Every finding on record at Springbrook Center

Based on record review and interviews, the facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift. This resulted in a resident falling from the lift sling onto floor during the transfer from bed to wheelchair and sustaining fractured ribs, lacerated spleen, and a fractured left arm, for 1 of 3 residents reviewed for falls with major injury (#1).Findings:On 10/27/25, the Division of Licensing and Certification received a report from the facility stating on 10/25/25 a nurse was preparing medications in front of R1's room when he/she heard a loud sound and upon turning around, R1 was found lying face down on the floor. Staff reported that the resident fell from the total lift during transfer from bed to wheelchair. When the resident was turned onto his/her back, it was observed that one of the sling loops had come off the lift hook, resulting in the fall. The nurse's assessment revealed a contusion of the left forehead and bleeding from the nose. R1 complained of pain and limited range of motion in both arms. Staff initiated first aid and called 911. R1 was transferred by ambulance to the hospital and was admitted to the trauma unit. On 10/28/25 at 11:15 a.m., in an interview with a surveyor, the Director of Nursing (DON) and the Administrator discussed the incident. The DON stated two Certified Nursing Assistants (CNAs) were transferring R1 from the bed to the wheelchair using a total lift. CNA1 pulled the lift out to position R1 for transfer into the wheelchair. CNA2 was holding onto R1 in the sling and guiding R1 into the chair. The DON stated R1 then rolled out of the sling and onto the floor. The nurse on duty was standing outside the room at the medication cart and heard the bang, turned to look and saw R1 on the floor. The first thing the nurse noticed was the loop was off of the swing bar on the electric lift. On 10/28/25 at 4:00 p.m., in an interview with a surveyor, CNA2 demonstrated how he/she assisted R1 with the transfer. The bed was to the left of the room, the lift facing towards the door. The wheelchair was facing toward the bed. R1 was facing toward the lift. CNA1 moved the lift while CNA2 guided the resident in the sling to position into the wheelchair. CNA2 was standing on the right side of the wheelchair. CNA2 stated both CNAs applied the sling for R1. During the lift, R1 suddenly flipped over from the sling and onto the floor. CNA2 stated R1 used a blue (extra large) sling and when the loops were attached to the hangar bar, green loops were applied on both sides of the head and black loops on both sides of the legs. The surveyor asked how CNA2 knows the loops are secured and how many times the loops are checked before a transfer takes place. CNA2 stated I do not know how many times I checked it. I just made sure it is safe.On 10/28/25, R1's clinical record was reviewed. The record indicated R1 was diagnosed with dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, limited mobility, and other morbidities. The Minimum Data Set (MDS) 3.0, Quarterly Assessment, dated 10/17/25, Section GG. Functional Abilities and Goals, revealed R1 was dependent on staff and required full assistance with bed mobility, transfers, and toileting. R1's care plan, revised on 8/5/25, included the intervention to provide R1 with assist of 2 (staff), using a mechanical lift and a green full body sling for all transfers. Review of the Lift-Transfer Evaluation for R1, dated 9/18/25, indicated R1's weight was 239.2 pounds, and the height was 60 inches, and required a blue (extra large) sling for use with the electric mechanical lift.A review of the hospital admission history and physical notes, dated 10/25/25, stated, R1's injuries included acute left rib fractures #8 and #9, displaced fractures of the distal radius and ulna with overlapping fracture segments, and splenic laceration with subcapsular hematoma.A review of the facility's Operation Competency Assessment for the Invacare Reliant 450 and 600 Full Body Lifts, noted under the section Operation of power lift, that staff Checks again that the sling straps are properly connected to hanger bar hooks before transfer.On 10/29/25 at 10:40 a.m., in a telephone interview with a surveyor, the DON confirmed the care plan and Kardex had not been updated to reflect the change from a green to a blue sling. During an interview, the surveyor asked what did staff do next before R1 was transferred to the wheelchair? CNA1 stated, We lift (him/her) up and open the legs of the Hoyer. The surveyor asked did staff double check straps before staff moved R1, to make sure everything was safe? CNA1 stated Not that day. On 10/29/25 at 11:30 a.m., in a telephone interview with a surveyor, the RN on duty at the time of the incident stated I was the one to fill out the incident report and I tried to determine the cause. The first thing I thought was the Hoyer pad must've been broken. On the upper left side of the sling, there was no break on the hooks. The sling was hanging down. I wondered how did he/she fall? I was asking questions of the CNAs and they said he/she jerked and moved and that caused the cradle to change balance. I was trying to check if that would loosen the hook on the cradle. It can open, but there's still some space. I know the upper left (loop) was completely off and hanging on the floor. It was hanging when I first came into the room. The other 3 (loops) were still attached. The Hoyer pad had no breaks and there were no broken parts of the Hoyer.The EMS (Emergency Medical Services staff) used the same Hoyer pad to lift R1 onto the stretcher.A review of preventive maintenance and safety inspections noted the lift in use at the time of the incident, #8, was inspected by facility maintenance on 9/30/25, and also by an independent contractor in October, 2025. A review of the facility's Safe Resident Handling/Transfer Equipment Policy, dated 3/1/24, stated Staff will complete training and demonstrate competency in the use of safe resident handling equipment. Manufacturers' instructions will be used for all safe resident handling equipment.During an interview with the Administrator stated CNA staff must complete training for use of the mechanical lifts at the time of hire and annually. The training consists of an online module and then hands-on competency training with the rehab department. A review of the training for CNA1 noted training was provided on 7/19/25 and competency was demonstrated at the staff skills fair on 8/6/25. CNA2 was provided training on 7/8/25 and demonstrated competency at the skills fair on 7/31/25.A review of the manufacturer's operator and maintenance manual, stated in Section Lifting the Patient, page 14, When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur. Adjustments for safety and comfort should be made before moving the patient.Page 15, Before transferring a patient from a stationary object (wheelchair, commode or bed), slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again.

Based on observations, record review, and interviews the facility failed to implement the care plan interventions for 1 of 7 residents reviewed for transfers using a mechanical lift. (Resident #7) Findings: Resident #7's Minimum Data Set 3.0, quarterly assessment dated [DATE], section GG functional abilities and goals revealed he/she was dependent on staff and required full assistance with transfers. The most recent Lift Transfer evaluation completed on 11/4/25 indicated the residents weight was 195 pounds and required a purple (medium) sling for use with the electric mechanical lift. The care plan and the corresponding Kardex (used by the Certified Nursing Assistant) revised on 11/7/25 include the nursing interventions of Provide resident/patient with dependent assist of 2 for transfers using a mechanical lift with medium (purple) full body sling based on manufacturers guide and nursing assessment. On 11/20/25 at 8:50 a.m., observation of Resident #7 in his/her wheelchair with a green (large) sling underneath his/her body. On 11/20/25 at 9:28 a.m., during an interview, Certified Nurses Aid (CNA) #5 stated the slings sizes that are to be used for each resident are on the iPad (system used for CNA Kardex and documentation) and the sling size goes by color of the edges, for example purple is medium. On 11/20/25 at 9:31 a.m., during an interview, CNA #3, stated the sling size is on the Kardex and we do it by color. That's how you know what size sling it is by the color on the edges. On 11/20/25 at 9:33 a.m., during an interview, CNA #1, stated the sling size is in the Kardex on the tablet, the edge of the sling is the size by color. On 11/20/25 at 10:24 a.m., during an interview, CNA #4 stated she knows which sling to use by the Kardex and the color is in the Kardex. She doesn't know what the sizes are, she just goes by the color the Kardex says. On 11/20/25 at 10:54 a.m., during an interview, CNA #6, stated she knows what size sling to use by the Kardex. The color of the lining on the outside depicts the size of the sling. The Kardex would say green large or purple medium. On 11/20/25 at 9:49 a.m., both the surveyor and the Regional Administrator observed Resident #7 in the dining room with a green (large) sling under him/her in the wheelchair. At this time, the care plan was reviewed with the Regional Administrator who confirmed Resident #7 was not in the correct sling as per his/her plan of care.

Based on record review and interviews, the facility failed to revise a care plan to reflect the correct size sling used for transfers with a mechanical lift for 1 of 3 residents reviewed for falls with major injury (#1).Findings:On 10/28/25, R1's clinical record was reviewed. The record indicated R1 was admitted to the facility in November, 2020. Diagnoses included: dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, limited mobility, and other morbidities. The Minimum Data Set (MDS) 3.0, Quarterly Assessment, dated 10/17/25, Section GG. Functional Abilities and Goals, revealed R1 was dependent on staff and required full assistance with bed mobility, transfers, and toileting.The care plan and corresponding Kardex (used by Certified Nursing Assistants), revised on 8/5/25, included the intervention to provide R1 with assist of 2 (staff), using a mechanical lift and a green full body sling for all transfers. Review of the Lift-Transfer Evaluation for R1, dated 9/18/25, indicated R1's weight was 239.2 pounds, and the height was 60 inches. The assessment indicated R1 required a blue (extra large) sling for use with the electric mechanical lift. On 10/28/25 at 4:00 p.m., in an interview with a surveyor, CNA2 stated R1 used a blue (extra large) sling.On 10/29/25 at 10:40 a.m., in a telephone interview with the Director of Nursing and Assistant Director of Nursing, a surveyor discussed that R1's care plan and Kardex indicated a green, size large, sling was to be used for transfers, but staff reported a blue sling was used when transferring R1.The Director of Nursing confirmed the care plan and Kardex for R1 had not been updated to reflect the change from a green to a blue sling. The Assistant Director of Nursing stated R1 met the manufacturer's requirements for the blue sling.

Based on observation and interview, the facility failed to ensure that sterile technique was maintained during a pressure ulcer dressing change for 1 of 1 residents observed. (Resident #1) On 7/31/25 at 10:57 a.m., LPN #1 was observed performing a dressing change on Resident #1's stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, LPN #1 retrieved a piece of silver alginate dressing that had been resting on the outer wrapper of the product packaging, a surface that is not sterile, and inserted it into the tunneling wound using a sterile cotton-tipped applicator. At that time, the surveyor intervened and asked whether the outer surface of the packaging was sterile. LPN #1 acknowledged that it was not and agreed that this action could have contaminated the dressing. Physician's orders dated 7/22/25 directed daily cleansing Vashe solution, drying, and application of silver alginate to the wound bed.The facilities policy titled Wound Dressings - Aseptic Technique includes the following directive: Step 17: Open dressing(s) without contaminating. Keep the dressing(s) within the open packet and place it directly on top of the barrier.On 7/31/25 at 2:55 p.m. the surveyor discussed this finding during an interview with the Administrator, Director of Nursing (DON) and the Market Clinical Advisor.

Based on the complaint intake form, clinical record reviews, interviews, and facility policy, the facility failed to identify the appropriate resident when passing medications resulting the CNA-M admisistering medications to the incorrect resident that resulted in a resident being transported to an Acute Care Emergency Department and later admitted to the hospital critical care unit for monitoring and treatment of low blood pressure. (Resident #1) Findings: The Division of Licensing and Certification received an Adult Protective Services (APS) complaint that indicated on 5/8/25, at 9:20 a.m., Resident #1 received another resident's medications which resulted in a hypotensive episode. Resident #1 was transported to the emergency room and subsequently admitted to the critical care unit (CCU). A review of nursing documentation dated 5/8/25 at 9:33 a.m., stated, [Med tech] approached me [Nurse] and stated that she gave the meds of [room [ROOM NUMBER]B to room [ROOM NUMBER]A]. On assessment, patient appears to be stable and no complaints. Vital signs were taken immediately and stable. Reported incident immediately to [Doctor] and [Nurse Practice educator]. He/she was reevaluated by MD immediately. A review of the physician note dated 5/8/25, signed at 11:18 a.m., stated, I was asked to see [Resident #1] acutely as [he/she] received the wrong medications on morning pass. Meds taken at 09:20 this morning incorrectly received: Amlodipine 10 mg (milligram), Aspirin 81 mg, Calcium carbonate 500 mg, Clonidine 0.3 mg, Furosemide 80 mg, Losartan 100 mg, Metoprolol tartrate 100 mg, Nephro-Vite 0.8 mg, Omeprazole 20 mg, Prednisone 30 mg, Sertraline 100 mg, Sevelamer 800 mg . My greatest concern is for [his/her] blood pressure, having received amlodipine 10/clonidine 0.3/losartan 100/metoprolol 100 as well as furosemide 80 (but [he/she] usually takes torsemide 10 mg daily). Blood pressure checks every 15 minutes through 8 PM . As such, we will have a low threshold for sending to ER, but currently with a strong BP (Blood Pressure) and safe to continue to monitor here with frequent checks. A nursing note dated 5/8/25 at 1:57 p.m., stated, [Resident #1] was transferred to hospital for abnormal Vital Signs. On 5/12/25 at 1:08 p.m., during an interview with Certified Nurse's Assistant - Medication Aide (CNA-M) #2, she stated she had grabbed the medication cards from the slot labeled 6A (indicating the medications were for the resident in room [ROOM NUMBER] bed A). She then opened up the Medication Administration Record for the name on the card and began preparing the medications. She then entered the room and asked the resident in 6A if he/she was [the name on the medication cards]. The resident stated he/she was that name and was given the medications. When the CNA-M #2 returned to the cart, she realized she had given resident in room [ROOM NUMBER]A resident in room [ROOM NUMBER]B's medications. She immediately notified the nurse. At this time, the CNA-M #2 confirmed she failed to identify the resident using the picture and the identification bracelet he/she had on. The facilities Identification of Patient policy and procedure revised on 10/15/24 states, Purpose: To identify a method of patient identification. Practice Standards: Staff will use at least two patient identifiers to verify patient identity while being evaluated or prior to undergoing procedures/treatments. The facilities Medication Administration General Guidelines policy and procedure revised on 1/25 states, Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include: Check identification band, Check photograph attached to medical record, Verify resident identification with another nursing care center personnel. Note: the residence room number or physical location is not used as an identifier. On 5/12/25 at 4:20 p.m., during the exit interview with the Market Clinical Advisor, Administrator, Administrator in Training, and the Director of Nursing, the above failure to identify the resident prior to administering medications, failure to follow basic principles of medication administration safety and the facilities own policy on resident identification resulting in Resident #1 being admitted to the CCU was confirmed. On 5/12/25 Resident #1 remained at the hospital being treated for receiving the wrong medications.

Based on facility policy, record reviews, observations and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Multidrug-Resistant Organisms (MDRO's) colonized in sputum and wound care for a 2 of 2 sampled residents (Resident #48 and #79) for 1 of 1 day of survey (9/23/24). This has the potential to affect all 21 residents on the Wayside Gardens unit. Findings: Facilities procedure for Enhanced Barrier Precautions, revised 5/1/24 states, all patients with any of the following: Infection or colonization with a targeted MDRO (Multidrug-resistant organisms) . and Chronic wounds and/or indwelling medical devices (e.g. central line, urinary catheter, enteral feeding tube, tracheostomy, or ventilator) regardless of MDRO colonization status. PPE (Personal protective Equipment) used for these situations during high contact patient cared activities: device care or use .tracheostomy, wound care; any skin opening requiring a dressing, and PPE required, Gown, gloves prior to high contact care activity and Face protection may also be needed if performing activity with risk of splash or spray. Facilities procedure for Tracheostomy Care and Tracheostomy Suctioning instructs nursing to Put on PPE including eye protection and face mask, as indicated Facilities procedure for wound Dressings: Aseptic instructs nursing to apply personal protective equipment as indicated, Apply clean gloves . Discard soiled dressing and gloves .preform hand hygiene. Apply gloves. Cleanse or irrigate wound and periwound gently . 1. Review of Resident #48's medical record had Special Instructions: MDRO: MRSA [Methicillin-resistant Staphylococcus aureus], PSEUDOMONAS AERUGINOSA (Enhanced Barrier Precaution). Outside the entrance to Resident #48's bedroom was a stop sign stating, Enhanced Barrier Precaution instructing nursing to wear gown and gloves prior to . wound care: any opening requiring a dressing and face protection may also be needed if preforming activity with risk of splash or spray. A cart with PPE was available outside of the room which contained gowns, masks and eye protection. On 9/23/24 at 9:10 a.m., the surveyor observed Resident #48's tracheostomy care with the Licensed Practical Nurse (LPN). The LPN entered the room, preformed hand hygiene and applied sterile gloves. She completed the tracheostomy care which included suctioning the tracheostomy cannula, removing the soiled split sponge, cleaning around the stoma, removing the inner cannula and replacing with a new cannula and applying a new splint sponge around the stoma all without the use of the appropriate Personal Protective Equipment (PPE) of a gown and face/eye protection. At this time, surveyor asked the LPN if she is to wear a gown, face/eye protection while preforming tracheostomy care. LPN stated, she does not wear a gown and or face/eye protection, only gloves when she performs the trach care. 2. Review of Resident #79's medical record had Special instructions: MDRO risk- due to wounds (Enhanced barrier precaution). Outside the entrance to resident #79's bedroom was a stop sign stating, Enhanced Barrier Precaution instructing nursing to wear gown and gloves prior to . wound care: any opening requiring a dressing and face protection may also be needed if preforming activity with risk of splash or spray. A cart with PPE was available outside of the room which contained gowns, masks and eye protection. On 9/23/24 at 9:20 a.m., the surveyor observed Resident #79's wound care with the LPN. The LPN prepared the wound care supplies, spraying the gauze with the wound wash. She then applied clean gloves and removed the soiled dressing, then cleansed the wound with the wet gauze. She then obtained the wound wash spray and sprayed the wound bed and patted it dry with another gauze pad. With the same gloved had she then applied the primary dressing of xeroform and then the secondary foam dressing. At this time, the surveyor discussed the lack of PPE and the lack of hand hygiene preformed between removing old dressing and cleansing/applying new dressing. The LPN stated, she should have washed wash her hands and applied new gloves before cleansing and applying the new dressing. On 9/23/24 at 9:42 a.m., during an interview with the Director of Nursing, the above was discussed. On 9/23/24 at 11:27 a.m., during an interview, the Infection Preventionist confirmed the nurses are expected and educated on the use Enhanced Barrier Precautions and should wear a gown, glove and whole face covering and/or mask/goggles when preforming tracheostomy or wound care due to risk of splashes or sprays.

Based on record reviews, observations and interviews the facility failed to provide Activities of Daily Living (ADL) care in the area of showers/bathing for 1 of 33 residents reviewed (#18), and in the area of nutrition for 1 of 2 sampled residents during 2 of 5 days of survey. (#53). Findings: 1. On 7/15/24 at 11:44 a.m., in an interview with a surveyor, Resident #18 stated a couple weeks ago (she) did not get her weekly shower, due on Sundays, for 2 weeks until her family said something to staff. A review of the clinical record for Resident #18 revealed diagnoses that included multiple sclerosis and an above the knee amputation of the left leg. The quarterly Minimum Data Set 3.0 (MDS) assessment, completed on 7/6/24, indicated Resident #18 required partial to moderate assistance for showering/bathing. The current care plan stated Resident #18 required extensive 1-person assistance for bathing, and a total mechanical lift, with 2-person assistance to transfer to a shower. A review of Certified Nursing Assistant (CNA) documentation noted Resident #18 received one shower in the month of June, on 6/23/24. There was no documentation from staff stating Resident #18 refused weekly showers. On 7/18/24 at 11:10 a.m., in an interview with the Market Clinical Advisor and the Administrator, the surveyor discussed that staff documentation indicated Resident #18 received only one shower in June. 37648 2. Resident #53's ,Quarterly Minimum Data Set 3.0 dated 6/30/24, under section GG0130A Eating states, resident requires supervision or touching assistance - helper provides verbal cues or touching/steadying assistance as resident completes activity. The most recent ADL care plan revised on 3/14/23 states, resident requires assistance/is dependent of ADL care, with instructions for nursing to, Provide resident/patient with set-up assist for self feeding and supervision and cues- This includes putting utensils in hand or problem solving with resident for eating. On 7/15/24 at 9:41 a.m., observation of Resident #53 sleeping in a Broda chair at the dining room table with a cup of chocolate milk in front of him/her. At 12:24 p.m., observation of Resident #53 sleeping at the dining room table with an untouched lunch tray in front of him/her and the cup of chocolate milk on the side of the tray. At 12:37 p.m., observation of a certified nursing assistant (CNA) approach the table and then walked away, with no resident contact. At 12:45 p.m., while the resident was sleeping, the CNA removed the uneaten lunch tray, and left a slice of watermelon. At 12:48 p.m., while the resident was still sleeping, the CNA discarded the uneaten slice of watermelon. At no time did the CNA attempt to wake up the resident or assist him/her with eating. On 7/15/24 at 12:52 p.m., during an interview with the Licensed Practical Nurse (LPN) Manager, the above was discussed. The LPN manager stated Resident #53 typically does not feed oneself and needs assistance. On 7/15/24 at 3:53 p.m., during an interview, Resident #53's guardian stated, she wondered about Resident #53's eating and if his/her behaviors occur because he/she is hungry. On 7/16/24 from 8:10 a.m. to 11:52 a.m., the surveyor observed the following: Resident #53 was sleeping in the Broda chair sitting at the dining room table with his/her right side against the wall. In his/her lap is an empty cup. A breakfast tray in front of him/her contained chocolate milk, a banana, a blueberry muffin, scrambled eggs and a bowl of cereal. While the resident slept, a CNA removed the cup from his/her lap and walked away. Then, at 9:13 a.m., while the resident slept, the CNA removed the uneaten breakfast and left the chocolate milk and blueberry muffin in front of him/her. At 11:24 a.m., while Resident #53 slept, a wandering resident was observed moving Resident #53's chair back away from the table. The CNA redirected the wandering resident and placed Resident #53 back at the table, then discarded the uneaten blueberry muffin, leaving the chocolate milk. At 11:52 a.m., lunch was delivered to Resident #53. During this time, the CNA did not attempt to wake up Resident #53 or assist with his/her meal. On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.

Based on observations, interviews and record reviews, the facility failed to develop care plans in the area of oxygen therapy for 4 of 5 residents reviewed for respiratory care (#17, #56, #72 and #310). In addition, the facility failed to implement a care plan in the area of Activities of Daily Living (ADL), nutrition and incontinence for 1 of 2 residents reviewed for ADL's (#53). Findings: 1. On 7/15/24 at 9:30 a.m., a surveyor observed oxygen equipment at Resident #17's bedside. A Review of Resident #17's Electronic Medical Record (EMR) found orders dated 4/8/24 for Oxygen therapy and Continuous positive airway pressure (CPAP) therapy. A review of Resident #17's care plan failed to include a focus, goal or intervention in the area of oxygen or CPAP therapy. 2. On 7/15/24 at 9:35 a.m,. a surveyor reviewed Resident #56's EMR showed orders dated 7/17/24 for oxygen therapy. A review of Resident #56's care plan did not include a focus, goal or intervention in the area of oxygen therapy. 3. On 7/15/24 at 9:45 a.m., a surveyor observed Resident #72 with a nasal cannula for oxygen therapy. A surveyor reviewed Resident #72's EMR and found an order dated 5/5/23 for oxygen therapy. Resident #72's care plan did not include a focus, goal or intervention in the area of oxygen therapy. 4. On 7/15/24 at 10:00 a.m., a surveyor observed Resident #310 with a nasal cannula for oxygen therapy during an interview. Resident #310's EMR found an order dated 7/14/24 for oxygen therapy. A review of Resident #310's care plan did not include a focus, goal or intervention in the area of oxygen therapy. On 7/17/24 at 1:50 p.m. a surveyor discussed the above findings with the Market Quality Specialist. 37648 5. Resident #53's most recent ADL care plan revised on 3/14/23 states, resident requires assistance/is dependent of ADL care, with instruction for nursing to, Lip plate for all meals, resident has limited vision to the left- please provide assist as needed as patient is not able to scan or see to the left, resident with limited vision and attention to left, approach resident from right side and Provide resident/patient with set-up assist for self feeding and supervision and cues- This includes putting utensils in hand or problem solving with resident for eating, The most recent Nutritional risk care plan last revised on 6/28/24 instructs nursing to, encourage resident to chew and swallow each bite and the most recent incontinence care plan last revised on 4/14/22 instructs nursing to, routine toileting, individualized schedule: 2 hours using toilet. On 7/15/24 from 12:24 p.m. to 12:48 p.m., observation of Resident #53 sleeping in a Broda chair at the dining room table with an uneaten lunch served on regular plate in front of him/her. At 12:37 p.m., observation of a certified nursing assistant (CNA) approach the table and then walked away, with no resident contact. At 12:45 p.m., while the resident was sleeping, the CNA removed the uneaten lunch tray, and left a slice of watermelon. At 12:48 p.m., while the resident was still sleeping, the CNA discarded the uneaten slice of watermelon. At no time did the CNA attempt to wake up the resident or assist him/her with eating. On 7/16/24 from 8:10 a.m. to 11:52 a.m., the surveyor observed the following: Resident #53 was sleeping in the Broda chair sitting at the dining room table with his/her right side against the wall. In his/her lap is an empty cup. While the resident slept, a CNA approached the resident from the left side and removed the cup from his/her lap and walked away. Then, at 9:13 a.m., while the resident slept, the CNA again approached the resident from the left side and removed the uneaten breakfast, served on regular plate, leaving the chocolate milk and blueberry muffin in front of him/her. At 11:24 a.m., the CNA again, approached the resident from the left side and discarded the uneaten blueberry muffin, leaving the chocolate milk. At 11:52 a.m., lunch was delivered to Resident #53 from the left side, usign a regular plate.During this time of 3 hours and 42 mins, the CNA continued to approach the resident from the left side, did not attempt to wake up the residen up to assist with his/her meal or offer toileting. On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 4 of 7 units (Wayside, Mayflower, Saccarappa and King), the clean utility room, the 3rd floor common area for 1 of 1 Environmental tours. Findings: 1. On 7/19/24 from 10:15 a.m. to 10:45 a.m., a surveyor conducted an environmental tour with the Administrator in which the following findings were observed and confirmed: Wayside Unit: -Resident room [ROOM NUMBER] - the bathroom walls were observed to be gouged, and/or water damaged with sheetrock exposed around the toilet. -Resident room [ROOM NUMBER]- The bathroom wall had water damage. The floor had dirt/debris around the base of the toilet. Saccarappa Unit: -Resident room [ROOM NUMBER] - the entrance door had a missing piece from the door. -Resident room [ROOM NUMBER] - the area under the window sill was open to the outside. Mayflower Unit: -Resident room [ROOM NUMBER]- the entrance door had approximately a 5 feet piece of laminate peeling off with a large chipped area. -The 3rd floor common area had two stained ceiling tiles. -The 3rd floor clean utility room had dirt/debris and trash on the floor. King Unit: -Resident room [ROOM NUMBER] - the wall is gouged. the resident bathroom wall cove base near the toilet was loose/peeling. -Resident room [ROOM NUMBER] - the door was chipped/gouged. -Resident room [ROOM NUMBER] - the bathroom wall to the left after entering the room was gouged. -Resident room [ROOM NUMBER] - the entrance door was missing a piece of laminate from the door -The unit kitchenette counter was missing multiple areas of laminate on the counter.

Based on facility policy, record reviews, observations and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Multidrug-Resistant Organisms (MDRO's) colonized in sputum and wound care for a 2 of 2 sampled residents (Resident #48 and #79) for 1 of 1 day of survey (9/23/24). This has the potential to affect all 21 residents on the Wayside Gardens unit. Findings: Facilities procedure for Enhanced Barrier Precautions, revised 5/1/24 states, all patients with any of the following: Infection or colonization with a targeted MDRO (Multidrug-resistant organisms) . and Chronic wounds and/or indwelling medical devices (e.g. central line, urinary catheter, enteral feeding tube, tracheostomy, or ventilator) regardless of MDRO colonization status. PPE (Personal protective Equipment) used for these situations during high contact patient cared activities: device care or use .tracheostomy, wound care; any skin opening requiring a dressing, and PPE required, Gown, gloves prior to high contact care activity and Face protection may also be needed if performing activity with risk of splash or spray. Facilities procedure for Tracheostomy Care and Tracheostomy Suctioning instructs nursing to Put on PPE including eye protection and face mask, as indicated Facilities procedure for wound Dressings: Aseptic instructs nursing to apply personal protective equipment as indicated, Apply clean gloves . Discard soiled dressing and gloves .preform hand hygiene. Apply gloves. Cleanse or irrigate wound and periwound gently . 1. Review of Resident #48's medical record had Special Instructions: MDRO: MRSA [Methicillin-resistant Staphylococcus aureus], PSEUDOMONAS AERUGINOSA (Enhanced Barrier Precaution). Outside the entrance to Resident #48's bedroom was a stop sign stating, Enhanced Barrier Precaution instructing nursing to wear gown and gloves prior to . wound care: any opening requiring a dressing and face protection may also be needed if preforming activity with risk of splash or spray. A cart with PPE was available outside of the room which contained gowns, masks and eye protection. On 9/23/24 at 9:10 a.m., the surveyor observed Resident #48's tracheostomy care with the Licensed Practical Nurse (LPN). The LPN entered the room, preformed hand hygiene and applied sterile gloves. She completed the tracheostomy care which included suctioning the tracheostomy cannula, removing the soiled split sponge, cleaning around the stoma, removing the inner cannula and replacing with a new cannula and applying a new splint sponge around the stoma all without the use of the appropriate Personal Protective Equipment (PPE) of a gown and face/eye protection. At this time, surveyor asked the LPN if she is to wear a gown, face/eye protection while preforming tracheostomy care. LPN stated, she does not wear a gown and or face/eye protection, only gloves when she performs the trach care. 2. Review of Resident #79's medical record had Special instructions: MDRO risk- due to wounds (Enhanced barrier precaution). Outside the entrance to resident #79's bedroom was a stop sign stating, Enhanced Barrier Precaution instructing nursing to wear gown and gloves prior to . wound care: any opening requiring a dressing and face protection may also be needed if preforming activity with risk of splash or spray. A cart with PPE was available outside of the room which contained gowns, masks and eye protection. On 9/23/24 at 9:20 a.m., the surveyor observed Resident #79's wound care with the LPN. The LPN prepared the wound care supplies, spraying the gauze with the wound wash. She then applied clean gloves and removed the soiled dressing, then cleansed the wound with the wet gauze. She then obtained the wound wash spray and sprayed the wound bed and patted it dry with another gauze pad. With the same gloved had she then applied the primary dressing of xeroform and then the secondary foam dressing. At this time, the surveyor discussed the lack of PPE and the lack of hand hygiene preformed between removing old dressing and cleansing/applying new dressing. The LPN stated, she should have washed wash her hands and applied new gloves before cleansing and applying the new dressing. On 9/23/24 at 9:42 a.m., during an interview with the Director of Nursing, the above was discussed. On 9/23/24 at 11:27 a.m., during an interview, the Infection Preventionist confirmed the nurses are expected and educated on the use Enhanced Barrier Precautions and should wear a gown, glove and whole face covering and/or mask/goggles when preforming tracheostomy or wound care due to risk of splashes or sprays.

Based on observations, interviews and record reviews, the facility failed to ensure that staff maintained the appropriate competency and skill required to provide tracheostomy care for 1 of 2 residents with tracheostomies on the Wayside Unit (#48). Finding: On 7/15/24 at 10:47 a.m., a surveyor observed a personal protective equipment station and signage advising Enhanced Barrier Precautions were required at the entrance of Resident #48's room The surveyor observed Resident #48 lying in bed, receiving oxygen via a tracheostomy. A review of Resident #48's clinical record revealed diagnoses including anoxic brain injury, seizure disorder, chronic respiratory failure with hypoxia, and developmental delay. The record revealed a history of drug resistant organisms in Resident #48's sputum: Methicillin Resistant Staphylococcus Aureus (MRSA) and Pseudomonas Aeruginosa. The quarterly Minimum Data Assessment (MDS) 3.0, completed 6/11/24, indicated Resident #48 is dependent upon staff for all ADLs and is nonverbal, requires suctioning, has a tracheostomy and receives oxygen. The current care plan includes appropriate interventions to address Resident #48's needs. Provider orders, signed 6/26/24, include tracheostomy care twice daily and as needed, suctioning twice daily and as needed, change the inner cannula of the tracheostomy every day shift and as needed. On 7/16/24, the surveyor requested to observe the Wayside Unit charge nurse perform tracheostomy care for Resident #48. At 12:30 p.m., the surveyor observed the Nurse Practice Educator (NPE) was present for the observation. The charge nurse stated he/she had asked the NPE to be present as he/she did not feel competent doing the procedure. During the procedure, the NPE coached and prompted the charge nurse for next steps using a check off sheet. At one point, Resident #48 appeared to have labored breathing with audible rhonchi and copious white secretions draining from the tracheostomy. The charge nurse began using a Yankauer suction around the outside edge of the tracheostomy. The surveyor asked the charge nurse if he/she was going to perform deep suction. The charge nurse then proceeded to provide deep suction. Afterwards, Resident #48 was observed to be calm and relaxed, with unlabored respirations. At approximately 1:30 p.m., the surveyor asked the charge nurse if he/she had received training on performing tracheostomy care. The nurse stated it had been about 3 years ago but he/she was usually assigned on the upstairs unit, and did not feel competent to do the care when the surveyor asked to observe. The surveyor asked what did the nurse do when Resident #48 requires deep suctioning? The nurse stated he/she calls an upstairs unit and requests another nurse come down to perform the procedure. The surveyor stated that on 7/15/24, the charge nurse had signed Resident #48's treatment administration record and indicated he/she had performed tracheostomy care and deep suctioning. The charge nurse stated he/she had the nurse who was going off duty perform the suctioning and he/she did all the other things and signed off the tasks. On 7/17/24 at 2:00 p.m., a review of the facility assessment, last revised 1/22/24, noted the facility stated it provides care for respiratory treatments including suctioning, tracheostomy care, ventilator or respirator. This includes policies and procedures to provide specialized respiratory care for tracheostomy or ventilator. The surveyor reviewed the procedures for tracheostomy care and suctioning, dated 7/15/21. On 7/17/24 at 2:50 p.m., the surveyor discussed the findings with the Administrator, who stated licensed nurses are required to complete a combination of online trainings and attend an annual skills fair where annual competencies are tested . On 7/17/24 at 3:00 p.m., in an interview with the surveyor, the Marketing Clinical Advisor, confirmed the last skills fair and competency testing for tracheostomy care and suctioning, that the charge nurse on the Wayside Unit completed was 9/29/22.

Based on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 19 residents reviewed. (Resident #419) Finding: On 9/23/2024 at 10:15 a.m., upon entrance to Saccarappa house, a surveyor observed the shower room door wide open, exposing a naked resident, sitting on a shower chair actively showering him/herself. A Certified Nurses Aid and a Registered Nurse were observed on the other side of the unit. Approx 1 min later, the Occupational Therapist (OT) came from the far end of the unit with a face cloth and a bottle. The Surveyor asked why the door was left open, the OT stated, I didn't mean to and entered the shower room and closed the door. At 10:29 a.m., both the resident and the OT exited the shower room. At this time, the above was confirmed with the OT. On 9/23/24 at approx. 10:45 a.m., the above was discussed with the Administrator

Based on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 19 residents reviewed. (Resident #419) Finding: On 9/23/2024 at 10:15 a.m., upon entrance to Saccarappa house, a surveyor observed the shower room door wide open, exposing a naked resident, sitting on a shower chair actively showering him/herself. A Certified Nurses Aid and a Registered Nurse were observed on the other side of the unit. Approx 1 min later, the Occupational Therapist (OT) came from the far end of the unit with a face cloth and a bottle. The Surveyor asked why the door was left open, the OT stated, I didn't mean to and entered the shower room and closed the door. At 10:29 a.m., both the resident and the OT exited the shower room. At this time, the above was confirmed with the OT. On 9/23/24 at approx. 10:45 a.m., the above was discussed with the Administrator

Based on policy review, clinical record review, observations and interviews, the facility failed to notify the provider and obtained orders for 1 of 6 residents reviewed for respiratory care (#33) and 1 of 6 residents reviewed for pressure ulcers (#48). In addition, the facility failed to assess a resident after an unwitnessed fall and complete neurological assessments as per facility policy for 1 of 3 residents reviewed for falls (#407). 1. On 7/15/24 at 11:05 a.m., a surveyor observed Resident #33 asleep in his/her bed on the Wayside Unit. The surveyor observed oxygen delivered at 3.5 liters/minute via nasal cannula with 2 oxygen tubes connected to the wall unit and only 1 tube connected to Resident #33. At 11:14 a.m., the surveyor discussed with the charge nurse that the oxygen was running but one tube was not connected to the resident. The charge nurse stated the extra tube was to be used with the nebulizer and then proceeded to turn that oxygen tube off. Resident #33 awoke and asked what the oxygen was set at. The charge nurse stated 3.5 liters. Resident #33 asked for the oxygen to be turned up to 4 liters and the charge nurse complied. A review of Resident #33's clinical record noted a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A physician order, dated 10/5/23, was noted for Oxygen at 3 liters/minute via nasal cannula continuously. Another order, dated 1/26/24, stated Oxygen 2.5 liters via nasal cannula to keep Oxygen Saturation greater than 90-94%. Review of a provider visit on 5/10/24, noted Stage 3 Severe COPD, O2 (oxygen) dependent, 3.5 liters, closer to usual baseline following treatment for exacerbation/pneumonia last month. Continue O2 nasal cannula. Review of nursing progress notes revealed a note dated 6/27/24 at 6:41 a.m., which stated Resident who had episode of shortness of breath and chest xray was negative, this a.m., his/her O2 (saturation) was around 87-88, 89, 90 on 5 liters (of) oxygen. Will share with other nurses and sbar (communication) with provider. A review of the July Treatment Administration Record noted Resident #33's oxygen saturation was checked every shift but did not indicate how much oxygen the resident was receiving at the time. On 7/17/24 at 9:20 a.m., the surveyor asked the charge nurse on the Wayside Unit to clarify Resident #33's oxygen order. The charge nurse reviewed the electronic record and stated the current order was 2.5 liters (per minute). The surveyor noted there were 2 orders, and the charge nurse confirmed both orders were in effect. He/she stated the order from 10/5/23 should have been discontinued. In addition, the charge nurse confirmed that documentation for the amount of oxygen being delivered should be included when oxygen saturation levels are checked. The surveyor asked if the charge nurse remembered turning Resident #33's oxygen up to 4 liters when he was asked to on 7/15/24. The nurse confirmed he/she had turned up the oxygen and stated Resident #33 had been at 4 liters for a couple of months and was getting 3.5 liters before that. It looks like 4 liters is his/her baseline already. We need to see if that's where he/she is at and let the provider know. On 7/17/24 at 9:45 a.m., the surveyor discussed the findings with the Market Clinical Advisor, who reviewed the provider orders and confirmed there were 2 oxygen orders in effect and no documentation of the amount of oxygen in use when the saturation level is obtained. 2. On 7/16/24, review of the clinical record for Resident #48 revealed documentation, dated 7/15/24, of a wound on the bilateral gluteal folds that was described as measuring 9.0 centimeters (cm) in length by 5.5 cm in width, and was erythemic and excoriated. There was no documentation of steps taken by staff to address the wound. On 7/17/24 at 9:15 a.m., in an interview with the Wayside Unit charge nurse, a surveyor asked what type of wound Resident #48 had on the gluteal folds. The charge nurse reviewed the electronic medical record and stated Resident #48's wound was moisture associated skin damage. The surveyor asked what type of treatment would be used. The charge nurse stated I would use Z-guard and combine it with miconazole. The surveyor asked if there was an order for this treatment. The charge nurse stated he/she had left a message regarding the wound for the nurse on the facility's skin care team. The charge nurse confirmed the provider had not been notified and no order had been obtained since the wound assessment was completed on 7/15/24. On 7/17/24 at 9:45 a.m., the surveyor discussed the finding with the Market Clinical Advisor and the Administrator. The Administrator confirmed the facility's process would be if a nurse found a new wound, the provider would be called, and an order obtained. 37648 50218 3. Review of Resident #407's clinical record revealed Progress Note dated 7/29/23 stating At approximately 0025 (12:25 a.m.) nursing staff including this nurse heard someone call out and a clash of noises coming from patient room. This nurse and other staff quickly responded and found resident on the floor laying supine, Resident said [he/she] lost balance on [his/her] way out from the bathroom and fell on to [his/her] bottom . Vital signs were WNL (within normal limits), neuros were baseline . Will continue to monitor. Review of Resident #407's entire clinical record lacked evidence of continued neurological monitoring or ''Neurological Evaluation Flow Sheet'' for fall occurring 7/29/23. On 7/15/24 at 1:26 p.m. during an interview, the Administrator was unable to provide evidence of continued neurological monitoring following the resident's fall on 7/29/23. Review of policy titled Falls Management last reviewed 3/15/24 states, . Any patient who sustains an injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check per policy . Review of policy titled Neurological Evaluation Flow Sheet states . Evaluate every 15 minutes for first 2 hours after final evaluation .After first 2 hours completed above, evaluate every 30minutes for 2 hours, after first 4 hours completed above, evaluate every hour for 4 hours .

Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Annual Long Term Care Survey Process for Federal Recertification dated 7/19/24, was followed and effective. The Federal citation F656 was cited again during the re-visit to the annual Long Term Care Recertification Survey. Finding: At Annual Long Term Care Survey Process for Federal Recertification, the following deficiency was cited, F656. During the follow up survey on 9/23/24, it was determined the F656 would be recited for the same issue: failure to implement a comprehensive person-centered care plan for each resident. On 9/23/24 at 4:15 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.

Based on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the Annual Long Term Care Survey Process for Federal Recertification dated 7/19/24, was followed and effective. The Federal citation F656 was cited again during the re-visit to the annual Long Term Care Recertification Survey. Finding: At Annual Long Term Care Survey Process for Federal Recertification, the following deficiency was cited, F656. During the follow up survey on 9/23/24, it was determined the F656 would be recited for the same issue: failure to implement a comprehensive person-centered care plan for each resident. On 9/23/24 at 4:15 p.m., during and interview, the above was confirmed with the Administrator and Director of Nursing.

Based on observations, record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for Activities of Daily Living (ADL) (#53). Finding: On 7/15/24 lunch meal and on 7/16/24 breakfast meal, Resident #53 was observed sleeping through both of the meals with no cueing provided by staff and did not consume any of the food or fluids provided. Review of the certified nursing aid documentation for 7/15/24 lunch and 7/16/24 breakfast states the amount eaten my mouth was 50%. The documentation for eating: self-performance for 7/15/24 lunch states resident was supervision with encouragement or cueing, and the lunch on 7/16/24 the documentation states resident was independent with no help or staff oversight at any time. On 7/17/24 at 8:11 a.m., during an interview with the Administrator, the above concerns were discussed.

Based on record review and interview the facility failed to follow through with a physician's order for a dental referral for 1 of 43 sampled residents (#29). Finding: Resident #29's clinical record contained a physician's order dated 3/18/23 instructing staff to refer the resident to a dentist for gingivitis and a cleaning. Resident #29's clinical record lacked evidence of any follow up with the dental referral. In an interview with the surveyor on 7/17/24 at 11:06 a.m. the Marketing Clinical Advisor confirmed that Resident #29's dental referral had not been scheduled.

Based on observations, and interviews the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart on 1 of 7 resident units in the facility. In addition, the facility failed by leaving a resident's medications unattended at a bedside, allowing residents and unauthorized persons access to medications. (#33) (Saccarappa House Unit, Wayside Unit). Findings: 1. On 7/15/24 at 9:42 a.m., two surveyors observed the unlocked and unattended medication cart in the hallway on Saccarappa House Unit. At 9:46 a.m., the Certified Medication Technician returned to the unlocked medication cart and began to prepare a resident's medication. On 7/17/24 at 11:27 a.m., the above finding was discussed with the Administrator and the Market Clinical Advisor. 37015 2. On 7/15/24 at 11:05 a.m., a surveyor observed Resident #33 asleep in bed. A cup of pills was observed on the overbed table next to Resident #33. At 11:14 a.m., the Wayside Unit charge nurse confirmed he/she had left the pills next to Resident #33, who must have forgotten to take them. On 7/15/24 at 1:15 p.m., the surveyor discussed the finding with the Market Clinical Advisor.

Based on observation and interviews, the facility failed to ensure that a resident was treated with dignity and respect for 1 of 11 residents reviewed. (Resident #5) Findings: On 4/25/2024 at 8:20 a.m., Resident #5 was observed in the common area of Wayside Gardens Unit in his/her wheelchair sitting at the dining table naked from the waist down. Two CNAs were observed also in the dining area serving other residents and did nothing to preserve the resident's dignity. (CNA1 and CNA2) The LPN (LPN1) who was passing meds nearby was called to assist in removing resident to his/her room. At 8:30 a.m. the Director of Nursing came to the unit and the above findings were confirmed with him at that time.