Every finding on record at Sudbury Pines Extended Care

Based on observation, and interview, the facility failed to adhere to professional standards of practice for food safety and sanitation to prevent contamination and the spread of foodborne illness to residents.Specifically, the facility failed to discard spoiled food and food that was past the use by date, failed to label and date prepared food and opened food packaging, and also failed to ensure dietary staff were wearing hair restraints in the main kitchen while preparing food.the facility failed to discard food that was past the use by date and failed to maintain the Station 2 nourishment kitchenette in a clean and sanitary manner. Findings include:Review of the facility policy titled Food Safety, revised 5/2025, indicated: -It is the policy of this facility to provide safe and sanitary storage, handling and consumption of all food including food and fluids brought to residents by family and other visitors. This includes storage, preparations, distribution, and serving food in accordance with professional standards for food service and safety. -The facility will follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. -Education of safe food handling will be provided to all staff, family, residents, resident council, visitors and community groups who may provide foods or fluid restrictions to residents of the facility. This education will include at a minimum: proper food handling to prevent foodborne illness. Proper labeling and dating of each item. Leftover foods will be used within 3 days or discarded. Review of the facility policy titled Food Storage, revised 6/2018, indicated: -It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner -Food storage areas shall be clean at all times -all food stored in dry good freezer or refrigerator will be dated month and year, unless opened this will be wrapped or put in a container with the Month/Day/Year label on it. 1. During the initial tour of the facility main kitchen on 4/16/26 at 7:23 A.M., the surveyor observed the following: >In the walk-in refrigerator: -Sealed bagged salad that expired 4/11/26, which was wilted and had brown lettuce and vegetables in the bag. -13 containers of strawberries in manufacturer's plastic containers. Eight containers had multiple strawberries with mold. -a bag of opened parmesan cheese in the manufacturer's bag, not sealed, no opened date, or expiration date on the bag. -a plastic bag of unopened broccoli with no expiration date. The broccoli stems were black and some of the broccoli florets had brown and yellow discolorations. -two glass containers with vegetables, no label or date. >In the reach in refrigerator: -Four dessert cups, no label or date. >In the food preparation area: -at the end of the steam tables, two trays of dessert cakes in metal sheet pans with plastic wrap on the trays, no label or date. On 4/21/26 at 11:47 A.M., during the follow-up visit to the facility main kitchen the surveyor observed: >In the walk-in refrigerator: -Three containers of strawberries in manufacturer's plastic containers, all three containers had moldy strawberries. -Five containers of blackberries in manufacturer's plastic containers. Two out of the five containers had moldy blackberries inside of the containers. >In the reach in refrigerator: -Three covered dessert cups, no label or date -Two Thick and Easy juices were opened, not dated -Two Thick and Easy dairy beverages that were opened, not dated >Two Dietary Aides with beards were preparing food for the lunch meal. Dietary Aide #1 had facial hair on the upper lip and chin which extended past the bottom of his chin and was not wearing a beard restraint. Dietary Aide #2 was wearing a surgical mask that was partially covering his facial hair, with exposed hair on the cheeks and neck. During an interview on 4/21/26 at 12:20 P.M., the Administrator said there should not be expired or moldy food in the kitchen. The Administrator said Dietary Aides #1 and #2 should be wearing facial hair restraints and that the hair restraints were available to the staff. During an interview on 4/21/26 at 12:50 P.M., the Food Service Director (FSD) said the moldy and expired food in the refrigerators should have been thrown out and should not have been in the refrigerators. The FSD said all the food that was open should have been labeled and dated when opened. The FSD said Dietary Aides #1 and #2 should have had beard restraints on while they were in the kitchen. The FSD further said beard covers are available for the staff to wear. 2. On 4/16/26 at 11:35 A.M., during a tour of Station 2 nourishment kitchenette the surveyor observed: -one sandwich labeled PBJ (peanut butter and jelly) and dated 4/10, and two sandwiches labeled PBJ and dated 4/11. -the dry snack drawer had a significant amount of food debris. During an interview on 4/16/26 at 11:45 A.M., Unit Manager (UM) #1 said the PBJ sandwiches should have been thrown away after three days but had not been thrown away. UM #1 also said that the snack drawer should not have food debris. UM #1 said it was the responsibility of the kitchen staff to maintain the refrigerator and the snack drawer in the nourishment kitchenette, and they had not done so.

Based on observation, interview, and record review, the facility failed to post daily required nurse staffing information as required.Specifically, the facility failed to:-post the actual hours worked by licensed and unlicensed nursing staff (Registered Nurses [RN], Licensed Practical Nurses [LPN] or Licensed Vocational Nurses [LVN], and Certified Nurses' Aides [CNA]) directly responsible for providing resident care per shift.-maintain a copy of the facility staffing records for 18 months.-post the staffing information in an area easily assessable to residents, staff, visitors. Findings include:The surveyor observed for the duration of the facility survey, that the nurse staffing information was handwritten with an erasable marker on a wipe-off board posted in the corner of the entrance to the Unit One dining room. The surveyor also observed that the wipe-off board with the handwritten nurse staffing information was located above eye level. The surveyor further observed that the handwritten information on the wipe-off board did not include the following requirements:-posting of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.-the staffing information was posted in an area that was easily assessable to residents, staff, visitors. During an interview on 4/22/26 at 7:19 A.M., the Director of Nursing (DON) said she was unsure where the nursing staffing information posting was located.During an interview on 4/22/26 at 8:15 A.M., the Scheduler said he reviews the daily census and writes the: -number of RNs per shift.-number LPNs per shift.-CNAs per shift.The Scheduler further said he did not have a record of previous nursing staffing postings as he only writes the nursing staffing information on a wipe-off board daily with an erasable marker. The Scheduler further said he did not include total hours worked per each discipline and that he was not aware the nursing staffing posting was supposed to be easily accessible to residents, visitors, and staff. During an interview on 4/22/26 at 11:15 A.M., the Administrator said she was unaware that the actual number of staff and total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift needed to be on the nursing staffing posting. The Administrator also said the facility has not maintained the posted daily staffing information for 18 months as required. The Administrator further said she was not aware the nursing staffing information posting was supposed to be easily accessible to staff, residents and visitors.

Based on record review and interview, the facility failed to ensure that one Resident (#3) of five applicable residents sampled for unnecessary medications, out of a total sample of 18 residents, was free from unnecessary psychotropic (any drug that affects behavior, mood, thoughts or perception) medications.Specifically, for Resident #3, the facility failed to ensure that laboratory monitoring was completed as ordered by the Physician for Clozaril (Clozapine: an antipsychotic medication used to treat severe Schizophrenia) medication use and levels, placing the Resident at risk of Clozaril toxicity and medical complications. Findings include:Review of the facility policy titled Antipsychotic Medication Use, revised September 2025, indicated:-Diagnoses of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident.-All antipsychotic medications will be monitored with necessary lab values and EKG (an electrocardiogram) monitoring as indicated by the Attending Physician (i.e. see Clozaril guidelines for ANC [absolute neutrophil count] monitoring). Review of the Clozapine Monitoring National Protocol Guidance, dated March 2025, provided by the facility indicated:*Purpose: to provide general guidance on absolute neutrophil count (ANC) monitoring during Clozapine initiation and maintenance treatment.-Appropriate monitoring of Clozapine is still recommended. *Indications: reducing suicidal behavior in patients with Schizophrenia or schizoaffective disorder.*Precautions: Hepatoxicity (liver failure), Eosinophilia (elevated number of eosinophils in the blood). Resident #3 was admitted to the facility in June 2022 with diagnoses including Alzheimer's Disease, delusional disorders, neurocognitive disorder, Dementia and Psychotic Disturbance.Review of the Minimum Data Set (MDS) Assessment, dated 1/24/26, indicated Resident #3:-has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of a possible 15 points.-received an antipsychotic medication and the antipsychotic was administered on a scheduled basis. Review of Resident #3's April 2026 Physician's orders indicated:-Clozaril levels every 6 months, start date 11/26/24.Review of Resident #3's Clinical Record titled Results indicated:-Clozaril level was drawn and resulted on 6/7/25. -Clozaril level was drawn on December 2025 but there was no result.Further review of Resident #3 clinical record failed to indicate any further evidence that the Clozaril level was drawn or resulted in December 2025.During an interview on 4/21/26 at 2:30 P.M., Nurse #1 said there was no evidence that a Clozaril level was drawn for Resident #3 after June 2025.During an interview on 4/21/26 at 3:00 P.M., the Director of Nursing (DON) said she would review the clinical record and get back to the surveyor.During an interview on 4/22/26 at 7:49 A.M., the DON said there was no evidence that the Clozaril that was drawn in December 2025 ever resulted. The DON said the Clozaril level was important as Resident #3 was hospitalized in October 2024 for Altered Mental Status changes and the hospital identified the Resident's Clozaril level was extremely elevated. The DON said while the Resident was hospitalized , the Clozapine medication was decreased, and the hospital recommended that the Clozaril levels be monitored every six months to avoid toxic levels in the Resident's blood. The DON said there was no evidence that the Clozaril level was drawn or resulted since June 2025 and there had not been any follow up until the surveyor requested to review the December 2025 Clozaril lab results on 4/21/26.During a follow-up interview on 4/22/26 at 10:15 A.M., the DON said the facility could not identify why there was no Clozaril level lab results available for December 2025. The DON further said the facility staff should have followed up with the Clozaril level, but they did not.

Based on observation, interview, and record review the facility failed to adhere to professional standards of practice for medication administration and ensure that significant medication errors did not occur for one Resident (#54) of four applicable residents for medication administration, out of a total sample of 18 residents.Specifically, for Resident #54, the facility failed to ensure that a Myrbetriq Extended Release Medication (used to treat overactive bladder) was not crushed per the manufacturing and pharmacy instructions on the medication label prior to the Nurse administering the medication to the Resident, when crushing the Myrbetriq Extended Release Medication would increase the likelihood of destroying the extended-release mechanism, causing the entire dose to be released at once (dose dumping), placing the Resident at risk of serious medical side effects. Findings include:Review of Highlights of Prescribing Information, revised on 3/2021, retrieved fromhttps://www.accessdata.fda.gov/drugsatfda_docs/label/2021/213801s000lbl.pdf, indicated:-Adult patients: Swallow MYRBETRIQ whole with water. Do not chew, divide, or crush. -Swallow the tablet whole with water.-Do not chew, divide, or crush the tablet under any circumstances.-Consult the doctor or pharmacist for alternatives, such as Myrbetriq granules for oral suspension, which can be prepared by a pharmacist and taken as liquid. Why this matters: -Crushing the tablet can alter the pharmacokinetics, leading to unpredictable absorption and potentially compromising safety and efficacy. This is particularly important for patients with conditions like high blood pressure, as Myrbetriq can increase blood pressure, and sudden release of the full dose could exacerbate the effect of the Myrbetriq medication. Review of the facility policy titled Administering Medication, revised October 2025, indicated:-The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. Resident #54 was admitted to the facility in January 2020 with diagnoses including overactive bladder, Hypertension, Anxiety and Depression. On 4/21/26 at 7:48 A.M., during a medication administration procedure, the surveyor observed Nurse #1 prepare and administer medications to Resident #54. The surveyor observed Nurse #1 pour Resident #54's Myrbetriq extended-release medication into a plastic pouch, then crushed the Myrbetriq medication and put the crushed medication in a container of apple sauce. Nurse #1 was observed administering the crushed Myrbetriq extended-release medication in apple sauce to Resident #54. Review of Resident #54's April 2026 Physician Orders indicated:-Myrbetriq Oral Tablet Extended Release 24 Hour 25 mg (Mirabegron), give one tablet by mouth one time a day related to Overactive Bladder, ordered 3/25/26. Review of the Myrbetriq Oral Tablet Extended Release 24 Hour 25 mg (Mirabegron) pharmacy label located on the plastic bag containing the Myrbetriq medication indicated Do Not Crush this medication. During an interview on 4/21/26 at 8:34 A.M., Nurse #1 said Resident #54 would only take his/her medications crushed in apple sauce. Nurse #1 said she has worked in the facility for 10 years and knew how the Resident took his/her medications. Nurse #1 said that she was unaware the Myrbetric medication was extended-release. Nurse #1 also said that she had not read the instructions on the Myrbetriq Extended-Release medication label that indicated Do Not Crush this medication. During a follow-up interview on 4/21/26 at 8:54 A.M., Nurse #1 said she should not have crushed the Myrbetriq extended-release medication, but she had crushed the medication. During an interview on 4/21/26 at 11:15 A.M., the Director of Nursing (DON) said her expectation was for Nurses to read all medication instructions located on the medication packaging before they administered medications. The DON said Nurse #1 should have followed the instructions on the medication label and should not have crushed the Myrbetriq extended-release medication. The DON further said it was a significant medication error because of the health risks related to crushing an extended-release Myrbetriq medication.

Based on observations, interviews, and record review, the facility failed to ensure that two Residents (#5 and #49) out of a total sample of 18 residents, were treated in a dignified manner by Certified Nurse Aides (CNA #2 and #1) who were providing assistance with meals.Specifically, the facility failed to:for Resident #5, provide a dignified dining experience when CNA #2 remained standing over the Resident at his/her bedside while assisting the Resident with his/her breakfast meal.for Resident #49, provide a dignified dining experience to the Resident, when CNA #1 remained standing while providing assistance with the breakfast meal at the Resident's bedside. Findings include:Review of the facility policy titled Assistance with Meals: Dignified and safe dining experience, revised April 2025, indicated: -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals Review of the facility policy titled [Facility Name] Feeding Protocol, undated, indicated: -For residents requiring assistance: -Nursing staff or Feeding Assistants will place tray on over bed table, position themselves at eye level and feed resident at a pace to ensure safety and dignity 1) Resident #5 was admitted to the facility in November 2023 with diagnoses including Dementia and nausea and vomiting, unspecified. Review of Resident #5's clinical record indicated: a diagnosis of Pneumonitis due to inhalation of food and vomit was added in February 2026. the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated was rarely or never understood. the Resident's Care Plan indicated his/her eating ability was dependent on staff. the Resident's Care Plan summary (Kardex) indicated he/she was dependent on staff for eating for all meals. the Resident's CNA flow sheets for March 2026 and April 2026 indicated that the Resident received total support from staff with eating for all meals. On 4/21/26 at 8:31 A.M., the surveyor observed CNA #2 standing above the Resident's eye level at the bedside of Resident #5 while assisting the Resident with the breakfast meal. The surveyor observed that 2 chairs were available adjacent to the Resident's bed for seating use. During an interview on 4/21/26 at 8:33 A.M., CNA #2 said that she always stood while assisting the residents with their meals. CNA #2 further said that she preferred to stand while assisting with resident meals. During an interview on 4/21/26 at 8:38 A.M., with Unit Manager (UM) #1 and CNA #2, CNA #2 said that she was instructed to sit while assisting residents with their meals, but she was standing today while assisting Resident #5 with his/her breakfast meal. 2) Resident #49 was admitted to the facility in April 2019 with diagnoses including Schizophrenia and carcinoma of unspecified bronchus and lung. Review of Resident #49's clinical record indicated: diagnoses of Dementia and Dysphagia were added to the Resident's clinical record in August 2023. the Resident's MDS assessment dated [DATE], indicated he/she was severely cognitively impaired in both short and long-term memory as evidenced by staff being unable to complete the Brief Interview for Mental Status (BIMS) Assessment. the Resident's Care Plan indicated his/her eating ability was dependent on staff. the Resident's Care Plan summary (Kardex) indicated he/she was dependent on staff for eating all meals. the Resident's CNA flow sheets for March 2026 and April 2026 indicated that the Resident received total support from staff with eating for all meals. On 4/21/26 at 8:25 A.M., the surveyor observed CNA #1 standing at the bedside of Resident #49 while assisting the Resident with the breakfast meal. During an interview on 4/21/26 at 8:35 A.M., CNA #1 said that she had been taught to stand while providing eating assistance to residents. During an interview on 4/21/26 at 8:40 A.M., with UM #1 and CNA #1, CNA #1 said she should have been seated beside Resident #49 while assisting him/her with the breakfast meal, but she was not seated. During an interview on 4/21/26 at 8:45 A.M., UM #1 said that the CNA's should always be seated beside the residents when physically assisting with a meal. UM #1 said that all staff have been instructed to sit during meal assistance provided to the residents. During an interview on 4/21/26 at 1:20 P.M., the Director of Nursing (DON) said that all CNA's were expected to sit when providing physical assistance during dining. The DON said CNA #1 and CNA #2 should have been sitting next to Resident #5 and Resident #49 as they assisted them with breakfast.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy when 1) on 5/07/25 Certified Nurse Aide (CNA ) was witnessed by a staff member to slap Resident #1 on the arm and 2) approximately on month prior CNA #1 had been witnessed by another staff member to slap Resident #1 on the arm, however neither staff member reported the alleged incident of abuse immediately as require, therefore placing Resident #1 and other residents at risk for abuse. Findings include: Review of the Facility's Abuse Policy, titled Abuse Prohibition Police and Procedure, dated as revised November 2017, indicated that all employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse or allegation of abuse they are told about by residents, families, visitors or other staff. Resident #1 was admitted to the Facility in April 2019, diagnoses included dementia, heart failure and delusional disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, 04/01/25 indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. 1. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/19/25, indicated that on 05/19/25, CNA #2 reported to Unit Manager #1 that on 05/07/24, she saw CNA #1 slap Resident #1 on the arm when he/she (Resident #1) was combative during care. Review of the Facility's Internal Investigation Report, dated 05/19/25, indicated that CNA #2 reported to Unit Manager #1 that on 05/07/25, she saw CNA #1 slap Resident #1 on his/her arm him/her when he/she was combative during care. The Facility's Internal Investigation Report indicated that CNA #2 did not report the allegation immediately, and waited until (05/19/25). During an interview on 06/10/25 at 12:12 P.M., (which included a review of her Written Witness Statement dated 05/19/25), CNA #2 said that on 05/07/25, she and CNA #1 were providing care to Resident #1 when he/she (Resident #1) became combative, and that she saw CNA #1 slap Resident #1 on the arm (unsure which one) two times. CNA #2 said she should have reported it immediately but she waited until 05/19/25 to report it to Unit Manager #1. During an interview on 06/10/25 at 1:00 P.M., (which included a review of his Written Witness Statement dated 05/19/25), Unit Manager #1 said that on 05/19/25 CNA #2 told him that on 05/07/25, she saw CNA #1 slap Resident #1 on his/her arm and hand (unsure which one). Unit Manager #1 said that he immediately took CNA #2's statement and reported the allegation to the Clinical Manager, the Director or Nurses, and the Assistant Director of Nurses. During an interview on 06/10/25 at 3:08 P.M., the Clinical Manager said that Unit Manager #1 reported to her on 05/19/25, that CNA #2 said that she saw CNA #1 slap Resident #1 on his/her arm. The Clinical Manager said she led the investigation and that CNA #2 told her that on 05/07/25, she and CNA #1 were providing care to Resident #1 when he/she grabbed CNA #1's arm and then CNA #1 grabbed Resident #1's arm and slapped it two times. The Clinical Manager said CNA #2 should have reported the incident immediately, but she had not, and waited until 05/19/25 (12 days later). 2. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/19/25, indicated that during their internal investigation into an allegation of resident abuse that had been reported by CNA #2 , the Facility determined that CNA #3 had not reported an allegation of abuse involving Resident #1 and CNA #1 that occurred sometime during the week of 04/14/25. Review of the Facility's Internal Investigation Report, dated 05/19/25, indicated that while the Facility was conducting their internal investigation into CNA #2's report of resident abuse involving CNA #1, in reviewing CNA #3's written statement and interview, dated 05/20/25, that although she (CNA #3) had not witnessed CNA #1 slap Resident #1 on 05/07/25, she said she had witnessed CNA #1 slap Resident #1 on the arm sometime during the week of 04/14/25. Review of the Facility's Internal Investigation Report indicated that CNA #3 had not reported the allegation until she wrote her statement on 05/20/25 (approximately one month later). During an interview on 06/11/25 at 12:01 P.M., (which included review of her Written Witness Statement, dated 05/20/25), CNA #3 said that sometime during the week of 04/14/25 (she could not remember the day or time), she and CNA #1 were getting Resident #1 into bed, and he/she (Resident #1) was screaming. CNA #3 said she then saw CNA #1 slap Resident #1 on his/her left arm. CNA #3 said she should have reported the allegation immediately, but had not. CNA #3 said that instead, she put it in her statement that she wrote on 05/20/25, and told the DON and Clinical Manager. During an interview on 06/10/25 at 3:08 P.M., the Clinical Manager said that the Facility was not aware of CNA #3's abuse allegation involving Resident #1 and CNA #1 until she (CNA #3) told her and also wrote it in her written witness statement (for the abuse allegation that occurred on 05/07/25). The Clinical Manager said CNA #3 should have reported the allegation immediately but had not.

Based on documentation review and staff interview, the Facility staff failed to comprehensively assess the facility resources needed to provide sufficient support and care for the resident population as outlined in the Facility Assessment. Findings include: Review of the Facility Assessment, dated 1/9/25, indicated the following: - Religious, ethnic, or cultural factors that affect the delivery of care and services, such as: Facility Answer: -Food and Nutrition requirements: many modified diets for dysphagia, puree or moist ground with thickened liquids. -Activities: no significant factors identified. -Language translation requirements: One resident speaks Creole understands simple English and this resident has expressive aphasia in both English and primary language. The Facility did not fully assess, describe, or identify all ethnic or cultural groups specific to their population. -Equipment and Supplies (medical and non-medical): Facility Answer: sufficient resources. The facility did not identify medical and non-medical equipment and supplies needed to provide sufficient support and care to the facility resident population. - Detailed review of resources available to meet the needs of the resident population: Facility Answer: A breakdown of the training, licensure, education, skill level and measures of competency for all personnel; all are updated at present time-education and in-servicing needs are identified with new admissions, readmissions, declines in function and capability of residents needing more care and potentially specified needs met now vs prior, short term vs long term debility changes that warrant staff intervention-notification to Staff Ed include Admissions, Medical Director, Director of Clinical Services, Physicians, DON (Director of Nursing), MDS (Minimum Data Set) Nurse, Administration and Managers, Rehab, Administrator, etc. The Facility did not identify a comprehensive description of education and competencies needed to provide sufficient care to the facility resident population. - Nursing: Facility Answer: Nursing continues with staff vacancies, mainly with staff put on medical leave. Have been able to staff facility, however staff have been performing overtime. This is increasing payroll. The Facility did not assess or provide an individualized or comprehensive description on how the Facility plans to recruit, maintain or collaborate with medical practitioners. The Facility did not complete an adequate, specific, comprehensive and individualized Facility Assessment to reflect how the Facility ensures that resident specific needs are met based on its population and staffing. During an interview with the Administrator on 3/6/25 at 11:53 A.M., the above observations were discussed. The Administrator said we have just followed what we have been using provided to us by the insurance company and was not aware education and other information was required. The Administrator then said we as an independent facility made up a Facility Assessment template of what DPH (Department of Public Health) might want.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, 1. The facility failed to ensure treatment carts and medication rooms were locked while a nurse was not present. 2. The facility failed to ensure drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the medication room and medication carts on two of two units. 3. The facility failed to ensure that medications were dated once opened, according to manufacturer's guidelines. Further, the facility failed to ensure that medications with shortened expiration dates were removed from the medication cart when expired and were not available for administration in two of two medication carts observed. Findings include: Review of the facility policy titled Storage of Medications, dated April 2007, indicated The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. On 3/4/25 at 3:29 P.M., the surveyor observed a treatment cart on Station One unlocked in the hallway. No staff were present at the treatment cart. On 3/4/25 from 8:00 A.M. to 8:40 A.M., the surveyor observed the medication room on Station Two unlocked, the surveyor was able to access medications. No staff were present in the medication room. On 3/4/25 from 11:55 A.M. to 12:12 P.M., the surveyor observed the medication room on Station Two unlocked, the surveyor was able to access medications. No staff were present in the medication room. On 3/5/25 at 7:01 A.M., the surveyor observed the medication room on Station Two unlocked, the surveyor was able to access medications. No staff were present in the medication room. During an interview on 3/5/25 at 7:02 A.M., Nurse #1 said the medication room is unlocked and shouldn't be. Nurse #2 said the facility keeps changing the code on the door so she left it unlocked. During an interview on 3/6/25 at 8:56 A.M., the Director of Nursing said medication carts, medication rooms and treatment carts should always be locked unless at nurse is at a cart or in the med room. 49880 2. Review of facility policy titled Storage of Medications, reviewed 10/21/24, indicated the following: -The facility shall store all drugs and biologicals in a safe, secure and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. -Medications requiring refrigeration must be stored in a refrigerator locked in the drug room at the nurses' station or other secured location. -Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. On 3/4/25 at 6:45 A.M., on the Station One Unit, upon entering the facility the surveyor observed two unlocked medication carts and one unlocked treatment cart on the unit. On 3/4/25 from 2:39 P.M. through 2:46 P.M., the surveyor observed the Station One low side medication cart unlocked unattended, during the continuous observation the surveyor observed one housekeeper, multiple CNAs, the Food Service Director, and the oxygen delivery man walk near the unlocked and unattended medication cart. On 3/4/25 at 3:29 P.M., 3:41 P.M., 3:47 P.M., 4:10 P.M., and 4:36 P.M., the surveyor observed the Station One treatment cart unlocked and unattended. The surveyor opened the treatment cart drawers and observed prescription ointments and creams. On 3/5/25 at 7:37 A.M. during an observation of the Station One medication room, Nurse #4 opened the medication room for the surveyor, let the surveyor in and walked away, leaving the surveyor unsupervised in the medication room. During an interview on 3/4/25 at 2:46 P.M., Nurse #3 said that the medication cart should have been locked when unattended but was not. During an interview on 3/6/25 at 8:31 A.M., Unit Manager #1 said that he would expect that nurses lock the medication and treatment carts when they walk away, and it is not left unlocked and unattended. During an interview on 3/6/25 at 8:39 A.M., the Director of Nurses said that medication and treatment carts should be locked when unattended. The Director of Nurses said only authorized personnel should have access to the medication room, and the nurse should not have left the surveyor unattended in the medication room. 3. During an observation on 3/5/25 at 7:03 A.M., of the high-end medication cart on the Station One unit the following observations were made: -One unopened vial of Procrit in the medication cart in a bag that indicated to keep refrigerated. -One opened and expired vial of Insulin Aspart, dated as opened 1/24/25 and expired on 2/22/25, in the medication cart and available for administration. -One Arnuity Ellipta inhaler, dated as opened 12/22/24 and expired on 2/2/25, in the medication cart and available for administration. During an interview on 3/5/25 at 7:10 A.M., Nurse #4 said that when medications expire, they should be removed from the medication cart and if it says to refrigerate the medication it should be in the fridge until administration. During an observation on 3/5/25 at 7:13 A.M., of the low-end medication cart on the Station One Unit the following observations were made: -One open vial of Lantus Insulin, dated as opened 1/27/25 and expired on 2/24/25, in the medication cart available for administration. -One vial of Insulin lispro, dated as opened 1/27/25 and expired on 2/24/25, in the medication cart and available for administration. -One vial of Lantus Insulin, opened and undated in the medication cart and available for administration. -One Trelegy Elipta inhaler, opened and undated in the medication cart and available for administration. The inhaler reads to discard after 6 weeks. During an interview on 3/5/25 at 7:18 A.M., Nurse #4 said that nurses should be checking expiration dates before administering medications and medications that are expired should be discarded. She also said that inhalers should be labeled with an open date. During an interview on 3/6/25 at 8:31 A.M., Unit Manager #1 said that expired medications should be removed from the medication carts. He also said that any medication with a shortened expiration date should be labeled when opened to include the open and expiration date. During an interview on 3/6/25 at 8:39 A.M., The Director of Nurses said that it is her expectation that medications with shortened expiration dates are labeled with an open and expiration date and that when they are expired, they should be removed from the medication cart.

Based on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner. Specifically, 1. On the Station 1 and Station 2 Units, the facility failed to provide a dignified dining experience. 2. For Resident #60, the facility failed to ensure staff consistently covered his/her catheter drainage bag. Findings include: Review of the facility policy titled Dignity, dated August 2009, indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall treat cognitively impaired residents with dignity and sensitivity. 1. On 3/4/25 from 8:30 A.M. to 8:35 A.M., the surveyor observed a Certified Nurse Aide (CNA) was standing while feeding a resident in bed on the Station 2 Unit. On 3/4/25 at 9:58 A.M., a staff member was observed standing over a resident during breakfast while feeding a resident who was in bed on the Station 1 Unit. On 3/4/25 at 12:04 P.M., the surveyor observed a CNA was standing while feeding a resident in the dining room Station 2 Unit. On 3/5/25 at 12:13 P.M., the surveyor observed a CNA was standing while feeding a resident in the dining room Station 2 Unit. On 3/6/25 at 7:57 A.M., the surveyor observed a CNA was standing while feeding a resident in the dining room Station 2 Unit. During an interview on 3/6/25 at 8:31 A.M., CNA #3 said staff should be seated while assisting a resident with their meal. During an interview on 3/6/25 at 7:43 A.M., Unit Manager #2 said staff should be seated while assisting residents with their meals. 49880 During an observation on 3/4/25 at 8:24 A.M., in the Station One dining room the surveyor observed a Certified Nurse's Aide (CNA) walking around the dining room and assisting multiple residents with their meals. The CNA was standing over each resident, providing two to three bites of food, then going to help another resident, each time standing over the resident to provide eating assistance. During an interview on 3/6/25 at 8:57 A.M., the Director of Nurses said that staff should be sitting while assisting residents with meals. During an interview on 3/6/215 at 10:11 A.M., the Director of Nursing said staff should not be standing over residents while assisting them with feeding. 44095 2. Review of the facility policy titled, Quality of Life - Dignity, dated as revised August 2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered. Resident #60 was admitted to the facility in September 2022 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/7/25, indicated Resident #60 was dependent on staff for activities of daily living. This MDS indicated Resident #60 required an indwelling catheter. On 3/4/25 at 10:29 A.M., 3/5/25 at 7:48 A.M., 10:07 A.M., and at 1:47 P.M., and on 3/6/25 at 10:58 A.M., the surveyor observed Resident #60 in his/her room from the hallway, Resident #60's urinary drainage bag was exposed without a privacy bag. Resident #60's roommate was present in the room. During an interview on 3/6/25 at 8:41 A.M., Unit Manager #1 said staff should ensure that Resident #60's urinary drainage bag is stored in a privacy bag. During an interview on 3/6/25 at 11:51 A.M., the Director of Nursing (DON) said staff should ensure that Resident #60's urinary drainage bag is stored in a privacy bag.

Based on observations and interviews, the facility failed to provide a homelike environment during dining on two of two nursing units. Specifically, on the Station 1 and Station 2 Units, residents were observed eating meals on meal trays in the dining rooms. Findings include: Review of the facility policy titled Homelike Environment, dated 3/5/25, indicated To create a more homelike safe environment that offers our residents greater dignity and autonomy, ensuring resident's preferences, needs and values guide decisions and care. On 3/4/25 at 8:09 A.M., the surveyor observed Station 2's dining room, all residents were served their meals on meal trays and staff did not remove the meal trays. On 3/4/25 at 12:01 P.M., the surveyor observed Station 1's dining room, all residents were served their meals on meal trays and staff did not remove the meal trays. On 3/4/25 at 12:05 P.M., the surveyor observed Station 2's dining room, all residents were served their meals on meal trays and staff did not remove the meal trays. On 3/5/25 at 8:30 A.M., the surveyor observed Station 2's dining room, all residents were served their meals on meal trays and staff did not remove the meal trays. On 3/5/25 at 12:20 P.M., the surveyor observed Station 2's dining room, all residents were served their meals on meal trays and staff did not remove the meal trays. During an interview on 3/6/25 at 8:31 A.M., Certified Nurse Aide #3 said staff should remove the resident's meal off the meal tray when eating in the dining room. During an interview on 3/6/25 at 7:43 A.M., Unit Manager #2 said staff should remove the resident's meal off the meal tray when eating in the dining rooms.

Based on observations, interviews, and record review, the facility failed to accurately assess the use of an alarmed velcro seat belt as a potential restraint for one Resident (#18) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Use of Restraints, dated April 2017, indicated 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. Resident #18 was admitted to the facility in August 2021 with diagnoses that included dementia, dysphagia, repeated falls, and anxiety disorder. Review of Resident #18's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. The MDS further indicated he/she is dependent on staff for activities of daily living, a trunk restraint was not used and a chair that prevents rising was not used. On 3/4/25 at 11:59 A.M., the surveyor observed Resident #18 in the dining room in a reclined position in his/her geri reclining chair with a seat belt in place. On 3/5/25 at 11:17 A.M., the surveyor observed Resident #18 in the dining room in a reclined position in his/her geri reclining chair with a seat belt in place. Review of Resident #18's physician order, dated 7/21/22, indicated: Device- Alarm Seat Belt on wheelchair resident can release device on verbal command 10 out of 10 times or resident cannot walk/transfer and is an extensive assist or physically dependent on staff for locomotion/ambulation; Has consent; Pre-assessment and reviewed quarterly and as needed. Review of Resident #18's fall care plan, dated 1/9/23, indicated I have a (clip belt seat belt) on my (recliner) that does not meet the criteria for a restraint. Review of Resident #18's restraint assessment, dated 2/6/25, indicated the alarmed seat belt is not a restraint. During an interview and observation on 3/5/25 at 11:17 A.M., Certified Nurse Aide (CNA) #3 said she has taken care of Resident #18 many times and he/she cannot self-release his/her seatbelt. CNA #3 said the Resident needs the seatbelt to keep him/her in the chair because he/she tends to lean or slide out of the chair. The Resident was unable to self release the seatbelt during this observation. During an interview on 3/5/25 at 11:18 A.M., Unit Manager #2 said Resident #18's alarmed seat belt is not a restraint because he/she does not ambulate and he/she has never been able to self release the belt. Unit Manager #2 said Resident #18 is a fall risk and this is a fall intervention to keep the Resident from falling out of their chair. During an interview on 3/6/25 at 9:10 A.M., the Director of Nurses (DON) said Resident #18 could never self-release his/her alarmed velcro belt. The DON said the Resident is a fall risk and this is an intervention to keep this Resident from falling. The DON said the Resident can change his/her position at times and this is why the velcro belt is used.

Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for seven Residents (#18, #24, #58, #61, #26, #39, and #9) out of a total sample of 26 residents. Specifically, 1. For Residents #18, #24, #58, #61, #26 and #39, the facility failed to provide assistance and/or supervision with meals as per the plan of care. 2. For Resident #9, the facility failed to provide assistance with grooming. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated March 2018, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: d. Dining (meals and snacks). 1a. Resident #18 was admitted to the facility in August 2021 with diagnoses that included dementia, dysphagia, repeated falls, and anxiety disorder. Review of Resident #18's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. The MDS further indicated he/she is dependent on staff for eating. On 3/4/25 from 8:28 A.M. to 8:39 A.M., the surveyor observed Resident #18 awake and in bed, their breakfast tray was left on the nightstand next to him/her not set up for consumption. The surveyor observed multiple staff members walk by the Resident's room. On 3/5/25 from 8:14 A.M. to 8:27 A.M., the surveyor observed Resident #18 awake and in bed, their breakfast tray was left on their over-the-bed table in sight and in reach, not set up for consumption. The surveyor observed multiple staff members walk by the Resident's room. On 3/6/25 from 8:18 A.M. to 8:26 A.M., the surveyor observed Resident #18 awake and in bed, their breakfast tray was left on their dresser in front of his/her bed in sight. The surveyor observed multiple staff members walk by the Resident's room. Review of Resident #18's eating care plan, dated 2/19/24, indicated Eating goals over next 90 days select one: Dependent. Review of Resident #18's active Certified Nurse Aide (CNA) Kardex (form explaining to staff the needs of each Resident), indicated he/she is dependent on staff for eating. During an interview on 3/6/25 at 8:31 A.M., CNA #3 said there are not enough staff members on this floor to assist all the residents that need assist on this floor. CNA #3 said the tray should not be left for a resident who needs assistance with their meal. During an interview on 3/6/25 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each residents care plan and CNA Kardex. During an interview on 3/6/25 at 8:59 A.M., the Director of Nurses said she expects staff to follow each residents care plan and CNA Kardex. 1b. Resident #24 was admitted to the facility in July 2021 with diagnoses that included Alzheimer's disease, dysphagia, anxiety and depression. Review of Resident #24's most recent Minimum Data Set (MDS) assessment, dated 1/14/25, indicated he/she was assessed by nursing staff to have moderate cognitive impairments. The MDS further indicated he/she needed partial/moderate assistance from staff for eating. On 3/4/25 at 8:26 A.M., the surveyor observed Resident #24 awake and in bed, their breakfast tray was left on the bedside table next to him/her not set up for consumption. No staff were in the room. On 3/4/25 from 11:52 A.M. to 12:11 P.M., the surveyor observed Resident #24 in the dining room with his/her lunch tray. No staff were observed assisting the Resident with his/her meal. On 3/5/25 from 12:03 P.M. to 12:13 P.M., the surveyor observed Resident #24 in the dining room with his/her lunch tray. Resident #24 was observed to not initiate self feeding. On 3/6/25 from 8:22 A.M. to 8:27 A.M., the surveyor observed Resident #24 awake and in bed, their breakfast tray was partially set up, drinks were left covered. Resident #24 was observed to not initiate self feeding. Review of Resident #24's eating care plan, dated 2/19/24, indicated Eating goals over next 90 days select one: Partial/Moderate Assistance. Review of Resident #24's active Certified Nurse Aide (CNA) Kardex, indicated he/she needs partial/moderate assistance from staff for eating. During an interview on 3/6/25 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each resident's care plan and CNA Kardex. During an interview on 3/6/25 at 8:59 A.M., the Director of Nurses said she expects staff to follow each resident's care plan and CNA Kardex. 1c. Resident #58 was admitted to the facility in August 2020 with diagnoses that included dementia, glaucoma, transient visual loss, and delusional disorders. Review of Resident #58's most recent Minimum Data Set (MDS) assessment, dated 11/28/24, indicated he/she scored a one out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she requires partial/moderate assistance from staff for eating. On 3/4/25 from 8:14 A.M. to 8:20 A.M., the surveyor observed Resident #58 in the dining room with his/her breakfast tray. Resident #58 was observed to not initiate self-feeding. On 3/4/25 from 12:14 P.M. to 12:16 P.M, the surveyor observed Resident #58 in bed, his/her tray was left of the over the bed table next to the bed not set up for consumption. On 3/5/25 from 8:00 A.M. to 8:27 A.M., the surveyor observed Resident #58 in the hallway with his/her breakfast tray. Resident #58 was observed to not initiate self-feeding. On 3/6/25 from 8:18 A.M. to 8:34 A.M., the surveyor observed Resident #58 in his/her bed with his/her breakfast tray. Resident #58 was observed to not initiate self-feeding. Review of Resident #58's eating care plan, dated 2/19/24, indicated Eating goals over next 90 days select one: Partial/Moderate Assistance. I am easily distracted and need constant coaxing and reminders to finish my meals . will not finish my meal nor really eat without your intervention whether it be verbal cues or physical assistance. Review of Resident #58's active CNA Kardex, indicated Eating: Partial/moderate assist. During an interview on 3/6/25 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each resident's care plan and CNA Kardex. During an interview on 3/6/25 at 8:59 A.M., the Director of Nurses said she expects staff to follow each resident's care plan and CNA Kardex. 1d. Resident #61 was admitted to the facility in August 2021 with diagnoses that included dementia, Alzheimer's disease, anxiety disorder, pressure ulcer of right heel, and major depressive disorder. Review of Resident #61's most recent Minimum Data Set (MDS) assessment, dated 2/13/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated he/she is dependent on staff for eating. On 3/4/25 from 8:15 A.M. to 8:32 A.M., the surveyor observed Resident #61 in the dining room with his/her breakfast tray in just out of reach of him/her not set up for consumption. On 3/4/25 from 12:06 P.M. to 12:23 P.M., the surveyor observed Resident #61 in the dining room with his/her lunch tray in just out of reach of him/her not set up for consumption. On 3/5/25 from 8:05 A.M. to 8:11 A.M., the surveyor observed Resident #61 in the dining room with his/her breakfast tray in just out of reach of him/her not set up for consumption. On 3/5/25 from 12:13 P.M. to 12:17 P.M., the surveyor observed Resident #61 in the dining room, staff were assisting other residents with their meals. Resident #61 did not have a meal tray or assistance during this time, all other residents had meal trays during this observation period. On 3/6/25 from 7:55 A.M. to 8:02 A.M., the surveyor observed Resident #61 in the dining room with his/her breakfast tray in just out of reach of him/her not set up for consumption. Review of Resident #61's eating care plan, dated 2/19/24, indicated Eating goals over next 90 days select one: Supervision or Touching Assistance. Review of Resident #61's active CNA Kardex, indicated he/she was dependent on staff for eating. During an interview on 3/6/25 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each resident's care plan and CNA Kardex. During an interview on 3/6/25 at 8:59 A.M., the Director of Nurses said she expects staff to follow each resident's care plan and CNA Kardex. 45984 1e. Resident #26 was admitted to the facility in February 2016 with diagnoses including schizophrenia, dysphagia and seizures. Review of Resident #26's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident was unable to complete the Brief Interview for Mental Status exam indicating the resident has severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for activities of daily living and requires partial/moderate assistance with eating. The surveyor made the following observations: - On 3/4/25 at 12:34 P.M., Resident #26 was eating lunch in the dining room. Resident #26 was feeding him/herself without any staff assistance. The Resident had pureed food remnants around his/her mouth and it was spilling onto his/her chest. - On 3/5/25 at 9:04 A.M., Resident #26 was observed sitting in his/her bed with his/her breakfast in front of him/her on the bedside table. Resident #26 was feeding him/herself with no staff assistance. - On 3/5/25 at 12:24 P.M., Resident #26 was eating lunch in the dining room. Resident #26 was feeding him/herself without any staff assistance, the Resident has spilled coffee and food all over his/her feeding protector. - On 3/6/25 at 8:19 A.M., staff brought in Resident #26's breakfast while he/she was lying in bed. Staff set up the tray and left the room. Resident #26 was observed to have pureed food all over his/her mouth and it was dripping onto his/her chest and was eating very quickly. At 8:34 A.M., Resident #26 was observed to tilt his/her all the way back while swallowing food. At 8:35 A.M., Resident #26 finished his/her entire breakfast with no staff assistance. Review of Resident #26's document titled CNA Flow Sheet Worksheet, revised and dated 9/27/23 indicated that Resident #26 requires Partial/moderate assist with all meals. Review of Resident #26's eating care plan dated 10/27/23 indicated the following interventions: - Eating goals over the next 90 days: partial/moderate assistance. - I have dysphagia and I am a real choking hazard waiting to happen. I eat too fast or eat bites that are too large and need to be slowed down and reminded to take small bites with rest periods between so I can thoroughly chew my food and swallow accordingly. - Assist me/feed me with eating when I become fatigued or disinterested or confused or focused elsewhere - I have been known to pocket my food - I need encouragement to eat by my helpers Review of Resident #26's Nutrition care plan related to chewing and swallowing difficulties due to dysphagia, dated 2/4/25, indicated the following interventions: Staff to monitor for s/sx (signs/symptoms) of chewing or swallowing difficulties. Review of Resident #26's Dietary Assessment, dated 2/4/25, completed by the Registered Dietitian, indicated Resident #26 needs to be physically assisted with his/her ability to eat. During an interview on 3/6/25 at 8:58 A.M., Certified Nursing Assistant (CNA) #7 said Resident #26 only requires supervision with meals because he/she has choking concerns and has a history of seizures. During an interview on 3/6/25 at 9:05 A.M., CNA #8 said we use the Resident's flow sheets to know what level of ADL care they need. CNA #8 continued to say Resident #26 only needs supervision with meals due to choking. During an interview on 3/6/25 at 9:38 A.M., Nurse #2 said Resident #26 only needs supervision with his/her meals due to choking and seizures and he was aware the Resident did not get supervision this morning. Nurse #2 was not aware Resident #26 was supposed to have partial/moderate assistance with meals. During an interview on 3/6/25 at 9:52 A.M., Unit Manager #1 said he thought Resident #26 only needed supervision with meals and not staff assistance. During an interview on 3/6/25 at 10:11 A.M., the Director of Nursing (DON) said we check Resident's flow sheets to know what level of ADL assistance a resident needs. The surveyor and DON reviewed Resident #26's flow sheet and the DON said he/she should be receiving partial/moderate assistance with all meals. 45343 1f. Resident #39 was admitted to the facility in March 2016, with diagnoses including Alzheimer's Disease, dysphagia (difficulty swallowing), and major depressive disorder. Review of Resident #39's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has severe cognitive deficits. The MDS further indicated Resident #39 requires dependent assistance for eating On 3/4/25 at 8:15 A.M., 8:25 A.M., and 8:30 A.M., the surveyor observed Resident #39 awake lying in bed, with their breakfast tray left on the bedside table next to him/her. There was no staff observed providing assistance with self-feeding. On 3/5/25 at 8:04 A.M., 8:12 A.M., and 8:25 A.M., the surveyor observed Resident #39 awake lying in bed with their breakfast tray left on his/her dresser next to his/her bed. There was no staff observed providing assistance with self-feeding. On 3/6/25 at 8:04 A.M., 8:15 A.M., and 8:28 A.M., the surveyor observed Resident #39 awake lying in bed, with their breakfast tray left on the bedside table next to him/her. There was no staff observed providing assistance with self-feeding. Review of Resident #39's eating care plan, dated 10/25/23, indicated EATING GOALS OVER NEXT 90 DAYS SELECT ONE: DEPENDENT. Further review of Resident #39's Kardex (a form indicating level of assistance a resident requires) dated as of 3/13/24 indicated he/she is dependent on staff for eating. During an interview on 3/6/25 at 8:31 A.M., CNA #3 said there are not enough staff members on this floor to assist all the residents that need assist on this floor. CNA #3 said the tray should not be left for a resident who needs assistance with their meal. During an interview on 3/6/25 at 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each resident's care plan and CNA Kardex. During an interview on 3/6/25 at 8:59 A.M., the Director of Nurses said she expects staff to follow each resident's care plan and CNA Kardex. 2. Resident #9 was admitted to the facility in December 2020, with diagnoses including Peripheral vascular disease, Type 1 Diabetes Mellitus, schizoaffective disorder, and major depressive disorder. Review of Resident #9's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15, indicating he/she has severe cognitive impairments. The MDS also indicated Resident #9 requires substantial/maximal assistance for all self-care activities. On 3/4/25 at 7:40 A.M., 8:30 A.M., and 12:15 P.M.; 3/5/25 at 7:00 A.M., 8:16 A.M. and 12:05 P.M.; 3/6/25 at 8:59 A.M., and 3/6/25 at 7:55 A.M., Resident #9 was observed with upper lip hair. Resident #9 said he/she normally does not have facial hair, and staff normally remove his/her facial hair on their shower day. Review of the unit shower schedule on 3/6/25 at 7:58 A.M., indicated Resident #9's shower day is Mondays (P.M.). Review of Resident #9's nursing notes failed to indicate he/she refused care. During an interview on 3/6/25 at 10:10 A.M., Unit Manager #2 said we normally shave Residents during morning care with their permission. Unit Manager #2 said if a resident refuses care, the Certified Nursing Assistant will notify her and they will reattempt care. Unit Manager #2 said she was not notified Resident #9 was refusing care. During an interview on 3/6/25 at 9:01 A.M., the Director of Nursing said she would expect facial hair to be removed with the resident's permission during routine care and any refusals should be documented in the medical record.

Based on observations, record review and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for four Residents (#61, #60, #69, and #78) out of a total of 26 sampled residents. Specifically, 1. For Resident #61 who has a pressure ulcer, the facility failed to ensure that his/her air mattress had a physician's order in place and failed to set it to the Resident's weight. 2. For Resident #60 who has a pressure ulcer, the facility failed to ensure that his/her air mattress was set to the physician's orders. 3. For Resident #69 who has a pressure ulcer, the facility failed to follow the wound doctor's recommendation for sitting up in a wheelchair for no more than one hour each day. 4. For Resident #78, who has a pressure ulcer, the facility failed to ensure that his/her air mattress had a physician's order in place and failed to implement physician's orders for heel lifters and blanket lifters while in bed. Findings include: Review of Facility policy titled Policy for Bed Air Mattress, dated as updated 12/29/22, indicated the following: -A Bed Air Mattress can be utilized to provide pressure relief surface for Residents exhibiting tissue loss or residents with loss of mobility and potential for tissue loss. [sic] -Doctors order is obtained for residents without contradictions; an air mattress may be unsuitable for residents with spinal orthopedic fractures or whose body habitus does not meet the size limits as per manufacturer guidelines. -Air mattress use is documented in nursing and CNA care plans and the resident is required/ documented to have assist of 2 for bed mobility and transfers with air mattress in place. -Resident is weighed weekly and air mattress is calibrated with internal pressure of Air Mattress. Accurate weight is documented in the physician's order. Review of Facility policy titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol, dated as revised April 2018, indicated the following: -The physician will order pertinent wound treatments, including reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and the application of topical agents. 1. Resident #61 was admitted to the facility in August 2021 with diagnoses that included dementia, Alzheimer's disease, anxiety disorder, pressure ulcer of right heel, and major depressive disorder. Review of Resident #61's most recent Minimum Data Set (MDS) assessment, dated 2/13/25, indicated he/she was assessed by nursing staff to have severe cognitive impairment. Further review of the MDS indicated he/she is at risk for developing pressure ulcers and has one stage 2 unhealed pressure ulcer over a boney prominence. On 3/5/25 at 6:53 A.M., the surveyor observed Resident #61 in bed on an air mattress, the air mattress was set to 180 lbs (pounds). Review of Resident #61's weights indicated: - 3/6/25 weight 111.2 lbs. - 3/3/25 weight 111.2 lbs. Review of Resident #61's Braden (Scale for predicting pressure sore risk) score, dated 2/12/25, indicated a score of 10 indicating he/she is at high risk for developing pressure ulcers. Review of Resident #61's active physician orders failed to indicate an order was in place for his/her air mattress. During an interview on 3/6/25 at 7:42 A.M., Unit Manager #2 said Resident #61 is on an air mattress and that the Resident does have a pressure ulcer on their foot. Unit Manager #2 said the air mattress should be set to the Resident's weight and there should be a physician's order in place. During an interview on 3/6/25 at 8:58 A.M., the Director of Nursing said if a resident is on an air mattress nursing should have put in a physicians order and the air mattress should be set to weight. 44095 2. Resident #60 was admitted to the facility in September 2022 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/7/25, indicated Resident #60 was dependent on staff for activities of daily living. This MDS indicated Resident #60 was assessed as at risk for developing pressure ulcers and he/she had one unhealed pressure ulcer/injury. Review of Resident #60's physician's order, dated 2/21/25, indicated: - Right buttock stage 2 pressure ulcer: wash area with vashe, pat dry, apply calcium alginate and cover with optifoam daily and as needed, every day shift. Review of Resident #60's physician's order, dated 1/31/25, indicated: - Air Mattress - Dial - Monitor - setting every shift to confirm correct internal pressure setting based on the resident's current weight - choices are 65, 115, 155, 200, 240, 285, 325 pounds - weights less than 10 pounds difference before next level will be pushed to next highest level over that. Review of Resident #60's plan of care related to impaired skin integrity, dated 2/3/25, indicated: - Air Mattress- Digital/Dial - Monitor setting on residents current weight - change setting if weight setting does not match current weight accordingly - scales vary on different machines - settings should be next highest level (example 135 pounds would register at 150 mark) - If weight is 10 pounds less than next highest category than setting should allow for clothing, fluid, and food (example 140 pounds would be set not at 150 but 200 pounds). Review of Resident #60's weights indicated he/she weighed the following: - On 3/4/25 and 3/5/25 172.3 pounds, and - On 3/6/25 169.4 pounds. On 3/4/25 at 10:29 A.M., 1:11 P.M., and at 4:13 PM, on 3/5/25 at 6:39 A.M., 7:48 A.M., 11:37 A.M., 1:47 P.M., and at 3:17 P.M., and on 3/6/25 at 6:46 A.M., and at 7:18 A.M., the surveyor observed Resident #60 in bed, his/her air mattress dial was set between 320 and 350 pounds. The dial on Resident #60's air mattress included the following numbers 80, 120, 150, 180, 210, 250, 280, 320, and 350 pounds. Comparative review of the physician's order failed to include numbers that coincided with Resident #60's air mattress. During an interview on 3/6/25 at 7:48 A.M., Certified Nurse Assistant (CNA) #5 said he just completed care for Resident #60, and he does not adjust air mattress settings. During an interview on 3/6/25 at 7:53 A.M., Nurse #6 said that air mattress settings are checked every shift based on the physician's order. Nurse #6 said that Resident #60's air mattress should be set to his/her weight. During an interview on 3/6/25 at 8:38 A.M., Unit Manager #1 said that Resident #60 has an air mattress for his/her pressure ulcer. Unit Manager #1 said that nurses should check air mattress settings during their medication pass and document according to the physician's order. During an interview on 3/6/25 at 11:47 A.M., the Director of Nursing (DON) said Resident #60 has a pressure ulcer and his/her air mattress should be set to his/her weight to help heal his/her pressure ulcer. 45984 3. Resident #69 was admitted to the facility in December 2024 with diagnoses including pressure ulcer of sacral region, anxiety disorder, bipolar disorder and bronchitis. Review of Resident #69's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident is dependent on staff for ADLs including transferring from a bed to chair and has a stage 4 pressure ulcer. The surveyor made the following observations: - On 3/4/25 at 12:17 P.M., Resident #69 was sitting in his/her wheelchair in his/her room. At 2:06 P.M., Resident #69 was still sitting in his/her wheelchair in his/her room. Resident #69 told the surveyor that his/her butt hurt and he/she has been sitting in his/her wheelchair since lunch at noontime. Resident #69 continued to say that staff will eventually get to him/her to put him/her in bed. At 2:41 P.M., Resident #69 was still sitting in his/her wheelchair in his/her room. Resident #69 was sitting in his/her wheelchair for two hours and twenty-four minutes. - On 3/5/25 at 12:01 P.M., Resident #69 was sitting in his/her wheelchair in his/her room. At 12:36 P.M., Resident #69 told the surveyor that his/her butt hurts when he/she sits in his/her wheelchair for too long. At 1:27 P.M., Resident #69 was still sitting in his/her wheelchair in his/her room. Resident #69 was sitting in his/her wheelchair for one hour and twenty-six minutes. Review of Resident #69's weekly Wound Care Specialist Physician Follow up Visit notes dated 12/27/24, 1/3/25, 1/10/25, 2/7/25, 2/14/24, 2/21/25 and 2/28/25 indicated the following: - Plan: Emphasized the importance of limiting time to chair to <1 hr/day (less than one hour per day) to prevent further deterioration (of sacral wound). Review of Resident #69's physician's orders failed to indicate an order to limit the amount of time Resident #69 sits down in his/her wheelchair due to his/her sacral wound. Review of Resident #69's Mobility/Transfer - Chair/Bed to - chair transfer care plan indicated the following interventions dated 12/30/24: Dependent; Hoyer 2+ person, I am not safe transferring myself from bed to chair and need helpers to provide physical assistance during the transfer. Review of Resident #69's Certified Nursing Assistant (CNA) flow sheet indicated that the Resident is dependent on staff for transferring from chair/bed to chair. Review of Resident #69's impaired functional mobility due to a sacral wound care plan indicated the following intervention dated 1/31/25: Please follow wound team guidelines of patient being OOB (out of bed) in chair for no more than 45 minutes per day to facilitate wound healing. Review of Resident #69's document titled Braden Scale for Predicting Pressure Sore Risk dated 1/28/25 indicated that the Resident was a high risk for developing pressure ulcer sores. During an interview on 3/6/25 at 8:58 A.M., CNA #7 said Resident #69 requires a Hoyer lift to get out of bed and the Resident will tell staff when he/she wants to go back to bed from his/her chair. CNA #7 then said the Resident has the worst pressure ulcer in the building right now. During an interview, with a translator on 3/6/25 at 9:07 A.M., CNA #5 said Resident #69 is dependent on staff and she usually stays in his/her wheelchair for 2-3 hours each day. CNA #5 then said Resident #69 has pain on his/her backside if he/she sits for too long and he/she tells us when he/she wants to go back to bed. During an interview on 3/6/25 at 9:38 A.M., Nurse #2 said Resident #69 is up in his/her wheelchair for meal times. Nurse #2 then said the facility has a wound team that comes in weekly and the Unit Manager and Director of Nursing (DON) will round with them to document any recommendations they make for each resident. Nurse #2 said these recommendations almost always get implemented by the facility. During an interview on 3/6/25 at 10:11 A.M., Unit Manager #1 said he does rounds with the wound team when they come to the building and he will receive recommendations. Unit Manager #1 then said he will let the Nurse Practitioner or DON know, he then said he has never seen the facility not accept recommendations made by the wound team. Unit Manager #1 then said Resident #69 usually goes into his/her wheelchair by 10:30 A.M., and will stay in it for a couple of hours. During an interview on 3/6/25 at 10:11 A.M., the DON said herself and the Unit Manager will round with the wound team and implement any recommendations they make. The DON said Resident #69 is usually in his/her wheelchair for an hour to two hours depending on how much he/she can handle. The DON said the facility should be implementing the recommendations from the wound team to limit Resident #69 from being in his/her wheelchair for no more than an hour and there should be a physician's order so staff know. 49880 4. Resident #78 was admitted to the facility in March 2024 with diagnoses that included metabolic encephalopathy, moderate protein calorie malnutrition and diabetes. Review of Resident #78's MDS, dated [DATE], indicated a Brief Interview for Mental Status score of 6 out of 15, indicating severe cognitive impairment. The MDS further indicated that the Resident did not have any pressure ulcers. Review of the Braden Score for Predicting Pressure Sore Risk Assessment, dated 12/2/24, indicated that Resident #78 was at high risk for development of pressure ulcers with a score of 10. Review of Resident #78's most recent wound consult note, dated 2/28/25, indicated the following: -Stage 3 pressure ulcer (full thickness wound) is located on the sacrum. -Wound size is 1.5 cm (centimeters) length, 1.0 cm width and 0.1 cm depth. -Assessment: Not improved stage 3 pressure ulcer. -Off loading discussed: suggest mattress upgrade. Review of Resident #78's active care plan, dated 5/10/24, indicated, I have pressure ulcer or potential for pressure ulcer development [related to history] of ulcers, immobility. [sic] 4a. On 3/4/25 at 7:59 A.M., Resident #78 was observed lying in bed on his/her back. There was an air mattress on the bed set to 270 pounds. Resident #78 said that he/she has a wound on their bottom. -On 3/5/25 at 6:58 A.M., Resident #78 was observed lying in bed on his/her back. There was an air mattress on the bed set to 270 pounds. -On 3/5/25 at 9:26 A.M., and 12:57 P.M., Resident #78 was observed lying in bed on his/her back. There was an air mattress on the bed set to 330 pounds. -On 3/6/25 at 7:42 A.M., Resident #78 was observed sleeping in bed on his/her back. There was an air mattress on the bed set to 330 pounds. Review of Resident #78's medical record indicated a current weight of 141.9 pounds on 3/4/25. Review of Resident #78's active physician's orders failed to indicate an order for the use of an air mattress. During an interview on 3/5/24 at 1:00 P.M. Nurse #5 said that air mattress settings are determined by the resident's weight. She said that residents who use an air mattress should have a physician's order for use that includes the settings. Nurses check the settings every shift. During an interview on 3/6/25 at 8:27 A.M., Unit Manager #1 said that air mattress settings are based on the resident's weight. He said that there should be a physician's order for use of an air mattress with the settings included in the order. He said that if the setting of an air mattress is too high, it would be too hard and defeat the purpose of using an air mattress and a wound could potentially worsen. During an interview on 3/6/25 at 8:40 A.M., the Director of Nurses said that an air mattress should be set to the resident's weight, or the closes possible weight based on the air mattress. She said that there should be a physician's order in place indicating the setting for the air mattress and nurses should be ensuring the correct settings every shift. The Director of Nurses said that an air mattress set at a weight too high for a resident would defeat the purpose of using an air mattress. 4b. Review of Resident #78's physician's orders indicated the following: -Sacrum pressure ulcer: wash area with vashe (or similar antibacterial wound cleanser) pat try, apply calcium alginate and cover with optifoam daily and as needed, dated 3/1/25. [sic] -Blanket lifter for feet at all times when in bed every shift for wound care, dated 5/10/24. -Heel lifters while in bed every shift, dated 4/11/24. -On 3/4/25 at 7:59 A.M., Resident #78 was observed lying in bed on his/her back. An air mattress was in place. The Resident's bilateral heels were directly on the mattress, and blankets were directly over his /her feet. No blanket lift or heel lifters were in use. -On 3/5/25 at 6:58 A.M., 9:26 A.M., and 12:57 A.M., Resident #78 was observed lying in bed on his/her back. An air mattress was in place. The Resident's bilateral heels were directly on the mattress, and blankets were directly over his/her feet. No blanket lift or heel lifters were in use. -On 3/6/25 at 7:42 A.M., Resident #78 was observed sleeping in bed on his/her back. An air mattress was in place. The Resident's bilateral heels were directly on the mattress and blankets were directly over his/her feet. No Blanket lift or heel lifters were in use. Review of the March 2025 Treatment Administration Record (TAR) indicated that Resident #78's blanket lifter and heel lifters were applied as indicated in the physician's orders. During an interview on 3/6/25 at 8:27 A.M., Unit Manager #1 said that Resident #78 is accepting of care and does not refuse care. He said that staff should be implementing heel and blanket lifters as indicated in the physician's orders. He said that the Resident is at risk for skin breakdown. During an interview on 3/6/24 at 8:40 A.M., the Director of Nurses said that staff should be implementing physician's orders for a blanket lift and heel elevation. She said that if a resident refuses, it should be documented as refused.

Based on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for three Residents (#60, #17, and #41) out of a total sample of 26 residents. Specifically: 1. For Resident #60, the facility failed to ensure nursing provided two-person assistance with a lift (Sara lift, a sit-to-stand style lift). 2. For Resident #17, the facility failed to ensure he/she was consistently provided with a smoking apron while smoking. 3. For Resident #41, the facility failed to ensure nursing provided a bed and chair alarm as ordered by the physician and plan of care. Findings include: 1. Review of the facility policy titled, Lifting Machine, Using a Mechanical, dated as revised July 2017, indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturer's training or instruction. -General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 3. Types of lifts that may be available in the facility are: c. Sit-to-stand lift 1. Resident #60 was admitted to the facility in September 2022 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 12/26/24, indicated that Resident #60 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #60 required dependent (total) assistance for chair/bed-to-chair transfers. Review of Resident #60's plan of care related to toilet transfers, dated 1/21/24, indicated: - I use a Sara lift for transferring for toileting hygiene. Review of Resident #60's plan of care related to mobility and transfers, dated 1/21/24, indicated: - Dependent Sara lift 2 People Required. Review of Resident #60's Fall- Near Fall/ Assisted down or caught, incident report, dated 1/19/25 at 7:52 A.M., indicated the following: - Incident Description: this writer was at the med cart when the Certified Nursing Assistant (CNA) approached to report the near fall. When I arrived in the room, I found the resident in a supine position. Holding on with his/her right hand of metal on the side of the bed. - Immediate Action Taken: The CNA said the resident was standing on the Sara lift and suddenly he/she slides down, he tried to hold him/her he couldn't, then lower him/her to the floor. CNA said the resident did not hit his/her head. The resident as well said he/she didn't hit his/her head. - Other Info: Was lowered to the floor during transfer. Resident was weak and legs gave out. Staff Statement: 1/19/25 Resident slide off the Sara lift during transfer from bed to wheelchair. I tried to catch him/her, unsuccessful. I slid him/her to the floor. He/she did not hit her head. [sic] Review of the NURSING - Incident/Accident/Fall Reporting & Intervention Note, dated as 1/19/25, indicated: - Fall: The CNA said that the resident was standing on the Sara lift and suddenly he/she slides down, he tried to hold him/her, couldn't then lower him/her to the floor. During an interview on 3/6/25 at 9:16 A.M., CNA #6 said on 1/19/25 he transferred Resident #60 by himself when he/she slid from the Sara lift. On 3/6/25 at 7:18 A.M., the surveyor observed CNA #5 go into Resident #60's room alone with the Sara lift. The surveyor stayed at the door and the surveyor observed the CNA providing care. The surveyor did not leave the door, and the surveyor did not observe any additional staff members entering the room. On 3/6/25 at 7:41 A.M, the surveyor observed CNA #5 transfer Resident #60 alone with the Sara lift. There was a bright pink piece of paper on the Sara lift which indicated THIS LIFT REQUIRES 2 ASSISTS, there were no additional staff members in the room. During an interview on 3/6/25 at 7:47 A.M., CNA #5 said he could use one to two staff members for the Sara lift. CNA #5 said he was alone when he transferred Resident #60. During an interview on 3/6/25 at 11:53 A.M., the Director of Nursing (DON) said on 1/19/25 Resident #60 slid from the Sara lift. The DON said that CNA #6 did not use a second person when transferring Resident #60 and he should have. The DON said that after Resident #60's fall on 1/19/25 the facility educated all staff on using two assists with the Sara lift and even added bright pink paper on the lifts that indicated 2 assists. The surveyor made the DON aware of the observation on 3/6/25 at 7:41 A.M., the DON said that CNA #5 should have used a second staff member for the transfer. 2. Review of the facility policy titled, Smoking Policy - Residents, dated as revised 6/12/23, indicated the Facility shall establish and maintain safe resident smoking practices according to local, state, and federal regulations. -Policy and Procedure The facility allows smoking for residents, visitors, and staff but only in specific areas outside and for the residents under direct supervision at specific time frames. The facility prohibits any smoking inside the building. The facility screens the residents for their ability to smoke and adhere to the rules. It someone is non-compliant with the rules and conditions, then they are at risk of losing their ability to smoke, Smoking ability can be restricted or denied if staff determine there is a safety concern. 9. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges. If the resident elects to pursue smoking cessation medication or strategies, then the MD/PA/NP will be notified for an evaluation. 10. Residents are assessed on admission for smoking safety and assessed as needed. Safety aprons are recommended for individual needs and if resident cannot stand up immediately from a seated position for safety. Aprons can also be requested by any resident for a safer smoking experience 11. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 12. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Resident #17 was admitted to the facility in September 2015 with diagnoses including impulsiveness, age related cataracts, hearing loss, and chronic obstructive pulmonary disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated that Resident #17 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. This MDS indicated Resident #17 required supervision or touching assistance with eating and required assistance with dressing. Review of the facility provided form titled Smoking Residents/ Smoking Apron, dated as revised 1/22/25, indicated Resident #17 required a smoking apron while in wheel chair. Review of Resident #17's physician's order, dated 6/9/22, indicated: - Resident will be allowed to Smoke cigarettes outside under facility supervision as long as Facility Smoking Policy is followed - Smoking is a Privilege and NOT a Right - Smoking can be restricted for violating the facility smoking policy Review of Resident #17's plan of care related to smoking, dated 10/16/15, indicated: - I will wear smoking apron if warranted. - Smoking to be suspended if I become very demanding and create an outburst/scene around smoking or I am in violation of facility smoking policy. - I will be assessed for ability to smoke safely. - I will be considered a Smoking Risk and therefore be subject to smoking privileges being denied for giving cigarettes and other smoking materials and lighter to other residents. - I believe and will tell others I am exempt from following the smoking policy. I feel entitled and can smoke where I like. I have been educated and reminded on multiple occasions by staff and Administrator of smoking policy. I have been educated regarding the smoking policy with other smokers in a group and also privately. I continue to feel entitled, I continue to remain defiant regarding following policy and when staff re-educate and remind me I claim they are picking on me, being mean to me, yelling at me. Review of Resident #17's NURSING-SPEC Smoking Assessment (ADMISSION/PRN) dated 9/19/24, indicated: Resident need for adaptive equipment 7a. Smoking apron- (considerations for use of a Smoking Apron could be obesity, unable to move lower extremities, decreased sensation, poor communication, or cognitive deficit making the presence of a burning ember unnoticed or unable to alleviate situation/move or understand danger or sensations relative to burning flesh): this was checked off. On 3/4/25 at 9:31 A.M., on 3/5/25 at 11:25 A.M., and on 3/5/25 at 4:31 P.M., the surveyor observed Resident #17 in his/her wheelchair outside smoking without a smoking apron. During an interview on 3/5/25 at 11:30 A.M., Resident #17 said he/she just finished smoking, and he/she did not have a smoking apron on. Resident #17 said he/he is supposed to wear a smoking apron, but staff do not always put the apron on him/her. During an interview on 3/6/25 at 8:42 A.M., Unit Manager #1 said Resident #17 should wear a smoking apron, and he/she sometimes doesn't want to wear them, and when he/she doesn't want to wear the smoking apron staff need to get involved to ensure he/she wears the smoking apron. During an interview on 3/6/25 at 11:39 A.M., the Director of Nursing (DON) Resident #17 should wear a smoking apron, if he/she refuses the apron staff should encourage him/her to wear the apron. 3. Review of the facility policy titled, Falls and Fall Risk, Managing, dated as revised March 2018, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 8. Position change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines if the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Resident #41 was admitted to the facility in December 2019 with diagnoses including glaucoma, dementia, and psychosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/26/24, indicated that Resident #41 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #41 was dependent on staff for activities of daily living Review of Resident #41's physician's order, dated 12/5/22, indicated: - Personal Alarm while in bed (alarm 0= alarm on and working, 1= alarm not on, 2=not in bed), Please double [NAME] all resident with personal alarms while in bed, every shift. Review of Resident #41's physician's order, dated 9/5/24, indicated: - Chair alarm pad while in chair or wheelchair (alarm 0=alarm on, 1=alarm off, 2= not in chair or wheel chair), every shift. Review of Resident #41's plan of care related to high risk for falls, most recently reviewed on 11/19/24, indicated: - Personal Alarm in Bed, dated as initiated 12/5/22. - I use chair pad alarm, electronic alarm. Ensure the device is in place as needed, dated as initiated 9/6/24. Review of Resident #41's current care card, dated as revised 11/8/23, indicated: - bed alarm in bed. On 3/4/25 at 8:14 A.M., 9:59 A.M., 3:28 P.M., and at 4:11 PM the surveyor observed Resident #41 in bed without the use of a bed alarm. On 3/4/25 at 11:58 A.M., and at 4:39 P.M., the surveyor observed Resident #41 out of bed in his/her wheelchair without the use of a chair alarm. On 3/5/25 at 6:38 A.M., 9:32 A.M., and 1:19 P.M., the surveyor observed Resident #41 in bed without the use of a bed alarm. On 3/5/25 at 1:00 P.M., the surveyor observed Resident #41 out of bed in his/her wheelchair without the use of a chair alarm. During an interview on 3/5/25 at 1:07 P.M., Certified Nurse Assistant (CNA) #7 said that he routinely cares for Resident #41, CNA #7 said that Resident #41 has not used a bed alarm for about 2 years. CNA #7 said he was not aware that Resident #41 required a chair alarm. There was no chair alarm on Resident #41. During an interview on 3/5/25 at 1:10 P.M., Nurse #5 said that Resident #41 is a fall risk, and he/she uses bed and chair alarms. During an interview on 3/6/25 at 11:41 A.M., the Director of Nursing (DON) said Resident #41 has a history of falls and nursing should implement the bed and chair alarms.

Based on observations, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for three Residents (#34, #50, and #69) out of sample of 26 residents. Specifically, 1. For Resident #34, the facility failed to ensure that nursing changed Resident #34's oxygen tubing as ordered by the physician. 2. For Resident #50, the facility failed to routinely change and date nebulizer tubing. 3. For Resident #69, the facility failed to ensure oxygen was being administered per the physician's order. Findings Include: Review of the facility policy titled Oxygen Administration, undated, indicated the following: Purpose -The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation -Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. -Review the resident's care plan to assess for any special needs of the resident. 1. Resident #34 was admitted to the facility in December 2019 with diagnoses including chronic obstructive pulmonary disease, hematuria, and obesity. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/26/24, indicated that Resident #34 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #34 required oxygen therapy. On 3/4/25 at 7:53 A.M., and at 8:25 A.M., the surveyor observed Resident #34 receiving oxygen via nasal cannula. The nasal cannula tubing was dated 11/28. Resident #34 said he/she was not sure when his/her oxygen tubing was last changed by nursing and Resident #34 said he/she would allow the tubing to be changed. Review of Resident #34's physician's order, dated 8/6/20, indicated: - Oxygen - Oxygen (O2) 2 liters via nasal cannula to maintain O2 saturation above 88% - document that O2 on by initialing. Review of Resident #34's physician's order, dated 3/28/24, indicated: - Change Oxygen tubing & Humidifier every Wednesday on 11-7, every night shift, every Wednesday, change tubing and humidifier date tubing please. Review of Resident #34's Treatment Administration Record (TAR), dated February 2025, indicated nursing changed the tubing as ordered by the physician most recently on 2/26/25. On 3/4/25 at 12:19 P.M., the surveyor observed Resident #34's nasal cannula tubing dated as 3/4/25. The surveyor asked Resident #34 about the new tubing. Resident #34 laughed and said, someone came in and woke me up to change the tubing about an hour ago. During an interview on 3/5/25 at 10:13 A.M., Unit Manager #1 said oxygen tubing should be changed weekly according to the physician's orders. Unit Manager #1 reviewed Resident #34's TAR and he said that Resident #34's oxygen tubing was last changed on 2/26/25 by Nurse #3. The surveyor shared the observation of the tubing that was dated as 11/28 on 3/4/25 at 7:53 A.M. During an interview on 3/5/25 at 10:21 A.M., Nurse #3 said oxygen supplies are stored in the medication room, and when there is an order to change the oxygen tubing nursing is required to label and date the tubing with tape and a permanent marker, Nurse #3 removed a permanent marker and tape from the medication cart to show the surveyor what she would use to label and date oxygen tubing. Nurse #3 said that she could not recall ever changing Resident #34's oxygen tubing. During an interview on 3/6/25 at 11:42 A.M., the Director of Nursing (DON) said nursing should change oxygen tubing according to the physician's orders. 45343 2. Resident #50 was admitted to the facility in June 2021 with diagnoses including acute respiratory failure with hypoxia, shortness of breath, bacterial pneumonia, and asthma. Review of Resident #50's most recent Minimum Data Set (MDS), dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) exam score of 9 out of a possible 15, indicating he/she has moderate cognitive impairments. Further review of the MDS indicated Resident #50 requires dependent assistance for daily self-care activities and is on oxygen therapy. Review of Resident #50's physician orders indicated the following: - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol), 3 ml inhale orally every 6 hours for Shortness of Breath or Trouble Breathing, initiated 2/2/24. -Nebulizer-change nebulizer administration setup every week on Wednesday 3-11 shift, every evening shift, every Wednesday, initiated 4/24/24. On 3/4/25 at 8:05 A.M., and 4:09 P.M., 3/5/25 at 9:53 A.M., and 5:10 P.M., and 3/6/24 at 7:50 A.M., the surveyor observed Resident #50's nebulizer machine and tubing on his/her nightstand with the tubing dated 1/8/25. Review of the January and February Treatment Administration Record (TAR) indicated that the tubing was changed 1/15/25, 1/22/25, 2/5/25, 2/12/25, 2/19/25, and 2/26/25. During an interview on 3/6/25 at 8:41 A.M., Unit Manager #2 said the nebulizer tubing should be changed weekly and labeled with the date it was changed. During an interview on 3/6/25 at 9:10 A.M., the Director of Nursing said any resident on oxygen or a nebulizer should have the tubing changed and labeled weekly on 11 P.M. to 7 A.M. shift. 45984 Resident #69 was admitted to the facility in December 2024 with diagnoses including pressure ulcer of sacral region, anxiety disorder, bipolar disorder and bronchitis. Review of Resident #69's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident is dependent on staff for ADLs and requires oxygen therapy. The surveyor made the following observations: - On 3/4/25 at 9:20 A.M. and 12:25 P.M., Resident #69 was awake in bed not receiving any supplemental oxygen. Resident #69 said he/she believes he/she only needs to wear it at nighttime. - On 3/5/25 at 7:26 A.M., 12:03 P.M. and 12:36 P.M., Resident #69 was in his/her room, not receiving any supplemental oxygen. - On 3/6/25 at 7:11 A.M., Resident #69 was sleeping in bed not receiving any supplemental oxygen. Review of Resident #69's physician's order dated 2/28/25: Oxygen - Oxygen 2 liters via nasal cannula to maintain O2 sats (saturation) above 88% - document that O2 (oxygen) was on by initialing, every shift. Review of Resident #69's Oxygen Therapy Care Plan indicated the following intervention dated 12/30/24: Oxygen Settings: I have O2 via nasal prongs/mask @ (2) L (liters) continuously. During an interview on 3/6/25 at 9:52 A.M., Unit Manager #1 reviewed Resident #69's care plan with the surveyor and he said it needs to be updated as he believes the Resident only needs oxygen at nighttime. Unit Manager #1 said Resident #69's physician's order implies he/she should be receiving supplemental oxygen each nursing shift. During an interview on 3/6/25 at 10:11 A.M., the Director of Nursing (DON) said Resident #69's physician's order and oxygen care plan need to be updated.

Based on observation, record review and interview, the facility failed to ensure that three Residents (#61, #39 and #62), who are diagnosed with dementia, received appropriate treatment and services to attain his/her highest practical physical, mental and psychosocial well-being, out of a total sample of 26 residents. Specifically the facility failed to ensure a dignified dining experience for residents with dementia or Alzheimer's disease when staff pushed their meals away from them so that they could not reach them. Findings include: Review of the policy titled Dementia Clinical Protocol, dated 10/21/24, indicated Direct care staff will support the resident in initiating and completing activities and tasks of daily living. a. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. 1. Resident #61 was admitted to the facility in August 2021 with diagnoses that included dementia, Alzheimer's disease, anxiety disorder, pressure ulcer of right heel, and major depressive disorder. Review of Resident #61's most recent Minimum Data Set (MDS) assessment, dated 2/13/25, indicated he/she was assessed by nursing staff to have severe cognitive impairments. Further review of the MDS indicated he/she is dependent on staff for eating. On 3/4/25 from 8:15 A.M. to 8:32 A.M., the surveyor observed Resident #61 in the dining room with his/her breakfast tray just out of reach of him/her not set up for consumption, the two other tablemates were eating and being assisted by staff members. Resident #61 was observed to grab at his/her breakfast tray and his/her tablemates. Staff were observed to push away Resident #61's meal tray out of reach. On 3/4/25 from 12:06 P.M. to 12:23 P.M., the surveyor observed Resident #61 in the dining room with his/her lunch tray just out of reach of him/her not set up for consumption. Resident #61 was observed to get agitated and grind his/her teeth, the three other tablemates had their trays and were receiving assistance from staff members. Resident #61 was observed to bang his/her spoon on the table and reach out for his/her tablemates meal trays. On 3/5/25 from 8:05 A.M. to 8:11 A.M., the surveyor observed Resident #61 in the dining room with his/her breakfast tray in just out of reach of him/her not set up for consumption, the two other tablemates were eating and being assisted by staff members. On 3/5/25 from 12:13 P.M. to 12:17 P.M., the surveyor observed Resident #61 in the dining room, staff were assisting other residents with their meals. Resident #61 did not have a meal tray or assistance during this time, all other residents had meal trays during this observation period. The two other tablemates were receiving assistance from staff members who had their backs to the Resident. On 3/6/25 from 7:55 A.M. to 8:02 A.M., the surveyor observed Resident #61 in the dining room with his/her breakfast tray just out of reach of him/her not set up for consumption. Resident #61 was observed to grab at his/her breakfast tray and his/her tablemates. Staff were observed to push away Resident #61's meal tray out of reach. During an interview on 3/6/25 at 8:31 A.M., Certified Nurse Aide (CNA) #3 said there are not enough staff members on this floor to assist all the residents that need assist on this floor. CNA #3 said the tray should not be left for a resident who needs assistance with their meal. During an interview on 3/6/25 at 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each resident's care plan and CNA Kardex. During an interview on 3/6/25 at 8:49 A.M., the Director of Nursing said that she would expect residents are assisted by staff as the meal is delivered to them and the resident is not left with the tray in front of them with nothing set up. If the resident needs assistance with meals, she would expect to at least have the drinks set up for consumption. She said staff should not be putting a meal in front of a resident and then pushing it away from them and telling them to wait. 45343 2. Resident #39 was admitted to the facility in March 2016, with diagnoses including Alzheimer's Disease, dysphagia (difficulty swallowing), and major depressive disorder. Review of Resident #39's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has severe cognitive deficits. The MDS further indicated Resident #39 requires dependent assistance for eating On 3/4/25 from 12:06 P.M. to 12:24 P.M., the surveyor observed Resident #39 seated in the dining room with their lunch tray set in front of him/her at the table. Resident #39 was observed attempting to reach for food items on his/her lunch tray. There was no staff observed providing assistance with self-feeding. On 3/5/25 from 12:06 P.M. to 12:24 P.M., the surveyor observed Resident #39 seated in the dining room with their lunch tray set in front of him/her at the table. Resident #39 was observed attempting to reach for food items on his/her lunch tray. There was no staff observed providing assistance with self-feeding. On 3/6/25 from 8:04 A.M. to 8:28 A.M., the surveyor observed Resident #39 awake lying in bed with their breakfast tray left on the bedside table next to him/her. Resident #39 was observed attempting to reach for rood items on his/her breakfast tray. There was no staff observed providing assistance with self-feeding. Review of Resident #39's eating and nutrition care plan indicated the following: -EATING GOALS OVER NEXT 90 DAYS SELECT ONE: DEPENDENT, initiated 10/25/23. -Nutrition: Fed by staff utilizing cueing and encouragement to complete meals, needs fluids to swallow, initiated 12/18/24. Review of Resident #39 cognitive care plan indicated the following: - As my dementia progresses, I may become malnourished, dehydrated and behavioral because I have: difficulty noticing food and getting snacks - I do not feel as hungry/thirsty as before; I have a change in my sense of smell or taste; an inability to use eating utensils properly due to physical dexterity limitations as well as level of confusion; difficulty communicating my needs; swallowing problems; level of frustration with my lack of abilities update my MD, initiated 1/5/25. Further review of Resident #39''s Kardex (a form indicating level of assistance a resident requires) dated as of 3/13/24 indicated he/she is dependent on staff for eating. During an interview on 3/6/25 at 8:31 A.M., CNA #3 said there are not enough staff members on this floor to assist all the residents that need assist on this floor. CNA #3 said the tray should not be left for a resident who needs assistance with their meal. During an interview on 3/6/25 at 8:30 A.M., Unit Manager #2 said they do not have enough staff to feed every resident on this floor. Unit Manager #2 said staff should be following each resident's care plan and CNA Kardex. During an interview on 3/6/25 at 8:49 A.M., the Director of Nursing said that she would expect residents are assisted by staff as the meal is delivered to them and the resident is not left with the tray in front of them with nothing set up. If the resident needs assistance with meals, she would expect to at least have the drinks set up for consumption. She said staff should not be putting a meal in front of a resident and then pushing it away from them and telling them to wait. 49880 3. Resident #62 was admitted to the facility in November 2021 with diagnoses that included Alzheimer's disease. Review of Resident #62's Minimum Data Set (MDS) Assessment, dated 1/23/25, indicated a Brief Interview for Mental Status score of 0 out of 15, indicating severe cognitive impairment. The MDS further indicated the Resident is dependent for activities of daily living including eating and that the Resident complains of pain or difficulty with swallowing. Review of Resident #62's active eating assistance care plan, dated as revised 2/1/23, indicated, I have been known to try to grab out at others food. I do not know what to do with my utensils, so I need to be fed. I also have been known to take my napkin and put it in my food, my dementia has been progressing. The care plan also indicated, eating goals over the next 90 days: dependent [sic] Review of Resident #62's active cognitive function care plan, revised 9/2/23, indicated I have impaired cognitive function/dementia or impaired thought processes r/t [related to] Alzheimer's with behavioral disturbance, Vascular Dementia, Paranoia, disorganized thought, visual hallucinations, delusions, cognitive deficits, major neurocognitive disorder, altered mental status, depression. [sic] During an observation on 3/4/25 at 12:01 P.M., in the Station One dining room, Resident #62 had a meal tray in front of him/her on the table. the plate was covered, and all the drinks were covered. At 12:12 P.M., the tray remained in front of Resident #62, and he/she was trying to pull off the cover. No staff had attempted to sit with or assist the Resident. The Resident was able to partially uncover the meal, and a staff member came over, recovered the meal, pushed it further away from the resident and told him/her to wait a few more minutes. There were five other residents at the same table, all eating their meals or being assisted by staff with their meals during this time. At 12:17 P.M., a staff member sat with Resident #62 and began to assist him/her with their meal. During an interview on 3/6/25 at 8:49 A.M., the Director of Nursing said that she would expect residents are assisted by staff as the meal is delivered to them and the resident is not left with the tray in front of them with nothing set up. If the resident needs assistance with meals, she would expect to at least have the drinks set up for consumption. She said staff should not be putting a meal in front of a resident and then pushing it away from them and telling them to wait.

Based on observations, record review and interview the facility failed to ensure the physician was notified when one Resident (#28), out of a total sample of 26 residents, was not utilizing a Bipap (Bilevel positive airway pressure, a machine used to treat sleep apnea) machine as indicated in the physician's orders. Findings Include: Resident #28 was admitted to the facility in March 2016 with diagnoses that include acute on chronic respiratory failure, obstructive sleep apnea and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 11/26/24 indicated that a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated oxygen use, and did not indicate the use of non-invasive mechanical ventilation (Bipap). Review of Resident #28's physician orders indicated the following orders, dated 2/12/25: -BIPAP: Change BIPAP Device water daily (use sterile or distilled water). [sic] -BIPAP: Apply BIPAP Device at night and as needed (titrate oxygen to maintain SATS (oxygen saturation) greater than 90%) (BIPAP 0= BIPAP Device on, 1=BIPAP Device off. [sic] -On 3/4/25 at 8:06 A.M., Resident #28 was observed sitting up in bed. He/she said that he/she was having a hard time breathing. Resident #28 was on oxygen via nasal cannula at four liters per minute. Resident #28 said that he/she is supposed to use a Bipap machine at night for sleep apnea but that he/she has never used it since receiving it because the staff do not know how to apply it. The Bipap machine was observed on the bedside table with the mask in a bag. -On 3/5/25 at 6:55 A.M., Resident #28 was observed sitting up in his/her bed. Resident #28 said that the Bipap was not applied overnight and that no staff offered to apply Bipap for him/her. The Bipap machine was observed on the bedside table with the mask in a bag in the same position as the previous day. -On 3/6/25 at 7:43 A.M., Resident #28 was observed sitting up in bed. Resident #28 said that staff had not attempted to apply the Bipap machine the night before. The Bipap machine was observed on the bedside table with the mask in a bag in the same position as the previous day. The Bipap machine was observed to be unplugged with the cord wrapped up on the bedside table behind the machine. Review of the February 2024 Treatment Administration Record (TAR) indicated Bipap was not applied seven times and was applied ten times for a total of seventeen opportunities Review of the March 2024 TAR indicated that the Bipap was not applied 3/1 through 3/4 and that it was applied overnight on 3/5. Review of the medical record failed to indicate that Resident #28 refused the use of Bipap. Further review of the medical record failed to indicate that the physician was notified that the Resident was not utilizing the Bipap machine as ordered at night. Review of a physician's progress note, dated 2/27/25, failed to indicate the non-use of the Bipap machine and indicated Obstructive sleep apnea is followed, and no new hypoxia is noted. During an interview on 3/5/25 at 6:59 A.M., Nurse #4 said that Resident #28 sometimes refuses the Bipap machine. She said that it should be documented in the medical record but isn't sure if the physician is aware. During an interview on 3/5/25 at 1:00 P.M., Nurse #5 said that she works day shift with Resident #28. She said that sometimes Resident #28 refuses the Bipap at night. She said if a resident refuses a treatment then the physician should be notified and it should be documented in the medical record. She is not sure if the physician is aware that Resident #28 is not using the Bipap machine. During an interview on 3/6/25 at 8:21 A.M., Unit Manager #1 said that Resident #28 has had orders for the use of Bipap for about a month. He said the recommendations for use came from the hospital from his/her most recent hospitalization . Unit Manager #1 said that he was not aware that Resident #28 had not been utilizing the Bipap machine. Unit Manager #1 said that if the Resident is not utilizing the Bipap machine then the physician should be notified and it should be documented in the medical record, as it could have negative outcomes for the resident. During an interview on 3/6/25 at 8:46 A.M., the Director of Nursing said she would expect that if the Resident is not utilizing the Bipap machine that the physician would be notified, and it would be documented in the medical record. During a telephone interview on 3/6/25 at 10:47 A.M., Physician #1 said that he was not aware that the Resident was not utilizing the Bipap machine.

Based on interview and record review, the facility failed to report a bruise of unknown origin to the State Agency within the mandated time-frame for one Resident (#24) out of a total of 26 sampled residents. Findings include: Review of the facility policy titled Abuse Prohibition, reviewed 10/21/24, indicated It is the policy of the facility to assure an environment free of abuse, neglect, mistreatment and misappropriation of resident property. At risk resident: Resident with the highest risk, i.e., at risk of abuse and neglect include resident who have dementia; residents with no/few visitors; residents who are totally dependent on care; residents with communication disorders. Protection and Notification: Upon receiving an allegation of abuse, supervisors will take necessary steps to protect all residents and then immediately notify the Director of Nursing Services who will notify the Administrator. If the Director of Nursing is unavailable then the report will go directly to the Administrator. The facility will report and investigate all allegations of resident abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property. A thorough investigation will be completed under the direction of the Director of Nursing Services and/or Administrator. Other personnel (Social Worker, etc.) will be included in the investigation as necessary and appropriate. The results of the investigation will be documented and reviewed with the Administrator. This report and review will be completed within 24 hours of the allegation or within 2 hours of the allegation if the event involved abuse or results in serious injury and the investigation will be ongoing thereafter. The facility Administrator will provide proper notification of administrative staff and all required state and other regulatory agencies. Resident #24 was admitted to the facility in July 2021 with diagnoses that included Alzheimer's disease, dysphagia, anxiety and depression. Review of Resident #24's most recent Minimum Data Set (MDS) assessment, dated 1/14/25, indicated he/she was assessed by nursing staff to have moderate cognitive impairments. Further review of the MDS indicated he/she is dependent on staff for all Activities of Daily Living (ADLs). On 3/4/25 at 7:40 A.M. , the surveyor observed Resident #24 in bed with a dark purple bruise under his/her left eye that was approximately 3 inches by 1 inch. On 3/4/25 at 11:52 A.M., the surveyor observed Resident #24 in the dining room with a dark purple bruise under his/her left eye. During an interview on 3/6/25 at 7:43 A.M., Unit Manager #2 said Resident #24 has had a bruise under his/her left eye since 2/16/25 which was much bigger then and he/she reported this bruise to the Director of Nursing on 2/16/25. During an interview on 3/6/25 at 8:52 A.M., the Director of Nursing (DON) said she was aware of the bruise when it happened because staff told her. The DON said she did not report the bruise of unknown origin to the State Agency as potential abuse and said she is not sure if she should have. During an interview on 3/6/25 at 12:00 P.M., the Administrator said a bruise of unknown origin should be reported within two hours from when it was reported to the DON to the State Agency but was not. Review of the State Agency's reporting system from 2/16/25 to 3/5/25 failed to indicate that the facility reported Resident #24's bruise to his/her face of unknown origin.

Based on record review and interviews, the facility failed to thoroughly investigate an bruise of unknown origin, for one Resident (#24) out of a total sample of 26 residents. Specifically for Resident #24 who on 2/16/25 was found to have a bruise under his/her left eye by a Certified Nurses Aide, the facility staff failed to complete a thorough investigation. Findings include: Review of the facility policy titled Abuse Prohibition, reviewed 10/21/24, indicated It is the policy of the facility to assure an environment free of abuse, neglect, mistreatment and misappropriation of resident property. At risk resident: Resident with the highest risk, i.e., at risk of abuse and neglect include resident who have dementia; residents with no/few visitors; residents who are totally dependent on care; residents with communication disorders. Protection and Notification: Upon receiving an allegation of abuse, supervisors will take necessary steps to protect all residents and then immediately notify the Director of Nursing Services who will notify the Administrator. If the Director of Nursing is unavailable then the report will go directly to the Administrator. The facility will report and investigate all allegations of resident abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property. A thorough investigation will be completed under the direction of the Director of Nursing Services and/or Administrator. Other personnel (Social Worker, etc.) will be included in the investigation as necessary and appropriate. The results of the investigation will be documented and reviewed with the Administrator. This report and review will be completed within 24 hours of the allegation or within 2 hours of the allegation if the event involved abuse or results in serious injury and the investigation will be ongoing thereafter. The facility Administrator will provide proper notification of administrative staff and all required state and other regulatory agencies. Resident #24 was admitted to the facility in July 2021 with diagnoses that included Alzheimer's disease, dysphagia, anxiety and depression. Review of Resident #24's most recent Minimum Data Set (MDS) assessment, dated 1/14/25, indicated he/she was assessed by nursing staff to have moderate cognitive impairments. Further review of the MDS indicated he/she is dependent on staff for all Activities of Daily Living (ADLs). On 3/4/25 at 7:40 A.M. , the surveyor observed Resident #24 in bed with a dark purple bruise under his/her left eye that was approximately 3 inches by 1 inch. On 3/4/25 at 11:52 A.M., the surveyor observed Resident #24 in the dining room with a dark purple bruise under his/her left eye. During an interview on 3/6/25 at 7:43 A.M., Unit Manager #2 said Resident #24 has had a bruise under his/her left eye since 2/16/25 which was much bigger then. Unit Manager #2 said the nurse that initiated the incident failed to complete it and did not write a nursing progress note, did not alert the health care proxy (HCP) or the medical doctor (MD). Unit Manager #2 said it is her responsibility to make sure these incident reports are completed and to make sure all statements from staff are gathered but said the only statement that was obtained was from the Certified Nursing Assistant who found the bruise. Unit Manager #2 said there is still not a competed investigation done for his/her bruise nor was there an intervention put into place. During an interview on 3/6/25 at 8:52 A.M., the Director of Nursing (DON) said a nurse initiated a incident report for the bruise found under Resident #24's left eye but never finished it. The DON said the nurse should have gathered more statements, wrote a nursing progress note, alerted the HCP and MD, do a skin check for the newly found bruise and put an intervention into place to keep the resident safe but none of that was done. During an interview on 3/6/25 at 12:00 P.M., the Administrator said she would expect that her staff complete a full and thorough investigation on a bruise of unknown origin but it was not.

Based on observation, record reviews and interviews, the facility failed to ensure resident centered care plans were implemented for three Residents (#58, #60 and #50) out of a total sample of 26 residents. Specifically, 1. For Resident #58, the facility failed to implement his/her clothing protector at meal times per the plan of care. 2. For Resident #60, the facility failed to ensure nursing implemented his/her care plan for transfers which indicated he/she required two person assist. 3. For Resident #50, the facility failed to implement oxygen when out of his/her room. Findings include: Review of the facility policy titled Assessments and Care Planning, dated 12/16, indicated the following: The comprehensive care plan will: -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Aid in preventing or reducing decline in the resident's functional status and/or functional level. -The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). -Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 1. Resident #58 was admitted to the facility in August 2020 with diagnoses that included dementia, glaucoma, transient visual loss, and delusional disorders. Review of Resident #58's most recent Minimum Data Set (MDS) assessment, dated 11/28/24, indicated he/she scored a one out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further review of the MDS indicated he/she requires partial/moderate assistance from staff for eating. On 3/4/25 from 8:14 A.M. to 8:20 A.M., the surveyor observed Resident #58 in the dining room eating from his/her breakfast tray without a clothing protector on. On 3/5/25 from 8:00 A.M. to 8:27 A.M., the surveyor observed Resident #58 in the hallway eating from his/her breakfast tray without a clothing protector on. On 3/6/25 from 8:18 A.M. to 8:34 A.M., the surveyor observed Resident #58 in his/her bed eating from his/her breakfast tray without a clothing protector on. Review of Resident #58's eating care plan, dated 2/19/24, indicated I feel more comfortable and protected when I wear a cloth towel protector at meals. During an interview on 3/6/25 8:30 A.M., Unit Manager #2 said she expects nursing staff to follow each resident's care plan. During an interview on 3/6/25 at 8:59 A.M., the Director of Nurses said she expects staff to follow each resident's care plan and if it says to put a clothing protector on Resident #58 then he/she should have one on at meals. 44095 2. Review of the facility policy titled, Lifting Machine, Using a Mechanical, dated as revised July 2017, indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturer's training or instruction. -General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 3. Types of lifts that may be available in the facility are: c. Sit-to-stand lift Resident #60 was admitted to the facility in September 2022 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 12/26/24, indicated that Resident #60 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #60 required dependent (total) assistance for chair/bed-to-chair transfers. Review of Resident #60's plan of care related to toilet transfers, dated 1/21/24, indicated: - I use a Sara lift for transferring for toileting hygiene. Review of Resident #60's plan of care related to mobility and transfers, dated 1/21/24, indicated: - Dependent Sara lift 2 People Required. Review of Resident #60's Fall- Near Fall/ Assisted down or caught, incident report, dated 1/19/25 at 7:52 A.M., indicated the following: - Incident Description: this writer was at the med cart when the Certified Nursing Assistant (CNA) approached to report the near fall. When I arrived in the room, I found the resident in a supine position. Holding on with his/her right hand of metal on the side of the bed. - Immediate Action Taken: The CNA said the resident was standing on the Sara lift and suddenly he/she slides down, he tried to hold him/her he couldn't, then lower him/her to the floor. - Other Info: Was lowered to the floor during transfer. Resident was weak and legs gave out. Staff Statement: 1/19/25 Resident slide off the Sara lift during transfer from bed to wheelchair. I tried to catch him/her, unsuccessful. I slid him/her to the floor. He/she did not hit her head. [sic] Review of the NURSING - Incident/Accident/Fall Reporting & Intervention Note, dated 1/19/25, indicated: - Fall: The CNA said that the resident was standing on the Sara lift and suddenly he/she slides down, he tried to hold him/her, couldn't then lower him/her to the floor. During an interview on 3/6/25 at 9:16 A.M., CNA #6 said on 1/19/25 he transferred Resident #60 by himself when he/she slid from the Sara lift. On 3/6/25 at 7:18 A.M., the surveyor observed CNA #5 go into Resident #60's room alone with the Sara lift. The surveyor stayed at the door and the surveyor observed the CNA providing care. The surveyor did not leave the door, and the surveyor did not observe any additional staff members entering the room. On 3/6/25 at 7:41 A.M, the surveyor observed CNA #5 transfer Resident #60 alone with the Sara lift. There was a bright pink piece of paper on the Sara lift which indicated THIS LIFT REQUIRES 2 ASSISTS, there were no additional staff members in the room. During an interview on 3/6/25 at 7:47 A.M., CNA #5 said he could use one to two staff members for the Sara lift. CNA #5 said he was alone when he transferred Resident #60 from the bed to the wheelchair. During an interview on 3/6/25 at 11:53 A.M., the Director of Nursing (DON) said that nursing should follow the care plan and use a two person assist. 45343 3. Resident #50 was admitted to the facility in June 2021 with diagnoses including acute respiratory failure with hypoxia, shortness of breath, bacterial pneumonia, and asthma. Review of Resident #50's most recent Minimum Data Set (MDS), dated [DATE], indicated that he/she had a Brief Interview for Mental Status (BIMS) exam score of 9 out of a possible 15, indicating he/she has moderate cognitive impairments. Further review of the MDS indicated Resident #50 requires dependent assistance for daily self-care activities and is on oxygen therapy. Review of Resident #50's physician orders indicated the following: -Oxygen 2-3 liters via nasal cannula to maintain O2 Sats above 88% - document that O2 on by initialing (3 OF 3), every shift, initiated 3/14/24. -Place portable liquid oxygen on when out of room, initiated 4/24/24. Review of Resident #50's oxygen care plan indicated the following: -Oxygen settings: I have O2 (oxygen) via nasal prongs/mask @ (2-3) L (liters) continuously, initiated 3/14/24. -Provide me extension tubing or portable oxygen apparatus if I am out of my room, initiated 3/14/24. On 3/4/25 at 12:15 P.M., and 4:32 P.M., and 3/5/25 at 9:53 A.M., 12:13 P.M., 12:26 P.M., and 5:10 P.M., Resident #50 was observed in the dining room not receiving oxygen and with his/her portable oxygen tank and tubing attached to the handle of his/her wheelchair. Review of Resident #50's nursing documentation failed to indicate Resident #50 refused to wear his/her oxygen when out of his/her room. During an interview on 3/6/25 at 8:41 A.M., Unit Manager #2 said Resident #50 should have his/her oxygen on when he/she is out of their room, but at times he/she takes it off. During an interview on 3/6/25 at 9:10 A.M., the Director of Nursing said Resident #50's oxygen should be on when out of his/her room and documented if the resident refuses.

Based on records reviewed, interviews and observations for one of four sampled residents (Resident #1), the Facility failed to prevent an accident with injury, when on 2/24/19 Resident #1, who was known by staff to require leg rests when being transported in his/her wheelchair, was knowingly transported by Certified Nurse Aide (CNA) #1 in his/her wheelchair without leg rests, Resident #1 put his/her foot down during the transport, fell forward out of the wheelchair and sustained a laceration to his/her forehead, which required sutures to close. Findings include: The Facility Policy titled Assistive Devices and Equipment (revised in (MONTH) (YEAR)) indicated devices and equipment that assist with resident mobility and safety are provided, and recommendations for the use are based on the comprehensive assessment and documented in the resident's plan of care. Resident #1's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment, dated 01/31/19, indicated Resident #1 was cognitively intact, had upper extremity range of motion impairment on both sides and required extensive assist with one person assist for locomotion with a wheelchair. The Certified Nurse Aide (CNA) Care Plan, dated 09/11/17, (no additional updated care plans provided at time of survey) indicated Resident #1 was unable to ambulate and was totally dependant on others for the use of the wheelchair. Review of Resident #1's CNA Care Plan indicated there was no documentation to support the facility had provided updated information in the plan care to the CNA's related to the need for leg rests. There was no section in the plan of care that referenced the use of leg rests. Resident #1's Interdisciplinary Care Plan, initiated on 07/18/17, updated with a target date of 01/04/19, indicated he/she was totally dependant on one staff member for locomotion with a wheelchair due to limited physical mobility related to weakness. The Progress Note, dated 02/24/19, indicated Resident #1 fell out of his/her wheelchair and sustained a deep cut to the left side of the forehead, and he/she was to be sent to the hospital for further evaluation and treatment as ordered by the Physician. The Hospital Discharge Instructions, dated 02/24/19, indicated Resident #1 was diagnosed with [REDACTED]. The Progress Note, dated 02/25/19, indicated Resident #1 returned to the Facility with five sutures to the laceration on his/her forehead. The Fall Reduction Committee document indicated that prior to 02/24/19, Resident #1 had no history of falling from the wheelchair since the year (YEAR). The Surveyor interviewed CNA #1 at 1:15 P.M. On 03/07/19. CNA #1 said she knew Resident #1 required leg rests attached to the wheelchair. CNA #1 said on 02/24/19 at 4:00 P.M. she transferred Resident #1 out of bed into the wheelchair and brought him/her out to the hallway. CNA #1 said she could not locate the wheelchair leg rests, so he/she transported Resident #1 out into the hallway, in the wheelchair without them. CNA #1 said at approximately 8:00 P.M, on 2/24/19, she transported Resident #1 back to his/her bedroom without his/her leg rests attached to the wheelchair. CNA #1 said she needed to verbally prompt Resident #1 a few times to elevate his/her legs while being transported the wheelchair. CNA #1 said as she entered the bedroom propelling the wheelchair, Resident #1 placed a foot down on the floor, which stopped the wheelchair from moving and he/she fell forward to the floor striking his/her head and obtaining a laceration. Review of the Daily Nursing Sheet for 02/22/19, 02/23/19 and 02/24/19 indicated Nurse #1, Nurse #2, Nurse #3, Nurse #4, CNA #2, CNA #3 and CNA #4 were assigned to work shift(s) during those three days on Resident #1's Unit. The Surveyor interviewed Nurse #1 at 12:10 P.M., Nurse #2 at 12:50 P.M., Nurse #3 at 10:55 A.M., Nurse #4 at 11:50 A.M., CNA #2 at 10:40 A.M., and CNA #3 at 11:15 A.M. on 03/15/19. Nurse #1, Nurse #2, Nurse #3, Nurse #4, CNA #2, and CNA #3 all said, it was known by staff that Resident #1 required the use of leg rests when he/she was transported in the wheelchair by staff. The Surveyor interviewed the Director of Clinical Services at 11:20 A.M. on 03/07/19. The Director of Clinical Services said Resident #1 required leg rests when he/she was in the wheelchair and said CNA #1 was aware of this need. The Director of Clinical Services said CNA #1 propelled Resident #1 on 2/24/19, seated in the wheelchair without leg rests, Resident #1 put his/her feet down and fell forward out of the wheelchair hitting his/her head on the floor.

Based on records reviewed and interviews for 1 of 3 sampled residents (Resident #1) the facility failed to prevent a medication error when Nurse #1 gave Resident #1 medications prescribed to another resident. Resident #1 became lethargic and his/her heart rate and blood pressure dropped. Resident #1 was transferred to the Hospital where he/she was treated for [REDACTED]. Findings include: The Facility Policy titled Administering Medications, revised December 2012, indicated the individual administering medications must verify the resident's identity before giving the resident his/her medications. Resident #1's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 2 which indicates cognitive impairment. A Nurse Progress Note, dated 9/2/16, indicated Resident #1 received another resident's medication, in error, which included: - [MEDICATION NAME] 25 milligrams (mg; a beta blocker medication to treat high blood pressure) - [MEDICATION NAME] 20 mg (a medication to treat heartburn) - [MEDICATION NAME] 100 mg (an antipsychotic medication to treat [MEDICAL CONDITION]) - [MEDICATION NAME] 50 mg (an antidepressant used to treat depression) - Klonopin 0.75 mg (a sedative used to treat [MEDICAL CONDITION] or anxiety) - Acidophilus ( a medication used to maintain an acidic environment within the body) - Cranberry Capsule (a medication to prevent and treat urinary tract infections) The Nurse Progress Note indicated the Nurse Practitioner and Resident #1's Legal Guardian were notified regarding the medication error, and orders were obtained to monitor Resident #1's vital signs and neurological signs. At approximately 1:00 P.M. Resident #1 blood pressure was 78/60 (normal is 120/80), his/her heart rate was 48 (normal is 60-100), and he/she had increased lethargy. The Nurse Practitioner was notified and Resident #1 was transferred to the hospital for evaluation. The surveyor interviewed Nurse #1 at 1:35 P.M. on 10/21/16. Nurse #1 said she administered Resident #1 another resident's medication after becoming distracted with an altercation that occurred on the unit. The Medication Administration Incident Report, dated 9/2/16, indicated Nurse #1 administered the wrong dose of medication to the wrong patient and failed to identify the patient prior to administering the medications. The Hospital Transfer Report, dated 9/4/16, indicated Resident #1's primary discharge [DIAGNOSES REDACTED]. Resident #1 received intravenous (administered directly into a vein) fluids for his/her low blood pressure and heart rate. Resident #1 also had a prolonged QT wave (a heart rhythm disorder) on his/her EKG (an electrocardiogram test used to check for problems with the electrical activity of the heart) and was given [MEDICATION NAME] (a medication given to treat symptomatic [MEDICAL CONDITION] secondary to a beta blocker overdose).

Based on interviews and record review for 1 of 3 sampled residents (Resident #1), who required assistance from staff with care, the Facility failed to ensure that the Certified Nurse Aide (CNA) #1 followed Resident #1's plan of care, which resulted in Resident #1 sustaining a fractured right hip. On 12/27/13, CNA #1 provided personal care to Resident #1 without a second staff member present. During care, Resident #1 turned, began to fall out of bed, and CNA #1 grabbed his/her right leg to keep him/her from falling. CNA #1 heard a cracking sound (from Resident #1's leg); and Resident #1 was assessed, transferred to the Hospital, and diagnosed with [REDACTED]. Findings include: The CNA Kardex (used by staff to communicate a resident's care needs), dated 9/20/13, indicated Resident #1 required assistance of two staff for positioning and bathing. The Plan of Care regarding bed mobility and bathing, dated 9/30/13, indicated Resident #1 required assistance of two staff for bed mobility and bathing. The Surveyor toured the Long Term Care Unit on 2/27/13 at 7:30 A.M. and 11:00 A.M. and observed that the facility kept the CNA Kardex (used as a reference by direct care staff which contained a resident's care needs) with the Nurse Aide Daily Flow Sheet. The Assignment Sheets, dated 12/1/13, 12/6/13, 12/10/13, 12/11/13, 12/12/13, 12/13/13, and 12/26/13, indicated CNA #1 cared for Resident #1. The Nurse Aide Daily Flow Sheet, dated from 12/1/13 to 12/31/13, indicated CNA #1 documented having provided Resident #1 with assistance to reposition on 12/1/13, 12/6/13, 12/10/13 to 12/13/13, and 12/27/13. CNA #1 documented Resident #1 was repositioned with the assistance of two staff members. The Progress Note, dated 12/27/13 at 11:57 P.M., indicated while CNA #1 provided personal care to Resident #1 in bed, Resident #1 became resistive, grabbed the side rail, and turned to the side. The Progress Note indicated as Resident #1 turned to the side, he/she began to slide off of the bed. The Progress Note indicated CNA #1 grabbed Resident #1 to prevent him/her from falling and heard a crack. The Surveyor interviewed CNA #1 at 10:25 A.M. on 2/27/14. CNA #1 said on 12/27/13, he did not have another staff present when he bathed Resident #1 because he thought Resident #1 did not require assistance of two staff for bathing and turning. CNA #1 said when Resident #1 turned, his/her left leg swung over his/her right leg and the momentum caused Resident #1 to start falling off the bed. CNA #1 said he grabbed Resident #1's right leg, the leg closest to him, to prevent Resident #1's fall and when he grabbed Resident #1's right leg he heard a snap. CNA #1 said Resident #1 complained of pain and he sent for the nurse. The Progress Note, dated 12/27/13, indicated the nurse assessed Resident #1 whose right leg was shorter than the left leg (abnormal assessment finding indicative of a possible fracture), Resident #1 complained of pain, and was transferred out to the Hospital for evaluation. The Radiology Report, dated 12/27/13, indicated Resident #1 sustained a right [MEDICAL CONDITION]. The Surveyor interviewed the Director of Nurses (DON) at 10:00 A.M. on 2/27/14. The DON said CNA #1 did not follow Resident #1's plan of care which contributed to Resident #1's right [MEDICAL CONDITION].

Based on interviews and review of the clinical record for 1 of 3 sampled residents (Resident #1), for required assistance from staff for care, the Facility failed to ensure that the Certified Nurse Aide (CNA) #1 bathed and turned Resident #1 with assistance of two staff, resulting in Resident #1's fractured right leg. During care, Resident #1 turned, began to fall out of bed, and CNA #1 grabbed his/her right leg to keep him/her from falling. CNA #1 heard a snap and resident sustained [REDACTED]. Findings include: The Surveyor interviewed the Rehabilitation Director at 12:50 P.M. on 2/27/14. The Rehab Director said Resident #1 assisted with turning by grabbing the side rail and pulling his/herself over, however, Resident #1 needed two staff present as he/she tended to get very anxious and agitated and needed encouragement and calming. The Nurse Aide Daily Flow Sheet, dated from 12/1/13 to 12/26/13, indicated two staff assisted Resident #1 with transfers, bed mobility, and bathing. The Nurse Aide Daily Flow Sheet, indicated CNA #1 documented having provided Resident #1 with assistance to reposition on 12/1/13, 12/6/13, 12/10/13 to 12/13/13, and 12/27/13. CNA #1 documented Resident #1 was repositioned with the assistance of two staff members. The Assignment Sheets, dated 12/1/13, 12/6/13, 12/10/13, 12/11/13, 12/12/13, 12/13/13, and 12/26/13, indicated that CNA #1 cared for Resident #1. The Surveyor interviewed CNA #4 at 1:47 P.M. on 2/27/14. CNA #4 said that on 12/27/13 he assisted CNA #1 with Resident #1's transfer back to bed he then left the room. CNA #4 said CNA #1 did not ask him to assist with Resident #1's personal care or with turning and repositioning. The Surveyor interviewed CNA #5 at 2:05 P.M. on 2/27/13 and CNA #6 at 1:25 P.M. on 2/28/14. CNA #5 and CNA #6, both scheduled 12/27/13 with CNA #1, said CNA #1 did not ask them for assistance with Resident #1's personal care or with turning and repositioning. The Progress Note, dated 12/27/13 at 11:57 P.M., indicated while CNA #1 provided personal care to Resident #1 in bed, Resident #1 became resistive, grabbed the side rail, and turned to the side. The Progress Note indicated as Resident #1 turned to the side, he/she began to slide off of the bed. The Progress Note indicated CNA #1 grabbed Resident #1 to prevent him/her from falling and heard a crack. The Surveyor interviewed CNA #1 at 10:25 A.M. on 2/27/14. CNA #1 said on 12/27/13 Resident #1 became agitated and anxious but he could not remember why. CNA #1 said he did not have another staff present when he bathed Resident #1 because he thought Resident #1 did not require assistance of two staff for bathing and turning. CNA #1 said he repositioned Resident #1 in bed without assistance prior to 12/27/13. The Surveyor toured the Long Term Care Unit on 2/27/13 at 7:30 A.M. and 11:00 A.M. and observed that the facility kept the CNA Kardex with the Nurse Aide Daily Flow Sheet. CNA #1 said Resident #1 assisted with turning by grabbing onto the rail and pulling his/herself over to the right side of the bed. CNA #1 said there were 2 rails up on the right side of the bed. CNA #1 said he stood on the left side of the bed as Resident #1 turned toward the right. CNA #1 said when Resident #1 turned, his/her left leg swung over his/her right leg and the momentum caused Resident #1 to start falling off the bed. CNA #1 said he grabbed Resident #1's right leg, the leg closest to him, to prevent Resident #1's fall. CNA #1 said when he grabbed Resident #1's right leg he heard a snap. CNA #1 said Resident #1 complained of pain and he sent for the nurse. The Progress Note, dated 12/27/13, indicated the nurse assessed Resident #1 whose right leg was shorter than the left leg (abnormal finding indicative of a possible fracture). The Progress Note indicated Resident #1 rated his/her pain as 10/10. The Progress Note indicated Resident #1 was transferred out to the Hospital for evaluation. The Surveyor interviewed Nurse #1 on 2/27/14 at 9:35 A.M. Nurse #1 said that on 12/27/13 CNA #1 came to her and reported he had just broken Resident #1's leg. Nurse #1 said Resident #1 told her he rolled Resident #1 over to provide care when Resident #1 began to roll out of bed. Nurse #1 said CNA #1 told her that he grabbed Resident #1 to keep him/her from falling and heard a snap. Nurse #1 said when she assessed Resident #1, his/her right leg was shortened. Nurse #1 said she sent Resident #1 to the Hospital and after spoke with CNA #1. Nurse #1 said CNA #1 told her he did not have a second staff member present when he bathed Resident #1 and he/she repositioned. The Radiology Report, dated 12/27/13, indicated Resident #1 suffered a right hip fracture. The Surveyor interviewed the Director of Nurses (DON) on 2/27/14 at 10:00 A.M. The DON said Resident #1 returned to the Facility after surgical repair of his/her hip fracture.

Based on interview and record review, for three of four sampled residents (Resident #1, Resident #2 and Resident #3, ), the Facility failed to ensure that Certified Nurse Aide (CNA) #1 immediately reported allegations of abuse of Resident #1, Resident #2 and Resident #3 by Accused CNA #1. In addition, until 3/22/11, the Facility failed to thoroughly investigate and interview all identified victims, including Resident #3 as well other residents, who may have been abused or witnessed abuse, and staff. Findings included: 1. Review of the Facility's internal investigation documents indicated that on 3/15/11, CNA #1 provided a written statement (Document #1) which indicated that approximately two weeks earlier CNA #1, while assisting Accused CNA #1 with Resident #1's incontinence care, heard Resident #1 say, Stop it! This is sexual abuse! I will report you! CNA #1 indicated CNA #1 never reported this incident to any nurse prior to 3/15/11. Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, dated 3/17/11 with an assessment reference date of 3/10/11, indicated Resident #1 scored thirteen out of fifteen correct answers on the Brief Interview for Mental Status (BIMS), a score which indicated Resident #1 had unimpaired cognition.The MDS indicated that Resident #1 required the assistance of two people for transfers and positioning in bed. The MDS indicated that Resident #1 was incontinent of bowel and bladder. Surveyor #1 interviewed Resident #1 at 1:30 P.M on 3/21/11 and at 3:30 P.M. on 3/22/11. Resident #1 said that every time Accused CNA #1 was assigned to care for Resident #1 or Accused CNA #1 answered Resident #1's call bell when Resident #1 needed incontinence care, Resident #1 knew Resident #1 was going to be sexually abused (finger in anus) by Accused CNA #1. Resident #1 said it was as if Resident #1 had no choice (but to be subjected to Accused CNA #1's actions). Resident #1 said that there was no mistaking what Accused CNA #1 was doing (when Accused CNA #1 put Accused CNA #1's finger in Resident #1's anus). Resident #1 also said that Accused CNA #1 liked to talk dirty to Resident #1 at these times. Surveyor #1 interviewed CNA #1 at 2:15 P.M. on 3/21/11. CNA #1 said and demonstrated to the Surveyor #1 that during the care episode in question with Resident #1 and Accused CNA #1, CNA #1 was facing Resident #1 holding Resident #1 in place as Accused CNA #1 cleaned Resident #1's perineal area from behind. CNA #1 indicated that Accused CNA #1 responded to Resident #1's upset statements (above) by laughing, saying it was joke and telling Resident #1 that CNA #1 was Resident #1's friend. CNA #1 indicated that from CNA #1's position, CNA #1 could not visualize Resident #1's backside or what Accused CNA #1 was actually doing to upset Resident #1. CNA #1 indicated that this kind of episode would occur between Resident #1 and Accused CNA #1 whenever CNA #1 assisted Accused CNA #1 with Resident #1's incontinence care. Surveyor #1 also reviewed a second written statement (Document #2), dated 3/15/11, provided by CNA #1 for the Facility's internal investigation and questioned CNA #1 about it while the ADON remained in the interview. In Document #2, CNA #1 indicated that on a recent unspecified date (subsequently determined as 3/8/11), Resident #1 approached the unit nurses' station in the wheelchair and confronted Accused CNA #1 in front of the nursing staff present (two unidentified nurses, CNA #1, CNA #2) with allegations of sexual abuse. CNA #1 indicated that the two nurses seemed to not hear what Resident #1 said, but CNA #1 heard it and heard CNA #2 tell Accused CNA #1 words to the effect of watch what you are doing (with Resident #1) or keep your hands to yourself. Resident #1 went on to tell Surveyor #1 that Resident #1 had recently (between 3/1/11 and 3/8/11) attempted to report the sexual abuse by Accused CNA #1 to an unidentified evening shift African-American female nurse. Resident #1 said Resident #1 was sure the unidentified nurse was not a CNA because the unidentified nurse pushed a medication cart and distributed medications to residents. Resident #1 said the unidentified nurse responded to Resident #1's report of sexual abuse by saying, That's a serious accusation. You should stop saying that. Resident #1 said that subsequent to Resident #1 making this report to the unidentified nurse, Resident #1 saw Accused CNA #1 at work in the Facility. 2. Review of the Facility's internal investigation documents indicated that on 3/15/11, CNA #1 provided a written statement (Document #1) which indicated that approximately two weeks earlier CNA #1, while assisting Accused CNA #1 with Resident #2's incontinence care, witnessed Accused CNA #1 pinch Resident #2's nipples and flick Resident #2's testicles causing Resident #2 to say, Stop it! CNA #1 indicated CNA #1 never reported this incident to any nurse prior to 3/15/11. Review of Resident #2's CNA Care Plan, reviewed 10/5/10, indicated Resident #2 was well-spoken and alert and oriented to person, place and time. Review of Resident #2's care plans, last reviewed 3/17/11, for mobility and activities of daily living, especially incontinence care and bed mobility, indicated that Resident #2 was dependent on two staff members for bed mobility and incontinence care and that Resident #2 was dependent on one staff member for locomotion (long distances) in the wheelchair. Surveyor #1 interviewed Resident #2 at 11:40 A.M. on 3/22/11. Resident #2 said that it was true that Accused CNA #1 had flicked Resident #2's testicles when Resident #2 was on Resident #2's side in bed receiving incontinence care from Accused CNA #1. Surveyor #1 reviewed the 3/15/11 documented interview between Resident #2 and the Director of Admissions (male nurse). The Admissions Director indicated Resident #2 stated that Accused CNA #1, on numerous occasions during Resident #2's incontinence care, would lotion Accused CNA #1's hand and stroke Resident #2's genitals. The Admissions Director indicated that Resident #2 stated Resident #2 once told Accused CNA #1 if Accused CNA #1 did not stop it, Resident #2 was going to report Accused CNA #1. The Admissions Director indicated Resident #2 stated that Accused CNA #1 responded by saying if Resident #2 reported Accused CNA #1 it would be the last thing Resident #2 ever did. 3. Review of the Facility's internal investigation documents indicated that on 3/15/11, CNA #1 provided a written statement (Document #1) which indicated that on 3/9/11 CNA #1, while assisting Accused CNA #1 with Resident #3's transfer, witnessed Accused CNA #1 push Resident #3 in the head a couple of times causing Resident #3 to tell Accused CNA #1 to stop it! Document #1 indicated Accused CNA #1 told Resident #3 that Accused CNA #1 was just kidding. Documentation #1 indicated that CNA #1 stated this kind of treatment to Resident #3 by Accused CNA #1 would occur whenever CNA #1 assisted Accused CNA #1 with Resident #1's care. CNA #1 indicated CNA #1 never reported this incident to any nurse prior to 3/15/11 Resident #3's quarterly Minimum Data Set (MDS), dated [DATE] with an assessment reference date of 3/10/11, indicated Resident #3 could hear and see adequately and had unimpaired expressive or receptive communication skills. The MDS indicated Resident #3 scored eleven out of fifteen correct answers on the BIMS, which indicated moderately impaired cognition (range 8-12 correct answers of fifteen). The MDS indicated Resident #3 was totally dependent on two people for bed mobility, transfers between surfaces or positions, dressing, toileting, personal hygiene and bathing. The MDS indicated Resident #3 did not ambulate. Review of Resident #3's CNA Care Plan, dated 10/5/10, indicated Resident #3 mumbled when communicating, was alert and oriented at times, confused at other times and had an impaired short-term memory. The CNA Care Plan indicated that Resident #3 could understand verbal instructions and utilized a wheelchair with assistance from another. Surveyor #2 also interviewed CNA #1 at 2:13 PM on 3/24/11. CNA #1 said that a couple of times CNA #1 observed Accused CNA #1 go up to Resident #3 specifically, unrelated to any care, and tap Resident #3 on the head and/or arms as one might do to get a child angry. CNA #1 said that Resident #3 did not like to be touched by people at baseline and each time Accused CNA #1 would touch Resident #3 in the manner described, Resident #3 would tell Accused CNA #1 to stop it. CNA #1 said that Accused CNA #1 would stop the behavior and tell Resident #3 that Accused CNA #1 was kidding. 4. On 3/21/11, the Administrator and ADON said the Facility had only interviewed Resident #1 and Resident #2 related to the allegations of abuse by the Accused CNA #1. On 3/22/11, the ADON interviewed all of the residents who resided on Resident #3's unit including Resident #3, who had been purported by the Facility Administrator (to Surveyor #1 and Detective #1) to be uninterviewable. The ADON documented Resident #3's responses to the interview questions and wrote a narrative describing the interview. The ADON indicated Resident #3, when asked how staff treated Resident #3, stated that it all depended on the way the staff person felt. If the staff person was having a bad day the staff person could be abusive such as pushing or hitting Resident #3.

Based on interview and record review, the Facility failed to ensure for one of four sampled residents (Resident #4) that care was provided in a manner that maintained or enhanced Resident #4's dignity and respect. Certified Nurse Aide (CNA) #1 reported that on the evening shift on 3/11/11, when the Accused Certified Nurse Aide (CNA) #1 and CNA #1 transferred Resident #4 to bed, the Accused CNA #1 said I do not like this "[***] ing" person (Resident #4) and I do not like this job or words to that effect. Findings included: The admission record indicated that Resident #4 was admitted to the Facility in January 2010. A Physician' s note, dated 1/25/10, indicated that Resident #4 's Health Care Proxy was activated due to Resident #4's dementia and confusion. A hospice note, dated 3/8/11, indicated that Resident #4 became a hospice patient for care and comfort measures. The annual Minimum Data Set (MDS) Assessment, dated 1/20/11, indicated: Resident #4' s hearing was adequate: Resident #4 had short term and long term memory problems, and Resident #4 had severely impaired cognitive skills for daily decision making. The plan of care' s intervention, dated 3/17/11, regarding Resident #4 's dependency on staff for activities, cognitive stimulation and social interaction indicated all staff were to converse with Resident #4 while providing care. The Administrator said Resident #4 was not interviewable due to Resident #4's memory impairment and medical condition. Certified Nurse Aide (CNA) #1 was interviewed on 3/21/11 at approximately 2:15 PM and on 3/24/11 at approximately 2 PM for clarification. CNA #1 said and CNA #1's statement, dated 3/15/11, dictated to the Assistant Director of Nurses (ADON) for the Facility's internal investigation indicated that during the evening shift on 3/11/11, the Accused CNA #1 and CNA #1 transferred Resident #4 back to bed. CNA #1 said and CNA #1's statement indicated that during the transfer the Accused CNA #1 forcefully transferred Resident #4 into the bed. CNA #1 said and CNA #1's statement indicated that in front of Resident #4 and CNA #1 the Accused CNA #1 said I do not like this "[***] ing" resident (Resident #4) and I do not like this job or words to that effect. CNA #1 said Resident #4 did not say anything. CNA #1 said CNA #1 was sad and mad with the Accused CNA #1 transferring Resident #4 too fast and with the Accused CNA #1's comments regarding Resident #4 and the job. Detective #1 was interviewed on 3/22/11 at approximately 10:30 AM. Detective #1 said during the Accused CNA #1's interview at the local police station, the Accused CNA #1 said that the incident with Resident #4 during the evening shift of 3/11/11, occurred as described in CNA #1's statement for the Facility's internal investigation. The Accused CNA #1 was interviewed on 3/21/11 at approximately 3:10 PM. The Accused CNA #1 said during the evening shift on 3/11/11, the Accused CNA #1 and CNA #1 transferred Resident #4 to bed. The Accused CNA#1 said that Accused CNA #1 did say in front of Resident #4 and CNA #1 that Accused CNA #1 didn' t like Resident #4 and Accused CNA #1 did not like the job.