Every finding on record at Villa at Stamford, The

Based on review of the Facility Assessment, facility documents, facility policy and interviews for 8 out of 11 licensed staff (agency and facility staff), the facility failed to ensure licensed staff competencies for Intravenous(IV) line management were completed for 2025 and for a sampled from 3 residents (Residents # 152, # 154 and # 155) having received IV therapy in 2025-2026, 5 agency licensed staff and three employees did not have certificates or competencies on file for 2025. The findings include: On 6/2/2026 at 11:25 AM an interview and facility document review with the Staff Development Nurse (RN #3) who provided licensed nurse IV line management certificates competencies were completed every 2 years by the facility. RN #3 was unable to provide any competencies completed in 2025 but was able to provide a couple licensed nurse competencies for 2026. RN #3 further indicated and other competencies for IV-line management for 2026 were still in the process of being completed.An interview and review of the Facility Assessment with the Administrator on 6/02/2026 at 12:20 PM indicated the Facility Assessment only indicated competencies would be completed in areas the facility provided resident care but did not indicate a frequency of the competency completion. The Administrator further indicated the frequency would be up to the staff development.On 6/3/2026 at 11:30 AM a request was made of the Director of Nursing Services to obtain the IV log at which time 3 random residents were chosen and noted to have received IV therapy administration, and the document would note the licensed staff who provided the care.1.Resident # 152 received IV therapy as ordered, sodium chloride 0.9% for hydration on 11/12/2025 started on the evening shift and ended on 11/13/2026 on the day shift.2. Resident #154 received IV therapy as ordered on 9/03/2025, Cefazolin Sodium(antibiotic) 2 grams reconstituted provided intravenously every 8 hours for pneumonia started on 9/3/2025 at 10:00 PM, received a dose on 6/4/2025 at 6:00 AM and the last dose at 2:00PM on 6/04/2026.3.Resident #155 received IV therapy, Sodium chloride 0.45% intravenous solution at 75 ml per hour for hydration for 2 days. The therapy started on 2/09/2026 during the evening shift and continuously through the evening shift on 2/10/2026.At 2:49 PM the DNS provided the requested documents but 2 of the 3 did not have the nurses who provided the care. At 3:10 PM the DNS had provided the staff who provided IV therapy. Upon receipt of the additional documents review identified 5 licensed staff that did not have certificates for IV-line management on file with the facility. The DNS indicated they were agency licensed staff and they are required to have the training to work in the facility. However, the DNS could not provide any evidence from the agency indicating the licensed staff were certified to provide IV therapy or had competencies to ensure they were observed to provide care according to standards of practice. The DNS indicated the facility did not have a policy related to agency licensed staff providing IV therapy. Four licensed facility licensed staff within the sample were found to have certification but no competency completed for 2025.A facility policy dated 1/2025 labeled Qualifications and responsibilities of licensed nurses providing IV Therapy indicated in part licensed staff attend and complete in-service education and competency evaluations as mandated.

Based on resident interviews, observations a review of facility practices and staff interviews, the facility failed to provide a comfortable, homelike dining experience for residents on 1 of 2 floors reviewed, the facility failed to ensure meals were not served on trays in a dimly lit dining room, residents not received meals at varying times, and ensure no delays in meal delivery to residents who eat in their rooms. The findings included: Resident interviews conducted during the facility tour identified concerns regarding meal service delays. Resident #36 reported that meals delivered to his/her room were frequently received late and he/she often waited extended periods for meal delivery after food had arrived at the nursing unit. Additional surveyor observations identified breakfast meal service being provided to residents in their rooms on multiple units by facility staff. As a result, additional observations were conducted during the noon meal service on 6/2/26.Meal delivery from the kitchen to the second-floor west unit was observed on 6/2/26. At approximately 11:54 AM, dietary staff transported a tray cart from the kitchen, arriving at the unit at approximately 11:55 AM in the presence of the surveyor and Director of Dining Services. Upon arrival, an additional meal tray cart was observed staged on the opposite side of the hallway that had not yet been distributed to residents.At approximately 12:02 PM, residents had not transported to the dining room for meal service. Residents who subsequently entered the dining room were served meals on trays. Observations further identified that the dining room lights were not illuminated, and there was no ambient music, television programming, or other environmental feature intended to enhance the dining atmosphere. Further observations identified that residents were not served meals simultaneously. Some residents received and began eating their meals, while other residents seated at the same tables remained waiting to be served. Staff were observed serving meals directly on trays rather than removing plates, beverages, and food items and placing them on the dining tables. As a result, residents sitting together began dining at different times. Additional observations identified an absence of homelike dining features. Dining tables lacked tablecloths, placemats, napkins, centerpieces, seasonal decorations, or other features commonly associated with a comfortable dining environment.At approximately 12:15 PM, observations identified residents who remained in their rooms had not yet received lunch service from the monitored meal rack. The last tray from the monitored rack was delivered at approximately 12:18 PM. At that time, the additional tray rack located on the opposite side of the hallway remained partially undelivered to residents residing on the unit.During an interview on 6/1/26, the Director of Dining Services stated residents selected their preferred meals weekly and that any questions or clarifications regarding meal selections were addressed by either him or the dietitian to ensure residents received their preferred meals and meals consistent with their prescribed diets.On 6/2/26 at approximately 11:55 AM, the Director of Dining Services confirmed that meals were transported to each unit immediately after plating for distribution, consistent with the surveyor's observations. Food temperatures were verified simultaneously by the Director of Dining Services and the surveyor and remained within acceptable ranges through the final tray delivery from the monitored rack at approximately 12:18 PM. The Director of Dining Services acknowledged the observed delays in meal delivery and stated dietary services were responsible for transporting meals to the unit, while nursing unit staff were responsible for distributing meals upon arrival.A review of facility practice identified that meal service was routinely provided on trays to both residents dining in communal dining rooms and residents receiving meals in their rooms, as evidenced by observations conducted on multiple units on 6/1/26, 6/2/26, and 6/3/26.Observations throughout the survey identified that residents dining in the dining room received meals on trays, were served at varying times, and dined in a dimly lit environment lacking common homelike dining features. Residents who remained in their rooms experienced delays in meal delivery after food had arrived at the unit. The dining room lacked lighting enhancements, ambient sound, and table settings commonly associated with a comfortable, homelike dining experience.

Based on review of the clinical record, review of facility documentation, review of facility policy and staff interviews for 1 of 3 residents reviewed for Nutrition (Resident #117), the facility failed to ensure staff monitored monthly weights for significant changes and obtain a reweigh per the facility policy. The findings include: Resident #117's diagnosis included dementia, dysphagia and severe protein calorie malnutrition. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #117's weight was 100 pounds and had no loss or gain of weight in the last 30 or 120 days.The quarterly nutritional assessment dated [DATE] indicated Resident #117 was at moderate nutritional risk, had a slow weight loss of 3.6 % over the prior 6 months which had been previously addressed. The note indicated the plan was to continue with Resident #117's current diet, give liquid protein supplements by mouth twice daily, monitor oral intake, laboratory bloodwork, and weights. The care plan dated 4/28/2026 indicated Resident #117 was at risk for malnutrition due to being underweight, having dysphagia, and multiple diagnosis. Interventions included: to monitor for difficulty swallowing, obtain laboratory bloodwork as ordered, monitor weights and oral intake, provide orals supplements as ordered along with high calorie items on his/her meal tray. The care plan further indicated Resident #117 had a self-care deficit for which s/he required total assistance with feeding. Resident #117's weight summary indicated on 4/04/2026 at 2:31 PM Resident #117 weighed 104 pounds and on 5/05/2026 at 3:00 PM weighed 96.6 pounds having a 7.4-pound weight loss. Review of the nursing and physician progress notes from 5/01/2026 through 05/13/2026 identified an Advanced Practice Registered Nurse (APRN) note dated 5/13/2026 which indicated Resident #117 was observed to be lethargic with a poor appetite, poor oral intake and decreased ability to adequately take deep breaths on respiratory examination. After assessment, laboratory tests and a chest x-ray were ordered along with the initiation of Intravenous(IV) hydration for a total of 2 liters. No notes indicated the awareness or notification of anyone regarding the 7.4-pound weight loss noted on 5/05/2026. On 6/03/2026 at 8:18 AM during an interview with the Director of Nursing Services (DNS), s/he indicated the facility procedure for obtaining and monitoring weights was to obtain weekly after admission for 4 weeks, then monthly. The DNS indicated the unit manager is responsible for checking the weight against the prior weight to see if there was a discrepancy and the dietician monitors the weights and notify nursing of any issues. An interview and clinical record review on 6/03/2026 at 8:28 AM with the Dietician identified a 7 percent weight loss in May(5/5/2026) further indicating nursing should have obtained a reweigh.However, review of the clinical record on 6/3/26 identified no re-weight and no dietician notes addressing the weight loss. The dietician further indicated his/her process was to check the monthly weights for the first week of the month and if reweights were needed s/he would provide nursing with a list of residents requiring reweights. After the list is sent to nursing the dietician will check weekly to see if the reweights were completed. The dietician further indicated s/he checks all monthly weights daily and Resident #117's weight loss was not noticed in the electronic documentation and somehow was missed. The dietician then contacted nursing to obtain Resident #117's June 2026 weight as soon as possible. An interview and facility document review with Nurse Aide (NA #6) on 6/03/2026 at 8:45 AM indicated a monthly weight list was kept on a clip board and the only weight documented on the sheet for May 2026 was the 5/5/2026 weight of 96.6 pounds. NA #6 further indicated s/he had not started the June monthly weights yet.An interview and clinical record review with RN #1, the unit manager for Resident #117, indicated the dietician notifies nursing if a reweight would be needed. RN #1 further indicated s/he does not review the monthly weights his/herself consistently. During the review of the clinical record RN #1 indicated there was no documentation regarding the weight loss or any poor intake or illness prior to 5/5/2026 when the weight was obtained. An interview with the dietician on 6/03/2026 at 9:20 AM indicated a weekly weight meeting occurs with the DNS, APRN and the dietician and at which time Resident #117 was addressed for poor oral intake on 5/13/2026 but the meeting did not indicate Resident #117's weight. An interview and record review with APRN #1 on 6/04/2026 at 1:05 PM indicated s/he was not aware of the 5/5/2026 weight loss but had been made aware of the poor oral intake on 5/13/2026 ( 8 days later). The dietician returned on 6/03/2026 at 1:30 PM and identified a reweight for Resident #117 was still 96.6 pounds and s/he would now follow up with notifications of the Medical Doctor (MD)/APRN and family and would decide on any further recommendations including a weekly weight until stable. The facility policy labeled Interpretation and Implementation-Weight Assessment indicated any weight change of 5 pounds or more since the last recorded weight will be retaken within 24 hours for confirmation and if the weight loss is confirmed, the dietician would be notified in writing.

Based on observation, review of facility policy and staff interviews for 1 of 3 medication carts ( 2 East) reviewed, the facility failed to ensure that medications in a medication cart were labeled appropriately. The findings include: On 6/2/2026 at 2:15 PM, an observation with LPN #5 of the 2 East Med Cart identified four loose pills in a clear medication cup that was stored in the locked top drawer of the cart. The medication cup was not labeled or marked with the medication name or dosage. The medication included the following: one large grey oval tablet with the markings L15, one small white oblong tablet with the markings F on one side and 5 4 on the other, one small white round tablet with the markings 210, and a small white oblong tablet with the markings 5056.An interview with LPN #5 indicated the medications were valsartan 320mg (for high blood pressure), escitalopram 10mg (for depression), amlodipine 5mg (for high blood pressure), and atorvastatin 10mg (for cholesterol). LPN #5 indicated the medication was intended for Resident #156 in the morning, but the resident refused it. LPN#5 indicated she kept the medication in the cart to try again later in the day. A review of the Medication Administration Record ( MAR) with LPN #5 identified the medication was documented as administered. LPN #5 indicated she forgot to update the MAR to document the refusal.On 6/2/2026 at 2:22 PM, the unit manager, LPN #6, indicated that changes had been made to Resident #156's physician's orders and the unlabeled medication in the medication cart should be discarded.A review of the Medication Storage policy identified that drug containers that had missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. The policy did not identify how staff should have managed medication that had been removed from its original packaging.

Based on clinical record reviews, observation, review of policy and staff interview for 1 of 25 residents ( Resident # 12) reviewed for enhanced barrier precautions, the facility failed to ensure staff donned appropriate Personal Protective Equipment ( PPE) for a resident requiring enhanced barrier precautions and for 1 of 1 resident (Resident # 148) reviewed for urethral catheter, the facility failed to ensure that a resident's urethral catheter was properly discarded. The findings included. Resident #148 was admitted with diagnoses that included dementia and vertebral fracture. The nursing admission assessment dated [DATE] identified Resident #148 was admitted with an indwelling urethral catheter. A physician's order dated 5/28/2026 directed to maintain a urethral catheter to drainage for urinary retention. A nursing progress note dated 5/30/2026 identified Resident #148's urethral catheter was found displaced during morning rounds and the resident indicated she/he had pulled out the catheter. A nursing note dated 5/31/2026 identified that a voiding trial was in progress for Resident #148 and the resident had voided twice. On 6/1/2026 at 10:58 AM (two days after Resident #148's catheter had been removed) a urethral catheter was observed in Resident #148's room on top of a dresser across from the foot of the bed. The catheter had the balloon at the tip of the catheter inflated. There was a urine collection bag attached to the catheter that contained yellow urine. On 6/1/2026 at 11:08 AM, an interview with the unit manager (LPN #4) indicated Resident #148 had a urethral catheter but had been undergoing a voiding trial. LPN#4 did not know why a used urethral catheter was on the resident's dresser but indicated the device should have been discarded. A review of the facility policy for Urinary Catheter Care did not identify where used indwelling catheters and drainage bags should be discarded after removal. However, the policy did indicate that when inserting indwelling catheters, any disposable items should be discarded in designated containers. Resident #12's diagnosis included diabetes mellitus and local infection of the skin. A physician's order dated 12/08/2025 directed to maintain Enhanced Barrier Precautions every shift related to wounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 as cognitively intact. The care plan dated 5/05/26 indicated Resident #12 required Enhanced Barrier Precautions related to having wounds. Interventions included: to wear gloves and a gown while providing high contact care activities and to follow proper PPE donning and doffing guidelines. An observation on 6/01/2026 at 9:12 AM identified NA# 1 providing personal care , noted turning and applying a disposable undergarment for Resident #12 in bed without the benefit of wearing a gown and only gloves. An interview with NA #1 on 6/01/2026 at 9:17 AM indicated NA #1 was providing personal care and dressing for the day. NA#1 further indicated she/he had been employed by the facility for years and she/he only had to wear gowns, if it was known that a resident had something that required staff to wear a gown. On 6/01/2026 at 9:18 AM an interview with the charge nurse, LPN #1, indicated Resident #12 was on Enhanced Barrier Precautions and NA#1 should have been wearing a gown when proving morning care and dressing for the day. On 6/01/2026 at 10:00AM the Director of Nursing services ( DNS) provided prior education regarding enhanced barrier precautions, and all other precautions labeled Infection prevention Winter Review, completed 2/12/26- 2/23/2026 for which NA #1 signed as attended on 2/12-13/2026. The DNS indicated s/he would follow up with NA #1 regarding enhanced barrier precautions. The facility policy dated 2/20/2025 labeled Enhanced Barrier Precautions indicated the implementation of Enhanced Barrier Precautions (EBP) was to prevent the spread of multidrug-resistant organisms (MDROs). One of the requirements to qualify for Enhanced Barrier Precautions included wounds. The policy further indicated hand hygiene by staff would occur upon entering and exiting the room and all staff performing high-contact activity including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.

Based on clinical record reviews, facility documentation and staff interview, the facility failed to ensure for 5 out of 8 sampled residents (Resident # 6, 38, #61, #98 and #115) reviewed for Resident Assessments within a transmission batch of 60 Minimum Data Set (MDS) assessments were transmitted timely. The findings included: On 6/03/2026 at 11:41 AM the administrator arranged a conference call with the 2 MDS Coordinators, Registered Nurse (RN) #4 and RN#5 who work remotely. The call began at 11:45 AM and ended at 12:08 PM. The following Resident's Minimum Data Set ( MDS) Assessments were transmitted after the 14-day timeline requirement for transmission to the Center for Medicare and Medicaid Services(CMS). 1.Resident #6's quarterly MDS assessment completed 5/16/2026 was noted with a transmission accepted 05/29/2026- 16 days after completion( 2 days late). 2.Resident #38's quarterly MDS assessment dated [DATE] completed 5/08/2026 was noted with transmission accepted 5/29/2026 7 days late. 3. Resident #61's quarterly MDS assessment dated [DATE] completed on 5/10/2026 with a noted transmission accepted on 5/29/2026 5 days late. 4.Resident #98's annual assessment was completed on 4/30/2026 noted with a transmission accepted on 5/29/2026 15 days late. 5.Resident #115's quarterly assessment dated [DATE] completed on 5/10/2026 with a noted transmission accepted on 5/29/2026 with transmission accepted on 5/29/2026 was 5 days late.6.Resident #115 also had an End of Stay PPS assessment dated [DATE] completed on 5/11/2026 with transmission accepted on 5/29/2026 which was 4 days late.Interview at 12:08 with the MDS Nurses RN #4 and #5 RN #5 on 6/3/26 11:41 AM indicated s/he believed the facility had 7 days to transmit with added days. However, she was unable to indicate the specifics, felt the export and submission process (transmission to CMS) needed to be reviewed to ensure the facility meets the 14-day submission/transmission deadline.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure wound care physician recommendations were transcribed accurately. The findings include: F684Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure wound care physician recommendations were transcribed accurately. The findings include: Resident #1 had a history of Alzheimer's dementia and urinary incontinence. The Resident Care Plan (RCP) dated 4/21/23 identified a toe wound. Interventions directed to observe for signs of infection and to provide treatments and dressing changes as ordered. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had short- and long-term cognition deficits, and was dependent for ADL care. Nursing note dated 5/23/23 at 3:40 PM identified Resident #1 was seen by MD #1 and the bilateral great toes were assessed by MD #1. Per MD, both toenails were ingrown and purulent drainage (pus like fluid) was expressed from the left medial (inner edge) great toe. A discolored area was noted on right medial great toe, but no purulent drainage. The note indicated Mupiricin (topical antibiotic) treatment was ordered. Wound care provider note dated 5/23/23 identified treatment recommendation for the first toe left lateral, apply Bactroban (topical antibiotic) to the wound base with a dry clean dressing every day. Physician Order dated 5/23/23 directed to apply Mupirocin (Bactroban) External Ointment 2% to the bilateral great toes topically every day shift for wound care for 14 Days. Cleanse bilateral great toe wounds with normal saline. Record review failed to identify the wound physician had directed the Bactroban to be applied to both toes. Nursing note dated 5/30/23 at 4:30 PM identified Resident #1 was seen by MD #1 and bilateral great toes were dry with no purulent drainage noted. No swelling or erythema noted. Treatment was changed to Betadine (topical antiseptic solution). Wound care provider note dated 5/30/23 identified treatment recommendation for the first left lateral toe to paint with Betadine every day and leave open to air. Physician Order dated 5/30/23 directed staff to apply Betadine (helps prevent infection) to the bilateral great toes for seven (7) days every day shift. Record review failed to identify the wound physician had directed the Betadine to be applied to both toes. Interview and record review with MD #1 on 4/30/26 at 10:05 AM identified Resident #1 had discoloration to the right toe, but only needed a treatment to the left toe because the right toe had no drainage. MD #1 stated on 5/23/23 he only wanted Bactroban placed on the left toe with a dry clean dressing to be changed once a day, and on 5/30/23 he only wanted Betadine placed on the left toe and not the right toe. MD #1 further stated that nursing should be following his would care recommendations and did not know why the order was placed for the bilateral toes when it should have been only the one (1) toe. Interview and record review with the Director of Nursing (DNS) on 4/30/26 at 10:45 AM identified the wound care order placed on 5/23/23 directed to apply Bactroban on the bilateral great toes, and did not match the wound treatment recommendation made on 5/23/23 by MD #1 to apply only to the first left lateral toe. Further, the wound care ordered placed on 5/30/23 directed to apply Betadine on the bilateral great toes and did not match the wound treatment recommendation made by MD #1 on 5/30/23 to apply only on the first left lateral toe. The DNS further stated the wound care orders should match the recommendations made by the wound care physician/MD #1 and did not know why the orders were entered incorrectly. Review of facility Physician Order Policy dated January 2025 directed staff to assure treatment orders are implemented accurately, timely and in accordance with the public health code and federal regulations.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for activities of daily living, the facility failed to ensure the clinical record was complete and accurate to include documentation of personal care. The findings include: Resident #1 had a history of Alzheimer's dementia and urinary incontinence. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had short- and long-term cognition deficits, and was dependent for ADL care. The Resident Care Plan (RCP) dated 4/21/23 identified a self-care deficit. Interventions directed to provide ADLs and mouth care. Record review of the Personal Hygiene ADL task for May of 2023 identified documentation was missing (blank) on 5/1, 5/5, 5/7, 5/10, 5/11, 5/13, 5/16, 5/17, 5/18, 5/20, 5/22, 5/23, 5/24, 5/25, 5/26 and 5/28/2023 (missing on 16 shifts for the month). Interview and record review with the Director of Nursing (DNS) on 4/30/26 at 10:45 AM identified the ADL Hygiene documentation was missing/blank on 15 shifts during 7 AM to 3 PM, and one (1) 3 to 11 PM shift during the month of May 2023, for a total of 16 shifts missing documentation. The DNS stated staff would have provided the care and staff should have documented on the ADLs provided on the ADL Personal Hygiene task, and she did not know why staff did not document the care. Review of facility Charting and Documentation Policy dated 1/14/2014 directed all services provided to the resident must be documented in the resident's medical record.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) reviewed for weight loss, the facility failed to ensure the clinical record was complete and accurate to include timely meal intake documentation. The findings include: Resident #1 had diagnoses that included Alzheimer's disease and anxiety. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS), indicative of being severely cognitively impaired and required maximum assistance for eating. The Resident Care Plan (RCP) dated 6/23/25 identified Resident #1 had an ADL deficit related to Alzheimer's disease and tardive dyskinesia. Interventions directed to feed resident meals. Review of meal intake documentation for Resident #1 identified from 5/25 through 6/23/2025 the meal intakes identified the following: • Resident #1's breakfast was not documented on: 5/27, 5/31, 6/1, 6/10, 6/13, and 6/14/25. • Resident #1's lunch was not documented on: 5/27, 5/31, 6/1, 6/10, 6/13, and 6/14/25. • Resident #1's dinner was not documented on: 5/25, 5/30, 5/31, 6/1, 6/2, 6/5, 6/7, 6/10, 6/11, 6/13, 6/15, 6/19, and 6/21/25. Interview with Dietician #1 on 6/23/25 at 10:25 AM identified Resident #1 was at risk for weight loss, and her observations and reviews had identified Resident #1 was a good eater. Further, the Dietician #1 indicated the staff should document meal intakes accurately after each meal. Interview and record review with the DON (Director of Nursing) on 6/23/25 at 1:20 PM identified it was her expectation that the nursing staff document each meal intake in the electronic medical records to ensure accurate representation of each meal for a resident. interview failed to identify why the meal intakes were not documented. Review of the Electronic Medical Records Policy dated 2/2021 identified the facility will ensure each record will be accurate, based on knowledge of resident information. Interview and record review with the DON (Director of Nursing) on 6/23/25 at 1:20 PM identified it was her expectation that the nursing staff document each meal intake in the electronic medical records to ensure accurate representation of each meal for a resident. interview failed to identify why the meal intakes were not documented. Review of the Electronic Medical Records Policy dated 2/2021 identified the facility will ensure each record will be accurate, based on knowledge of resident information.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of two (2) residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure that a resident (Resident #1)who had a history of speaking to another resident (Resident #2) in a deragatory manner were free from physical abuse. The findings include: 1. Resident #1 had diagnoses that included impulse disorder, unspecified intellectual disabilities, schizophrenia, and delusional disorder. The annual MDS dated [DATE] identified Resident #1 had short and long-term memory problems, was always incontinent of bowel and bladder, independent with wheeling the wheelchair, and dependent with ADLs. The care plan dated 12/12/24 identified Resident #1 has behavioral problems cries out frequently, diagnoses of developmental delay impulse disorder and delusions, accusatory towards other residents and staff, inappropriate hand gestures and language towards staff and other residents with interventions directed to allow time to de-escalate and re-approach if agitated, encourage the resident to express feelings appropriately, psych consult as needed, caregivers to provide opportunities for positive interaction and attention stop and talk to the resident when passing by, and praise any indication of the resident's progress/ improvement in behavior. 2. Resident #2 had diagnoses that included vascular dementia and adjustment disorder with anxiety. The care plan dated 10/15/24 identified Resident #2 has the potential to be physically/verbally inappropriate with staff and other residents related to dementia with interventions that directed to redirect negative behaviors, update MD and family as needed, and remove resident from situations triggering behavior, provide a calm environment during periods of agitation. The quarterly MDS dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of one (1) indicative of severely impaired cognition, was always continent of bowel and bladder, independent with locomotion and ADLs. A nurse's note dated 1/3/25 at 12:17 P.M. written by the DNS identified she was called to the unit at 10:40 A.M. to assess Resident #1 following an incident with Resident #2 witnessed by LPN #1. The DNS identified Resident #1 was quietly sitting in h/her wheelchair in the social service office, upon seeing this writer Resident #1 began to cry and repeatedly striking the right side of h/her cheek stating, he hit me. The DNS indicated Resident #1 would alternately calm down with some direction and then would immediately start striking h/her cheek again. The DNS indicated Resident #1 was unable to state more than he hit me. The DNS identified on initial exam slight redness to Resident #1's cheek bone was noted. A nurse's note dated 1/3/25 at 12:23 P.M. written by the DNS identified she was called to the unit at 10:40 A.M. to assess Resident #2. The DNS identified LPN #1 witnessed Resident #2 hitting Resident #1 hitting the cheek. The DNS indicated the residents were already separated. The DNS indicated upon investigation Resident #2 was unable to state what had occurred and Resident #2 was ambulating in hallway with no apparent injuries. A social worker's note dated 1/3/25 at 12:37 P.M. written by SW #1 identified she was informed Resident #2 hit Resident #1. SW #1 indicated she first spoke with Resident #2 who was unable to communicate details of the incident. SW #1 indicated she then asked Resident #1 what happened, and Resident #1 reported Resident #2 hit h/her in the face. SW #1 identified Resident #1 was smacking h/herself on h/her cheek stating Resident #2 hit h/her on the cheek. SW #1 identified Resident #1 reported h/she hit Resident #2 first because h/she does not like Resident #2. Review of the facility's accident and incident report dated 1/3/25 identified at 10:40 A.M. LPN #1 heard yelling coming from down the hallway and went to investigate. LPN #1 observed both Resident #1 and Resident #2 with their arms raised, LPN #1 called out 'stop' prior to reaching the residents, LPN #1 witnessed Resident #2 hit Resident #1 on the right cheek, and the residents were immediately separated. The facility's summary dated 1/8/25 identified upon investigation and interviews Resident #1 told SW #1 that h/she hit Resident #2 because h/she does not like h/her and Resident #2 had no recollection of the event. The findings identified Resident #1 struck out at Resident #2 as h/she walked by and Resident #2 who is cognitively impaired reacted. The facility's indicated the corrective action is in place and being implemented psychiatry and psychology review with support services implemented, staff educated to separate residents if they are in the same vicinity. Interview with LPN #1 on 1/28/25 at 10:25 A.M. identified on 1/3/25 she heard yelling coming from down the hallway and went to investigate the yelling. LPN #1 identified she observed Resident #1 seated in h/her wheelchair with h/her hands raised as though she was ready to hit Resident #2 who was standing next to Resident #1. LPN #1 indicated she yelled 'stop' as she walked toward the residents and witnessed Resident #2 with a closed fist hit Resident #1's right cheek. LPN #1 identified she immediately separated the residents, and she remained with Resident #2 until the DNS came to the unit. LPN #1 identified prior to 1/3/25 there has been issues for some time with Resident #1's behaviors towards Resident #2. LPN #1 identified Resident #1 tells Resident #2 I don't like you, Resident #1 has put h/her hands up towards Resident #2 as though she wanted to hit h/her, and Resident #1 has spit in the direction of Resident #2. LPN #1 identified in the past Resident #2 has always been non-reactive to Resident #1's comments and gestures and at times Resident #2 will just stop, stand, look at Resident #1 for a moment then keep walking in the hallway. Interview with LPN #2 on 1/28/25 at 11:14 A.M. identified prior to 1/3/25 whenever she was caring for Resident #1 she had to keep an 'eye' on h/her because Resident #1 would say to Resident #2 I don't like you while Resident #1 made hand gestures or had h/her hands raised at Resident #2. Interview with NA #2 on 1/28/25 at 11:30 A.M. identified prior to 1/3/25 on many occasions Resident #1 wheel h/herself towards Resident #2 telling Resident #2 I don't like you and has witnessed Resident #1 spitting towards Resident #2. Interview with SW #1 on 1/28/25 at 9:53 A.M. identified on 1/3/25 Resident #1 came into her office following the altercation with Resident #2, Resident #1 kept hitting h/her right cheek and face approximately 15 times stating, Resident #2 did that to me. SW #1 indicated on 1/3/25 Resident #1 reported that h/she hit Resident #2 first on h/her side because h/she doesn't like Resident #2. SW #1 identified Resident #1 does have a history of aggressive behaviors. SW #1 identified that is why Resident #1 is in a private room. SW #1 identified prior to 1/3/25 Resident #1 almost daily while sitting in the hallway tells Resident #2 I don't like you as Resident #2 walks by h/her, at times Resident #1 will also raise up h/her hands up at Resident #2, and Resident #1 would spit in Resident #2's direction. SW #1 indicated when she observed or heard Resident #1 saying I don't like Resident #2 she would take Resident #1 into her office staff to reset h/her and talk to Resident #1 about h/her behaviors. SW #1 indicated staff are aware of Resident #1's behaviors towards Resident #2, staff do redirect Resident #1 and keep Resident #1 and Resident #2 separated during activities. SW #1 indicated Resident #2 has not reacted to Resident #1's behaviors in the past. Interview with APRN #2 (psychiatric) on 1/28/25 at 12:00 P.M. identified Resident #1 has a history of aggressive physical and verbal behaviors in the past which resulted in Resident #1 requiring a private room. APRN #2 identified Resident #1 is very child-like, loves to be the center of attention, and does become easily upset if h/she feels others are getting more attention than h/she is getting. APRN #2 identified she was aware prior to the altercation between Resident #1 and Resident #2 that Resident #1 exhibited verbal behaviors toward telling Resident #2 I do not like you. APRN #2 identified she herself has heard Resident #1 stating I don't like Resident #2 with Resident #2 being within hearing distance. APRN #2 identified during her visit with Resident #1 on 1/ 3/25 Resident #1 reported that h/she punched Resident #2 first because h/she does not like Resident #2. APRN #2 indicated on 1/3/25 when Resident #1 struck out at Resident #2 h/she reactively punched Resident #1 back. Review of Resident #1 and Resident #2's plan of care failed to address the frequent negative comments and actions by Resident #1 to Resident #2 prior to 1/3/25 until after the incident when Resident #1's care plan identified to keep Resident #2 away from Resident #1. Interview with the DNS on 1/28/25 at 12:30 P.M. identified she was aware prior to 1/3/25 that Resident #1 would say h/she doesn't like Resident #2 in the hallway while Resident #2 walked by and at times Resident #1 would make inappropriate hand gestures and spit towards Resident #2. The DNS identified Resident #1 is care planned for h/her behaviors that include spitting, use of inappropriate hand gestures and language towards staff and other residents with interventions. LPN #1 witnessed Resident #2 hit Resident #1 on h/her right cheek. The DNS identified on 1/3/25 Resident #1 reported to SW #1 that h/she hit Resident #2 first because h/she doesn't like Resident #2. The DNS identified based on the investigation the allegation of resident-to-resident abuse was substantiated Resident #1 did hit Resident #2 on h/her side and Resident #2 reacted to being hit by hitting Resident #1's right cheek. Review of the facility Abuse Prevention policy, in part, identified the facility is committed to protecting residents from abuse by anyone including but not limited to facility staff, other residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.

Based on clinical record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse the facility failed to ensure the medical record was complete and accurate to include documentation of visits provided by social services following an allegation of abuse. The findings include: Resident #1 was admitted on [DATE] with diagnosis of hemiplegia/hemiparesis (weakness of one side of the body) following a cerebral infarction. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 9/4/24 identified Resident #1 had a self-care deficit. interventions directed to provide assistance with ADLS (ADL) and use of 1/4 side rails for bed mobility. Facility incident report dated 9/6/2024 identified Resident #1's family reported an allegation that a NA slapped Resident #1 on the back on 9/4/2024 about midnight. An assessment was completed with no injuries noted. The facility summary dated 9/11/2024 identified the accused NA denied the allegation, there were no witnesses to the alleged incident, Resident #1 did not report the allegation to any staff prior to the family report on 9/6/2024 at 4:30 PM, and the facility was unable to substantiate the allegation. Resident #1 and the family member were notified the facility was unable to substantiate the allegation and indicated they were satisfied with the results of the investigation. Clinical record review failed to identify the social worker documentation following up with Resident #1 after the allegation of abuse. Interview and record review with Social Worker (SW) #1 on 10/1/24 at 2:10 PM identified she saw Resident #1 for a follow up support visit on 9/10/2024 (after the allegation on 9/6/2024). SW #1 stated that she failed to write a note on the incident because she forgot, and stated she should have written a note after her visit with Resident #1. Interview with the DNS on 10/1/24 at 3:03 PM identified SW #1 should have written a note after her visit with Resident #1, and she stated she did not know why SW #1 did not write a note. Review of facility Charting and Documentation Policy dated April 2008, directed in part, to document all observations, medications administered, and services performed in the resident's clinical record.

Based on clinical record reviews, facility policy review, and interviews for one sampled resident (Resident #28) reviewed for dental services and for one sampled resident (Resident #45) with a surgical incision, the facility failed to follow dental orders as a prerequisite for a tooth extraction, and failed to administer the prescribed treatment to the left chest in accordance with the physician's order, The findings include: 1. Resident #28 was admitted to the facility on [DATE]. Diagnoses included dysphagia, oropharyngeal phase, cellulitis of face, unspecified protein-calorie nutrition, other psychoactive substance dependence, in remission, and other specified anxiety disorders. The speech screen dated 1/19/2021 identified the resident had a mechanically altered diet related to complaints of difficulty or pain when swallowing and the summary identified the resident had a mechanically altered diet, and a swallowing disorder. A recommendation was made for a swallow evaluation. Review of the Speech Therapy treatment encounter notes dated 1/30/2021 and 2/5/2021 identified Resident #28 was not happy with the modified diet and was able to successfully chew, swallow and had adequate oral clearance, at which time the diet was upgraded. The Dentist's note dated 2/23/24 identified Xray results indicated that root tip for tooth #21 needed to be extracted and would be done at the facility. Action required by nursing home staff identified the resident was to continue daily oral care and treatment planned for extraction at the facility with orders to administer Ativan 1mg one hour prior to procedure for anxiety and discontinue aspirin two days prior to procedure date. The procedure was scheduled for 3/22/24. Review of the Dentist's note dated 3/22/24 identified that the facility had not prepared the resident for the scheduled procedure as ordered, the aspirin had not been discontinued, and there was not an order in place for Ativan as requested for sedation. The note further identified another appointment was set for 5/1/24 The Dentist's note dated 5/30/2024 identified the extraction of root tip #21 had not been completed due to the facility not discontinuing the aspirin as previously ordered. Review of physician's orders for June and July 2024 identified an order for Aspirin 81 mg with directions to give 1 table by mouth at bedtime related to cachexia. The Physician's orders did not contain orders to hold the Aspirin and failed to identify an order for Ativan. Review of the Medication Administration Records for the months of June and July 2024 identified the resident received Aspirin 81 mg every day. Review of a signed paper pharmacy prescription dated 6/6/2024 identified an order for Ativan 1mg by mouth one hour prior to extraction on 6/17/2024, the order was signed by the provider and acknowledged by the nurse. The Annual Minimum Data Set (MDS) dated [DATE] identified Resident #28 had intact cognition, was independent with all mobility, transfers, ambulation, dressing, and hygiene, and that the resident's oral/dental status indicated the resident did not have any concerns with dental and was not edentulous. Review of the nursing progress notes dated 6/18/24 at 2:42 PM written by RN #2 (nursing supervisor) identified the facility was notified that the tooth extraction will be on June 24th and the dentist will be at the facility by 9:00 AM. Review of the nursing progress notes dated 6/24/24 at 4:18 PM identified the resident was supposed to have a tooth extraction but was unable to do so due to aspirin was not held for 3 days. The Dentist's note dated 6/24/24 identified that the extraction of tooth #21 was again not completed because the aspirin had not been held two days prior to the scheduled procedure. The note further noted that the extraction was necessary for the fabrication of dentures. The care plan dated 5/7/2024 identified Resident #28 had potential for oral health problems related to edentulous and does not wear dentures with goals to be free of infection, pain or bleeding in the oral cavity and be able to chew food without discomfort. Interventions included to monitor/document/report PRN any signs or symptoms of oral/dental problems needing attention, provide mouth care as per ADL personal hygiene and refer to dietician for adjustment in diet related to oral/dental condition but failed to identify the resident's ongoing work with the dentist in being fitted for dentures. Interview with Resident #28 on 7/22/24 at 11:48 AM identified he/she had no teeth and needed dentures. Resident #28 indicated that the dental appointments had been cancelled several times and the resident had not been fitted for dentures that the dentist indicated would happen in February 2024. Resident #28 identified there is some difficulty with foods, but the resident knows what to stay away from. Interview and chart review with LPN #2 on 7/24/24 at 11:00 AM identified that when the facility received new orders from a provider, the orders go into the 24-hour report and the medication is entered on the MAR. The nurses are able to go into the MAR and hold the medication for whatever dates it should be held. The doctors or consultants leave the paper flagged and whoever is working is responsible to take the order and follow through. Review of the dental notes (in the paper chart) dated 2/23/24 identified the dentist ordered Ativan and to stop the aspirin two days prior to the next scheduled treatment. LPN #2 identified the order did not seem like it was done and referred this writer to the nursing supervisor who handles the dental visits. Interview with the Nursing Supervisor (RN#2) on 7/24/24 at 11:25 AM identified the nurses input the medications in the computer when directed by the doctor's note. Based on her recollection, she indicated the dentist only cancelled the June appt and had to reschedule. The resident is scheduled for [DATE]th for the extraction. RN#2 stated she had surgery 1/29/24 and was out for approximately 6 weeks. She is not sure who was covering for her at the time. Interview with the DNS on 7/24/24 at 11:42 AM identified that RN #2 was out of work from 1/31/24 through 4/1/24 and noted that the other two nursing supervisors were responsible for managing the consult orders during that time. The DNS identified that all consultation correspondence goes through her, and that she is responsible for making sure the recommendations are followed through. She stated that the resident refused the dental care, however, was unable to provide documentation that the resident refused. Review of the dental notes identified the facility did not follow through on the recommendations/orders from the dentist on three different occasions. The nursing note dated 7/24/2024 at 2:29 PM identified an appointment for the tooth extraction scheduled for August 5th at 9:00 AM. Review of Physician's orders dated 7/24/24 identified an order to hold ASA 81mg 3 days before dental procedure with specific dates of 8/2/24 through 8/5/2024 and resume after procedure. Order was added by the nursing supervisor. Review of the facility dental policy identified the resident was able to be seen by the facility's consultant dentist, records of dental care provided shall be made part of the resident's medical record, and a resident needing dental services will be promptly referred to the dentist. 2. Resident #45 's diagnoses included fracture of sixth cervical vertebrae, type 2 diabetes mellitus, dementia, chronic kidney disease, and syncope and collapse. The admission MDS assessment dated [DATE] identified Resident #45 had moderate cognitive impairment and required extensive assistance for bed mobility, hygiene, toileting, and transfers, was non-ambulatory and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 6/17/24 identified Resident #45 with syncope and collapse. Care plan interventions directed to monitor resident for side effects of medication, medications as physician's orders, provide a safe environment, and update physician and family for resident condition as needed. The physician's order dated 6/27/24 directed to cleanse a small medial blister and apply 1 percent sulfadiazine cream (topical anti-bacterial medication) to the left chest twice per day. Review of the Treatment Administration Record (TAR) from 6/27/24 to 7/24/24 failed to identify that the 1 percent sulfadiazine cream was administered as directed by the physician. Interview with LPN #3 on 7/25/24 at 11:00 AM identified that the charge nurses are responsible for ensuring physician's orders are transcribed and administered properly. Review of the physician's orders dated 6/27/24 with LPN #3 identified the treatment order directing the administering of 1 percent sulfadiazine cream to the left chest twice per day to surgical incision. Further review of the medication record and the treatment administration record from 6/27/24 to 7/24/24 failed to reflect that the order was transcribed or administered as ordered. Interview with the DNS on 7/25/24 at 11:30 AM identified that she expects all of the licensed staff to follow the physician's orders. She identified that the 1 percent sulfadiazine cream should have been administered to the resident in accordance with the physician's order. The Physician Medication Orders policy identified that all medications would be administered upon the written order of a person duly licensed and authorized to prescribe in this state. 47489

Based on clinical record review, review of facility policy, and interviews for one sampled resident (Resident #23) reviewed for accidents, the facility failed to notify the resident's responsible party when the resident had an incident of smoking in their room. The findings include: Resident #23's diagnoses include chronic obstructive pulmonary disease, dementia, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, utilized a walker and wheelchair for mobility, was independent for eating, utilized set up or clean up assistance with oral hygiene and toileting, and required supervision for dressing and personal care. Resident #23's care plan dated 5/20/24 identified an ADL (activities of daily living) self-care performance deficit with interventions that included: limited assistance with a rolling walker on the unit, assistance with bathing/showering, personal hygiene and oral care. The care plan further noted Resident #23 was an elopement risk/wanderer related to impaired safety awareness with an intervention to redirect negative behaviors. The nursing note dated 7/20/24 at 2:53 PM written by RN #2 (Nursing Supervisor) identified Resident #23 was found smoking in his/her room with his/her spouse in the room. The resident was educated on the smoking policy and the danger of smoking in the room, a room search was conducted with no cigarettes and lighting materials found. The note further identified that the resident's spouse was instructed to not bring smoking supplies into the facility. Additionally, the APRN was contacted, and a new order was obtained for a Nicotine patch. The reportable event report dated 7/22/24 identified the resident was found smoking in his/her room. The report did not identify that the resident's responsible party was notified of the incident. Attempts to interview RN#2 concerning the incident with Resident #23 were made on 7/24/24 at 1:01 PM and on 7/25/24 at 9:18 AM. A message was left on both occasions. All attempts were unsuccessful. Interview with Person #1(Responsible Party) on 7/29/24 at 1:08 PM identified she was not notified of the smoking incident until 7/25/24, when she was sent an email from Social Worker #1. Interview with Social Worker #1 on 7/30/24 at 11:25 AM identified that she notified the conservator via email of the smoking incident on 7/25/24 but believes the conservator should have been notified sooner following the incident. She further noted that she would have expected the nurse on the unit to notify the resident's responsible party at the time of the incident. Interview with the DNS on 7/30/24 at 9:33 AM identified that resident responsible parties/conservators should be notified at the time of the incident. She would have expected the conservator to be notified sooner than 7/25/24 for the incident occurring on 7/20/24. The DNS further identified that she had not completed the reportable event report until 7/22/24 because she was busy when she was notified of the incident. Review of the facility Reportable Events Investigating and Reporting policy identified all accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge nurse and/or the department director of supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge nurse and/or the department director or supervisor shall complete a Reportable Event form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. The date/time the family is notified should be documented on the Reportable Event form.

Based on clinical record review, review of facility policy, and interviews for one of five sampled residents (Resident #100) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to complete a screening for a resident who required one following short-term approval. The findings include: Resident #100's diagnoses include paranoid personality disorder, delusional disorder, post-traumatic stress disorder and major depressive disorder, The quarterly MDS assessment dated [DATE] identified Resident #100 had intact cognition, utilized a wheelchair for mobility, was dependent for all activities of daily living (ADL's.) The assessment further noted the resident's diagnoses were depression, psychotic disorder, and post-traumatic stress disorder. Resident #100's care plan dated [DATE] identified the potential for behavioral problems related to paranoia, delusional, accusatory, towards staff makes fallacious statements. Interventions directed to administer medications as ordered, allow time to deescalate and reapproach if agitated, explain procedures prior to the initiation of a task. Review of PASRR screenings for Resident #100 identified a Level I screen was completed on [DATE], with an outcome to Refer for Level II onsite. The PASRR level I identified short term approval without specialized services with an end date of [DATE]. Review of the clinical record identified that a level II screen was completed on [DATE] (seven months later than the approved time for the resident to be in the facility). Interview with Social Worker #1 on [DATE] at 11:24 AM identified she should have submitted Resident #100 for a screening following the short-term approval ending on [DATE]. Social Worker #1 realized that she should have submitted Resident #100 for a Level II screen at the time of Resident #100's approval to reside in the nursing facility expired. Review of facility policy titled Pre-Admission Screen Annual Resident Review updated ,d+[DATE] directed PASARR to be completed by a Social Worker if not completed prior to admission. If the resident is admitted with a short term PASARR or time sensitive PASARR social worker will complete a new level screen and level of care if necessary. For each patient/resident requiring a Level II assessment a completed PASARR and mental illness intake form must be completed.

Based on observations, review of clinical records, review of facility policy, and interviews for two of two sampled residents (Resident #23 & #45) reviewed for accidents and splints/medical equipment, the facility failed to develop and implement a comprehensive care plan following an incident of unauthorized smoking in the facility and for the use of an Aspen neck collar (a neck brace that limits movement of the neck) and an implanted loop recorder ( a small device that monitor heart's electrical activity that is inserted under the chest skin). The findings include: 1. Resident #23's diagnoses include chronic obstructive pulmonary disease, dementia, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, utilized a walker and wheelchair for mobility, was independent for eating, utilized set up or clean up assistance with oral hygiene and toileting, and required supervision for dressing and personal care. Resident #23's care plan dated 5/20/24 identified an ADL (activities of daily living) self-care performance deficit and utilized limited assistance with a rolling walker on the unit, requires assistance for bathing/showering, personal hygiene and oral care. The nursing note dated 7/20/24 at 2:53 PM written by RN #2 (Nursing Supervisor) identified Resident #23 was found smoking in his/her room with his/her spouse in the room. The resident was educated on the smoking policy and the danger of smoking in the room, a room search was conducted with no cigarettes and lighting materials found. The note further identified that the resident's spouse was instructed to not bring smoking supplies into the facility. Additionally, the APRN was contacted, and a new order was obtained for a Nicotine patch. Review of Resident #23's care plan dated 5/20/24 failed to reflect that it was updated and/or revised following the incident of unauthorized smoking in the facility. Interview with RN#2 was attempted on 7/24/24 at 1:01 PM and on 7/25/24 at 9:18 AM, message left both times with no return call received. Interview with NA #5 on 7/25/24 at 9:46 AM identified she smelled smoke near Resident #23's room and knew that the next-door neighbor was on Oxygen, so she went into Resident #23's room and found Resident #23 in the bathroom flushing what she believed to be a cigarette down the toilet. The smell of the cigarette was stronger in the bathroom. NA #5 asked Resident #23 where he/she obtained the cigarette from and was told his/her spouse. At that time Resident 23's spouse was not in the room, however had been previously prior to the incident. NA#5 further identified that she notified the charge nurse on the unit, who in turn notified the nursing supervisor. Interview on 7/25/24 at 11:22 AM with the Director of Nursing (DON) identified the care plan had not been updated following the incident on 7/20/24 and she had not had time to update the care plan regarding this incident. Interview with Social Worker #1 on 7/25/24 at 11:40 AM identified that the care plan had not been updated but Social Worker #1 identified it probably should have and that she could go in and update it. Social Worker #1 identified that she, the Nurse Supervisor, or DON could update the care plan, however she had been so busy she hadn't done it yet. APRN #2's (psychiatric aprn) psychosocial note dated 7/22/24 indicated Resident #23 was childlike in presentation and once he/she had a drag he/she could not stop. APRN #2 identified Resident #23 had little to no executive decision-making capabilities and does not or is unable to focus on the consequences of his/her actions. Review of the Care Planning policy reviewed April 2024, directed the facilities Care Planning/Interdisciplinary team responsible for the development of an individualized comprehensive care plan for each resident. 2. Resident #45 's diagnoses included fracture of sixth cervical vertebrae, type 2 diabetes mellitus, dementia, chronic kidney disease, and syncope and collapse. The physician's progress note dated 5/29/24 at 2:20 PM identified Resident #45 was admitted to the facility for short term rehabilitation on 5/28/24 related to a unwitnessed fall with loss of consciousness. The note further identified Resident #45 had a fracture to the 6th cervical vertebrae requiring the use of an Aspen hard neck collar. The admission MDS assessment dated [DATE] identified Resident #45 had a moderate cognitive impairment and required extensive assistance for bed mobility, hygiene, toileting, transfer, non-ambulatory and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 6/17/24 failed to identify interventions related to the use of the Aspen neck collar. The physician's consultation notes dated 6/21/24 identified Resident #45 went for follow-up consultation related to the placement of a cardiac loop recorder for syncope. The consult identified Resident #45's incision site was clean and steri-strips (a thin sicky bandage that is used to help small cuts and wounds close) was applied. Further, the notes instructed to not remove the steri-strips and allow them to fall off on their own. Additionally, the note directed to not submerge the incision site, allow showers, monitor for signs and symptoms of infection including but not limited to redness, bleeding, exudate, escalating pain and fever, and to place an abdominal binder for orthostatic hypotension. Review of the RCP dated 6/10/24 failed to reflect the implementation of interventions to direct the care that was necessary for the surgical chest incision. Review of nursing notes from 6/21/24 to 7/24/24 failed to reflect that the left chest surgical incision was monitored for signs and symptoms of infection. Observation on 7/23/24 at 9:43 AM identified Resident #45 in his/her room, sitting in a wheelchair with a hard collar to his/her neck. Interview with LPN #3 on 7/25/24 at 11:00 AM identified Resident #45 was using an Aspen neck collar related to his/her cervical fracture and had an implantable loop recorder to the left chest because of cardiac problems. She also identified there would be a care plan related to the use of the Aspen neck collar and for the monitoring of the surgical incision to the left chest for the loop recorder. She further identified Resident #45 had gone to the cardiologist for a follow-up visit on 6/21/24 related to the implanted loop recorder and returned with instructions to monitor and for care of the left chest incision. Additionally, LPN #3 identified the charge nurses are responsible for ensuring that orders from a consultation are added to the RCP; however, she could not identify why the RCP did not address the use of the Aspen neck collar and the monitoring/care of the surgical incision. She further noted that she thought there was a physician's order related to the Aspen neck collar and monitoring of the surgical incision for the implant loop recorder. Interview and review of the physician's consultation with the DNS on 7/25/24 at 11:30 AM identified that it is an interdisciplinary approach between all departments to ensure that individualized comprehensive care plans are developed for each resident. She identified Resident #45 utilized an Aspen neck collar related to his/her cervical fracture and she would expect the RCP to address the use of the Aspen neck collar. She identified that the cardiologist had specific information on how to monitor the surgical chest incision that should have been added to the RCP. Although, she could not state a reason for why the RCP was not developed, she expected to have a care plan created for the use of Aspen neck collar and the implanted loop recorder. The Care Planning Interdisciplinary Team policy identified that the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. 47402

Based on observations, review of the clinical record, review of facility policy and interviews for one sampled resident (Resident #1) or who utilized splints, the facility failed to ensure the resident had splints in place daily as outlined in the physician's orders. The findings include: Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, legal blindness, rheumatoid arthritis, and vascular dementia. The Occupational Therapy Evaluation dated 4/1/2024 identified the upper extremity assessment was not tested due to contracture. The evaluation did not contain a rating that identified the degree/severity of the contracture. The MD/APRN progress note dated 6/19/2024 identified Resident #1 was evaluated by Occupational Therapy and identified physical exam findings of right hand in splint due to spasticity, Left hand with carrot. Strength was documented for bilateral upper extremities. The quarterly MDS assessment dated [DATE] identified Resident #1 had moderately impaired cognition, an upper and lower extremity impairment on one side, was dependent for all position changes, oral hygiene, toile [NAME], showering, dressing and personal hygiene. The care plan dated 6/27/2024 identified Resident #1 required assistance with ADL task performance related to left hemiplegia with interventions that included: soft collar on when out of bed, left resting hand orthotic on in the AM and off in the PM, right resting hand orthotic and left elbow extension orthotic on in the PM and off in the AM, perform skin checks when donning/doffing (putting on/taking off) the splints, wear as tolerated. Additionally, the care plan identified Resident #1 refuses to wear the soft collar at times. The Physician's orders for June and July 2024 identified Resident #1 had orders for a left elbow splint, right resting hand splint, left carrot, cervical collar on with AM care off with PM care as tolerated. Check skin and report breakdown or irritation with donning/doffing. Observation on 7/23/24 at 11:42 AM identified Resident #1 seated in a custom wheelchair in his/her room with a soft collar in place to the resident's neck. The left arm/hand appeared contracted and did not have a splint in place. The right arm/hand also appeared contracted and did not have a splint in place. Interview with Resident #1 at the time of the observation indicated there were splints that were not in place, and due to a visual deficit, the resident was not able to identify where in the room they might be. Resident #1 identified both hand splints and the elbow splint were not placed with morning care for a while and was unable to identify why they were not placed. Further, Resident #1 noted that he/she had not asked for the splints to be placed but had not refused to wear the splints. Observation and interview on 7/24/24 at 10:40 AM identified Resident #1 seated in a custom wheelchair with the soft collar in place. The left arm/hand appeared contracted, and the resident lifts the arm intermittently to an upright position (like raising the hand) with the hand toward the ear, and the elbow contracted. The right hand/arm is also contracted and was resting in the resident's lap. There are no splints in place on either of the upper extremities. The resident indicated the splints were not placed with AM care, and he/she identified that he/she had not asked for the splints to be placed. Observation on 7/25/24 at 9:31 AM identified Resident #1 being transferred out of bed and into the wheelchair. Subsequent observation on 7/25/24 at 11:00 AM identified Resident #1 in the custom wheelchair with the soft collar in place on the neck and a hand splint in place on the right hand. There was no elbow splint on the left elbow and there was not a hand splint on the left hand. Interview with the resident identified he/she had not had the splints in place for a while and that the right-hand splint was placed today, and the resident was not sure why it was the only one on. Resident #1 identified that if the neck splint was forgotten, he/she would complain about not having that due to the neck pain if the collar is not in place. Resident #1 also identified the left hand does hurt at times and indicated the fingernail pushed into the skin at times. Observation of the left hand identified there are no areas of redness or skin breakdown noted. Interview with LPN#1 on 7/25/24 at 11:09 AM identified NA#1 got the resident cleaned and out of bed this am, and she would expect the splints were placed at that time. However, both nursing and NAs are responsible for ensuring the splints are placed. Observation of the resident's room with LPN #1 identified she was not able to locate the elbow splint nor the left-hand splint (carrot). Interview with the Therapy Director on 7/25/24 at 11:41 AM identified resident therapy assessments are done quarterly for residents who required splinting or were on therapy service. He identified the expectation for the staff (nurses and NAs) are to do what they are supposed to do as outlined by orders or the plan of care. Interview with NA #1 on 7/25/24 at 12:07 PM identified that she sometimes places the hand splint on but sometimes none of the splints. When asked why the splints weren't placed, NA #1 shrugged. Subsequent to surveyor inquiry NA #1 went into the room, located the elbow splint, and placed the elbow splint on the resident. Interview with the DNS on 7/25/24 at 11:33 AM identified the splinting was on the task list for all the residents and that there should be a splint device task in the electronic health record (EHR). There is a plan of care that is printed and kept in the resident's room that outlines the splinting required for that particular resident. Observation and interview with Resident #1 on 7/29/24 at 10:29 AM identified resident in room seated in custom wheelchair, clean and dressed with soft neck collar, left elbow splint, right hand splint, and left-hand carrot splint in place. Resident #1 identified I'm trying to get used to these splints and laughed. Resident denied pain but stated her left arm and hand were a little sore. This Surveyor requested OT reevaluate as splints haven't been used in a while to assess worsening contracture. The Occupational Therapy Evaluation dated 7/29/2024 identified the upper extremity flexion and extension measured in degrees. Although requested, the facility did not provide a comparable assessment where degrees of contracture could be compared to identify worsened or improved conditions. Interview with OT #1 on 7/30/24 at 11:03 AM identified Resident #1 was re-evaluated the previous day and identified there was a 10 degree change in the elbow splint positioning indicating it was not a change in contracture but a change to the resident's comfort level of the splint. The OT identified the contractures were measured in three different positions and the splints were placed based on the passive range of motion. Review of the facility policy for Use of Orthotics for Contracture Management identified general guidelines that splints should be removed every two hours, the skin inspected and then the splint re-applied per wearing schedule. Wearing schedules were identified as individualized with the wearing tolerance determined by patient/skin tolerance, noted to be as short as one hour to as long as eight hours. The policy indicated that staff notify rehab if any splints were lost or missing to reduce the risk of further contractures.

Based on clinical record review, review of facility documents, review of facility policy, and interviews for one sampled resident (Resident #23) reviewed for accidents, the facility failed to provide adequate supervision to prevent the resident from smoking in his/her room. The findings include: Resident #23's diagnoses include chronic obstructive pulmonary disease, Dementia without behavioral disturbances and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, utilized a walker and wheelchair for mobility, was independent for eating, utilized set up or clean up assistance with oral hygiene and toileting, and needed supervision for dressing and personal care. Resident #23's care plan dated 5/20/24 identified the resident had an ADL self-care performance deficit and utilized limited assistance with a rolling walker on the unit, the resident requires assistance by staff for bathing/showering and requires assistance by staff with personal hygiene and oral care. The Nursing Supervisor's (RN #2) note dated 7/20/24 at 2:53 PM identified Resident #23 was found smoking in his/her room, spouse at bedside, and was educated on the smoking policy and danger of smoking in room, room was searched and no supplies were found, supplies were previously given back to spouse. Request given to spouse to not bring smoking supplies to resident. APRN contacted and new order for nicotine patch obtained. Interview with NA #5 on 7/25/24 at 9:46 AM identified she smelled smoke near Resident #23's room and knew that the next-door neighbor was on Oxygen, so she went into Resident #23's room and found Resident #23 in the bathroom flushing what she believed to be a cigarette down the toilet. The smell of the cigarette was stronger in the bathroom. NA #5 asked Resident #23 where he/she obtained the cigarette from and was told his/her spouse. At this time Resident 23's spouse was not in the room, however had been previously prior to the incident there for lunch. NA#5 indicated Resident #23 was a previous smoker. Interview with the Admission's Director on 7/25/24 at 10:10 AM identified upon admission residents are notified of their policies to include the no smoking policy during the admissions agreement process, however, could not locate the signed agreement for Resident #23 who was conserved. The Admissions Director indicated that she was originally admitted in 2020 and the agreement would have been signed at that time. Even though a discharge occurred on 3/11/21 return not anticipated, and the resident returned on 6/26/23 a new agreement would not have been signed because she knew Resident#23 was a previous resident and should have had those documents signed already. The admissions director indicated that she would only sign these documents with new admissions who have never been at the facility before. Interview with Medical Records on 7/29/24 at 10:40 AM indicated that medical records are kept for ten years for all patients and that years ago medical records were sent out to a central location, however now they keep them and that she has been working there since 2019 and since then they are kept in the building. She had already pulled Resident #23's information and looked for the signed admission paperwork from the facility and could not locate it and was not sure why it could not be located. Interview on 7/25/24 at 11:22 AM with the Director of Nursing (DON) identified that residents out of the facility for greater than 30 days would typically be new admissions into the facility, and she believed should have new facility admission paperwork signed. A resident such as Resident #23 who had been out of the facility discharged return not anticipated and gone for the two-year period would be a new admission. The DON also identified that she was still working on the Accident and Incident (A&I) report for the incident that occurred on 7/20/24 as she had been too busy to complete it, and although her and the social worker had just talked about what could be done nothing formally had been implemented. The DON had not had time to update the care plan either for this resident regarding this incident. Interview with Social Worker #1 on 7/25/24 at 11:40 AM identified that she and the DON spoke that morning about potential plans for the visit, however had not implemented anything formally. She said she had met with Resident #23 and their spouse separately about the dangers of the situation of smoking both medically and physically in the building. When asked to produce documentation of these conversations Social Worker #1 could not provide any documentation regarding these conversations. Social Worker #1 indicated that she must have not documented it and it must down on scratch paper. When a request for the scratch paper was requested documenting these conversations none could be located by Social Worker #1. Social Worker #1 identified that she told the spouse that he/she should see her first before visiting to ensure no smoking materials were brought to the resident however realized she was not always there when the spouse came. The care plan had not been updated but Social Worker #1 identified it probably should have and that she could go in and update it. Review of the A&I report on 7/25/24 provided by the DON dated 7/22/24 failed to include family notification or whether there was an investigation initiated into the incident. Disposition/comments included new order for nicotine patch, attached to the incident report was the nurses note from RN#1 from the original 7/20/24 incident. Review of Psychosocial note dated 7/22/24 from APRN #2 indicated Resident #23 was childlike in presentation and indicated once he/she had a drag he/she could not stop. Psych APRN #2 identified Resident #23 has little to no executive decision-making capabilities. Does not or is unable to focus on the consequences of his/her actions. On 7/25/24 at 2:04 PM a meeting was conducted with the DON and Regional Director of nursing from the facility in conjunction with DPH surveyors as well as DPH Supervisor to request a written plan be put into place to ensure the residents of the facilities safety. On 7/25/24 at 3:37 PM a written plan was received/approved by DPH supervisor. Interview with Resident #23 on 7/29/24 at 9:10 AM identified he/she was caught smoking in the bathroom and that he/she obtained the cigarettes and lighter from his/her spouses jacket pocket. Resident #23 identified the aide smelled the smoke and came in and that he/she had a craving for it and that he/she used to smoke but hadn't smoked in a long time. Interview with Person #2 on 7/29/24 at 9:28 AM identified he/she did not see Resident #23 take the smoking materials but that they were located in his/her coat pocket. Person #1 was upset with Resident #23 for doing this because he/she did not want to jeopardize their visits or Resident #23's ability to live in the facility. Review of the facility Reportable Events Investigating and Reporting policy reviewed April 2024, identified all accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge nurse and/or the department director of supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge nurse and/or the department director or supervisor shall complete a Reportable Event form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of the facility Smoking Policy- Residents reviewed April 2024, identified prior to, or upon admission, residents shall be informed that we are a smoke free policy. Smoking restrictions shall be strictly enforced. Staff/residents are not allowed to smoke within the facility or on the grounds. Review of the facility Location and Storage of Medical Records reviewed April 2024 identified the facility shall protect and safeguard its medical records. Closed and or thinned medical records will be stored in a locked room and protected from fire, water damage, insects and theft. Medical records may be scanned into Point Click Care (PCC) for long term retention. Records will be maintained for a minimum of [AGE] years.

Based on review of the clinical record, review of facility documentation, review of facility policies/procedures and interviews for one of three sampled residents (Resident #32), reviewed for transmission-based precaution (TBP) the facility failed to implement the appropriate transmission-based precaution for a resident actively infected with a multi-drug resistant organism (MDRO). The findings include: Resident #32's diagnoses included lymphedema, sepsis, Methicillin Resistant Staphylococcus Aureus (MRSA) infection and schizoaffective disorder. The quarterly MDS assessment dated [DATE] identified Resident #32 had intact cognition, required moderate assistance with transfers and toileting, independent with bed mobility and personal hygiene, ambulatory with the utilization of a walker and a wheelchair. The assessment further identified Resident #32 active diagnoses in the last 7 days included MDRO, and wound infection. The care plan dated 2/20/24 identified Resident #32 had enhanced barrier precaution related to left extremity wound with interventions that included to utilize gloves, and gown following proper donning and doffing when providing high contact activities. The care plan further identified Resident #32 was resistive and non-compliant with care related to refusing dressing changes and wound treatment with interventions that included accept resident's right to refuse, leave and return 5 to 10 minutes later to try again. Review of Resident #32's clinical records identified laboratory testing of a wound culture collected on 4/5/24 with a reported result dated 4/9/24 identified heavy growth of pseudomonas aeruginous, and moderate growth of MRSA. The physician's order dated 4/10/24 directed Vancomycin 1 gram every 12 hours intravenous for left leg wound infection and Cefepime 2 gram every 8 hours intravenous for left leg wound. The physician's order for the month of April 2024 also directed enhance barrier precautions (EBP) due to lower extremity wound and cleans both lower extremity wounds with normal saline, apply Medihoney (wound healing and debridement) to wound bed followed by non-adhesive dressing abdominal pad wrap with a kerlix from foot to knee daily and as needed related to MRSA. The physician's orders for the month of April 2024 failed to identify that Resident #32 was directed to be placed on contact precautions. Review of the facility's infection control active MDRO tracking sheet for the month of April 2024 identified Resident #32 had signs and symptoms of wound drainage, site of infection was a wound, positive culture for MRSA dated 4/9/24, treated with intravenous antibiotics, and isolation type for Resident #32 identified enhanced barrier precautions. According to the Centers for Disease Control and Prevention (CDC) Appendix A which provides the type and duration of precautions recommended for selected infections and conditions recommendations for MDRO such as MRSA required contact and standard precautions. CDC further recommends that contact precautions should be used for all residents infected or colonized with a MDRO in situations such as the presence of acute diarrhea, draining wounds or other sites of secretions or excretions that are unable to be covered or contained, and gloves and gown are required to be don and worn before entering the resident's room. In addition, CDC recommends the utilization of Enhanced Barrier Precautions when infection or colonization with an MDRO when contact precautions do not otherwise apply, and gown and gloves are to be don and worn prior to high contact care activities such as dressing, providing hygiene, transferring, bathing/showering, wound care and toileting hygiene. Review of the facility weekly wound tracking documentation sheet dated 4/9/24 identified left medial calf and left lateral calf had heavy blue/green serous drainage. Also, the left inferior ankle had heavy blue/green drainage. The nurse's note dated 4/10/24 at 10:32 AM written by the ADNS (RN #4) identified the treatment nurse reported increase drainage from the left leg wounds and a call place to APRN to update. The nurse's note dated 4/11/24 at 3:01 PM written by Charge Nurse (LPN #5) identified that Resident #32 dressing changed to left lower leg wound had copious amount of greenish drainage noted and resident was encouraged to elevate leg. The Nurse's note dated 4/23/24 at 12:36 PM written by RN #4 identified heavy serious drainage noted on old dressing. Wound progress note dated 4/23/24 written by Wound Physician MD #2 identified that Resident #32 continues to be aggressive during treatments, actively slapping examiner hands and putting his/her own hands into the wound beds. Interview with the Infection Preventionist (RN #3) on 7/25/24 at 10:57 AM identified that Resident #32 was positive for MRSA in the month of April 2024 where the resident was treated with intravenous antibiotic. RN #3 added that during this period active infection Resident #32 remained on enhance barrier precautions and not contact precautions. RN #3 identified that she kept Resident #32 on enhance barrier precaution as the resident's wound drainage was contained and she had not received any reports from the wound nurses or the charge nurse that Resident #32's wound drainage could not be contained or was the resident having large amounts of drainage from the wound. Interview with the DNS on 7/25/24 at 1:20 PM identified that if a resident was actively being treated for MRSA, he/she should be placed on contact precautions as it changes the mindset of the staff. The DNS further identified that Resident #32 should not have remained on EBP, and it was the responsibility of the Infection Preventionist nurse to review and make the decision as to the type of transmission-based precaution a resident should be placed on. Interview with the LPN #5 on 7/25/24 at 1:55 PM identified whether Resident #32 had any infection in April 2024 in which she identified that he/she had MRSA and cellulitis and was treated with intravenous antibiotics. LPN#5 was asked if Resident #32 was placed on contact precautions in April 2024 in which she stated she had to review the records. After LPN #5 review the clinical records, she responded that she was unable to identify that the resident was ever on contact precaution but rather was on EBP precautions. LPN #5 further identified that Resident #32's dressing was required to be changed daily. LPN #5 was asked to explain her note written on 4/11/24 as it relates to copious amount of drainage in which LPN #5 identified that the old dressing removed was saturated during the dressing change and she had placed a padding underneath to protect the bed during dressing change. She further identified that if Resident #32 required extra dressing change, he/she might not had allowed the nurse to perform the treatment as often times it would depend on the resident's mood at the time. LPN #5 was asked if there was a difference between contact precautions and EBP, in which she indicated yes as contact precautions is used for active infection wherein personal protective equipment (PPE) to worn when entering the room while EBP precautions is use for residents with wounds, gastrostomy tube, and foley tubes, and required the use of PPE when providing direct care activities. Interview with NA #6 and NA#7 on 7/25/24 at 2:20 PM identified was asked if they recalled Resident #32 ever being placed on contact precaution in the month of April 2024, wherein they identified that they could not recall Resident #32 was ever on contact precautions and that he/she has only on EBP. NA #7 and NA #8 asked if there was a difference between contact precautions and EBP in which they both responded that there is a difference as contact precautions required you to put on your PPE before entering the room while EBP required donning PPE only when we are about to do care any direct care with the resident. Interview with the RN #3 on 7/29/24 at 12:40 PM identified when asked if she had reviewed the nurse's notes dated 4/11/24 would she had place Resident #32 on contact precautions and she responded absolutely. RN #3 was also asked if Resident #32 had a history of weeping legs and often refuses or was compliant with dressing changes in which she indicated that Resident #32 had weeping legs and does refuse wound treatment at times. RN #3 also indicated that she was responsible for selecting the appropriate TBP for residents. Review of the Multidrug-Resistant Organisms policy and procedure identified that appropriate precautions will be taken when caring for individuals with known or suspected infection with a MDRO. The policy further identified that infection means that the organism is present and is causing illness and colonization means the organism is present in or on the body but not causing illness. The policy adds that the infection control committee may implement or consider the following to determine if contact precautions are need when individual's ability to contain the infected or colonized body fluids or site, keeping hands away from the infected or colonized areas, draining wounds, and behaviors that may increase the risk of transmission may indicate the need for contact precautions. Review of the Contact Precautions policy identified contact precautions are intended to prevent the transmission of infectious agents, like MDRO's that are spread by direct or indirect contact with the resident or resident's environment.

Based on facility documentation review and staff interviews for Three of Three Nurse Aides (NA #2 and NA #3, and NA#4), the facility failed to complete an annual performance evaluations. The findings include: Review of NA #2 personnel file identified a hire date of 7/24/2006 and failed to identify that a yearly performance evaluation was completed for 2023. Review of NA #3 personnel file identified a hire date of 4/29/2002 and failed to identify that a yearly performance evaluation was completed for 2023. Review of NA #4 personnel file identified a hire date of 12/7/2021 and failed to identify that a yearly performance evaluation was completed for 2023. Interview with DNS on 7/30/24 at 9:35 AM identified that each employee should have a performance review completed on their anniversary date and she was responsible for ensuring that the employee annual performance reviews were completed. She further identified that there was no annual performance review completed for NA #2, NA #3, and NA #4 for 2023. Review of facility Annual Employee Evaluations policy identified all employees would be subject to a written annual review by the department supervisor on their anniversary date.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident #1 ), who was reviewed for abuse, the facility failed to The findings include: Resident # 1's diagnoses included hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) affecting right dominant side. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively intact and required substantial assist with bed mobility and transfers. The Resident Care Plan dated 11/21/23 identified Resident #1 had an activity of daily living (ADL) self-care performance deficit related to disease process and a history of transient ischemic attacks (TIA) or mini stroke with interventions that directed to provide two (2) staff for bed mobility and transfer with mechanical lift and give medications as ordered by the physician and monitor side effects. Physician orders dated 11/30/23 directed aspirin 81 mg and clopidogrel bisulfate 75 mg (both blood thinners) The Advanced Practice Registered Nurse (APRN) note dated 12/21/23 at 6:04 PM identified a request was made to see the resident for follow up. An assessment identified Resident #1 had two ecchymotic (bruised) areas on left arm, the resident could not recall how it happened and denied pain. A nurse's note dated 12/24/23, subsequent to the identification of the bruise on the left arm, identified a peripheral line was inserted into the right forearm for intravenous (IV) hydration. Physician orders (from an outside specialty service consult) dated 1/3/24 directed gentle handling with turning and repositioning and noted Resident #1 had prescribed aspirin, Plavix (clopidogrel bisulfate) and displayed multiple bruises from aides/ nurses. Nurse's notes dated 12/21/23 through 1/10/24 identified no additional documentation related to the bruising noted on 12/21/23 and on 1/3/24. A 'soft' note (not part of the clinical record) dated 1/4/24 completed by the Director of Nursing identified she met with Resident #1 after reviewing the neurology consult on 1/3/24. She noted fading bruises to the right forearm. Resident #1 stated two staff were talking over h/her and thought that's when (the bruising) occurred. Resident #1 stated No when asked if s/he was treated inappropriately or in a rough manner. Resident #1 was on Plavix and aspirin and would be expected to bruise more readily, the responsible party was made aware of the situation and that the physician note suggested Resident #1 was prone to bruising due to medications. A second 'soft' note completed by the DNS (no date) identified she met a representative from Elderly Protective Services who indicated a report from a (community) medical office noted bruising at the time of a medical appointment, that Resident #1 denied staff touched h/her and that it was felt the bruising was likely due to intravenous therapy. An interview with Resident #1 on 1/31/24 at 10:12 AM identified the incident happened a long time ago, unable to say exactly what time frame, when two nurse aides were providing care to h/her in bed in the evening time. Resident #1 stated she did not know the names of the staff but that they were arguing in a different language. As the argument ensued, they became rough with h/her care. Resident #1 did not report the incident to anyone. However, the following day, Nurse Aide, NA #1 had observed a bruise on Resident #1's left arm and inquired about it. Resident #1 explained to NA #1 that the aides were arguing and were rough with care. NA #1 told Resident #1 that it needed to be reported. Resident #1 also stated it was inquired about at a recent community doctor visit subsequent to NA #1 observing and reporting the bruise. Resident #1 recalled that there were staff who came in to ask about the incident but could not recall who. Resident #1 recalled a representative from protective services also came to speak with h/her about the incident. Resident #1 stated she still works with one of the staff members and it made h/her uncomfortable. An interview with Licensed Practical Nurse, LPN #1 on 1/31/24 at 10:46 AM identified she received the consult upon return from the specialty service and reported the information immediately to the Nursing Supervisor. An interview with Registered Nurse, RN #1 on 1/31/24 at 11:37 AM identified he was the assigned Nursing Supervisor on 1/31/24 when Resident #1 returned from an outside community appointment. RN #1 stated LPN #1 reported the information noted on the specialty consult. RN #1 assessed Resident #1 and noted fading bruises to the upper left which did not include impressions of fingertips so was felt not consistent with abuse. RN #1 also did not speak to Resident #1 and inquire as to how the bruising occurred. RN #1 stated it was part of his role and responsibility to report an injury of unknown origin and should have done so when first discovered but it was at the end of the day. Instead, RN #1 passed the information along in the morning report the following day. An interview with the DNS on 1/31/24 at 12:32 PM identified first became aware of the allegation during morning report the following day on 1/4/24. The DNS spoke with Resident #1 who reported the bruising may have occurred when two aides were talking over h/her however, denied rough care. The DNS stated she observed fading bruises on the right arm but did not report or initiate an investigation as she was aware of a recent IV insertion, blood work and medication as a possible underlying cause and did not feel staff inflicted harm. The DNS further stated a representative from protective services came in to speak with Resident #1 and was unable to determine at the time of the visit that abuse occurred. An interview with APRN #1 on 1/31/24 at 12:37 PM identified she observed bruising on Resident left forearm on 12/21/23 which was unexplained. APRN ordered lab work and reported the bruising to LPN #1. A subsequent interview with LPN #1 on 1/31/24 at 1:10 PM identified she was unable to recall if bruising was reported to her on 12/21/23 but would normally notify a supervisor immediately of any bruising. An interview with NA #1 on 1/31/24 at 3:20 PM identified she was working on a weekend in recent weeks on the 3:00 PM shift to 11:00 PM shift when she observed a nasty bruise on the left upper arm. NA #1 asked Resident #1 how the bruise occurred and was told the evening before, two aides were arguing while providing care and became rough with care. NA #1 reported the allegation immediately to LPN #2. An interview with LPN #2 on 1/31/24 at 3:32 PM identified NA #1 reported rough care but believed it had already been previously reported by the outside community specialty service visit. An interview with the DNS on 1/31/24 at 3:37 PM identified she initially did not feel the issue rose to the level of mistreatment, However, subsequent to surveyor inquiry, felt that she should have reported the allegation. A review of the facility policy for Reporting a Suspicion of Abuse directs the Administrator, Director of Nursing or designee report any reasonable suspicion of abuse with required time frames to the state agency.

Based on clinical record review, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) who was reviewed for accidents, the facility failed to develop a care plan with interventions for the resident's known behavior of pushing the bed against the heating system and laying his/her head on the radiator unit to prevent an injury, a neck burn. The findings include: Resident #1's diagnoses that included dementia, metabolic encephalopathy, and psychoactive substance abuse. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long-term memory problems, rarely or never made decisions regarding tasks of daily life and required limited assistance of one (1) person with repositioning while in bed, getting in and out of the bed and chair and extensive one (1) person assistance with ambulating. The care plan dated 11/3/22 identified the resident has impaired cognitive function and dementia with behavioral disturbances. Interventions include monitor, document, and report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. The Facility Reported Incident form dated 11/23/22 at 9:00 AM identified Resident #1 was observed by a nurse aide with his/her bed pushed against the radiator wall, lying across the bed in the wrong direction and his/her head was resting on the radiator. The report indicated Resident #1 was assisted and repositioned and assessed by the Supervisor. Resident #1 was noted to have a temperature of 102.4 degrees and a pink area with denuded skin on the back of his/her neck that measured 4 centimeters (cm) x 5cm, all parties were notified, and Resident #1 was transferred to the emergency department for an evaluation. The Hospital Admission Summary dated 11/23/22 identified Resident #1 was found by the facility staff leaning up against the radiator while lying in bed, with a burn and blister on the posterior neck. Resident #1 was noted to have a cough, fever of 102 degrees and lethargy, thus Emergency Medical Services was activated, and the resident was given a Tylenol suppository in route to the hospital. The Hospital Wound Care note dated 11/25/22 identified the posterior neck wound appeared as a third degree burn at this time, the entire effected area measured 8cm x 7cm and presented as a full thickness wound with approximately 80% pink and red tissue and 20% light tan slough, the surrounding skin had intact blisters, there was scant serous drainage. The note indicated the wound was cleansed with normal saline, Silvadene to be ordered twice a day. The nursing progress skin and wound note dated 12/08/22 at 12:27 PM identified Resident #1 was readmitted to the facility last evening after treatment for a burn on the back of the neck and the area was assessed today. The note identified the wound measured 5cm x 4cm x 0cm, the area was covered 100% with dry slough, there was no swelling or erythema noted around area and no drainage was noted. The note indicated treatments were in place for Santyl daily at 2:00 PM and Silvadene every twelve (12) hours at 9:00 AM and 9:00 PM. Review of the care plan prior to the 11/23/22 incident failed to reflect Resident#1's known behavior of pushing the bed up to the radiator and lying crooked in bed with his/her head on the radiator was addressed and interventions implemented to prevent a potential injury. Upon further review, the care plan status-post the incident on 11/23/22 identified Resident #1 had the potential for impairment to skin integrity related to a burn on the back of the neck after resting on the radiator. Interventions included a nightstand was placed between the bed and radiator, the wheels were removed from the bed, maintain the bed in a low position, the radiator surface temperatures will be monitored with adjustments made as needed by maintenance, and to apply the treatment to back of neck burn as ordered. Interview with the Maintenance Director on 12/12/22 at 11:00 AM identified the facility does not check radiator temperatures but he does check water temperatures. The Maintenance Director indicated the temperatures in the boiler room are set to 140 degrees Fahrenheit, but once the fluid goes through the mixing value, the temperatures will drop to 120 degrees Fahrenheit. The Maintenance Director identified status post this incident, the set temperature was lowered and audits after the event have shown temperature ranges between 100-115 degrees Fahrenheit. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 12/12/22 at 11:30 AM identified NA #2 had requested if I could check on Resident #1 as Resident #1 was sleeping earlier when the breakfast tray was brought in. NA #1 indicated upon entering the room, Resident #1 was noted to be lying in bed (incorrectly positioned) with his/her head and neck area resting on the radiator. NA #1 identified she immediately notified NA #2 and the Registered Nurse (RN) #1 for assistance, and we were able to reposition Resident #1. NA #1 identified the position the bed was crooked, the end of the bed was pushed closely to the radiator, with approximately a one (1) foot clearance from the bed to radiator, and the top of the bed was in its original position but still crooked as it seemed that Resident #1 pushed the lower section closer to the radiator, and not the entire bed. NA #1 identified the wheels were in a locked position, but there was no dresser in between the bed and radiator. NA #1 identified Resident #1 had done this in the past approximately three (3) or more times and he/she usually uses a pillow on-top of the radiator. NA #1 identified she notified the nurse on the first occasion but could not recall who she contacted. NA #1 noted she did not report the other occasions in a formal manner but would notify the nurse as an update during the shift. Interview with NA #2 on 12/12/22 at 11:35 AM identified on 11/23/22, she performed rounds on Resident #1 at 7:30 AM, Resident #1 was sleeping at this time and the bed was in the correct position. NA #2 identified Resident #1's breakfast tray was delivered at 8:30 AM, but Resident #1 was still sleeping, and the bed was in the correct position. NA #2 identified after she dropped off the breakfast tray, she notified NA #1 if she could monitor Resident #1 while she attended to another resident. NA #2 identified at approximately 8:50 AM, NA #1 notified her that Resident #1 needed assistance and when she entered the room, she verified Resident #1's bed was positioned crookedly and closer to the radiator while Resident #1 was identified to be in bed (positioned incorrectly) and lying on the radiator with his/her head and neck area on the radiator. NA #2 identified Resident #1 has performed this behavior before, approximately two (2) to three (3) times, but she has never reported this because every time she came into the room and assisted Resident #1 during this observation, Resident #1 would always self-correct themselves and she did not believe it warranted further action. Interview with the Director of Nurses (DON) on 12/12/22 at 12:30 PM identified she was unaware of Resident #1's known behavior of utilizing the radiator to rest or lie on. The DON identified this was the first episode they were aware of and have implemented measures to prevent reoccurrence.

Based on a clinical record review, staff interviews and a review of the facility documentation for one of three sampled residents (Resident #2), the facility failed to provide adequate supervision to prevent an accident that resulted in an injury. The finding included: Resident #2's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] identified severely impaired cognition and total dependence with bed mobility, transfers, dressing, and personal hygiene with a two person assist. Review of the Resident Care Plan (RCP) dated 10/15/16 identified total dependence for activities of daily living as a problem, with interventions that included a hoyer lift for transfers, total assistance for bed mobility, transfers and all activities of daily living with a two person assist. Review of a reportable event form dated 12/2/16 at 11:30 AM identified when Resident #2 was turned during incontinent care, a linear 2.5 centimeter (cm) laceration to the right side of the head and a 3 cm laceration behind the resident's right ear was sustained. The resident was assessed and first aid was provided. The attending physician was notified and Resident #2 was transferred to an acute care hospital and admitted for head trauma. Review of the hospital documentation indicated sutures were placed and imaging was conducted that identified large bilateral subdural hematomas (SDH) along the parietal lobes. Additionally, small subarachnoid components in the right frontal and left parietal regions, [DIAGNOSES REDACTED] with a shunt catheter in place without evidence of a change in ventricle size and a suspected isodense left frontopariteal hematoma were identfied. The resident was discharged back to the facility on [DATE]. Interview with Nurse Aide (NA) #4 on 3/27/17 at 3:00 PM identified on 12/2/16 at approximately 11:30 AM she failed to ask another staff member to assist him/her with incontinent care as she felt the other nurse aides were busy and decided to turn Resident #2 without the benefit of another staff member. NA #4 indicated when the resident was turned his/her head hit against the side rail. NA #4 identified bleeding on his/her head and behind his/her ear. NA #4 indicated that when she turned the resident, the resident's head made contact with the bed remote. Interview with the Director of Nursing on 3/27/17 at 3:30 PM indicated NA #4 did not follow the plan of care that directed care a two person assist with bed mobility to ensure the safety of the resident and should have. Interview with MD #3 on 3/28/17 at 11:00 AM, a radiologist at the transferring hospital where Resident #2 was evaluated, indicated after a review of the imaging that was conducted on 12/2/16 identified extensive bilateral SDH's. MD #3 indicated they were acute and less than a week old at the time of the imaging. The facility policy entitled care planning directed in part that a comprehensive care plan would be developed by an interdisciplinary team that would incorporate identified problems, risk factors, treatment goals, objectives in measurable outcomes and reflect the current recognized standard of practice. Care plan interventions would be developed and the team would be responsible to review, update and revise the plan of care quarterly, with a change in condition, when an outcome had not been met or when the resident was readmitted to the facility after a hospital admission. Based on clinical record review and interviews for 2 (R#2, R#5) of 3 residents reviewed for accidents and/or supervision the facility failed to ensure the resident was cared for in a safe setting and/or provided appropriate supervision. The findings include: Resident (R) #5 was admitted to the facility with [DIAGNOSES REDACTED]. A minimum data set ((MDS) dated [DATE] indicated R#5 had severely impaired cognition, deficits in short and long term memory and exhibited behaviors such as rejection of care. In addition the MDS identified R#5 was independent in locomotion requiring no assistive devices. A Resident Care Plan (RCP) dated 9/3/16 indicated R#5 was a safety risk based on his/her dementia, exhibited behaviors and risk for falls. Interventions included to encourage R#5 to remain in supervised areas when out of bed. A physician's orders [REDACTED].#5 could ambulate without assistive devices requiring distant supervision. A nursing assistant (NA) care card indicated R#5 required distant supervision. Although the RCP indicated R#5 required distant supervision by staff, the RCP lacked specific interventions pertaining to R#5's supervision needs for outside appointments. A nursing progress note dated 10/7/16 identified that a vascular appointment (date not identified) was canceled and the next appointment was 10/19/16. However, a nursing progress note dated 10/10/16 identified a vascular appointment scheduled for 10/12/16. A nursing progress note dated 10/11/16 identified that the vascular office was contacted and office staff acknowledged an appointment for tomorrow (10/12/16). The clinical record failed to identify that R#5's family member was contacted about the medical appointment change and failed to address the coordination of R#5's supervision needs for this appointment. During an interview with Registered Nurse (RN) #1 on 3/28/17 at 12:10 PM, RN#1 indicated that on 10/12/16 at approximately 10:00 AM, he/she assisted staff to get R#5 ready for an outside appointment. RN#1 asked the NA if R#5 needed a staff member to accompany R#5 to the appointment, staff indicated R#5's family member usually met R#5 at his/her physician appointments. RN#1 attempted to contact R#5's family member to verify that the family would meet R#5 at the doctors office, however RN #1 could not reach the family member. In the meantime the transportation company staff arrived on the unit and escorted R#5 to his/her appointment. When RN#1 returned to the unit, he/she called the doctors office to notify them of R#5's arrival and the physicians office indicated R#5's appointment had been canceled. The transportation company was called and instructed to return R#5 to the facility. RN#1 identified that when R#5 left the unit without a staff member, R#5's safety was compromised. R#5 returned to the facility at approximately 12:00 PM with no injury or ill effect from the incident. RN#1 indicated he/she was not aware of who had canceled the 10/12/16 appointment. During an interview with The Director of Nursing (DNS) on 3/28/17 at 11:30 AM, the DNS indicated that prior to 10/12/16, Resident #5 had been going to MD appointments without staff. Following the incident on 10/12/16, staff accompany Resident #5 to all outside appointments.

Based on clinical record review and staff interview for one of six residents in the survey sample reviewed for accidents (R # 14), the facility failed to ensure the resident was supervised to prevent a fall resulting in an injury. The findings include: Resident #14 ' s [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had short and long-term memory problems, displayed physical behaviors directed toward others (occurred 4-6 days), required total care with bed mobility, transfer, and did not walk. A resident care plan dated 12/23/14 identified a potential for falls. Interventions included keep the bed in low position, 2 ¼ siderails up for turning and positioning, and transfer with assist of 2 people. A nurse aide assignment plan of care indicated the bed was to be in the lowest position at all times and to utilize 2 people for bathing. A physician's order [REDACTED]. A nurse ' s note dated 2/22/15 at 2:15 PM indicated R #14 had fallen out of bed and hit his/her head on the nightstand while NA # 1 was performing care. Resident was transferred to the emergency room for evaluation. A reportable event dated 2/22/15 indicated nurse aide #1 was providing care and the resident rolled out of bed. The resident sustained [REDACTED]. A hospital emergency room report dated 2/22/15 indicated the resident sustained [REDACTED]. An interview on 5/20/15 at 11:50 AM with NA # 1 indicated he/she was providing care to R #14 on 2/22/15. He/she had cleaned (bathed) and dressed the resident. He/she was about to get someone to help him/her transfer the resident when the roommate requested assistance. NA # 1 went to help the roommate for approximately 2 minutes. He/she heard a crash and looked over at R # 14 and saw him/her on the floor bleeding from his/her head. Nurse aide # 2 indicated he/she did not see how the resident got out of bed because his/her back was to the resident. Nurse aide # 1 indicated he/she had raised the bed from its low position because he/she was providing care. The bed was not lowered to its lowest position when he/she went to assist the roommate. Nurse aide # 1 indicated although it was the first time he/she had cared for R # 14, he/she did not look at the nurse aide assignment plan of care prior to giving the resident care. He/she was not aware the resident required 2 people to provide care. An interview on 5/20/15 at 12:45 PM with the DNS indicated the results of his/her investigation noted not only did NA # 1 not lower the resident ' s bed when he/she left the resident to help the roommate, but he/she did not follow the care plan that noted 2 people were to provide care (bath) to the resident.

Based on clinical record review, staff interviews, and review of facility documentation for one of four residents reviewed for accidents (Resident # 127), the facility failed to provide safe locomotion resulting in an injury. The findings include: Resident #127's [DIAGNOSES REDACTED]. A care plan dated 9/16/13 identfied a self care deficit related to total dependence with ADL's. Interventions included to establish a routine with the resident, occupational screen quarterly and as needed, identify self and procedures prior to event, and use simple verbal instructions. Review of the Reportable Event form dated 10/5/13 at 5:30 PM identified the left thumb was noted with a pale blue discolorization and swelling. The Physician was notified and directed to obtain an x-ray of the left thumb. X-ray report dated 10/5/13 identified a concern for possible fracture along the base of the first proximal phalange. Correlate with recent trauma. Hospital radiology report dated 10/6/13 identified thumb fracture, possible nondisplaced, incomplete fracture of the radial thumb sesamoid. Nurse's notes dated 10/5/13 at 5:30 PM identified that while the POA was visiting, he/she noticed swelling and blue discolorization to the left thumb 2nd phalange, ice applied, elevation of the left hand, left thumb sensitive, resident withdraws left hand when touched. Physician was notified and directed to obtain an x-ray. Nurses notes dated 10/5/13 at 11:00 PM noted the xray results indicated a possible fracture. The Physician was notified and directed to send the resident to the hospital for evaluation. Nurse's note dated 10/6/13 at 6:30 AM identified R#127 returned from the hospital with a [DIAGNOSES REDACTED]. Nurse's notes dated 10/6/13 at 2:30 PM identified as a late entry for 10/3/13 at approximately 1:30 PM, indicated that on 10/3/13, NA #4 was observed dragging R#127 in his/her wheelchair back to his/her room to provide care, when R#127's left hand got caught in the wheelchair wheel. Interview with LPN #4 on 4/16/14 at 9:30 AM indicated she/he observed NA #4 pulling R#127 backwards on 10/3/13 and observed R #127's left hand fall to the side of the wheelchair and get caught in the wheelchair wheel. Additionally LPN #4 indicated she/he observed the the left thumb/hand area and no swelling and/or redness was noted at that time so he/she did not notify the supervisor.

Based on clinical record reviews, reviews of facility documentation, review of facility policies and procedures and interviews for three of six residents reviewed for accidents (R#25, R #71 and R #105), the facility failed to ensure that totally dependent residents were handled and/or transferred appropriately to prevent injuries and/or failed to ensure that appropriate supervision and/or equipment was provided to prevent an injury and/or failed to maintain the environment in a hazard free manor. The findings included: 1. Resident #25's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was severely cognitively impaired, and required total assistance from staff for all activities of daily living including bed mobility and transfers. Physician orders [REDACTED]. Facility documentation dated 9/27/11 at 12:15 P.M. identified that during a transfer via mechanical lift, the resident sustained [REDACTED]. On 5/1/12 at 12:00 P.M. and 12:45 P.M., interviews and review of facility documentation with NA #2 and NA #4 indicated that after NA #2 set the resident up for transfer by positioning R #25 on the lifting pad and attaching it to the lift independently, NA #4 was called into the room to assist with the transfer. NA #2 and NA #4 further indicated that as NA #2 operated the lift and NA #4 guided the resident's body from the left side towards the resident's chair, the resident began to slip from the pad, causing it to swing back with the resident striking his/her head against the vertical column of the lift (in a snap-like motion per demonstration by NA #4). NA #2 and NA #4 further indicated that as soon as the resident struck his/her head, they returned the resident back to bed and called for the charge nurse (LPN #3). On 5/1/12 at 2:30 P.M. an interview and review of facility documentation with LPN #3 indicated that she was called to the room by the aides due to the resident striking his/her head against the lift. She indicated that the resident was in bed and was noted as having an abrasion to the back of the head, no bleeding involved, just a little bit of clear drainage. RN #3 was immediately notified. On 5/1/12 at 12:58 P.M. an interview and review of the clinical record and facility documentation with RN #3 (Nurse Supervisor) indicated that upon assessment, the resident had very little bleeding from a superficial abrasion on the back of the head. RN #3 noted that she questioned the aides regarding their transfer technique to determine how the resident sustained [REDACTED]. to avoid slippage. Subsequent to the resident striking his/her head on the mechanical lift, an increase in bleeding was noted on 9/27/11 at 3:50 P.M. during the APRN's assessment. The resident was transferred to the ER (emergency room ) via 911 per APRN's order. Review of the emergency room report noted that resident sustained [REDACTED]. a scalp laceration measuring 2cm in length and 2cm in depth and a hematoma 4cm in diameter. The resident's wound was closed with sutures and with staples. A CT scan of the resident's head and cervical spine revealed a large soft tissue occipital hematoma with no gross acute intracranial bleed. 2. Resident #71's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was severely cognitively impaired, and totally dependent on staff for all activities of daily living including bed mobility and transfers. The care plan dated 11/23/11 identified a problem with pain. Interventions included to monitor factors that precipitate pain and what may reduce it. Review of facility documentation and nurse's notes dated 12/14/11 at 11:00 A.M. identified, that NA #1 reported that R #71 had complaints of left hip pain during morning care, transfer and repositioning. The resident denied falling and/or bumping his/her hip against the wheelchair. Left hip range of motion (ROM) was limited due to pain. The notes identified continued complaints of pain even after receiving Percocet (pain medication). On 5/2/12 at 10:20 A.M. and 10:25 A.M. interviews and review of facility documentation with NA #1 and NA #3 indicated that although R #71 was known to complain about pain and yell/swear during care, the resident was complaining more than usual during care and upon touching the resident's left leg. NA #1 and NA #2 further noted that although they were aware of the resident's initial complaints of pain, they continued to transfer the resident out of bed via the mechanical lift to a wheelchair. NA #1 indicated that the resident continued to complain of pain during the transfer and even as she tried to reposition him/her in the wheelchair for comfort. Due to the resident's continuous complaints, NA #1 informed the charge nurse (LPN #1). On 5/2/12 at 10:00 A.M. an interview and review of the facility documentation with LPN #1 indicated that after NA #1 reported the resident's complaints of left hip pain, she assessed the resident left leg and saw no signs and/or symptoms of bruising or redness and due to the resident's continued complaints, LPN #1 notified the Nurse Supervisor (RN #3) to further assess the resident. On 5/2/12 at 10:40 A.M. an interview, and review of facility documentation and the clinical record with RN #3 indicated that she assessed the resident and although she agreed with LPN #1's initial assessment and saw no redness and/or bruising in the area of the resident's left hip, she noticed that the resident had limited range of motion to the left hip due to pain as she tried to lift the resident's left leg in the lower area of the hip during her assessment. Subsequent to the resident's repeated complaints of pain and RN #3's assessment, the APRN was notified and an x-ray of the resident's left hip was ordered. The Radiology report on 12/14/11 revealed a comminuted fracture of the proximal femur in the intertrochanteric region. The resident was sent to an acute care facility for further treatment and/or management of the fracture. Following the resident's admission to an acute care facility on 12/14/11, a second x-ray of R #71's left hip was obtained and revealed an intertrochanteric fracture with fragmentation. On 5/2/12 at 9:45 A.M. an interview and review of R #71's acute care x-ray films dated 12/14/11 with the Radiologist (MD #1) indicated his impression of the resident's fractures was that " fractures of this type are usually caused by a severe injury or some sort of trauma occurred". 3. Resident #105's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident was severely cognitively impaired, and required extensive physical assistance from two persons for transfers due to an unsteady balance. Physician orders [REDACTED]. Review of facility documentation dated 1/13/12 at 12:30 P.M. identified that the resident sustained [REDACTED]. On 4/30/12 at 12:55 P.M. and 1:05 P.M. interviews and review of the facility documenation with NA #6 and NA #5 indicated that after transferring the resident into his/her wheelchair, they looked down and saw that the resident's right lower leg was bleeding and that there was blood on the w/c in the area that holds the foot pedal and/or foot rest. NA #5 further indicated that the resident has very fragile skin and that that the foot rest and/or foot pedal were removed from the w/c prior to the transfer and after the resident received the laceration, "the wheelchair was examined and it was discovered that the part where the foot rest goes into was sharp". The chair was taken away and the resident was provided with another one. On 4/30/12 at 1:20 P.M. an interview and review of the clinical record and statements provided by staff during this investigation with the DON identified that the resident was not transferred in accordance with the physician's orders [REDACTED]. Subsequent to surveyor's inquiry on 4/30/12 and/or during a final interview with the DON on 5/7/12 at 9:15 A.M. prior to the exit conference on 5/7/12 at 2:00 P.M., no further response and/or information regarding the appropriateness of the resident's transfer by NA #5 and NA #6 on 1/13/12 was forthcoming. A review of an Occupational Therapy Weekly Progress summary dated 1/18/12 noted that the resident's wheelchair was evaluated upon patient (resident) receiving a laceration. The wheelchair was discontinued and the resident was provided with a modified tilt and space wheelchair with padding to the leg rest to protect the resident' skin integrity. On 5/1/12 at 2:40 P.M. an interview and review of the rehab note with the Director of Rehab (DOR) indicated that although the resident's wheelchair was inspected before he/she received it, to her knowledge a chair would not have been given to the resident if it had sharp edges. Upon further inquiry with the DOR regarding the reason for the discontinuation of the resident's former wheelchair and/or a request to inspect it, the DOR became flustered, indicated that the chair was thrown out because it was "old and probably because of the sharp edges". 4. A tour with the Head Custodian on 5/2/12 at 10AM identified the following potential accident hazards: a. On Unit 1 East: The drain in the shower was uneven and had a broken metal drain cover causing potential for falls and/or injury to the skin. b. Tiles were dirty and chipped. Along the lower wall across from the shower, the tiles were chipped, jagged and sharp. c. The tub room had a cracked and peeling ceiling above the tub. d. The paper towel holder was rusted with sharp edges. e. On Unit 1 West: The shower room had two metal protrusions from a broken towel bar. f. The soap dish that was recessed into the tile, was loose and pulling away from the wall. g. The tub room across from the shower had missing tiles. h. On Unit 2 West: The following resident rooms had broken, jagged aluminum window blinds: Rooms 235, 236, 237, 238, 239, 241, 244, and 249. i. In room 246 the call light system between the two beds had exposed wires and a missing metal plate to cover wires. Interview at that time with the Head Custodian noted that the nurses on each unit complete work orders and place them in different locations on each unit to report problems. The Head Custodian stated he was unaware of the above findings and that if he was aware, he would have done something about it. He did report that he had requested new blinds but was waiting for the approval. Review of documentation from Environmental Rounds conducted on 2/17/11 identified that there were exposed wires from the call light system in room 246 at that time. In addition, a work order dated 1/2/12 requested new blinds for rooms 243. 248, and 246. A work order dated 4/20/12 requested the blinds be removed due to "falling apart, looks awful! ". A notation was made by the Head Custodian that the old one was removed and thrown in the dumpster. "did not replace it with any". ead Head

Based on clinical record review, observation, and staff interview for one of three sampled residents with heel pressure ulcers (R#106) the facility failed to provide care and services for the prevention. The findings include: Resident #106's [DIAGNOSES REDACTED]. A Significant Minimum Data Set ((MDS) dated [DATE] identified the resident as severely cognitively impaired, limited assistance with bed mobility, extensive assistance with transfers, at risk for pressure ulcers and a decline in activities of daily living (ADL's). A care plan dated 12/27/10 identified the resident with a history of a resolved left heel blister on 10/03/10. Although the current care plan dated 12/27/10 identified a potential for alteration in skin breakdown, with interventions that included weekly skin checks and turn and repositioning every two hours, the care failed to include heel offloading. A nurse's note dated 1/16/11 identified that the resident as unable to stand and ambulate. A nurse's note dated 1/19/11 identified a request for a physical therapy (PT) evaluation due to the resident's increased weakness and inability to stand and ambulate. A physician's orders [REDACTED]. A nursing note dated 2/22/11 identified a darkened area to the left heel. Review of the Advanced Practice Registered Nurse (APRN) progress note dated 2/23/11 identified a deep tissue injury (DTI) of the left heel which measured 1.0 centimeter (cm) by 1.0 cm with a blister under the skin. A physician's orders [REDACTED]. An APRN note dated 3/02/11 identified a pressure ulcer on the left medial heel, unstageable, which measured 2.0 cm by 3.0 cm. A physician's orders [REDACTED]. Observation of the left heel on 3/10/11 at 2:00 PM identified a brown colored area on the left heel with a partial fluid filled blister within the area which measured approximately 2.0 cm by 3.0 cm. Review of the care plan with the Assistant Director of Nursing (ADNS) on 3/08/11 at 2:00 PM identified that the care plan lacked interventions to include heel off loading until 2/23/11 when a DTI was identified. Interview with the APRN on 3/14/11 at 10:55 AM and review of the APRN progress notes identified the area on the left heel as an unstageable left heel pressure ulcer as documented in the clinical record. Review of the facility Pressure Ulcer Policy for prevention identified to suspend heels while in bed for pressure relief.