Every finding on record at Vernon Rehabilitation and Healthcare Center

Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews for three sampled residents (Resident #16, Resident #26 and Resident #109) with open wounds, the facility failed to ensure the residents were placed on Enhanced Barrier Precautions (EBP) to ensure appropriate personal protective equipment (PPE) is utilized when providing resident care activities. The findings include: Resident #16's diagnoses included type 2 diabetes mellitus, mild protein-calorie malnutrition and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, required maximal assistance with dressing, personal hygiene and supervision with ambulation. Review of the wound list provided by the facility identified Resident #16 had a vascular wound to the left great toe. Review of the facility's EBP tracking for July 2026 that was last updated on 7/22/26 at 9:30 AM failed to identify Resident #16 was placed on EBP due to a wound on the left great toe. The wound progress note dated 7/16/26 at 11:49 AM written by MD #1 identified Resident #16 was evaluated for a new open wound to the left great toe that appeared to be vascular in origin. The note further identified the wound is mainly covered in fibrinous tissue with a small amount of granulation and will begin alginate with silver to attempt to dry out and close the wound. The wound progress note dated 7/23/26 at 10:01 AM written by MD #1 identified the wound is all granulation but is measuring larger with large amount of drainage. The note further identified there were no peri wound infectious signs and would increase frequency to twice daily to ensure dressings changed and moisture controlled. Review of Resident #16's clinical record failed to reflect that the resident was placed on EBP when it was first identified. Observation on 7/23/26 at 10:30 AM failed to identify posted signage outside the resident's room identifying the need for Enhanced Barrier Precautions (EBP) which should note the need to wear gloves and gown for the following high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. Interview with LPN #4 on 7/23/26 at 11:36 AM identified that when a resident is placed on EBP the infection preventionist lets the staff know as well as a physician's order would be in place, a sign along with a cart containing PPE would be placed outside of the resident's room. Interview with the Infection Preventionist (IP) (RN #3) on 7/23/26 at 12:20 PM identified she did not want to check to see if the resident had a signage outside of his/her room for EBP because she knows it is not there nor after reviewing the records is there a physician's order or care plan directing for EBP. RN #3 identified it was her responsibility to ensure residents with open wounds with the exception of skin tears are placed on EBP and to add the residents to the EBP tracking sheet. She further identified staff is made aware when a resident is on EBP based on the EBP sign that is posted outside the resident's room, along with the nurse aide resident care card, the physician order and the resident's care plan. RN #3 further identified that wounds are discussed weekly on Thursday (7/16/26), but she did not attend last week's meeting where this resident would have been discussed because of the new open wound. Subsequent to surveyor's inquiry, a sign was posted for EBP outside of the resident's room, a physician's order was put in place as well as the care plan was updated to reflect that the resident was on EBP precautions on 7/23/26. Interview with wound nurse (LPN #6) on 7/23/26 at 3:25 PM identified wounds are discussed every Thursday, which the IP nurse attends and other members of the interdisciplinary team, after which the IP nurse would place the resident on EBP precautions. She further identified as the wound nurse when doing wound care, she automatically wears PPE, so she never checks to see if the resident is on EBP but moving forward she will be checking. Interview with NA #9 on 7/27/26 at 11:38 AM identified when a resident is on EBP there is a sign posted outside the resident's room and if there are two residents within the room the sign would indicate if it were door or window bed. NA #9 further identified it would also be written on the nurse aide care card, but she typically looks for the sign posted outside of the resident's room as the PPE supply cart is not always placed immediately outside the room for residents on EBP but in the hallway close to the EBP resident's room.Review of the Enhanced Barrier Precautions policy identifies an order for enhanced barrier precautions will be obtained for resident with any of the following wounds example chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers and/or indwelling medical devices. The policy further identifies EBP should be used for the duration of the affected residents' stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at higher risk. Resident #26's diagnoses included pressure ulcer of sacral region, weakness, and hypertension. The admission MDS assessment dated [DATE] identified Resident #26 had intact cognition, required moderate assistance with toileting hygiene, lower body dressing, and supervision/touch assistance with bed mobility and transfers. The assessment further identified Resident #26 had one stage 3 pressure ulcer with treatments that included pressure reducing device for bed, turn and repositioning program, and pressure ulcer care.The care plan dated 7/11/26 identified Resident #26 had an actual skin breakdown related to stage 3 pressure injury located on his/her coccyx with interventions that directed wound evaluation weekly to determine progress of deterioration of wound, treatment as ordered and low air loss mattress. The physician's order dated 7/11/26 directed to cleanse coccyx with normal saline pat dry, then apply collagen particles followed by dry clean dressing every evening shift and as needed if displaced or soiled. The wound notes dated 7/23/26 at 9:55 AM written by MD #1 identified Resident #26 first seen on 7/10/26 who was recently admitted from hospital with a stage 3 pressure ulcer to coccyx. The note further identified wound evaluation on 7/23/26 identified the wound to the coccyx measured 1.0 centimeters (cm) in length by 0.4 cm in width and 0.2 cm in depth draining large amount of serosanguineous drainage.Review of the facility's EBP tracking for July 2026 that was last updated on 7/22/26 at 9:30 AM failed to identify Resident #26 was placed on EBP due to community acquired stage 3 pressure ulcer on coccyx. Review of Resident #26's clinical record failed to reflect that the resident was placed on EBP. Observation on 7/22/26 and on 7/23/26 at 9:30 AM failed to identify posted signage outside the resident's room identifying the need for Enhanced Barrier Precautions (EBP) which should note the need to wear gloves and gown for the following high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. Interview with LPN #4 on 7/23/26 at 11:36 AM identified that when a resident is placed on EBP the infection preventionist lets the staff know as well as a physician's order would be in place, a sign along with a cart containing PPE would be placed outside of the resident's room. Interview with the Infection Preventionist (IP) (RN #3) on 7/23/26 at 12:20 PM identified she did not want to check to see if the resident had a signage outside of his/her room for EBP because she knows it is not there nor after reviewing the records is there a physician's order or care plan directing for EBP. RN #3 identified it was her responsibility to ensure residents with open wounds with the exception of skin tears are placed on EBP and to add the residents to the EBP tracking sheet. She further identified staff is made aware when a resident is on EBP based on the EBP sign that is posted outside the resident's room, along with the nurse aide resident care card, the physician order and the resident's care plan. RN #3 further identified she is aware that the resident was admitted with a stage 3 pressure ulcer on coccyx and he/she should have been placed on EBP. Subsequently to surveyor's inquiry, a sign was posted for EBP outside of the resident's room, a physician's order was put in place as well as the care plan was updated to reflect that the resident was on EBP precautions on 7/23/26. Interview with wound nurse (LPN #6) on 7/23/26 at 3:25 PM identified wounds are discussed every Thursday, which the IP nurse attends and other members of the interdisciplinary team, after which the IP nurse would place the resident on EBP precautions. She further identified as the wound nurse when doing wound care, she automatically wears PPE, so she never checks to see if the resident is on EBP but moving forward she will be checking. Interview with NA #9 on 7/27/26 at 11:38 AM identified when a resident is on EBP there is a sign posted outside the resident's room and if there are two residents within the room the sign would indicate if it were door or window bed. NA #9 further identified it would also be written on the nurse aide care card, but she typically looks for the sign posted outside of the resident's room as the PPE supply cart is not always placed immediately outside the room for residents on EBP but in the hallway close to the EBP resident's room.Review of the Enhanced Barrier Precautions policy identifies an order for enhanced barrier precautions will be obtained for resident with any of the following wounds example chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers and/or indwelling medical devices. The policy further identifies EBP should be used for the duration of the affected residents' stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at higher risk. Resident #109's diagnoses included type 2 diabetes mellitus, hypertension, and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #109 had intact cognition, requiring set-up or clean-up assistance with personal hygiene and was independent with bed mobility and transfer. The assessment further identified Resident #109 was at risk for pressure ulcers with treatments that included pressure reducing devices for chair and bed. Review of the wound list provided by the facility identified Resident #109 had a diabetic ulcer to his/her left plantar foot. Review of the facility's EBP tracking for July 2026 that was last updated 7/22/26 at 9:30 AM failed to identify Resident #109 was placed on EBP due to a wound on the left foot. The physician's order dated 6/26/26 directed to cleanse left plantar foot with normal saline, pat dry, then apply collagen particles to wound area and cover with dry clean dressing daily by the day shift. The wound progress note dated 7/23/26 at 9:58 AM identified Resident #109 had an ongoing wound to the left foot. The left foot plantar proximal area measured 0.5 centimeter (cm) in length by 0.6cm in width by 0.3 cm in depth draining moderate amount of serosanguinous drainage. Review of Resident #109's clinical record failed to reflect that the resident was placed on EBP when wound to left foot was reopened. Observation on 7/22/26 at 9:40 AM failed to identify a posted signage outside the resident's room identifying the need for Enhanced Barrier Precautions (EBP) which noted the need to wear gloves and gown for the following high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tube, tracheostomy and wound care for any skin opening requiring a dressing. Interview with LPN #4 on 7/23/26 at 11:36 AM identified that when a resident is placed on EBP the infection preventionist lets the staff know as well as a physician's order would be in place, a sign along with a cart containing PPE would be placed outside of the resident's room. Interview with the Infection Preventionist (IP) (RN #3) on 7/23/26 at 12:20 PM identified she did not want to check to see if the resident had a signage outside of his/her room for EBP because she knows it is not there nor after reviewing the records is there a physician's order or care plan directing for EBP. RN #3 identified it was her responsibility to ensure residents with open wounds with the exception of skin tears are placed on EBP and to add the residents to the EBP tracking sheet. She further identified staff is made aware when a resident is on EBP based on the EBP sign that is posted outside the resident's room, along with the nurse aide resident care card, the physician order and the resident's care plan. RN #3 identified is aware that Resident #109 had previous wounds, so this was an ongoing wound as he/she would be on and off EBP, so this resident should have been placed on EBP when the wound was reopened. Subsequently to surveyor's inquiry, a sign was posted for EBP outside of the resident's room, a physician's order was put in place as well as the care plan was updated to reflect that the resident was on EBP precautions on 7/23/26. Interview with wound nurse (LPN #6) on 7/23/26 at 3:25 PM identified wounds are discussed every Thursday, which the IP nurse attends and other members of the interdisciplinary team, after which the IP nurse would place the resident on EBP precautions. She further identified as the wound nurse when doing wound care, she automatically wears PPE, so she never checks to see if the resident is on EBP but moving forward she will be checking. Interview with NA #9 on 7/27/26 at 11:38 AM identified when a resident is on EBP there is a sign posted outside the resident's room and if there are two residents within the room the sign would indicate if it were door or window bed. NA #9 further identified it would also be written on the nurse aide care card, but she typically looks for the sign posted outside of the resident's room as the PPE supply cart is not always placed immediately outside the room for residents on EBP but in the hallway close to the EBP resident's room.Review of the Enhanced Barrier Precautions policy identifies an order for enhanced barrier precautions will be obtained for resident with any of the following wounds example chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers and/or indwelling medical devices. The policy further identifies EBP should be used for the duration of the affected residents' stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at higher risk.

Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #102) reviewed for foot care, the facility failed to ensure the resident received podiatry services for trimming of toenails when requested. The findings include:Resident #102 was admitted to the facility in September of 2025 with diagnoses that included type 2 diabetes mellitus, depression, and hyperlipemia. The quarterly MDS assessment dated [DATE] identified Resident #102 had intact cognition, was dependent on staff for putting on and/or taking off footwear, lower body dressing, personal hygiene and transfers. Interview on 7/21/26 at 12:30 PM with Resident #102 identified that he/she wanted his/her toenails trimmed and noted that since being admitted to the facility, he/she had not seen a podiatrist or had the toenails trimmed. The care plan dated 5/24/26 identified Resident #102 had the potential for diabetes complications with interventions that included diabetic foot care, and blood sugar monitoring. A review of the monthly physician's orders from December/2025 through July/2026 identified an order that directed for weekly skin checks every Wednesday on the evening shift. Review of Resident #102's electronic and physical clinical records failed to identify a consent to treat for podiatry services in the facility or that the resident would make alternative arrangements to receive podiatry services in the community. The clinical records also failed to identify that the resident had received podiatry services since admission. Observation with NA #3 on 7/22/26 at 10:20 AM identified Resident #102 lying in bed, NA#3 asked for permission to look at his/her toenails, which the resident indicated that it was okay. NA #3 then performed hand hygiene, donned gloves, and removed the covers over Resident #102's legs and noted the resident's toenails needed to be trimmed. Resident #102 indicated he/she told the nurse that his/her toenails needed to be trimmed about a month ago. Interview with NA #3 on 7/22/26 at 10:20 AM identified she was aware that the resident's toenails needed to be trimmed and had made the regular charge nurse aware. Review of the weekly skin checks for the period of May/2026 through July 22, 2026, identified weekly skin checks were completed weekly. Further, review of the clinical records did not reflect documentation that Resident #102 was offered/refused podiatry services. Interview with the Unit Secretary on 7/22/26 at 10:25 AM identified the resident did not have a Request for Service form completed. She identified that if a resident requests to have podiatry services they would be provided with the Request for Service form which indicates the various services provided within the facility and the resident/responsible party would select the services they wanted or decline services. The unit secretary indicated she would get back to the surveyor regarding podiatry services for Resident #102. She then returned to the surveyor to identify that Resident #102's Power of Attorney (POA) would not sign the consent form for podiatry services and did not want the services. When asked for the consent form which identified the resident's POA had declined the services, the unit secretary referred to the DNS. Interview with the Unit Secretary, in the presence of the DNS and LPN #1 (Regional Reimbursement Nurse) on 7/22/26 at 10:45 AM identified the podiatrist provides podiatry services at the facility monthly and as needed. The Unit Secretary identified the consent form was left in Resident #102's room for the POA to sign. The resident's family and the nurse during the day were aware that the form was left for the POA to sign. They also identified it was the resident who requested to have podiatry services, but they needed to obtain consent from the resident's POA for the resident to be seen. After the DNS and LPN #1 reviewed Resident #102's clinical record, they identified that the resident was not conserved, the resident had intact cognition and could have provided the facility with consent to receive podiatry services when the resident requested. They further identified that they had no answer as to why Resident #102 was not asked to provide consent for podiatry services. Observation with LPN #1 on 7/22/26 at 10:50 AM identified Resident #102 lying in bed, LPN #1 asked Resident #102 permission to assess his/her feet, and the resident consented. LPN #1 removed Resident #102 covers on legs and noted on the left foot: the great toenail extended over the tip of the toe measured 1.1 centimeters (cm); the 2nd toenail extended over the tip of the toe measured 0.2 cm with a scab area noted towards the top of the toe, and the 3rd toenail extended over the tip pf the toe measured 0.3 cm. On the right foot: the great toenail extended over the tip of the toe measured 1.1cm; the 2nd toenail extended over the tip of the toe measured 0.4 cm; the 3rd toenail extended over the tip of the toe measured 0.5 cm and the 4th toenail extended over the tip of the toe measured 0.4cm. LPN #1 identified she did not like to see the toenails that long when skin checks are completed weekly which includes checking the length of the toenails. A review of the Podiatrist's service dates at the facility for the period of February/2026 through July 8, 2026, identified that the Podiatrist visited the facility a total of 6 times to provide podiatry services.A review of the list of residents scheduled to be seen by the Podiatrist on July 8 & 27, 2026 and August 10, 2026, did not include Resident #102.Interview with the DNS and the ADNS on 7/22/26 at 2:53 PM identified that all long-term care residents are provided with the Request for Service form. They identified the form is typically distributed by the unit secretary and the form identifies the services the resident wants the facility to provide or not to provide and the completed form is kept in the resident's clinical record; however, Resident #102 was not seen by podiatry because they were awaiting consent from the POA. In addition, the facility had never asked the resident to sign the form for podiatry services although the resident is cognitively intact. Subsequent to surveyor's inquiry, Resident #102 was provided with the Request for Service form and signed the form consenting to podiatric treatment on 7/22/26. Interview with the evening shift Charge Nurse (LPN #5) on 7/23/26 at 3:10 PM identified Resident #102's shower day is on the evening shift, and a skin check is completed on the resident's shower day. LPN #5 identified that when a skin check is completed it includes checking the resident's nails on fingers and feet. LPN #5 identified she noticed Resident #102's toenails needed to be trimmed about a month ago and made the unit secretary aware, but she is not sure if it had been addressed. Interview with LPN #1 on 7/27/26 at 9:30AM identified that the in house APRN trimmed resident #102's toenails on 7/23/26. Review of the Podiatry Services policy identified it is the policy of the facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. The policy further identifies residents requiring foot care who have complicating disease processes will be referred to qualified professionals such as a Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy.

Based on observations, clinical record review, review of facility policy and interviews for one sampled resident (Resident #99) reviewed for call bell usage, the facility failed to ensure the resident had an appropriate call bell based on their functional abilities to use to call for assistance. The findings include:Resident #99's diagnoses include vascular disorder of the intestine, ileostomy, and protein-calorie malnutrition. The Occupational Therapy note dated 6/4/26 at 2:34 PM identified Resident #99 had decreased strength and bilateral upper extremity range of motion (ROM) impairments. The note further identified the resident would benefit from adaptive equipment for self-feeding. The admission MDS assessment dated [DATE] identified Resident #99 had intact cognition, required supervision or touch assistance with eating and oral hygiene, was dependent on staff for lower body dressing, toileting hygiene, and required maximal assistance with transfers. The assessment further identified Resident #99 required moderate assistance with ambulation of up to 10 feet and was dependent on staff for ambulating 50 feet. The assessment further identified the resident was receiving occupational therapy services. The care plan dated 6/8/26 identified Resident #99 receiving occupational therapy for alteration in self-care/ADL (activities of daily living) deficit related to decreased strength with interventions that included assistance of one staff for lower and upper dressing and ADL retraining. The care plan further identified Resident #99 required the use of adaptive equipment with interventions that directed assistance with self-feeding as needed and built-up utensils, lip plate, cup with handle and lid with all meals. Observation on 7/21/26 at 10:20 AM identified Resident #99 lying flat in bed, and upon approach for the purpose of interviewing the resident he/she requested assistance. The Surveyor asked if he/she had pressed the call bell which was looped around the right upper siderail. The resident indicated he/she was unable to reach the call bell and cannot press the button on the call bell due to having carpal tunnel in his/her hand. The resident's roommate interrupted to indicate that when Resident #99 needs assistance, he/she presses his/her call bell, and when the staff comes in he/she lets them know that his/her roommate needs assistance. Resident #99 was asked if he/she could use his/her left arm to reach and press the call bell; he/she then attempted to reach the call bell but was unable. Resident #99 identified he/she was unable to independently turn in bed to use his/her left hand to activate the call bell. Observation on 7/22/26 at 11:35 AM identified Resident #99 seated in a wheelchair on the left side of the bed and the call bell was clipped to the bed linens on the left side of the bed but was positioned out of the resident's reach. Observation on 7/22/26 at 1:05 PM identified Resident #99 seated in a wheelchair on the left side of the bed and the call bell clipped to the bed linens on the left side of the bed out of the resident's reach. NA #7 was seated beside the resident assisting Resident #99 with lunch. The location of the call bell was pointed out to NA #7, and he/she noted that Resident #99 could not reach the call bell. NA #7 handed the call bell to the resident, and the resident was asked to press the call bell. Resident #99 attempted to press the call bell but was unable to press the button. Resident #99 identified that she had made the staff aware in the past month that he/she was unable to use the call bell. Interview with NA #7 on 7/22/26 at 1:10 PM identified that she should have positioned the call bell within reach of the resident; however, she noted she was unaware that Resident #99 was unable to use the call bell as this was her first day caring for the resident.Interview with NA #3 on 7/22/26 at 1:10 PM identified that she has cared for Resident #99 in the past and noted the resident is unable to press the call bell button. She further noted that the resident's roommate presses his/her call bell when the resident needs assistance. When asked if she had made the nurse aware that the resident was unable to use the call bell, NA #3 identified that the nurses are aware, because the roommate is who calls for the resident when assistance is needed. Observation on 7/22/26 at 1:25 PM identified that the Nursing Supervisor (RN #4) entered Resident #99's room to assess the resident's ability to use the call bell. RN #4 identified that the charge nurse reported that the resident was unable to use the call bell. Resident #99 was unable to hold the call bell and press the button at the same time. RN #4 verified that the call bell was functioning and noted that she would provide the resident with another type of call bell. RN #4 ascertained that she had no reports prior to that day of the resident's inability to use the call bell. Interview with the DNS and the ADNS on 7/22/26 at 2:53 PM identified that it is the facility's practice to assess the ability to use the call bell on admission and if a resident is unable to use the call bell, they would substitute the call bell with the touch call bell or a handheld bell. The DNS identified that the facility does not have a formal assessment document pertaining to the use of the call bell. The DNS further identified that if a staff member is aware that a resident cannot use the call bell, she would expect them to report this to the supervisor or manager. After the observation with RN #4 and interviews with staff on 7/22/26, an observation at 3:10 PM identified Resident #99 seated in the wheelchair with the overbed table positioned in front of the resident with a touch call bell device on the table. Interview with OT #1 on 7/23/26 at 9:33 AM in the presence of the Rehabilitation Director identified residents are typically evaluated on their ability to use the call bell on admission. She identified that Resident #99 resided on the first floor when first admitted and had recently moved to the second floor around the end of June. OT #1 further identified the use of the call bell has not been their focus for this resident, as their focus during current sessions are on transfers, toileting and being able to feed him/herself. Interview with LPN #4 (day shift charge nurse) on 7/23/26 at 11:11 AM identified that Resident #99's roommate uses his/her call bell to call for assistance for Resident #99. LPN #4 further identified she was aware that the resident did not use the call bell but did not ask why;.Interview with LPN #5 (evening shift charge nurse) on 7/23/26 at 3:10 PM identified she was aware that Resident #99's roommate calls for assistance for the resident. She further acknowledged that she did not ask why but in hindsight she noted she should have asked the reason for the roommate calling for assistance for Resident #99. A request for a policy that addressed call bell usage and/or accommodation of needs when a resident is unable to use the traditional call bell, but the facility was unable to provide a policy.Interview with the DNS on 7/27/26 at 2:12 PM identified the practice of the facility is to provide residents with adaptable equipment to meet their needs.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #5) with an allegation of neglect, the facility failed to ensure the potential abuse was reported to the state survey agency. The findings include:Resident #5's diagnoses include a right femur and a right radius fracture. The admission MDS assessment dated [DATE] identified Resident #5 had intact cognition, a functional range of motion deficit affecting an upper extremity, and required total assistance with toileting, and bed mobility. It further noted the resident had an indwelling catheter and was always incontinent of bowel. The physician's orders dated 6/21/26 directed to turn and reposition every 2 hours, float heels in bed as tolerated every shift, and assist of one staff member with bed mobility, transfers, toileting, bathing and dressing.Interview with Resident #5 on 7/21/26 at 10:53 AM identified that during the first week of being admitted to the facility, he/she had a negative interaction with NA#1. Resident #5 identified that NA#1 was rude, yelled, and left him/her in a soiled brief for four hours. The resident further identified that there have been a couple of other times when NA #1 has spoken rudely or he/she has been made to wait over an hour for assistance with incontinent care. Further, Resident #5 noted that one of the nursing supervisors spoke with him/her regarding the situation with NA #1 and noted that NA #1 had not provided care for a while. Resident #5 indicated that the nursing supervisor and the DNS were aware of the details of his/her concerns because he/she has spoken with them about his/her concerns. A review of the state survey agency's reporting portal identified that a reportable event was not submitted regarding Resident #5's allegation of neglect. A request for accident and incident reports regarding Resident #5 was made but there were none regarding any allegations of abuse and/or neglect. Review of an email dated 6/26/26 provided by Resident #5's family member (Person #1), identified that he/she notified the social worker (SW #2) of the negative interaction between Resident #5 and a nurse aide. The email alleged Resident #5 requested assistance to be changed due to incontinence and the nurse aide responded to Resident #5 by accusing the resident of intentionally soiling himself/herself for attention and refused to change the resident. Review of social worker notes for the month of June/2026 and July/2026 failed to identify what action or follow up was taken as a result of the allegation of mistreatment. Interview with the DNS and the ADNS on 7/22/26 at 9:04 AM identified the ADNS conveyed that she conducted the initial interview with Resident #5 regarding the customer service complaint against NA #1 and indicated that it appeared Resident #5 did not want NA#1 providing care due to a personality conflict. The ADNS identified that Resident #5 did not articulate that NA#1 spoke rudely or made Resident #5 wait a long time for care. Interview with the DNS on 7/27/26 at 10:42 AM identified that the family did not send an email to her, and she did not have an email and indicated the initial investigation was initiated based on verbal notification from SW#2 regarding a NA who was not personable.Interview with SW#2 (no longer works at the facility) on 7/27/26 at 11:44 AM identified that she was the only social worker managing the entire building at that time and briefly looked at the email and knew she would not be able to follow through with it so forwarded it to the DNS. SW#2 indicated that she did not follow up with Resident #5 after forwarding the email to the DNS. Interview with the ADNS on 7/27/26 at 12:10 PM identified that at the time of the initial incident she was only aware of a complaint of a flat affect from the NA#1. The ADNS reviewed the copy of the email referenced above and indicated that she had seen the email for the first time 30 minutes prior to speaking with this Surveyor and identified that if she had that information initially that would have guided the questioning of the resident differently.Interview with the DNS, ADNS, Administrator and Admissions Director on 7/27/26 at 12:30 PM identified that the initial allegation should have been treated as an allegation of neglect/abuse and investigated comprehensively and reported to the state survey agency. The DNS indicated that she had taken the response from the ADNS questioning of Resident #5 as a basis for treating it as a customer service issue. The administrator identified that based on the information the facility had at the time, the customer service response was appropriate and pointed out that the email had been received and reviewed at that time, the Administrator indicated that with the additional information it should have been investigated and reported. A review of the interview with the DNS, and SW#2 identified that although the DNS was in receipt of the email from Person #1 with the allegation of neglect, the DNS failed to ensure the allegation was reported to the state survey agency. Subsequent to surveyor inquiry, a reportable event report was submitted to the state survey agency on 7/21/26. The facility policy for Incidents and Accidents identified incidents/accidents that require an incident/accident report include alleged abuse will be entered into the appropriate form/system within 24 hours of occurrence and all pertinent information documented, which includes the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders or follow up interventions.The facility policy for Abuse, neglect and Exploitation identified the definition of abuse means the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish and includes the deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. The policy indicates that the facility will provide residents, representatives and staff, information on how and whom they may report concerns, incidents and grievances without the fear of retribution and identified possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. The policy identified the facility will make efforts to protect residents from further abuse with room or staffing changes, provide emotional support and revise the resident's care plan. In addition, the policy indicated that reporting of the alleged violations to the Administrator, state survey agency, and adult protective services or police within specified time frames will be completed.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure, and interviews for one sampled resident (Resident #5) with an allegation of mistreatment, the facility failed to ensure an allegation of mistreatment/neglect was thoroughly investigated. The findings include:Resident #5's diagnoses include a right femur and a right radius fracture. The admission MDS assessment dated [DATE] identified Resident #5 had intact cognition, a functional range of motion deficit affecting an upper extremity, and required total assistance with toileting, and bed mobility. It further noted the resident had an indwelling catheter and was always incontinent of bowel. Interview with Resident #5 on 7/21/26 at 10:53 AM identified that during the first week of being admitted to the facility, he/she had a negative interaction with NA#1. Resident #5 identified that NA#1 was rude, yelled, and left him/her in a soiled brief for four hours. The resident further identified that there have been a couple of other times when NA #1 has spoken rudely or he/she has been made to wait over an hour for assistance with incontinent care. Further, Resident #5 noted that one of the nursing supervisors spoke with him/her regarding the situation with NA #1 and noted that NA #1 had not provided care for a while. Resident #5 indicated that the nursing supervisor and the DNS were aware of the details of his/her concerns because he/she has spoken with them about his/her concerns. A review of the state survey agency's reporting portal identified that a reportable event and summary of investigation was not submitted regarding Resident #5's allegation of neglect. A request for accident and incident reports regarding Resident #5 was made but there were none regarding any allegations of abuse and/or neglect. A review of the facility's grievance log/book, identified none pertaining to Resident #5.Review of an email dated 6/26/26 provided by Resident #5's family member (Person #1), identified that he/she notified the social worker (SW #2) of the negative interaction between Resident #5 and a nurse aide. The email alleged Resident #5 requested assistance to be changed due to incontinence and the nurse aide responded to Resident #5 by accusing the resident of intentionally soiling himself/herself for attention and refused to change the resident.Review of social worker notes for the month of June/2026 and July/2026 failed to identify what action or follow up was taken as a result of the allegation of mistreatment. Interview with the DNS on 7/21/26 at 2:35 PM identified the facility did not have an accident/incident (A&I) Investigation completed for the allegation relayed by Resident #5 but had looked into a complaint made by Resident #5 regarding NA#1 being flat (affect) and not engaging while providing care. The DNS indicated that NA#1 was removed from the schedule for the weekend and provided with education regarding customer service and provided a statement. The DNS identified that she was not aware of any concerns regarding neglect or abuse and was notified of the event verbally by the social worker. Interview with the DNS and the ADNS on 7/22/26 at 9:04 AM identified the ADNS conducted the initial interview with Resident #5 regarding the customer service complaint and indicated that it appeared Resident #5 did not want NA#1 providing care due to a personality conflict. The ADNS identified that Resident #5 did not articulate that NA#1 spoke rudely or made Resident #5 wait a long time for care and indicated that regarding this new allegation Resident #5 had been consistent with the details reported to the facility. The DNS and ADNS did not provide documentation of the meeting or actions taken due to information provided by Resident #5. Review of the Resident #5's clinical record failed to identify documentation of a meeting or the information ascertained from the meeting. Interview with NA#1 on 7/22/26 at 1:54 PM identified NA#1 was aware Resident #5 had made a complaint with the facility on 6/26/26 about NA#1 being monotone and not over expressive. NA#1 indicated there was a stressed interaction at the end of a night shift when getting Resident #5 up for the day and on an evening shift a day or two later when NA#1 noticed Resident #5's call bell had been alarming for a long time so NA#1 went to Resident #5's room to reassure the resident that another NA would be in shortly to which Resident #5 accused NA#1 of not liking him/her. Interview with the Scheduler on 7/22/26 at 2:02 PM identified NA#1 was removed from the schedule for 6/26 through 6/28/26 per the DNS because she wanted time to provide customer service education.Interview with Person #1 (Resident #5's family member) on 7/22/26 at 2:07 PM identified that a complaint/concern was sent to the social worker on 6/26/26 conveying concerns regarding NA#1. Person #1 identified that Resident #5 indicated being left alone without a call bell and in a soiled brief for hours. Person#1 identified that Resident #5 identified NA#1 shouted during the interaction but identified that he/she had not included that information in the email sent to the social worker. Person #1 indicated that feedback from Resident #5 was that NA#1 no longer provided care. Person#1 further noted that the social worker had responded in an email that the concerns expressed in the email would be passed along to the DNS. Person #1 identified that he/she had received no further information from the facility and no one from the facility had contacted him/her. Subsequent to surveyor inquiry the care plan dated 7/23/26 identified Resident displayed symptoms r/t a traumatic event with interventions of two-person for care. Interview with Person#2 (Resident #5's family member) on 7/27/26 at 10:30 AM identified he/she had texted the Assistant Admission's Coordinator on 6/23/26 at 8:30 AM and notified her of Resident #5's concern of sitting in a soiled brief for a long period and indicated that Resident #5 was reluctant to report a staff member. Person#2 identified that the Assistant Admission's Coordinator noted that she would send an email to the SW#2 regarding the concern.Review of an email chain provided by Person#1 on 7/27/26 at 11:13 AM identified an email sent to SW#2 on 6/26/26 at 1:01 PM indicating Resident#5 had verbalized filing several complaints regarding NA behavior and identified an interaction that a NA told Resident #5 that he/she soiled the brief on purpose to get attention and refused to change the resident. The email requested SW#2 meet with Resident #5 to see if the concerns were valid. Subsequent emails in the email chain dated 6/26/26 at 1:06 PM indicated that the concern had been passed on to the DNS.Interview with the Assistant Admission's Coordinator on 7/27/26 at 11:31 AM identified that she had received a text from Person#2 on 6/23/26 identifying a concern. The Admission's Assistant denied knowing specifics of the allegation but did send an email to SW#2 on 6/23/26 identifying Person#1 and #2 would like to touch base regarding Resident #5 and included contact information for Person #1 and #2. Interview with SW#2 (social worker) on 7/27/26 at 11:44 AM identified that she was the only social worker managing the entire building at that time and briefly looked at the email and knew she would not be able to follow through with it and forwarded it to the DNS. SW#2 denied being notified of any concerns by the Assistant Admission's Coordinator and indicated that she did not follow up with Resident #5.Interview with the DNS on 7/27/26 at 11:47 AM identified SW#2 had forwarded the email received from Person #1 on 6/26/26 at 1:08 PM and that she read the email at that time and indicated that the ADNS was with her and also reviewed the email at that time and knew there was an allegation of a NA refusing to provide care and that the ADNS was the person who interviewed Resident #5 at that time. Interview with the ADNS on 7/27/26 at 12:10 PM identified that at the time of the initial incident she was only aware of a complaint of a flat affect from the NA. The ADNS reviewed the copy of the email provided by the Surveyor and indicated that she saw the email for the first time 30 minutes prior and identified that if she had known of the details at the time she spoke with the resident it would have guided the questioning of the resident differently.Interview with the DNS, ADNS, Administrator and Admissions Director on 7/27/26 at 12:30 PM identified that the initial allegation should have been treated as an allegation of neglect/abuse and investigated comprehensively and reported to the state survey agency. A review of the interview with the DNS, and SW#2 identified that although the DNS was in receipt of the email from Person #1 with the allegation of neglect, the DNS failed to ensure the allegation was thoroughly investigated. The facility policy for Abuse, neglect and Exploitation identified the definition of abuse means the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish and included the deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. The policy indicates that the facility will provide residents, representatives and staff information on how and whom they may report concerns, incidents and grievances without the fear of retribution and identified possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. The policy identified an immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation. The written procedures for investigations include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment occurred, the extent and cause and providing complete and thorough documentation of the investigation. The policy identified the facility would make efforts to protect residents from further abuse with room or staffing changes, providing emotional support and revision of the resident's care plan for changes as a result of the incident. The policy indicated that reporting of the alleged violations to the Administrator, state agency, adult protective services or police within specified time frames.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for respiratory care, the facility failed to ensure an order was obtained timely for use of a continuous positive airway pressure machine. The findings include: Resident #1's diagnoses included respiratory failure with hypoxia (low oxygen level) and COPD. The admission assessment dated [DATE] identified that Resident #1 was alert and oriented and had a continuous positive airway pressure (CPAP) machine. Nursing Admission Note dated 1/9/2025 at 11:35 PM identified Resident #1 used a CPAP machine and received respiratory treatments. The Resident Care Plan (RCP) dated 1/9/2025 identified Resident #1 had a care plan for cardiopulmonary symptoms. Interventions directed to administer medications as ordered, monitor for change in breathing pattern and lung sounds, and oxygen saturation every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and used oxygen and a CPAP machine. Review of APRN's note dated 1/10/2025 at 8:12 AM identified Resident #1 received oxygen and used a CPAP machine at night. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented, and used oxygen and a CPAP machine. Record review failed to identify a physician order for the use of a CPAP machine. Interview and record review with the DNS on 2/3/2025 at 1:55 PM, identified the DNS was unable to provide documentation to reflect that facility had an order for CPAP machine use. She further indicated that the facility Noninvasive Ventilation policy directed that the facility obtain an order for the use of CPAP and that a physician order should have been obtained for the use of the CPAP machine. Interview failed to identify why an order was not obtained. Review of facility Noninvasive Ventilation Policy directed in part, to provide noninvasive ventilation per physician orders. The facility will obtain an order for the use of CPAP device and settings from the practitioner.

Based on observations, review of the clinical record, and interviews for the only sampled resident (Resident # 46) reviewed for Hospice, the facility failed to follow a physician's order for the application of arm protectors, for 1 of 3 residents (Resident #96) reviewed for nutrition, the facility failed to obtain and document the resident's weekly weights per physician orders for a resident with a significant weight loss. The findings include: 1. Resident #46's diagnoses included dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #46 was severely cognitively impaired and totally dependent for bed mobility, upper and lower body dressing, and transfers. A Physician's order dated 9/9/24 directed to apply bilateral arm protectors to be worn at all times, may be removed for care and reapplied every shift. The Resident's Care Plan in effect from 10/1/24 to 10/11/24 identified a potential for skin impairment. Interventions included apply bilateral arm protectors to be worn at all times, may be removed for care and reapplied, observe for changes in skin integrity, and update the provider. Review of the undated nurse aid care card directed that bilateral arm protectors were to be worn at all times. Observations on 10/10/24 at 12:15 PM and 2:33 PM, and again on 10/11/24 at 10:04 AM identified Resident #46 sitting up in the wheelchair next to the bed in his/her room without the benefit of arm protectors. Resident #46 was noted to be wearing a short sleeve garment during both observations and both upper arms were exposed to his/her hands. An interview with NA #4 on 10/11/24 at 10:04 AM identified that although a review of the NA care card directed to apply bilateral arm protectors, NA #4 indicated bilateral arm protectors were not present on the care card. NA #4 stated that in the last year, sometimes bilateral arm protectors were placed on Resident #46 and sometimes not. Further, NA #4 searched Resident #46's room, drawers, and closet but was unable to locate any arm protectors which could be placed on Resident #46. Review of Resident #46's Treatment Administration Record (TAR) identified that although bilateral arm protectors were signed off as applied on 10/10/24 during the 7:00 AM to 3:00 PM shift, observations on that day failed to identify the arm protectors had been placed on Resident #46. An interview with the DNS on 10/11/24 at 10:50 AM indicated that bilateral arm protectors were noted on Resident #46's RCP and NA care card but were identified as skin protection versus what the physician's order indicated, bilateral arm protectors, and that the skin protection devices should have been applied. Although requested, the facility indicated there was no policy for the use of arm protectors. 2. Resident #96's diagnoses include cerebral infarction, cholecystitis, and dysphagia. The Resident Care Plan (RCP) dated 3/8/24 through 9/11/24 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included a regular ground diet with thin liquids, encourage fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #96 had moderate cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. An Advanced Practice Registered Nurse order dated 8/7/24 directed weekly weights be taken for Resident #96 every Wednesday at shower-time by 7:00 AM to 3:00 PM staff. Review of Resident #96's electronic medical record (EMR) and Treatment Administration Record (TAR) identified missing documentation of weekly weights or documented resident refusal for the dates of 8/21/24, 8/28/24, 9/4/24, 9/11/24, and 9/25/24 (missing 5 of 9 opportunities). The Nurse Aide (NA) Care Card identified that Resident #96's weights should be monitored. The NA Care Card did not indicate when to weigh, how often to weigh, or who was responsible for weighing Resident #96. An interview with Licensed Practical Nurse (LPN) #5 on 10/10/24 at 10:44 AM identified the only place she documents a resident's weight was in the EMR. NAs do not document the weights of residents but do weigh the residents. NAs write the resident's weight on a piece of paper, which is handed to the LPN, for review and documentation within the EMR and TAR. LPN #5 was not able to identify the reason weights were not documented for the dates 8/21/24, 8/28/24, 9/4/24, 9/11/24, and 9/25/24 despite the TAR indicating a check mark as completed. An interview with Registered Nurse (RN) #4 on 10/10/24 at 11:01 AM identified that weights taken on residents should only be entered into the resident's chart. If a weight was not charted in the weights section of the EMR, it might also be referenced in a RN progress note. RN #4 was not able to locate any weights documented in a progress note for the dates 8/21/24, 8/28/24, 9/4/24, 9/11/24, and 9/25/24. RN #4 indicated RN #5 was responsible for ensuring LPNs and RNs documented weights in the resident chart. An interview with RN #5 on 10/10/24 at 11:12 AM identified that there was a pattern of weights being marked as taken by a check mark, with no weight being documented. RN #5 stated there was a step in the order entry process that was omitted which included triggering a mandatory weight value documentation at the time of documenting a weight was completed. Subsequent to surveyor inquiry, a change was made to the order that initiates a hard stop and requires a weight be documented when charting a weight was taken. Review of the Weight Assessment and Intervention Policy identified that weights are to be recorded in each resident's electronic medical record and in the unit's weight record chart. 50249 51182 51756

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #85) reviewed for hospitalization , the facility failed to ensure that a resident who was hospitalized for digoxin toxicity did not receive the same high risk medication (digoxin) on readmission from the hospital which resulted in a significant medication error. The findings include: Resident #85 's diagnoses included atrial fibrillation, congestive heart failure, and thrombophilia. The admission nursing assessment dated [DATE] identified Resident #85 was cognitively intact, required staff assistance with toileting, required total/maximum assistance of two staff members for transfers, and was non-ambulatory. Review of the Resident Care Plan (RCP) in effect 9/30/24 through 10/11/24 identified Resident #85 was at risk for cardiac distress. Interventions included to administer medications as ordered and monitor for adverse effects. The RCP failed to identify that Resident #85 had been hospitalized with digoxin toxicity. A hospital discharge interagency referral form (W10) dated 9/30/24 identified Resident #85 had been admitted to the hospital after being sent out from the facility due to severe bradycardia related to digoxin toxicity and was discharged back to the facility on [DATE]. The discharge instructions included to stop taking digoxin 250 micrograms (mcg) daily. A physician's order dated 9/30/24 directed to administer digoxin 250 mcg by mouth in the morning for atrial fibrillation. Review of the October medication administration record (MAR) for Resident #85 identified that digoxin 250 mcg had been administered on 10/1/24 at 9:00 AM. A physician's order dated 10/1/24 directed to discontinue the digoxin 250 mcg order. A nurse practitioner note (NP) dated 10/1/24 at 4:00 PM identified that Resident #85 was seen after being readmitted from the hospital. Resident #85 was in the hospital for bradycardia related to digoxin toxicity for which he/she received 7 doses of Digibind (an antidote to treat a life-threatening overdose of digoxin). The note further identified that digoxin was to be avoided. Interview with Registered Nurse (RN) #3 on 10/10/24 at 11:45 AM identified that she had entered the admission medication orders for Resident #85 into the electronic medical record (EMR) on 9/30/24. RN #3 stated that she had completed a drug regimen review (DRR) with the covering on-call Nurse Practitioner (NP). She entered the orders under the attending medical doctor's name due to the covering NP's name not being available in the Electronic [NAME] Record (EMR) system. Further RN #3 indicated that she would have documented the completion of the DRR in her nursing progress note to show the NP, not the attending physician, had completed the DRR with her. RN#3 stated she could not recall entering the order for digoxin and that she would not have entered an order for a medication that was not listed on the W10 from the hospital but could not recall the specific circumstances. RN#3 stated she was not aware Resident #85 was treated for digoxin toxicity, and that if she had known she would not have entered the order for digoxin into Resident #85's EMR. Review of the progress notes written on 9/30/24 for Resident #85 failed to identify a note authored by RN #3. Interview with the Assistant Director of Nursing Services (ADNS) on 10/10/24 at 2:00 PM identified that on 10/2/24 she had co-signed Resident #85's nursing admission assessment from 9/30/24 after verifying that the orders in the EMR matched the W10 however, she had not done the DRR. The ADNS stated that the DRR would have been done at the time of re-admission by the RN entering the medication orders. The ADNS further identified that re-admission orders are not double checked on the 11-7 shift. The policy was that re-admission orders were reviewed in morning report the following day, and the order summary report, which was used for the DRR, was printed and signed by two nurses and the MD or APRN to verify accuracy. The ADNS further identified that the order for digoxin 250 mcg for Resident #85 was seen on review in morning report and subsequently it was discontinued. Review of the order summary report used for the DRR for Resident #85 identified a signature from APRN #1 on 10/1/24, and only one nurse's signature, RN #3, on 9/30/24. Interview with Pharmacist #1 on 10/11/24 at 9:50 AM identified that digoxin being given after digoxin toxicity was a major medication error and demonstrated a deficiency in the transition of care. Pharmacist #1 stated that the facility's first priority on re-admission would have been to determine what had changed for Resident #85. Pharmacist #1 further identified that digoxin being ordered and given following Resident #85's hospitalization for digoxin toxicity was highly negligent, as digoxin was one of the worst medications for Resident #85 to have received if he/she wasn't supposed to be administered digoxin. Further digoxin would slow down an individual's heart rate and could result in cardiac insufficiency. Interview with Licensed Practical Nurse (LPN) #2 on 10/11/24 at 10:20 AM identified that she could not specifically recall administering medications to Resident #85 on 10/1/24 following his/her re-admission the previous evening. LPN #2 stated that if the EMR directed digoxin be given and the documentation showed she had administered the medication, then she did. LPN #2 stated that if a medication had not been available for Resident #85, she would have gone to retrieve it from the pyxis machine (emergency medication storage) and if it had not been available in the pyxis machine she would have called the pharmacy to have it sent to the facility. LPN #2 stated she would have then documented within the EMR the appropriate code for the medication not being available and written a progress note documenting steps she had performed to obtain the medication. Review of the Medications policy directed, in part, all medications administered to the resident should be ordered by the physician, and medications should be dispensed using the correct protocol for the mobile medications cart. Although requested, a facility policy for Drug Regimen Review was not provided.

Based on review of the clinical record, facility policy, and staff interviews for 1 of 3 residents (Resident #96) reviewed for weight loss, the facility failed to notify the dietician in order to make recommendations when a significant weight loss occurred. The findings include: Resident #96's diagnoses include cerebral infarction, dysphagia, and cholecystitis. The Resident Care Plan dated 3/8/24 through 7/2924 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included to provide a regular ground diet with thin liquids, encouraging fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. Resident #96's admission Nutritional Evaluation from the dietician and dated 3/11/24 at 11:53 AM identified Resident #96 weighed 141.2 pounds (lbs.). The Nutritional Evaluation further identified the dietician was provided with Resident #96's food preferences and did not identify any dietary concerns, or cultural accommodation needs for meal offerings. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. A record review of Resident #96's weights identified the following weight entries: On 3/11/24 a weight of 141.2 lbs., on 4/16/24 a weight of 132.0 lbs. (a 10.2 lb./6.25% loss in one month). On 5/11/24 Resident #96 weighed 130.8 lbs., and on 6/11/24 weighed 128.8 lbs., a 12.2 lb. loss over 3 months (8.78%). Physician's order dated 5/20/24 directed to administer House Supplement 120 milliliter (ml) twice daily (34 days after a 10.2 lb/6.25% weight loss). A Dietician's progress note dated 7/29/24 identified a weight loss of 13.5 lbs. from a pre-hospital weight (on 7/13/24) and recommended a Glucose Control supplement of 120 milliliters three times a day. Physician progress notes dated 7/31/24 identified Advanced Practice Registered Nurse (APRN) #1 evaluated Resident #96's weight loss and referred him/her to the Dietician for supplements. An interview with Registered Nurse (RN) #5 on 10/10/24 at 11:24 AM identified that nursing was responsible for the monitoring of weights and weight trends for residents. When a concern with a resident's weight was identified, nursing was responsible to notify both the dietician and the provider, but RN #5 was unable to identify that the dietician had been notified prior to 7/29/24. An interview with Advanced Practice Registered Nurse (APRN) #1 on 10/10/24 at 11:38 AM identified that she was made aware of Resident #96's weight loss all along and no medical consultation was required for the weight loss. An interview with the Dietician on 10/11/24 at 9:50 AM identified that she did not receive any notification of Resident #96's weight loss in March 2024 through June 2024. The first time she was notified of Resident #96's weight loss was on 7/29/24. Review of the Weight Assessment and Intervention Policy identified that any verified weight change of 5 lbs. or greater should be reported to both the dietician and the practitioner.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #3) reviewed for abuse, the facility failed to report injuries of unknown source to the state agency (SA) timely. The findings include: Resident #3's diagnoses included vascular dementia, osteoarthritis and a fracture of the left hand. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 was significantly cognitively impaired and required substantial/maximal assistance with transfers and toileting, and supervision or touching assistance with bed mobility. The Resident Care Plan dated 5/13/24 identified a risk for skin injuries (bruising/bleeding/skin tears) and a potential for falls. Interventions included to inspect skin daily during care, encourage to call for assistance, and orient to surroundings. An APRN progress note dated 7/4/24 at 1:01 PM identified Resident #3 had an area of bruising (spontaneous ecchymosis) on the lateral side of his/her left orbital (eye) area with no concern for fracture or pain. A nurse's progress note dated 7/8/24 at 2:39 PM identified Resident #3 had a slight bluish/purple hue to his/her pinky and ring finger extending up to the top of the back of his/her hand. An APRN progress note dated 7/11/24 at 9:41 AM, for a date of service on 7/10/24, identified Resident #3's left hand had no obvious bruising or deformity with mild swelling to the left side which appeared non-tender with movement. The APRN progress note further indicated the bruise to Resident #3's left periorbital (eye) area was non-tender. An APRN progress note dated 7/11/24 at 9:56 AM identified Resident #3 had bruising of the left hand and bruising of the left eye. The APRN progress note further indicated that Resident #3 stated that he/she fell from a chair and could not recall the day. Additionally, the APRN progress note identified that after discussion with Resident #3's responsible party, an x-ray of the left hand was ordered. A radiology (x-ray) result report for Resident #3 dated 7/11/24 at 12:00 PM identified an acute hairline non-displaced fracture of the 4th metacarpal of the left hand with diffuse osteopenia and soft tissue swelling indicated. An APRN progress note on 7/11/24 at 2:15 PM identified that Resident #3's left hand x-ray had revealed an acute non-displaced fracture of the 4th metacarpal (bones that connect the finger to the wrist), and the family requested to have Resident #3 evaluated further at the hospital Emergency Department. A nurses note dated 7/11/24 at 4:23 PM identified that the DNS was notified of Resident #3's acute left hand fracture of the 4th metacarpal bone and that Resident #3 had self-reported a fall. A Reportable Event form signed as filed on 7/12/24, identified Resident #3 had new bruising and swelling noted to the left hand on 7/10/24 with x-rays taken on 7/11/24. The x-ray report dated 7/11/24 indicated a fracture of the left hand, 4th metacarpal. The DNS and APRN were notified, an investigation was initiated, and the family was present. Family requested transfer of Resident #3 to the hospital Emergency Department for further evaluation. A nurses note dated 7/12/24 at 8:11 AM identified that Resident #3 had returned from the hospital Emergency Department with a diagnosis of closed fracture of the left metacarpal bone and a left orbital contusion. Interview and record review on 10/11/24 at 10:00 AM with PT #1 indicated that she was familiar with Resident #3 as she was asked to evaluate Resident #3 post incident on 7/12/24. A review of PT #1's treatment encounter note identified Resident #3 was unable to perform fall recovery tasks and that he/she would be unable to perform floor to standing position on his/her own without physical assist. PT #1 further indicated that Resident #3 would not be able to get up on his/her own if he/she fell as he/she required moderate to maximum assistance for wheelchair to bed transfers. Although Resident #3 reported that he/she had fallen, the resident would have been unable to rise independently from a fall. Interview and record review with APRN #1 on 10/11/24 at 10:14 AM identified that she had evaluated Resident #3 on 7/10/24 and although he/she had a bruise to his/her left eye, she did not see an injury to his/her left hand. APRN #1 indicated that when she evaluated Resident #3 on 7/11/24 she did see a bruise to his/her left hand and ordered an x-ray which showed a fracture. APRN #1 further identified that due to Resident #3's advanced dementia and inability to get up on his/her own, she did not believe Resident #3's report of falling or that a fall had caused his/her injuries. Additionally, APRN #1 indicated that although she was notified and saw Resident #3 in person on both dates, she was unsure if the facility further investigated how the injury had occurred or if the facility had notified the SA timely. Interview with the facility's Medical Director, MD #1, on 10/11/24 at 12:38 PM indicated she was unable to identify a possible cause of Resident #3's injuries and that although the injuries were reported to her, she did not evaluate Resident #3 and did not know the mechanism of injury. Interview and record review with the DNS on 10/11/24 at 1:15 PM indicated that Resident #3 had sustained a left eye bruise and a left hand fracture in July 2024. The DNS identified that without a witnessed fall incident, investigation information indicating the resident fell and was assisted to rise, and with the residents advanced dementia, the facility was unable to determine the cause of the injuries. The DNS indicated that Resident #3's left eye bruise and left hand fracture were considered injuries of unknown source, and the fractured hand should have been correctly classified as a possible allegation of mistreatment (injury of unknown origin) and subsequently sent to the SA, per the facility Abuse/Neglect/Exploitation policy. The DNS was unable to identify a reason Resident #3's injuries of unknown origin were not reported timely, but she was not in the DNS role at that time. Review of the facility policy, Abuse/Neglect/Exploitation, dated 4/29/24, directed that possible indicators of abuse include physical injury of a resident of unknown source. The Abuse/Neglect/Exploitation policy further directed that all alleged violations would be reported to the SA immediately if the event resulted in serious bodily injury, and that the results of the facility's investigation would be reported to the SA. Review of the facility policy, Unexplained Injuries, dated 5/10/23, directed that an injury shall be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious. The policy further directed that reporting and investigation procedures for injuries of unknown source would be implemented in accordance with the facility's abuse policies and procedures.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #96) reviewed for weight loss, and for 1 of 6 sampled residents (Resident #706) reviewed for unnecessary medications, the facility failed to revise the Resident Care Plan (RCP) when a change occured. The findings include: 1. Resident #96's diagnoses included cerebral infarction, dysphagia, and right sided hemiplegia and hemiparesis. An initial Nutritional Evaluation dated 3/11/24 at 11:53 AM and written by the dietician identified that on 3/11/24, Resident #96 weighed 141.2 pounds (lbs.). The Nutritional Evaluation further identified the dietician was provided with Resident #96's food preferences and did not identify any dietary concerns or cultural accommodations for meal offerings. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. The Resident Care Plan (RCP) dated 3/8/24 through 7/29/24 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included a regular ground diet with thin liquids, encouraging fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. The RCP further identified that Resident #96 had Halal cuisine and food, and communication barriers. A record review of Resident #96's weights identified the following weight entries: An admission weight on 3/11/24 was 141.2 lbs., on 4/16/24 a weight of 132.0 lbs. was recorded for a 10.2 lb. loss (6.25% in one month). On 5/11/24 Resident #96 weighed 130.8 lbs., and on 6/11/24 weighed 128.8 lbs., a 12.2 lb. loss over 3 months (8.78%). On 9/17/24 Resident #96 weighed 115.2 lbs. (18.4% loss over 6 months), and on 10/2/24 weighed 112.2 lbs. for a total loss of 29 lbs. The RCP dated 3/8/24 through 9/11/24 failed to identify that the care plan was reviewed and revised following Resident #96's significant weight loss. An interview with the dietician on 10/11/24 at 9:50 AM identified she was notified on 7/29/2024 of Resident #96's weight loss. She was unaware of a pattern of weight loss for Resident #96 before 7/29/24. Review of the Weight Assessment and Intervention Policy identified that care planning for weight loss shall address the cause of the weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. 2. Resident #706's diagnoses included atrial fibrillation, hypertension, and congestive heart failure. The admission nursing assessment dated [DATE] identified Resident #706 was cognitively intact, required staff assistance with toileting, was dependent with transfers, and was non-ambulatory. A physician's order dated 9/25/24 directed to administer warfarin 3 milligrams (mg) by mouth at bedtime every Monday, Wednesday, and Friday for atrial fibrillation. Review of the Resident Care Plan (RCP) dated 9/25/24 through 10/10/24 failed to identify Resident #706 was on an anticoagulant. A warfarin worksheet entry dated 9/26/24 identified that 1 dose of warfarin was held and not administered on 9/26/24 and then a Prothrombin Time and International Normalized Ratio (PT/INR) blood test (which monitored how well the blood thinning medication was working to prevent blood clots) was completed on 9/27/24. In an interview and clinical record review with the MDS (Minimum Data Set) Coordinator Licensed Practical Nurse (LPN) #3 on 10/10/24 at 10:30 AM, the clinical record failed to include an anticoagulation focus, goal, and intervention in the RCP. LPN #3 identified that there had been an anticoagulation focus on admission on 9/25/24 for Resident #706, but that she had resolved this focus on 9/26/24 when she didn't see an active order for an anticoagulant in Resident #706's electronic medical record. LPN #3 identified that due to Resident #706 being on warfarin, it should have been included in the RCP, and if there had been a hold order in the electronic medical record, she would not have resolved (discontinued) the anticoagulation focus. Subsequent to surveyor inquiry, an anticoagulation care plan was added with a potential for bleeding and interventions to administer the anticoagulant medication per the physician's order and observe for bruising or bleeding were added to Resident #706's RCP. Review of the High Risk Medications-Anticoagulants policy directed, in part, that the resident's plan of care shall alert staff to monitor for adverse consequences and risks associated with anticoagulants included bleeding such as bleeding gums, nosebleed, unusual bruising, and blood in urine or stool. 51183

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for positioning and mobility, the facility failed to provide range of motion (ROM) to a dependent resident. The findings include: Resident #357's diagnoses included fracture of the right humerus (broken bone of the upper arm), and congestive heart failure. The Admission Nursing Evaluation dated 10/3/24 identified Resident #357 was cognitively intact, mobility was very limited and was unable to make significant changes independently, and his/her ability to walk was severely limited and required moderate assistance. The Resident Care Plan dated 10/4/24 identified Occupational Therapy for alteration in self-care and activities of daily living (ADLs) deficit related to decreased strength. Interventions included Occupational Therapy 5 times a week, non-weight bearing (NWB) of the right upper arm, leave the sling on at all times, may remove 3 times daily for active range of motion (AROM) of the right elbow, wrist, and fingers only. A physician's order dated 10/4/24 directed non-weight bearing of the right upper extremity (arm), sling on at all times, may remove 3 times daily to perform AROM of right elbow, wrist, and fingers only. Observation and interview with Resident #357 on 10/7/24 at 12:48 PM, identified that his/her sling was not being removed 3 times daily to perform AROM of right elbow, wrist, and fingers per what he/she was instructed to do in the hospital. The Hospital Discharge Summary instructions dated 10/2/24 directed the right upper extremity (arm) should remain in a sling at all times, however, should be removed approximately 3 times per day to perform range of motion at the elbow, wrist, and fingers to prevent stiffness. In an interview and clinical record review on 10/9/24 at 11:53 AM with Licensed Practical Nurse (LPN) #2 facility documentation failed to identify that Resident #357's sling was to be removed 3 times a day to perform AROM to the elbow, wrist, and fingers per the hospital Discharge Summary. Additionally, a review of the Treatment Administration Record (TAR) failed to direct the nursing staff to remove the sling and provide AROM 3 times daily. An interview and clinical record review with PT (Physical Therapist) #1 on 10/9/24 at 12:06 PM identified the AROM order for Resident #357 was entered into the computer system on 10/4/24 and should have been followed by staff. Interview and clinical record review with the Director of Nurses on 10/9/24 at 12:39 PM identified the order for Resident #357's sling removal for staff to provide AROM 3 times daily, but the information had been entered into the computer system inaccurately. Further, the DNS indicated although there was a physician order, the nursing staff had not been prompted to provide Resident #357 with AROM and would not have known to provide range of motion per the hospital Discharge Summary due to the way the order was entered. Subsequent to surveyor's inquiry on 10/9/24 a therapy order; NWB, Therapy to perform AROM of right elbow, wrist, fingers, as tolerated by Resident #357. Although requested, a facility policy for Physical Therapy was not provided.

Based on review of the clinical record, facility documentation and interviews for the only sampled resident, (Resident #46), reviewed for hospice, the facility failed to collaborate and communicate the provision of hospice services with the contracted hospice provider. The findings include: Resident #46's diagnoses included major depressive disorder, dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. A W-10 (transfer document) signed by Resident #46's physician on 3/22/23 directed Resident #46 to be admitted to the facility on comfort care and to notify hospice with any changes in condition or needs. The Nursing Admission Evaluation dated 3/23/23. Identified Resident #46 was totally dependent for personal hygiene, mobility, transfers, and toilet use. Further, Resident #46's discharge goal was to remain in the facility with hospice care coordination. The nursing admission note dated 3/23/23 at 7:42 PM identified that when Resident #46 arrived, he/she was unable to communicate due to cognitive impairment, required total care, and the contracted hospice nurse had evaluated Resident #46 and had not recommended any new orders. The APRN admission note dated 3/24/23 at 1:01 PM identified Resident # 46 was receiving hospice services. Review of Resident #46's Resident Care Plan (RCP) dated 3/23/23 through 9/16/24 identified the resident was receiving contracted hospice services. The RCP failed to include a contracted hospice provider plan of care for Resident #46. Review of Resident #46's clinical record identified an initial Hospice Election, State of Connecticut form dated 6/28/22 (9 months prior to Resident #46's admission to the facility), which was signed by the Power of Attorney (POA). Additional hospice information present in the clinical from prior to the resident's admission included an Interdisciplinary Plan of Care and revision/Physician Orders from 6/30/2022 and 9/30/2022. The only post admission documentation located in Resident #46's clinical record was 1 hospice provider comprehensive nursing assessment dated [DATE] and 6 contracted hospice provider social work notes. The clinical record post facility admission failed to contain a hospice election form signed after admission in March 2023, the initial hospice physician's certification, an every 6 month physician recertification renewal for continued hospice services, coordination of which hospice provider staff would be providing care, documentation of facility visits/notes (other than social work notes) by the hospice providers, schedules, or a hospice Resident Care Plan. Interview and review of the clinical record with Social Worker (SW) #2 on 10/9/24 at 2:00 PM identified she assumed she was responsible to coordinate hospice services for Resident #46 and that the process for facility staff to communicate with hospice was done so verbally. SW #2 indicated she believed hospice staff wrote any recommendations related to Resident #46's care in the physician orders. SW #2 was unable to explain how nursing knew when hospice staff were scheduled to visit with Resident #46. SW #2 stated she ran the Resident Care Plan conferences, but the hospice team had never attended, asked about attending the Resident Care Plan meeting, and, except for an initial meeting with a hospice nurse on Resident #46's admission (19 months prior), she has never met with any hospice provider team members to coordinate Resident #46's care. SW #2 indicated that all hospice documentation for Resident #46 should be in the resident's clinical record or in a hospice binder. Review of the clinical record and inspection of the nursing station failed to identify any hospice information with the exception of a hospice sign-in visit log, the nursing assessment dated [DATE], and the 6 social work notes since Resident #46's admission in March of 2023. Interview and review of the clinical record with the DNS on 10/10/24 at 3:28 PM failed to reflect hospice documentation in Resident 46's clinical record or a hospice binder. The DNS identified that based on documentation in Resident #46's clinical record, she was unaware of which hospice provider disciplines (staff) participated in Resident #46's care or how often visits occurred. Although hospice provider staff verbally communicated the plan of care with facility nursing and/or the APRN, the policy was that communication would be documented in the paper chart. The DNS indicated that SW #2 coordinated hospice provider care and she would have to speak to her regarding the location of documentation for Resident #46's. The DNS indicated that hospice nurses come in to see Resident #46 and according to what they determine, information should be communicated in writing and placed in the paper chart. The DNS stated she was not aware that the last hospice care plan update was on 3/23/23. The DNS stated nurses follow the facility change of condition policy when hospice needs to be notified of changes for Resident #46. The DNS reviewed the clinical record of Resident # 46 and did not locate an updated plan of care, nursing visit forms, signed hospice election form, the physician initial certification or recertifications, or any scheduled visits. The DNS was unable to explain how facility staff on other shifts would be able to review hospice information. The DNS stated the ADNS, and nursing supervisor were responsible for implementation of issues identified in Resident #46's record. The DNS indicated that the lack of information regarding hospice was due to lack of coordination with hospice. Although attempted a phone interview with hospice nurse on 10/10/24 at 2:35pm, an interview was not obtained. Subsequent to surveyor inquiry, the facility obtained updated plans of care, completed nursing weekly visit forms, a hospice election form, a physician's certification and recertifications for Resident #46's clinical record. Although requested, the facility identified that there was no policy for Hospice.

Based on clinical record review, observations, review of facility policy and staff interviews for 2 of 3 residents, (Resident #96 and #406), reviewed for nutrition and hydration, for Resident #96 the facility failed to implement interventions for a resident who continued to experience significant weight loss, and for Resident #406, the facility failed to consistently document intake and output for a resident on intravenous hydration. The findings include: 1. Resident #96's diagnoses include cerebral infarction, cholecystitis, and dysphagia. The Resident Care Plan (RCP) dated 3/8/24 through 9/11/24 identified Resident #96 was on a mechanically altered diet secondary to dysphagia. Interventions included a regular ground diet with thin liquids, encouraging fluids, intake and output as needed, nutritional assessments as needed, supplements as ordered, and weights as ordered. A Nutritional Evaluation dated 3/11/24 at 11:53 AM written by the dietician identified Resident #96's weighed 141.2 pounds (lbs.) and identified the dietician was provided with Resident #96's food preferences, did not identify the dietician had any dietary concerns, and did not make any recommendations for cultural accommodations for meal offerings. The admission Minimum Data Set assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required set-up assistance with eating and required substantial assistance with chair/bed to chair transfers. A record review of Resident #96's weights identified the following weight entries: An admission weight on 3/11/24 was 141.2 lbs., on 4/16/24 a weight of 132.0 lbs. was recorded for a 10.2 lb. loss (6.25% in one month). On 5/11/24, Resident #96 weighed 130.8 lbs., and on 6/11/24 weighed 128.8 lbs., a 12.2 lb. loss over 3 months (8.78%). On 9/17/24 Resident #96 weighed 115.2 lbs. (a 26 lb/18.4% loss over 6 months), and on 10/2/24 weighed 112.2 lbs. for a total loss of 29 lbs in 205 days. A progress note by Advanced Practice Registered Nurse (APRN) #1 dated 3/8/24 identified Resident #96's albumin level, (a measure of the amount of protein in an individual's blood plasma that can be an indicator of malnutrition) was 3.8 (Normal albumin levels range from 3.5 to 5.5). A progress note by APRN #1 dated 4/2/24 identified Resident #96's albumin level, was 3.1 (Normal albumin levels range from 3.5 to 5.5). APRN #1 did not indicate within the progress note that Resident #96's albumin had decreased since the last albumin level of 3.8 obtained on 3/8/2024. A dietician progress note dated 4/15/24 identified that Resident #96 had an approximate 50%-75% meal intake, albumin levels were within normal limits per 4/2/24 labs (despite an albumin level being in the below normal range), and meal preferences were provided as requested. No diet changes were recommended. The dietician's note failed to acknowledge or address Resident #96's significant weight loss and failed to acknowledge Resident #96's albumin level per 4/2/24 labs was below normal limits. A progress note by APRN #1 dated 5/7/24 identified that she was aware of Resident #96's 11 lb. weight loss since admission and she stated the reports she had received from nursing was the resident ate well. APRN #1's progress note failed to address Resident #96's significant weight loss at that time and no interventions for the resident's continued weight loss were added to his/her plan of care. The Medication Administration Record (MAR) for July 2024 indicated a House Supplement of 120 milliliters (ml) to be administered twice a day was added to Resident #96's plan of care on 5/20/24 (35 days after the 10.2 lb./6.25% one month weight loss was documented on 4/16/24) and was discontinued on 7/20/24 when Resident #96 was hospitalized for cholecystitis. A progress note by APRN #1 dated 7/22/24 identified Resident #96's albumin level was 3.0 (Normal albumin levels range from 3.5 to 5.5). APRN #1 did not indicate within the progress note that Resident #96's had further decreased since the last albumin level of 3.1 obtained on 4/2/24. A dietician progress note dated 7/22/24 identified that Resident #96 had an approximate 50%-75% meal intake, had not lost any weight during his/her recent hospitalization for cholecystitis, and the resident was maintaining his/her weight without gain. No diet changes were recommended. The dietician's note failed to address the severe weight loss for Resident #96's since admission, (a 12.2 lb/8.8%. loss over 3 months from 3/11/24 through 6/11/24). The Medication Administration Record (MAR) from 7/30/24 through August 2024 identified a House Supplement Glucose Control Boost of 120 ml to be administered 3 times a day was added to the Resident #96's plan of care on 7/30/24. An interview with the dietician on 10/11/24 at 12:47 PM identified she was unable to determine if adding the Glucose Control Boost supplement in April would have prevented or slowed down the weight loss for Resident #96. Review of the Weight Assessment and Intervention Policy identified that any verified weight change 5 lbs. or greater should be reported to both the dietician and the practitioner. The dietician will review the unit weight record by the 15th of the month to follow weight trends over time. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort. Care plans for weight loss should include identified causes of the weight loss, goals and benchmarks for improvement, and timeframes and parameters for monitoring and reassessment. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month - 5% weight loss is significant; greater than 5% is severe b) 3 months - 7.5% of weight loss is significant; greater than 7.5% is severe c) 6 months - 10% weight loss is significant; greater than 10% is severe 2. Resident #406 's diagnoses included dementia, malnutrition, and small bowel obstruction. A Nutritional Evaluation dated 9/16/24 identified a total fluid need of 1392 milliliters (ml) in 24 hours. A good appetite was noted on admission with poor intake noted the past few days with some meals refused. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #406 was severely cognitively impaired with long- and short-term memory loss and required total assistance with all activities of daily living. A physician's order dated 9/20/24 at 8:30 AM directed intravenous hydration (IV) of dextrose 5 percent (%), 1/2 normal saline at 60 milliliters (ml) per hour for 2 liters. A nurse's note dated 9/21/24 at 4:42 PM identified Resident #406's IV was patent (functioning), Foley urinary catheter output was 840 (cubic centimeters) cc, and the resident had poor oral intake. A nurse's note dated 9/22/24 at 10:57 PM identified resident #406 had independently pulled out his/her IV at 3:30 PM, the supervisor was notified, and the IV nurse was to reinsert the IV to continue therapy. Additionally, the Resident #406 had taken 25% or less of his/her meal, and that the IV nurse had reinserted the IV access at 8:00 PM. A physician's order dated 9/23/24 at 3:30 PM directed IV hydration of dextrose 5%, 1/2 normal saline at 75 ml per hour for 3 liters for hypernatremia (high sodium level) and anemia (low red blood cell count). Review of the intake and output worksheets for 9/23/24 failed to identify any IV intake for the 7:00 AM to 3:00 PM shift, 3:00 PM to 11:00 PM shift, or the 11:00 PM to 7:00 AM shift. Additionally, the document failed to identify if Resident #406 had any output for the 7:00 AM to 3:00 PM shift and failed to identify 24-hour totals. A nurse's note dated 9/24/24 at 4:06 PM identified that Resident #406 independently pulled out the IV. The nurse practitioner (APRN) was notified and instructed to have the IV replaced. Review of intake and output documents for 9/24/24 on the 7:00 AM to 3:00 PM shift failed to identify IV intake, on the 11:00 PM to 7:00 AM shift the documentation failed to identify IV or per orum (oral PO) intake and 24-hour totals were not calculated. Review of intake and output documents for 9/25/24 failed to identify IV intake or output on the 7:00 AM to 3:00 PM shift. Although Resident #406 should have received 600 ml of IV fluid on the 11:00 PM to 7:00 AM shift, the documentation indicated 250 ml of IV fluid was received and documentation failed to identify a 24-hr total. A physician's order dated 9/26/24 directed intravenous hydration of dextrose 5% 1/2 normal saline at 75 ml per hour for 1 liter. An APRN progress note dated 9/26/24 identified blood work indicating hypernatremia: Sodium 148, (normal 135-145), slowly trending down. Resident #406 has completed intravenous fluids. Oral intake is fair. Intravenous fluid dextrose 5% 1/2 normal saline at 75 milliliters per hour for 7 days, 3 liters, discontinue when complete. Review of the intake and output documents for 9/26/24 for the 7:00 AM to 3:00 PM failed to identify IV intake or any output. Additionally, the documents failed to identify any intake or output for the 3:00 PM to11:00 PM shift and failed to identify a 24-hour total. A nurse's note dated 9/27/24 at 6:23 AM identified IV Dextrose 5% 1/2 normal saline infusing at 75 milliliters per hour. Review of intake and output documents on 9/27/24 failed to identify any intake, for the 11:00PM to 7:00 AM shift, the 7:00 AM to 3:00 PM shift, failed to identify any output, and the 3:00 PM to 11:00 PM failed to identify any intake or output; no 24-hour totals were calculated. On 9/28/24 the documents failed to identify intake for 11:00 PM to 7:00 AM, 7:00 AM to 3:00 PM, or 3:00 PM to 11:00 PM shifts. Additionally, output was identified only for the 11:00 PM to 7:00 PM shift, was 100 ml, and 24-hour totals were not calculated. On 9/29/24 documents failed to identify intake for the 11:00 PM to 7:00 AM and 3:00 PM to 11:00 PM shifts and failed to identify a 24-hour total. A physician's order dated 9/30/24 at 1:00PM directed intravenous hydration dextrose 5% 1/2 normal saline at 75 ml per hour for 2 liters. An APRN note dated 9/30/24 in part, identified poor oral intake, hyperosmolality and hypernatremia: sodium 147 mEq /Liter (normal 135-145) intravenous fluid dextrose 5% 1/2 normal saline at 75 ml per hour for 2 bags. Mucous membranes dry, malnourished, thin, alert and confused. A nurse's note dated 9/30/24 at 12:53 PM identified that Resident #406 did not have an active IV site on assessment. A nurse's note dated 9/30/24 at 10:22 PM identified the APRN ordered IV therapy and IV nurse to place an IV at 4:30 PM. IV fluids were started at 5:00 PM. On 9/30/24 the intake and output documents failed to identify intake for 11:00 PM to 7:00 AM shift, failed to identify output on 7:00AM to 3:00 PM shift, and failed to identify intake or output on 3:00 PM to11:00 PM, with no 24-hour totals. A nurse's note dated 10/1/24 at 10:40 PM identified a second IV bag was hung and infusing. Resident #406 did not eat their dinner meal. On 10/1/24 the intake and output documents failed to identify IV intake or output for 7:00 AM to 3:00 PM shift, failed to identify IV intake or output for 3:00 PM to 11:00 PM shift, and failed to identify a 24-hour total. A nurses note dated 10/2/24 at 2:38 AM identified Resident #406 independently pulled out the IV at 1:30 AM. Approximately 400 ml of IV fluid was remaining and the APRN was notified and instructed to hold reinsertion and resumption of fluids until seen by the house ARPN in the morning. On 10/2/24 the intake and output documents failed to identify output on 7:00 AM to 3:00 PM, and 3:00 PM to11:00 PM shifts. Additionally, the documents failed to identify a 24-hour total. A Physician's order dated 10/3/24 at 4:00PM directed intravenous hydration dextrose 5% 1/2 Normal saline at 60ml per hour for 2 liters for hypernatremia. An ARPN note dated 10/4/24 for follow up for dehydration: most recent blood work shows sodium of 148 (normal 135-145). In the past Resident #406 has been given several liters of fluids, and the sodium level has stayed in the high 140's. Nursing staff report resident #406's appetite is poor, and Resident #406 gets agitated with care. The Resident Care Plan dated 10/4/24 identified nutrition and hydration. Interventions included to encourage fluids, intake and output as needed, nutritional assessment, and weight as ordered. A nurses note dated 10/5/24 identified Resident #406's IV infiltrated into the forearm and elbow. The IV was removed and a call was placed to the IV nurse for reinsertion because 1.25 liters of IV fluid was remaining. A nurse's note dated 10/5/24 at 11:21 PM identified that the IV was infusing. An APRN note date 10/6/24 identified intravenous fluid dextrose 5% 1/2 normal saline at 60 ml per hour for hypernatremia for 3 days to infuse 2 liters. A nurses noted dated 10/6/24 at 4:16 AM identified that Resident #406 pulled out the IV saline lock with 100ml left in bag, the APRN was notified and instructed to encourage oral fluids. A physician's order dated 10/7/24 at 1:20 PM directed to reinsert the IV, dextrose 5% 1/2 normal saline at 75 ml per hour for 3 liters for hypernatremia and leukocytosis. A nurse's note dated 10/8/24 identified dextrose 5% 1/2 normal saline infusing at 75 ml per hr. A nurse's note dated 10/9/24 identified fluids were not able to be run due to IV not being patent. The provider assessed Resident #406 and ordered STAT (immediate) labs. On 10/9/24 at 10:28 PM, IV hydration was noted, 3rd bag hung at 8:00 PM. A physician's order dated 10/9/24 directed to hold IV fluids until IV line reinserted. Observation on 10/9/24 at 11:15 AM Resident #406 noted to be restless in bed, uncovering self, without an IV running. NA #2 repositioned Resident #406 in bed for comfort. Observation on 10/10/24 at 9:25 AM, Resident #406 was lying in bed, with IV infusing in the left arm, somewhat restless but more awake. Interview with LPN #1 on 10/9/24 at 12:30 PM identified that although Resident #406 had been receiving IV fluids from 10/3/24 through 10/9/24 according to the nurse progress notes, intake and output records could not be located. LPN #1 indicated that Resident #406 should have intake and output documents since s/he was on an IV hydration. Additionally, LPN #1 stated she had not started an intake and output document for Resident #406 as yet, but she would start one for today. Interview with MDS/Case Manager LPN #3 on 10/9/24 at 3:00 PM identified that she could not locate any additional intake and output documents from 10/3/24 through 10/9/24 and could not locate 24-hour totals in the progress notes for any of the days Resident #406 had an IV from 9/20/24 until present. Interview and clinical record review with DNS on 10/10/24 at 10:21 AM identified that the facility policy was to ensure IV fluid amounts were documented on the intake and output form. Review of Resident #406's intake and output record with DNS identified numerous missing and blank intakes as noted. The DNS identified that both oral and IV intake as well as output should be recorded as well as 24-hour totals. The charge nurse was responsible to calculate the total for the shift they worked and the 11:00 PM to 7:00 AM nurse was responsible to calculate the 24 totals. The DNS was unable to explain the omissions. Review of the intake and output (I&O) recording policy directed, in part, intake and output of fluids is documented when indicated by attending physician order or by nursing per resident diagnosis and or treatment. I&O recording may be instituted per an attending physician order or by a licensed nurse for any resident with the following: intravenous therapy for hydration, and urinary catheter. Nursing staff will be responsible for completing the I&O records at the end of each shift. Information obtained from the I&O will be totaled daily and reviewed to ensure resident's intake and output are sufficient to meet the resident's needs. 51182

Based on interviews, observations and facility policy for the only sampled resident (Resident #96) reviewed for cultural food preferences, the facility failed to ensure the dietician identified and provided Halal cuisine. The findings include: Resident #96 was admitted to the facility in March 2024 with diagnoses that included cerebral infarction, dysphagia, and right sided hemiplegia and hemiparesis. A Resident Care Plan (RCP) dated 3/8/24 identified Resident #96 followed Halal cuisine and food with interventions that included for Resident #96's family to come in for support, and the family wanted to provide translation as well. Additional interventions included to observe for any changes in baseline cognition, mood or behavior and offer and allow family to visit often. An initial Nutritional Evaluation dated 3/11/24 at 11:53 AM and written by the dietician identified that on 3/11/24, Resident #96 weighed 141.2 pounds (lbs.). The Nutritional Evaluation further identified the dietician was provided with Resident #96's food preferences and did not identify any dietary concerns or cultural accommodations for meal offerings (despite the RCP dated 3/8/24 indicating Resident #96 followed a Halal cuisine diet). The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #96 had severe cognitive impairment, required substantial assistance with chair/bed to chair transfers, and required set-up assistance with eating. A physician order dated 4/15/24 directed a ground texture, thin consistency diet with no concentrated sweets (but failed to identify Resident #96 followed a Halal cuisine). On 10/8/24 at 12:37 PM, observation of Resident #96's meal identified he/she was served pumpkin dump cake, mashed potatoes, and cut mixed vegetables (green beans, carrots and cauliflower). On 10/9/24 at 12:33 PM, observation of Resident #96's meal tray identified the meal ticket noted ground consistency, vegetarian diet, dislikes ham, pork, sausage, bacon, chicken, veal and turkey, fish was ok. Further observation of the meal identified Resident #96 was served a crustless egg salad sandwich, 2 pieces of toast, buttered noodles and a Styrofoam container of a white substance. On 10/11/24 at 9:43 AM, interview with the Director of Dietary identified she was aware that Resident #96 was being provided a vegetarian diet (although Resident #96 was not a vegetarian) but was unaware Resident #96 followed a Halal cuisine diet prior to admission. Additionally, the Director of Dietary indicated had she been aware of Resident #96's Halal diet, she would have been able to accommodate the cultural diet request because she was familiar with a supplier who could provide Halal foods. On 10/22/24 at 9:50 AM, interview with the dietician identified being unaware of Resident #96's cultural requirements of a Halal diet (despite the RCP dated 3/8/24 indicating Resident #96 followed a Halal cuisine diet). Additionally, she identified being able to accommodate a Halal diet into Resident #96's nutritional diet plan, and was aware Resident #96's family brought in food for the resident in the evening. Interview with Social Worker (SW) #2 on 10/11/24 at 12:23 PM identified she spoke regularly with the family, was aware Resident #96 was Muslim, followed a Halal diet, and that Resident #96's family brought in Halal food every evening for dinner because Resident #96 ate nothing provided by the facility for lunch and dinner. Facility policy regarding Cultural Competent Care identified each resident will be assessed upon admission to determine if they are culturally diverse and once identified, food preparation/choices will be added to the Resident Care Plan. Additionally, resident specific approaches will be developed and included in the RCP.

Based on clinical record review, interviews and facility documentation for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to report a change of condition to the physician and/or Advanced Practice Registered Nurse timely. The findings included: Resident #1 had diagnoses of unspecified congestive heart failure, unspecified osteoarthritis, and unspecified abnormalities of gait and mobility. Review of the Resident Care Plan dated 6/26/24 identified Resident #1 had a potential for falls with interventions that included the bed to be in the lowest position, encourage to call for assistance, call bell with in reach and to keep the resident's area clutter free. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, had no limitation with Range of Motion (ROM), required set-up assistance with eating. Review of a Reportable Event form dated 7/11/24 at 2:00 AM identified Resident #1 was found lying on the right side of his/her bed towards the window of his/her room, and had no physical injuries noted. Resident #1 further identified he/she had been dreaming and rolled out of bed. Review of nursing notes dated 7/11/24 at 2:35 AM identified the resident had an unwitnessed fall out of bed. The neurological checks were initiated per facility protocol with no changes in mental status, no bump on head noted upon head assessment, however mild pain was reported to Resident #1's right shoulder, the resident stated that it had been sore since last fall at home. Resident #1 had good range of motion to both upper and lower extremities, and the resident was lifted back to bed (via hoyer lift) with the assistance of four (4) staff members. Review of post fall event evaluation dated 7/11/24 at 8:05 AM identified that the resident had active range of Motion (ROM) in the bilateral upper extremities. A nurse's note written by Licensed Practical Nurse (LPN) #1 dated 7/12/24 at 4:18 PM identified Resident #1 could not grasp with the right hand since falling, the left hand grasp continued to be weak per baseline, that the resident needed assistance with eating during this shift, and was fed by his/her son on the previous 3:00 PM to 11:00 PM shift, the APRN was notified of the change in condition, evaluated the resident, and suggested to continue with the current pain medication regimen. Review of the neurological observation record identified that the residents hand grasps were equal until 7/12/24 at 8:45 AM when it was identified that the hand grasps were unequal and the left hand was noted to be weaker than the right. Review of the untimed Advanced Practical Registered Nurse (APRN) #2 note dated 7/12/24 identified a follow-up visit for left shoulder pain, indication that imaging was done following his/her fall and was negative for fractures, yet noted significant osteroarthritis, and the directive was to continue with tramadol (a pain medication) as needed. Review of a nursing note written by Registered Nurse (RN) #1 on 7/13/24 at 8:08 PM identified that the social worker had approached her and reported that the Resident #1 had a functional decline since his/her fall on 7/11/24 and was fed by his/her son during the week when the resident was able to perform this task independently before the fall. The resident further identified that h/she pain in both upper extremities since falling two days prior, weakness, difficulty grasping items, and was only able to take a few steps. The resident had weak hand grasps, was unable to lift his/her arms past his/her shoulders, and was unable to bend or lift his/her knees above the bed. The APRN/Physician was called at 6:26 PM, Resident #1 was sent to the emergency room for further evaluation at approximately 7:00 PM. Interview with Advanced Practical Registered Nurse (APRN) #1 on 8/14/24 at 1:35 PM identified an assessment of Resident #1 was performed on the morning of h/her 7/11/24 fall. Resident #1 had complained of left shoulder pain in the trapezius region of his/her shoulder, presented as confused a little more than usual, did not present with stroke-like symptoms, and had limited but symmetrical bilateral upper extremity range of motion, and good bilateral hand grasps. APRN #1 further indicated that he went to assess the resident and had no concerns for one-sided deficit, neck pain, or decreased ambulation, no slurred speech, that Resident #1 presented with symmetric facial movements, and that the x-ray ordered for his/her left shoulder was negative. Interview with LPN #1 who worked on 7/12/24 during the 7:00 AM to 3:00 PM on 8/14/24 identified Resident #1 was complaining of pain and weakness to both upper extremities during the nursing assessment that morning and noticed that Resident #1's hand grasp was weaker on the right side as compared to the left. LPN #1 indicated he/she informed APRN #2 (who was on duty at the facility) of his/her findings and following assessment, APRN #2 had directed LPN #1 to continue treating Resident #1's pain. Interview with Nurse Aide (NA) #1 on 8/14/24 at 3:00 PM identified he/she worked the 3:00 PM to 11:00 PM shift on 7/12/24. NA #1 indicated between 3:45 PM and 4:00 PM on 7/12/2/24, Resident #1 had reported he/she couldn't dial the phone and that he/she felt numbness and tingling in his/her hands. NA #1 indicated he/she assisted Resident #1 with dialing the phone, however when he/she handed the phone to Resident #1, the resident dropped the phone as he/she was unable to hold onto it. NA #1 indicated reporting this concern to the floor nurse, however, does not remember who she specifically informed regarding Resident #1's change in status and indicated the resident was freaking out over her hands. (The clinical record failed to identify that the resident had been assessed or that the physician was notified). Interview with APRN #2 on 8/14/24 at 2:23 PM identified he/she saw Resident #1 on 7/12/24 for a follow up visit related to his/her shoulder pain, and was not informed that the resident was complaining of weakness to both upper extremities or that the right hand grasp was weaker than the left. APRN # 2 identified that/she went to see Resident #2 specifically for a follow-up visit related to his/her fall. Interview with SW#1 on 8/14/24 at 12:26 PM identified he/she was approached by Person #1 on 7/13/24 and was informed Resident #1 was unable to feed him/herself independently, use or hold onto the phone independently, and that family was assisting Resident #1 with eating. SW#1 further identified he/she then checked in with Resident #1 who indicated a difference in his/her ability to grasp items and difficulty ambulating. SW#1 indicated he/she informed RN#1 of Resident #1's status and RN #1 went in to assess the resident. Interview with the Administrator on 8/14/24 at 5:10 PM identified his/her belief that APRN #2 had evaluated Resident #1 for the change of condition related to his/her hand grasps on 7/12/24 and that Resident #1's inability to dial/hold onto the phone during the 3:00 PM to 11:00 PM shift was related to this concern. Attempts were made to contact to RN #1 was made, however, unsuccessful. Attempts to obtain the hospital paperwork were unsuccessful. Review of the Notification of Changes policy directed to consult with the resident's physician and resident's representative when there is a significant change in the resident's physical, mental, or psychosocial condition.

Based on review of the clinical record, observations, facility policy review, and interviews for one of three units reviewed for medication storage, the facility failed to discard Resident #46's expired Insulin and failed to date a multidose medication vial after opening. The findings include: Resident #46's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was severely cognitively impaired and required extensive assistance of one staff member for activities of daily living (ADLs). A Resident Care Plan dated 5/4/22 identified a potential for complications from diabetes with interventions that included to administer Insulin as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation, interview and review of facility policy with LPN #2 on 6/28/22 at 1:12 PM during inspection of the medication cart identified Resident #46's vial of [MEDICATION(S)] Insulin dated as opened on 5/25/22 (34 days prior). According to the label on the Insulin vial, the medication expired 28 days after opening (6/24/22). Additionally, a multidose vial of [MEDICATION(S)] that was noted to be partially used, failed to indicate the date that the vial had been opened. LPN #2 indicated that per the facility policy, both vials of medication would need to be discarded, the [MEDICATION(S)] because it had been expired four days earlier, and the [MEDICATION(S)] as she could not identify a date when the vial had been opened or if the medication had been open beyond the [MEDICATION(S)]'s 28 day expiration date.

Based on clinical record review, observations, and interviews for one of five units reviewed for respiratory equipment, the facility failed to appropriately store Resident #145's Continuous Positive Airway Pressure (C-PAP) mask while not in use. The findings include: Resident #145's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Admission assessment dated [DATE] did not identify Resident #145's level of cognition or assistance required for activities of daily living. The Care Pathway dated 6/22/22 identified Resident #145 had obstructive sleep apnea. Interventions included to encourage C-PAP use, monitor for sleep apnea, and monitor for snoring while asleep. An admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 6/22/22 at 10:00 PM identified Resident #145 stated he/she used the C-PAP nightly, however, the resident was unable to place the C-PAP mask or turn on the machine, and stated that someone does this for him/her at home. The APRN progress note dated 6/23/22 identified Resident #145 was alert and confused. Observation on 6/27/22 at 11:07 AM identified Resident #145 asleep in bed with the C-pap mask resting on the bedside stand without the benefit of being covered. Observations on 6/28/22 at 10:12 AM and at 1:42 PM identified the C-PAP mask resting on the floor and the mask was without the benefit of being protected in a plastic bag. Interview with LPN #2 on 6/28/22 at 1:24 PM identified that the C-PAP mask should be stored in a bag and not on the floor. Interview with LPN #3 on 6/29/22 at 8:50 AM identified that proper C-PAP mask storage includes placing the mask in a plastic bag for protection and leaving next to the bedside. Subsequent to surveyor inquiry, LPN #3 indicated the respiratory provider was called, the mask and tubing were replaced, and properly stored at the bedside. The facility did not have a storage policy for a C-PAP equipment.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of one resident (Resident #37) reviewed for medication administration, the facility failed to ensure a therapeutic diet when administering a liquid oral supplement. The findings include: Resident #37 's diagnoses included cerebral infarction, dysphagia, and diabetes. A physician's diet order dated 10/4/21 and updated monthly through June 2022 directed to provide a regular diet, puree texture, with nectar consistency. A Dietician note dated 4/14/22 at 12:21 PM indicated that Resident #37 continued to receive Glucerna supplement three times daily and was recorded as taken well, with stable weight and to continue with supplement, The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was a severely cognitively impaired and required extensive assistance of 2 person for bed mobility, was dependent for transfers and required bathing with 2-person assistance. The MDS further identified Resident #37 required extensive assistance of 1 person for eating, and toilet use and required a mechanically altered diet (ex: pureed food, thickened liquids). The Resident Care Plan (RCP) dated 5/4/22 identified Resident #37 required a mechanically altered diet secondary to dysphagia with interventions that included to provide assistance with all meals, use of built-up utensils, a scoop plate for all meals and a Dycem placemat. The RCP further indicated to monitor oral intake and provide a supplement as ordered. The RCP dated 5/4/22 further indicated Resident #37 had a nutrition/hydration concern with interventions that included a regular puree diet with nectar thickened liquids and extra gravy with meals, to encourage fluids, monitor intake and output as needed, conduct a nutritional assessment and to obtain weights as ordered. The RCP dated 5/4/22 further indicated Resident #37 had a speech therapy plan of care for oropharyngeal dysphagia. Interventions included aspiration precautions, compensatory swallowing strategies, dietary meal planning, position at 90 degrees during meal and for ½ hour after eating and to provide small bites and sips of food and fluids. Observations on 6/29/22 at 8:30 AM identified LPN #2 administering liquid Glucerna poured straight from the box to a cup and administer to Resident #37 without the benefit of reconstituting the supplement to a nectar consistency. No coughing or difficulty swallowing was noted during LPN #2's assistance with drinking the supplement. Interview and clinical record review, with Speech Pathologist #1 on 6/29/22 at 11:50 AM indicated that Glucerna was considered a thin liquid that could be thickened and that it was the responsibility of the person administering the drink to thicken the Glucerna to the correct consistency ordered. Facility policy dated 4/16/16 and revised on 12/21 indicated that the facility provides thickened liquids as prescribed to residents that require them. It further indicated that a thickened liquid refers to liquids that has been altered to facilitate safe oral intake and is ordered as part of a treatment for a disease or clinical condition, such as dysphagia due to stroke or oral cancer or a neuromuscular disease. In conclusion, the facility failed to ensure that Resident #37 received supplements thickened to the safe consistency of nectar thick as ordered by the physician.

Based on observations, interviews, clinical record review, facility documentation and facility policy review for one of five sampled residents (Resident #21) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure that Resident #21 was provided with incontinence care timely. The findings included: Resident #21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was mildly cognitively impaired and required one person physical assistance for toilet use and 2 person physical assistance for bed mobility and transfers. The MDS also identified Resident #21 was always incontinent of bowel and frequently incontinent of bladder. The Resident Care Plan (RCP) dated 5/6/22 identified Resident #21 was incontinent of bowel and bladder, and a goal included to assist with toileting needs. Interventions included to utilize incontinence briefs or pads. Initial observation on 6/29/22 at 9:32 AM identified Resident #21 was soiled with urine per resident report to surveyor. Resident #21 indicated I really let a lot of water out. Surveyor notified LPN #2 of report immediately following notification from Resident #21. LPN #2 was observed speaking with Resident #21, and asked if the resident would like to be cleaned up, and if the resident would like to be dressed and placed in the resident's wheelchair. Resident #21 answered yes. LPN #2 notified Resident #21 that It may be a minute since I have to find someone and you need an assist of two. Resident #21 answered Okay. Subsequent to the initial observation on 6/29/22 at 9:32 AM, at 9:37 AM (5 minutes after the initial interview with Resident #21) NA #1 was seen entering and exiting the room directly next to Resident #21. NA #1 was observed bringing clean linen into the room, and several minutes later again bringing clean linen into the room. Observation on 6/29/22 at 9:44 AM (12 minutes after the initial interview with Resident #21) identified that surveyor again spoke to Resident #21, who stated no one had come to the room to address his/her incontinence. At that time, LPN #2 was observed entering the room directly across from Resident #21 and asking a female resident in that room if she needed assistance to the rest room. LPN #2 was observed assisting the resident to the bathroom. At 9:49 AM, observation identified that NA #1 was still in the room next to Resident #21 providing care; LPN #2 was identified leaving the unit through a back stair well. Observation 6/29/22 at 9:54 AM (22 minutes after the initial interview with Resident #21) identified LPN #2 returned to the unit and was observed sitting at a computer located at the nurses' station. At 9:55 AM, Resident #21 was speaking on the telephone. At 9:58 AM surveyor spoke with Resident #21, who again reported they haven't come in yet. While exiting Resident #21's room, NA #1 was observed typing at a keyboard of a facility computer terminal located in an alcove of the resident's hallway. Interview with LPN #2 on 6/29/22 at 10:10 AM (38 minutes after the initial interview with Resident #21) at the nurses' station identified Resident #21 had still not been assisted with cleaning following his/her incontinence episode. LPN #2 further identified Resident #21 had not been provided incontinent care because his/her aide went on break, I told him it may be a little bit. LPN # 2 further indicated another aide was not available to assist Resident #21 because they were with other residents Subsequent to surveyor inquiry, LPN #2 was seen speaking to NA #1, and then NA #1 entered Resident #21's room, then requested assistance from another NA who brought a mechanical lift to Resident #21's room. Interview with NA #1 at 10:15 AM identified that she confirmed she was assigned to Resident #21 for care. Interview with the DNS on 6/29/22 at 11:00 AM identified that Resident #21 should have had incontinent care performed without waiting. The DNS identified that residents should not have to wait, and that if there was a wait, it should not take 40 minutes to receive care. Additionally, the DNS identified that the specific staff assigned to a resident are not the only staff available who can provide assistance; rather, any clinical staff who were in a role to provide care can assist a resident with incontinence care. The facility policy Incontinence dated 2/2022 identified, in part, that all residents that are incontinent will receive appropriate treatment and services. Compliance guidelines identified that residents that are incontinent of bowel or bladder will receive appropriate treatment to prevent skin breakdown, infections, and continence to the extent possible.

Based on clinical record review, facility documentation and staff interview for 1 of 3 sampled residents reviewed for falls (Resident # 32) the facility failed to ensure the mechanical lift pad was properly positioned to prevent a fall. The findings include: Resident # 32's [DIAGNOSES REDACTED]. Physician orders dated 2/1/18 directed Hoyer lift transfers with assist of two out of bed to customized wheelchair. The quarterly MDS dated [DATE] identified the resident was moderately impaired cognition, total dependence on 2 staff members for transfers and utilizes a wheelchair for mobility. The RCP dated 12/21/17 identified alteration in ADL's, self-care deficit related to [MEDICAL CONDITION]. Interventions included transfer via Hoyer lift with assist of two to custom wheelchair. Facility documentation dated 2/12/18 at 6:40PM identified the resident fell to the floor during a Hoyer lift transfer. The documentation noted that when NA # 1 raised the resident in the lift, and NA # 2 removed the chair from under the resident, the resident flipped out of the Hoyer pad and fell to the floor. The documentation further noted that during the investigation it was determined that the back right loop may not have been securely in place on the lift and as the lift was turned the pad loop dislodged causing the resident to fall. Nurse's notes dated 2/12/18 at 6:40PM identified called to resident's room, resident found lying on the prone position on the floor. The resident was assessed and complained of pain all over. The physician was notified and the resident was transferred to the hospital for an evaluation. The SBAR Communication form dated 2/12/18 at 7PM identified the resident fell and had worsening of chronic pain. Review of the discharge summary dated 2/13/18 identified the resident sustained [REDACTED]. Interview with NA # 4 on 7/25/18 at 10:55AM stated that she and NA # 1 hooked the resident up to the lift and she was operating the lift. NA # 4 stated that after the lift cleared the wheelchair, the chair was removed and NA # 1 went to the other side of the bed to assist moving the resident over the bed. NA # 4 stated that when she began to turn the lift the resident flipped out of the lift and fell to the floor. NA # 4 stated that she observed that the top right loop of the lift pad was not connected to the lift. The NA further stated that after they hook the lift pad loops to the lift they do not recheck them to ensure they were in place. Interview with NA # 1 on 7/25/18 at 1:20PM stated that when she came into the room to assist NA # 4 with the transfer, the lift pad was already hooked up to the lift, but did not physically check to ensure they were secure NA # 1 stated she was behind the resident while the resident was lifted off the chair. NA # 1 stated that she removed the resident chair and went around to the side of the bed to assist the resident over the bed when she heard the resident scream and saw the resident flip out of the lift and land on the floor. NA # 1 stated that she saw that one of the pad loops was not connected to the lift. Interview with RN #5 (Supervisor) on 7/25/18 at 4:30PM stated that he was called to the room and found the resident on the floor after falling from the lift. RN # 5 stated he assessed the resident who was complaining of pain, notified the MD and transferred the resident to the hospital for an evaluation. RN # 5 further stated that he check the lift and pad after the incident and found nothing wrong. Interview with the DON on 7/25/18 at 1:47PM stated that the facility investigation determined that the resident fell from the lift because the back right loop of the pad was not placed securely on the lift. The DON stated that the lift and pad were checked after the incident and found nothing to be wrong. The DON further stated that after the incident all NA's had competencies completed on using mechanical lifts. Review of the facility policy for Hoyer lifts identified lifts will be used for residents who are unable to stand. The policy identified that after the lift pad is attached, staff are to ensure all loops are secure. During an interview with the DON on 7/25/18 at 1:47PM stated that the facility implemented a plan of correction after the incident occured to include review of the Hoyer lift policy with all NA's, competencies on all NA's for Hoyer Lift transfers and bimonthly audits.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents reviewed for pressure ulcers, (Resident #217), the facility failed to ensure measures were in place to prevent a pressure ulcer. The findings include: Resident #217 was admitted [DATE] after a right total knee arthroplasty. The admission MDS assessment dated [DATE] identified Resident #217 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative moderate cognitive impairment, required extensive assistance of one staff for bed mobiliy and two staff for transfers, was not at risk for pressure ulcers, was currently free from pressure ulcers, and utilized pressure reducing devices for the chair and bed. The Resident Care Plan (RCP) dated 2/1/16 for right total knee arthroplasty identified skin integrity interventions of assessing for skin breakdown secondary to decreased mobility, right lower extremity immobilizer, and weight bearing as tolerated. Nursing note dated 2/12/16 at 12:09 PM identified a large blister measuring 6cm x 4.2cm with an opening at 12 o'clock. The nursing note also identified that Resident #217 reported that the heel had previously broken down a few years ago after surgery and spending time in the hospital. physician's orders [REDACTED]. Nursing note dated 2/12/16 at 6:22 PM identified the left heel broken blister along with an additional right heel small broken blister with skin intact measuring 3 cm x 3 cm. Interview with RN#4 on 7/14/16 at 12:50 PM identified the resident was determined not to be at risk for pressure ulcers, was able to move in bed and ambulated by discharge on 2/16/16 and RN#4 was not aware of the preious pressure ulcer until the resident developed blisters on 2/12/16. Review of faciliy pressure ulcer guidelines policy identified plans will be developed based on each resident's ability to periodically change positions and their comprehensive skin assessment with support surfaces/pressure redistribtuion devices including, in part, heel lift suspension boots, and heel protectors.

Based on observations, clinical record review, review of facility documentation, review of hospital record, review of facility policy, and interviews, for three of six residents (Resident #40, Resident #53, and Resident #59) reviewed for accidents, the facility failed to ensure transfer recommendations made by rehab were acted upon timely and/or failed to provide adequate supervision for a resident on a mechanical ground consistency diet which resulted in a choking incident and/or failed to ensure the gait belt was used during a transfer according to the policy and resident care plan to prevent a fall. The findings include: a. Resident #53's [DIAGNOSES REDACTED]. The Resident Care Plan (RCP) dated 7/15/15, and updated 12/23/15, identified a poor trunk balance and risk for falls. Interventions directed to consult with rehab if problems and to assist with transfers as needed. A physician's order dated 12/16/15 directed staff to assist Resident #53 out of bed to custom wheel chair as tolerated with lap tray, foot box and head rest. The quarterly MDS assessment dated [DATE] identified Resident #53 had severely impaired cognitive skills for daily decision making and required extensive assistance of two for transfers. Review of the clinical record identified a nursing referral to rehab dated 12/18/15 requesting evaluation for weakness, unsafe for nurse aide to stand pivot, and a request Hoyer for transfers. Rehab recommendation dated 12/22/15 directed staff to transfer Resident #53 with a Hoyer lift. Review of the clinical record failed to identify a physician's order for transfer status. Review of the nurse's notes from 12/18/15 through 12/25/15 failed to reflect any change in transfer status. Review of the nurse aide transfer documentation from 12/1/15 through 1/17/16 identified Resident #53 required extensive assistance of two staff for transfers. Review of facility incident report dated 1/17/16 at 7:45 PM identified NA #1 transferred Resident #53 from the wheelchair into the bed with one staff assist, and after Resident #53 was in bed, a 7 x 5 centimeter (cm) skin tear was noticed on Resident #53's left lower leg. Additional review of the incident report identified Resident #53 was transferred to the emergency room and received five sutures for the skin tear. Review of emergency department discharge paper work dated 1/17/16 identified in part, that Resident #53 had a 5 cm curved laceration to the distal left leg through the dermis and subcutaneous tissue, and the laceration was closed with five sutures. An interview with NA #1 on 7/11/16 at 9:55 AM identified NA #1 transferred Resident #53 by him/herself, guiding Resident #53 under his/her arms while Resident #53 held onto the side rail. NA #1 stated after Resident #53 was in the bed Resident #53 stated his/her leg was bleeding, and NA #1 notified the nurse. Interview, record review, and review of incident report dated 1/17/16 with ADON on 7/11/16 at 11:24 AM identified although the incident report dated 1/17/16 identified Resident #53 required one staff assist for transfers, there was no physician ' s order, care plan, or nurse aide care card that directed how Resident #53 transferred. ADON stated the transfer status should be identified in the physician ' s orders and/or the care plan and was unable to provide documentation of Resident #53's transfer status orders at the time of the incident on 1/17/16. ADON was unable to provide documentation that the rehab recommendation dated 12/22/15 was followed up on. Interview and review of clinical record with Director of Rehab, with DON present, on 7/11/16 at 12:01 PM identified Resident #53 was seen by rehab on 12/22/15 and rehab recommended a Hoyer lift be used for transfers for Resident #53, and stated after 12/22/15 Resident #53 should have been a Hoyer lift for transfers. Phone interview with Hospice Care Coordinator on 7/11/16 at 1:28 PM identified on 12/23/15 hospice was notified by facility nursing staff that as of 12/22/15 Resident #53 had a new order for a Hoyer transfer and was no longer able to participate with transfers. Observations on 7/11/16 at 1:33 PM identified Resident #53 was transferred from his/her wheelchair to bed by NA #2 and NA #3 using a Hoyer lift. Interview and record review with DON on 7/11/15 at 2:35 PM identified the facility did not notify the attending physician of the rehab recommendation dated 12/22/15 for Hoyer transfers and stated staff should have obtained a new order for Hoyer transfers when rehab recommended it. Interview and record review with MDS RN on 7/12/16 at 10:10 AM identified Resident #53 required extensive assistance of two staff for transfers from 12/1/15 through 1/17/16. During a phone interview and record review, on 7/12/16 at 2:50 PM, MD #1 stated he/she had access to Resident #53's clinical record and identified if he/she was notified of rehab's recommendation to change Resident #53's transfer status to Hoyer lift it would be included in his/her notes and nurse's notes. MD #1 further stated there was no information included in either his/her notes or the nurse's notes to indicate he/she was notified of rehab's recommendation. MD #1 further stated that he/she would have wanted to have been notified of rehab's recommendation, and that he/she would have given an order to make Resident #53 a Hoyer transfer if he/she was notified. b. Resident #59's [DIAGNOSES REDACTED]. Resident #59's Quarterly MDS dated [DATE] identified that the resident was cognitively impaired and that Resident #59 required supervision with all meals with one person. The Resident's Care Plan dated 3/16/16 identified that Resident #59 had dysphagia, had a tendency to pocket food, and refused to wear his/her dentures. Interventions directed nursing staff to provide a mechanically altered diet which consisted of ground mechanical/soft texture, to supervise the resident with all meals, and to cue Resident #59 to take small bites. The Physician's orders dated 11/10/15 through 5/24/16 directed staff to provide a regular diet, ground/mechanical soft texture, and thin consistency liquids. Review of the Facility's Accident and Injury Report (A+I) for Resident #59 dated 5/24/16 identified that at 5:30 PM on 5/24/16, Resident #59 was choking and required the Heimlich maneuver. Review of LPN#1's nursing note dated 5/24/16 reflected that Resident #59 was choking on his/her food and the Heimlich maneuver was performed with success. Further review of the A+I indicated that a Brussels sprout was expelled from the resident during the procedure. The physician was notified and Resident #59 was observed for 72 hours post procedure with no adverse outcome. In addition, Brussels sprouts were removed from the ground menu diet by dietary on 5/25/16 and a recommendation for a speech evaluation for Resident #59 was completed. The physician's order dated 5/26/16 directed staff to discontinue Resident #59's ground consistency diet and the new order directed staff to provide a regular pureed texture diet. On 6/10/16, the physician further directed staff to provide a nectar thick consistency for all liquids and to continue the pureed texture consistency diet after the speech evaluation was completed. Interview with the Dietician on 7/13/16 at 1:05 PM identified that prior to the incident on 5/24/16 with Resident #59, that Brussels sprouts were appropriate for a ground consistency diet but that the Brussels sprouts should have been chopped into smaller pieces before serving it to the residents. He/she further stated that Brussels sprouts were removed from the ground consistency diet for all residents on 5/25/16 as a precautionary measure to ensure that an incident like this one does not occur again. Interview with LPN#1 on 7/13/16 at 4:45 PM identified that on 5/24/16 during dinner service, Resident #59 was eating in his/her room and that LPN#1 was present with Resident #59 when he/she began to eat dinner. LPN#1 stated that Resident #59 began to forcefully cough and his/her face became blue. LPN#1 performed the Heimlich maneuver and a round and firm Brussels sprout was expelled from the resident. LPN#1 further stated that he/she could not recall if all of the Brussels sprouts were a chopped consistency before the resident began to eat his/her meal. The facility failed to provide the appropriate meal to ensure that the Brussels sprouts were chopped for a resident on a ground consistency diet which resulted in the resident choking. Review of the Facility's Policy on Texture Modification for Mechanical Soft Diets directed in part that Brussels Sprouts should be cooked and chopped before serving to residents who are on a ground consistency diet. c. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident #40 had intact cognition, required extensive assistance with transfers & toilet use, and had falls in the past ninety days. The care plan dated 5/11/16 identified Resident #40 had a history of [REDACTED]. Physician ' s orders dated 7/1/16 directed the following; sit to stand from recliner chair with supervision, ambulate with a quad cane and supervision in the room, and provide limited assistance of one staff in the hall for safety with the wheelchair following. Additionally, do not attempt to assist with pivot transfers as the resident will shift weight to the right side in order to clear the left foot in transfers and ambulation and staff to assist with transfers to and from the toilet to a raised toilet seat. Accident/incident report dated 7/11/16 identified that the resident stated to a nurse at 9:30AM that a nurse aide pushed him/her while in the bathroom on 7/10/16 and he/she fell . Interview with Resident #40 on 7/11/16 at 11:30AM identified that while being assisted to the bathroom last evening (7/10/16), a nurse aide pushed him/her and he/she fell and had to go to the hospital. The resident indicated he/she sustained a sprained ankle. Additionally, although he/she did not think the push was abusive, he/she felt that the nurse aide was rushing him/her with care. Interview with the Administrator on 7/13/16 at 2:00PM identified that NA#4, should have been utilizing the gait belt during the transfer, as it is facility policy. A call was placed to NA#4 on 7/14/16 at 11:00AM for an interview, and a message was left, however, an interview was not obtained. Review of the facility policy on transfer/gait belts directs that transfer/gait belts will be used for resident transfers and gait/ambulation training.

Based on review of the clinical record, review facility documentation and interviews for one of five sampled residents review for accidents (R#174), the facility failed to ensure that the resident's hot beverage was at the appropriate temperature to prevent an accident. The findings include: 1. Resident #174's [DIAGNOSES REDACTED].A quarterly assessment dated [DATE] identified BIMS of 13 indicating cognition and memory intact, independence with eating and extensive assistance with personal hygiene. Additionally, noted impaired Range of Motion (ROM) with upper and lower extremities. The RCP updated on 2/4/15 identified a problem with cognitive deficits. Approaches included encouraging independent decision and assist when needed to ensure safe appropriate choices. The nurse's note dated 4/24/15 identified that the charge nurse was notified that Resident # 174 had spilled hot chocolate on her/himself during P.M. care and that the resident was noted with discolorations to bilateral inner thighs, denied pain and verbalized I do not feel anything . Resident # 174 indicated that she/he forgot to tell the staff that she/he had spilled the hot beverage. The resident was assessed and noted with a reddish 8.4 Centimeter (CM) by 4.0 CM serous filled blaster (8.6 CM by 2.7 CM) on the right thigh and a reddish 10.8 CM by 2.5 CM with serous filled blister on the left thigh, the physician was notified and staff was directed to apply Silver Sulfadiazine cream (Agent used to treat serious burns) 1 % twice a day to the right and left thigh. Review of facility documentation dated 4/24/15 identified that at 5:30 P.M. during dinner, Resident #174 spilled a hot beverage (i.e. hot chocolate) on his/her lap resulting in discoloration to the right and left thighs. The Hot water/Coffee temperature log dated 4/9/15 identified the hot water/coffee temperature was 180 degrees F at 11:15 A.M. The next recorded hot water/coffee monitoring was not conducted until 4/30/15 (20 days later) which identified a temperature of 178.5 degrees F. A review of the facility monitoring of hot water temperatures during meal time lacked evidence that the facility monitored hot water temperatures on 4/10 through 4/29/15 to ensure safe water temperatures for meal time. Interview and review of the clinical record on 6/17/15 at 3:25 P.M. with LPN#1 indicated that he/she was called to Resident #174's room per request of Nurse Aide (NA#1) to assess the resident's right and left thighs. LPN #1 further indicated that NA # 1 informed her/him that Resident # 174 spilled hot chocolate on him/herself, did not have any pain and did not want to leave the dining room but chose to stay and eat his/her dinner. On 6/17/15 at 1:15 P.M. during an interview and review of facility documentation with the Food Service Director (FSD) identified that after being notified of the event of 4/24/15 by the DNS, he/she contacted the service vendor for the kitchen ' s hot water dispenser and / or coffee dispenser to come into the facility to evaluate the hot water dispenser because the dietary department could not adjust the hot water dispenser machine. Interview with the FSD on 6/18/15 at 9:50 A.M. identified that on 4/28/15 the service vendor calibrated the hot water dispenser from 170 degrees Fahrenheit (F) down to 160 degrees F. The facility policy and procedure for Hot Water/ Coffee Temperature Log notes that the temperature for all Hot water/coffee must be taken and log in on a log sheet prior to meal service. Additionally, directs facility staff to test the temperature of the hot water/ coffee by pouring the hot water/coffee into a cup and inserting a digital thermometer into the center of the cup. To hold the thermometer for 15 seconds then log the temperature on the log sheet and notes that temperatures of all hot beverages should be between 150-160 degrees.