diagnoses that included Type 2 Diabetes, non-pressure chronic ulcers of the skin, and a history of malignant neoplasm of bladder.The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12 indicative of moderately impaired cognition.The Resident Care Plan (RCP) dated 2/11/2026 identified Resident #7 was at risk for falls with interventions that directed to anticipate the resident's needs and keep personal items within reach.Interview with Person #1 on 3/5/2026 at 10:23 AM, identified he/she notified the Administrator about Resident #7's missing electronic device/tablet approximately one month ago.A review of facility documentation from 1/1/2025 to 3/10/2026 identified no grievances filed regarding missing items or the missing electronic device/tablet, and no State Reportable event was completed for Resident #7's missing device. Interview with Social Worker #1 (SW) on 3/10/2026 at 10:02 AM identified Person #2 (Resident #7's conservator) informed her Resident #7's electronic device/tablet was missing when he/she returned from the hospital. SW #1 indicated she was never told the electronic device/tablet was stolen, only that a replacement was needed. SW #1 identified she did not document the communication with Person #2 in a social service progress note within Resident #7's medical record.Interview with Person #2 on 3/10/2026 at 2:31 PM identified Resident #7 was transferred to the hospital in November 2025, and his/her electronic device/tablet was stolen while he/she was in the hospital. Person #2 indicated he/she notified the Administrator that Resident #7's electronic device/tablet was stolen and was told by the Administrator the facility would investigate the missing device.Interviews with the Director of Nursing Services (DNS), the Administrator, and SW #1 on 3/11/2026 at 9:57 AM identified the facility did not file a State Reportable event for Resident #7's missing electronic device/tablet, and an investigation was not completed.Subsequent to surveyor inquiry, the facility reported an allegation of misappropriation of property to the State Agency on 3/11/2026 at 2:30 PM.Review of the facility Abuse policy identified, in part, that reporting of alleged violations are to be made to the Administrator with notification provided to the state agency, ombudsman, resident representative, law enforcement officials, and primary physician.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #43) reviewed for nutrition, the facility failed to provide a resident with a physician-ordered assistive device for eating. The findings include:Resident # 43 had diagnoses that included Parkinson's Disease, dementia, and bilateral nuclear cataracts.A physician's order dated 12/13/2024 directed adaptive equipment consisting of a divided plate for all meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderately impaired cognition and required set-up assistance for eating.The Resident Care Plan (RCP) dated 2/18/2026 identified Resident #43 was at risk for nutrition problems related to Parkinson's, dementia, impaired mental health, and a significant weight change. Interventions included monitoring/recording/reporting to the Medical Doctor signs and symptoms of malnutrition and providing and serving the diet as ordered.An observation and interview on 3/5/2026 at 12:20 PM identified Resident #19 seated in the dining room with his/her lunch without the benefit of a divided plate, although the meal ticket directed adaptive equipment consisting of a divided plate. SLP #1 identified Resident #43 required the adaptive equipment listed, but the divided plate had not been provided. SLP #1 identified the kitchen was responsible for providing the divided plate.Interview on 3/5/2026 at 12:25 PM with the Director of Dietary identified Resident #43 required adaptive equipment, but the divided plate had not been provided. The Director of Dietary identified that the Cooks are responsible for providing adaptive equipment. The Director of Dietary identified that the divided plate should have been provided to Resident #43 with his/her lunch meal. The Director of Dietary indicated it was an error.Interview on 3/13/2026 at 12:06 PM with [NAME] #1 identified she is responsible for placing food on a divided plate for residents with an order for a divided plate. [NAME] #1 indicated that during tray line, she was made aware that a divided plate was needed for certain residents as the kitchen staff would call the order out to her when reading the ticket. [NAME] #1 identified Resident #43's lunch meal should have been served on a divided plate.Review of the facility's Resident Adaptive Feeding Equipment Changes Policy identified that orders for feeding adaptive equipment should be included on pre-printed dietary tray tickets and staff should check for tray accuracy prior to trays going to the units.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #22) reviewed for activities of daily living, the facility failed to ensure the clinic record was complete and accurate to include personal care. The findings include:a.Resident #22 was admitted to the facility in July 2025 with diagnoses that included diabetes and heart disease.The Resident Care Plan dated 10/15/25 identified that Resident #22 was at risk for falling with interventions that directed to keep personal items and the call light within reach.The quarterly MDS dated [DATE] identified Resident #22 had moderately impaired cognition, and required supervision or touching assistance for showers, transfers, bathing, and dressing the lower body.The physician's orders dated 1/1/26 directed weekly showers with the assistance of 1 staff member, every Wednesday on the 3:00 PM - 11:00 PM shift.Review of the Treatment Administration Records (TAR) identified on 1/7/26, 1/14/26, 1/21/26, and 1/28/26 during the 3:00 PM to 11:00 PM shifts, LPN #3 signed off Resident #22 received his/her weekly shower. Review of the TARs identified on 2/4/26, 2/11/26, 2/18/26, and 2/25/26 during the 3:00 PM to 11:00 PM shifts, LPN #3 signed off Resident #22 received his/her weekly shower. Review of the TAR dated 3/4/26 identified on the 3:00 PM to 11:00 PM shift, LPN #3 signed off Resident #22 received his/her weekly shower.Interview with Resident #22 on 3/5/26 at 11:00 AM identified he/she had not received a weekly shower for at least the last 3 weeks. Resident #22 further indicated he/she had only received maybe 2 showers in the last few months.Interview with LPN #3 on 3/10/26 at 12:21 PM identified she was the charge nurse for Resident #22 on 1 /7/26, 1/14/26, 1/21/26, 1/28/26, 2/4/26, 2/11/26, 2/18/26, 2/25/26, and 3/4/26 from 3:00 PM to 11:00 PM. LPN #3 identified although she never witnessed Resident #22 receiving a shower nor did she confirm with the nurse aides that a shower was provided, she signed off on Resident #22's TARs. b. Review of Resident #22's nurse aide flowsheet dated 1/7/26, identified NA #4 signed off Resident #22 was independent with showers.Review of Resident #22's nurse aide flowsheets dated 1/4/26, 1/21/26, and 1/28/26 identified showers were documented as N/A (the key code indicated NA was not applicable).Review of Resident #22's nurse aide flowsheet dated 2/11/26, identified NA #5 signed off Resident #22 was independent with showers.Review of Resident #22's nurse aide flowsheets dated 2/18/26 and 2/25/26, identified showers were documented as N/A (the key code indicated NA was not applicable).Review of Resident #22's nurse aide flowsheets dated 2/1/26 through 2/28/26 identified activities of daily was not documented on 14 shifts over 28 days. Review of Resident #22's nurse aide flowsheets dated 3/1/26 through 3/9/26 identified activities of daily was not documented on 4 shifts over 9 days. Interview with NA #3 for Resident #22 on 3/10/26 at 9:31 AM identified that she works full-time and is assigned to care for Resident #22. NA #3 identified she was trained on how to document on the nurse aide flowsheet. NA #3 identified Resident #22 required maximum assistance with showers and could not be left alone. NA #3 identified she provided Resident #22 with only one shower on 2/4/26. Interview and clinical record review with NA #4 on 3/10/26 at 1:53 PM identified that she did not give Resident #22 any showers despite documenting that showers were given.Interview with NA #5 on 3/10/26 at 2:11 PM identified when she documents on flowsheets a 6 means independent for showers, and NA means no shower was given that day. NA #5 indicated Resident #22 was independent with showering. NA #5 identified that she could not recall whether Resident #22 received showers in February 2026.Interview and clinical record review with the DNS on 3/10/26 at 2:30 PM identified documentation must be complete and accurate to reflect care provided. The DNS identified LPN #3's signature on Resident #22's TARs indicated Resident #22 received his/her weekly shower. The DNS identified the documentation was inaccurate because LPN #3 only conducted the skin evaluation and did not ensure Resident #22's shower was provided.Interview with Administrator on 3/10/26 at 3:00 PM identified her expectation is for nurses and nurse aides to document in the electronic medical record the complete and accurate information every day.Interview with the DNS on 3/11/26 at 9:20 AM identified nurse aides are expected to document in the medical record throughout the day and ensure it is completed by the end of their shift. The DNS identified that the documentation must be both complete and accurate and staff should only document what they did for the residents. The DNS stated she is responsible for ensuring the nurse aides complete their documentation by shift end.Review of facility Charting and Documentation Policy identified services provided to the residents, progress towards the care plan goals, or any changes in the residents' medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record as indicated. Documentation in the medical record will be objective, complete, and accurate. Entries may only be recorded in the resident's clinical record by licensed personnel in accordance with state law facility policy. Certified nursing assistants may only make entries in the residents' medical chart as permitted by the facility policy.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for personal property, the facility failed to conduct a complete and thorough investigation for an allegation of misappropriation of property. The findings include:Resident #7 had diagnoses that included Type 2 Diabetes, non-pressure chronic ulcers of the skin, and a history of malignant neoplasm of bladder.The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12 indicative of moderately impaired cognition.The Resident Care Plan (RCP) dated 2/11/2026 identified Resident #7 was at risk for falls with interventions that directed to anticipate the resident's needs and keep personal items within reach.Interview with Person #1 on 3/5/2026 at 10:23 AM, identified he/she notified the Administrator about Resident #7's missing electronic device/tablet approximately one month ago.Review of facility documentation, clinical record, and Social Service progress notes from 1/1/2026 through 3/10/2026 was unable to provide documentation to reflect an investigation was completed for Resident #7's alleged stolen electronic device/tablet.Interview with Social Worker #1 (SW) on 3/10/2026 at 10:02 AM identified Person #2 (Resident #7's conservator) informed her Resident #7's electronic device/tablet was missing when he/she returned from the hospital. SW #1 indicated she was never told the electronic device/tablet was stolen, only that a replacement was needed. SW #1 identified she did not document the communication with Person #2 in a social service progress note within Resident #7's medical record.Interview with Person #2 on 3/10/2026 at 2:31 PM identified Resident #7 was transferred to the hospital in November 2025, and his/her electronic device/tablet was stolen while he/she was in the hospital. Person #2 indicated he/she notified the Administrator that Resident #7's electronic device/tablet was stolen and was told by the Administrator the facility would investigate the missing device.Interviews with the Director of Nursing Services (DNS), the Administrator, and SW #1 on 3/11/2026 at 9:57 AM identified the facility did not complete an investigation regarding Resident #7's missing electronic device/tablet.Subsequent to surveyor inquiry, the facility initiated an investigation and reported an allegation of misappropriation of property to the State Agency on 3/11/2026 at 2:30 PM. Review of the facility Abuse policy identified in part, that reporting of alleged violations are to be made to the Administrator with notification provided to the state agency, ombudsman, resident representative, law enforcement officials, and primary physician. Unless otherwise requested by the resident, the social service representative will provide the administrator and the director of nursing services with a written report of his/her findings through social service progress notes in the medical record.

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure staff were provided education on the benefits and risk associated with COVID-19 vaccination and failed to ensure staff were offered the COVID-19 vaccine or information on obtaining it. The findings include:Interview with LPN #1 (Infection Preventionist) on 3/10/26 at 8:12 AM identified the facility no longer offered COVID-19 vaccines to staff at the facility. LPN #1 identified the previously completed staff consent forms were shredded. LPN #1 identified staff were not offered COVID-19 vaccines or provided with education on the benefits and risks associated with COVID-19 vaccine. On 3/10/2026 at 8:26 AM, a request was made to the Administrator, Director of Nursing (DNS), and Infection Preventionist (IP) for COVID-19 staff education documentation. The facility did not provide documentation showing staff education on COVID-19 vaccination, including information on vaccine availability or where staff could receive the vaccine.Interview the Physical Therapist #1 (Director of Rehabilitation) on 3/10/26 at 10:22 AM identified during the facility's influenza clinic in October 2025, staff were informed that the facility would no longer provide the COVID-19 vaccine. Review of the facility Nursing and Infection Prevention Policy identified annual reviews were completed on 12/6/2024 and 12/2/2025. Review of facility Staff Vaccines: Influenza, Pneumococcal. and COVID-19 immunizations policy dated 8/23, identified all facility staff are to be fully vaccinated against COVID-19 with any of the approved vaccines unless there is a documented medical or religious exemption on file.

Based on facility documentation review, facility policy review, and interviews, the facility failed to address the Resident Council's repeated requests regarding the use of personal items for the Resident Council group reviewed. The findings include: Review of the Resident Council meeting minutes dated 12/10/25 identified residents inquired about having and using a hair dryer. Review of the Resident Council meeting minutes dated 1/13/26 identified residents again requested the use of a hair dryer. The meeting minutes identified staff informed the residents that blow dryers are not permitted due to fire hazard risk.A Resident Council Meeting was held on 3/9/26 at 12:56 PM with Residents #17, # 29, #40, #52, and #77. The residents identified hair dryer use was discussed in both December and February meetings, and they were told each time hair dryers were not permitted due to fire hazard concerns. The residents identified the Director of Maintenance had informed the Director of Recreation that residents still could not have hair dryers.Interview with the Assistant Maintenance Director on 3/16/26 at 12:07 PM identified he was instructed by the Director of Maintenance that residents were not allowed to have hair dryers because they are fire hazards. The Assistant Maintenance Director indicated a hair dryer could cause a fire if dropped in water, could short-out an electrical circuit, and it was against state regulations, though he was unable to identify the specific regulation. Interview with the Director of Recreation on 3/16/26 at 12:12 PM identified she records the Resident council meeting minutes. The Director of Recreation identified she recalled Resident #52, who is alert and oriented, requesting a hair dryer. The Director of Recreation indicated after speaking with the Director of Maintenance, she informed the residents that hair dryers were not allowed due to fire hazard concerns. The Director of Recreation identified when the issue was raised again in February 2026, she informed residents that the Director of Maintenance had already declined the request, so she did not consult him again. The Director of Recreation identified she did not report the issue to the Administrator.Interview with the Administrator on 3/16/26 at 12:20 PM indicated she became aware of Resident #52's hair dryer request only after reviewing the Resident Council minutes. The Administrator indicated staff had not asked her whether residents were permitted to have a hair dryer, and she believed the Resident Council went directly to Maintenance. The Administrator identified she did not know whether residents are permitted to have a hair dryer. and viewed the issue as a life safety matter.Review of the Resident and Facility Handbook identified personal possessions that are electrical equipment brought into the facility must be inspected and tagged by the maintenance staff between 8:00 AM and 4:00 PM Monday through Friday prior to usage. (Please note: Fire and Safety Code prohibit the use of extension cords.)

Based on review of the clinical record, facility policy, observations, and interviews for 1 of 3 residents (Resident #2) reviewed for pressure ulcers, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care for a resident on precautions. The findings include: Resident #2 had diagnoses that included quadriplegia, Stage 4 pressure ulcer of the left and right buttock, Stage 4 pressure ulcer of sacral region, flaccid neuropathic bladder, and carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA) (a type of bacteria that causes skin infections and is resistant to many antibiotics, making it harder to treat).The annual MDS assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition, and dependent with bed mobility and transfers. The MDS further identified Resident #2 had three (3) stage 4 pressure ulcers.The physician's order dated 3/2/2026 directed Enhanced Barrier Precautions (EBP) related to chronic wounds, a suprapubic catheter, colostomy, history Extended-spectrum beta-lactamases (ESBL) (an enzyme with resistance to some antibiotics) and MRSA, and use of PPE per instruction on signage on every shift.The Resident Care Plan (RCP) dated 3/3/2026 identified Resident #2 was on EBP related to chronic wounds, a suprapubic catheter, colostomy, history of ESBL and MRSA with interventions that directed to maintain EBP per facility policy.Observation on 3/9/2026 at 1:03 PM noted Resident #2 had signage outside of his/her room regarding the need for EBP and directed during high contact activities a gown and gloves must be worn.Observation and interviews with NA #1 and NA #2 on 3/9/2026 at 1:04 PM identified Nurse Aide (NA) #1 and NA #2 were providing personal care to Resident #2 and were not wearing the appropriate PPE (no isolation gowns). NA #1 and NA #2 identified they had provided a bed bath to Resident #2 without the benefit of isolation gowns. NA #1 and NA #2 identified they were aware Resident #2 was on EBP. NA #1 and NA #2 indicated they forgot to put on gowns, which they should have worn.Interview with the DNS on 3/9/2026 at 1:30 PM identified for residents on EBP, nursing staff should don an isolation gown and gloves when providing personal care or with high contact activity. The DNS indicated all staff had been educated on EBP. The DNS identified NA #1 and NA #2 should have known what PPE was required and should have donned an isolation gown when providing care to Resident #2. The DNS identified that she was unsure why NA #1 and NA #2 did not wear appropriate PPE when providing personal care to Resident #2.Review of the facility Enhanced Barrier Precautions policy identified in part that enhanced barrier precautions will be used for residents with infection or colonization of a Multidrug Resistant Organism, or with wounds or indwelling medical devices, regardless of Multi Drug Resistant Organism colonization status. EBP employs gown and glove use during high contact resident care activities.

Based on observations, interviews, and review of facility policy, the facility failed to post notice of the availability of the survey results in areas of the facility readily accessible to residents, family members, and legal representatives of residents. The findings include: Observations on 3/5/26 at various times identified the survey team could not locate any notices about the availability of the facility's survey results.Interviews with Resident Council members (Residents #17, #29, #40, #52, and #77) on 3/9/26 at 12:56 PM identified they did not know what the state survey results were or where they were located. The residents indicated staff had never reviewed this information with them individually or during Resident Council meetings.Observations on 3/10/26, 3/11/26, and 3/16/26 at various times identified the survey team could not locate any notices regarding the availability of the survey results.Interview with NA #6 on 3/16/26 at 9:22 AM revealed she did not know where the state survey results were located.Interview with NA #7 on 3/16/26 at 9:24 AM identified she believed state survey results should not be left out for residents or visitors. NA #7 indicated she would direct anyone requesting the results to ask the Director of Nurses (DNS).Interview with LPN #3 on 3/16/26 at 9:27 AM identified she believed the state survey results were kept in a binder at the desk but must be requested.Interview with LPN #4 on 3/16/26 at 9:30 AM identified she did not know where the state survey results were located.Interview with RN #2 (day shift supervisor), on 3/16/26 at 9:32 AM identified she did not know where the state survey results were located.Interview and observation with the DNS on 3/16/26 at 9:33 AM, the DNS indicated the survey results were kept in the front lobby. The DNS searched the reception and lobby areas but was unable to locate the results.Interview with Receptionist #1, with the DNS present, on 3/16/26 at 9:35 AM identified the results were not kept at the reception desk, and she did not know their location.Interview and observation with the Administrator, with the DNS present, on 3/16/26 at 9:36 AM identified the state inspection reports for the last three years were kept behind the reception desk. The Administrator pointed to a sign posted on the side wall above the front desk indicating a most recent copy of our state results can be found at the reception desk. The Administrator retrieved a binder labeled state survey binder, which contained complaint reports dated 10/24/23, 2/22/24, 12/16/24, and 3/5/25. The DNS stated she had not noticed the sign until the Administrator pointed it out. The sign was posted on a side wall behind the reception area, approximately 5 feet 4 inches from the floor, and not at wheelchair eye level.Review of the facility Resident Rights policy identified the guidelines are to follow the federal and state laws that guarantee certain basic rights to all residents at the facility and these include the right to examine the survey results.

Based on observation, review of clinical records, facility documentation, interviews, and policies, for six (6) of sixteen (16) residents, who required total assistance with bathing, incontinent care, and repositioning, (Resident #60, #27, #44, #4, #77, and #17), the facility neglected to provide the necessary care resulting in Immediate Jeopardy, and for one of three residents reviewed for abuse (Resident #45), the facility failed to ensure that the resident was free from abuse. Additionally, for 9 residents (Resident #5, 23, 32, 35, 39, 40, 47, 53, 63) who were not provided incontinent care on 8/19/21 during the 3:00 PM - 11:00 PM shift, the facility failed to ensure the residents was free from neglect. And for 1 resident (Resident #79), who rang the call bell for over 2 hours during the 11:00 PM - 7:00 AM shift without a response, the facility failed to ensure the resident was free from neglect. The findings include Please Cross Reference F 725 The findings include: 1. Resident #60's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 8/1/21 identified the Resident had an ADL deficit related to Dementia. Interventions included assist with ADL's as needed. On 9/4/21 at 12:35 PM during tour of C wing, Resident #60 was observed placing a plate of food in the top drawer of the dresser. Upon surveyor inquiry, NA #6 stated, oh s/he always does that. NA #6 was observed to remove the plate of food from the dresser drawer. At 12:38PM, the commode near R #60's bed was soiled with feces including the floor. The Resident was observed with visible feces on his/her hands. NA #6 was heard to say to the LPN on the unit, in the presence of the Administrator, the Resident needs to be cleaned and we need housekeeping. Observation at 12:55 PM noted NA #6 walking down the hallway and reported to the nurse she was going to lunch. Interview at that time with NA #6 stated that she did not provide care to the Resident because s/he's not my Resident and she (NA #6) needed to go to lunch. The NA further stated that she was going to tell the Resident's Aide when she found her, that Resident #60 needed incontinent care. The facility failed to provide care to the Resident for at least seventeen (17) minutes although numerous staff members were aware the Resident was incontinent and had feces on his/her hands. Interview with the Administrator and LPN #3 on 9/4/21 at 12:55 PM stated NA #6 should have provided care to the Resident when s/he was observed with feces on his/her hands. After surveyor inquiry, the NA #6 was instructed to provide incontinent care to the Resident and then suspended pending investigation. Interview with the Administrator and DON on 9/5/21 at 2:00 PM stated that although they removed NA #6 from the schedule, they had not yet started the investigation related to neglecting to provide care to Resident #60. 2. On 9/4/21 during a tour of the facility starting at 11:45 AM, the following was observed: On the A wing- 15 of the 26 Residents were observed in bed, B wing- 8 of 33 Residents were observed in bed, and on the C wing- 12 of the 33 Residents were observed in bed. Interviews with the staff on the units during tour stated some Residents prefer to stay in bed until after lunch and they were doing the best they could. On 9/4/21, the facility submitted an action plan to the Department to address the care needs of the Residents. The facility identified that the Supervisor would conduct rounds on Residents every two (2) hours to ensure timely care was provided and the Charge Nurses were to assist with rounds on the units. 3. Resident #27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 6/30/21 identified the resident had bowel and bladder incontinence related to impaired cognition and mobility. Interventions included offer toileting on rounds. On 9/5/21 at 10:30 AM, Resident #27 was observed lying in bed on his/her back. Observations at 12:01 PM noted the Resident was in the same position, in bed lying on his/her back. Observation with RN #2 (Supervisor) at 12:01 PM identified that the Resident's brief and bottom sheet were saturated with urine. The brief had areas of dark and light yellow, and visible brownish colored rings. The Resident's bottom bed sheet was noted with darkened rings of urine. Interview at that time with RN #2 stated that she was responsible to cover the NA's assignment due to a call out and for the first 2 hours of the shift (7AM-9AM) she was not able to provide any personal care to any residents. RN #2 stated she was trying to get breakfast trays out and oversee the building during that time. Interview with NA #1 at 12:01 PM stated she had yet to provide any care to the Resident because she was the only NA on the unit. RN #2 and NA #1 further stated during the period of 7:00 AM until 12:01 PM, the Resident was boosted in bed for breakfast but not checked for incontinence. Interview with the DON on 9/5/21 at 1:30 PM stated that Residents should be checked for and provided incontinent care every two hours. 4. Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS dated [DATE] identified that the Resident had severe cognitive impairment, required extensive assistance of two for bed mobility, extensive assistance for bathing, was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, and had Incontinent Associated [CONDITION(S)] (IAD). Interview with Nurse Aide #8 on 9/6/21 at 5:45 PM identified that she had entered the resident's room around 5:00 PM to provide incontinent care and found the Resident with the lunch tray still in front of h/her and the resident covered in food particles. NA #8 further stated that she provided incontinent care for the Resident at 5:00 PM and identified that the incontinent brief was saturated with urine, and the bed linens had also been saturated with urine requiring a complete linen change of the bed. Interview with NA #1 on 9/6/21 at 7:40 PM identified that she had worked the 7:00 AM to 3:00 PM shift, there were only two (2) NA's for 33 residents and the other NA had left at 12:00 PM leaving her to care for 33 Resident's from 12:00 PM until 2:00 PM when her shift ended. No other NAs worked on the unit from 2:00 PM to 3:00 PM. NA #1 stated that Resident #44 was only provided with his/her meals during her shift and although she adjusted the position of the Resident at meal time to prepare for the meal, she did not provide any other positioning, bathing, or incontinent care for the entire 7:00 AM to 3:00 PM shift (a total of 8 hours). NA#1 stated that she did not inform the Charge Nurse or the Supervisor that she could not provide care for Residents #44 because that is the usual staffing pattern, and there have been times where she has worked the 7:00 AM to 3:00PM shift for 33 residents by herself, and the administration is already aware of the staffing issues. 5. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS dated [DATE] identified that the resident was cognitively intact, required extensive assist of two staff for bed mobility, total care for bathing, was frequently incontinent of bladder, always incontinent of bowel, and was at risk for skin breakdown. A care plan dated 7/27/21 identified that the resident was at risk for pressure ulcers related to immobility and incontinence with interventions to keep skin clean and dry, to offer toileting on rounds, and to encourage repositioning four times a shift. Observation with the Director of Nurses (DON) on 9/6/21 at 6:35 PM of Resident #4's incontinent care identified that when the Nurse Aide rolled the Resident over to remove the incontinent brief, the brief was saturated with urine that was brown in color and had a strong urine odor and when NA #1 removed the brief it tore in half. Interview with the Resident on 9/6/21 at 6:15 PM identified that she had last had care at 5:00 AM and she had been wet all day. Interview with the Director of Nurses at the time of the observation identified that it would seem that the Resident had been not been provided with incontinent care for at least 3-4 hours and should be provided with incontinent care every 2 hours. Interview with NA #1 on 9/6/21 at 7:40 PM identified that she had worked the 7:00 AM to 3:00 PM shift, there were only two (2) NA's for 33 Residents and the other NA had left at 12:00 PM leaving her to care for 33 Residents from 12:00 PM until 2:00 PM when her shift ended. No other NAs worked on the unit from 2:00 PM to 3:00 PM. NA #1 stated that Resident #4 was only provided with his/her meals during her shift and although she adjusted the position of the Resident at meal time to prepare for the meal, she did not provide any other positioning, bathing, or incontinent care for the entire 7:00 AM to 3:00 PM shift (a total of 8 hours). NA#1 stated that she did not inform the Charge Nurse or the Supervisor that she could not provide care for Residents #4 because that is the usual staffing pattern, and there have been times where she has worked the 7:00 AM to 3:00PM shift for 33 residents by herself, and the administration is already aware of the staffing issues. 6. Resident #77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A five (5) day MDS dated [DATE] identified that the Resident had severe cognitive impairment, required total care of two staff for bed mobility, required extensive assistance with bathing, was frequently incontinent of bladder, had pressure ulcers, and was at risk for further pressure ulcers. A care plan dated 8/23/21 identified that the Resident was at risk for pressure ulcers related to history of pressure ulcers, incontinence, impaired mobility, and refusing care at times, with interventions that included to assist with repositioning 4 times a shift, and to keep skin clean and dry. Review of wound sheets dated 9/2/21 identified that the resident's pressure ulcers were present on admission, and included the following, the resident had a stage II pressure ulcer to the left and right heel, the right lateral ankle, and the left lateral foot. The wound sheet further identified the Right greater trochanter had a stage III pressure ulcer, and the coccyx had a stage IV pressure ulcer. Observation with the DON on 9/6/21 at 6:00 PM of Resident #77's incontinent care identified that the incontinent brief was saturated with brown colored urine, and the bed linens beneath the incontinent brief had a large brown stain. Interview with the DON at the time of the observation identified that the diaper appeared to be saturated in urine, and the brown stain was most likely dried urine. The Resident's perineal area had redness and the Resident's buttocks had blanchable redness. Interview with Nurse Aide (NA) #1 on 9/6/21 at 7:40 PM identified that she had worked the 7:00 AM to 3:00 PM shift and there were only two (2) NA's for 33 Residents, and the other NA had left at 12:00 PM, leaving her the only NA until 2:00 PM when her shift ended. NA #1 stated that she entered Resident #77's room on 2 occasions to offer care, which the Resident refused, however she did not report the refusals to the Charge Nurse, although she was aware that she should have. Furthermore, NA #1 stated she was aware that the Resident should be given incontinent care every 2 hours (4 times a shift), and she was not able to go back to the Resident's room because she did not have time to do so. NA #1 identified that Resident #77 was provided with repositioning at mealtime, but otherwise she did not provide positioning, incontinent care, or bathing for the entire 7:00 AM to 3:00 PM shift. Interview with Licensed Practical Nurse (LPN) # 1 on 9/7/21 at 4:14 AM identified that he was the charge nurse for Resident #77 on 9/6/21 during the 7:00 AM to 3:00 PM shift. LPN #1 stated that NA#1 did not report that the Resident refused care on the 7:00 AM to 3:00 PM shift. LPN#1 stated that the Resident does refuse care, but if it had been reported to him, he would have gone in and talked to the Resident, which would usually result in h/her accepting care. 7. Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A re-admission assessment dated [DATE] identified that the Resident was alert to person only, required total care with bathing, toileting, extensive assistance with mobility, and was incontinent once or more per shift. A care plan dated 9/6/21 identified that the Resident had potential for pressure ulcers related to incontinence and immobility with interventions that included to assist with toileting as needed, assist with repositioning 4 times a shift, and pressure reducing cushion to the wheelchair and mattress to the bed. Interview with NA #8 on 9/6/21 at 5:45 PM identified that she had entered the Resident's room around 5:30 PM to provide incontinent care, and identified that the incontinent brief was saturated with urine, and the bed linens had also been saturated with urine requiring a complete linen change of the bed. Interview with NA #9 on 9/6/21 at 8:00 PM identified that she had worked the 11:00 PM to 7:00 PM shift from 9/5-9/6/21, and that she had provided incontinent care and repositioning care to Resident #4 and Resident #77 around 5:00 AM. NA #9 stated that NA #10 was assigned to Resident #17 and #44 and did last rounds at 5:00 AM. Multiple attempts were made to reach NA #10 but were unsuccessful. Interview with NA #1 on 9/6/21 at 7:40 PM identified that she had worked the 7:00 AM to 3:00 PM shift, there were only two (2) NA's for 33 residents and the other NA had left at 12:00 PM leaving her to care for 33 Resident's from 12:00 PM until 2:00 PM when her shift ended. No other NAs worked on the unit from 2:00 PM to 3:00 PM. NA #1 stated that Resident #17 was only provided with his/her meals during her shift and although she adjusted the position of the Resident at meal time to prepare for the meal, she did not provide any other positioning, bathing, or incontinent care for the entire 7:00 AM to 3:00 PM shift (a total of 8 hours). NA#1 stated that she did not inform the Charge Nurse or the Supervisor that she could not provide care for Residents #17 because that is the usual staffing pattern, and there have been times where she has worked the 7:00 AM to 3:00PM shift for 33 residents by herself, and the administration is already aware of the staffing issues. NA #1 further stated that it was impossible to provide care to all 33 Residents on the unit including Resident #4, #17, #44, and #77 who all required turning, repositioning and incontinent care every 2 hours. Interview with the Director of Nurses on 9/6/21 at 6:36 PM identified that she had been in the building since 11:00 AM on 9/6/21, and was unaware that there were only 2 NA's on the B wing, was unaware that there was only 1 NA on the B wing from 12:00 PM to 2:00 PM, and that there were no Aides on the B wing from 2:00 PM to 3:00 PM. The DON identified that the Resident's should have been provided with bathing, incontinent care, and repositioning every 2 hours. The DON further identified that she had not assisted with any care on any of the units, she stated that if they need help, they will let me know. Interview with Registered Nurse (RN) #1 on 9/7/21 at 10:30 AM identified that she was the Nursing Supervisor on 9/6/21 for the 7:00 AM to 3:00 PM shift, and was aware of the staffing issue on the B wing, and she had tried to contact all of the staffing agencies and called all of the staff and no one was able to come in that day. RN #1 identified that she had provided care to Resident #79 throughout the shift but did not provide any care for any other residents on B wing. Interview with LPN #1 on 9/7/21 at 4:14 AM identified that the staffing on 9/6/21 for the 7:00 AM to 3:00 PM shift on 9/6/21 was not unusual, and he helps as much as he can, but on 9/6/21 he did not provide any care to Resident #4, #17, #44, or #77, nor was he informed by NA#1 that she could not complete her assignment, if he had been informed he would have done his best to help her. All residents had a skin audit on 9/6/21 and no new areas of skin integrity impairment were identified. Residents #4, #17, #44, and #77 were last provided incontinent care turning and repositioning at approximately 5:00 AM on 9/6/21 and were then provided incontinent care and positioning between 5:00 PM and 6:00 PM by the 3:00 PM to 11:00 PM shift. The Resident's did not receive incontinent care and positioning for 12 and 13 hours. Although the facility submitted a plan on 9/4/21 that identified the Supervisors would conduct rounds every two hours, Charge nurses to assist with rounds on the units, and NA's to perform rounds to assigned residents every two hours and as needed, review of the audits dated 9/5/21 and 9/6/21 failed to identify the audits were consistently completed. Review of the audit results with the RN Supervisor (RN#2) on 9/5/21 at 10:00 AM identified she has been unable to make rounds every two hours in accordance with the action plan because of short staffing. Interview with the DON on 9/5/21 at 12:40 PM stated that staff education began on 9/4/21 to address the timeliness of providing care, audits were developed to monitor care and the Supervisors were expected to complete these audits to ensure care was provided every two hours. Review of the audits with the Administrator on 9/6/21 at 6:30 PM verified that the audits were incomplete for 9/5/21 and 9/6/21. The Administrator identified that she was unsure if they were done or not, as the DON had told the staff to pass along the need to do the audits in shift report. Review of the Activity of Daily Living (ADL) policy identified that the residents will be provided with ADL's with the support and assistance they need. Review of the abuse/neglect policy identified all Residents have the right to be free from physical abuse and neglect. The policy identified neglect is any failure to provide goods or services necessary to avoid physical harm or mental anguish. On 9/7/21, the facility submitted a revised action plan to address the failure to provide care to residents in a timely manner which included: Education that care would be provided to Residents every two (2) hours and as needed, Supervisors and Charge Nurses on each wing (A, B, C) would verify care was provided then document which resident was observed utilizing the audit tool. All NAs would be reeducated that care would be provided every two hours and as needed and immediately report if a resident refuses care and if the NA cannot complete their assignment. Care audits will be done daily for a week, weekly for a month, and monthly for 3 months to monitor that care is being provided then be reviewed at the Quality Assurance meetings. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated. 8) R #45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified the resident with severe cognitive impairment, rejection of care, and supervision to limited assistance with ADL's. The RCP dated 7/19/21 identified the resident used [CONDITION(S)] medications related to behavioral management. Interventions include administer medications as ordered, monitor target behaviors, encourage resident to express feelings and psych follow up. Facility documentation dated 8/26/21 at 10:00 PM noted a staff to resident altercation. NA (#11) pushed R #45 by linen closet and kept antagonizing the resident. The documentation identified that the RN Supervisor heard yelling and saw NA #11 and resident standing by wall and the resident lunged forward at NA, the NA was yelling at the resident and pushed the resident. The documentation identified the NA left the unit and came back 3 times and got in the face of the resident and was yelling at the resident. The documentation further identified the allegation was not substantiated as the resident was the aggressor and the agency NA had a reactionary response to the situation. Review of Nurse's notes dated 8/26/21 at 11:57 PM noted that yelling was heard in hallway at approximately 10:00 PM and noted R #45 standing up by wall and attempting to go towards NA who was yelling and stating, I'm sick of you, come and get it. The note identified the RN told the NA to leave the unit. The note identified the NA came back to the unit 3 times and one time the NA went into R #45's room. Interview with RN #2 (RN Supervisor) on 9/4/21 at 2:30 PM stated that she was at the nursing station when she heard yelling in the A wing hallway. RN #2 stated that she ran to the unit and saw R #45 standing against the wall near the linen closet and saw NA #11 standing in front of the resident yelling at him/her get out of her face and leave me alone. RN #2 stated that she immediately separated the resident and NA and told the NA to leave the unit. RN #2 stated that while she was assessing the resident the NA came back towards the resident making a fist with one hand and punching it into the other stating I'm gonna get you. RN #2 stated the NA was very aggressive towards the resident and she had to stand between the resident and NA. Interview with NA #3 on 9/4/21 at 3:10 PM stated that she was at the linen closet and R #45 was behind the door and grabbed her arm, then NA #11 came to the linen closet and told the resident to leave me alone. NA #3 stated that the resident made a comment to NA #11 and NA #11 told the resident get up, get up and do something about it. NA #3 stated the resident stood up and NA #11 put her hands on the resident's chest and shoved the resident into the wall. NA #3 stated that the RN Supervisor (RN #2) came running down and told NA #11 to leave the unit and was trying to calm the resident down and get the resident back into the wheelchair. NA #3 stated that NA #11 kept coming back towards the resident calling the resident names and making a fist and punching it into her other hand. NA #3 stated that at no time did the resident touch NA #11. Interview with LPN #7 on 9/10/21 at 12:17 PM stated that she was at the nursing station when she heard a loud commotion going on down the hallway and she heard NA #11 telling the resident I'm tired of you picking on me, talking smack. LPN #7 stated she saw NA #11 slapping her fists into the palm of her other hand and telling the resident if you want to do something stand up. LPN #7 stated she saw the resident stand up from the wheelchair and the NA placed her hands on the resident and pushed the resident across the hall into the wall. LPN #7 stated that she told the Supervisor what happened, and she and the supervisor went down the hallway. LPN #7 stated that at no time did she see the resident touch the NA. Interview with NA #11 on 9/10/21 at 12:30 PM stated that she was getting linen out of the closet when R #45 was there and swearing at her. NA #11 stated that the resident stood up and grabbed my neck and arm choking me. NA #11 stated she pushed the resident off her and was told she had to leave. NA #11 further stated that at no time did she touch the resident except to take his/her hands off her. Interview with LPN #6 on 9/10/21 at 12:47 PM stated that she was in the hallway doing her medication pass when NA #3 called her to say R #45 had his hands on her arms. LPN #6 stated to the resident to remove his/her hands and the resident did. LPN #6 stated that she heard arguing and saw R #45 at the linen closet pushing the wheelchair petals into the door bumping NA #11. LPN #6 stated that she heard NA #11 saying to the resident come on man, and she told the resident to move away. LPN #6 stated within seconds they were arguing again and heard NA #11 saying I'm tired of you always messing with me. LPN #6 stated she told the resident again to move away. LPN #6 stated that she observed the NA making a fist and punching her other hand and the resident stated what you gonna do, don't make me stand up. LPN #6 stated that NA #11 said stand up, stand up. LPN #6 stated the resident stood up and lunged towards NA #11, putting his/her hands on the NA's left shoulder and on the top of the chest below the neck, and NA #11 pushed the resident off her onto the wall across the hall. LPN #6 stated that the other nurse and supervisor came, and the resident and NA were separated. LPN #6 stated that the resident is unstable on feet and she was not sure if the resident lunged toward the resident or was off balance. The facility failed to ensure that Resident #45 was free from abuse. Review of the abuse/neglect policy identified all Residents have the right to be free from abuse. 9. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse aide care card identified to check Resident #5 for incontinence on rounds and wash, rinse and dry perineum, change clothing as needed after incontinence episodes and encourage Resident #5 to participate with ADLs as able. The quarterly MDS dated [DATE] identified Resident #5 had severely impaired cognition, required total assistance with toilet use, and was always incontinent of urine and stool. Review of the nurse aide flowsheet dated 8/19/21 on the 3:00 PM - 11:00 PM shift identified toilet use (incontinent care) activity did not occur. The August 2021 nurse aide flowsheet failed to reflect complete documentation for all shifts. The care plan dated 8/11/21 identified Resident #5 has bladder incontinence related to confusion, impaired mobility, inability to communicate needs, and physical limitations. Interventions included to check for incontinence on rounds. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Interview with RN #3 on 9/2/21 at 5:36 PM identified on 8/19/21 he was notified by LPN #9 and NA #14 that 9 residents were found soaked, saturated, and soiled with urine or feces when rounds were made at the beginning of the 11:00 PM - 7:00 AM shift. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/19/21 at the beginning of the 11:00 PM - 7:00 AM shift during her round she observed Resident #5's bed linens were saturated with urine, so she provided Resident #5 a bed bath and changed the bed linen. NA #14 indicated after she provided care to Resident #5, she notified LPN #9 and RN #3 that Resident #5 was soiled and saturated and left in a urine-soaked bed. Interview with LPN #9 on 9/7/21 at 8:57 AM identified when she made round on 8/19/21 at the beginning of her shift on the 11:00 PM - 7:00 AM she and NA #14 observed Resident #5 bed linens were saturated with urine, and NA #14 provided Resident #5 with a bed bath and changed the bed linen. LPN #9 indicated she notified RN #3 that Resident #5 bed was soiled and saturated and left in a urine-soaked bed. Interview LPN #9 on 9/7/21 at 9:00 AM identified after care was provided to Resident #5, she and NA #14 made round and observed a total of 9 residents that were saturated and soiled with urine or feces. 10. Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse aide care card identified to offer Resident #23 the bed pan/commode every 2 hours. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition and required supervision with toilet use and was always continent of urine and stool. The care plan dated 6/22/21 identified Resident #23 has an ADL self-performance and mobility deficit related to deconditioning left sided weakness. Interventions failed to reflect how peri-care was provided. Review of the August 2021 nurse aide flowsheet identified toilet use activity did not occur. Additionally, documentation was incomplete for all shifts. Interview LPN #9 on 9/7/21 at 9:00 AM identified after care was provided to Resident #5, she and NA #14 made round and observed a total of 9 residents that were saturated and soiled with urine or feces. Resident #23 and his/her bed linens were saturated with urine, so she provided Resident #23 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #23 and the bed linen was saturated with urine. LPN #9 indicated NA #14 provided Resident #23 with a bed bath and changed the bed linen. 11. Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse aide care card identified to offer Resident #32 to the toilet at 3:00 AM rounds. Instruct Resident #32 to use bed pan for toileting. The care card failed to reflect how resident uses the toilet during the day and evening. The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, required extensive assistance with toilet use and was frequently incontinent of urine and stool. Review of the August 2021 nurse aide flowsheet identified Resident #32 was continent. The flowsheet failed to reflect complete documentation for all shifts. The care plan dated 8/19/21 identified Resident #32 had an ADL self-care performance and mobility deficit related to impaired cognition and deconditioning. Interventions included to encourage the resident to assist in ADL performance to promote independence. The care plan failed to reflect interventions related to continence and toilet use. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/19/21 when she arrived for the 11:00 PM - 7:00 AM shift, Resident #32 and his/her bed linens were saturated with urine. NA #14 identified Resident #32 placed him/herself into the wheelchair and propelled him/herself to the nurse's station. Resident #32's brief was saturated with urine which left a trail of urine on the floor from the residents room to the nurse's station. NA #14 indicated she provided Resident #32 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #32 was completely soaked/saturated in urine. LPN #9 indicated Resident #32 came to the nurse's desk and a trail of urine followed him/her from the room to the nurse's desk. NA #14 provided Resident #32 with bed bath and linen change. 12. Resident #35 was admitted to the facility on [DATE]/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse aide care card identified Resident #35 was incontinent: check for incontinence on rounds. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 6/29/21 identified Resident #35 has bladder incontinence related to confusion, dementia, impaired mobility, inability to communicate needs. Interventions included to check for incontinence on rounds. Wash, rinse, and dry perineum. Change clothi [TRUNCATED]

Based on observation, review of clinical records, facility documentation, interviews, and policies, for one of three residents at risk for elopement, (Resident #45), the facility failed to provide the necessary supervision when the resident was left unattended outside by staff on two occasions resulting in a finding of Immediate Jeopardy. In addition, the facility failed to check the placement and function of the resident's wander guard in accordance with facility policy. Additionally, for 2 of 7 residents (Resident #37 and 79) reviewed for accidents, the facility failed to ensure a safe environment resulting in injury. The findings include: The findings include: 1. Resident #45 had a diagnosis of an [CONDITION(S)] and [CONDITION(S)]. Review of the State of Connecticut court of probate paperwork dated 5/28/21 identified that the resident had been involuntarily conserved due to inability to make decisions even with appropriate assistance and was unable to meet essential requirements for personal needs. A quarterly Minimum Date Set dated 6/21/21 identified that the resident had severe cognitive impairment, required limited assist with activities of daily living, and required supervision with locomotion while in a wheelchair on and off the unit. A nurse's note dated 7/4/21 at 3:49 PM identified that the resident was sitting at the front door and when the door opened the resident bolted through the door and the staff were unable to stop him. A nurse's note dated 7/13/21 at 11:01 AM identified that the resident was able to remove the wander guard, two (2) wander guards were found in the Resident's drawer, and the wander guard was moved to the underside of the resident's wheelchair. A care plan dated 7/14/21 identified that the resident was an elopement risk with repeated attempts to exit the building, and has a history of cutting the wander guard off with interventions that included distracting the resident from exit seeking behavior, staff to sit with the resident while outside, and a wander guard which will be checked for placement twice a shift, and function will be checked daily. A nurse's note dated 7/17/21 at 6:31 PM identified that the resident had wheeled past a family member who was coming into the building, and was able to exit the building, the resident was yelling that h/she was going home and proceeded in the wheelchair to the end of the sidewalk . A nurse's note dated 7/21/21 at 3:46 PM identified that the resident packed up belongings and then attempting to get out the locked front door, h/she was positioned at the front door waiting for a staff or visitor to enter the facility so h/she could get out the door. The resident had attempted to enter the code into the door lock unsuccessfully. A nurse's note dated 7/28/21 at 8:32 PM identified that the resident wanted to go outside after dinner, it was explained to the resident that someone needed to be with h/her, and that someone would go out with h/her around 6:00 PM. At 5:45 PM the resident was observed climbing out of the window in the dining room, and only had one foot inside the building. A nurse had gone outside and was able to steady the resident so h/she would not fall. The resident was difficult to redirect and sat in the middle of the road for 15 minutes. The resident was subsequently placed on one to one supervision until psychiatric services could evaluate h/her. Psychiatric services made some medication changes, determined that the resident was not a threat to self or others and the one to one was discontinued. A nurse's note dated 8/12/21 at 7:10 PM identified that the resident asked to go outside, and h/she was told it would be a minute or so. The resident immediately became aggressive then opened the window in the dining room, but did not go out the window, was redirected and then taken to sit on the secured patio outside of B wing (the secured patio is surrounded by a white fence). a. A nurse's note dated 8/26/21 at 6:25 PM written by Registered Nurse (RN) #2 identified that the resident was observed in the back of the building and found in a rut by the C wing exit door. The resident stated that h/she left the unsecured patio area in the front of the building because h/she wanted to go for a ride. It was explained to the resident that it was a safety issue because there was a hill on the property which put him/her at risk for injury. The resident refused to come back into the building and was left sitting in front of the glass door on the unsecured patio by RN #2 . Interview with RN #2 on 9/8/21 at 1:16 PM identified that she was the nursing supervisor on 8/26/21 and was alerted by a Nurse Aide (NA) that the resident was out on the sidewalk by the C wing door. RN #2 immediately ran to the area and helped the resident to get h/her wheelchair out of the rut. The resident refused to go back inside, therefore; the Supervisor placed the resident in front of the glass door so h/she could be seen by the Receptionist. RN #2 identified that she was uneasy leaving the resident outside, however, she was told by Administration that it was OK if the Receptionist watched the resident. Interview with Receptionist #1 on 9/6/21 at 6:00 PM stated that she let Resident #45 out onto the unsecured patio in front of the building on 8/26/21 and on that particular day there were many residents out front therefore she was not able to maintain the resident in her line of vision. Receptionist #1 stated that she left the front desk area to use the bathroom and when she came back she was notified that the resident had been found on the sidewalk in front of the C wing exit door. The Receptionist identified that she is not required to find coverage for her breaks, and although she knew that she was supposed to watch the resident and was aware that the resident wore a wander guard device, she was not aware that the resident was an elopement risk. Interview with the Director of Nurses on 9/6/21 at 6:30 PM identified that the resident gets agitated at times when he cannot go outside, and does not like to sit on the secured patio, therefore, the resident is allowed to sit outside on the unsecured patio in front of the building as long as the receptionist is at the front desk and can supervise h/her. However, on 8/26/21 the resident was out on the unsecured patio in front of the building and not in the direct line of sight of the Receptionist as h/she should have been. The DON identified that the receptionist should have placed the resident where she could see h/her and alerted a staff member if she needed to go on a break to provide coverage for the supervision of Resident #45 . b. On 9/6/21 at 4:08 PM, the surveyor observed Resident #45 in his/her wheelchair on the front patio of the facility unsupervised. As the surveyor entered the building the resident followed the surveyor through the front door and the wander guard alarm sounded, there were no staff readily visible upon entry into the building. Interview with the Director of Nurses on 9/6/21 at 4:20 PM verified that the resident did have a wander guard on and was an elopement risk. The DON further stated that the resident was usually let outside to sit in the front of the building and the Receptionist watches the resident through the glass door. (Receptionist was not present at the time of the observation). The DON identified that the resident must have been let outside by a staff member because a code must be entered into the keypad to allow the door to open and silence the alarm. The DON was unable to identify which staff member allowed the resident to sit outside unsupervised. Interview with Receptionist #2 on 9/6/21 at 5:00 PM identified that Resident #45 was not outside when she left for the day at 3:00 PM. She further identified that when the resident does go outside she keeps an eye on him through the glass window. Interviews with staff throughout the building on 9/6/21 at 4:40 PM failed to identify which staff member disarmed the wander guard and let the resident out of the building unsupervised. Review of the elopement policy identified that safe environment is provided for Residents who are at risk to wander. c. Review of Resident #45's August 2021 Treatment Administration Record (TAR) identified that 7 out of 31 days the wander guard function was not checked, and the placement was not checked for 30 times out of a possible 186 times for the month. d. Review of the July 2021 TAR identified that Resident #45's the wander guard function was not checked on 2 days out of 31 and the placement was not checked for 19 times out of possible 92 times for the month. e. Review of the June 2021 TAR identified that Resident #45's wander guard function was not checked for 7 days out of 30 days, and the placement was not checked 13 times out of a possible 90 times. Interview with the DON on 9/7/21 identified that the wander guard function should be checked daily, and per the physician's order, placement should be checked 2 times a shift. Review of the wander guard policy identified that the wander guard function will be checked once daily and the placement will be checked once a shift. On 9/7/21 the facility submitted an immediate action plan to include facility wide education of staff to ensure the safety of Residents that require wander guard monitoring. All Residents who wear wander guards that request to sit outside will be supervised by a staff member. A facility wide audit of Residents with wander guards will be completed to ensure placement and function are being monitored and that physician's orders and care plans are up to date. Wander guard audits will be completed weekly for 4 weeks, and monthly for 3 months or until the Quality Insurance and Performance Improvement (QAPI) committee determines resolution. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] with seizures, acute and chronic [CONDITION(S)], heart failure, hypertension, [CONDITION(S)]. The annual MDS dated [DATE] identified Resident #37 had intact cognition, was always continent of bowel and bladder and required supervision with toileting. Additionally, the resident required extensive assistance for dressing and limited assist for personal hygiene. The Occupation Therapy note dated 4/13/21 indicated Resident #37 had a raised toilet seat/commode for transfers and toileting. The reportable event form dated 5/8/21 at 2:30 PM indicated Resident #37 was in the bathroom and caught his/her left outer lower leg on the raised toilet seat. A laceration noted which was Y shaped measuring 4.0 cm x 2.5 cm x 0.4cm wound. The laceration was from the raised toilet seat front knob. Blood was noted all over it and the leg was caught on it causing laceration. Interventions included the raised toilet seat to be changed and a pressure dressing applied to Resident #37's leg and ice until transferred to hospital for stitches. The care plan indicated the intervention to have maintenance change the raised toilet seat in bathroom, on maintenance book to be done on Monday 5/10/21. The APRN note dated 5/8/21 at 8:37 AM noted Resident #37 had a left leg open area due to knob on the raised toilet seat with large amount of blood noted. Resident #37 was on [MEDICATION(S)] and area looks deeply impacted. Send resident to the emergency room for further evaluation. The nurses note dated 5/8/21 at 6:54 PM noted Resident #37 returned from the hospital with 9 stitches to the laceration of the left outer lower leg. Attempted to call emergency room because no information on stitches or [CONDITION(S)] shot on discharge paperwork. The nurses note dated 5/8/21 at 7:02 PM indicated put in maintenance book to have raised toilet seat removed and another one reapplied due to knob in front caused laceration. The hospital discharge paperwork dated 5/8/21 indicated Resident #37 went to the emergency room for a laceration to the left lower leg. An interview with the Administrator on 9/15/21 at 9:00 AM indicated she did not recall if she went and looked at the raised toilet seat that caused the laceration to Resident #37's leg. An interview with the Director of Maintenance on 9/15/21 at 9:40 AM indicated he did not have any of the maintenance logs prior to 7/21/21. The DOM indicated he was not at the facility in May 2021. Interview with DNS #2 on 9/15/21 at 9:45 AM indicated she did recall the incident. DNS #2 indicated she did not see the raised toilet seat until after it was changed. DNS #2 indicated the supervisor informed her there was something very sharp on the leg of the raised toilet seat that caused the laceration and the supervisor told her she put in the maintenance book to have it changed. DNS #2 indicated the first raised toilet seat was like a commode with legs but the new one was just the plastic that screws onto the top of the toilet. DNS #2 indicated she did not ask the DOM at that time to see the commode because all she cared was that it had already been changed. Interview with RN #2 on 9/15/21 at 10:00 AM indicated she did remember looking at the raised toilet seat that was like a commode with metal legs over the toilet and on one of the legs where there was a bolt, it had a very sharp edge, and there was blood on it so she knew that was where Resident #37 had received the laceration to his/her left lower leg on the outside. RN #2 noted the bolt stuck out and was not covered and was not flush. RN #2 indicated she sent Resident #37 to the hospital and he/she returned with 9 stitches. RN #2 indicated she put it in the maintenance book, but she removed it with maintenance later on that shift and maintenance put a new raised toilet seat on. 3. Resident #79 was admitted to the facility on [DATE] with diagnoses that included severe [CONDITION(S)], reduced mobility, anxiety disorder and major depressive disorder. Review of the May 2021 physician's orders directed to transfer the resident via a mechanical lift with the assistance of 3 staff. Review of the weight's summary dated 5/18/21 identified Resident #79 weighed 402.1 lbs. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, and transfer activity occurred only once or twice during the reference period. Additionally, the MDS identified transfers occurred with 2 person plus physical assistance. The care plan dated 6/2/21 identified Resident #79 had a self-performance and mobility deficit related to deconditioning and weakness. Interventions included to encourage the resident to participate in ADLs to promote independence. The care plan failed to reflect the physician's order for transfers via mechanical lift with the assistance of 3 staff. Review of the nurse aide care card failed to reflect that the resident required the assistance of 3 staff during mechanical lift transfers. Interview with Resident #79 on 8/16/21 at 1:05 PM identified that sometime in May 2021, during a mechanical lift transfer from the bed to the wheelchair, with NA #1 and NA #23, the lift tilted to the side with the resident in it and the nurse aides had to struggle to keep the resident from falling onto the floor in the lift. Resident #79 indicated he/she was upset that the incident happened and was scared because he/she thought that he/she was going to fall onto the floor. Resident #79 indicated that during the incident they were all screaming as the nurse aides were trying to get him/her into the wheelchair. Resident #79 indicated that both nurse aides are small and short and during the incident, the lift hit the resident in the head. Resident #79 indicated that the nurse aides could have gotten really hurt. Both nurse aides had to struggle to keep the resident from falling onto the floor in the lift. Resident #79 indicated he/she landed in the wheelchair in a slouching position. Resident #79 indicated after the incident, NA #23 was pinned in back of the wheelchair against the wall, and the lift flipped backwards and fell on to NA #1 and she got hurt. Resident #79 indicated NA #1 and NA #23 started yelling for LPN #1. Resident #79 indicated LPN #1 came into the room and helped to reposition him/her properly in the wheelchair and help the 2 nurse aides. Interview with Resident #4 on 8/16/21 at 1:12 PM identified he/she was in the room and witnessed the incident with Resident #79 when the mechanical lift tilted, and the 2 nurse aides got hurt. Resident #2 indicated the incident happened in May 2021. Resident #4 indicated the privacy curtain was not pulled for privacy and he/she could see everything that happened. Resident #4 indicated NA #1 and NA #23 were getting Resident #79 out of the bed with the lift and when NA #1 started turning the lift around to put Resident #79 into the wheelchair, the lift tilted and both nurse aides were doing their best to prevent Resident #79 from falling and to get him/her into the wheelchair. Resident #2 indicated the 2 nurse aides managed to get Resident #79 into the wheelchair, but NA #23 got pinned between the back of the wheelchair and the wall, and the tilted lift fell on NA #1. Both nurse aides started yelling for help. Interview with NA #1 on 8/16/21 at 1:30 PM indicated she was not aware that Resident #79 required the assistance of 3 staff with mechanical lift transfers and indicated the nurse aide care card did not reflect that information. NA #1 indicated on 5/28/21 she and NA #23 were transferring Resident #79 from the bed to the wheelchair in the lift, and the lift tilted. NA #1 indicated she and NA #23 tried as hard as they could to prevent the lift from fully tipping over and to get the resident into the wheelchair. NA #1 identified she was afraid that Resident #79 would land on the floor. As they turned the lift toward the wheelchair, it tilted, and she and NA #23 did everything they could to prevent Resident #79 from falling onto the floor in the lift and to get the resident into the wheelchair safely. When they managed to place the resident into the wheelchair, NA #23 got pinned behind the wheelchair and the wall, and the mechanical lift fell on NA #1. NA #1 indicated she and NA #23 started yelling for LPN #1. LPN #1 came into the room to help properly position Resident #79 into the wheelchair. Both nurse aides were doing everything possible to prevent the resident from falling on the floor as the lift was tilted. NA #1 indicated it is the facility policy to have 2 nurse aides at all times when the mechanical lift is being used on a resident. Interview with NA #23 on 8/16/21 at 3:26 PM identified that a couple of months ago, she and NA #1 were transferring Resident #79 from the bed to the wheelchair via a mechanical lift and indicated they are required to have 2 staff members when using the mechanical lift. NA #23 indicated she was not aware that Resident #79 needed the assistance of 3 staff with transfers using the mechanical lift. NA #23 indicated the 600-pound capacity mechanical lift was used, the resident was properly position on the lift pad, and the base was opened. As the resident was being transferred to the wheelchair, the lift tipped over. NA #23 was positioned in back of the wheelchair guiding the resident into the wheelchair. NA #23 identified when the lift tipped, Resident #79 fell into the wheelchair and NA #23 was pinned between the wheelchair and the wall. Both she and NA #1 started screaming for help. NA #23 indicated Resident #79 was crying and cursing during and after the incident. Interview with LPN #1 on 8/16/21 at 3:47 PM identified he was aware of the mechanical lift incident involving Resident #79. LPN #23 indicated he heard yelling and he ran into Resident #79's room and observed Resident #79 slouching in the wheelchair. LPN #1 indicated he assessed Resident #79 but failed to document the assessment in the clinical record and failed to notify the physician, APRN or the conservator of the incident. LPN #1 indicated Resident #79 did not fall or was injured, and that was why he didn't document the incident in the clinical record or notify the physician or the conservator. LPN #1 indicated the 2 nurse aides did get hurt. Interview with RN #4 on 8/16/21 at 4:00 PM identified she was aware of the incident on 5/28/21 with Resident #. RN #4 indicated Resident #79 did not fall on the floor and was not injured and that is why she did not complete a reportable event form. RN #4 indicated she assisted in helping to properly position Resident #79 in the wheelchair after the incident. RN #4 indicated she assessed Resident #79 but did not document the assessment or notify the physician or conservator. RN #79 indicated she was not aware of the physician's order to have 3 staff transfer Resident #79 with mechanical lift and was not aware that the nurse aide care card did not include that information. Interview with the Former DNS on 8/17/21 at 2:05 PM identified she was on vacation when the incident happened and indicated she would have expected RN #4 and LPN #1 to assess Resident #79, document the incident in the clinical record and complete a reportable event form. Interview with the Director of Physical Therapy on 8/17/21 at 2:42 PM indicated he was not aware of the incident with the mechanical lift on 5/28/21. The Director of Physical Therapy indicated the nursing department did not notify the rehabilitation department and identified the rehabilitation department recommend that Resident #1 have the assistance of 3 staff during mechanical lift transfers. Interview with MD #2 on 8/17/21 at 4:06 PM identified the facility did not notify her of the mechanical lift incident that took place on 5/28/21 with Resident #79 but she would have expected to be made aware even if the resident was not injured. MD #2 indicated the facility staff should have followed the order that directed to provide the assistance of 3 staff with mechanical lift transfers. Review of the mechanical lift procedure policy identified the mechanical lift will be used to transfer patient/resident for whom manual transfer is not recommended. Because of mechanical lift models may vary in weight capacity, check the manufacture's specifications before attempting patient/resident transfer. Make sure the bed and wheelchair wheels are locked before beginning the transfer. Always have two people to perform this procedure; one to operate the lift and one to observe and reassure the patient/resident. The facility failed to provide 3 staff during a mechanical lift transfer on 5/28/21 with Resident #79. Subsequently, there was an incident in which the lift tilted with the resident in it and he/she was hit in the head with the lift, and 2 nurse aides were injured.

Based on a review of facility documentation, interviews, and policy review, the facility failed to ensure that staffing levels were adequate to meet the needs of four (4) of thirty three (33) residents on the B wing (Residents #4, #17, #44, and Resident #77) in accordance with the plan of care which resulted in a finding of Immediate Jeopardy. Additionally, for 2 out of 3 wings reviewed for staffing, the facility failed to ensure there was sufficient nurse staffing to meet the needs of the residents on 9/3/21 at the beginning of the 7:00 AM to 3:00 PM shift and for 1 resident (Resident #79), reviewed for an allegation of neglect, the facility failed to have sufficient nursing staff to maintain the residents highest practicable physical, mental, and psychosocial well-being. The findings include: Please cross reference F 600 The findings include: 1. Review of the schedule for B wing dated 9/6/21 for the 7:00 AM to 3:00 PM shift identified the census was 33 and there was one (1) charge nurse, and two (2) Nurse Aides (NA) assigned. NA #5 worked 7:00 AM until 12:00 PM, and NA#1 worked 8:00 AM until 2:00 PM. B wing was staffed with 1 NA from 7:00 to 8:00 AM (NA #5), 2 NA from 8:00 AM until 12:00 PM (NA #1 & 5), and 1 NA from 12:00 PM until 2:00 PM (NA #1). There were no NA ' s on the unit from 2:00 PM until 3:00 PM. Interview with Nurse Aide (NA) #1 on 9/6/21 at 7:40 PM identified that she was unable to provide incontinent care, bathing and turning and repositioning to Resident #4, Resident #17, Resident #44, and Resident #77. NA #1 stated that she didn't have time to provide care to all of the residents, because there were 2 NA for 33 residents (approximately 17 residents each) and then at noon she was the only NA for 33 residents. NA #1 further identified that she was able to set up and provide the meals for Resident #4, Resident #17, Resident #44 and Resident #77, but she was unable to provide any other care for the 7:00 AM to 3:00 PM shift. NA #1 identified that she had worked on 9/6/21, although it was her day off, she had informed the facility ahead of time that she could only work until 2:00 PM. Multiple attempts to contact NA #5 were unsuccessful. Interview with the Director of Nurses on 9/6/21 at 6:36 PM identified that she had been in the building since 11:00 AM on 9/6/21 and was unaware of that there were only 2 NA on the B wing. The DON stated she was also unaware that there was only 1 NA on the B wing from 12:00 to 2:00, and that there were no Aides on the B wing from 2:00 PM to 3:00 PM. Review of the 7:00 AM to 3:00 PM schedule for 9/6/21 with the DON identified that there had been one agency NA that was a no call, no show and one call out for the 7:00 AM to 3:00 PM shift on 9/6/21, leaving only 2 NA to work the unit. The DON identified that the residents are heavy care on B wing and the wing should have 4 NA on the 7:00 AM to 3:00 PM shift. The DON identified that the residents should have been provided with bathing, incontinent care, and repositioning every 2 hours, and the NA should have asked for help if she could not do so. Interview with LPN #1 on 9/7/21 who was the charge nurse on B wing on 9/6/21 at 4:14 AM identified that the staffing on 9/6/21 for the 7:00 AM to 3:00 PM shift on 9/6/21 was not unusual. LPN #1 stated that when NA#5 came to work on 9/6/21, it was identified that she was not on the schedule, however she agreed to stay until 12:00 PM. Interview with Registered Nurse (RN) #1 on 9/7/21 at 10:30 AM identified that she was the nursing supervisor on 9/6/21 for the 7:00 Am to 3:00 PM shift and was aware of the staffing issue on the B wing, and stated that she had tried to contact all of the staffing agencies and called all of the staff and no one was able to come in that day. Interview with the Staffing Coordinator (SC) on 9/7/21 at 1:00 PM identified that she was not in the building on 9/6/21 because it was a holiday. The SC identified that there is no staffing policy, but the B wing should have at least 3 NA, but ideal staffing would be 4 NA on the 7:00 Am to 3:00 PM shift. The SC further identified that the facility has contracts with four (4) staffing agencies and when she calls, they usually don't have anyone available. The staffing coordinator identified that the facility is also having a job fair to recruit staff, and the facility offers bonuses in an attempt to get staff to work extra shifts. The SC further identified that at times when there are not enough NA's licensed staff will work as NA's. The facility submitted and action plan to the Department on 9/7/21 that identified that nursing management, department heads and staff that have a NA certification, temporary NA's, and agency staff will be utilized when the staffing is inadequate. The nursing scheduler and nursing supervisors were educated on notifying Administration and the Director of Nurses when staffing levels do not meet the State Agency Public Health Code for staffing. Staffing audits will be conducted daily for a week, weekly for a month, and monthly for 3 months. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated. 2. Review of the census list on 9/3/21 identified the facility capacity is 97 beds and the census was 85 residents in the facility. There were 22 residents on A wing, 31 residents on B wing, and 32 residents on C wing. Tour of the wings on 9/3/21 at 7:05 AM identified the following: A wing had 2 nurse aides on the 7:00 AM - 3:00 PM shift, (22 residents). B wing had zero nurse aides and one LPN, (31 residents). C wing had zero nurse aides and ne LPN, (32 residents). Interview with LPN #3 on 9/3/21 at 7:20 AM on C wing identified she was aware that the 11:00 PM - 7:00 AM nurse aides had left, and that there were no nurse aides on during the 7:00 AM - 3:00 PM shift on C wing. LPN #3 indicated the facility has been short of staff for a very long time. LPN #3 indicated that some nurse aides come in at 8:30 AM or 9:00 AM or 9:30 AM. LPN #3 indicated that it is very difficult to try and pass out the medications and answer the call lights until a nurse aide comes in. Observation between 7:30 AM - 7:40 AM identified the following: A wing had 2 nurse aides and one LPN, (22 residents). B wing had zero nurse aides and one LPN, (31 residents). C wing had zero nurse aides and ne LPN, (32 residents). Interview with LPN #1 on 9/3/21 at 7:33 AM on B wing identified he was aware that the 11:00 PM - 7:00 AM nurse aides had left, and there were no nurse aides on the 7:00 AM - 3:00 PM shift when he made round at the beginning of the shift, and there were still no staff on the wing at 7:30 AM. LPN #1 indicated that a nurse aide should have stayed on the unit until the 7:00 AM - 3:00 PM shift came in. On 9/3/21 at 7:44 AM identified NA #5 arrived on C wing. Interview with NA #5 identified she punched in at 7:21 AM and she is the only nurse aide on the C wing. Observation on 9/3/21 at 7:57 AM identified NA #22 coming from A wing to B wing. Interview with NA #22 identified she was asked to go to B wing and monitor the call lights and pass out the breakfast trays until a nurse aide came in. Observation between 8:00 AM - 8:30 AM identified the following: A wing with one nurse aide and one LPN on the wing, (22 residents). B wing with one nurse aide and one LPN on the wing, (31 residents). C wing with one nurse aide and one LPN on the wing, (32 residents). On 9/3/21 at 8:41 AM, NA #24 went to the Human Resource (HR) office. Interview with NA #24 identified she punched in at 8:30 AM. NA #24 indicated today was her day off and the facility called her to come in because they needed help. NA #24 indicated she was directed to go to C wing. On 9/3/21 at 8:44 AM, NA #25 arrived. Interview with NA #25 identified she was supposed to be at the facility at 8:00 AM and she is from an agency. NA #25 indicated she notified HR that she cannot be at work at 8:00 AM for personal reasons and indicated when she arrived, she was directed to go to B wing. On 9/3/21 at 8:50 AM, NA #26 arrived. Interview with NA #26 identified she was schedule to come in at 9:00 AM. She indicated she was directed to go to B wing until another nurse aide comes in and then she will become the half between B and C wing. Interview with the Administrator on 9/3/21 at 9:00 AM identified she was not aware that the 11:00 PM - 7:00 AM staff had left the facility before the 7:00 AM - 3:00 PM staff came in. She indicated the facility has been experiencing some staffing challenges at times. She indicated the facility supplement with three agencies for nurse aides. The Administrator indicated in-services will be given to the nurse's aide. Interview with Human Resource Director on 9/3/21 at 1:00 PM identified she was not aware that some of the nurse aides were not on the wings. She indicated staffing has been challenging for all shifts. Human Resource Director indicated the facility has placed an ad for nurse aide. Interview with the DNS on 9/3/21 at 2:34 AM identified she was not aware of the schedule issues this morning. The DNS indicated the supervisor called her and notified her that DPH was at the facility, but they did not inform her that there were only 2 nurse aides in the facility at the time of the call. She indicated that the 11:00 PM - 7:00 AM staff should have remained on the wing until the 7:00 AM - 3:00 PM staff came in. Review of the regulations of Connecticut State Agencies identified the facility's administrator and director of nurses shall meet at least once every 30 days to determine the number, experience, and qualifications of staff necessary to comply with this section. The facility shall maintain written and signed summaries of actions taken and reasons, therefore. In a chronic and convalescent nursing home, there shall be at least one licensed nurse on duty on each patient always occupied floor. In no instance shall a chronic and convalescent nursing home have staff below the following standards: The facility failed to ensure there was sufficient staffing to meet residents needs on 9/3/21 at the beginning of the 7:00 AM to 3:00 PM shift. 3. Resident #79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the orders identified Resident #79 requires the assistance of 2 staff (extensive assistance) for upper/lower body dressing, and toilet transfers and limited assistance for personal hygiene. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, required extensive two-person physical assistance with toilet use and extensive one-person physical assistance with personal hygiene. Additionally, the MDS indicated Resident #79 was always continent of urine. The care plan dated 6/2/21 identified Resident #79 had a self-performance and mobility deficit related to deconditioning and weakness. Interventions included to encourage the resident to participate in ADLs to promote independence. The care plan did not address how staff should provide assistance regarding Resident #79's bowel and bladder needs. Interview with Resident #79 on 8/16/21 at 1:05 PM identified that usually when he/she rings the call bell, it takes the nurse aides 40 minutes to an hour to answer. Resident #79 indicated that sometime in June 2021, during the 11:00 PM - 7:00 AM shift, he/she needed help and rang the call bell for approximately 4 hours, but the staff did not answer or come to his/her room. In another incident, Resident #79 indicated recently, after returning from a hospitalization , during an 11:00 PM - 7:00 AM shift, the resident rang the call light because he/she had to urinate. Resident #79 could not remember the exact time but was also yelling for help. The staff on the night shift never came into his/her room to help or provide care so he/she had to urinate in the bed and lay in it. Resident #79 indicated that when the 7:00 AM - 3:00 PM shift arrived, the nurse aide answered the call light a little after 7:00 AM. Resident #79 indicated at that time, NA #1 provided care and the resident reported to NA #1 that he/she had been ringing for help since 5:00 AM and had been laying in urine because no one came to help. Resident #79 indicated he/she lays in bed waiting for staff to answer the call bell, it happens all the time, it goes on all the time. The resident stated he/she many times has had to urinate right in his/her bed and lay in the urine, screaming for help because no one comes, and he/she and the bed gets cold because it's wet. The resident indicated he/she has had to call 911 in the past when staff don't answer the call bell. The resident indicated he/she rings for the bedpan and will urinate on the bedpan, but if no one comes, he/she has no choice and cannot hold it, so will urinate in the bed. If staff answer his/her call light in a timely manner, he/she uses the bed pan. Interview with Resident #4, (Resident #79's roommate), on 8/16/21 at 1:12 PM identified he/she does not remember the exact date but does remember an incident when he/she was woken up by Resident #79 screaming for help at approximately 5:00 AM. Resident #4 indicated the night shift did not come to answer the call bell or come in the room to help Resident #79. It wasn't until the day shift arrived that Resident #79 received help. Interview with NA #1 on 8/16/21 at 1:30 PM identified she does not remember exactly the day or date, but it happened when Resident #1 came back from the hospital recently. NA #1 indicated when she came in at 7:00 AM, Resident #79's light was ringing, and she answered the call light. NA #1 indicated Resident #79 was crying and stated that the nurse aide (lady) on the night shift did not provide care. NA #1 indicated Resident #79 and his/her bed and linens were saturated with urine, so she provided Resident #79 a bed bath and changed the bed linen. NA #1 indicated after she provided care to Resident #79, she notified RN #2 and LPN #1 of Resident #79's complaint that the night shift had not provided care and that Resident #79 was soiled and saturated and left in a urine-soaked bed. Interview with LPN #1 on 8/16/21 at 3:47 PM identified he is the regular nurse on the B unit and assigned to Resident #79. LPN #1 indicated he does not remember NA #1 reporting to him that Resident #79 was complaining about the night shift not answering the call light or providing the resident the bed pan, and subsequently the resident soiled and saturated the bed with urine. LPN #1 indicated that one time during the day shift, he does remember an incident when Resident #79's family member called the facility and reported that if someone does not go into the resident room to provide toileting assistance that he/she was going to call 911. The facility failed to provide sufficient nursing staffing to ensure Resident #79, who was alert, oriented and continent, was free from neglect during the 11:00 PM - 7:00 AM shift, when staff did not provide assistance with toilet use when requested, and subsequently the resident urinated in the bed, was left in a urine saturated bed and found in a urine saturated bed by the day shift over 2 hours later.

Based on observations, review of the clinical record, facility documentation, interviews, and policy review, the facility failed to ensure that visitors were screened for symptoms of COVID-19 upon entry into the facility in accordance with facility policy, failed to maintain compliance with the submitted action plan to address screening of visitors, failed to ensure the COVID-19 observation unit had proper signage posted at the entrance of the unit, failed to ensure staff utilized Personal Protective Equipment (PPE) while caring for Residents on the observation unit, and that PPE was properly discarded after use, resulting in a finding of Immediate Jeopardy. Additionally, the facility failed to ensure an adequate number of gloves were readily available to staff for care, and for 1 resident, (Resident #48) the facility failed to ensure infection control measures were implemented related to respiratory and G tube care. The findings include: 1. On 9/4/21 at 10:53 AM, the surveyor entered the building and remained in the entryway until 11:00 AM. During that time staff were observed in the hallways and walking by but did not approach the surveyor to provide screening for COVID-19. Further observation noted four (4) visitors in the dining room visiting with R#25 and R #78. At 11:00 AM the surveyor walked to the A/B wing nurse's station to ask for the person in charge. The RN Supervisor greeted the surveyor and upon inquiry was told they had no one to sit at the front desk to monitor visitors who entered the building. As of 11:10 AM, no staff had inquired if the surveyor was screened. Further interview with the RN Supervisor at 11:10 AM stated that the Receptionist was not available until 2:00 PM and people will not be screened. The RN Supervisor stated that she does not have enough staff in the building to have someone sit at the front desk to screen people, so she will screen them if she sees them. Observations at 11:23 AM noted the RN Supervisor went to the dining room where the four (4) visitors were and had them complete the COVID-19 screening questions and the RN Supervisor was observed to take each visitors temperature. Interview with R #78 visitors at 11:30 AM stated they arrived at 10:40 AM and they were not screened until now when the RN Supervisor came into dining room. Interview with R #25's visitors at 11:30 AM stated they arrived at 11:10 AM and they were also not screened until now when the RN Supervisor came into room. Interview with the Administrator on 9/4/21 at 12:40 PM stated the facility policy directed that all people who enter the building are to be screened prior to going anywhere in the building. The Administrator stated that the person who was supposed to be the weekend Receptionist was currently working in the kitchen as a dietary aide because they are short of help. Review of the indoor visitation policy dated 4/2021 identified that all visitors will have their temperature taken and be screened for COVID-19 symptoms. On 9/4/21, the facility provided the Department with an action plan that identified all visitors would be screened for COVID-19 symptoms including temperature prior to visitation. The on-duty Receptionist will screen all visitors, and in the absence of the Receptionist, the Nursing Supervisor or designee will perform visitor screening and temperature. 2. Upon surveyor entrance into the facility on [DATE] at 7:30 AM there were no staff in the lobby to screen for symptoms of COVID-19 in accordance with facility policy and the submitted action plan dated 9/4/21. The surveyor entered the dining room adjacent to the entrance to the facility, and ten (10) minutes later (7:40 AM) the Administrator entered the facility. Subsequent to surveyor request, the surveyor was screened for COVID-19 symptoms. Interview with the Administrator on 9/7/21 at 7:40 AM identified that the Supervisor should have screened the surveyor, however, there was no way to identify when a visitor entered the front entrance because the door is unlocked at 6:30 AM. The Administrator stated that the front door would now remain locked until 8:00 AM when the Receptionist arrives. This intervention was added to the action plan originally submitted on 9/4/21 . 3. Interview with the Director of Nurses (DON) on 9/6/21 at 5:30 PM identified that the C wing was the COVID-19 observation unit (quarantined unit) because a Nurse Aide who worked on 9/3/21 had tested positive for COVID-19 on 9/5/21. a. Observation on 9/6/21 at 6:00 PM of the C wing unit identified that although the doors to the entrance of the unit were closed, the doors lacked signage to identify what type of PPE was necessary to be worn on the unit. Interview with the Director of Nurses on 9/6/21 at 6:00 PM identified that she was unaware that the entrance to the unit required signage to alert those who enter of what type of PPE is required. Review of CDC Guidelines (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) directed in part to place signage at the entrance to the COVID-19 unit that instructs staff they must wear personal protective equipment (PPE ). b. Tour of the COVID-19 observation unit on 9/6/21 at 6:15 PM with the Director of Nurses and the Administrator identified that room [ROOM NUMBER] had a yellow precautions sign outside the door indicating that the resident required droplet and contact precautions (gloves, gown, eye protection, and a face mask). Further observation identified that Nurse Aide (NA) #1 and NA #2 were in the room preparing to take the resident to the bathroom, both were in close proximity to the resident, and only wearing a surgical mask and gloves, and lacked the necessary face shield and isolation gown. Interview with NA#1 and NA#2 at the time of the observation identified that they did not know that the unit was a COVID-19 observation unit, and that they were required to wear PPE. NA#1 and NA#2 further identified that they had been providing personal care such as toileting, incontinent care, and repositioning for several residents since the beginning of their shift at 3:00PM without the benefit of face shields or isolation gowns. NA#1 and NA#2 identified that they did not see the yellow isolation signs posted outside of every room. Interview with Licensed Practical Nurse (LPN) #2 on 9/6/21 at 6:25 PM, who was the charge nurse on the observation unit, identified that she had given all of the residents their medications and was not aware that she needed to wear anything else but a face mask while administering medications, she thought that full PPE needed to be worn when only giving personal care . CDC Guidance identified that HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Interview with the DON at the time of the observation identified that she did not think that the PPE was necessary because the residents were all negative when they had their rapid COVID tests on 9/5/21 (2 days after the potential exposure to COVID-19). Interview with the Administrator at the time of the observation identified that the facility had a plentiful supply of PPE, and that the residents were to be on observation for COVID-19 for 14 days and PPE is required until the 14 days has concluded, regardless of what the COVID test results were. c. On 9/6/21 at 8:30 PM on the COVID-19 observation unit, NA #1 was observed to exit out of a droplet precaution room, removed her isolation gown while in the hallway, crumbled it in her gloved hands then walked half the length of the hallway to dispose of the isolation gown. Review of the Centers for Disease Control Guidelines for the removal of PPE (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) identified that all PPE must be removed prior to exiting the resident's room. Review of the facility policy for PPE on a COVID-19 observation unit dated 12/2020 identified that a face mask, eye protection, gloves, and an isolation gown were necessary to provide care to residents on the observation unit. Subsequent to observations, on 9/6/21, the facility provided the Department with an immediate action plan that included staff education regarding the requirements of PPE use on the COVID-19 in accordance with CDC guidelines. d. On 9/7/21 at 10:30 AM, the doors to the COVID-19 observation unit lacked signage to inform staff/visitors that the unit was under quarantine, despite the same observation the day prior. Interview with the Administrator on 9/7/21 at 10:30 AM identified that she would ensure signage was added to the doors of the COVID observation unit. Subsequent to this observation, signage was placed on the doors at the entrance of the COVID-19 observation unit which indicated that the unit was quarantined. e. Further observation on 9/7/21 at 10:32 AM identified a droplet and contact precaution sign outside of room [ROOM NUMBER]. Physical Therapist (PT) #1 was identified to be in the room repositioning Resident #53 in bed, the resident was noted to cough several times while being repositioned. PT #1 was wearing gloves and a face mask; however, he lacked a face shield and an isolation gown while providing care to the resident. Interview with PT #1 at the time of the observation identified that he was unaware that the unit was under observation for COVID-19, and he had not seen the yellow isolation sign upon entering the room. Interview with the Administrator on 9/7/21 at 10:30 AM identified that PT#1 should have been wearing a face shield and gown in addition to the face mask and gloves while caring for the resident. f. During tour of the COVID-19 observation unit on 9/7/21 at 10:55 AM, Resident #25 was sitting on h/her bed without a face mask and was speaking to a visitor who also lacked a face mask. Interview with the visitor at the time of the observation identified that he worked at a group home where the Resident resided previously, and visited the resident daily, however he did not know that Resident #25 was on observation for COVID-19 exposure. Interview with LPN #2 on 9/7/21 at 11:00 AM, who was Resident #25's nurse, identified that she was aware that the visitor was in Resident #25's room, and did not inform him that the entire unit was on observation for COVID-19 exposure, nor offer him any PPE. g. Further tour of the COVID-19 observation unit on 9/7/21 at 11:00 AM identified that a visitor was observed coming out of Resident #80's room. Interview with the visitor at the time of the observation identified that she was from the Resident's group home and was not informed that the Resident was on an observation unit for COVID-19 exposure. The visitor was observed wearing a face mask upon exiting the room and identified to the surveyor that she was not wearing any other PPE besides the face mask while visiting the resident. Interview with the Administrator on 9/7/21 at 11:05 AM identified that Resident #25 and Resident #80 did not qualify for compassionate care visits and she thought that the visitors from the group home were allowed because they were included in the Resident's plan of care. Review of the plan of care for Resident #25 and Resident #80 failed to reflect any interventions including visits from group home staff. Review of the facility visitation policy dated 4/2021 identified that indoor visitation should be limited solely to compassionate care visits for vaccinated and unvaccinated residents that are in quarantine until they have met the criteria for release from quarantine. h. Further tour of the COVID-19 observation unit on 9/7/21 at 11:00 AM identified that NA #8 came out of a droplet precaution room and took her gown off, crumpled it up in her un-gloved hands and walked down the hallway to dispose of the gown. Interview with the Administrator on 9/7/21 at 12:00 PM identified that the gowns should be offed prior to leaving the room and that she would be obtaining more receptacles for the used PPE so the Nurse Aide's don't have to walk down the hallway to dispose of them. Over the course of multiple days, the facility failed to ensure infection control practices were implemented in accordance with policies despite immediate action plans submitted to the Department resulting in Immediate Jeopardy. On 9/7/21 the facility submitted an immediate action plan that included: The front door will remain locked until the Receptionist reports to work. All visitors will be screened by the Receptionist, Nursing Supervisor or designee to include screening questions and temperature with results recorded in a log. Facility wide re-education on proper use of PPE, audits daily for seven days and weekly for 4 weeks and monthly for 3 months, and audits will be forwarded to the QAPI Committee for further review and recommendations for a three-month period or until the committee determines resolution. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated. 2. Observation on 9/2/21 at 9:05 AM on C wing identified RN #4 left a resident's room and went in and out of 4 different other rooms looking for gloves. No gloves were found in the 4 rooms. RN #4 asked a nurse aide for gloves and the nurse aide pulled a pair of gloves out of her scrub pocket. Tour of A wing, B wing, and C wing on 9/2/21 at 9:15 AM with RN #4 identified the following; Of the 13 rooms on A wing, gloves were not available in 10 rooms/bathrooms: rooms 3, 4, 5, 6, 7, 9, 10, 11, 13, and 15. Of the 17 rooms on B wing, gloves were not available in 11 rooms/bathrooms: rooms #16, 17, 19, 20, 21, 23, 24, 25, 26, 29, and 31. Of the 17 rooms on C wing, gloves were not available in 16 rooms/bathrooms: rooms 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, and 49. Interview with NA #9 on 9/2/21 at 10:05 AM on C wing identified she was aware that there were no gloves in the resident rooms. NA #9 identified that she must go and get one box of gloves from the supervisor's office at the beginning of her shift (7:00 AM - 3:00 PM) and place the box of gloves on the railing in the hallway. NA #9 indicated that one box of gloves is to be used among all the staff on the whole unit for the shift. NA #9 indicated that she must put extra gloves in her scrub pocket. NA #9 indicated that the DNS informed the staff that the facility will not be putting gloves in the resident rooms anymore. Interview with LPN #3 on 9/2/21 at 10:08 AM identified she was not aware that the resident rooms did not have gloves and indicated she uses the gloves on the medication cart and at times the nurse's aides will get gloves from the medication cart. Interview with NA #6 on 9/2/21 at 10:12 AM identified she was aware there were no gloves in the resident rooms. NA #6 identified there have not been gloves in the rooms for a very long time and she does not know why. NA #6 indicated when she needs gloves, she must stop resident care, leave the room, and get the gloves in the hallway. Observation with RN #4 on C wing on 9/2/21 at 10:15 AM identified one box of gloves on the railing in the hallway. Interview with LPN #5 on 9/2/21 at 10:25 AM identified she was aware that the resident rooms did not have gloves and identified that when she needs gloves, she gets them from the medication cart. LPN #5 indicated she does not know who is responsible to replenish the rooms with gloves. Interview with RN #4 on 9/2/21 at 10:35 AM identified she was not aware that the resident rooms and bathrooms did not have boxes of gloves available. RN #4 indicated central supply staff is to supply the rooms with gloves. RN #4 indicated that she was not aware that the DNS notified the staff that gloves will not be provided in the resident rooms. Observation on 9/2/21 at 10:43 AM of Physical Therapist (PT) #3 on the B wing leaving the residents room, walking approximately 10 feet to the medication cart to obtain gloves, and re-entering the resident's room to continue therapy. Interview with PT #3 identified gloves had not been readily available for staff in the resident rooms for a very long time (months), which resulted in the staff having to search for gloves prior to caring for a resident or having to leave a resident's room to obtain additional gloves during care. Interview with LPN #1 on 9/2/21 at 10:45 AM on the B wing identified he was aware that there are no gloves in the resident rooms. LPN #1 indicated the facility does not put gloves in the room, and the facility does not want gloves in the rooms. LPN #1 indicated it has been this way for a while. LPN #1 indicated that the medication cart has gloves, and the nurse's aide must go to the supervisor office for gloves, and they are allowed one box for the wing and shift. Interview with NA #5 on 9/2/21 at 10:50 AM on the B wing identified she was aware that there are no gloves in the resident rooms. NA #5 indicated at the beginning of the shift (7:00 AM - 3:00 PM) she must go to the supervisor's office and get one box of gloves and place the box of glove on the railing in the hallway. She identified that the one box of glove is to be used among the staff for the wing for the shift. NA #5 indicated that she put multiple gloves in her scrub pocket because it's difficult to be in the middle of care and have to stop and go and get gloves out in the hallway. Observation on B wing on 9/2/21 at 10:51 AM one box of gloves on the railing in the hallway. Interview with NA #20 on 9/2/21 at 10:52 AM on the B wing identified she was aware that there are no gloves in the resident rooms. She identified that one staff must get one box of glove from the supervisor's office at the beginning of the shift (7:00 AM - 3:00 PM) and place the box of glove on the railing in the hallway. She indicated that one box of glove is to be used among the staff on the unit for the shift. She indicated during care if she needs glove, she must stop and go into the hallway and get another pair of gloves. Interview with Housekeeping Director on 9/2/21 at 10:59 AM identified she was not aware of the resident rooms not having gloves available to the staff. She indicated central supply is responsible to put gloves in the resident rooms. She indicated the Administrator asked her to go and put a box of gloves in all the rooms right now. Interview with the Administrator on 9/2/21 at 11:07 AM identified she was aware that the resident rooms did not have gloves available to the staff. She indicated since 8/2020 during the Covid-19 pandemic, the facility did not have gloves in the resident rooms. The gloves have been controlled in the supervisor office since she has been at the facility (8/2020). The Administrator identified that was the procedure that was in place at the facility when she was employed. She indicated when a resident is positive Covid-19 a box of gloves is put in the rooms or on the isolation cart. Interview with DNS on 9/2/21 at 11:10 AM identified she was aware that the resident rooms did not have gloves. She identified gloves are kept in the supervisor's office and the staff is to get a box at the beginning of each shift due to excessive use, control and to prevent overuse. The DNS indicated it is the company's rule. The DNS indicated gloves should have been readily available to staff for resident care and universal standard precaution. Interview with NA #12 on 9/2/21 at 12:05 PM identified she was aware that there were no gloves in the resident rooms. NA #12 identified there has been no gloves in the resident room since her employment in 1/2021. She indicated she get a used box of gloves from the previous shift or searches for a box of gloves. She indicated that she keeps the box of gloves with her going from resident room to resident room. Interview with NA #21 on 9/2/21 at 12:19 AM on A wing identified she was aware of the resident rooms not having gloves. She indicated it has been like this for a very long time. NA #21 indicated she must search for gloves or go to the supervisor's office for one box of gloves. And she places the one box of gloves on railing in the hallway for the staff on the wing. Interview with the former DNS on 9/2/21 at 2:06 PM identified she was aware of the resident rooms not having gloves. The former DNS identified that this was the procedure for the facility for approximately a year. She identified that gloves should have been readily available for staff in the resident's room for care not having to go out into the hallway when needed. The former DNS indicated that is not the correct universal standard precaution. Interview with NA #2 on 9/2/21 at 4:21 AM identified she was aware that the resident rooms did not have gloves. She indicated that she gets one box of gloves from the supervisor's office and stuff her pocket with gloves. NA #2 indicated she places the box in the linen closet for the rest of the shift. NA #2 indicated the facility stop putting gloves in the resident rooms since the beginning of the year. Interview with RN #2 on 9/2/21 at 4:44 PM identified she was aware that there were no gloves in the resident rooms and the bathrooms. RN #2 identified that the staff is supposed to come to the supervisor's office, and they are provided with one box of gloves for the whole wing. She indicated that gloves had not been readily available in resident rooms since the beginning of the year. She indicated universal precaution is gloves are available in resident rooms for care. Interview with Central Supplies staff on 9/8/21 at 12:38 PM identified she was told by the Administrator last year not to put any gloves in the resident's rooms and bathrooms. She indicated the Administrator directed her to put gloves in the supervisor's office only. She indicated she was only doing what she was told by the Administrator. Subsequently to surveyor inquiry, the facility's Housekeeping Director brought additional boxes of gloves to A, B, and C wings and stocked the resident rooms with gloves. Review of the facility gloving policy identified to prevent the transmission of infectious organisms between residents, staff and visitors. Protective gloves should be worn by all personnel during any procedure that may involve handling secretions and excrements of blood or bodily fluids. Gloves should only be worn once and then discarded. Gloves must be changed in between resident contact. Gloves must be changed any time their integrity is compromised. It is the policy of this facility that gloves be worn with reasonable anticipation of contact or handling of blood or body fluids, mucous membranes, non-intact skin, potentially infectious materials, when performing vascular access procedures, and/or touching contaminated surfaces. Review of the CDC (Center for Disease Control) guidelines for PPE for Isolation Precautions identified to wear gloves when it is anticipated that contact with potentially infectious materials could occur on the patient or the patient's surrounding environment and change gloves during patient care when the hands move from a contaminated body-site to a clean body site. Standard Precautions: infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. Standard precautions include but are not limited to hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; safe injection practices, and respiratory hygiene/cough etiquette. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, properly clean and disinfect or sterilize reusable equipment before use on another patient). The use of PPE during resident care is determined by the nature of staff interaction and the extent of anticipated blood, body fluid, or pathogen exposure to include contamination of environmental surfaces. Furthermore, appropriate use of PPE includes but is not limited to the following: o Gloves worn before and removed after contact with blood or body fluid, mucous membranes, or non-intact skin; o Gloves changed, and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. The facility failed to ensure an adequate number of gloves (personal protective equipment) were readily available to staff accordance to universal standard precautions and infection control policies. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's order dated originally 7/4/21 and current through 9/13/21 directed to change disposable oxygen supplies every week and as needed on (Saturday 11:00 PM - 7:00 AM) shift. Label and date all supplies every Saturday night. Physician's orders dated originally dated 7/4/21 and current through 9/13/21 directed to suction [CONDITION(S)] as needed. Suctioning is a sterile procedure, and a new sterile gloves and suction catheter should be used each time. Physician's orders dated originally 7/4/21 and current through 9/13/21directed to administer cool mist aerosol via air compressor with 2 Liters of oxygen via liquid or concentrator to [CONDITION(S)] mask to equal 28% oxygen every shift. The admission MDS dated [DATE] identified Resident #48 had intact cognition and required extensive assistance with personal hygiene. The care plan dated 7/21/21 and currently in effect identified Resident #48 has a [CONDITION(S)]. Interventions included to provide [CONDITION(S)] care as needed, suction as necessary, and use universal precautions as appropriate. Additionally, Resident #48 requires a J-tube. Interventions included to provide local care to J-tube site as ordered and monitor for sign and symptoms of infection. Further, Resident #48 has Chronic Obstructive Pulmonary Disease ([CONDITION(S)]). Interventions included to administered oxygen per physician's order. Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Label and date all supplies every Saturday night. Documentation on 7/10/21, 7/17/21, and 7/24/21 identified oxygen supplies were changed with nurses' initials. Review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Label and date all supplies every Saturday night. Documentation on 8/7/21, 8/14/21, 8/21/21, and 8/29/21 identified oxygen supplies were changed with nurses' initials. Review of the September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Label and date all supplies every Saturday night. Documentation on 9/4/21 identified oxygen supplies were changed with nurse initial. Observation with LPN #3 on 9/9/21 at 11:15 AM identified the following: a. Used suction tubing with no cover lying on table. b. Nebulizer handheld with no cover lying on the table, c. Oxygen nasal cannula tubing with a piece of tape around tubing dated 7/25/21. (Resident #48 was on continuous cool mist aerosol via air compressor with 2 Liters of oxygen via liquid or concentrator to [CONDITION(S)] mask to equal 28% oxygen every shift). d. Catheter syringe with no cover lying on the table. Interview with LPN #3 on 9/9/21 at 11:16 AM identified she was not aware of the issue until now and she was not the charge nurse on duty. LPN #3 indicated it was the 11:00 PM to 7:00 AM nurse's responsible to change the oxygen tubing weekly per the physician's order. LPN #3 indicated the equipment's should have been covered with the plastic bags. Interview with RN #9 on 9/14/21 at 8:21 AM identified she was the charge nurse on duty on 9/9/21 from 9:00 AM - 11:30 AM and she was not aware of the issue. RN #9 indicated she does not recall if the respiratory equipment's was covered or not in the plastic bags. Interview with the DNS on 9/15/21 at 11:31 AM identified she was not aware of the issue. The DNS indicated the nurse's should have changed the oxygen tubing per physician's order and placed the plastic covers after each equipment usage. Subsequent to surveyor inquiry, Resident #48's oxygen tubing was changed and dated 9/9/21. Additionally, the suction tubing, handheld nebulizer, and catheter syringe was discarded and replaced. Review of the provide clean nebulizer equipment policy identified to ensure clean nebulizer treatments. It is the policy of the facility to provide clean nebulizer treatments. Place nebulizer tubing & accessories in plastic bag. Review of the facility replace oxygen tubing & set up policy identified it is the policy of this facility to provide a clean oxygen delivery system. Replace oxygen tubing weekly. Record date & initials. Place oxygen tubing & accessories in plastic bag that is dated & initials. Review of the facility gastrostomy/jejunostomy site care policy identified to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Review of the facility per nasal cannula policy identified nasal cannula shall be changed every week. The facility failed to ensure infection control practices were maintained related to respiratory and g-tube equipment and facility failed to change oxygen tubing per physician's orders.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #79), reviewed for an allegation of neglect, the facility failed to ensure the resident was free from neglect. The findings include: Resident #79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the orders identified Resident #79 requires the assistance of 2 staff (extensive assistance) for upper/lower body dressing, and toilet transfers and limited assistance for personal hygiene. Review of the weight's summary dated 5/18/21 identified Resident #79 weighed 402.1 lbs. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, required extensive two-person physical assistance with toilet use and extensive one-person physical assistance with personal hygiene. Additionally, the MDS indicated Resident #79 was always continent of urine. The care plan dated 6/2/21 identified Resident #79 had a self-performance and mobility deficit related to deconditioning and weakness. Interventions included to encourage the resident to participate in ADLs to promote independence. The care plan did not address how staff should provide assistance regarding Resident #79's bowel and bladder needs. Review of the nurse aide care card directed to record bowel movement pattern each day (describe the amount and consistency). The nurse aide care card did not address how staff should provide assistance regarding Resident #1's bowel and bladder needs. Interview with Resident #79 on 8/16/21 at 1:05 PM identified that usually when he/she rings the call bell, it takes the nurse aides 40 minutes to an hour to answer. Resident #79 indicated that sometime in June 2021, during the 11:00 PM - 7:00 AM shift, he/she needed help and rang the call bell for approximately 4 hours, but the staff did not answer or come to his/her room. In another incident, Resident #79 indicated recently, after returning from a hospitalization , during an 11:00 PM - 7:00 AM shift, the resident rang the call light because he/she had to urinate. Resident #79 could not remember the exact time but was also yelling for help. The staff on the night shift never came into his/her room to help or provide care so he/she had to urinate in the bed and lay in it. Resident #79 indicated that when the 7:00 AM - 3:00 PM shift arrived, the nurse aide answered the call light a little after 7:00 AM. Resident #79 indicated at that time, NA #1 provided care and the resident reported to NA #1 that he/she had been ringing for help since 5:00 AM and had been laying in urine because no one came to help. Resident #79 indicated he/she lays in bed waiting for staff to answer the call bell, it happens all the time, it goes on all the time. The resident stated he/she many times has had to urinate right in his/her bed and lay in the urine, screaming for help because no one comes, and he/she and the bed gets cold because it's wet. The resident indicated he/she has had to call 911 in the past when staff don't answer the call bell. The resident indicated he/she rings for the bedpan and will urinate on the bedpan, but if no one comes, he/she has no choice and cannot hold it, so will urinate in the bed. If staff answer his/her call light in a timely manner, he/she uses the bed pan. Interview with Resident #2, (Resident #79's roommate), on 8/16/21 at 1:12 PM identified he/she does not remember the exact date but does remember an incident when he/she was woken up by Resident #79 screaming for help at approximately 5:00 AM. Resident #2 indicated the night shift did not come to answer the call bell or come in the room to help Resident #79. It wasn't until the day shift arrived that Resident #79 received help. Interview with NA #1 on 8/16/21 at 1:30 PM identified she does not remember exactly the day or date, but it happened when Resident #79 came back from the hospital recently. NA #1 indicated when she came in at 7:00 AM, Resident #79's light was ringing, and she answered the call light. NA #1 indicated Resident #79 was crying and stated that the nurse aide (lady) on the night shift did not provide care. NA #1 indicated Resident #79 and his/her bed and linens were saturated with urine so she provided Resident #79 a bed bath and changed the bed linen. NA #1 indicated after she provided care to Resident #79, she notified RN #2 and LPN #1 of Resident #79's complaint that the night shift had not provided care and that Resident #79 was soiled and saturated and left in a urine-soaked bed. Interview with LPN #1 on 8/16/21 at 3:47 PM identified he is the regular nurse on the B unit and assigned to Resident #79. LPN #1 indicated he does not remember NA #1 reporting to him that Resident #79 was complaining about the night shift not answering the call light or providing the resident the bed pan, and subsequently the resident soiled and saturated the bed with urine. LPN #1 indicated that one time during the day shift, he does remember an incident when Resident #79's family member called the facility and reported that if someone does not go into the resident room to provide toileting assistance that he/she was going to call 911. Interview with RN #4 on 8/16/21 at 4:00 PM identified she does not remember NA #1 informing her that Resident #79 complained that the night shift did not provide care during the shift and that the resident was left in a urine-soaked bed. Interview with Social Worker #1 on 8/17/21 at 9:53 AM identified she was not aware of the resident's complaint regarding the night shift not providing him/her with care during the night. Interview with The Former DNS on 8/17/21 at 2:05 PM identified she was not aware of the alleged complaint by Resident #79 that the 11:00 PM - 7:00 AM shift did not provide care for 2 hours and that the resident was left in a urine soaked bed. Review of the nurse's notes dated 7/1/21 through 8/16/21 failed to reflect the facility addressed Resident #79's alleged complaint to NA #1 that the night shift (11:00 PM - 7:00 AM shift) did not provide the bed pan after the resident rang the call light at approximately 5:00 AM, until NA #1 came in on the day shift, (7:00 AM - 3:00 PM shift) and NA #1 provided care, a little after 7:00 AM, 2 hours. Review of the bowel/bladder, nursing policy identified to establish a nursing care plan on an individualized basis for bowel/bladder retraining, continence management, for incontinence management. Review of the abuse and neglect policy identified residents have the right to be free from abuse, corporal punishment, involuntary seclusion, and psychosocial harm. Resident will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Neglect - any failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Reporting mechanism: Facility in-house reporting - whenever there is a witnessed or alleged report of a resident abuse action, as defined above, the following is initiated. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. The facility failed to ensure Resident #79, who was alert, oriented and continent, was free from neglect during the 11:00 PM - 7:00 AM shift, when staff did not provide assistance with toilet use when requested, and subsequently the resident urinated in the bed, was left in a urine saturated bed and found in a urine saturated bed by the day shift over 2 hours later.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #1) reviewed for accidents, the facility failed to ensure that the resident's environment was free of accident hazards and failed to provide the necessary supervision to prevent an accident. The findings include: Resident #1's diagnoses included COVID-19, muscle weakness, major depressive disorder, spinal stenosis and fracture of the left neck femur. An MDS assessment dated [DATE] identified Resident #1 had moderately impaired cognition, required extensive assistance of one for bed mobility, total assistance of two for transfers, did not ambulate, did not self-propel in the wheelchair and had not fallen within the past six months. The care plan dated 5/19/20 identified Resident #1 was at risk for falls related to limited mobility with interventions that included, 7-3 staff to toilet on last rounds, ensure that call bell is within reach during rounds, patient educated to ask for assistance to move further back onto mattress when he/she is having difficulty positioning self. The care plan further identified that the resident had been educated to call for assistance when wanting to go to bathroom. Review of the facility's reportable event documentation on 7/20/20 identified that on 7/8/20 at 3:20 PM, Resident #1 was observed on the floor by two nurse aides. The documentation notes that the resident had attempted to get out of his/her wheelchair which had resulted in the resident falling. Resident #1 was found lying on his/her right side on the floor with the right side touching the radiator. The documentation noted that the nurse aides moved the resident away from the radiator and noted that the radiator was turned on. The charge nurse and the RN supervisor were notified. Reportable event documentation further identified that Resident#1 was noted with multiple reddened skin areas with the existence of multiple intact blisters. The resident had two areas on the right upper arm that measured 6.5 centimeters in length (cm) by 5 cm in width and another that measured 11cm by 9cm. In addition, the documentation noted an area on the right lower back that measured 5cm by 4cm with 4 blisters noted on the reddened area. The documentation further noted that the resident denied hitting his/her head and complained of pain to his/her right side. In addition, the reportable event documentation noted that the resident's responsible party and the APRN were notified. The APRN ordered Xeroform dressings to be changed three times per day and cover with a dry protective dressing and monitor the burn areas every shift. An APRN note dated 7/09/20 at 12:40 PM identified that Resident#1 slid off the bed and suffered second degree [CONDITION(S)] to the right side of his/her back. The APRN noted that the areas were clean with no signs and symptoms of infection and were tender to touch. The APRN further noted to continue with dressing changes as ordered, administer [MEDICATION(S)] as needed, neuro's intact to baseline, safety measures maintained, vital signs stables and continue with plan of care. Review of the medication administration record (MAR) on 7/20/20 identified Resident #1 was administered [MEDICATION(S)] HCl (narcotic pain medication)10mg on 07/09/20 at 3:28 PM for a pain level of 6 (the pain scale is from 1 to 10 with 10 being the worst and 1indicating mild pain). On 07/10/20 at 12:13 PM for a pain level of 7 and on 07/14/20 at 3:57 PM for a pain level of 9. Resident #1 received [MEDICATION(S)] HCl 5mg on 07/10/20 at 6:10 AM for a pain level of 4. A social service note dated 7/10/20 at 8:31AM noted that Social Worker #1 met with Resident #1 and noted that the resident reported that the [CONDITION(S)] hurt but expressed no other issues or concerns. An APRN note dated 7/10/20 at 3:52 PM identified that a follow up visit was made to Resident #1 to follow up with the resident for status post fall with burn injuries to the lower back. The APRN's note identified that the area did not appear to be infected, the resident reported mild pain and the APRN continued with the dressing changes as ordered. The note further identified that Resident #1 would be seen by the facility's wound physician. The APRN directed to administer pain medication as needed. The APRN also noted that vital signs were stable and to continue to monitor the burn areas for signs and symptoms of infection, encourage fluids, maintain safety, neuro's intact to baseline and continue with plan of care. A social services note dated 7/10/20 at 5:07 PM identified that Resident #1 reported that his/her [CONDITION(S)] hurt and that the nurse was aware of it. A Rehabilitation Fall Screen dated 7/13/20 identified that Resident #1 was recently discharged from PT on 7/3/20 due to higher functional level. Resident #1 was not recommended for skilled rehab and evaluation. Resident #1 was identified as an assist of one with transfers. The evaluation recommended supervision of the resident when in wheelchair. A physician order dated 07/14/20 directed to cleanse right upper arm burn wound with normal saline, apply Xeroform and foam dressing every other day on 7-3 shift. The orders also identified a PT/OT screen evaluation was ordered. Review of the wound documentation on 7/20/20 identified Resident #1 had a right upper arm wound. Wound type identified as burn. Measurements identified as 18cm x 12cm x 0cm (length x width x height). A second wound identified on right back side. Wound type identified as burn. Measurements identified as 5cm x 4cm x 0cm (length x width x height). Interview with Resident #1 on 7/20/20 at 10:30 AM identified that he/she had fallen and sustained [CONDITION(S)] from the radiator. The resident identified that the [CONDITION(S)] had been painful, but he/she had been receiving pain medication. Resident #1 identified that he/she was on the floor for not more than 10 minutes. Interview with the Director of Maintenance (DOM) on 7/20/20 at 11:05 AM identified that he and the Assistant Director of Maintenance (ADOM) were the only two staff members authorized to turn the heat on/off for the facility. The DOM noted that all radiators were turned off on June 1st, 2020 for AC implementation. The DOM could not identify who turned on the radiators, but believed it was a house-keeping employee who no longer worked for the facility. The DOM further identified that the electrical component to the radiators can only be turned on by accessing a panel which is locked. The DOM identified that radiator temperatures are not monitored, but he monitors when it's time to turn on/off the radiators for AC to be used in the facility. He identified ways to prevent a recurrence from happening would include ensuring that all electrical panels are locked. He further identified that he and the ADOM would only have access to the locked panel. He noted the house-keeping team would be in-serviced regarding assisting residents with maintenance concerns. The DOM identified he would perform audits all month to ensure the panels remain locked and would submit the results to the Administrator upon completion and would also have a team discussion involving the Administrator to formulate a plan for the winter months. Potential ideas included coverings for the radiators. Interview with CNA #1 on 7/20/20 at 1:20 PM identified the resident fell during shift report and she entered the room at approximately 3:30-3:40 PM and found the resident on the floor. CNA #1 identified that the resident stated, I had to use the bathroom. CNA #1 identified that the RN Supervisor came immediately after to assess the resident and the resident was found to have burn/blisters. Interview with RN #1 on 7/22/20 at 1:15 PM identified that on the day of the fall, she was receiving report when Resident #1 called out for help. Two nurse aides entered the room first and discovered the resident on the floor. RN #1 identified that she went in immediately afterwards to assess the resident and noted the wounds on the back and arm caused by the radiator. RN #1 believed the resident was on the floor for approximately 5-10 minutes prior to being discovered. RN #1 identified the radiator was enclosed in the metal casing and was hot to touch. RN #1 noted that the APRN was updated and new orders went into place including wound dressings and monitoring the sites for infection. RN #1 identified that Resident #1's room was changed in order to prevent reoccurrence and the radiators were turned off. Review of facility documentation on 7/27/20 identified a report by Coastal Mechanical Services Inc. dated 7/23/20 that identified that they performed an inspection of the electric heater in Resident #1's room and identified that the heater was operating safely. Interview with the APRN on 8/5/20 at 12:30 PM identified that on the day of the incident facility staff called to report Resident #1's fall. APRN #1 identified that Resident #1 suffered second degree [CONDITION(S)] on the lateral arm and back. APRN #1 identified that orders placed after the fall included wound dressings and frequent monitoring for infection. APRN #1 noted Resident #1 had a previous order for pain medication ([MEDICATION(S)] HCL) and did not want to add more pain medications to what the resident already had in place and noted that the pain medication currently ordered would cover the resident's pain as needed. Review of the fall policy identified the purpose was to prevent reoccurrence of falls and/or serious injury to a resident with falls. The procedure identified to keep the resident in the position that he/she fell . Call the RN Supervisor or an RN. The RN Supervisor or RN is to assess the resident for injury and range of motion. The RN Supervisor or RN will also assess the resident for immediate injury prior to moving the resident. Vital signs are to be taken post fall. File a reportable event with documentation of physician and family notification. Notify the rehab department for resident screening. The facility failed to ensure that the resident's environment was free of accident hazards and failed to ensure the necessary supervision to prevent an accident.

7. Based on review of clinical records, review of facility policies, observations, and interviews, the facility failed to ensure that interventions were consistently implemented and/or that preventive measures were in place to avoid pressure ulcer development and/or failed to provide a comprehensive skin assessment that resulted in the identification of pressure areas initially assessed at a Stage III and/or failed to ensure that the areas identified were assessed in accordance with facility policies for five of six residents, Residents #11, #12, #66, #82, and #93,who developed a pressure ulcer. The findings include: a. Resident #12 (R #12) had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] identified that R #12 had severe cognitive impairment, was totally dependent for bed mobility and transfers, required a feeding tube, and had a Foley catheter. The assessment further identified that R #12 had limited range of motion of the upper and lower extremities bilaterally. Although the MDS identified that R #12 had no pressure ulcers, a Braden scale risk assessment dated [DATE] identified R #12 at moderate risk for development of pressure ulcers with a score of fourteen. The care plan dated 8/21/13 identified that R #12 required total assistance with all Activities of Daily Living (ADL's) with interventions that included transfer with mechanical lift of two persons and maintain good body alignment. The care plan further identified the risk for skin breakdown related to altered mobility, [MEDICAL CONDITION] and a history of pressure ulcers with interventions that included to assist the resident in repositioning frequently, to observe skin condition with all ADL's, and to report any abnormalities. Physician order [REDACTED]. Review of the nursing note dated 9/4/13 identified that while providing care to R #12 on 9/4/13, a nursing assistant showed the nurse an area on the resident's back. Upon assessment of the area, the documentation identified that R #12 had developed two pressure areas that measured 4.0 centimeters (cm.) by 1.5 cm and 2.5 cm by 2.0 cm. The documentation further identified the areas were blanchable and intact but looked purplish in color. A revision to the plan of care on 9/4/13 included an intervention to ensure that the resident was not lying on the oxygen tubing. Interview with RN #2 on 11/18/13 at 9:50 AM identified that he/she was the nurse present when R #12's pressure areas were initially identified. RN #2 identified that R #12's oxygen tubing was behind the resident's back and the tubing was positioned where the two areas were observed. RN #2 identified that the oxygen tubing had caused the pressure to the resident's back. Interview with the Director of Nursing on 11/18/13 at 11:00 AM identified the root cause of the pressure ulcer was the oxygen tubing. The facility skin integrity report dated 9/4/13 identified that R #12 had a pressure ulcer on the right scapular which was subsequently assessed as a 4.0 cm by 1.5 cm intact, facility acquired, Deep Tissue Injury (DTI). In addition, the facility skin integrity report dated 9/4/13 identified that R #12 also had a facility acquired Stage III pressure ulcer on the right medial scapula that measured 2.5 cm by 2.0 cm. Review of the Advanced Practice Registered Nurse (APRN) progress note dated 9/4/13 described R #12's skin integrity impairments as a DTI on the right upper back that measured 4 cm by 1.5 cm with deep purple discoloration and a second superficial open wound on the right upper back that measured 2.5 cm by 1.2 cm. Although the pressure areas were assessed and treated by the APRN on 9/4/13, the pressure areas continued to breakdown and progress. Review of the skin integrity report dated 9/24/13 identified that R #12's right upper back wound had progressed to one unstageable pressure ulcer with 50% necrotic tissue. The area measured 2.5 cm by 2.0 cm by less than 0.1 cm with a moderate amount of serous drainage. Observation of R #12's treatment to the right upper back on 11/18/13 at 10:30 AM identified an approximate 2.0 cm circular open area with 100% slough with a surrounding 0.5 cm circular reddened area and surrounding purplish area on the upper right back. b. Resident #11 (R #11) had [DIAGNOSES REDACTED]. Review of clinical record dated 1/17/13 identified that R #11 was discharged from services by the wound consultant due to a resolved Stage II pressure ulcer on coccyx with recommendations to follow up as needed. Review of R #11's care plan dated 8/1/13 identified that the resident was at risk for skin breakdown with interventions that included to assist with turning and repositioning frequently, to apply barrier cream/protective lotion as needed with each cleansing, to observe skin condition with ADL care daily, and to report abnormalities. The care plan further directed that pressure redistribution surfaces be applied to bed and chair as per protocol and to utilize positioning devices as appropriate to prevent pressure over boney prominences. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #11 had severe cognitive impairment, was totally dependent on staff for bed mobility, transfers, toilet use and personal hygiene, and required extensive assist of one person for transfers. The MDS identified that R #11 had no pressure ulcers Review of clinical record identified that although a skin audit was completed on 11/1/13 with no abnormalities noted, three days later on 11/4/13, R #11 was identified to have a new Stage III pressure ulcer was noted on the left buttocks that measured 3.5 centimeters (cm.) by 1.5 cm. Interview, clinical record review, and facility documentation review with the DNS on 11/14/13 at 11:15 AM identified that he/she had concerns regarding how the wound could have been initially identified as a Stage III when R #11's skin was noted to be intact on 11/1/13. The DNS stated he/she was unable to explain how the wound was only noted when it was already a Stage III pressure ulcer. In addition, interview and record review with LPN #5 on 11/14/13 identified that no Braden assessment was completed at the time R #11's new pressure area was noted and lacked an assessment by an RN at the time of the initial observation on 11/4/13. c. Resident #66 (R #66) had [DIAGNOSES REDACTED]. Review of the care plan dated 8/9/13 identified that R #66 was at risk to develop a pressure ulcer with interventions that included to monitor the skin for signs/symptoms of skin breakdown and to observe the resident's skin condition with ADLs care daily and report abnormalities. The Minimum Data Set ((MDS) dated [DATE] identified that R #66 had moderate cognitive impairment, required extensive assistance for Activities of Daily Living (ADLs), and had no pressure ulcers. On 8/28/13, R #66 was found to have developed a 1.0 centimeter (cm.) by 0.6 cm. by less than 0.1 cm. Stage II pressure ulcer on the coccyx which documentation identified as closed as of 9/24/13. Subsequent to the development of the pressure ulcer, a low air loss mattress was applied to the resident's bed. Although review of the clinical record dated 9/24/13 through 10/8/13 identified that weekly skin checks were completed, the record lacked documentation that daily skin checks were provided with ADL care. Review of the skin integrity report and wound care notes dated 10/8/13 identified that R #66 had developed a 0.6 cm. by 0.5 cm. by less than 0.1 cm unstageable pressure ulcer on the coccyx with light serous exudate that progressed to a Stage III ulcer on 10/15/13 and lacked documentation of any skin abnormalities prior to the observation of the unstageable pressure ulcer. d. Resident #82 (R #82) had [DIAGNOSES REDACTED]. The annual Minimum Data Set, dated dated dated dated 09/17/13 identified that R #82 was alert and oriented although required extensive assistance with mobility and the assist of two with turning and repositioning. The care plan dated 9/23/13 identified that R #82 was at risk for skin breakdown related to impaired mobility, bladder and bowel incontinence, and refusal to get out of bed. The care plan further directed interventions that included to provide pressure redistribution surfaces to the bed and the chair. Interventions for refusal of care or treatment directed staff to reapproach the resident at a later time if at first she/he refused care or treatments. R #82 was admitted to the hospital on [DATE] for a scheduled procedure and returned to the facility on [DATE] at 6:00 PM. Review of the Admission Nursing assessment dated [DATE] at 6:06 PM indicated that R #82 had two abdominal wounds present upon admission, but no other skin impairments were identified upon admission. The Skin Integrity Report dated 11/3/13 identified a 1.0 cm by 1.0 cm pink but intact area on the coccyx but the area was not identified as a pressure ulcer. Two days later on 11/5/13, the Skin Integrity Report identified that the resident's coccyx area was now a Stage III pressure ulcer that measured 1.3 cm x 1.0 cm. Record review on 11/13/13, identified a wound care physician's note dated 11/5/13 that indicated a Stage III pressure ulcer was present with a duration of greater than one day. Interview with the Director of Nursing (DNS) on 11/13/13 at 3:00 PM stated that he/she was responsible for wound tracking in the facility. The DNS further stated that the documentation of the staging of the pressure ulcer on 11/3/13 was inaccurate. e. Review of the Weekly Skin Intergrity Tracking Report dated 11/5/13 indicated that R #82 had a Stage III pressure ulcer to the coccyx. Wound Care physician orders [REDACTED]. Observation on 11/14/13 at 11:50 AM identified that R #82 did not have a low air loss mattress on his/her bed. R #82 was observed lying flat on his/her back with the bed elevated 35-40 degrees on a regular mattress. Interview with the Director of Nursing (DNS) on 11/14/13 at 12:15 PM stated that R #82 had refused to have a low air loss air mattress. In addition, the DNS stated that the resident occassionaly refused to be repositioned. Interview with Resident #82 on 11/14/13 at 12:30 PM identified that although he/she did initially refuse to have a low air mattress, he/she would be interested in trying the device if it would help to heal his/her wound. Review of the clinical record lacked documentation to reflect that the air mattress was offered and/or encouraged on more than one occasion and/or that the facility had provided education to the resident on the benefits of utilizing a low air loss mattress. f. Resident #93 (R #93) had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that R #93 was cognitively impaired, totally dependent on staff for all ADLs, frequently incontinent of bowel, and had a 2.0 by 3.3 by 0.6 cm. Stage IV pressure ulcer on the coccyx. Physician orders [REDACTED]. Observation on 11/14/13 at 11:35 AM identified that R #93 was laying on his/her left side. A foul odor was noted to be coming from the resident's room. Interview with NA #6 at the time of the observation identified that he/she had already provided morning care was waiting for the nurse before providing additional care to the resident. At 12:20 PM on 11/14/13, the surveyor requested to observe the resident's wound dressing. Upon turning the resident to the right side, R #93's Stage IV pressure ulcer was noted to be uncovered, had a foul odor, and that the resident had been incontinent of stool. Interview with NA #6 at the time of the observation identified that he/she had removed the dressing when he/she provided morning care at approximately 10:40 AM as the dressing had become soiled with stool. NA #6 stated that he/she did not report the uncovered wound to the licensed staff. Subsequent to surveyor inquiry, LPN #3 was notified and subsequently placed a clean, telpha type dressing over the wound though was not observed to cleanse the wound prior to application of the dressing. Subsequent interview with LPN #3 on 11/14/13 at 12:55 PM identified that the facility did not have the medicated ointments as prescribed by the physician in order to complete R #93's wound care. LPN #3 stated that he/she placed a STAT (immediate) order for the medicated ointment and expected its delivery to the facility quickly. Interview with the DNS on 11/14/13 at at 5:00 PM identified that the medicated ointments had still not arrived. At 5:06 PM, more than five hours after LPN #3 was observed to placed only a telpha dressing over R #93's wound, the physician was notified, a comparable treatment order was obtained, and R #93's wound care was completed. Interview with LPN #3 on 11/15/13 at 11:15 AM identified that he/she knew there was only a small amount of the ointment when he/she performed the dressing change on 11/13/13 but thought there would be enough to do the dressing on 11/14/13. LPN #3 stated that when the pharmacy did not deliver the necessary medicated ointment timely, he/she should have notified that physician for new orders. Interview with the DNS on 11/15/13 at 9:30 AM indicated that LPN #3 should have reordered the ointment when he/she noticed the amount was low and that the LPN should have notified the physician for new orders when the medication was not delivered timely. Facility policy directed in part, that implementation of an individual's skin integrity management occurs within the delivery of care. The policy directed that staff would continually observe and monitor residents for changes and implement revisions to the plan of care. In addition, the policy lacked documentation to reflect information related to the potential for pressure ulcer development related to use of necessary equipment (ie: oxygen tubing).