Every finding on record at Stamford Care Center

Based on observations, interviews, clinical record, and policy reviews for 1 of 3 sampled residents (Resident #23) reviewed for pressure ulcers, the facility failed to provide services to prevent worsening of 2 pressure wounds for a dependent resident. The findings include:Resident #23's diagnoses included open wound of the lower back and pelvis, quadriplegia (paralysis affecting all 4 limbs and the torso), and malnutrition.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a Brief Interview of Mental Status of 00 indicating severe cognitive impairment and was totally dependent on staff for toileting, transfers, and changing positions in bed (rolling, lying and sitting). Additionally, Resident #23 was at risk for developing pressure ulcers and did not have any current unhealed pressure ulcers/injuries. The MDS identified skin ulcer/injury treatments included a pressure reducing device for the bed, a turning and repositioning program and application of non-surgical dressings.The Resident Care Plan dated 1/15/26 and in effect on 1/28/26 identified Resident #23 had a reopened stage 4 pressure ulcer wound to the sacrum and an unstageable pressure ulcer wound to the right upper back. Interventions included low air loss mattress to be checked for proper setting and function every shift, turn and position every 2 hours, and to monitor nutritional status.Review of the facility provided in-house acquired pressure ulcer list provided on entrance to the facility on 2/8/26 identified Resident #23 had a stage 4 pressure ulcer that had previously healed and reopened on 1/28/26 and a pressure ulcer to the right lower back.Review of quarterly skin evaluations dated 7/22/25 and 10/1/25 identified Resident #23 had a Braden Scale evaluation score of 8 indicating a very high risk for pressure ulcers. Although requested a Braden Scale evaluation was not located in the clinical record and not provided for January 2026.A physician's order dated 2/6/25 and in effect through 2/10/26 directed an air mattress to be set to (the resident's) weight and to check function and settings every shift.A physician's order dated 1/28/26 directed to turn and reposition Resident #23 every 2 hours when in bed, daily, every shift, for pressure ulcer/injury.Review of Resident #23's Nurse Aid (NA) Documentation Turning and Repositing Report which included all 3 shifts, dated 1/1/26 to 1/31/26 failed to identify a signature that would have indicated that Resident #23 was turned/repositioned for 28 of 93 turning and repositioning opportunities. (30.1% of January's shift documentation).Review of the wound care specialist progress note dated 1/28/26 identified Resident #23 was being seen for the first evaluation of an existing wound. Wound #1 was an unstageable pressure wound to the right lower back that measured 1 centimeter (cm) x 1.5 cm x 0 cm, and wound #2 was a stage 4 pressure wound to the sacrum that measured 1 cm x 0.2 cm x 0.3 cm. The assessment/plan included, in part, a redistribution mattress per facility protocol, and to reposition Resident #23 every 2 hours.Review of the wound care specialist progress note dated 2/4/26 identified Resident #23 was seen for evaluation and management of wounds. Wound #1 was an unstageable pressure wound to the right lower back that measured 1 cm x 2 cm x 0 cm (an increase from 1 cm x 1.5cm x 0 cm on 1/28/26) and wound #2 was a stage 4 pressure wound to the sacrum that measured 1 cm x 0.2 cm x 0.3 cm (no change from the evaluation on 1/28/26). The assessment/plan included, in part, a redistribution mattress per facility protocol, and to reposition Resident #23 every 2 hours.Review of Resident #23's Nurse Aid (NA) Documentation Turning and Repositing Report including all 3 shifts dated 2/1/26 to 2/10/26 failed to identify a signature which would have indicated that Resident #23 was turned/repositioned for 43 of 115 turning and repositioning opportunities. (37.3% of February's shift documentation).The undated Nurse Aid Care Card (directs NA care) directed Resident #23 had a low air loss mattress to be checked for proper function and setting every shift and that he/she was to be turned/repositioned every 2 hours.Review of the facility Turning & Repositioning Program identified residents should be repositioned to face the door from 6:00 AM to 8:00 AM, 12:00 PM to 2:00 PM, 6:00 PM- 8:00 PM and 12:00 AM to 2:00 AM, repositioned to face the window from 8:00 AM to 10:00 AM, 2:00 PM to 4:00 PM, 8:00 PM to 10:00 PM, and 2:00 AM to 4:00 AM, and repositioned on their back from 10:00 AM to 12:00 PM, 4:00 PM to 6:00 PM, 10:00 PM to 12:00 AM and 4:00 AM to 6:00 AM.Observations on 2/8/26 at 6:55 AM (should have been facing the door 6:00 AM -8:00 AM), 2/8/26 at 9:41 AM (should have been facing the window 8:00 AM to 10:00 AM) and 2/8/26 at 12:20 PM (should have been facing the door 12:00 PM to 2:00 PM) identified Resident #23 in bed on his/her back with the pressure relieving mattress set to 160 pounds at normal pressure.Observations on 2/9/26 at 8:25 AM (should have been facing the window 8:00 AM to 10:00 AM) and 2/9/26 at 10:12 AM (correctly positioned) identified Resident #23 in bed on his/her back with the pressure-relieving mattress set to 160 pounds at normal pressure.Interview with Licensed Practical Nurse (LPN) # 7 on 2/9/26 at 10:12 AM identified the facility policy for turning and repositioning residents directed that residents with repositioning orders be turned/repositioned every 2 hours by the NA's per the schedule and that the unit nurse would then verify compliance with repositioning and sign off as completed in the electronic health record. Interview, observation, and record review with Registered Infection Prevention Nurse (RN) #1 on 2/9/26 at 12:31 PM identified the facility policy directed residents at risk and with wounds be part of a universal turning and repositioning program where residents were turned every 2 hours alternating facing the door, on their back and facing the window. Additionally, RN #1 identified pressure alternating mattresses were provided to at risk residents and set per the resident's weight, with responsibility for the preventive measures being a collaborative effort between NA's and unit nurses. Observation of Resident #23 with RN #1 identified him/her positioned on his/her back (should have been facing the door 12:00 PM to 2:00 PM) and the pressure relieving mattress set to 160 pounds at normal pressure. RN #1 identified that Resident #23 should have been facing the door per the turning and rescheduling program, and upon record review, RN #1 identified that the pressure relieving mattress should not have been set to 160 pounds, but rather 91 pounds (to reflect the resident's current weight). She could not identify why Resident #23 was not positioned per the positioning schedule or why the mattress was set to an inaccurate weight, stating education was still ongoing.Subsequent to surveyor inquiry observation on 2/10/26 at 7:47 AM identified Resident #23 turned to his/her side and the pressure alternating mattress set between 80 and 120 pounds.Interview and record review with RN #1 on 2/10/26 at 9:28 AM identified Resident #23's wounds were first identified on 1/28/26 and the wound on the sacrum was a reopened wound that had healed approximately 1 year ago. RN #1 identified that the lower back area was an unstageable wound that measured 1 cm x 1.5 cm x 0 cm on 1/28/26, 1 cm x 2 cm x 0 cm on 2/4/26 and the measurement obtained on 2/10/26 was 2 cm x 2.2 cm x 0 cm, indicating the lower right back wound had worsened. Review of the reopened stage 4 wound to the sacrum with RN #1 identified a measurement of 1 cm x 0.2 cm x 0.3 cm on 1/28/26, 1 cm x 0.2 cm x 0.3 cm on 2/4/26, and 2 cm x 2.2 cm x 0.3 cm on 2/10/26, indicating the sacral wound had worsened. Additionally, RN #1 identified a lack of turning and repositioning and an inappropriately set pressure relieving mattress as well as poor nutrition status would cause the wounds to worsen.Interview with the Dietician #1 on 2/10/26 at 9:50 AM identified she was familiar with Resident #23 because he/she frequently triggered for weight loss due to fluctuations in meal intake. Additionally, although she was not aware of sacral wound worsening between 1/28/26 and 2/4/26, or the newly identified measurements obtained 2/10/26 Dietician #1 stated Resident #23 was already receiving interventions for being at high risk such as fortified cereal, high calorie supplements, and high protein nutritional shakes so there was not much that could be added from a nutritional standpoint.Interview and record review with wound APRN #1 on 2/10/26 at 10:15 AM identified she was following Resident #23 weekly for the lower right back and sacral wound identified on 1/28/26. Review of the wound measurements with APRN #1 obtained on 2/10/26 identified both the wounds were larger in size since she last evaluated them on 2/4/26. Additionally, APRN #1 identified that Resident #23 was a very compromised individual with an overall decline in health, and the worsening of the wounds could be attributed to a compilation of factors which included the lack of turning and repositioning and an incorrectly set air mattress.Review of the Pressure Injury/Pressure Assessment Prevention and Management Policy directed in part that the facility will provide care and services consistent with professional standards of practice to prevent pressure injury/ulcer development and promote the healing of existing pressure injuries/ulcers. Additionally, develop a positioning schedule, avoid positioning residents on the pressure injury, and use a low air loss mattress for residents with a preexisting Stage 3 or 4 pressure injury.Review of the Specialty Mattress Policy directed, in part, that settings will be checked every shift by a licensed nurse and documented.Review of the Turning and Repositioning Policy dated 7/2020 directed, in part, that it was the facility's policy to identify residents who require turning and repositioning and place them on a repositioning schedule.

Based on observations, interviews, facility documentation, and facility policy, the facility failed to provide safe and comfortable air temperature levels in resident rooms and common areas. The findings include: During an initial tour of the facility, observation and interview with Licensed Practical Nurse (LPN) #5 on 2/8/26 at 7:02 AM, identified the 1st Floor East hallway air temperature was noted to be cold. LPN #5 was dressed in a winter hat, 2 sweaters, and a scarf. LPN #5 stated that it's freezing on the 1st floor and is always like this at night. Observation and interview on 2/8/26 at 7:11 AM with Resident #52 identified him/her in bed, covered with 3 blankets, and the facility heating system in the room was running at the highest possible setting. Using a probe thermometer, the room temperature read 69.8 degrees Fahrenheit ( F). Resident #52 stated, I'm freezing. Interview with the Administrator on 2/8/26 at 7:42 AM identified that the facility was aware of the heating issue and that their intervention had been to close resident doors to preserve heat within the rooms. Observation and re-interview with LPN #5 on 2/8/28 at 7:52 AM at the 1st Floor East Unit nurses' station identified she remained dressed in her winter clothing and was noted to be visibly shaking. A probe thermometer was used to monitor the air temperature at the nursing station (an area also utilized by residents) and identified a reading of 57.6 F. LPN #5 stated, I'm so cold. Observation of Housekeeper #1 on 2/8/26 at 9:56 AM noted that he remained in his winter coat while performing housekeeping duties on the 1st Floor East Unit while cleaning the hallway with 1 resident present in the area. The temperature reading in this area at 9:56 AM using a probe thermometer was 61.3 .Observation, interview, and facility tour with the Maintenance Director on 2/8/26 at 9:57 AM using an ambient air temperature thermometer directed away from the heat source identified the following: 1st Floor Lobby 53 F- 1 resident was present by door receiving medications.68 F in resident room [ROOM NUMBER]- 1 resident was present in the room.69 F in resident room [ROOM NUMBER]- 1 resident was present in the room.70 F in resident room [ROOM NUMBER]- 1 resident was present in the room.64 F at the entrance to the 1st Floor East Resident Dining Room.61 F in the 2nd Floor East Resident Dining Room.59 F in the 2nd Floor East Resident Hallway, - 1 resident was present in hallway.67 F in the 2nd Floor Resident Community Room- 3 residents were present in the Community Room.65 F in the 4th Floor Resident Hallway- 4 residents were present in the hallway.63 in the elevator used for resident transport.The Maintenance Director stated that the facility was aware of heating issues, however, temperature logs (not currently available) had not reflected temperatures observed as low as the measured probe thermometer or ambient air temperatures that had currently registered. Observation on 2/8/26 at 10:19 AM identified Resident #84, eating breakfast, seated on the side of the bed and wearing a winter coat. Re-interview with Administrator on 2/8/26 at 10:37 AM identified that this was the first time temperature issues had been identified in the facility. The Administrator stated that the changes in the outside air temperature contributed to the facility heating issue and the plan was to close resident doors, check resident temperatures, and start a Quality Assurance and Improvement Project (QAPI) to monitor temperatures in the facility to ensure residents' comfort. Interview and review of the facility Temperature Logs dated 1/26/26 to 2/1/26 with the Maintenance Director on 2/8/26 at 10:45 AM identified the facility was in compliance with the requirement and that temperatures had ranged between 72 F and 78 F. Further, the Maintenance Director stated the facility was aware of the heating issue and had contacted a heating company to inspect and maintain the heating system. Subsequent to Surveyor Inquiry on 2/8/26 the facility obtained and installed warm air heating units for the 1st Floor East and 2 units for the 2nd Floor to help provide comfortable ambient temperature levels in resident rooms and care areas identified with inadequate temperature readings.A Resident Council Meeting, held on 2/9/26 at 10:17 AM (following supplement heat installation) with Residents #48, # 51, #89, #118, #140, #144, #147, and #156 identified residents had concerns with cold facility temperatures prior to commencement of the state recertification survey that had begun on 2/8/26. Residents stated they had brought concerns to nursing about being uncomfortable and needing heat for at least two weeks. Although requested, documentation of temperature logs dated 2/2/26-2/7/26 and confirmation of documentation that a heating company had been contacted prior to surveyor inquiry, were not provi

Based on interviews, a sample test tray, facility documentation, and policy, the facility failed to provide appetizing and palatable food. The findings include:Review of the Resident Council Minutes dated 9/26/25 identified Resident concerns that meat was not tender and hard to chew (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 11/21/25 identified Resident concerns that food was delivered cold, and the meat was not tender (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 12/24/25 identified Resident concerns about the pork being overcooked, the facility response from the Dietary Food Director was to speak to the cooks regarding overcooking protein.Review of Resident Council minutes dated 1/27/26 identified Resident concerns with the repetitive chicken meals given frequently with the same seasoning, the facility response from Dietary Food Director was to speak with cooks regarding improved seasoning options.Interview with Resident #7 on 2/8/26 at 9:38 AM described the food as terrible, always late and cold, stating he/she usually asked for the food to be warmed up.Interview with Resident #28 on 2/8/26 at 9:45 AM identified the food tasted disgusting and was always cold.Interview with Resident #140 on 2/08/26 at 9:39 AM identified the food was of low quality, did not taste good, and was always cold.A Resident Council meeting was held on 2/9/26 at 11:12 AM with 13 residents who identified that the quality of food was lacking and often cold.A lunch test tray was requested with the Dietary Director on 2/8/26 at 11:11 AM, a second request for a test tray was made 2/8/26 at 1:00 PM and delivered 2/8/26 at 1:20 PM. Multiple surveyors sampled lunch and found the food to be unappetizing and not palatable. Surveyors found that the mashed potatoes lacked flavor, although the roast beef was not tough, it was accompanied by watery gravy that was lumpy and separating, and the vegetables consisted of watery, overcooked cauliflower, broccoli, and green beans. No dessert was provided. Interview with the Regional Dietary Director on 2/8/26 at 1:57 PM identified that upon hearing the multiple food complaints, he tried the lunch served that day and noted that the vegetables tasted like cauliflower but were overcooked, and the instant mashed potatoes tasted as such (indicating instant and from a box flavor). Additionally, the Regional Dietary Director identified it was challenging to make meals that included different consistencies, but he spoke to the kitchen staff regarding adding flavor into the food by using seasoning such as garlic and parsley to make the food more appetizing.Review of the Meal Service Assistance of Residents policy directed, in part, that facility protocol was to provide each resident with a nourishing, palatable diet at the proper temperatures.Review of the Standardized Recipes Policy dated 11/16 directed in part that food preparation methods conserve the nutritive value, flavor, and appearance of food.Review of the Timely Meal Service Policy directed in part that food be served at preferable temperatures.

Based on interviews, observations, and facility documentation, the facility failed to provide meals at regularly scheduled intervals. The findings include:Review of the Resident Council Minutes dated 10/27/25 identified Resident concerns that food trucks were late to some of the units. (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 11/21/25 identified Resident concerns that food took too long to be delivered and was cold (there was no response noted from the Dietary Department).Review of the Resident Council Minutes dated 12/24/25 identified Resident concerns with the food trucks, and food not being passed out when it reached the unit destination (there was no response from the facility).Review of Resident Council minutes dated 1/27/26 identified Resident concerns with the meals arriving cold and late, response from the Dietary Food Director was to adjust tray delivery timing.Observation and review of facility documentation identified the breakfast meal truck was delivered to the 4th floor on 2/8/26 at 9:03 AM but according to the 4th floor breakfast delivery schedule posted, the cart should have arrived between 7:30 AM and 8:00 AM. The nursing staff prepared trays at 9:20 AM (1 hour and 20 minutes late), passed meals out to the dining room, then resident rooms. The last breakfast tray was delivered at 9:42 AM. Interview with Resident #28 on 2/8/26 at 9:45 AM the food tastes disgusting and is always cold, identifying the food has been running late for about a week.Interview with Resident #7 on 2/8/26 at 10:16 AM identified he/she just received breakfast, it was ice cold and will ask to have it warmed up, which is a common occurrence.Observation and review of facility documentation identified the lunch meal truck was delivered to the 4th floor on 2/8/26 at 12:45 PM, but according to the 4th floor lunch delivery schedule posted, the cart should have arrived between 12:00 PM to12:30 PM (15 minutes late and 3 hours and 3 minutes after the last breakfast tray had been delivered).Further review of facility documentation identified that the dinner meal was to be delivered to the 4th floor between 4:00 PM and 4:30 PM. This indicated that dinner was scheduled to arrive between 6 hours and 18 minutes to 6 hours and 48 minutes following the delivery of the last breakfast tray to the 4th floor and 3 hours and 15 minutes to 3 hours and 43 minutes after the lunch meal truck had been delivered. The time between the dinner meal cart delivery from 2/7/26 until breakfast would have been scheduled to be 17 hours and 12 minutes. The requirement for time between meals should be no greater than 16 hours with resident body consent and appropriate nourishing snack.Observation and interview in the kitchen with the Dietary Director on 2/9/26 at 7:45 AM identified kitchen staff started to plate the breakfast meal for delivery to the 4th floor. The Dietary Director indicated that the 4th floor food plating should have begun at 7:00 AM (45 minutes earlier), however, the cook had arrived late. The facility posted that breakfast should arrive between 7:30 AM and 8:00 AM.Observation on 2/9/26 identified the breakfast meal truck for the 4th floor arrived at 8:20 AM (20 minutes late), with the last tray delivered at 9:01 AM.Observation of the kitchen and interview with the Dietary Director on 2/9/26 at 12:28 PM identified kitchen staff began to plate the food for the 4th floor. The Dietary Director indicated that the 4th floor food plating usually began around 11:45 AM but was unable to identify the reason kitchen staff had started 43 minutes late at 12:28 PM, and that the lunch meal cart should have arrived on the 4th floor between 11:45 AM and 12:00 PM (28 minutes prior to when staff began to plate the 4th floor lunch meal). Observation on 2/9/26 identified the lunch meal truck for the 4th floor arrived at 12:42 PM, (42 minutes later than the latest posted scheduled delivery time for the 4th floor at 12:00 PM.Observation on 2/9/26 at 2:02 PM identified Nurse Aid's on the 2nd floor beginning to pass out lunch (Lunch delivery for the 2nd floor was posted as12:45 PM to 1:30 PM).Interview with the Director of Nurses on 2/9/26 at 2:05 PM identified that although there were challenges in the past with the kitchen things have gotten a lot better, however she was not aware that meals were consistently served late, or that certain residents only had 3 hours between breakfast and lunch being served. Additionally, the DNS stated there were microwaves available on the units for anyone that received their food cold, however, she could not identify how nonverbal dependent residents who could not advocate for themselves were guaranteed a timely hot meal.Interview with the Administrator on 2/9/26 at 2:48 PM identified that the elevator had not been functioning since 2/3/25 due to a water pipe burst, but that meals should still have been delivered in a timely manner. Additionally, the Administrator identified education on timely meal service was initiated earlier that day.Review of the Timely Meal Service Policy directed in part that food will be delivered promptly to assure safe, palatable and high-quality food served at the right temperature. Additionally, food will be distributed promptly with supervision as needed.

Based on a tour of the Dietary Department, interviews, and facility documentation, the facility failed to ensure open food items were dated, failed to identify expiration dates, and failed to ensure food was stored and served under sanitary conditions. The findings included:Tour of the Dietary Department on 2/8/26 at 6:42 AM with [NAME] #1 identified the following:1. a. The outside thermometer display of the milk cooler identified a temperature reading of 55 degrees Fahrenheit, and despite taking out all the milk crates, [NAME] #1 failed locate a thermometer inside the cooler to take a temperature reading to ensure milk was being maintained at optimal temperature.b. Refrigerator #1 (juice cooler) was noted to contain a tray of sandwiches and desserts wrapped in plastic, on individual plates without the benefit of being labeled with a preparation date or expiration date.c. The walk-in cooler was noted to have the door propped open with a cart for an unidentified amount of time and was not being used by staff.d. The walk-in cooler was noted to have 4 large roast beef chucks cooling without the benefit of being covered.e. The walk-in cooler was noted to have a metal pan containing chicken thighs in marinade, covered with a plastic wrap, located on the second shelf with 2 packages of bologna being stored directly underneath on the bottom shelf.f. The walk-in freezer was noted to contain 2 bags of onion rings and 1 bag of tater tots in the original plastic containers without the benefit of being labeled with a date of opening or expiration date. g. Initial entry into the kitchen identified 1 cook and 3 dietary aids preparing breakfast without the benefit of hats, hair nets, and for 2 bearded dietary aids, no beard restraints were being used.Interview with [NAME] #1 on 2/8/26 at 7:31 AM identified it was facility policy that the cooler, refrigerator and freezer temperatures were recorded daily by the Dietary Director, and that although the thermometer could not be located it should have been in the milk cooler because the outside temperature reading was inaccurate. Additionally [NAME] #1 identified the cooler should have been closed with the roast beef chucks covered, raw chicken should have been kept on the bottom shelf when marinating, and all food items should contain a label with the date opened or prepared and the expiration date which was the responsibility of the cook. [NAME] #1 could not identify why facility policy was not followed.Subsequent to surveyor inquiry [NAME] #1 obtained a thermometer to put in the milk cooler, covered the roast beef chucks, moved the raw chicken to a lower rack, removed the frozen onion rings and frozen tater tots and staff applied hair and beard restraints as needed.Observation of the 4th floor dining room on 2/8/26 at 9:35 AM identified Resident #65 approach staff with a complaint of sour milk. Observation of the milk container identified that the milk was not expired and was well within the expiration date. Interview with the Dietary Director on 2/8/26 at 11:11 AM identified cooks were responsible for checking temperatures daily, stating that although the outside of the milk cooler had an inaccurate reading, the thermometer that was in the milk cooler was 36 degrees Fahrenheit at 6:00 AM per the record sheet. (Cook #1 had failed to locate a record sheet on 2/8/26 at 7:30 AM, failed to indicate he recorded a temperature after noting a temperature of 55 degrees Fahrenheit, and was unable to locate a thermometer inside the milk cooler when asked about the external thermometer reading). A current observation with the Dietary Director inside the milk cooler identified a reading of 20 degrees Fahrenheit. Additionally, the Dietary Director identified it was the cook's responsibility to ensure food items were covered when cooling, raw meat was kept on the bottom shelf, and refrigerator/cooler doors kept closed when not in use. The Dietary Director also specified that premade labels were utilized, to identify when food was prepared or opened and when it expired, and that everyone in the kitchen was expected to wear hair nets and beard restraints as needed. The Dietary Director could not identify why facility policies were not followed.2. Observation with the Dietary Director on 2/9/26 at 10:50 AM identified Dietary Aide (DA) #3 in the food preparation area with a tray of salads on the counter without the benefit of a beard restraint.Interview with DA #3 identified that he was aware of the facility policy on hair and beard guards and although he was just talking to the cook, because he was in the prep area he should have been wearing a beard restraint.Subsequent to surveyor inquiry DA #3 applied a beard restraint.Review of the Employee Sanitary Practices Policy directed in part that employees will wear hair restraints (hair nets, hats, and/or beard restraint) to prevent hair from contacting exposed food.Review of the Food Storage Policy directed in part that all foods will be labeled with a use by date when opened and stored in an appropriate manner. Additionally, all foods not labeled with an expiration date will be discarded.The General Guidelines for Food Safety Policy directed in part to label and date foods and put foods away promptly.

Based on observations, review of clinical records, facility documentation, facility policies and interviews for 1 of 3 sampled residents (Resident #22) reviewed for a Peripherally Inserted Central Catheter (PICC line) the facility failed to adhere to the Enhanced Barrier Precaution (EBP) policy, for 1 of 3 sampled residents (Resident #23) reviewed for pressure ulcers, the facility failed to ensure a peripherally inserted Intravenous (IV) site was rotated according to physician orders or infection control standards, for 1 of 3 sampled residents (Resident #108) reviewed for pressure ulcers, the facility failed to perform appropriate hand hygiene during a dressing change, and during a review of the facility infection control tracking practices, the facility failed to maintain an accurate up-to-date list of residents who required Enhanced Barrier Precautions (EBP) or Transmission Based Precautions (TBP) and failed to implement the facility policy for residents with a Multi-Drug-Resistant Organism. The findings include: 1. Resident #22's diagnoses included acute osteomyelitis (bone infection), of the left ankle and foot, cellulitis of the left lower foot, and Klebsiella Pneumoniae (bacterial) infection. The admission Minimum Data Set assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status score of 15 indicating intact cognition, and was independent with eating and drinking, and required minimal/moderate assistance with bathing and dressing. The Resident Care Plan dated 1/8/26 identified Resident #22 had impaired skin integrity related to osteomyelitis, a limb alert related to Intravenous (IV) access and was on antibiotic IV therapy for 6 weeks related to osteomyelitis. Interventions included administering medication as ordered, monitor for effects, provide protective/preventive skin care per protocol, check placement of the IV site for limb alert on right side, and monitor skin integrity and signs and symptoms of infection during daily care. A physician's order dated 1/14/26 directed EBP during high-contact resident care activities for residents with indwelling medical devices such as a PICC line. Observations and interview on 2/8/26 at 12:03 PM, identified an EBP sign posted on the door of Resident #22's room and a cart outside of the room containing Personal Protective Equipment (PPE). LPN #6 was observed to enter the room with an IV bag in her hand without the benefit of placing on PPE. LPN #6 proceeded to administer Resident #22's IV fluid and exited the room. LPN #6 indicated that the EBP sign on the door indicated that Resident #22 was on EBP precautions and when she administered the IV, she should have been dressed in a gown with gloves on and should have washed or sanitized her hands, but she had missed a few steps. Interview with Infection Preventionist, Registered Nurse (RN) #1, on 2/9/26 at 8:55 AM identified that staff education for EBP was completed on 2/2/26 and 2/6/26 as a review of annual competencies. RN #1 stated that a gown and gloves should have been used during the administration of Resident # 22's IV. Interview with the Director of Nursing Services on 2/10/26 at 8:48 AM identified that any resident being administered an IV through a PICC line (a high contact activity) required a gown and gloves, including Resident #22. The Enhanced Barrier Precautions Policy dated 7/23 directed, in part, that the facility will implement enhanced barrier precautions to include any resident with a PICC line. Staff will perform hand hygiene and don (place) PPE before providing high-contact care to the residents and will perform hand hygiene after providing high-contact care. 2. Resident #23's diagnosis included dementia, adult failure to thrive and functional quadriplegia. A quarterly Minimum Data Set assessment dated [DATE] identified Resident #23 had short and long-term memory problems and required total assistance with dressing, bed mobility, and transfers. A Resident Care Plan dated 1/29/26 identified Resident #23 received Intravenous (IV) therapy for hydration. Interventions included administer IV infusion per physician orders, per physician order may extend site use 5-7 days if there were no complications. Change the IV bag every 24 hours. Change the IV tubing every 72 hours. Change site dressing/cap every week. A physician's order dated 1/28/26 directed to administer dextrose 5% at 75 milliliters per hour for 1 day. Observation on 2/8/26 (12 days after insertion) at 6:55 AM, 9:41 AM, and 12:20 PM identified a peripheral IV remained in Resident #23's right hand without the benefit of a dressing secured only by tape and lacked a date Observation on 2/9/26 (13 days after insertion) at 8:25 AM identified a peripheral IV remained in Resident #23's right hand. Review of the clinical record failed to indicate a new physician order to extend the peripheral insertion site time frame or documentation that the peripheral IV site was changed after the 5–7-day physician ordered time limit. Interview and review of the intravenous Infusion Therapy Log with the DNS on 2/9/26 at 1:07 PM indicated that Resident #23 might have needed further IV fluids and the peripheral IV could remain in place for 7 days. The DNS was unaware how long the IV site remained in place. Interview with the DNS and Advanced Practice Registered Nurse (APRN) #2 on 2/9/26 at 1:36 PM indicated that APRN #2 did not know why Resident #23 continued to have a peripheral IV catheter placed to the right hand. APRN #2 indicated she would review the resident's record and that when she was notified of the prolonged IV peripheral line placement on 2/9/26, she had ordered repeat laboratory studies on 2/9/26 when this was brought to her attention, and the peripheral IV catheter needed to be removed. The CDC guidelines indicate that peripheral intravenous catheters are typically replaced every 72 to 96 hours to minimize risk of infection and phlebitis. Although requested, a facility policy for changing IV catheters was not provided. 3. Resident #108's diagnosis included a stage 4 (full thickness wound with extensive tissue loss exposing underlying muscle, tendon, ligament, cartilage or bone) pressure ulcer of the sacral region, legal blindness, and low back pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #108 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, and required set-up assistance with eating, moderate assistance with bed mobility, substantial maximal assistance with dressing, and total dependance on staff with transfers. A physician's order dated 11/3/25 and in effect on 2/9/26 directed to clean the stage 4 pressure ulcer with normal saline or wound cleanser, pat dry with gauze, apply calcium alginate to the wound bed, cover with a foam dressing every 8 hours and as needed if the dressing was missing or soiled. Observation on 2/9/26 at 12:44 PM identified LPN #3 performed Resident #108's sacral wound treatment. After removing the old dressing, she failed to cleanse or sanitize her hands prior to placing new gloves and cleansing the wound. Interview with LPN #3 on 2/9/26 at 12:44 PM indicated that she should have cleansed her hands prior to placing clean gloves and cleansing Resident #108's wound. Subsequent to surveyor inquiry, LPN #3 washed her hands with soap and water prior to applying clean gloves. Interview with Director of Nursing Services on 2/9/26 at 1:07 PM indicated that during a dressing change, hand hygiene would be performed following removal of the old dressing, removing gloves and placing on new clean gloves. Although requested a facility policy for hand hygiene during dressing changes was not provided. 4. Observations during a facility tour on 2/8/26 and 2/9/26 throughout the day identified signage outside resident rooms 102, 108, 112, 119, 209, 210, 234, 321, 331, 427, and 440 required Enhanced Barrier Precautions. A review of the Infection Control program with Registered Nurse (RN) #1 (Infection Preventionist) on 2/9/26 at 9:44 AM identified a current list of residents who required Enhanced Barrier Precautions (EBP) by unit and 2 current residents who required Transmission Based Precautions (TBP). Although signage outside resident rooms 102, 108, 112, 119, 209, 210, 234, 321, 331, 427, and 440 had been identified as requiring EBP precautions during the program review, RN #1 had failed to include these room numbers as residents who required EBP. Additionally, RN #1 provided a list of residents who had a history of a Multi Drug Resistant Organisms (MDRO). Interview with RN #1 on 2/9/26 at 9:44 AM indicated that residents with a history of MDRO's did not need to be on any precautions because they were colonized. Review of the EBP policy with RN #1 contradicted her statement and that residents with MDRO colonization should be placed on EBP. Interview on 2/9/26 at 1:07 PM with the DNS indicated if the residents were colonized with Methicillin Resistant Staphylococcus Aureus (MRSA), an MDRO, they did not need to be on EBP. Review of the EBP policy with the DNS contradicted her statement indicating that residents with a history of an MDRO would need to be placed on EBP. Additionally, The DNS could not explain why the list of EBP residents did not match the signage on the doors of the residents' rooms but suggested that those residents may have been newly admitted or recently had room changes. The DNS could not explain why the EBP list was not accurate, indicated that RN #1 was responsible for updating the EBP list, and that the supervisors on the weekend would place residents on precautions but would fail to update the list. The EBP and MDRO lists would be updated in the weekly Standards meeting. Interview on 2/9/26 at 1:36 PM with the DNS and RN #1 identified the EBP list did not match because RN #1 was responsible and in the process of updating the list. Subsequent to surveyor inquiry, an updated EBP list was provided. Subsequent review of the residents who had sign placement without being added to the current list of residents who required EBP failed to identify that they had been admitted over the weekend. A review of the Enhanced Barrier Precaution policy, in part directed, Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities which provide opportunities for transfer of MDROs to staff hands and clothing when caring for residents known to be colonized or infected with a MDRO. The Infection Preventionist keeps an ongoing list of residents with colonized MDROs and distributes the list of residents colonized with a MDRO to other disciplines. Signage (will be placed) on the door or wall outside the resident room indicating the type of precautions and required Personal Protective Equipment (PPE). Signage should also clearly indicate the high contact resident care activities that require the use of gowns and gloves.

Based on interviews, observations, review of clinical records, and review of facility policy for 2 of 5 sampled residents, (Resident #23 and #128) reviewed for dignity, the facility failed to assist residents to eat in a dignified manner and for the entire facility failed to ensure appropriate food plating to maintain a dignified dining experience. The findings include: 1. Resident #23's diagnoses included unspecified dementia, functional quadriplegia (paralysis of all 4 extremities and torso), and adult failure to thrive. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had short-and long-term memory problems, was dependent on staff for eating, and required partial/moderate assistance for chair/bed-to-chair transfers. The Resident Care Plan (RCP) dated 1/15/26 identified Resident #23 had a self-care deficit related to dementia and functional quadriplegia. Interventions included that he/she was dependent on staff for eating. Interview and observation with Nurse Aid (NA) #1 on 2/8/26 at 9:40 AM identified that Resident #23 was in bed with the head of the bed raised, and his/her breakfast on the bedside tray table. NA #1 was observed standing on the left side of Resident #23's bed, over and above eye level assisting him/her to eat. NA #1 indicated that she normally sat down when feeding residents, but no chair was available in which to sit. Additionally, NA #1 identified that she should have been sitting down when assisting Resident #23 to eat per the facility policy. 2. Resident #128's diagnoses included vascular dementia, hypertension, and pain in the joints of the left hand. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #128 had a Brief Interview of Mental Status score of 4 out of 15 indicating severe cognitive impairment, required setup or clean-up assistance with eating, and was independent for bed mobility and transfers. The Resident Care Plan (RCP) dated 12/11/25 identified Resident #128 was at risk for nutritional deficit related to pain. Interventions included for staff to monitor the percentage (%) of meals and fluids consumed and encourage the resident to consume greater than 75% of meals. Additionally, Resident #128 was at risk for dehydration and/or fluid overload. Interventions included providing diet and appropriate staff assistance with meals. Interview and observation with Nurse Aid (NA) #6 on 2/8/26 at 8:13 AM identified that Resident #128 was sitting down in a chair at a table in the dining room with his/her breakfast. NA #6 was observed standing next to Resident #128, above, and not at eye level, and assisting him/her with breakfast. NA #6 indicated that it was the NA's responsibility to assist residents with eating as needed or if required per the facility policy. NA #6 indicated that she always stood when feeding the residents because it was easier and she thought it was permissible to stand while assisting a resident to eat. Subsequent to surveyor inquiry, NA #6 moved an empty chair next to Resident #128 and assisted the resident to eat his/her breakfast while sitting down. Interview and policy review with the Assistant Director of Nurses (ADNS) on 2/8/26 at 9:49 AM identified that NAs should follow the Activities of Daily Living policy and Resident Care Plan when assisting residents to eat. Additionally, the ADNS indicated that both NA #1 and NA #6 should have been seated while assisting Resident #23 and #128 to eat instead of standing as that was an undignified way to assist with meals. Review of the facility's dignity policy dated 11/17 directed, in part that that staff are to sit next to a resident when assisting to feed and converse with the resident. Review of the facility's meal service-assistance of resident's policy dated 4/16, directed, in part that staff members are seated when feeding residents. The policy directed staff to sit next to or face resident while assisting with the meal to promote socialization and correct feeding techniques. 3. Interview and observation with [NAME] #1 on 2/8/26 at 6:45 AM noted food plated into disposable cardboard to go containers. [NAME] #1 identified that due to the elevator not functioning for approximately a week, food was plated onto the disposable to-go containers, placed in black plastic container on wheels, then taken outside and around the facility onto the units by kitchen staff. Interview with Resident #7 on 2/8/26 at 9:38 AM described the food as terrible, always late and cold, stating he/she usually asks for the food to be warmed up. Interview with Resident #28 on 2/8/26 at 9:45 AM identified the food tastes disgusting and is always cold. Interview with Resident #140 on 2/08/26 at 9:39 AM identified the food as being low quality, not tasting good and always cold. Observation on 2/8/26 at 9:01 AM identified the breakfast meal truck delivered to the 4th floor, with all food within disposable cardboard to go containers then placed onto the table. The nursing staff served residents their meals by placing the disposable to go containers on plastic trays, adding beverages, then proceeded to pass out the meals to the residents in the dining room. Remaining disposable to go container meals were placed into a metal frame food truck with curtains that was taken onto the unit to give to residents dining in their rooms. Observation on 2/8/26 at 12:45 PM identified the lunch meal truck delivered to the 4th floor with food on porcelain plates, with lids and warming bases. Interview with the Regional Dietary Director on 2/8/26 at 1:35 PM identified that the facility tried to make it easier on staff by serving meals in the disposable to go cardboard containers, however it was an undignified dining experience for the residents, so they switched back to the porcelain plates with heated bases and covers. Interview and observation with the Regional Dietary Director on 2/9/26 at 12:28 PM noted lunch being plated onto disposable cardboard to go containers, identifying that due to heavy nature of the plates, and lack of support during transportation of the food from the kitchen, then outside, then to the units might cause the porcelain plates to break. The Regional Dietary Director further identified it was safer for residents to receive the food in disposable cardboard to go containers, despite the impact of suboptimal temperatures affecting food quality and the lack of a dignified resident dining experience. Interview with the Director of Nurses on 2/9/26 at 2:05 PM identified that although there were challenges in the past with the kitchen, such as delays and cold food, things had gotten a lot better. The DNS noted she was not aware that meals were consistently served late or that they were currently being served in disposable cardboard to go containers. Additionally, the DNS identified she felt it was undignified to serve residents cold meals in disposable to go containers, but stated there were microwaves available on the units, and she was under the impression that the kitchen resumed plate service subsequent to surveyor inquiry on 2/8/26. Interview with the Administrator on 2/9/26 at 2:48 PM identified she was not aware that the kitchen staff went back to serving resident meals in disposable cardboard to go containers, and although it was more work for the kitchen staff, it was undignified dining experience, and she would contact the kitchen to go back to appropriate use of dishware for plating meals. Subsequent to surveyor inquiry, observation on 2/10/26 at 9:13 AM identified meals were being served on plates rather than disposable to go containers. Review of the meal service assistance of residents directed in part that is was facility protocol to provide each resident with a nourishing, palatable diet at proper temperatures.

Based on interviews, review of clinical records, review of documentation and facility policy for 2 of 5 residents, (Residents #30 and #36) reviewed for abuse, the facility failed to investigate an allegation of resident-to-resident abuse. The findings include:1. Resident #30's diagnoses included vascular dementia with agitation, anxiety disorder, and major depressive disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status (BIMS) score of 0 indicating severe cognitive impairment, required substantial/maximal assistance with upper/lower body dressing and partial/moderate assistance with transfers.The Resident Care Plan (RCP) dated 1/27/26 identified Resident #30 had a mood state problem related to diagnosis of anxiety and depression. Interventions included to orient to facility/staff and validate feelings by offering emotional support and reassurance. Additionally, the RCP identified Resident #30 had the potential to demonstrate verbally abusive behaviors related to screaming and yelling. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalated the behavior.2. Resident #36's diagnoses included unspecified dementia, depression, and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 had a Brief Interview of Mental Status (BIMS) score of 6 indicating severe cognitive impairment, was dependent on staff for toileting, upper/lower body dressing, and transfers.The Resident Care Plan (RCP) dated 1/22/26 identified Resident #36 was at risk of being a victim of abuse, neglect and/or mistreatment. Interventions included staff to advise the resident to seek out staff for assistance if they had difficulty with others. Review of a health status note dated 1/27/26 at 11:49 AM identified that Resident #36 was observed with dark red bruising around both eyes. The physician and responsible party were notified. Resident #36 stated I don't know what happened.Review of a nurse progress note dated 1/27/26 at 6:15 PM identified that Resident #36 was transferred to the hospital per a physician order for evaluation of redness around his/her eyes. The resident responsible party was notified.Review of the Emergency Department (ED) discharge note dated 1/27/26 at 10:43 PM identified that Resident #36 presented to the ED for evaluation of facial trauma. Resident #36 stated that he/she was hit in the face by another resident and was unsure when it happened. The ED note identified that the ED physician spoke with the nursing supervisor at the facility, who stated that the bruising was first noticed several days before, did not believe that Resident #36 was hit by anyone, and was unsure how the bruising happened.Review of the state agency's incident reporting system identified the facility reported the observations of bruises of unknown origin on 1/28/26 later adding a summary to include the allegation of resident-to-resident abuse.Review of the facility's Accident and Incident (A&I) report dated 1/28/26 identified that Resident #36 stated to facility staff that a girl with long hair hit her and her roommate hit her. The A&I failed to identify an investigation to the allegation of resident-to-resident abuse. Interview with the Director of Nurses (DNS) on 2/10/26 at 10:27 AM identified that the DNS and ADNS were responsible for ensuring allegations of abuse were investigated thoroughly. Initially in the interview, the DNS indicated that she was aware of the allegation of resident-to-resident abuse involving Resident #30 and Resident #36. The interview then identified that an investigation was not completed because the DNS was unaware of the allegations of resident-to-resident abuse.Review of the facility's reporting and investigation of resident abuse, neglect, misappropriation/ exploitation and mistreatment policy dated 10/22 directed, in part, that the administrative and nursing department will assist in the coordination of the investigation of all allegations of exploitation, neglect, mistreatment, physical, sexual, mental or verbal abuse. Additionally, it identified that staff involved and other witnesses will be identified and interviewed regarding any known knowledge of the allegation.

Based on interviews and review of the clinical record for 1 of 5 sampled residents (Resident #60) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to coordinate with the state designated authority following the initial 30-day Level 1 PASRR approval. The findings include:Resident #60 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and bipolar disorder.The comprehensive Minimum Data Set assessment dated [DATE] identified a diagnosis of bipolar disorder.The comprehensive Minimum Data Set assessment dated [DATE] (39 days after admission) identified a diagnosis of bipolar disorder but failed to identify a Level II PASRR had been completed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was moderately cognitively impaired and required total dependence for oral hygiene, toileting hygiene, eating, and bathing. Resident #60 received antipsychotic, antianxiety, and antidepressant medication, and identified a diagnosis of bipolar disorder.Review of the clinical record identified a PASRR Level I assessment dated [DATE]. A diagnosis of bipolar disorder was noted, and the Level I PASRR directed that a PASRR Level II assessment must be conducted if Resident #60 was to remain in the facility past 30 days.Review of the clinical record failed to identify a completed PASRR Level II assessment. Interview and clinical record review with the Social Worker (SW #2) on 2/10/26 at 1:37 PM identified a Level II PASRR was not in the clinical record as the facility never sent notification to the state designated authority that a Level II PASRR was required when Resident #60's initial 30 days had been completed by 9/17/25 and was 173 days past due. SW #2 stated that Resident #60 was self-pay and, therefore, did not require a PASRR Level II Screen to be completed.Center for Medicaid Services (CMS) in the Long Term Care Resident Assessment Instrument (RAI) stated that all individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions. Individuals who have or are suspected of having MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #108) reviewed for pressure ulcers, the facility failed to follow the physician's order for an air mattress inflation setting and for 1 of 3 sampled residents, (Resident #132) reviewed for respiratory care, the facility failed to set a residents oxygen liter flow per the physician's order. The findings include: 1.Resident #108's diagnosis included a stage 4 (full thickness wound with extensive tissue loss exposing underlying muscle, tendon, ligament, cartilage or bone) pressure ulcer of the sacral region, legal blindness, and low back pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #108 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and required partial/moderate assistance with bed mobility, substantial maximal assistance with dressing, and total dependence with transfers and toileting. The Resident Care Plan dated 12/30/25 identified Resident #108 with an impairment to skin integrity related to a stage 4 sacrum pressure ulcer that was present upon admission. Interventions included providing an air mattress, skin assessments and care interventions per protocol and physician orders, preventative pressure relief devices and turn and reposition measures. The physician's order in effect from 12/30/25 through 2/9/26 directed to check the air mattress for proper functioning and settings and set to weight every shift. A review of Resident #108's weights identified that on 1/30/26 a weight of 182.2 pounds was documented and on 2/6/26 a weight of 184.8 pounds was documented. A review of the clinical record and monthly Medication Administration Records and Treatment Administration Records for January and February 2026, failed to indicate Resident #108's air mattress was checked for functioning, settings, or weight every shift as directed on the physician's orders. Observations on 2/8/26 at 10:28 AM, 2/9/26 at 9:36 AM, and 2/9/26 at 12:44 PM identified the air mattress setting was set between 280 and 320. Interview and clinical record review with the Director of Nursing Services (DNS) on 2/9/26 at 1:07 PM identified that Resident #108's air mattress setting was between 280 and 320 (at 300). The DNS indicated that the facility practice was to set an air mattress per a resident's weight and that Resident #108's current weight was 184 pounds. The DNS additionally stated that this may have been Resident #108's preference but the physician order directed the mattress to be set to the resident's weight and not per the resident's preference. Review of the use of specialty mattress replacement surfaces policy directed, in part, residents will be evaluated to determine the need for placement on or use of a specialty mattress replacement surface, obtain a physician order and nursing will adjust the settings per the manufacturer instructions. The settings will be checked by a licensed nurse and documented every shift. 2.Resident #132's diagnoses included congestive heart failure, type 2 diabetes, and atrial fibrillation. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #132 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment, was dependent on staff for upper body dressing, personal hygiene, and transfers and that Resident #132 required continuous oxygen therapy. The Resident Care Plan (RCP) dated 12/17/25 identified Resident #132 had an altered respiratory status evidenced by shortness of breath, dyspnea, decreased endurance, and anxiety. Interventions included maintaining a clear airway and providing the over-bed table for positioning comfort while sleeping. A physician's order dated 11/30/25 directed to administer oxygen at 3 liters per minute via nasal canula as needed. Observation on 2/8/26 at 7:16 AM and 2/9/26 at 9:18 AM identified Resident #132 lying in bed with the head of the bed elevated being administered oxygen at 2 liters per minute. Interview, clinical record review, and observation with the Licensed Practical Nurse (LPN) #7 on 2/9/26 at 9:23 AM identified oxygen administration should be set according to the physician's order, and it was the responsibility of the assigned nurse to ensure the correct oxygen setting. LPN #7 identified that Resident #132's had a physician's order directing oxygen administration at 3 liters per minute as needed but upon observation, Resident #132 was lying in bed, receiving oxygen at 2 liters per minute. LPN #7 indicated that the oxygen administration was set incorrectly, that she had not checked Resident #132's oxygen administration setting at the beginning of the shift as she was busy providing care to other residents and she would change the oxygen setting to the correct rate of oxygen administration 3 liters per minute. Interview Director of Nursing (DNS) on 2/9/26 at 10:35 AM identified oxygen administration should be set according to the physician's order and that it was the responsibility of the unit nurse to ensure the correct oxygen setting. The DNS could not identify why Resident #132's oxygen administration was set incorrectly and would begin re-educating the nurses on how to properly check and set oxygen administration per physician's order. Review of the facility's oxygen therapy policy dated 6/17 directed, in part that a physician's order is needed for oxygen administration and will specify the concentration (liter flow), type and duration of therapy. Additionally, the policy directed that nursing staff will set up, check and supervise all treatments.

Based on interviews, observations, review of the clinical record, and facility policy for 1 of 2 sampled residents, (Resident #11) reviewed for elopement (wandering away), the facility failed to ensure placement of an anti-wandering (Wander guard) transmission device per the physician order for a resident at high risk for elopement. The findings include:Resident #11's diagnoses included Parkinson's disease, unspecified dementia, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment, was independent for oral and personal hygiene, and required supervision or touching assistance for walking.The Resident Care Plan (RCP) dated 1/27/26 identified Resident #11 was an elopement risk/wanderer related to confusion and dementia. Interventions included placement of an Wander guard transmission device to the right ankle and to check placement of the device every shift.A physician's order dated 3/12/25 and in effect on 2/9/26 directed to check the Wander guard transmission device function every night shift. Wander guard transmission device with an expiration date of 11/7/25, and to check placement of the Wander guard transmission device every shift.Review of an Unsafe Wandering/Elopement Risk assessment dated [DATE] identified Resident #11 was at risk for elopement.Observation on 2/9/26 at 11:29 AM identified Resident #11 was sitting in a chair at a table in the dining room. A Wander guard device was not present on his/her right or left ankle.Interview, observation, and clinical record review with Licensed Practical Nurse (LPN) #8 on 2/9/26 at 11:31 AM identified that it was the assigned nurses responsibility to ensure residents with a physician's order for a Wander guard transmission device (indicating to her an elopement risk) had the device in place. Review of Resident #11's clinical record identified an active physician order for a Wander guard transmission device to be present on his/her right ankle. Observation of Resident #11 identified him/her sitting in the dining room without the benefit of the Wander guard to the right ankle or other extremity, adding that she had not yet checked placement this shift. Resident #11 indicated that I took that off months ago. After receiving permission, LPN #8 searched Resident #11's room, but was unable to locate a Wander guard device. Subsequent to surveyor inquiry, LPN #8 indicated that she would contact the provider for a new Wander guard transmission device order to be placed on Resident #11. Interview with the Medical Director on 2/9/26 at 11:45 AM identified that an active order for a Wander guard transmission device meant the device needed to be on the resident. The MD indicated that the expiration date on the order was a reminder the resident needed to be re-assessed for the risk of elopement.Interview with the Director of Nursing (DNS) on 2/9/26 at 12:45 PM identified that residents with physician orders for a Wander guard transmission device should have the device placed on the resident and it was the unit nurse's responsibility to check and document placement every shift. The DNS indicated she was made aware that Resident #11 was observed without his/her Wander guard transmission device but did not believe Resident #11's statement indicating I took it off months ago to be true. The interview failed to identify how long the Wander guard transmission device had not been present on Resident #11 and that a new Wander guard device had been placed per the physician order.Subsequent to surveyor inquiry, a physicians order dated 2/9/26 for Resident #11 was obtained and directed to check the Wander guard transmission device function every shift with an expiration date of 7/25/26.Review of the facility's Elopement Prevention Policy dated 7/18 directed, in part that the Wander guard transmission device is placed on residents with an elopement risk and is to be worn twenty-four (24) hours a day. Additionally, the policy identified that the Licensed Nurse should initiate an emergency CCP meeting if the resident removes or refuses the wander guard transmission device.

Based on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #48) reviewed for nutrition, the facility failed to follow physician orders to monitor intake and output accurately for a resident receiving hemolytic treatments. The findings include:Resident #48's diagnoses included hypertensive chronic kidney disease stage 5, dependence on hemolytic treatments and diabetes with chronic kidney disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 had a Brief Interview for Mental Status Score of 14 indicating intact cognition, required supervision with bed mobility, partial moderate assistance with dressing and transfers, and was dependent on staff for toileting.The Resident Care Plan dated 12/14/25 identified a potential for fluid volume overload related to end stage renal disease on hemolytic treatments. Interventions included administering medications and diet as ordered, monitor, document, and report to the physician signs and symptoms of fluid overload, anorexia, anxiety, difficulty breathing, increased respirations, edema and sudden weight gain.Physician's order in effect from 1/1/26 through 2/10/26 directed a fluid restriction of 1000 milliliters (ml) in 24 hours and to monitor intake and output for a total of 1000 ml fluid restriction and, if not met, notify the physician.A review of the Medication Administration Record (MAR) dated 1/1/26 through 1/31/26 identified total 24-hour fluid intake amounts as follows:1/1/26 -300 ml1/2/26 -200 ml1/3/26, 1/19/26, and 1/30/26 -0 ml1/4/26, 1/8/26, 1/14/26, 1/18/26, 1/21/26, 1/27/26, and 1/29/26 -240 ml1/5/26 -40 ml1/6/26, 1/7/26, 1/9/26, 1/12/26, 1/13/26, 1/23/26, and 1/26/26 -480 ml1/10/26 -250 ml1/15/26, 1/16/26, and 1/22/26 -280 ml1/20/26 and 1/28/26 -360 ml1/24/26 -220 ml1/25/26 -700 ml1/31/26 -120 ml(Resident #48 failed to meet his/her fluid restriction any day in January)A review of the nursing progress notes from 1/1/26 through 1/31/26 failed to identify fluid intakes or notification of the physician when the fluid restriction minimum was not met.A weight change note written by the facility dietician dated 1/30/26 at 5:03 PM identified a weight change of 5 percent (%) 9.3 pounds. The Advanced Practice Registered Nurse (APRN) was notified of Resident #48's weight status with fluctuations anticipated related to fluid.A review of Medication Administration Record dated 2/1/26 through 2/10/26 identified total intakes as follows:2/1/26 -180 ml2/2/26 -280 ml2/3/26 -160 ml2/4/26, 2/5/26 and 2/9/26 -480 ml2/6/26 -240 ml2/7/26 -0 ml2/8/26 -300 ml(Resident #48 failed to meet his/her fluid restriction any day as yet in February)A review of the nursing progress notes from 2/1/26 through 2/9/26 failed to identify fluid intakes or notification of the physician when the fluid restriction minimum was not met.A weight change note written by the facility dietician dated 2/6/26 at 11:09 AM identified the hemolytic treatment dietitian was updated of Resident #48's total weight increased from 174.16 pounds to 179.01 pounds and reported that Resident #48 continued to come in over the target weight. Further, the facility dietician recommended to continue to encourage and educate the importance of fluid restriction.Observation on 2/8/26 a 12:33 PM, identified an intake and output binder located at the nursing station with intake and output worksheets for individual residents. A worksheet for Resident #48 was not present in the binder.Interview and record review with the facility Dietitian on 2/10/26 at 9:46 AM identified that she was responsible for monitoring intake, output, and fluid restrictions by reviewing the information entered in the electronic medical record in the task section completed by Nurse Aids (NA)'s. The facility Dietician identified that although Resident #48 had fluid intakes recorded on the Medication Administration Record (noted to be well below the fluid restriction allowed) she indicated that the amounts could not accurately reflect Resident #48's fluid intake as evidenced by the fluctuations in Resident #48's weight and weight gain. Although a binder labeled intake and output was noted at the nurses' station, the Dietician stated she was not aware of any paper worksheets used to monitor intake, output, or fluid restriction amounts. The Dietician stated she had spoken with the hemolytic treatment center dietitian because Resident #48's weights were over the target amount indicating that this was because Resident #48's fluid intake was over the 1000 ml fluid restriction. The facility Dietician indicated that a possibly reason for the overage was that Resident #48 had a recent room change, was attending more activities, and had increased opportunities to consume fluids.Interview and record review with the Director of Nursing Services on 2/10/26 at 10:13 AM identified that she needed to check the intake and output policy as well as the fluid restriction policy and was unable to identify knowledge of how facility intake and output or fluid restriction amounts were being maintained by her nursing staff.Review of the Assessment and Care of Residents receiving hemolytic treatment policy directed, in part, restrict fluid intake per physician orders, if on fluid restrictions, monitor intake and output if ordered.Review of the Measurement of Intake and Output policy directed, in part, the licensed nurse is responsible for calculation and recording of intake and output. Intake and output may be ordered by a physician or may be started as a nursing measure for any resident with fluid restriction. The charge nurse will enter the order/need for intake and output monitoring in the electronic MAR. The licensed nurse will record fluid intake such as fluids taken during medication pass. The charge nurse will review the NA documentation utilizing the lookback report in Point of Care (POC) and total the amount of intake and output from all sources for the shift. The charge nurse will document the shift total in their progress note. The 7:00 AM to 3:00 PM Unit Manager or designee was responsible for the 24-hour total at 7:00A M. The 24-hour period will be calculated from 7:00 AM to 7:00 AM and recorded in Point Click Care MAR/progress notes.Review of the Hydration policy directed, in part, conditions when intake and output may be indicated but not limited to fluid restriction, hemolytic treatments. The NAs shall record oral intake and output on the intake and output worksheet each shift and shall report amounts to the charge nurse. The charge nurse will document the total amount consumed every shift on the Medication Administration Record. During the collection of intake and output, if a resident has not met their 24-hour fluid requirements for 3 consecutive days, the following action should be taken: complete a hydration evaluation.

Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #48) reviewed for hemolytic treatments, the facility failed to monitor the Arteriovenous (AV) fistula site for function. The findings include:Resident #48 's diagnoses included hypertensive chronic kidney disease stage 5, dependence on dialysis and diabetes with chronic kidney disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 had Brief Interview for Mental Status (BIMS) Score of 14 indicating intact cognition and was independent with eating, required supervision with bed mobility, and partial moderate assistance with dressing.The Resident Care Plan dated 12/16/25 identified Resident #48 needed hemolytic treatments related to end stage renal disease. Interventions included checking for AV shunt/fistula bruit and thrill and providing hemolytic treatments via left AV fistula every Tuesday, Thursday and Saturday and as needed per the hemolytic treatment center plan.The physician's orders dated 1/15/26 through 2/10/26 directed to provide hemolytic treatments on Tuesday, Thursday, and Saturday, pick up 8:45 AM, but failed to direct monitoring of the AV fistula for bruit and thrill. Observation of Resident #48 on 2/8/26 at 12:33 PM identified an AV fistula in left upper arm.A review of pre and post hemolytic treatment center notes completed by the facility and sent to the hemolytic treatment center dated 1/10/26, 1/15/26, 1/17/26, 1/20/26, 1/24/26, and 1/27/2 identified that although an area to include AV fistula monitoring was available, facility staff failed to include the area was being monitored for function per the Resident Care Plan.Interview and record review with Director of Nursing on 2/10/26 at 10:00 AM identified that she did not know if Resident #48 had an AV Fistula and was unaware if a bruit or thrill was being monitored for function. If monitoring was occurring, the documentation could have been located in the Medication Administration Record.Review of the clinical record from 1/15/26 through 2/10/26, physician's orders, nurse's notes and Medication Administration Record failed to identify monitoring of the AV fistula function for a bruit and thrill.Review of the assessment and care of residents receiving hemolytic treatment policy directed, in part, nursing to complete the pre hemolytic treatment assessment in Point Click Care (PCC). Assessment of the dialysis access site should be done upon return from dialysis and recorded on the post dialysis assessment. Check access site daily for evidence of bleeding, drainage, discoloration, redness, heat, swelling or pain. If bleeding occurs at the access site, apply manual pressure for 10 minutes. Notify physician or Nurse Practitioner for uncontrolled bleeding and prepare resident for transfer to the emergency room. Check daily for bruit and thrill. Remove Band aids within 24 hours. Notify physician or Nurse Practitioners if absence of thrill or bruit. The Medical Director and Director of Nursing and/or designee shall be responsible for ensuring compliance with this policy.

Based on clinical record reviews, facility documentation, and staff interviews for one (1) of three (3) sampled residents (Resident #1) who required staff assistance with personal hygiene, the facility failed to ensure the resident was positioned safely in the bed and the correct number of staff assistance were present in accordance with the care plan prior to adjusting the height of the bed to prevent the resident from sliding out of the bed. The findings include: Resident #1's diagnoses included hemiplegia, hemiparesis, vascular dementia, aphasia, cerebrovascular disease, disorder of bone density and structure. The significant change Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS of 0 out of 15 indicating Resident #1 never or rarely made decisions regarding tasks of daily life, did not exhibit behavioral symptoms, and was dependent on staff with bed mobility, personal hygiene, toileting, dressing, and transfers. The Resident Care Plan dated 4/21/25 identified Resident #1 had a lack of functional physical mobility and self-care deficit related to cerebrovascular disease with functional quadriplegia. Interventions directed total assist of two (2) staff with bed mobility and transfers The Situation Background Assessment Recommendation (SBAR) note dated 5/11/25 at 7:51 AM identified Resident #1 sustained a witnessed fall during care. Resident #1 was observed in the supine position and moaning while lying on floor and unable to verbally express his/her pain. The note indicated the physician was notified and recommended to send Resident #1 to the hospital. The hospital record dated 5/11/25 at 8:35 AM identified Resident #1 presented after a witnessed fall, a Computerized Tomography (CT) scan of the chest, abdomen, and pelvis was conducted and identified Resident #1 had sustained an acute comminuted and mildly displaced fracture of the proximal right femur. Resident #1 was admitted for further management. The facility's summary report dated 5/16/25 identified on 5/11/25 at 7:45 AM the 7AM-3PM nurse aide, Nurse Aide (NA) #1, reported a witnessed fall, Resident #1 had slid out of the bed to the floor while she was adjusting the bed. NA #1 explained Resident #1 was positioned on his/her right side, in a sitting position with a pillow between his/her legs. NA#1 identified she started adjusting the bed when Resident #1 slid off the right side of the bed landing in a sitting position on the floor. NA #1 stated she was unable to reach Resident #1 from where she was standing. Interview with NA #1 on 6/2/25 at 11:48 AM identified she was assigned to Resident #1 on the 7AM-3PM shift on 5/11/25. NA #1explained she gathered the supplies and then adjusted the height of the bed, but she did not first check to ensure Resident #1 was in a safe position. NA #1 identified as she was raising the bed she noticed Resident #1 started to slide out of the bed and she could not grab Resident #1 in time to prevent the fall to the floor. NA #1 stated although she saw Resident #1 was on their side, she did not know Resident #1 was on the edge of the bed before adjusting the height of the bed and indicated she should have checked to ensure Resident #1 was in a safe position before adjusting the height of the bed. Interview with the Director of Rehabilitation on 6/2/25 at 12:50 PM identified Resident #1 was dependent on staff and required two (2) staff members for transfers and bed mobility. Interview and record review with the Director of Nursing (DON) on 6/2/25 at 1:14 PM identified when NA #1 went to provide care to Resident #1, Resident #1 was on her/his side and while NA #1 was adjusting the height of the bed Resident #1 slid out of the bed onto the floor. The DON indicated NA #1 did not see Resident #1 was on the edge of the bed because Resident #1 had a sheet on him/her. The DON stated it would be her expectation that staff ensured a resident was in a safe position prior to adjusting the bed. The DON identified considering Resident #1 was on an air mattress, when the bed was adjusted the air in the mattress could have shifted causing the resident to slide out of bed.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in a dignified manner. The findings include: Resident #1 was admitted with diagnoses that included borderline personality disorder and depression. A quarterly MDS assessment dated [DATE] identified Resident #1 was alert and oriented, was dependent for transfer with a Hoyer lift to a customized motorized wheelchair, maximal assistance for bed mobility, and had an indwelling urinary catheter. The RCP dated 3/21/2024 identified a risk for distress related to limitations leading to initiating conflicts with staff. Interventions directed to monitor anxiety, anticipate and meet needs, explain care, and allow time to answer questions and verbalize feelings. Review of an audio recording dated 5/14/2024 identified a staff member was providing care to Resident #1 and Resident #1 called NA #3 by his/her first name. The conversation between NA #3 and Resident #1 began at approximately 1 minute and 30 seconds into the recording, and was a loud and emotional sounding exchange. Resident #1 complained of pain, was moaning, and telling NA #3 that she was a terrible NA. Resident #1 told NA #3 to wait to provide care as he/she had to wash the bedside table prior to the staff starting care. NA #3 questioned that Resident #1was not ready, and Resident #1 responded he/she did not have to be ready because NA #3 was late. NA #3 responded that Resident #1 had plenty of time to be ready prior to the staff member's entry into Resident #1's room, stating that they could have been done already (if she didn't have to wait). Resident #1 responded back that he/she did not need to do it ahead of time and continued to complete the task. Care began to be provided with Resident #1 directing the correct way to place the brief under him/her at 2 minutes 40 seconds into the audio. Resident #1 requested that the pad under him/her be checked as he/she believed it to be wet, stating if it was wet it needed to be changed and both briefs were wet, and the bed linen seemed damp. NA #3 responded to Resident #1 in a loud tone that sounded aggravated, saying, Come on, let's go, Jesus Christ at the 3 minutes, 30 seconds mark on the recording. NA #3 continued to provide care and Resident #1 directed NA #3 to change her gloves. NA #3 responded with a tense sounding voice, I know, I know, stay on your side please. Resident #1 responded that he/she only can use one (1) hand to hold his/herself over asking who else was in the room helping NA #3. NA #3 responded loudly Who do you want, stated two (2) other NA names, stated they were not coming into Resident #1's room, and stated they don't like you and they took care of you the other night (6 minutes, 3 seconds). Resident #1 directed loudly to NA #1 to change her gown and NA #3 responded loudly, I did. Resident #1 directed NA #3 loudly to fix my foot and change your gloves with NA #3 responding loudly, I did. Resident #1 then told NA #3 to move to another floor with NA responding, who is going to do you then? and Resident #1 identified another NA and stated, I don't like you. NA #3 responded You don't like me? continuing to respond to the Resident #1's negative about her. NA #3 moved on to empty Resident #1's foley bag with Resident #1 providing direction and NA #3 responding that she was doing it correctly arguing with Resident #1 in a loud voice, and Resident #1 continued to become more agitated using increasingly foul language and berating NA #3. NA #3 left room said goodbye and left the room at the 12 minute mark. A facility reportable event form dated 5/17/2024 at 3:30 PM identified an allegation of staff to resident abuse without injury. Resident #1 identified that he/she had a recording of NA #3 who told her that NA #3 did not like him/her and that it was abuse. A facility summary dated 5/19/2024 identified after an investigation, the allegation was not substantiated. Interview with the ADNS on 6/3/2024 at 1:30 PM identified should not change Resident #1's self-directed schedule as it can cause his/her behaviors to escalate; staff should work through his/her care is to address needs as per resident preferences. The ADNS stated, subsequent to the allegation reported on 5/17/2024, the plan of care was updated to direct two (2) staff members to be in the resident's room when providing care. Interview with the Administrator on 6/3/2024 at 2:00 PM identified on 5/17/2024 when she became aware of the recording, she spoke with Resident #1 and Resident #1 no longer had access to the recording for the Administrator to hear. The Administrator stated she investigated the allegation made on 5/17/2024, was unable to substantiate an allegation of abuse, and indicated staff should treat residents with respect and dignity. Although attempted, interviews with NA #3 and the DON were unable to be completed during the survey. The facility Residents' [NAME] of Rights Policy, directed in part, that residents have the right to be treated with consideration, respect and full recognition of your dignity and individuality.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for weight loss, the facility failed to ensure significant weight loss was reported to the responsible party in a timely manner. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required supervision with set up assist with eating. A Resident Care Plan dated 5/9/23 identified Resident #1 had a potential for nutritional deficit related to advanced age, variable intake and non-compliance with therapy with interventions that directed to monitor weights as ordered, report significant changes to the Dietitian and physician and monitor labs reporting abnormal (levels) to the physician. The weight record dated 7/1/23 identified Resident #1 had a significant weight loss of 20.4 pounds (lbs.) between 6/1/23 and 7/1/23. A Dietitian progress note dated 7/5/23 identified Resident #1 experienced a significant 5% weight loss from 150.4 lbs to 131 lbs. noting Resident #1 was within h/her desired weight range. An Advance Practice Registered Nurse note dated 7/11/23 identified Resident #1 was being evaluated due to decreased weight and appetite. Resident #1's weight decreased from 151.4 lbs. to 131 lbs. in a month with decreased oral intake variably 51%-75%. Weight loss discussed with the dietitian and recommended to monitor weekly weights and increase nutritional supplements. A plan was in place to meet with the responsible party related to decreased weight. A review of the nursing, APRN and dietitian progress notes dated 7/11/23 through 8/3/23 did not identify the responsible party had been notified of the significant weight loss. A Care Plan progress note dated 8/3/23 failed to identify a documented discussion related to Resident #1's significant weight loss. An interview with the Dietitian on 11/7/23 at 12:30 PM identified Resident #1 had experienced significant weight loss between 6/1/23 and 7/1/23 of approximately 20 lbs. Resident #1 was previously obese but was then within a desired weight range. The Dietitian did not notify the responsible party of the weight loss as she thought it was the responsibility of the nursing staff to notify the responsible party. The Dietitian stated she recently understood it to be part of her role. An interview with the Director of Nursing on 11/9/23 at 3:30 PM identified she would expect the dietitian to notify the responsible party of weight significant weight changes and then discuss a plan with the interdisciplinary team to address the concern. A review of the facility policy for unplanned weight loss directed to discuss with the resident and family about nutritional goals following any unplanned weight loss. A review of the Dietitian job description identified the Dietitian collaborates with the resident /family member and health care team to assess nutrition and nutrition education needs of the resident.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure an allegation of abuse was thoroughly investigated. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The baseline Resident Care Plan dated 12/28/22 identified Resident #1 had impaired cognitive function and was at risk to be a victim of abuse, neglect, or mistreatment in a congregate setting interventions directed to anticipate needs and monitor mood and behavior and provide early interventions. A social worker Plan of Care note dated 8/3/23 (initiation date 1/24/23) identified Resident #1 was accusing staff of physical abuse. A review of the nursing, Advanced Practice Progress notes dated 1/22/23 through 1/25/23 did not include a documented account of the incident. An interview with the Director of Nursing and review of the facility documentation on 11/9/23 at 2:30 PM did not identify a documented investigation regarding the incident. An interview with the Director of Nursing on 11/9/23 at 2:40 PM identified that although she was not employed at the facility at the time of the incident, however, any allegation of abuse should be investigated. An interview with (the former) Social Worker, SW #1 on 11/16/23 at 12:50 PM identified the responsible party of Resident #1 had alleged abuse but was never able to provide any specific details. While SW #1 indicated the allegation was investigated he was unable to explain why there was no documentation detailing the event or investigation. A review of the abuse policy dated 10/2022 directed that the facility immediately commence an investigation following an allegation of abuse and submit findings to the Administrator and other state officials.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure the care plan was updated resident known to have frequently exhibited behaviors. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required assistance with bed mobility and transfers. The Resident Care Plan dated 2/8/23 identified Resident #1 had impaired cognitive function, required assistance with activities of daily living (ADL) and was at risk for falls with interventions that directed to anticipate needs, provide one person assist with bed mobility and provide two quarter side rails while in bed. An Advanced Practice Registered Nurse Note dated 2/23/23 at 8:15 PM identified at 2:00 PM, Resident #1 experienced a fall and sustained a 4 centimeter (cm) laceration between the left thumb and first digit. A pressure dressing was applied and resident #1 was transferred to an outside hospital for evaluation of the wound. Hospital Patient information details notes dated 2/23/23 identified Resident #1's was evaluated following a fall out of bed at the facility. A wound along the left hand was closed with seven (7) sutures. Recommendations were made to remove sutures within 7-10 days. A facility Reportable Event dated 2/23/23 at 2:20 PM identified Resident #1 was observed laying on the left side on the floor mat in h/her room. Resident #1 was combative during transfer from floor to bed. While in bed Resident #1 attempted to get out of bed again and was assisted to h/her wheelchair and brought to the nursing station. A laceration to the left hand was observed between the left thumb and left index finger. The laceration was cleansed with normal saline and dressed. Resident #1 transferred to hospital for evaluation. Seven (7) sutures were applied to the left-hand laceration. Resident #1 was holding on the side rails and the wheelchair handles during transfers and had fragile skin. The care plan was revised to include the application of lambskin to wheelchair handles and padding to the side rails. An interview with Nurse Aide, NA #1 on 11/9/23 at 11:26 AM and 11/9/23 at 2:18 PM identified she had worked the 7:00 AM to 3:00 PM shift on 2/23/23 when the unwitnessed fall occurred. NA #1 could not recall the details but did remember Resident #1 as having blood on h/her hand when NA #1 first observed h/her on the floor next to h/her bed. NA #1 indicated Resident #1 had previously exhibited behaviors including grabbing at the bed rails and wheelchair handles prior to 2/23/23 to assist in moving around. An interview with the Assistant Director of Nursing (ADON) on 11/9/23 at 2:07 PM identified Resident #1 was known to flail arms and grab at the bed/wheelchair rails prior to 2/23/23. The ADON indicated it occurred to her to have the padding placed on the bed rails and wheelchair after Resident #1 sustained the injury. An interview with the Director of Nursing on 11/9/23 at 3:30 PM identified she would expect interventions be in place as a preventive measure to reduce the risk of injury for a resident who exhibited behaviors that included grabbing at the bed rails and wheelchair handles. Review of facility Care Plan Process Policy identified the care plan are developed by the interdisciplinary team for a comprehensive care plan to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho-social well-being.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a accidents and weight loss, the facility failed to ensure suture removal was completed timely, and to ensure that physicians orders were followed for bloodwork. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. 1) The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required assistance with bed mobility and transfers. a) The Resident Care Plan dated 2/8/23 identified Resident #1 had impaired cognitive function, required assistance with activities of daily living (ADL) and was at risk for falls with interventions that directed to anticipate needs, provide one person assist with bed mobility and provide two quarter side rails while in bed. An Advanced Practice Registered Nurse Note dated 2/23/23 at 8:15 PM identified at 2:00 PM, Resident #1 experienced a fall and sustained a four (4) centimeter (cm) laceration between the left thumb and first digit. A pressure dressing was applied and resident #1 was transferred to an outside hospital for evaluation of the wound. The post Patient Visitation Information dated 2/23/23 identified Resident #1 was evaluated following a fall at the facility seven (7) sutures were placed along the left hand with suture removal in 7-10 days. An Advanced Practice Registered Nurse (APRN) progress note dated 4/5/23 Resident #1 became combative with attempts to remove (7) sutures from the left hand (40 days after sutures were placed at the hospital). The responsible party came in and the sutures were removed difficulty. An interview with APRN #1 on 11/7/23 at 12:02 PM identified she had previously attempted to remove the sutures but was only able to remove (2) due to Resident #1 being resistive to care. On 4/5/23 the Responsible party was called in and the APRN #1 was able to remove the remainder of the sutures. APRN #1 indicated she could have explored alternative interventions to ensure Resident #1's sutures were removed timely according to hospital recommendations. The facility did not have a policy on suture removal. b) The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment required supervision with set up assist with eating. The Resident Care Plan dated 5/9/23 identified Resident #1 had a potential for nutritional deficit related to advanced age, variable intake and non-compliance with therapies with interventions directed monitor weight as ordered, report significant changes to the Dietitian and physician and monitor labs reporting abnormal (levels) to the physician. The weight record dated 7/1/23 identified Resident #1 had a significant weight loss of 20.4 pounds (lbs.) between 6/1/23 and 7/1/23. A Dietitian progress note dated 7/5/23 identified Resident #1 experienced a significant 5% weight loss from 150.4 lbs. to 131 lbs. noting Resident #1 was within h/her desired weight range. An Advance Practice Registered Nurse note dated 7/11/23 identified Resident #1 was being evaluated due to decreased weight and appetite. Resident #1's weight decreased from 151.4 lbs. to 131 lbs. within a month with decreased oral intake variably 51%-75%. The weight loss discussed with the dietitian and recommended to monitor weekly weights and increase nutritional supplements. A plan was in place to meet with the responsible party related to decreased weight. A nutritional assessment dated [DATE] identified Resident #1 was consuming at least 50% of most meals and documented as taking supplements. A request was made for a basic metabolic profile or BMP (measures chemistry of blood), complete blood count or CBC (measures properties of blood, prealbumin (protein from the liver that determines if there is enough nutrition in the diet) and, thyroid stimulating hormone or TSH (measures thyroid hormones). Physician's orders dated 7/17/23 directed laboratory (lab) diagnostic testing including BMP, CBC, prealbumin and TSH. A subsequent physician's order dated 8/4/23 directed CMP, CBC, Prealbumin, TSH. A review of the clinical record did not identify that labs were obtained as ordered on 7/17 and 8/4/23. An interview with APRN #1 on 11/9/23 at 11:56 AM identified she she had ordered labs after learning of Resident #1's significant weight loss and they were not obtained and likely re-ordered the labs after learning they were not obtained. APRN #1 stated she spoke with staff about this issue and was not clear whether Resident #1 had refused the testing or that it was not done. There was no documented follow up regarding the labs in the APRN progress notes. An interview with the Director of Nursing on 11/9/23 at 3:30 PM identified she had verified with the contracted lab services that the lab testing ordered on 7/17/23 and 8/4/23 were not obtained. The DNS indicated she would expect that if it were a case where Resident #1 refused, she would expect the nurse to notify the supervisor, reapproach and document efforts in the clinical record. A review of the facility policy for weight loss directed for any unplanned weight loss recommendations would be made for pertinent lab testing including a thyroid panel, CBC, and BMP.

Based on observation, review of facility documentation, job descriptions, and interview for 3 of 4 floors, the facility failed to ensure the environment was clean, maintained in good repair and homelike, and failed to ensure the clean linen cart covers were intact, and failed to ensure the door to a resident's room was good repair. The findings include: 1. Observation during the initial tour on 9/13/23 at 11:00 AM, and again on 9/15/23 at 10:15 AM with the Maintenance/Housekeeping Supervisor, Regional [NAME] Services, and the CEO (Interim Administrator) identified the following: One clean linen cart on each of the Two East, Two West, Three [NAME] A, and Four [NAME] B units, located in the hallway was identified damaged, torn and/or worn. Interview with the CEO (Interim Administrator) on 9/15/23 at 10:37 AM identified he was not aware of the damaged, torn and/or worn linen cart covers and identified the facility will purchase new linen covers for carts. Interview with the Regional [NAME] Services Person on 9/15/23 at 10:39 AM identified he was not aware of the issue. Interview with the Maintenance/Housekeeping Supervisor on 9/15/23 at 10:45 AM identified he was not aware of the damaged, torn, and/or worn linen cover carts. 2. Review of the environmental rounds worksheet for infection prevention control (monthly log) identified the last infection control monthly rounds were completed on 5/17/23, 3 1/2 months ago. Review of the environmental rounds audit tool dated 8/18/23 at 11:00 AM identified documentation that the environment is clean (walls, floors, drapes/blinds, furniture, linens, privacy curtains, window/sills, beds, bathrooms). The form failed to reflect what unit the environment rounds were performed. Observations on 9/13/23 at 11:00 AM through 2:00 PM, and on 9/15/23 at 10:15 AM with the Maintenance/Housekeeping Supervisor, Regional [NAME] Services, and the CEO identified the following. a. Damaged, chipped, stains and/or marred bedroom walls on Two [NAME] A unit in rooms 222, and 227. Two [NAME] B unit in rooms 233, 234, 235, 236, 237, and 240. Three [NAME] A unit in rooms 320, 321, 326, and 328. Three [NAME] B unit in rooms 331, and 339. Four [NAME] B unit in rooms 432, 434, 435, 436, 438, and 439. b. Damaged, chipped, stains, and/or marred bathroom walls on Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in room [ROOM NUMBER]. Four [NAME] B unit in room [ROOM NUMBER]. c. Damaged, chipped, stains and/or marred walls in the hallways on Three [NAME] A unit and Four [NAME] B unit. d. Damaged, chipped, marred and/or peeling doors in the bedroom on Two [NAME] B unit in room [ROOM NUMBER], Three [NAME] A unit in room [ROOM NUMBER] and Four [NAME] B unit in room [ROOM NUMBER]. e. Damaged, and/or rusty bedroom radiator on Two [NAME] B on unit in room [ROOM NUMBER]. f. Damaged, and/or rusty bathroom radiators on Two [NAME] B unit in rooms 236, and 237, and on Three [NAME] A unit in room [ROOM NUMBER]. g. Damaged, cracked, and/or stains on the bedroom ceiling on Two [NAME] A unit in room [ROOM NUMBER]. Two [NAME] B unit in rooms 234, and 238. Three [NAME] A unit in rooms 337, 338, 322, 324, 327, 329, and 330. Three [NAME] B unit in rooms 331, 335, 336, and 339. Four [NAME] B unit in room [ROOM NUMBER]. h. Damaged, cracked, and/or stained ceiling in the bathroom on Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in rooms [ROOM NUMBER]. Four [NAME] B unit in room [ROOM NUMBER]. i. Damaged, bent, and/or missing window blinds in bedroom on Three [NAME] A unit in room [ROOM NUMBER]. Three [NAME] B unit in rooms 335, and 339. Four [NAME] B unit in room [ROOM NUMBER]. j. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on Three [NAME] A unit in room [ROOM NUMBER], and 326. Four [NAME] B unit in room [ROOM NUMBER]. k. Damaged, broken, missing, peeling and/or dirty cove base in the bathroom on Three [NAME] B in rooms 333, and 336. l. Damaged, torn, stains, and/or off-track privacy curtains on Two [NAME] A unit in rooms [ROOM NUMBER]. Two [NAME] B unit in rooms 236, and 239. Three [NAME] A unit in rooms 320, 321, 322, 323, 324, 325, 326, 327, and 329. Three [NAME] B unit in room [ROOM NUMBER]. Four [NAME] B unit in rooms 434, 435, 436, and 438. m. Damaged, torn, stains, and/or off-track window curtains on Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in rooms 320, 323, 324, 325, 327, and 328. Three [NAME] B unit in room [ROOM NUMBER]. Four [NAME] B unit in rooms 434, and 438. n. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bedroom on Two [NAME] A unit in rooms 220, 222, 224, 226, and 229. Two [NAME] B unit in rooms 231, 233, 234, 235, 236, 238, 239, and 240. Three [NAME] A unit in rooms 320, 321, 322, 323, 324, 325, 326, 327, 328, 329, and 330. Three [NAME] B unit in rooms 331, 333, 335, 336, 337, 338, and 339. Four [NAME] B unit in rooms 431, 432, 434, 435, 436, 437, 438, and 439. o. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bathroom on Two [NAME] B unit in rooms 236, and 240. Three [NAME] A unit in rooms 322, 324, 325, 326, 327, 328, and 329. Three [NAME] B unit in rooms 333, 335, 336, 337, and 339. Four [NAME] B unit in rooms 431, 434, 435, 436, 437, and 438. p. Damaged, cracked, and/or missing floor tile in the bathroom on Four [NAME] B unit in room [ROOM NUMBER]. q. Damaged, cracked, and/or missing floor tile in the bedroom on Three [NAME] A unit in room [ROOM NUMBER]. Three [NAME] B unit in rooms 337, and 338. r. Damaged, chipped, missing, broken, and/or scarred dresser drawer in the bedroom on Two [NAME] A unit in rooms [ROOM NUMBER]. Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in rooms 320, 326, 327, 328, 329, and 330. Three [NAME] B unit in rooms [ROOM NUMBER]. Four [NAME] B unit in rooms 433, and 435. s. Damaged, broken, and/or missing dresser drawer knob in bedroom on Three [NAME] B unit in rooms 333, and 337. t. Two [NAME] A Dining Lounge: Damaged, cracked, and/or missing floor tile. Damaged, chipped, stains and/or marred walls. u. Two [NAME] B Hallway: Damaged, chipped, stains and/or marred walls. v. Damaged, dirt, dust, and/or rusty tray table on Three [NAME] A unit in rooms 321, and 324. w. Damaged, chipped, stains and/or marred bathroom door on Three [NAME] A unit in rooms 321, and 329. Three [NAME] B unit in rooms 331, and 335. Four [NAME] B unit in room [ROOM NUMBER]. x. Damaged, and/or stains on bed footboard in bedroom on Three [NAME] A unit in room [ROOM NUMBER]. y. Damaged, and/or rusty bedframe in bedroom on Three [NAME] A unit in room [ROOM NUMBER]. z. Four [NAME] B hallway damaged, and/or stain ceiling tile. aa. Bathroom sink faucet constant dripping water on Three [NAME] B unit in room [ROOM NUMBER]. bb. Damaged and/or rusty bathroom sink faucet on Three [NAME] A unit in room [ROOM NUMBER]. cc. Three [NAME] A Dining Lounge: Damaged, chipped, stains and/or marred walls. Damaged, broken, missing, peeling and/or dirty cove base. Refrigerator side panel and door panel rusty and/or stain. dd. Third floor elevator door frame damaged. Third floor elevator Corridor: Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor. Interview on 9/15/23 at 10:37 AM with the CEO (Interim Administrator) identified he was not aware of the environmental issues in the resident rooms. The CEO (Interim Administrator) indicated he will be having a meeting with the Maintenance/Housekeeping Supervisor, Maintenance department, and housekeeping staffs regarding the environment cleanliness, and repairs. Interview on 9/15/23 at 10:39 AM with the Regional [NAME] Services identified he was not aware of the environmental issues. The Regional [NAME] Services indicated going forward he will be meeting with the maintenance and housekeeping department staff regarding the cleanliness and repair of the environment. Interview on 9/15/23 at 10:43 AM with the Maintenance/Housekeeping Supervisor identified he was not aware of the issues. The Maintenance/Housekeeping Supervisor indicated he also oversees the housekeeping department. The Maintenance/Housekeeping Supervisor indicated that maintenance of the facility is ongoing. The Maintenance/Housekeeping Supervisor indicated that staff are responsible to notify the maintenance department with issues or problems that require repair. The Maintenance/Housekeeping Supervisor indicated going forward the maintenance department will address the environmental issues in a timely manner. Although requested, a facility environmental rounds policy was not provided. Review of the facility job description for the maintenance supervisor identified primary purpose of the job is to inspect, maintain and repair the facility environment and equipment, and maintain quality maintenance services throughout the facility. Received and follow preventative maintenance schedule/instructions as assigned. Perform routine maintenance and repair on the facility and equipment to include plumbing, plastering, electrical, carpentry, mechanical, etc., as directed, in accordance with established procedures. Review of the facility job description for the maintenance assistant identified the primary purpose of your job position is to maintain the grounds, facility, equipment in a safe and efficient manner in accordance with current applicable federal, state, and local standards, guidelines regulations, our established policies and procedures, and as may be directed by your supervisor, to assure that a successful maintenance program is maintained at all times. As the maintenance assistant, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Review of the facility job description for the director of housekeeping identified the primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the housekeeping department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe, and comfortable manner. As the director of housekeeping, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Review of the facility job description for the housekeeping worker identified is responsible for cleanliness of facility as per training and in accordance with current federal, state and local standards, guidelines and regulations governing our facility. 4. Observation on 9/12/23 at 10:10 AM identified the door to room [ROOM NUMBER], which was occupied by two residents was closed, and was extremely difficult to open. Upon departure of the room, the surveyor was not able to close the door. The ADNS was in the corridor and was notified immediately that the door was difficult to open and now unable to be closed. An interview with the ADNS on 9/12/23 at 10:15 AM identified the door should open with less effort and should be able to close without extreme effort as well. The ADNS promptly notified the Maintenance Director who called an assistant to remove the hinge as he monitored the door's response. Interview with the Maintenance Director on 9/12/23 at 10:25 AM identified he was not aware of the malfunctioning door until the ADNS's notification. The Maintenance Director identified he was uncertain of the reason for the malfunction, however indicated he would repair the door immediately. Interview with the Administrator on 9/12/23 at 11:00 AM identified he would move the residents to different rooms to maintain droplet precautions that both residents were on and their safety. Interview with the Administrator, Regional Maintenance Director and Maintenance Director on 9/15/23 at 10:20 AM identified the screw on the top hinge of the door (room [ROOM NUMBER]'s fire door) measured at 3/4 inch (standard size) had split the wood resulting in the door's inability to hang properly making the door difficult to open and close. Additionally, the Regional Maintenance Director identified all fire doors in the facility are inspected annually in September, and the fire door inspection was scheduled for 9/20/23. The Regional Maintenance Director identified the doors can become misaligned by simple activity of care givers bumping into the door with a mechanical lift or cart. The Regional Maintenance Director identified the doors are reviewed as part of the monthly environmental rounds. The environmental rounds binder for 2023 identified the unit was last inspected in June 2023 with only cosmetic concerns identified. The Maintenance Director identified every month a different location in the facility is selected and reviewed. As concerns are brought to the attention of his department, an evaluation is done, and the problem resolved. The Maintenance Director, the Regional Maintenance Director, and Administrator identified their initial awareness of the door malfunction was upon Surveyor inquiry. The Maintenance Director identified his staff review the maintenance log immediately at the start of the workday and there was no mention of the difficulty of opening and closing the door for room [ROOM NUMBER] was ever identified as a problem. The Regional Maintenance Director identified his department responded immediately and the current status of the door is the vendor will assess the door 9/20/23 and a replacement is most likely to be recommended. The Regional Maintenance Director identified fire doors are custom made for the frame, so if the vendor does not have this standard door size in inventory, the repair can be a few weeks as a custom door is made and delivered. The Administrator identified the residents assigned to the new rooms would remain in those rooms until the matter is resolved and the door for room [ROOM NUMBER] is safe. The timeline for the malfunction of the door was unable to be determined, however nurse aides and housekeeping staff had been in that room the morning of 9/12/23 prior to the Surveyor's identification of the malfunctioned door. The policy for malfunctioning equipment repair states to ensure the safety of residents, employees and others, all employees are expected to identify items or equipment that are damaged or require repair which may pose potential safety hazards. Items or equipment needing repair are to be removed from use immediately and tagged Out of Order.

Based on clinical record review, facility documentation, and interviews, for one of three residents reviewed for pressure ulcers, (Resident #1), the facility failed to ensure that additional pressure relieving interventions were in place to prevent a pressure ulcer from developing for a resident who was newly assessed to be a high risk for skin breakdown. The findings include: Resident #1 had a [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified that the resident's skin was intact. A care plan dated 8/28/17 identified that the resident had a potential for skin breakdown related to left sided weakness with interventions that included turning and repositioning every two hours, pressure relief devices and to report changes to the physician. Review of a Braden scale assessment (an assessment used to determine a risk for skin breakdown) dated 9/23/17 identified that the resident was at low risk for pressure ulcers. Review of a physical therapy note dated 10/17/17 identified that the resident presented with impairments in bed mobility secondary to deficits in proprioception, left sided weakness with decreased tone throughout and range of motion deficits. A subsequent Braden scale assessment dated [DATE] identified that the resident was newly identified as a high risk for skin breakdown. A quarterly minimum (MDS) data set [DATE] identified that the resident had moderate cognitive impairment, required extensive assistance of two persons for bed mobility, limited range of motion in the lower extremity on one side and was at risk for developing pressure ulcers. Review of the Treatment Administration Records (TAR) for (MONTH) and (MONTH) (YEAR) identified that the staff was applying skin prep every shift to the resident's bilateral heels and the resident's heels were to be offloaded but were not. Further review identified that (MONTH) (YEAR) TAR's were unavailable for review. Review of a nurses note dated 12/11/17 identified that the resident was noted with a Deep Tissue Injury (DTI) of the left heel that measured four centimeters (cm) by six cm, the Advanced Practice Registered Nurse (APRN) was notified and ordered skin prep daily and to apply boots to the bilateral legs at all times. Review of the facility wound tracking record dated 12/11/17 identified that the DTI on the left heel measured four cm by six cm and was purple in color with no drainage and was being treated with skin prep and offloading. Review of the clinical record failed to identify any additional pressure relieving interventions were in place to address the resident's high risk for skin breakdown identified on 11/29/17. Interview with Registered Nurse (RN) #1 (the facility wound nurse) on 9/4/18 at 1:00 PM identified that when the resident was admitted on [DATE] he/she had reddened and boggy heels and skin prep was applied to the bilateral heels as a nursing measure every shift. RN#1 further stated that when he/she evaluated the resident heels the next day, they were free from redness and were not boggy so she did not feel heel elevation was necessary but kept the skin prep in place as a preventative measure. Additionally, RN #1 identified that if the resident had a Braden scale assessment completed that identified a change from low risk to high risk for skin breakdown, the facility should have put an intervention into place such as heel elevation and/or an air mattress to address the decline. RN #1 stated that although the heels were elevated with boots subsequent to the DTI on the left heel, she was unable to find any documentation that the facility had placed any new pressure relieving devices into place after the decline in the Braden scale on 11/29/17. Interview with the Director of Nurses on 9/6/18 at 10:30 AM identified that after a resident is noted with a decline in the Braden scale, a new intervention should be added to address the decline and the nurse who completes the Braden scale with the decline should alert the supervisor of the decline so interventions could be put into place. Interview with APRN #1 on 9/6/18 identified that Resident #1 had profound left sided weakness and often neglected his/her left side due to a [MEDICAL CONDITION]. APRN#1 further identified that although the facility was applying skin prep to the heels, it does not provide pressure relief and would not have prevented the DTI. APRN #1 indicated that the resident's heels should have been elevated due to the resident's left sided weakness prior to the DTI on 12/11/17. Review of the pressure ulcer assessment, prevention and management policy identified that a DTI results from intense or prolonged pressure and shear at the bone and muscle interface. The policy further identified the residents who are at risk for pressure injury, the facility should consider using devices to keep pressure off of the heels by placing a pillow under the length of the leg to suspend the heels. Review of the Braden scale policy identified that the interdisciplinary team will review Braden scale risk factors and re-evaluate quarterly or more often if a subscale or total score indicate any change in the resident's condition.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 5 residents (Resident #88), who were dependent on staff for care and reviewed for pressure ulcers, the facility failed to ensure the resident was free from neglect when the resident did not receive care for over 5 hours, and as a result, the resident developed new skin injuries and exhibited pain. The findings included: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#88 per facility protocol every shift, may use positioning wedge to assist with repositioning, and to utilize and air mattress. Additionally, the physician's orders [REDACTED]. A quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition, required extensive assistance of 2 staff with bed mobility, toilet use, dressing, and personal hygiene, was always incontinent of bladder and bowel, was at risk for the development of pressure ulcers and had unhealed pressure ulcers including unhealed stage 3 or 4 pressure ulcers. Additionally, Resident #88's weight was 201 lbs. The care plan dated 8/10/18 identified Resident #88 was at increased risk for skin breakdown related to diabetes, tissue injury, incontinence and limited mobility. Interventions included to turn and reposition Resident #88 every 2 hours and as needed. A wound care note dated 8/13/18 identified Resident #88 had a community acquired stage III pressure wound on the sacrum with moderate serous exudate, and no indication of pain. The wound measured 8.0cm by 4.0cm by 0.2cm with a surface area of 32.00cm². Recommendations included to limit sitting to 60 minutes, off-load wound, reposition per policy, gel cushion to chare and a group 2 mattress. Observations of Resident #88 on 8/20/18 between 6:54 AM identified the resident was in bed, leaning to the left, on his/her back with the head of the bed raised to approximately 45 degrees. Additionally, Resident #88's head was resting against the left side rail. Resident #88 was on a low air loss mattress set at 250lbs, and was covered at the time. Intermittent observations on 8/20/18 between 6:54 AM to 10:44 AM, 3 hour and 50 Minutes identified that although staff were noted to briefly go into and out of Resident #88's room during this time, the resident remained in the same position, leaning to the left, on his/her back with the head of the bed raised to approximately 45 degrees, and with his/her head resting against the left side rail. Observation on 8/20/18 at 10:44 AM with the staff development nurse, (RN #6) identified staff went into Resident #88's room to provide care. When Resident #88 was repositioned for care by staff, (and was no longer resting against the left side rail) he/she complained of pain to the left elbow, and subsequently was medicated for pain prior to care. Resident #88's left elbow was noted to be red upon inspection. Observation of Resident #88 with the infection control nurse/wound nurse, (RN #4) on 8/20/18 at 11:16 AM identified the resident was on his/her back with the head of the bed raised to approximately 45 degrees, and a heavy fabric incontinent pad under him/her. Resident #88's brief was noted to be applied tightly, and upon removal, both sides of the groin were noted red/excoriated, with deep lines of demarcation bilaterally, and a linear abrasion on the left side. When Resident #88 was turned on his/her side, the heavy fabric incontinent pad was noted to be wrinkled/bunched under him/her, and the residents buttock was observed to be red, with deep lines of demarcation from the heavy fabric incontinent pad. Additionally, Resident #88 had been incontinent of a large amount of stool. Continued observation at that time with RN #4 identified Resident #88's the left groin was noted to have a new open area that measured 3.5cm x 0.8cm. The resident's right groin was noted with a new deep red linear excoriation that measured 13.0cm x 0.8cm. Further, frank bleeding was noted from Resident #88's left anterior stump which exposed 3 new open bleeding areas. One area, the proximal open linear wounds (clustered) measured 7.0cm x 2.5cm, and the other area, the distal open linear wound measured 3.0cm x 0.8cm. RN #4 indicated the new open areas/deep demarcations were due to the brief. The linear demarcations lined up with the diaper. Facility wound documentation dated 8/20/18 identified the following; The sacral stage III pressure ulcer measured 6.0cm by 6.6cm by 0.1cm (increased in width by 2.6cm) A facility acquired (8/20/18) skin tear to the left anterior groin that measured 3.5cm x 0.8cm. A facility acquired (8/20/18) skin tear to the left posterior proximal stump that measured 2.5cm by 7.0cm, A facility acquired (8/20/18) skin tear to the left posterior distal stump that measured 3.0cm x 0.8cm. Subsequent to physician notification a physician's orders [REDACTED]. Left groin: cleanse with normal saline, pat dry, apply a wound size piece of calcium alginate to the open area and cover with dry protective dressing daily and as needed if soiled. Left posterior stump: cleanse with normal saline pat dry and apply calcium alginate to open area, cover with a dry protective dressing, daily and as needed if soiled. Leave brief open at all times and utilize disposable chucks (incontinent pads) under Resident #88's sacrum and buttocks. A skin/wound note written by the infection control nurse/wound nurse, (RN #4) dated 8/20/18 (identified during observation with surveyor) identified that when Resident #88's brief was opened today, several new skin injuries were identified, frank bleeding noted, areas cleansed and covered. The note identified that the wounds to the groin and upper posterior stump are due to the diaper as the wounds have a linear presentation and line up with the diaper. Interview with the nurse aide assigned to Resident #88, (NA #3), on 8/20/18 at 11:25 AM identified he/she provided incontinent care and repositioning with the assistance of NA #4 after breakfast. (Breakfast service was observed from approximately 8:00 AM through 9:00 AM). (This timeline is in conflict with video surveillance). Interview with NA #4 on 8/20/18 at 11:49 AM identified he/she fed Resident #88 breakfasts, and although he/she did assist NA #3 with Resident #88's personal care, the care was provided before breakfast, not after. (The timeline of the provision of care before breakfast is in conflict with video surveillance). Observation on 8/21/18 identified Resident #88's air mattress was set at 250lbs. Interview and observation with RN #4 on 8/22/18 at 12:13 PM identified Resident #88's air mattress was set at 230lbs. Review of the clinical record with RN #4 at that time identified that Resident #88's current weight was 186 pounds. Additionally, RN #4 indicated that the air mattress setting should be set to the resident's weight, and staff should be using a disposable (thin) incontinent pad. Subsequent to surveyor inquiry, a physician order [REDACTED].#88's weight of 180 pounds. In a subsequent interview with NA #3 on 8/22/18 at 1:55 PM indicated that although he/she was aware of and had seen the new open areas, that were bleeding, on Resident #88's left stump, NA #3 did not report the new areas to the nurse because he/she knew that RN #4 would return to see Resident #88, and he/she planned on reporting it at that time. Interview and review of facility investigation and/or video monitoring of the 4 west unit on 8/23/18 at 6:58 AM with the DNS and VP of Clinical Operations, (RN #7) for the date and time frame of 8/20/18 between 5:26 AM to 11:00 AM identified that 2 nurse aides were observed to enter Resident #88's room at 5:26 AM to provide care (5:26 AM to 5:37), 11 minutes. Additionally, the video monitoring identified that the next time 2 staff entered Resident #88's room to provide care was at 11:00 AM, (subsequent to surveyor inquiry) over five 5 hours later. The policy on specialized mattresses identified low air loss alternating pressure mattress is used for stage III, IV, multiple pressure ulcers and unstageable unless otherwise ordered by the physician. Staff will follow manufactures guidelines when applying the low air loss mattress alternating pressure mattress. The manufacturer recommendations references to set the air mattress in static mode using the weight of the resident. Review of the abuse policy directed every resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property and exploitation. Additionally, to provide a safe environment and protect residents from abuse. Neglect is defined as the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. The facility failed to off load the residents sacral wound according to the wound consultant recommendations, failed to turn and reposition the resident every 2 hours according to the care plan, failed to provide care for over 5 hours (based on video monitoring), failed to ensure the air mattress was set according to the resident's weight for 3 days during the standard survey, failed to utilize the appropriate incontinent pad between the resident and the air mattress, and failed to apply a brief to prevent skin injury (which was in place for over 5 hours). As a result, Resident #88 developed a facility acquired skin tear to the left anterior groin that measured 3.5cm x 0.8cm, a facility acquired (8/20/18) skin tear to the left posterior proximal stump that measured 2.5cm by 7.0cm, and a facility acquired (8/20/18) skin tear to the left posterior distal stump that measured 3.0cm x 0.8cm. The skin injuries were documented as being due to the diaper as the wounds had a linear presentation and lined up with the diaper. Additionally, Resident #88's sacral pressure ulcer width increased 2.6cm. Further, subsequent to physician notification, the new open areas required treatments and modification to the plan of care.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 5 residents (Resident #88), who were dependent on staff for care and reviewed for pressure ulcers, the facility failed to provide care in accordance with professional standards of practice, and the comprehensive person-centered care plan when the resident did not receive care for over 5 hours, and as a result, the resident developed new skin injuries and exhibited pain. Additionally, for 1 resident (Resident #28) reviewed for rehabilitation, the facility failed to ensure a follow up neurology appointment was scheduled according to the physician's orders [REDACTED].>1. Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#88 per facility protocol every shift, may use positioning wedge to assist with repositioning, and to utilize and air mattress. Additionally, the physician's orders [REDACTED]. A quarterly MDS dated [DATE] identified Resident #88 had severely impaired cognition, required extensive assistance of 2 staff with bed mobility, toilet use, dressing, and personal hygiene, was always incontinent of bladder and bowel, was at risk for the development of pressure ulcers and had unhealed pressure ulcers including unhealed stage 3 or 4 pressure ulcers. Additionally, Resident #88's weight was 201 lbs. The care plan dated 8/10/18 identified Resident #88 was at increased risk for skin breakdown related to diabetes, tissue injury, incontinence and limited mobility. Interventions included to turn and reposition Resident #88 every 2 hours and as needed. A wound care note dated 8/13/18 identified Resident #88 had a community acquired stage III pressure wound on the sacrum with moderate serous exudate, and no indication of pain. The wound measured 8.0cm by 4.0cm by 0.2cm with a surface area of 32.00cm². Recommendations included to limit sitting to 60 minutes, off-load wound, reposition per policy, gel cushion to chare and a group 2 mattress. Observations of Resident #88 on 8/20/18 between 6:54 AM identified the resident was in bed, leaning to the left, on his/her back with the head of the bed raised to approximately 45 degrees. Additionally, Resident #88's head was resting against the left side rail. Resident #88 was on a low air loss mattress set at 250lbs, and was covered at the time. Intermittent observations on 8/20/18 between 6:54 AM to 10:44 AM, 3 hour and 50 Minutes identified that although staff were noted to briefly go into and out of Resident #88's room during this time, the resident remained in the same position, leaning to the left, on his/her back with the head of the bed raised to approximately 45 degrees, and with his/her head resting against the left side rail. Observation on 8/20/18 at 10:44 AM with the staff development nurse, (RN #6) identified staff went into Resident #88's room to provide care. When Resident #88 was repositioned for care by staff, (and was no longer resting against the left side rail) he/she complained of pain to the left elbow, and subsequently was medicated for pain prior to care. Resident #88's left elbow was noted to be red upon inspection. Observation of Resident #88 with the infection control nurse/wound nurse, (RN #4) on 8/20/18 at 11:16 AM identified the resident was on his/her back with the head of the bed raised to approximately 45 degrees, and a heavy fabric incontinent pad under him/her. Resident #88's brief was noted to be applied tightly, and upon removal, both sides of the groin were noted red/excoriated, with deep lines of demarcation bilaterally, and a linear abrasion on the left side. When Resident #88 was turned on his/her side, the heavy fabric incontinent pad was noted to be wrinkled/bunched under him/her, and the residents buttock was observed to be red, with deep lines of demarcation from the heavy fabric incontinent pad. Additionally, Resident #88 had been incontinent of a large amount of stool. Continued observation at that time with RN #4 identified Resident #88's the left groin was noted to have a new open area that measured 3.5cm x 0.8cm. The resident's right groin was noted with a new deep red linear excoriation that measured 13.0cm x 0.8cm. Further, frank bleeding was noted from Resident #88's left anterior stump which exposed 3 new open bleeding areas. One area, the proximal open linear wounds (clustered) measured 7.0cm x 2.5cm, and the other area, the distal open linear wound measured 3.0cm x 0.8cm. RN #4 indicated the new open areas/deep demarcations were due to the brief. The linear demarcations lined up with the diaper. Facility wound documentation dated 8/20/18 identified the following; The sacral stage III pressure ulcer measured 6.0cm by 6.6cm by 0.1cm (increased in width by 2.6cm) A facility acquired (8/20/18) skin tear to the left anterior groin that measured 3.5cm x 0.8cm. A facility acquired (8/20/18) skin tear to the left posterior proximal stump that measured 2.5cm by 7.0cm, A facility acquired (8/20/18) skin tear to the left posterior distal stump that measured 3.0cm x 0.8cm. Subsequent to physician notification a physician's orders [REDACTED]. Left groin: cleanse with normal saline, pat dry, apply a wound size piece of calcium alginate to the open area and cover with dry protective dressing daily and as needed if soiled. Left posterior stump: cleanse with normal saline pat dry and apply calcium alginate to open area, cover with a dry protective dressing, daily and as needed if soiled. Leave brief open at all times and utilize disposable chucks (incontinent pads) under Resident #88's sacrum and buttocks. A skin/wound note written by the infection control nurse/wound nurse, (RN #4) dated 8/20/18 (identified during observation with surveyor) identified that when Resident #88's brief was opened today, several new skin injuries were identified, frank bleeding noted, areas cleansed and covered. The note identified that the wounds to the groin and upper posterior stump are due to the diaper as the wounds have a linear presentation and line up with the diaper. Interview with the nurse aide assigned to Resident #88, (NA #3), on 8/20/18 at 11:25 AM identified he/she provided incontinent care and repositioning with the assistance of NA #4 after breakfast. (Breakfast service was observed from approximately 8:00 AM through 9:00 AM). (This timeline is in conflict with video surveillance). Interview with NA #4 on 8/20/18 at 11:49 AM identified he/she fed Resident #88 breakfasts, and although he/she did assist NA #3 with Resident #88's personal care, the care was provided before breakfast, not after. (The timeline of the provision of care before breakfast is in conflict with video surveillance). Observation on 8/21/18 identified Resident #88's air mattress was set at 250lbs. Interview and observation with RN #4 on 8/22/18 at 12:13 PM identified Resident #88's air mattress was set at 230lbs. Review of the clinical record with RN #4 at that time identified that Resident #88's current weight was 186 pounds. Additionally, RN #4 indicated that the air mattress setting should be set to the resident's weight, and staff should be using a disposable (thin) incontinent pad. Subsequent to surveyor inquiry, a physician order [REDACTED].#88's weight of 180 pounds. In a subsequent interview with NA #3 on 8/22/18 at 1:55 PM indicated that although he/she was aware of and had seen the new open areas, that were bleeding, on Resident #88's left stump, NA #3 did not report the new areas to the nurse because he/she knew that RN #4 would return to see Resident #88, and he/she planned on reporting it at that time. Interview and review of facility investigation and/or video monitoring of the 4 west unit on 8/23/18 at 6:58 AM with the DNS and VP of Clinical Operations, (RN #7) for the date and time frame of 8/20/18 between 5:26 AM to 11:00 AM identified that 2 nurse aides were observed to enter Resident #88's room at 5:26 AM to provide care (5:26 AM to 5:37), 11 minutes. Additionally, the video monitoring identified that the next time 2 staff entered Resident #88's room to provide care was at 11:00 AM, (subsequent to surveyor inquiry) over five 5 hours later. The policy on specialized mattresses identified low air loss alternating pressure mattress is used for stage III, IV, multiple pressure ulcers and unstageable unless otherwise ordered by the physician. Staff will follow manufactures guidelines when applying the low air loss mattress alternating pressure mattress. The manufacturer recommendations references to set the air mattress in static mode using the weight of the resident. The facility failed to off load the sacral wound according to the wound consultant recommendations, failed to turn and reposition the resident every 2 hours according to the care plan, failed to provide care for over 5 hours, failed to ensure the air mattress was set according to the resident's weight for 3 days during the standard survey, failed to utilize the appropriate incontinent pad between the resident and the air mattress and failed to apply a brief to prevent skin injury. As a result, the resident developed a facility acquired skin tear to the left anterior groin that measured 3.5cm x 0.8cm, a facility acquired (8/20/18) skin tear to the left posterior proximal stump that measured 2.5cm by 7.0cm, and a facility acquired (8/20/18) skin tear to the left posterior distal stump that measured 3.0cm x 0.8cm. The skin injuries were documented as being due to the diaper as the wounds had a linear presentation and lined up with the diaper. Additionally, subsequent to physician notification, the new open areas required treatments and modification to the plan of care. 2. Resident #28's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #28 had moderately impaired cognition, required extensive assistance with bed mobility, transfers and toileting, and was independent with eating. The care plan dated 7/11/18 identified Resident #28 had a self-care performance deficit. Interventions included to provide extensive assistance with bed mobility, transfers, dressing and toilet use. A physician's orders [REDACTED].#28 in the hospital for the stroke. Additionally, the order identified if it was not apparent who the neurologist was, or if the information was not in the current record, a suggestion of 2 alternative s were given. Interview with APRN #1 on 8/23/18 at 9:14 AM identified that he/she wrote the order dated 8/3/18 for a neurologist follow up after he/she received a telephone call from the Resident #28's responsible representative, who felt, that although the resident had refused follow up appointments in the past, would now be accepting to see a neurologist, and that the resident had been seen by the pulmonologist. APRN #1 identified that Resident #28 had reached his/her potential with rehabilitation, and although the appointment was not urgent, he/she would have expected the facility staff to follow the order. Interview and review of the clinical record with RN #2 on 8/23/18 at 9:35 AM failed to reflect that the physician's orders [REDACTED]. Interview with Medical Records/Appointment Scheduler on 8/23/18 at 9:43 AM identified that he/she had never been made aware Resident #28 needed to be seen by the neurologist until it was brought to his/her attention today.

Based on clinical record reviews, observations, review of facility investigations, and staff interviews for four of six sampled residents reviewed for accidents (R #148, 65, 95, 140), the facility failed to transport and/or transfer the resident in a safe manner, and/or failed to ensure a the mechanical lift straps were securely hooked prior to a transfer and/or failed to initiate care plan interventions to prevent falls, and/or accidents with injuries. The findings include: 1. Resident #148's [DIAGNOSES REDACTED]. The 30 day MDS dated [DATE] identified that the resident was without significant cognitive impairment, had no problem behaviors, required the assistance of 2 staff for bed mobility, extensive assistance from one staff for transfers and bathing, and had impaired range of motion of both upper and lower extremities on one side. The care plan dated 3/25/14 identified ADL deficit due to stroke and decreased muscle strength. Interventions included implement measures to facilitate self care. The physical therapy discharge summary dated 4/18/14 identified that the resident and caregivers were instructed in safe transfer techniques, safety precautions and use of assistive devices. Nurse's notes dated 5/12/14 identified that the resident was being transported via the shower chair into the shower room when the door to the shower room inadvertently closed on the 2nd toe the left foot. The facility investigation dated 5/12/14 identified that there was no way for NA # 4 to safely get the resident into the shower room alone due to the rigidity of the left leg and logistics of the physical plant layout. The resident sustained [REDACTED]. Observation of the shower room on 1/6/15 at 11:30 AM with RN#4 noted a very narrow, short hallway with a wall at the end. The tub room door on the left and shower room door on the right were flush to the wall making it impossible to make a turn into the shower room with a leg extended. Also noted was that the door to the shower room closed very rapidly and forcefully. The automatic closure on the tub room door (which had closed into the resident's left foot causing the laceration and fracture) had been removed. Interview and review of the incident with the DNS on 1/7/15 at 6:45 AM noted that NA#4 should have had assistance to hold both doors open while getting the resident into the shower room. The NA received a written warning and re-education subsequent to the incident. At 10 AM, the DNS indicated that there was also a problem with the threshold to the shower room at that time; it had a raised entry that required the aide to actually pick the wheelchair up to get over it while trying to hold 2 doors open. 2. Resident #65's [DIAGNOSES REDACTED]. A significant change MDS dated [DATE] identified the resident had moderately impaired cognition, was totally dependent on staff for ADL's including requiring the assistance of two for bed mobility and transfers. The Care Plan dated 9/17/14 identified a self care deficit and a risk for falls related to decreased functional mobility. Interventions directed the use of a Hoyer lift for transfers with 2 staff assistance. Physician order's dated 10/10/2014 directed the use of a tilt in space wheelchair when out of bed. A Communication Form/progress note dated 10/20/14 identified while transferring the resident out of bed to a wheelchair, the Resident slid out of the Hoyer sling and landed on the floor. The resident hit his/her head causing a hematoma and bleeding. The physician was notified and the resident was transferred to the ED for evaluation. The facility investigation of the incident identified the Hoyer lift pad became unhooked as the NA's were lifting the resident off the bed. Further review of the nurse's notes identified that the resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An interview and review of facility documentation on 1/6/14 at 10:30 AM with NA#1, identified that she/he failed to check the Hoyer straps to ensure they were securely fastened before lifting the resident of the bed. An interview, and review of facility documentation on 1/6/2015 at 10:35 AM with the ADNS identified that he/she responded to the incident and found the resident on the floor. The Hoyer lift and pad were inspected and found to be in good working order and both NA's stated that Hoyer strap became unfastened causing the resident to slide out of the sling. Both NA's were provided with education to ensure Hoyer straps are checked prior to lifting residents. 3. Resident #95's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified R # 95 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, and toileting. A RCP dated 5/29/14 and last updated on 12/21/14 identified a moderate to high risk for falls and/or injury related to dementia, history of falls, balance, gait deficits, decreased functional mobility, and poor safety awareness. Interventions included place all personal items and resident controlled equipment within reach, anticipate the resident needs, and to provide non-slip footware as resident tolerates and allows. An observation on 1/5/14 at 9:50 AM noted R #95 with a hematoma on the left lateral brow. The area was purple in color with a triangular area approximately 1 cm on the left cheek. A yellow discoloration was noted from the left eye to the left side of the chin. An observation and interview on 1/6/15 at 10:30 AM with RN # 5 and LPN #1 noted R#95 in his/her wheelchair. The resident was wearing only regular socks (without non-skid grip) and no shoes. The resident was attempting to self-propel his/her wheelchair and his/her feet were noted to be sliding on the floor. At that time the RCP was reviewed and LPN #1 noted the resident should have non-slip footwear on. LPN #1 directed NA #9 to apply non-skid footwear on the resident. Review of the nurse's notes and/or facility reports and interview on 1/7/15 at 10:00 AM with RN #3 noted that R #95 had fallen on 7/14/14. The resident care plan was revised at that time to include anticipate needs to avoid independent ambulation attempts. On 8/10/14, R #95 fell and was transferred to the emergency room for evaluation. There was no documentation that the RCP was revised after that fall. On 9/21/14, the resident fell and the RCP was revised to encourage the resident to call for assistance, however the resident was severely cognitively impaired. On 12/21/14, the resident fell and was barefoot at the time of the fall. No new interventions and/or revision of the RCP was noted after the fall. RN #3 indicated that although he/she was responsible to review and revise the RCP on a quarterly basis, the unit manager would be responsible to review and revise the RCP after a fall. RN#3 indicated that when the care plan is updated, the new intervention should be communicated to the NA via the Resident care guide. Interview and review of care card with NA #9 on 1/7/14 at 10:20 AM identified that Resident #95 does not ask to be toileted and does not ring the call bell. NA#9 noted that he/she moves in and out of the bed independently and that he/she can't watch the resident 24 hours a day. NA# 9 identified he/she had toileted Resident #95 at 8 AM and he/she voided and had been incontinent in the brief. After breakfast he/she picked up the tray and Resident #95 was laying in the bed. The next time he/she saw Resident #95 was at 9:45 AM when he/she was summoned to the room because Resident #95 was attempting to go to the bathroom. NA# 9 identified that he/she had not put non-skid socks on Resident #95 because he/she was not aware that Resident #95 required non-skid socks until told by LPN #1. Review of the December medication administration records identified that Resident #95 had received Tylenol 650 mg for left eyebrow pain on 12/21/14, and Trazadone for agitation. On 12/23/14, the resident required Trazadone 25 mg at 11:30 PM for increased agitation, on 12/24/14 received APAP 650 mg for complaints of a headache and on 12/25/14 had received Trazadone 25 mg for agitated behaviors. 4. Resident # 140's [DIAGNOSES REDACTED]. A RCP dated 12/1/14 identified a risk for falls and/or injury. Interventions included anticipate and meet the resident's needs. A resident care guide indicated the resident required assist of 2 for transfers. Review of a facility investigation dated 12/14/14 at 4:15 PM indicated that after placing R#140 back to bed, NA #7 noted the resident's right hand was swollen, with a bruise to the back of the fourth finger and tender to touch. The physician was notified and directed to obtain an x-ray of the right hand. The investigation indicated that on 12/14/14 NA #5 and NA #6 had transferred R#140 out of bed utilizing a Sara mechanical lift without assessment and consent of licensed staff or therapy staff. An x-ray report dated 12/14/14 identified an oblique fracture of the fifth metacarpal shaft, with soft tissue swelling. An interview on 1/6/15 at 11:00 AM with NA #5 indicated he/she was aware R#140's plan of care directed a stand pivot transfer with assist of two staff members, however that morning NA #5 felt R #140 was too unstable to transfer with two staff members and decided to utilize the Sara lift. Nurse aide #5 indicated this was not reported to the nurse. A review of the reportable event form and investigation and interview on 1/6/15 at 10:30 AM with the ADNS indicated R # 140 had never been assessed for a Sara mechanical lift transfer and was to stand and pivot with assist of two when transferring. The facility investigation identified NA #5 and NA #6 failed to follow the resident's plan of care for a stand pivot transfer and transferred R #140 on 12/14/14 utilizing the Sara lift.

Based on clinical record review, review of facility investigation and interview for the only sampled resident with a significant medication error (R#168), the facility failed to ensure that the resident received critical medication as directed by the physician resulting in hospitalization . The findings include: Resident #168's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident was alert and oriented, and mostly independent with ADL's. The care plan failed to reflect the resident's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. On 7/26/14, the resident was transferred to the hospital with lethargy and fever. The resident was admitted with [MEDICAL CONDITION]. While hospitalized , the resident informed the physician that several doses of the [MEDICATION NAME] were not administered by the facility prior to hospitalization . The facility investigation which began on 7/28/14 after the hospital contacted them regarding the missing medication doses, noted that 3 doses of the medication were not administered between 7/14 and 7/26/14. On 7/30/14, the facility received a call from the hospital stating that the hospital was reporting the lack of administration of [MEDICATION NAME] to the State and the physician felt that returning the resident to the facility was an unsafe discharge. The investigation identified that on 7/31/14, the DNS met with the hospital physician and was informed that missing just one dose of [MEDICATION NAME] was enough to cause a crisis in the resident's condition. The facility investigation identified 3 nurses who omitted the medication (RN#7, RN#8 and LPN#7). All were interviewed and admitted that they could not find the drug (the kardex noted that it was in the refrigerator), did not call the physician, and did not notify the supervisor. The nurses were suspended pending the outcome of the investigation. RN#8 was terminated and RN#7 and LPN#7 received final written warnings as a result of the investigation. The resident returned to the facility on [DATE] with supervisors overseeing and ensuring that both daily doses of [MEDICATION NAME] were administered. Audits indicated that the daily oversight of the nursing staff continued through October. Interview and review of the investigation and clinical record with the DNS on 1/6/15 at 7:15 AM noted that the medication omissions were reported by the hospital and verified by the DNS upon investigation. The DNS indicated that the kardex was clearly marked that the medication was in the refrigerator, but none of the nurses looked there for the medication.

Based on observation, clinical record review, review of facility investigation, and interview for one of three residents in survey sample reviewed for accidents (R#157) the facility failed to maintain lift devices without sharp edges resulting in a laceration. The findings included: Resident #157's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident had severe cognitive impairment, and required total assistance from facility staff with activities of daily living (ADL) including transfers between surfaces e.g. bed to chair. The resident care plan (RCP) dated 7/2/12 identified a potential alteration in skin related to decreased mobility and fragile skin. Interventions included assess skin weekly, reposition every two hours, and to follow physician orders [REDACTED]. Facility investigation documentation dated 8/16/12 identified that while R#157 was being transferred via a mechanical sit/stand assist lift, the resident sustained [REDACTED]. It identified that the manufacturer installed plastic "hand placement target" was the cause of the injury and that the hard plastic was loose. Corrective interventions were identified that included communication with manufacturer, inspection of all facility lifts and removal of the hand placement target hard plastic. Observation of all five (5) facility sit/stand mechanical lifts on 3/20/13 identified that one (1) lift located on the 2 East unit (facility acquired 8/23/12) had a hard black "hand placement target" on both of the lift/ hand holding bars. Further observation with the Director of Nursing and Maintenance man #1 present identified that the hard black plastic (hand target) had raised, protruding sharp edges located on the bottom of the bar. Subsequent to identifying the protruding sharp plastic, the material was removed from the lift device. Interview with LPN #2 on 3/19/13 at 12:13 PM indicated that nurse aide (NA#4) reported that R#157 was bleeding on his/her right hand. LPN#2 indicated that he/she had observed that the Sara (mechanical sit/stand assist lift) had black plastic protruding at the bottom of the lifting/hand holding bar where the resident's hands were placed during transfer. Interview and review of facility preventative maintenance documentation on 3/21/13 at 9:10 AM with the Director of Maintenance indicated that all devices are inspected once yearly by the manufacturer and monthly by the facility maintenance department. Facility preventative maintenance policy and procedure identified that the intent of the program was to establish a building where the environment is safe and comfortable, essential utilities are delivered without interruption and mechanical systems and equipment operate safely and reliably.