Every finding on record at Village Crest Center for Health & Rehabilitation

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with the plan of care. The failure resulted in a resident to fall and a right tibial and trimalleolar (three ankle bones) fracture. The findings include: Resident #1's diagnoses included atrial fibrillation, osteoporosis, muscle weakness, and anxiety. The Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen (8/15), indicative of moderate cognitive impairment and was dependent assistance with ADL's and transfers. The Resident Care Plan (RCP) dated 5/17/2026 identified Resident #1 was at risk for falls related to deconditioning, gait and balance impairment, and psychoactive medication use. Interventions directed two-person assist for all transfers, with mechanical lift transfers using a split sling (two staff). Physician order dated 7/6/2026, directed Physical Therapy (PT) and Occupational Therapy (OT) evaluation. Review of the OT Evaluation and Plan of Treatment documentation dated 7/8/26 identified Resident #1 was dependent for transfers, used a CAM boot (immobilizer) and was non-weight bearing until 7/7/2026 due to a May 2026 left ankle fracture. Resident #1 was required to wear the CAM boot for transfers, and directed to transfer with a Hoyer Lift. Resident #1's Care Card (NA card directing care needs) dated 7/11/2026 directed Resident #1 was dependent for all transfers and required the use of a mechanical lift with a split sling and two (2) staff for all transfers. The Facility Reportable Event Form dated 7/12/26 at 3:30 PM identified Resident #1 was confused, required a mechanical lift for transfers, and was assisted to the bathroom in his/her room, by Nurse Aide (NA) #1. Resident #1 stated he/she could stand but was unable to bear weight and was lowered to the floor. Resident #1 complained of pain in the right thigh and the right leg was bent at the knee with the foot externally rotated and shortened slightly. Resident #1 was transferred to the hospital and diagnosed with a right tibial (larger, inner lower leg bone) and trimalleolar fracture. Resident #1 returned from the hospital with a splint in place. The report indicated NA #1 was provided education to follow the plan of care for resident transfers. The facility investigation summary dated 7/17/2026 identified Resident #1 sustained the injury from the transfer performed by NA #1. Review of a nursing note dated 7/12/2026 at 4:37 PM written by RN #1 identified she assessed Resident #1 after the fall. Resident #1 was lying on his/her left side on the shower room bathroom floor, with NA #1 present. Resident #1 had asked NA #1 to take him/her to the bathroom and stated he/she could stand. Upon attempting to bear weight, Resident #1's right leg crumpled underneath him/her, and NA #1 lowered Resident #1 to the floor, and Resident #1 stated he/she heard his/her bones crunching. Resident's right leg was bent at the knee, with his/her foot externally rotated and slightly shortened. Upon attempting to straighten his/her leg, Resident #1 complained of pain; no further movement of the right lower leg was attempted. 911 was called and Resident #1 was transferred to the hospital. Review of the Hospital Discharge summary dated [DATE] identified the radiology report identified an acute segmental fracture of the mid tibial diaphysis (middle long section of the shinbone) with a slight anterior apex angulation (bone bent out of alignment), a fracture of the medial malleolus (bony bump on each side of the ankle), and a nondisplaced fracture of the fibular neck (crack near the top of the outer lower leg bone just below the knee). The imaging also identified a healing fracture of the distal fibula and diffuse soft tissue swelling of the right lower extremity. The overall radiologic impression was multiple acute fractures involving the mid tibial diaphysis, medial malleolus, and fibular neck, accompanied by diffuse (wide area) soft tissue swelling. Nursing note dated 7/12/2026 at 9:05 PM identified Resident #1 returned from the hospital with a right tibial fracture and right complex ankle fracture and would require knee surgery and a follow-up appointment to be scheduled with MD #1. New orders were obtained for non-weight bearing, Percocet 5/325 milligrams (mg), one to two tablets every six hours as needed for pain and to monitor the right lower extremity for pallor (pale), pulselessness, increased pain, paresthesia (numbness) or paralysis. Interview and record review with the Director of Rehabilitation (DOR) on 8/3/2026 at 10:25 AM identified that prior to Resident #1's fall on 7/12/2026, Resident #1 required a Hoyer lift and two (2) staff for all transfers. The DOR stated NA #1 did not follow the plan of care when he/she did not use a Hoyer lift and transferred Resident #1 alone. Interview with NA #1 on 8/3/2026 at 10:45 AM identified on 7/12/2026, at the beginning of the 3:00 PM to 11:00 PM shift, Resident #1 urgently requested to use the bathroom. NA #1 stated he repeatedly asked Resident #1 what type of bathroom assistance the resident used, and Resident #1 had stated he/she used the toilet with one (1) staff could assist. During the transfer, Resident #1 was standing for approximately 15 seconds when Resident #1's leg gave out, causing Resident #1 to fall to the floor. NA #1 stated he lowered Resident #1 to the floor and Resident #1 did not fall hard. Resident #1 had was injured during the transfer, and NA #1 notified the nurse. NA #1 stated he performed the transfer without assistance from another staff member and he did not verify Resident #1's transfer status prior to performing the transfer alone. NA #1 stated he did not utilize a gait belt, and stated he should have verified Resident #1's transfer status, should have used a Hoyer lift and had a second staff member with him for the transfer. NA #1 stated it was a busy start to the shift and Resident #1 had asked urgently to use the bathroom, which contributed to NA #1 acting independently rather than obtaining assistance. Further, NA #1 indicated he had recently completed the classroom for the NA course, had not yet taken the exam, and was orienting with another NA. Interview failed to identify why NA #1 did not have his preceptor (person orienting) with him when he performed the transfer for Resident #1. Interview and record review with the Director of Nursing (DON) and RN #2 on 8/3/2026 at 12:45 PM identified NA #1 failed to follow Resident #1's plan of care related to transfers, which resulted in Resident #1 sustaining a right ankle/leg fracture. Interview identified NA #1 should have had a second staff member assist, and used a Hoyer lift for the transfer. Interview identified NA #1 was orienting, had not yet taken the NA exam, and should have had his preceptor with him when he performed the transfer. Interview failed to identify why NA #1 did not have the preceptor NA with him. Although requested, the facility did not provide a policy for following the care plan and following physician orders. Review of facility documentation identified staff education was initiated on 7/12/2026 and directed to follow physician orders and resident care plans for transfers. Audits were initiated and reviewed by a QAPI meeting, and a finding of past non-compliance was identified as of 7/14/2026.

51183 Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #24) reviewed for falls, the facility failed to provide a transfer according to physician orders which resulted in a fall with injury and failed ensure all appropriate doors were secured on the locked memory care unit. The findings include: 1. Resident #24's diagnoses included transient cerebral ischemic attack, morbid obesity, and difficulty in walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was moderately cognitively impaired, had no falls since the previous assessment (5/18/23), had received physical therapy services from 6/2/23 through 7/4/23, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for transfers. A physician order dated 8/23/23 directed to provide extensive assistance of 1 staff member for bed mobility, Resident #24 required the use of a Sarita lift for transfers, was non-ambulatory, required limited assistance for upper extremity dressing, required extensive assistance with lower body dressing, and was independent with eating. The Resident Care Plan (RCP) dated 8/28/23 identified Resident #24 was at risk for falls related to deconditioning, gait/balance problems, psychoactive drug use, and a prior fall without injury on 5/29/23. Interventions included every shift must ensure Resident #24 was wearing non-skid socks while in bed and physical therapy to evaluate as ordered or as needed. Additionally, the RCP dated 8/28/23 identified Resident #24 had an activities of daily living (ADL) deficit related to generalized weakness especially to the lower extremities. Interventions included Resident #24 required extensive assistance by 1 staff member to turn and reposition in bed and required the use of a Sarita (mechanical lift) with assistance by 2 staff members for transfers. The Nurse Aide (NA) care card for Resident #24 dated 9/1/23 identified to transfer Resident #24 assist out of bed (OOB) to the chair/wheelchair as tolerated with assistance of 1 staff member (a discrepancy with physician orders and RCP in effect at that time directing to utilize a Sarita lift for transfers) and Resident #24 was to be transferred using the Sarita with the assistance of 2 staff members. A nursing note written by Registered Nurse (RN) #3 on 9/8/23 at 10:26 AM identified she had been requested to assess Resident #24 following a fall. The note identified that upon RN #3 entering the room, Resident #24 was observed sitting on the floor next the bed with his/her legs outstretched. The note identified Resident #24 verbalized pain to the right ankle with and without manipulation of the ankle. Additionally, the nursing note identified NA #1 reported Resident #24's leg appeared to twist as NA #1 lowered Resident #24 to the floor during a transfer. The note identified no bruising or swelling was observed to the right ankle, Resident #24 was assisted back to bed using a mechanical lift, and the Advanced Practice Registered Nurse (APRN) #1 and Resident #24's responsible party were updated. The note further identified an x-ray was ordered to rule out injury to the right ankle. A facility Reportable Event form identified on 9/8/23 at 10:00 AM Resident #24 was lowered to the floor by NA #1 during a transfer after which Resident #24 verbalized pain to the right ankle. The report identified x-rays were performed and identified 2 fractures: the base of the medial malleolus (inner side of the ankle) and distal fibular (end of leg bone near the ankle) fracture. The report identified Resident #24 was sent to the hospital ED for evaluation and treatment. The RE identified Resident #24's physical status before the event was to transfer with extensive assistance of 1 staff member (a discrepancy with the physician order dated 8/23/23 which directed Resident #24 required extensive assistance of 1 staff member for bed mobility, required use of a Sarita for transfers and was non-ambulatory), and Resident #24's physical status after the event was transfer with mechanical lift and assistance of 2 staff members. A nursing note written by Licensed Practical Nurse (LPN) #8 and dated 9/9/23 at 2:33 AM identified x-rays of the right ankle were completed at 12:30 AM. A radiology report dated 9/9/23 at 4:40 AM identified 3-view right ankle x-rays had been completed for Resident #24 on 9/8/23 with findings of an acute nondisplaced fracture at the base of the medial malleolus (inner side of the ankle) with an acute comminuted nondisplaced distal fibular (end of leg bone near the ankle) fracture. Diffuse osteopenia (decreased bone density) was seen. A nursing note written by RN #8 on 9/9/23 at 6:48 AM identified Resident #24 was status post a fall with complaints of pain to the right ankle, the x-ray results were positive for fractures to the medial malleolus and distal fibula, and the on-call Advanced Practice Registered Nurse was updated and directed to send Resident #24 to the hospital emergency department (ED). A nursing note written by LPN #8 on 9/9/23 at 7:44 AM identified Resident #24 was transferred to the hospital ED at 7:40 AM with all required paperwork. The note identified Resident #24's right leg and ankle were swollen with no bruising noted, Resident #24 complained of knee pain and Tramadol (pain medication) was administered at 7:00 AM. A nursing note written by RN #7 on 9/9/23 at 5:08 PM identified Resident #24 returned to the facility from the hospital emergency department at 3:30 PM with a diagnosis of a right ankle fracture, a soft cast in place to the right lower extremity and the on-call medical doctor was updated on Resident #24's return. Interview with NA #1 on 5/5/25 at 2:15 PM identified she was the NA caring for Resident #24 on 9/8/23 and indicated the NA care card in the computer was confusing and directed that Resident #24 could either be transferred by a stand/pivot transfer and the assistance of 2 staff members or by a Sarita lift. NA #1 identified she was unable to locate another staff member to assist her with the transfer and thought she would be fine to complete the transfer by herself. NA #1 identified as she was transferring Resident #24 from the bed to the wheelchair by herself when Resident #24's legs buckled and as NA #1 lowered Resident #24 to the floor, Resident #24's ankle went backwards and twisted. NA #1 identified that the instructions on the NA care card were confusing and she did not ask a staff member for clarification regarding if Resident #24 transfer status. NA #1 further noted if Resident #24 needed to be transferred by the Sarita lift, she still should have had a second staff member with her for Resident #24's transfer. Interview with the DNS on 5/5/25 at 2:30 PM identified the policy for any mechanical lift including the Sarita was that 2 staff members were required for the transfer with the mechanical lift without exception. The DNS identified NA #1 should have completed the transfer using a Sarita lift, should have had a second staff member with her for the transfer and did not follow facility policy for use of the Sarita lift. Review of the Mechanical Lift policy directed, in part, 2 staff members must be involved in the transfer of a resident with a mechanical lift, when lifting a resident from the floor, two staff members including a licensed nurse must be present while operating the mechanical lift, and documentation of need for a mechanical lift was in the care plan and NA care card. 2. Review of the Resident Listing Report dated 4/28/25 indicated there were 30 residents living on the facility's secured/locked memory care unit. An observation on the secured /locked memory care unit with the Director of Maintenance on 4/28/25 at 12:45 PM identified the shower room contained a metal nail clipper and a bottle with a white liquid in it (soap). Additionally, the door to the room labeled dentist office was propped open with a garbage can, and the door to the room labeled soiled utility, which was equipped with a key pad locking mechanism (the mechanism had been bypassed), was not locked/secured. The soiled utility room contained two bottles of cleaning solution with liquid in them. Interview with the Maintenance Director on 4/28/25 at 12:49 PM while on the secured locked memory care unit identified he was not aware the dentist office and soiled utility room doors were not locked/secured. The Maintenance Director indicated the soiled utility room should have been locked/secured and staff should have only used the keypad code to gain access to the room. He demonstrated how the keypad code could be bypassed, resecured the keypad lock and stated he would plan to install a different lock on the door that could no longer be bypassed. Observation and interview with LPN #2 on 4/28/25 at 1:05 PM identified the door to the room labeled dentist office was found propped open and not locked/secured as it should have been. LPN #2 indicated she was not sure why the door was not locked/secured but sometimes nursing staff used the room for charting. LPN #2 identified the nursing station was also equipped with a retractable plastic barrier that could be pulled to deter access to the area behind the nurse's station (where the dentist office was located) but that it was not pulled/secured and should have been. Subsequent to surveyor inquiry, on 4/28/25 at 1:08 PM the retractable barrier was pulled/secured by LPN #2. Interview with the Administrator on 4/28/25 at 1:20 PM identified all doors on the secured locked memory care unit should have been locked/secured for the safety of the residents. The Administrator indicated he would have expected the soiled utility and dentist office doors to always be locked/secured. The Administrator identified he would speak to the nursing supervisor about providing staff further education and oversight on keeping all doors locked/secured on the unit. Subsequent to surveyor inquiry, on 4/29/25 at 10:00 AM the door to the shower room on the secured locked memory care unit was now equipped with a keypad locking mechanism. Review of the facility policy, Living Legacy Memory Care Unit, undated, directed the unit provided a secure environment where the safety and well-being of residents is maintained. The policy further directed the unit was a safe, secured physical environment which allowed maximum freedom, safety, and a sense of security for residents and families.

Based on the tour of the Dietary Department and Nourishment Rooms, staff interviews, and review of facility policies, the facility failed to ensure opened items were labeled and dated when opened, food that was expired was discarded and the 3 of 3 nourishment refrigerator/freezer/ice makers were sanitary. The findings included: Tour of the Dietary Department on 4/28/25 at 10:40 AM during the initial walk through with the Dietary Director identified the following: a. 16 hot dog buns were in an opened package and not dated when opened b. 1 loaf of French bread, opened and not dated when opened c. 2 slices of French toast on a plate, covered with plastic wrap and located in the walk in refrigerator and not dated when opened d. 8 donuts in a box that was opened and not dated when opened e. 1 package (5 lb) egg noodles with an expiration date of 4/2023 f. 1 (48 ounces) plastic container of honey that was ¾ full, opened and not dated when opened g. 1 bag of peas located in the walk in refrigerator was opened and not dated, with a hole in the packaging h. 1 (5 pound) bag of egg noodles was opened and not dated when opened, located in the dry storage room i. 1 (5 pound) package of elbow macaroni that was ½ full, was opened and not dated when opened, located in the dry storage room j. 1 (25 pound) bag of rice that was ½ full and opened located in the dry storage room, was not dated when opened k. 4 (28 ounce) cans of pinto beans with an expiration date on 10/19/23 An observation made with the Dietary Director on 4/30/25 at 9:30 AM of the walk in refrigerator identified the following: a. 4 loaves of cooked meatloaf, on a tray uncovered and undated b. 1 loaf package of white American cheese that was ½ full, opened and not dated when opened c. tomato juice in a 1-gallon plastic container approximately ¾ full, opened and not dated when opened d. prepared soup in a plastic container that was approximately ½ full dated 4/23/25 (7 days old) e. sliced beef with prepared gravy in a metal container dated 4/23/25 (7 days old) f. a small chaffing metal container approximately ½ full of cooked egg noodles was dated 4/23/25 (7 days old) g. 1 package of Tortellini with an expiration date of 3/23/24 h. 1 plastic container of beef broth approximately 1/3 full, not labeled, and not dated On 4/30/25 at 10:35 AM a tour of the nourishment rooms with Dietary Director identified the following: 2nd floor nourishment room: a. The coffee maker was soiled with a heavy accumulation of coffee grounds on the machine and staining covering the machine. b. a single serving size box of cereal with an expiration of dated 4/7/25 was located on the counter c. 2 chocolate cookies on a plate, loose, and uncovered were located on the counter d. 2 slices of bread not dated on a plate, uncovered, not dated located on the counter e. the refrigerator was observed to have brownish drip marks on multiple shelves on the inside The 3rd floor nourishment room was identified with the following: a. The ice maker was observed with a brown substance in the ice scoop container located attached to the side of the ice maker b. The wall was coming away with noted debris behind the ice maker toward the floor c. 1 package (approximately 1 lb) of brown sugar was opened and not dated d. 1 foil wrapped item not dated (unable to determine what the item was without unwrapping) e. The nourishment room refrigerator was noted to be tacky to touch with brown substance located along the inside door, bottom of the refrigerator, plastic shelving 4th floor nourishment room: a. The ice maker was noted to have a heavy accumulation of a brown and white substance on front grate and along the side. The ice scoop container which also had a brown substance at the bottom of the holder b. 1 container (32 ounce) of mayo that was almost full, opened and not dated when opened c. 1 container (24 ounce) of salsa that was ¾ full, opened and not dated when opened Interview on 4/30/25 at 11:00 AM with the Dietary Director identified that he was unsure of the policy on items to be labeled with the date and going through inventory for expired food items. He also identified that the nourishment room refrigerator/freezer/ice makers needed to be cleaned on all 3 units, Further, identifying that the dietary department was responsible for maintaining the cleanliness of the nourishment rooms, and that he makes round to check on the cleanliness but apparently not often enough. Review of the facility policy for Storage of food and supplies food, non-food items, and supplies used in food preparation and service shall be stored in such manner as to maintain safety and sanitation of the food or supply for human consumption at outline in the federal drug administration food code, state regulation, and city/county health codes. Identified labeling and rotating food supply, food products that are opened and not completely used, transferred from its original container package to another storage container, or prepared at the facility and stored should be labeled as its contents and used by dates. Also identified was food removed from its original container must be labeled with the common name of the food. Further identifying that refrigerator time/temperature safety, ready-to-eat food that was opened but not completely used and was held for longer than 24 hours should be labeled with the common names and use by day, with day 1 counted as the day the item was opened. Rotate food product (dry, refrigerated, or frozen) to ensure the oldest inventory was used first. Discard food that exceeds their used by date or expiration date, was damaged, spoiled, has the time/temperature danger zone requirements, or was incorrectly stored such that it was unsafe, or its safety was uncertain.

Based on observations, staff interview, review of the clinical record and facility policy for 6 residents (Resident #4/Resident #36 (roommates), Resident #13/Resident #25 (roommates)and Resident #33/Resident #37 (roommates) on isolation precautions, the facility failed to ensure the nursing staff donned the appropriate Personal Protective Equipment (PPE) and for 1 of 6 sampled residents (Resident #36) reviewed for infection control documentation, the facility failed to ensure documentation was accurate and consistent regarding the type of precautions Resident #36 required. The findings include: 1a. Resident #4 was admitted in April 2021 with diagnoses that included Alzheimer's disease and dementia (was roommates with Resident #36). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a short/long term memory problem and had severely impaired cognitive skills for tasks of daily living. Additionally, the MDS identified Resident #4 required substantial/maximal assistance with upper body dressing and was totally dependent for lower body dressing and personal hygiene. Nursing notes dated 4/28/25 and 4/30/25 identified Resident #4 was tested for Covid-19 with negative results on both days. Observation during a tour of the facility on 4/29/25 at 9:50 AM, identified Licensed Practical Nurse (LPN ) #3 was preparing medications at the medication cart in the hall on the 3rd floor in front of Residents #4/Resident #36's room. The room had a sign posted on the door frame stating that room was on transmission-based precautions for droplets (related to Resident #4's roommate/Resident #36 testing positive for Covid-19) and required staff to don a gown, eye protection, an N95 face mask and gloves. Further observation identified LPN #3 entered the room to pass medications to Resident #4, wearing only a surgical mask (and failed to apply a gown, eye protection, an N95 mask or don gloves) . Interview with LPN #3 on 4/30/25 at 12:45 PM identified that she did not don a gown, gloves, eye protection or an N95 mask when going into Resident #4/Resident #36's room on 4/29/25 at 9:50 AM and she was only wearing a surgical mask because she was administering medications to Resident #4 who tested negative for Covid-19 on 4/28/25. Further interview with LPN #3 identified she should have donned a gown, eye protection, gloves and N95 face mask which were located outside of the room and she should don the proper PPE to go into any residents room that was labeled as droplet precautions regardless of the residents' roommates status of infection. b. Resident #36 was admitted to the facility in April 2024 (was roommates with Resident #4) with diagnoses that included Alzheimer's disease, malignant neoplasm of the breast, immunodeficiency due to drugs and tested positive for Covid-19 on 4/27/25. A physician's order dated 4/28/25 identified Resident #36 was put on contact and droplet precautions every shift for 10 days, ending on 5/8/25 due to Covid-19. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #36 was severely cognitively impaired and required partial/moderate assistance with toilet hygiene and required supervision with upper/lower body dressing and personal hygiene. Nursing notes dated 4/28/25 through 5/2/25 identified Resident #36 was showing symptoms of dry cough, stuffy nasal passages, weakness and increased difficulty in walking on 4/27/25 then tested positive for Covid-19 on 4/28/25 at 6:48 AM. Further review identified implementation of precautions were documented; however, the type of precautions implemented were inconsistent and differed with each day/different shifts: on 4/28/25 at 6:48 AM the nurse documented transmission- based precautions (TBP) then on the same day 4/28/25 at 2:00 PM, a different nurse documented Resident #36 was on enhanced-barrier precautions (EBP). On 4/29/25 at 6:48 AM and 9:42 PM and 4/30/25 at 5:54 AM TBP was documented, but on 4/30/25 at 6:38 PM, EBP was documented. Further review of the nursing notes identified inconsistent documentation of the type of precautions documented for Resident #36 continued through 5/5/25. 2a. Resident #13 had diagnoses that included asthma, anxiety, and chronic peripheral venous insufficiency. (was roommate with Resident #25) The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired, was up-to-date with COVID-19 vaccinations, was independent with eating and personal hygiene, and required setup or clean-up assistance with bed/chair transfers. The Resident Care Plan (RCP) dated 4/16/25 identified Resident #13 was at risk for complications of asthma related to seasonal allergies. Interventions included to assist Resident #13 in identifying asthma triggers and strategies for prevention, encourage prompt treatment of any respiratory infection, and give medications as ordered. b. Resident #25's diagnoses included being positive for Covid-19, pleural effusion, and dementia. (Resident #25's roommate was Resident #13). A physician's order dated 4/25/25 directed for isolation related to being positive for Covid-19, every shift for infection control measures for 10 days. The Resident Care Plan (RCP) dated 4/25/25 identified that Resident #25 was confirmed Covid-19 positive with interventions that included contact/droplets precautions, assist resident with the application of face mask as needed, and assist resident with hand hygiene as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #25 was moderately cognitively impaired, required supervision for bed mobility, transfers, eating, and toilet use. Additionally, the MDS identified Resident #25 was up to date with Covid-19 vaccinations. i. Observation on 4/29/25 at 9:50 AM identified signage posted on the door frame of the room that indicated Resident #25 was on contact/droplet precautions and staff and/or visitors entering the room were required to don the following personal protective equipment (PPE) prior to entering the room: gown, N95 mask, eye protection/shield, and gloves. Observation at that time noted Licensed Practical Nurse (LPN) #1 in the room wearing a blue surgical mask (not an N95 mask), failed to don a gown, eye shield and gloves and standing in front of the bed conversing with Resident #25. Interview with LPN #1 on 4/29/25 at 9:53 AM identified Resident #25 was on contact/droplet transmission-based precautions, and the signage posted on the doorframe of Resident #25's room directed staff/visitors to don the PPE listed on the signage prior to entering the room. LPN #1 identified that while she was wearing a surgical mask, she should have been wearing an N95 mask, gown, eye shield and gloves. LPN #1 identified she had been in a rush and had not put on the required PPE before entering the room. Interview with the Infection Preventionist (RN #3) on 4/30/25 at 12:20 PM identified prior to entering a room with signage posted that indicated one or both the residents in that room were on contact/droplet precautions, all staff were required to don the appropriate PPE (gown, N95 mask, eye shield, and gloves) before entering the room. RN #3 identified that even if a staff member was entering the room to assist the resident who was not on contact/droplet precautions, the staff were still expected to don the required PPE prior to entering the room. RN #3 identified wearing the required PPE was part of infection prevention. ii. An observation made outside of Resident #25's room on 5/1/25 at 7:50 AM identified signage was posted outside the room, that the resident's were on enhanced barrier precautions (EBP) which directed that isolation droplet/contact precautions were in place and that staff must wear gloves, a gown, N95 mask and eye protection upon entering the room. A cart containing isolations gowns and other personal protective equipment (PPE) was observed outside of Resident #13's/Resident #25's room. Additionally, Nurse Aide (NA) #6 was observed to don gloves, a gown, an N95 mask but failed to don eye protection upon bringing a breakfast tray into the room. An interview on 5/1/25 at 7:59 AM with NA #6 once she exited Resident #25's room the cart outside the room did not contain any eye protection, that she needed to request more be brought up to the unit and NA #6 knew the policy for wearing eye protectors in a room with droplet/contact precautions but she went in the room anyway without wearing. An observation of the unit on 5/1/25 at 8:00 AM identified that other EBP carts were placed in the hallway with one cart containing 3 eye protectors not far from Resident #13's/Resident #25's room. An interview on 5/1/25 at 8:20 AM with the Director of Nursing (DNS) identified that full PPE was to be worn when entering Resident #25's room which included eye protectors. Also, identifying that was the policy and what the signage was outside the doorway of the room. 3a. Resident #33 had diagnoses that included COVID-19, dementia, and depression.(Resident #33 was roommates with Resident #37). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was cognitively intact, was up-to-date with COVID-19 vaccinations, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 1/30/25 identified Resident #33 was at risk for altered respiratory status/difficulty breathing. Interventions included administer medication as ordered, oxygen per medical doctor (MD) orders, and monitor for signs and symptoms of respiratory distress and report to MD as needed: increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, and confusion. A physician order dated 4/25/25 directed isolation for positive COVID-19 every shift for 10 days. b. Resident #37 had diagnoses that included lymphedema, epilepsy, and stroke. (Resident #37 was roommates with Resident #33). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, was not up-to-date with COVID-19 vaccination, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility, and substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 4/2/25 identified Resident #37 had a Multi-Drug Resistant Organism (MDRO) infection/colonization of a wound to the right leg. Interventions included enhanced barrier precautions: don gown and gloves when performing high contact care activities, and private room or cohort with appropriate roommate. Observation on 4/29/25 at 10:04 AM identified signage posted on the door frame of the room that indicated Resident #33 was on contact/droplet precautions and staff and/or visitors entering the room were required to don the following personal protective equipment (PPE) prior to entering the room: gown, N95 mask, eye protection/shield, and gloves. Nurse Aide (NA) #1 was observed in the room, walked away from the foot of Resident #33's bed and stopped at the disposal receptacles and removed her gown and gloves and placed the used gown in the laundry receptacle and the gloves in the trash can. The observation identified NA #1 was wearing a blue surgical mask (and not an N95 mask) that she did not take off prior to exiting the room and going into the hallway. Interview with NA #1 on 4/29/25 at 10:05 AM identified Resident #33 was on contact/droplet transmission-based precautions, and the signage posted on the doorframe of Resident #25's room directed staff/visitors to don the PPE listed on the signage prior to entering the room. NA #1 identified that although she was wearing a surgical mask, gown and gloves inside the room, she should have been wearing an N95 mask instead of the surgical mask and an eye shield also. NA #1 identified she had not donned all the required PPE because she had rushed into the room because she heard Resident #33's roommate (Resident #37) crying. Interview with the Infection Preventionist (RN #3) on 4/30/25 at 12:20 PM identified prior to entering a room with signage posted that indicated one or both the residents in that room were on contact/droplet precautions, all staff were required to don the appropriate PPE (gown, N95 mask, eye shield, and gloves) before entering the room. RN #3 identified that even if a staff member was entering the room to assist the resident who was not on contact/droplet precautions, the staff were still expected to don the required PPE prior to entering the room. RN #3 identified wearing the required PPE was part of infection prevention. Review of the COVID-19 policy directed, in part, under the section for PPE, upon entry to a COVID-19 positive resident room all healthcare workers are to wear an N95 mask, eye protection, gown and gloves which is to be removed prior to exiting the room. Review of the policy for Precautions to prevent infection identified that there are two tiers of precautions to prevent infectious agents, Standard Precautions and Transmission -Based Precautions. Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiological important pathogens, which require additional control measures to effectively prevent transmission. Further, identified to make PPE, including gowns, and gloves available immediately outside the resident's room when on Transmission-Based precautions. Also, identified for Standard and Enhance Barrier Precautions PPE was always readily available to all staff. Gloves are in each resident room, gowns are available in/on linen carts, eye protection and face mask are available in the clean utility room.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #33) reviewed for dental services, the facility failed to ensure timely dental services were provided related to non-restorable teeth. The findings include: Resident #33's diagnoses included weakness and partial paralysis affecting the left side following a stroke, dementia, and depression. The face sheet identified Resident #33's payor source was Medicaid. The Resident Care Plan (RCP) dated 2/14/23 and currently in effect identified Resident #33 had oral/dental health problems related to poor dentition. Interventions included monitor/document/report any signs and symptoms of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, teething missing/loose/broken/eroded/decayed and report pain, bleeding, broken teeth to the nurse. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #33 had intact cognition and required set up assistance with eating and oral hygiene. Additionally, the MDS identified Resident #33 required partial assistance with personal hygiene. A dental hygienist (RDH) note dated 11/2/23 at 4:18 PM and written by RDH #1 identified Resident #33 was seen for a comprehensive oral examination, routine oral cleaning, and fluoride treatment. The note identified Resident #33 expressed his/her concern again regarding the desire to have his/her teeth repaired. The nursing supervisor was informed of the dentist (DMD) #1's previous recommendation for Resident #33 to see a dentist in the community, and that a referral letter and x-rays were located in Resident #33's electronic medical record (EMR). A letter by DMD #1 and dated 1/31/24 identified Resident #33 was referred for dental services for evaluation and treatment regarding full mouth rehabilitation. The consult identified Resident #33 was asymptomatic at that time, however he/she had multiple non-restorable teeth with potential for developing acute episodes. The consult identified Resident #33 had expressed desire for dental implants. The consult further identified the facility staff would provide whatever additional medical information was required and dental radiographs would also be made available. A dental hygienist note written by RDH #1 and dated 2/2/24 at 5:04 PM as a late entry for 1/31/24 identified Resident #33's oral exam revealed poor oral hygiene and multiple teeth in various stages of failure. The note identified Resident #33 again asked about having implant retained dentures. The note identified Resident #33 was reminded that a referral to a dental provider in the community was indicated for this type of dental care. The note identified the nursing supervisor was informed of Resident #33's request and that a referral letter had been updated and made available in Resident #33's EMR. A dental hygienist note written by RDH #1 and dated 7/26/24 at 10:06 PM identified Registered Nurse (RN) #1 had been informed of the dental concerns regarding Resident #33. A dental hygienist note written by RDH #1 and dated 11/22/24 at 9:11 PM identified the nurse on duty notified RDH #1 that Resident #33 had requested to be seen by the dentist and that Resident #33 wanted to do something about his/her teeth and had changed his/her mind about implants. The note identified Resident #33 just wants to get the bad ones removed and partial dentures made. The note further identified Resident #33 would be seen by DMD #1 for further evaluation. A dental hygienist note written by RDH #1 and dated 12/6/24 at 9:57 PM identified Resident #33 was seen for exam and consultation regarding treatment options. The note identified Resident #33 was previously referred to a dental provider in the community for dental care as he/she had specifically asked for dental implants. The note identified the referral was not carried out and the reason was unknown. The note identified Resident #33's exam revealed complete fracture of almost all of his/her remaining teeth with only retained roots remaining. Additionally, RDH #1's note identified treatment options were discussed and Resident #33 indicated he/she was ready to have all remaining teeth removed and dentures fabricated. The note identified implants were discussed and if possible, Resident #33 wanted to have implants to assist in retaining the dentures. The note identified RN #1 was informed of Resident #33 wishes, and arrangements would be made for referral to an oral surgeon for full mouth tooth removal. The note further identified a dental referral letter would be made available in the EMR and once complete healing occurred, arrangements would be made for consultation and treatment regarding denture fabrication. A letter by DMD #1 dated 12/6/24 identified Resident #33 was referred for dental services for removal of all remaining teeth and alveoloplasty in preparation for fabrication of full dentures. The letter identified facility staff would provide whatever additional information was required. The letter further identified a request to forward a copy of the consultation to the fax number indicated on the letter. A dental hygienist note dated 3/14/25 at 9:57 PM identified Resident #33 was seen for an oral exam and Resident #33 inquired when his/her teeth would be removed so he/she could have dentures made. The note identified the social worker was consulted about DMD #1's referral to an oral surgeon for removal of all remaining teeth and recommendation of dentures and that Resident #33 had inquired about the treatment and wanted to proceed. The note identified the social worker requested nursing staff be informed. The note identified RN #3 was informed of the referral to an oral surgeon for removal of all remaining teeth and recommendation of dentures and that Resident #33 had inquired about the treatment and wanted to proceed. Observation on 4/28/25 at 1:25 PM identified Resident #33 was missing several teeth on both the top and bottom, and Resident #33 had visible tooth fragments along the top of the bottom gums and the gums were red. Interview with Resident #33 on 4/28/25 at 1:25 PM identified his/her teeth could be painful at times, and that his/her teeth were falling out. Resident #33 identified the meals provided look like they had been through a ricer because of the condition of his/her teeth, and that the meals were not very appealing because of that. Resident #33 identified that he/she was supposed to be getting his/her teeth fixed, but didn't know how or when that was going to happen. Interview with Registered Nurse (RN) #3 on 4/30/25 at 11:15 AM identified on 3/14/25 when she received a referral for Resident #33 to be seen by an oral surgeon for removal of teeth, she had given a slip to the receptionist who makes resident appointments. RN #3 identified she had notified RN #1 of the referral so that she could keep track of the appointment(s), and that she had not heard anything additional since that date of 3/14/25. Interview with Reception #1 on 4/30/25 at 11:20 AM identified she was responsible for making resident appointments and that Resident #33 was scheduled to go out to the dental health clinic for a consult with the oral surgeon 5/1/25 at 11:00 AM. Reception #1 identified Resident #33 had an appointment scheduled 4/11/25, but that transportation had not shown up, so the appointment needed to be rescheduled. Interview with Resident #33 on 5/5/25 at 9:15 AM identified he/she was seen by the dentist at the facility and was supposed to get dentures but he/she doesn't know when because first the rest of his/her teeth needed to be removed. Resident #33 identified that when he/she eats it is uncomfortable because the food rubs against some of the broken teeth, but that the discomfort is only momentary and goes away quickly so he/she doesn't ask for medication. Resident #33 identified that the facility had not helped to his/her satisfaction with getting an appointment in the community for dental services, that he/she does not know what the delay is with getting an appointment to get his/her remaining teeth pulled. Interview with RN #1 on 5/5/25 at 10:15 AM identified referrals from DMD #1 are uploaded into the EMR, then the referral was approved by the Medical Doctor/Advanced Practice Registered Nurse (MD/APRN) and then it goes to the front desk for the appointment to be made. RN #1 identified it was the responsibility of the charge nurse and/or the Supervisor to ensure recommendations from DMD #1 are followed up on and that appointments or follow-up visits are made. RN #1 identified that when an appointment needed to be rescheduled the receptionist would reschedule the appointment and then let the nurses know of the new appointment date. Interview with DMD #1 on 5/5/2025 at 10:49 AM identified Resident #33 had initially requested to get something permanent like implants to replace his/her missing and broken teeth which required a referral. DMD #1 identified she had written a letter and uploaded it into the EMR and then spoke with nursing to explain what Resident #33's wishes were. DMD #1 identified that she had written multiple referral letters for Resident #33. DMD #1 identified she and RDH #1 had followed up with the facility and followed through with reminding the nursing staff many times of the referral letter(s) in Resident #33's EMR. DMD #1 identified there was a delay in Resident #33 receiving outside services to facilitate his/her acquiring implants/dentures, and DMD #1 did not know the reason for the delay. DMD #1 identified communication from the facility wasn't ideal as nursing staff did not communicate changes or delays to DMD#1. Interview with Reception #1 on 5/5/25 at 11:50 AM identified she did not recall receiving a referral for Resident #33 for dental services from an outside resource until recently (this year). Reception #1 identified she did not retain the referral sheets/forms she received from the nursing staff for longer than 3 to 4 months after making an appointment. Reception #1 identified the excel spreadsheet she used on her computer for resident appointment scheduling went back to at least 2023 and identified she had searched through all resident appointments since January 2023 and she had located only 3 appointments for Resident #33 for dental services outside of the facility. All 3 appointments were with Resident #33's oral surgeon's office, and it was Resident #33's initial consultation with the oral surgeon which needed to be rescheduled 2 times. The original appointment was scheduled for 4/11/25 but the wheelchair transport did not arrive to pick Resident #33 up and the appointment was rescheduled for 5/1/25. On 4/30/25 Resident #33 was positive for COVID requiring the appointment on 5/1/25 to be rescheduled for 5/15/25 (but failed to identify dental services had been scheduled from her recommendations on 11/2/23, 2/2/24, and 12/6/24) when RDH #1 initially requested Resident #33 be seen by a dentist in the community related to a desire to have his/her teeth repaired. Interview with Director of Nursing Services (DNS) on 5/5/2025 at 12:05 PM identified she was unaware of referrals for dental services for Resident #33 prior to December 2024. After being informed the first referral letter from DMD #1 for Resident #33 was 2/16/23, the DNS was unable to identify reasons for the delay in Resident #33 receiving dental services from an outside resource. DNS further identified the nursing staff did not typically write notes in the EMR to document barriers or difficulties for the scheduling of appointments for residents. Review of the Dental Services policy directed, in part, the facility is responsible to provide an outside resource, routine, and emergency dental services to meet the needs of each resident, assistance for dental care upon the resident's request, and the facility will also assist with providing transportation as needed. The policy further directed in the event there is a delay in obtaining a dental appointment, the facility will document the reason for the delay.

Based on observation(s), review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #286) reviewed for non-pressure skin conditions, the facility failed to obtain wound treatment orders upon admission for a resident with a surgical wound and a venous stasis ulcer. The findings include: Resident #286 was admitted to the facility in April 2025 with diagnoses that included chronic venous hypertension with inflammation, cellulitis of the lower limbs, and cutaneous abscess of left foot. Review of the hospital discharge records dated 4/26/25 identified Resident #286 had a left leg cellulitis and abscess with surgical debridement and a right lower extremity cellulitis and venous ulcer. The discharge records directed to continue daily dressing changes with Betadine and dry sterile dressing as well as Sodium Hypochlorite topical solution applied to foot ulcers daily with a dressing of gauze and gauze roll bandage twice daily. Although the discharge records further indicated see instructions with regards to treatments for the left and right lower extremity areas, they failed to identify wound treatment/dressing change orders and instructions for those areas. The admission nursing assessment dated [DATE] identified Resident #286 required assistance with transfers and activities of daily living. The admission skin assessment identified a right lower extremity venous ulcer and cellulitis on bilateral lower extremities with a surgical wound (abscess debridement) on the left foot. The admission physician's orders dated 4/26/25 directed Sodium Hypochlorite External Solution 0.125%, apply topically to foot ulcers daily every shift for wounds but failed to identify wound treatment/dressing change orders for Resident #286's bilateral lower extremities (venous ulcers/cellulits and surgical wound). The Resident Care Plan dated 4/28/25 identified cellulitis, a left foot abscess debridement, and chronic venous ulcers. Interventions included to provide treatments as ordered and provide wound care. An admission nursing note written by Registered Nurse (RN) #4 and dated 4/26/25 at 4:14 PM identified Resident #286's discharge medications and orders were reviewed to ensure a safe transition of care and hospital discharge orders were reviewed and updated as appropriate with the on-call provider. Observation on 4/28/25 at 11:10 AM identified Resident #286 was seated at the bedside in his/her wheelchair with his/her left lower extremity elevated and resting on the bed. Resident #286 had gauze dressings in place to his/her bilateral lower extremities and the dressing to the left lower extremity had red/brown colored drainage coming through the dressing and onto the bed sheet. Both lower extremity dressings were labeled and dated 4/28/25. An admission APRN note written by APRN #1 and dated 4/28/25 at 11:15 AM identified Resident #286 had chronic venous leg ulcers and an incision and drainage of a left foot abscess on 4/19/25. Although the progress note indicated to continue wound care with Sodium Hypochlorite 0.125% solution daily, the progress note failed to identify comprehensive wound treatment/dressing change orders for Resident #286's right lower extremity cellulitis and left foot surgical wound. The progress note further identified Resident #286 was to receive continued wound care and antibiotic therapy while at the facility with wound consult, treatment and assessment per protocol. The Treatment Administration Record (TAR) for April 2025 directed Sodium Hypochlorite External Solutions 0.125%, apply to foot ulcers daily topically every day shift for wounds. The TAR failed to identify wound treatment or dressing application directives for the resident's bilateral lower extremities. Interview and review of the clinical record with the Infection Preventionist (RN #3) on 5/1/25 at 2:45 PM identified Resident #286's wound treatment/dressing change orders were not obtained and incomplete to Resident #286's bilateral lower extremities since his/her admission on [DATE]. RN #3 indicated the hospital discharge orders were unclear and should have been clarified on admission by the nursing supervisor. RN #3 identified that since Resident #286's admission on [DATE], the nurses were putting dressings on Resident #286 without orders in place but she was unsure what was the dressing treatments consisted of. RN #3 indicated nursing should have clarified and obtained orders with the on-call provider on admission or subsequently with the APRN or Medical Director, and she was unsure why that was not done. RN #3 stated she had placed a call to Resident #286's podiatrist and infectious disease physician today and was awaiting a call back. Interview and review of the clinical record with the DNS on 5/1/25 at 3:12 PM indicated although, on admission, the nursing supervisor did assess and document Resident #286's wounds, she failed to clarify and obtain complete treatment/dressing orders. Review of the clinical record with the DNS identified that directives (site, frequency, dressing/gauze type) for how to dress the resident's wounds were not in place and nurses should not have been completing dressing changes on Resident #286 without wound treatment orders in place. The DNS indicated the nurses should have reached out and obtained the needed orders for Resident #286 and she was unsure why that was not done but would make sure it was addressed. Subsequent to surveyor inquiry, review of the physician's orders for 5/1/25 indicated new physician's orders for wound care were obtained for Resident #286 as follows: 1. Sodium Hypochlorite External Solution 0.125 % Apply to Right lateral calf topically every day shift for vascular, cleanse with Sodium Hypochlorite external solution 0.125% solution and pat dry. Apply Betadine moistened gauze and bordered foam daily and as needed (prn) AND apply to Right lateral calf topically as needed for vascular, cleanse with sodium Hypochlorite external solution 0.125% solution and pat dry. Apply Betadine moistened gauze and bordered foam prn if dressing missing, dislodged or soiled. 2. Sodium Hypochlorite External Solution 0.125 % Apply to Left medial foot surgical topically every day shift for wounds, cleanse with Sodium Hypochlorite 0.125 % and pat dry. Apply Betadine moistened gauze, ABD pad followed by gauze wrap daily and prn AND apply to Left medial foot topically as needed for surgical if dressing missing, dislodged or soiled. Interview with APRN #1 on 5/5/25 at 10:27 AM identified treatments and dressing changes should have been clear and updated and if wound care orders were vague or there was a discrepancy on the hospital discharge paperwork, the nursing staff should have called the hospital to clarify the orders. APRN #1 indicated the medical director was at the facility over the weekend when Resident #286 was admitted on [DATE], and it could have been addressed with him at that time as well. APRN #1 identified the nurses should not have been completing dressing changes on Resident #286 without comprehensive wound treatment orders in place and she was unsure why it was missed and was unaware of the issue when she saw the resident on 4/28/25. Attempts to contact RN #4 (the admitting RN Supervisor) were unsuccessful. Review of facility policy, Transcription of Orders, dated 01/2024, directed the facility was to establish guidelines for accepting and reviewing orders and orders were considered but not limited to medications, labs, diagnostics, or consultations. The policy further directed that orders are accepted by a registered nurse or a licensed practical nurse and can be obtained over the phone or from discharge and transfer paperwork from the hospital.

Based on interviews, clinical record review, and facility policy for one of three residents (Resident #22) reviewed for advanced directives, the facility failed to ensure the Resident Care Plan accurately reflected Resident #22's code status. The findings include: Resident #22 was admitted to the facility in April 2025 with diagnosis that included chronic obstructive pulmonary disease, diabetes, and falls. A Social Service initial assessment dated [DATE] identified that Resident #22 was a full code. There were no physician orders on admission directing Resident #22's code status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was moderately cognitively impaired, required set up assistance for eating, maximal assistance for toileting, showering, and dressing. Also identified was Resident #22 required moderate assistance with transfers. The Resident Care Plan (RCP) dated 4/15/25 identified that Resident #22's code status was cardiopulmonary resuscitation with interventions directed to review advanced directives with resident/responsible party on admission and at least quarterly, and honor advanced directives as directed by the resident/responsible party for guidance. Review of the signed advanced directive consent/acknowledgement release form dated 4/15/25 identified that Resident #22 wishes were to be a Do Not Resuscitate (DNR). An interview and review of the RCP on 4/28/25 at 2:22 PM with RN #1 identified that the RCP was incorrect, and that Resident #22 was a DNR, but the current care plan had Resident #22 identified as a full code. Further identifying that any nurse can update the care plan when the code status was changed, and it should have been updated to the correct code status. Review of the facility policy for Advanced Care Planning Code status identified that orders not to attempt cardiopulmonary resuscitation of a resident will be in writing, after consent has been obtained. This procedure will clarify the rights and obligations of residents, families, and other health care providers. Every resident admitted to the facility was presumed to consent to the administration of cardiopulmonary resuscitation in the event of cardiac/respiratory arrest unless there was a consent to a Do Not Resuscitate order. Further identified that upon admission the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident/family representative. A physician's order must be written accordingly. Also, identified documentation of the resident's choice to opt for resuscitation or not to resuscitate shall be maintained in the medical record. Subsequent to surveyor inquiry the physician orders were updated to reflect DNR on 4/29/25 and the RCP was updated on 4/30/25 to the correct code status of DNR.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #53) reviewed for accidents, the facility failed to ensure orthostatic blood pressures were monitored per the physician's order for a resident with postural hypotension and history of repeated falls. The findings include: Resident #53's diagnoses included unspecified dementia, orthostatic hypotension, and repeated falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 was cognitively intact and required setup or clean up assistance with transfers and toileting and was independent with bed mobility. The Resident Care Plan dated 4/1/25 identified recurrent falls, a fall with rupture of the globe of the right eye and orthostatic hypotension. Interventions included to monitor vital signs and monitor for signs and symptoms of orthostatic hypotension. A physician's order dated 4/5/25 identified Resident #53 had a history of postural hypotension and directed to take orthostatic blood pressures daily. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025 failed to indicate an order for daily orthostatic blood pressures had been transcribed and therefor orthostatic blood pressures were not taken. Interview and review of the clinical record with Licensed Practical Nurse (LPN #3) on 5/1/25 at 10:28 AM identified that although Resident #53 had a current order for daily orthostatic blood pressures, she was unable to locate in the clinical record where the orthostatic blood pressure results were documented. LPN #3 indicated it would be the nurse who would obtain the orthostatic blood pressures and document the results in the clinical record. After review of the MAR and the TAR for Resident #53, LPN #3 identified that the orthostatic blood pressure order was not there, and she did not know the reason. LPN #3 further indicated that she had not taken orthostatic blood pressures on Resident #53 before and would need to check with her nursing supervisor. Interview and review of the clinical record with the Nursing Supervisor (RN #1) on 5/1/25 at 12:25 PM identified that the nurse that transcribed the order for daily orthostatic blood pressures (when the order was originally placed on 9/20/24) did so incorrectly in the electronic health record (EHR) and the order was not shared onto the MAR or TAR. RN #1 indicated the error with the order should have been discovered by nursing when an audit was done, but it appeared that had also been missed. RN #1 identified the mistake was due to a transcription error and oversight by nursing and that the daily orthostatic blood pressures had never been completed on Resident #53. RN #1 indicated it would have been her expectation that the order was appropriately placed in the MAR and the daily orthostatic blood pressures would have been monitored per the physicians order. Interview and review of the clinical record with the DNS on 5/1/25 at 3:20 PM identified the order for Resident #53 to have daily orthostatic blood pressures was not transcribed correctly and if the nurse did not indicate an area to put the order in the electronic health record, then it would not automatically go onto the MAR or TAR. The DNS indicated that although Resident #53 had repeated falls prior to his/her admission to the facility, daily orthostatic blood pressures were not monitored for Resident #53 since the order was placed (on 9/20/24). The DNS identified that order audits done by the nurse on the 11:00 PM to 7:00 AM shift should have discovered the order and corrected the transcription error and she was unsure of the reason that did not occur. Subsequent to surveyor inquiry, on 5/1/25, the order for daily orthostatic blood pressures for Resident #53 was discontinued by APRN #1. Interview with APRN #1 on 5/5/25 at 10:19 AM identified the order for Resident #53 to have daily orthostatic blood pressures was initially placed upon admission and she was not aware that it was not correctly transcribed or completed since then. The APRN indicated she would expect the order would have been correctly transcribed, daily orthostatic blood pressures would have been monitored and the nurse would have been responsible. APRN #1 identified that although Resident #53 was admitted to the facility with repeated falls and postural hypotension, since the resident has not had any recent falls and has a steady gait, she discontinued the order for daily orthostatic blood pressures on 5/1/25, after it was brought to her attention. Review of facility policy, Transcription of Orders, dated 01/2024, directed the facility was to establish guidelines for accepting, transcribing, and reviewing orders. The policy directed that transcribing is the recording of orders by a registered nurse or a licensed practical nurse and accuracy of orders must be reviewed and verified. Additionally, the policy directed the EHR process for the transcription of orders was to be followed.

Based on observations, review of clinical records, facility documentation, facility policy and interview for 2 of the 2 residents reviewed for infection control, the facility failed to ensure the peripheral lines had appropriate physician orders in place to rotate access site every 96 hours and as needed or the site was to be removed. 1. Resident #19's diagnosis included Covid 19, myocardial infarction, and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was cognitively intact, required maximal assistance for toileting, set up assistance for oral hygiene and eating. Also identified that Resident #19 was dependent on showering and transfers. Further identifying Resident #19 was not receiving intravenous therapy. A nursing note dated 4/16/25 at 11:42 AM written by Registered Nurse (RN) #1 identified a urine culture was obtained with sensitivities which the Advance Practice Registered Nurse (APRN) reviewed, and intravenous (IV) was to be started with a new order for IV Ceftriaxone. The Resident Care Plan (RCP) dated 4/16/25 identified IV medication of Ceftriaxone related to a urinary tract infection with intervention to rotate the peripheral site per protocol, observe/document/report as needed signs and symptoms of leaking at the IV site, and observe the IV dressing routinely for signs and symptoms of leakage/bleeding. Additionally, the RCP included to monitor site for placement, signs and symptoms of infection every shift and to change the dressing and site every 96 hours for peripheral lines. The Medication admission Record (MAR) dated 4/17/25 identified Ceftriaxone (an antibiotic) 2 grams daily, one time for a day for urinary tract infection for 5 days. Review of the physician orders and interview on 5/01/25 at 6:51 AM with the Director of Nursing services failed to identify a physician order that corresponded with the MAR dated 4/17/25 directing Ceftriaxone 2 grams daily. A nursing note dated 4/17/25 at 12:11 AM identified that Resident #19 was started on IV Ceftriaxone via left arm heplock due to a urinary tract infection. A nursing note dated 4/18/25 at 12:23 PM written by RN #1 identified the IV company was called to replace the peripheral IV and to continue with antibiotic treatment. A nursing note dated 4/18/25 at 9:39 PM identified Resident #19 peripheral IV was removed from his/her left arm and a new peripheral line was placed in his/her right hand, and the dressing was clean, dry, and intact. A nursing note dated 4/19/25 at 2:19 PM identified that Resident #19's IV to his/her right arm was flushed without difficulties, no infiltration noted, and no redness or swelling noted. The MAR dated 4/28/25 directed to flush the peripheral catheter with 10 cubic centimeters (cc) of Normal Saline every 8 hours while not in use (although there were no physician orders to correspond with the MAR instructions to flush the peripheral catheter). On 4/29/25 at 9:37 AM, interview with Resident #19 identified that he/she was receiving IV medications to his/her right arm. Observations at that time identified the dressing covering the IV insertion site was labeled 4/18/25 (11 days old). Interview on 4/29/25 at 9:50 AM with RN #1 identified that Resident # 19's peripheral line dressing should be changed one time a week and the last time it was changed was 4/18/25. Further, identifying the IV was last used on 4/22/25, had not been replaced/removed yet and the facility was waiting for lab results before removing it (the RCP interventions directed to change the IV site every 96 hours). RN #1 also identified a batch order set (a template type document that identifies routine IV orders for maintenance of the site) was to be put in place every time a resident was started on a peripheral IV which contained parameters to follow. Resident #19 did not have the batch order set in place when he/she was started on peripheral IVs and therefore the site wasn't rotated every 96 hours and the dressing not changed. RN #1 provided a copy of the batch order set which should have included the following: 1) Change IV tubing used for intermittent administration of fluids or medication every 24 hours for prophylaxis and as need prophylaxis. 2) Normal saline flush solution use 10 ml intravenously three times a day for infection. Flush before and after each medication administration, no flushing required with continuous infusions. 3) Monitor IV site for redness, swelling, drainage, any signs and symptoms of infection every shift for prophylaxis and as needed. 4) Rotate access site every 96 hours and as needed. Review of the nursing notes dated 4/29/25 at 11:47 AM identified the peripheral IV was discontinued. An interview on 5/1/25 at 6:51 AM with DNS identified that an IV peripheral line can stay in for 96 hours (Resident #19 was in place for 11 days), Resident #19 site should have been changed on 4/22/25 and IV parameters per the batch order set were not in place until 4/28/25. Also identifying that orders should have been put in place for each resident that was started on a peripheral IV and that she was responsible for this. Also identifying that it was an oversight. 2. Resident #236's diagnosis included sepsis, fracture of right femur, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #236 was moderately cognitively impaired, dependent on toileting and showering. and transfers. Also identified Resident #236 required moderate assist for eating, personal hygiene, and oral hygiene. Further identifying Resident #236 was receiving antibiotic therapy not through intravenous (IV) therapy. The nursing note dated 4/24/24 at 10:27 AM identified that Resident #236 was seen by the Advance Practice Registered Nurse (APRN) for right face cheek swelling, new orders in place for Prednisone 40 milligrams (mg) times 1, give now, then give 20 mg daily times 4 days, start a peripheral IV and give Ceftriaxone (an antibiotic) 1 gram x 5 days. The Resident Care Plan (RCP) dated 4/24/25 identified Resident #236 was on antibiotic therapy related to cellulitis to the right cheek with interventions to administer antibiotic medications as ordered by physician and monitor/document/report as needed adverse reactions to antibiotic therapy. The Medication Administration Record (MAR) dated 4/24/25 identified Ceftriaxone 1 gram IV every 24 hours for oral cellulitis for 5 days. A nursing note dated 4/29/25 at 1:22 PM identified Resident #236 was a day post IV of Ceftriaxone, no adverse reactions noted due to IV antibiotics. APRN notified, new orders given to discontinue the peripheral IV. An interview on 4/29/25 at 9:50 AM with RN #1 identified a batch order set was to be put in place every time a resident was started on a peripheral IV which contained perimeters to follow. Resident #19 and #236 did not have the batch order set in place when started on peripheral IV's. RN #1 provided a copy of the batch order set which included the following: 1) Change IV tubing used for intermittent administration of fluids or medication every 24 hours for prophylaxis and as need prophylaxis. 2)Normal saline flush solution use 10 ml intravenously three times a day for infection. Flush before and after each medication administration, no flushing required with continuous infusions. 3)Monitor IV site for redness, swelling, drainage, any signs and symptoms of infection every shift for prophylaxis and as needed. 4)Rotate access site every 96 hours and as needed. Subsequent to surveyor inquiry the MAR was updated on 4/29/25 to include parameters which directed to provide normal saline flush, use 10 milliliters intravenously one time a day for cellulitis, flush before and after each medication administration. Also, to monitor peripheral site for redness, swelling, drainage, any sign of infection every shift for prophylaxis. Review of the physician orders and interview on 5/1/25 at 6:51 AM with the DNS failed to identify a physician order was written that corresponded with the MAR directing Ceftriaxone 1 grams daily for 5 days. An interview on 5/1/25 at 6:51 AM with the DNS identified that an IV peripheral line can stay in for 96 hours and an order should have been put in place for each resident started on a peripheral IV. Also, identifying Resident #236 IV should have been pulled out on 4/28/25 not 4/29/25 and it was not pulled on time, it was an oversight. Further, identifying she was responsible over seeing this. Although requested, a written facility policy for maintaining a peripheral intravenous site was not provided, however the DNS identified that the facility uses the batch order set to direct the maintenance/treatment of a peripheral line.

Based on observations, interviews and review of facility policy for two of three medication storage rooms, the facility failed to ensure expired medication was disposed of and supplies and medications were stored properly. The findings include: a. Interview and observation of the 4th floor medication room with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:40 AM identified 20 hemoccult cards were observed that had an expiration date of 8/2023 and a bottle of hemoccult developer that expired in 8/2021 in the cabinet drawer. Further observation identified 6 full unopened tubes of Collagen Hydrogel (3 ounce each) with an expiration date of 3/31/ 25 and a 24-French 8.0 millimeter (mm) indwelling catheter with an expiration date of [DATE]. b. Interview and observation of the 3rd floor medication room with LPN #7 on [DATE] at 11:45 AM identified an unopened box of Lorazepam (a Schedule IV controlled medication) 30 milliliters (ml) oral concentrate on the bottom shelf in the medication refrigerator (not stored in a locked, affixed box) with other non-controlled medications stored with it (Insulins). The lock box that was present in the refrigerator was marked DO NOT USE. LPN #7 did not know the reason it was marked DO NOT USE and did not have a key to open it. The lock box was affixed to the inside of the refrigerator. Interview with the DNS on [DATE] at 2:15 PM identified she was not aware the lock box in the 3rd floor refrigerator was not being utilized for controlled medications such as the Lorazepam, or that it was marked DO NOT USE. A review of the maintenance log did not identify an entry regarding the 3rd floor lock box being broken in 2025. Interview with the DNS on [DATE] at 2:15 PM indicated that the Pharmacy representative did a monthly review of all the medication rooms and carts and a monthly summary report for each unit/floor was provided to the DNS. The date of the last pharmacy inspection was [DATE] for all three units but did not identify the failure of Lorazepam being in a locked box and affixed to the shelf. Additionally in the 3rd floor medication room, there was one box of COVID-19 tests in the overhead cabinet above the sink with an expiration date of [DATE], one pouch of COVID-19 rapid tests on the counter with an expiration date of [DATE] and a large cardboard box in a gray upright cabinet with 6 boxes of COVID-19 tests containing 4 tests each with an expiration date of [DATE]. Lastly, a two-thirds full gallon of distilled vinegar with a use by date written on it, [DATE] was identified to be in the medication room. Interview with the Regional Pharmacy Consultant on [DATE] at 2:00 PM identified the pharmacy consultant would not normally pick up on non-medication items. The Regional Consultant could not confirm the Lorazepam located in the 3rd floor medication room refrigerator was present at the time of the last pharmacy inspection on [DATE] as it was not identified on the summary report. Additionally, the Regional Consultant identified that Lorazepam locked in the medication refrigerator in the locked medication room would be sufficient. A review of the undated Medication Storage policy (PHNE132) identified Schedule II-V medications must be maintained in a separately locked, permanently affixed compartment or cabinet. The access system used to lock these medications cannot be the same access system used to lock other non-scheduled medications (i.e. two separate keys).

Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #33) reviewed for vaccinations, the facility failed to ensure the appropriate time was provided between COVID-19 vaccination administration. The findings include: Resident #33 had diagnoses that included weakness and partial paralysis affecting the left side following a stroke, dementia, and COVID-19. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was cognitively intact, used a wheelchair, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 8/6/24 identified Resident #33 was immunized against COVID-19, influenza, and pneumonia. Interventions included refer to the immunizations tab in Resident #33's chart for dates of vaccine administration. Review of the Immunization Report dated 4/30/25 identified Resident #33 received administration of the (Pfizer) COVID-19 2024-2025 on 10/9/24 in the left deltoid while in the facility and received administration of the (Pfizer) COVID-19 2024-2025 on 10/18/24 in the left deltoid (9 days after receiving a COVID-19 vaccine on 10/9/24) while in the facility. Interview with Registered Nurse (RN) #3 on 5/5/25 at 11:00 AM identified her process for administering vaccines was to obtain the consent signed by the resident/responsible party, provide the Vaccination Information Sheet (VIS), and after the vaccination was completed to enter the vaccine under the vaccination tab in the electronic medical record (EMR). RN #3 identified she administered most of the vaccinations, but sometimes she put an order in the EMR and scheduled the vaccine to be administered by the charge nurse. RN #3 identified per the Centers for Disease Control and Prevention (CDC) the COVID-19 vaccine for 2024 through 2025 was recommended to be given twice in the year, 6 months apart for residents who were immunocompromised. RN #3 identified in the EMR documentation of administration of a 2024 through 2025 COVID-19 vaccine given on 10/9/24. RN #3 identified she had documented administration of the 2024 through 2025 COVID-19 on 10/18/24. RN #3 identified that she was not aware a COVID-19 vaccine was administered on 10/9/24, and if she had seen the vaccine documentation, she would not have administered the 2024 through 2025 COVID-19 vaccine on 10/18/24 (9 days later). RN#3 was unable to identify the reason she had not seen the documentation for the 2024 through 2025 COVID-19 vaccination that was administered on 10/9/24 when she was administering the same 2024-2025 COVID-19 vaccination on 10/18/24. RN #3 identified vaccination administration was passed on in shift to shift report by the nurse who administered the vaccination. RN #3 identified she did not write progress notes after vaccine administration, and only documented the administration in the vaccination section of the EMR and that she did not think it was written policy to document vaccination administration in progress notes in the EMR. Review of the Infection Prevention and Control Program policy directed, in part, documentation for each resident who receives an immunization from facility staff would be in the resident's medical record and would include the date, site of administration, type of vaccine, dose, manufacturer, lot number, education provided, reactions if any, and the name of the person administering the vaccine.

Based on staff and resident interviews and observations within the secured unit, the facility failed to ensure state survey results were available and accessible on the secured unit for those residents who resided there. The findings include: During a resident council interview conducted on 4/29/25 at 9:55 AM, 5 residents who resided on the secured unit identified that they were not aware of where to find the state survey results. Observations during a tour of the facility on 4/30/25 at 2:25 PM identified that although the most recent state survey results from 2023 were available in the lobby of the facility, they were not available on the locked unit (3rd floor). Observation of an orange binder on the wall behind the nurse's desk marked State Survey, identified that it had dust on the binder and contained State Survey results from 2019 and was missing results from 2021 and 2023 re-certification surveys. Interview with the Administrator on 4/30/25 at 2:05 PM identified that management had been informed by the Ombudsman recently that the survey results needed to be on each wing as well as the lobby, believed that they recently put the survey results on each unit and was surprised they were not found and to ask the recreation director. Interview with the Recreation Director on 4/30/25 at 2:10 PM identified that he had been working here for only 8 months and did not know if the survey results were on each floor or if they were required to be. Interview with the Director of Nurses on 4/30/25 at 2:15 PM identified that she thought the survey results were placed on each floor however, was not sure where they would be and the scheduler might know where to find them. Interview and observation with the Scheduler on 4/30/25 at 2:20 PM identified that she wasn't sure where the survey results were located on each floor and she could not locate them.

Based on staff interview, observation and facility policy of the dumpster area, the facility failed to properly dispose of garbage and refuse. The findings include: On 4/30/25 at 9:15 AM observation of the dumpster area with the Dietary Director noted a heavy accumulation of debris alongside the dumpsters consisting of 1 discarded mattress, 2 bedside tables, 2 wheelchairs, leg rest for wheelchairs, 2 pink cloth large garbage containers, a green blanket, flowered curtains, window blinds, and a piece of therapy equipment. An interview with the Dietary Director on 4/30/25 at 9:20 AM identified that the area was not well kept or cleaned. He stated that the items were from maintenance and not dietary related items and that a pickup would be later that week or the following week. An interview, observation of the dumpsters and surrounding areas with the Maintenance Director on 4/30/25 at 9:30 AM identified that the items listed above had been outside the dumpsters for over a week. The Maintenance Director further identified that he usually does not call for a pickup of the debris until the pile was larger and more significant. Also, identifying he did not know the policy and did not think the area was clean and tidy. Subsequent to surveyors inquiry, the items were removed by the Maintenance Director who brought the items to a sister facility who had more room in their dumpster to accommodate the durable equipment. Review of the policy for Environmental Management identifies that a process was in place to inspect, maintain and clean grounds, parking lots and sidewalks. Further, identified a schedule plan to maintain areas free of debris, to empty/clean trash containers and maintain areas where compactors, dumpsters or collection containers are located.

Based on observations, interviews and review of facility policy for two of three medication storage rooms, the facility failed to ensure the medication rooms were clean. a. Interview and observation of the 4th floor medication room with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:40 AM identified the medication room floor was dirty with dried spilled liquids and debris. Additionally, 20 hemoccult cards were observed that had an expiration date of 8/2023 and a bottle of hemoccult developer that expired in 8/2021 in the cabinet drawer. LPN #2 identified that it was housekeeping's responsibility to clean the medication room floor, but the floor was not cleaned often. An interview with the Director of Facilities Housekeeping on [DATE] at 12:30 PM identified it was the responsibility of housekeeping staff to dust and mop the floors and clean other areas in the medication rooms daily. The housekeeping staff report directly to the Director of Facilities Housekeeping. b. Interview and observation of the 3rd floor medication room with LPN #7 on [DATE] at 11:45 AM identified the medication room tile floor was soiled, with a build-up of dust and debris around the floor. The were several tiles (6) in the room near where the medication cart was stored that were broken, crumbling and cracked. The sink around the faucet and the faucet had white build-up surrounding it. The base of the sink was also dirty with splashes of liquid and debris noted. Interview and observation of the 3rd floor medication room with Director of Facilities Housekeeping on [DATE] at 12:30 PM identified the broken tiles on the floor and the status of the sink. The Director of Facilities Housekeeping could not identify how long the sink and floor had been in disrepair, but had been aware of both issues ad noted he would change the tiles and the faucet. The unit maintenance book for the current year, 2025, did not identify the tiles and faucet had been reported and LPN #7 wasn't able to identify when it occurred or if this had been reported to the Director of Facilities Housekeeping A review of the housekeeping policy for Medication Rooms identified the medication room floors must be dust mopped and then damp mopped daily and stainless-steel fixtures and bright metal must be cleaned and polished with dry cloth and stainless-steel polish daily. A review of the Engineering Management Plan and Procedure identified furnishings, equipment and accessories shall be maintained in good order.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to provide adequate assistance during a bed linen change and as a result, the resident rolled out of bed onto the floor sustaining a left hip fracture. The finding includes: Resident #1 had diagnoses that included Alzheimer's disease, generalized muscle weakness, and difficulty walking. Review of Resident #1's side rail evaluation dated 6/14/24 identified the indication and use of the side rails is per the request of Resident #1 and h/her responsible party. The side rail evaluation identified Resident #1 has a self-care deficit with interventions that directed the use of quarter (1/4) side rails for assistance/enablers with bed mobility. The side rail evaluation identified for use of the side rails are not to exceed 28 inches in length from the head of bed. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, required maximal assistance with bed mobility, and dependent with transfers, Activities of Daily Living (ADLs), and was non-ambulatory. The care plan dated 6/21/24 identified Resident #1 has an ADL self-care performance deficit with interventions that included to provide total care with the assist of one for incontinent care and bed mobility, and two (2) upper 1/4 side rails for bed mobility. Review of the Facility reportable event form dated 8/27/24 at 10:00 P.M. identified Resident #1 rolled onto right side and fell out of bed with no signs of injury. The reportable event identified Resident #1 was assessed by the Registered Nurse (RN #2) and Resident #1 had no bruises and no signs of injuries. The treatment directed to monitor Resident #1's vital signs per protocol, observe and report any changes. The reportable event did not indicate if Resident #1's quarter side rails were up or in use when Resident #1 fell out of bed. Review of the change in condition assessment dated [DATE] at 10:00 P.M. completed by Registered Nurse (RN) #4 identified Resident #1 had an unwitnessed fall with no apparent injuries. RN #4 identified evaluation of Resident #1's neurological status identified no changes and Resident #1 had no complaints of pain. The pain tool assessment dated [DATE] at 10:00 P.M. conducted by RN #4 identified Resident #1 has no evidence of pain. The nurse's note dated 8/27/24 at 10:22 P.M. written by RN #2 identified Resident #1 rolled on to his/her right side in bed and then rolled onto the floor. RN #2 indicated Resident #1 had no injuries, vital signs stable, the on-call Advanced Practice Registered Nurse (APRN), and Resident #1's family were notified. The nurse's note dated 8/27/24 at 10:28 P.M. written by Licensed Practical Nurse (LPN) #3 identified while Resident #1 was in bed receiving a bed change Resident #1 rolled onto the floor. LPN #3 indicated Resident #1 had no injury and Resident #1's vital signs were stable. The change in condition follow-up note dated 8/28/24 at 2:00 A.M. written by the DNS identified the note as a follow-up note for Resident #1's fall. The DNS identified Resident #1 is now complaining of left hip pain and guarding was noted. The nurse's note dated 8/28/24 at 3:04 A.M. written by RN #1 identified Resident #1 was status post fall from the last shift. RN #1 identified Resident #1 is complaining of pain and was seen guarding left hip while being changed. RN #1 indicated Resident #1's left hip is aligned with no deformity or swelling noted. RN #1 identified she notified on-call physician MD #4 on 8/28/24 at 1:55 A.M., and a new order was obtained for a STAT x-ray of Resident #1's left hip. The nurse's note dated 8/28/24 at 3:59 A.M. written by LPN # 9 identified Resident #1 was medicated with Tylenol (a pain reliever) for left hip pain. LPN #9 identified she conducted passive range of motion to Resident #1's legs without complaints, but when Resident #1 was turned he/she was guarding the left hip and pelvic area. The nurse's note dated 8/28/24 at 6:51 A.M. written by LPN #9 identified that the administration of Tylenol was effective and Resident #1's pain scale was 0/10. Review of Resident #1's radiology results report dated 8/28/24 at 8:50 A.M. identified an acute-appearing fracture of the left femur with mild displacement. The nurse's note dated 8/28/24 at 12:15 P.M. written by LPN #2 identified Resident #1's X-ray results were reviewed with APRN #2 and a new order was obtained to transfer Resident #1 to the hospital for evaluation. Review of the Facility's Reportable Event Report dated 8/28/24 at 8:45 A.M. identified on 8/27/24 at 10:00 P.M., Nurse Aide (NA) #1 witnessed Resident #1 roll out of bed onto his/her back during care with no initial evidence of pain and no change in Range of Motion. On 8/28/24 at 3:00 A.M. Resident #1 complained of pain with noted guarding of left pelvic and hip region, the on-call physician was notified, an order was obtained for an X-ray which demonstrated an acute appearing fracture and Resident #1 was transferred to the hospital. Review of the facility's summary dated 8/30/24 at 2:16 P.M. on 8/27/24 Resident #1 fell out of bed during a bed linen change, sustaining a fracture of the left intertrochanteric (upper part) femur. Resident #1 was transferred to the hospital for evaluation and returned to the facility without surgical intervention. Interview with NA #1 on 9/19/24 at 10:30 A.M. identified Resident #1 was dependent with bed mobility with the assistance of one (1) staff. NA #1 identified on 8/27/24 at approximately 10:00 P.M. NA #1 was providing incontinent care and a complete bed change for Resident #1. NA #1 indicated Resident #1's bed was in a high position when he was changing the sheets, he was standing on the left side of the bed behind Resident #1 who was lying on his/her right-side center of the bed with his/her hands on the side rail as enablers. NA #1 identified he had one hand on Resident #1's waist when NA #1 pulled the soiled bed sheets out from under Resident #1. NA #1 identified he then had to release his hand from Resident #1's waist so he could tuck and secure the sheets to the mattress. NA #1 identified as he pulled on the sheets to tuck them Resident #1 rolled out of bed onto the floor. NA #1 identified that Resident #1's two (2) upper 1/4 side rails were both up when he pulled on the sheets and Resident #1's had h/her hands on the 1/4 side rails. NA #1 identified prior to Resident #1 falling out of bed he thought Resident #1 was able to grip the upper quarter side rails. NA #1 indicated he believes the reason Resident #1 fell out bed on to the floor was because when he pulled on the sheets to tuck them in, the weight of Resident #1's left leg pulled h/her off the bed. Interview with the DNS on 9/19/24 at 10:45 A.M. identified on 8/27/24 at 10:00 P.M. NA #1 had Resident #1 lying on his/her right-side when NA #1 moved to the left side of the bed to tuck the new sheet under the mattress when Resident #1 rolled out of the bed. The DNS identified Resident #1's care plan was updated with a new intervention that directed to provide the assistance of two with bed mobility.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for abuse, the facility failed to ensure a resident with known wandering behaviors was supervised to prevent an incident of sexual abuse. The findings include: Please cross reference F 657 1. Resident #2 diagnoses included Alzheimer's disease and generalized anxiety disorder. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, and was independent with transfers and ambulation. The care plan dated [DATE] identified Resident #2 has the potential for negative behaviors related to coping with Alzheimer's with interventions that directed to approach and speak in calm manner, divert attention, remove from an overstimulating environment, and redirect to an alternate location as needed. Review of APRN #1's note dated [DATE] identified she was asked to see Resident #2 related to symptoms of restlessness and agitation. APRN #2 identified upon assessment Resident #2 is observed pacing, tearful, and fearful. APRN #2 identified Resident #2 required frequent redirection and reassurance. APRN #2 indicated the plan was to start Resident #2 on Remeron and Trazodone for anxiety and agitation. A physician's order dated [DATE] directed to administer mirtazapine (Remeron) 7.5 milligrams (MG) by mouth at bedtime and administer 25 MG of trazodone every 8 hours as needed for anxiety/agitation. A nurse's note dated [DATE] at 4:16 A.M. written by RN #1 (11 PM-7 AM supervisor) identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. RN #1 identified Resident #2 was unable to be redirected. The nurse's note dated [DATE] at 4:42 A.M. written by RN #1 identified that Resident #2 is extremely anxious, entering other resident's rooms, and disrupting the floor. RN #1 indicated Resident #2 had an order in the past for Ativan as needed, but the order is expired. RN #1 identified she called the APRN #3 who was on-call, and a verbal order were obtained for Ativan as needed. A physician's order dated [DATE] directed to administer lorazepam (Ativan) 0.5 MG every 8 hours as needed for anxiety. The nurse's note dated [DATE] at 8:10 P.M. written by LPN #8 identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. LPN #8 indicated attempts to redirect with PRNs with little effect. LPN #8 identified Resident #2 was given a shower and it had a calming effect. Review of APRN #1's note dated [DATE] identified collaboration with the nurse and DNS regarding Resident #2 requiring near constant redirection. APRN #1 identified Resident #2 seen today for follow up evaluation after starting mirtazapine for depression, anxiety, and insomnia. APRN #2 identified Resident #2 has continued anxiety, near constant pacing on the unit, and requires much staff redirection. APRN #2 indicated Resident #2 would benefit from an increase in mirtazapine to 15 mg at bedtime. A physician's order dated [DATE] directed to administer mirtazapine 15 mg at bedtime. The nurse's note dated [DATE] at 10:18 A.M. written by LPN #2 identified this morning Resident #2 had increased anxiety, pacing in the hallway and stopping to try an open the doors. LPN #2 identified Resident #2 was unable to be redirected or distracted. LPN #2 indicated after multiple attempts Resident #2 took h/her morning medications. Review of APRN #1's note dated [DATE] identified Resident #2 has ongoing behaviors related to dementia. APRN #1 identified Resident #2 was pacing the unit and attempting to elope. APRN #1 indicated Resident #2 becomes agitated at times, verbally aggressive, and attempts to throw objects at staff. APRN #1 identified upon her assessment Resident #2 is restless and voices frustration. APRN #1 identified given Resident #2's symptoms h/she would benefit from liquid Depakote for behavioral disturbances. A physician's order dated [DATE] directed to administer valproate sodium oral solution 250 MG/5 milliliters (ML) 2.5 ml's orally two times per day related to Alzheimer's disease. The nurse's note dated [DATE] at 1:41 P.M. written by LPN #2 identified Resident #2 had increased anxiety, pacing the floor, and wandering into other resident's rooms. LPN #2 identified Resident #2 was unable to be redirected. LPN #2 indicated multiple attempts were made to administer as needed Ativan and Resident #2 initially refused stating 'you're trying to poison me'. LPN #2 identified after multiple attempts Ativan was administered to Resident #2. 2. Resident #3's diagnoses included Alzheimer's disease and unspecified dementia. The quarterly MDS dated [DATE] identified Resident #3 had short- and long-term memory problem with severely impaired cognitive skills for daily decision making and was dependent with ADLs. The care plan dated [DATE] identified Resident #3 had a potential of psychosocial well-being problem related to incident with a female resident being sexually inappropriate with interventions that directed to monitor for any changes in psychosocial well-being, social work to follow up, and consult with psychiatric/psychological services. A nurse's note dated [DATE] at 10:05 P.M. written by RN #5 identified at 8:15 P.M. she was notified by LPN #1 that NA #2 observed Resident #2 in Resident #3's room and Resident #2 was groping Resident #3 who was in bed. RN #5 indicated the residents were immediately separated and Resident #2 was taken out of Resident #3's room. RN #5 identified Resident #2 was placed on 1:1 observation. RN #5 identified she notified the on-call MD, DON, the police were called, and the responsible parties. The nurse's note dated [DATE] at 10:09 P.M. written by LPN #1 identified Resident #2 was very aggressive this shift cursing, pacing up and down hallway, and pushing items on the floor. LPN #2 identified she was told by NA #2 that Resident #2 was seen touching Resident #3's private part in h/her room asking for sex. A review of the Facility's Reportable Event form dated [DATE] identified on [DATE] at 8:00 P.M. Resident #2 was observed groping Resident #3. The facility's investigation identified on [DATE] Resident #2 was last seen at 7:00 P.M. wandering in and out of rooms and was able to be redirected. On [DATE] at 8:00 P.M. NA #2 did not see Resident #2 walking in the hallway prompting her to look for Resident #2 and NA #2 found Resident #2 in Resident #3's room. NA #2 noted that Resident #3's first strap of the Velcro on h/her brief was undone and Resident #2's hand was under the brief. NA #2 removed Resident #2 from Resident #3's room, informed LPN #1 of the incident, and Resident #2 was placed on one-to-one observation. Interview with NA #2 on [DATE] at 10:00 A.M. identified on [DATE] she observed Resident #2 pacing the hallways per h/her usual behaviors. NA #2 identified at times Resident #2 wandered into other resident's rooms, however was always re-directable. NA #2 identified on [DATE] at approximately 7:00 P.M. she observed Resident #2 standing outside of Resident #3's room which is across the hall from Resident #2's room. NA #2 identified she re-directed Resident #2 who continued to pace the hallways and at approximately 7:30 P.M. NA #2 identified at approximately 8:00 P.M. she came out of another resident's room and did not see Resident #2 in h/her room nor pacing in the hallways. NA #2 identified she went to look for Resident #2 and found Resident #2 in Resident #3's room. NA #2 identified she observed Resident #2 standing at Resident #3's bedside with Resident #3 laying h/her bed and observed Resident #2's hand on Resident #2's private part with one side of Resident #2's brief undone. NA #2 indicated she immediately removed Resident #2 from Resident #3's room reported the incident to LPN #1. Interview with LPN #1 on [DATE] at 9:25 A.M. she identified that Resident #2 at times wanders into other resident's rooms, although easily redirected. LPN #1 identified on [DATE] she observed Resident #2 was walking the hallways and at approximately 7:00 P.M. she and NA #2 observed Resident #2 standing in the doorway of Resident #3's room. LPN #1 identified NA #2 went down the hallway and redirected Resident #2 away from Resident #3's doorway and Resident #2 went into h/her own room. LPN #1 identified NA #2 reported to her that she found Resident #3 in Resident #2's with h/her hand on Resident #3's private part. LPN #1 indicated the residents were immediately separated and Resident #2 was placed on one-to-one observation. Interview with LPN #2 on [DATE] at 10:35 A.M. she identified Resident #2 paces the hallways on the unit and wanders into other resident's rooms. LPN #2 indicated Resident #2 is able to be redirected when h/she wanders into other resident's rooms; however, requires frequent redirecting. Interview with NA #3 on [DATE] at 10:50 A.M. she identified Resident #2 paces the hallways and wanders throughout the unit. NA #3 identified Resident #2 does wander into other resident's rooms and requires frequent redirection. Interview with the DNS on [DATE] at 12:00 P.M. identified prior to the incident that happened on [DATE] between Resident #2 and Resident #3 she was unaware that Resident #2 was wandering into other resident's rooms, if she had been aware she would have ensured a care plan was in place to address the wandering behaviors. The DNS indicated Resident #2 had no previous history of resident to resident incidents nor any history of inappropriate sexual behaviors. The DNS identified following the incident on [DATE] Resident #2 was placed on one-to-one monitoring until h/she was cleared by psych on [DATE]. Interview with APRN #1 on [DATE] at 1:25 P.M. she identified prior to the incident on [DATE] Resident #2 had no inappropriate sexual behaviors nor any other resident to resident incidents. APRN #1 identified Resident #2 has end stage dementia which can provoke inappropriate sexual behaviors and APRN #1 has adjusted Resident #2's Depakote dose to aid in impulsive behaviors. Review of facility abuse resident to resident policy identified, in part, the policy is to prevent residents residing in the facility from inflicting harm (physical/mental) on other residents. To ensure that any incident of inappropriate resident to resident contact is thoroughly investigated and managed to prevent reoccurrence.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for pressure injury, the facility failed to develop a comprehensive care plan with interventions to prevent skin breakdown when the resident was identified at high risk for developing pressure injuries. The findings include: Resident #4 had diagnoses that included multiple sclerosis, Guillan-Barre syndrome, and generalized muscle weakness. The nursing admission assessment dated [DATE] identified Resident #4 was alert to person, place, and situation, continent of bowel and bladder, required the assistance of one with bed mobility, assistance of 2 to ambulate, and Resident #4's skin was intact. Review of the Resident #4's Braden Scale for predicting pressure sores dated 6/22/24 identified Resident #4 was at high risk. The admission MDS dated [DATE] identified Resident #4's skin was intact, a formal clinical assessment was conducted, and determined Resident #4 was at risk for developing pressure ulcers/injuries. The nurse's note dated 7/24/24 at 12:37 P.M. written by RN #4 identified during weekly skin check Resident #4 was noted to have an intact fluid blister to the back of h/her left heel. RN #4 indicated skin prep was applied and APRN #2 was notified. RN #4 indicated she provided education to Resident #4 on offloading pressure to heels, frequent repositioning, maintain adequate nutrition, and wear proper fitting shoes. RN #4 identified she updated Resident #4's wife on the new blister on Resident #4's left heel and Resident #4's wife will bring in a larger pair of sneakers. The care plan dated 7/24/24 identified Resident #4 had the potential for skin breakdown due to decreased mobility with interventions that directed weekly skin evaluations, skin checks with care and report any changes to nurse and provide a pressure redistribution mattress. A physician's order dated 7/24/24 directed to apply skin prep to the blister on left heel every day and evening shift. Review of Resident #4's care plan dated 7/24/24 identified Resident #4 has a blister to left heel with interventions that directed heel boots on except for transfers and ambulation, sneakers on only when ambulating, and off load heels with heels boots when in bed and/or at all times. Review of MD #3's (wound doctor) note dated 7/26/24 identified Resident #4 is being seen for an initial wound assessment. MD #3 identified Resident #4's left heel has a deep tissue injury with non-blanchable deep red, maroon, or purple discoloration. MD #3 directed to off load Resident #4's heels per facility protocol. Interview and clinical record review with DNS on 9/19/24 at 12:30 P.M. she was unable to provide documentation to reflect that Resident #4 had a comprehensive care plan developed and implemented on 6/22/24 when Resident #4 was identified at high risk for developing pressure injuries. The DNS identified her expectation is when any resident is identified at risk for skin breakdown a comprehensive care plan is implemented with appropriate interventions. The DNS indicated on 7/24/24 after Resident #4 developed a deep tissue injury to h/her left heel a comprehensive care plan was developed and interventions were implemented. The DNS identified that off loading heels and turning every two hours is standard of practice, and although not documented prior to 7/24/24, both were in place. Review of the facility Baseline/Comprehensive Person-Centered Care Plan policy; in part, identified the interdisciplinary team will utilize the Comprehensive Person-Centered Care Planning process to address residents' strengths, needs, and/or problems identified on the admission discharge summary, as well as other professional assessments. The interdisciplinary team will identify functional disabilities and high-risk factors requiring interventions for potential improvement or prevention.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for behaviors, the facility failed to review and revise a resident's care plan when the resident was identified as wandering in and out of other resident's rooms. The findings include: Resident #2 diagnoses included Alzheimer's disease and generalized anxiety disorder. A nurse's note dated 7/21/24 at 8:37 P.M. written by LPN #8 identified Resident #2 pacing the unit, visibly upset, entering other resident's rooms. The care plan dated 8/15/24 identified Resident #2 has the potential for negative behaviors related to coping with Alzheimer's with interventions that directed to approach and speak in calm manner, divert attention, remove from an overstimulating environment, and redirect to an alternate location as needed. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, and was independent with transfers and ambulation. A nurse's note dated 8/21/24 at 4:16 A.M. written by RN #1 (11 PM-7 AM supervisor) identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. A nurse's note dated 8/21/24 at 4:42 A.M. written by RN #1 identified that Resident #2 is extremely anxious, entering other resident's rooms. A nurse's note dated 8/21/24 at 8:10 P.M. written by LPN #8 identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. LPN #8 indicated attempts to redirect with PRNs with little effect. LPN #8 identified Resident #2 was given a shower and it had a calming effect. A nurse's note dated 8/31/234 at 1:41 P.M. written by LPN #2 identified Resident #2 had increased anxiety, pacing the floor, and wandering into other resident's rooms. LPN #2 identified Resident #2 was unable to be redirected. LPN #2 indicated multiple attempts were made to administer as needed Ativan and Resident #2 initially refused stating 'you're trying to poison me'. LPN #2 identified after multiple attempts Ativan was administered to Resident #2. A nurse's note dated 8/31/24 at 10:05 P.M. written by RN #5 identified at 8:15 P.M. she was notified by LPN #1 that NA #2 observed Resident #2 in Resident #3's room and Resident #2 was groping Resident #3 who was in bed. RN #5 indicated the residents were immediately separated and Resident #2 was taken out of Resident #3's room. RN #5 identified Resident #2 was placed on 1:1 observation. Interview with LPN #1 on 9/18/24 at 9:25 A.M. she identified that Resident #2 is always pacing the hallways on the unit and at times Resident #2 wanders into other resident's rooms, and usually can be redirected out of other resident's rooms. Interview with NA #2 on 9/18/24 at 10:00 A.M. she identified Resident #2's baseline behaviors include pacing the hallways on the unit and wandering into other resident's rooms. Interview with LPN #2 on 9/18/24 at 10:35 A.M. she identified Resident #2 paces the hallways on the unit and wanders into other resident's rooms. LPN #2 indicated Resident #2 is able to be redirected when h/she wanders into other resident's rooms; however, requires frequent redirecting. Interview with NA #3 on 9/18/24 at 10:50 A.M. she identified Resident #2 paces the hallways and wanders throughout the unit. NA #3 identified Resident #2 does wander into other resident's rooms and requires frequent redirection. Interview and clinical record review with the DNS on 9/18/24 at 12:00 P.M. indicated prior to 8/31/24 she was unaware that Resident #2 had been wandering into other resident's room. The DNS identified she became aware of Resident #2's history of wandering while investigating the incident that happened on 8/31/24 when Resident #2 wandered into Resident #3's room and was observed inappropriately touching Resident #3. The DNS identified that she would expect to be notified when a resident is wandering into the other resident's rooms and the care plan should be reflective of the resident wandering into other resident's rooms. Subsequent to surveyor inquiry Resident #2's care plan was revised. Review of Resident #2's care plan dated 9/19/24 identified Resident #2 wanders on the unit and into other's rooms and demonstrated inappropriate sexual behavior toward a male resident with interventions directed to redirect, offer snacks/fluids, offer activity to patient when wandering into other's rooms. Review of the facility Baseline/Comprehensive Person-Centered Care Plan policy; directed in part, the interdisciplinary team will utilize the Comprehensive Person-Centered Care Planning process to address residents' strengths, needs, and/or problems identified on the admission discharge summary, as well as other professional assessments. The Comprehensive Person-Centered Care Plan will be periodically reviewed and revised by a team of qualified persons.

Based on observations, review of maintenance logs, and staff interview for 1 of 8 rooms (room [ROOM NUMBER]) observed during tour, the facility failed to ensure the air conditioner grill was not exposed and was free from dust/debris/sediment. The findings include: On 7/10/23 at 1:15 PM, an observation of the air conditioner in room [ROOM NUMBER], conducted with the Director of Maintenance identified an air-conditioned unit located below the window, without a grill cover, exposing dust, debris, sediment, and the presence of a green, fuzzy-like substance the behind vent grill. An interview with the Director or Maintenance at that time identified the air conditioners were checked for functionality and filters changed quarterly, but vent cleaning was not part of the maintenance. Additionally, he identified the facility was in the process of replacing the air conditioner units, and this unit was due. Review of maintenance logs on 7/12/23 at 12:00 PM indicated the air conditioner in room [ROOM NUMBER] was last checked for functionality and had the filter cleaned on 6/10/23.

Based on clinical record review, review of facility policy and interviews for one sampled resident (Resident #68) who was at risk for falls, the facility failed to ensure the resident had adequate supervision during ambulation resulting in the resident sustaining a fall. The findings include: Resident #68's diagnoses included bradycardia, history of falls, muscle weakness, difficulty walking, Alzheimer's disease, and dizziness. A fall risk assessment dated [DATE] identified Resident #45 was at risk for falls and that safety devices should be in place as well as appropriate footwear. A physical therapy discharge summary dated 11/21/22 identified Resident #68 required supervision for ambulation. A quarterly MDS assessment dated [DATE] identified Resident #68 had significant cognitive impairment, required supervision for transfers, bed mobility, ambulation, and eating, required limited assistance for toileting and hygiene. The assessment further noted that Resident #68 utilized a walker for mobility. The resident care plan (RCP) dated 1/28/23 identified Resident #68 had a history of falls, positional vertigo, and memory impairment with interventions that included: use of a rolling walker with staff supervision for ambulation up to 125 feet, supervision to move between surfaces when transferring. The nurse's note (SBAR) dated 4/8/23 at 3:17 PM identified Resident #68 was ambulating in the corridor with his/her walker and the activity person heard a thump. Resident #68 was found lying on the floor near the entrancce to the dining room. The fall was unwitnessed. Resident #68 complained of pain, and the resident's leg was noted to be externally rotated with poor range of motion. 911 was called, the family and the physician were notified. The nurse's note dated 4/8/23 at 5:56 PM identified Resident #68 had a fractured left hip. A Reportable Event Report dated 4/8/23 completed by RN #2 identified that the state survey agency was notified of the resident's fall and that an investigation into the fall was initiated. Review of the facility's investigation identified that written statements were obtained from all the staff on duty on the unit at the time the resident fell LPN #3 (charge nurse), NA #2 (assigned to the resident) and two other nurse aides. Review of the facility's investigation failed to identify why the resident's fall was unwitnessed by the unit staff and failed to identify a reason why the resident was ambulating independently without staff supervision. Interview with OT #1 on 7/13/23 at 11:30 AM identified she worked with Resident #68 in the past, and after reviewing the rehabilitation discharge summary dated 11/21/22 identified Resident #68 required supervision for ambulation. She further identified that the resident did not require staff to have physical hands on him/her during ambulation but noted that the resident needed to be in visual site during ambulation. She further indicated that if staff did not witness Resident #68's fall, they were not following the plan of care. Interview with LPN #3 on 7/13/23 at 12:00 PM identified that her understanding of the level of care Resident #68 required was visual supervision. She noted that the resident was typically steady with the use of the walker and self-initiated ambulation. She further identified that she did not see Resident #68 fall and reported she was in another resident's room when she heard a noise and went to investigate and found the resident on the floor in the hall by the dining room. LPN #3 further identified that she had observed Resident #68 ambulating prior to entering a resident room in response to the call bell ringing. LPN #3 further identified that all staff were responsible for supervising the resident during ambulation. Interview with NA #2 on 7/13/23 at 2:15 PM identified Resident #68's family had been visiting and after the visit, the resident went back to his/her room and shortly after began walking up and down the hallway. NA #2 noted that she was in and out of resident rooms providing care. NA #2 further identified that she thought the resident required supervision when ambulating but was not sure if that meant visual supervision. Review of the facility's Fall Prevention program identified that the agency implements interventions that may include assistance with activities of daily living and referrals to PT/OT for an evaluation of gait, balance, use of assistance divices and transfer techniques.

Based on a review of clinical records, review of facility documentation, review of facility policies and procedures, and interviews, for two of six residents who were conserved and identified to be at risk for elopement (R #1 and #2), the facility failed to provide the necessary supervision to prevent elopements resulting in immediate jeopardy. The facility initiated corrective measures on 6/14/19 and the immediacy was removed. The corrective measures were verified as implemented during the onsite visit by the surveyor on 6/28/19. The finding includes: a. R #1's [DIAGNOSES REDACTED]. R #1 was conserved. The wander risk assessment dated [DATE] identified R #1 was at risk for elopement. The quarterly MDS assessment dated [DATE] identified that R #1 had a BIMS score of 3 (severe cognitive impairment), was unable to recall the day, month or year, and required cueing with word recall, had behaviors one to three days out of the prior seven days that included pacing or rummaging, and ambulated independently. The Resident Care Plan (RCP) dated 4/25/19 identified R #1 was an elopement risk with interventions directed to utilize a wander guard bracelet, and check every shift for placement and nightly for function. Review of the clinical record identified that the wanderguard was checked for function in accordance with the plan of care. b. R #2's [DIAGNOSES REDACTED]. R #2 was conserved. The quarterly MDS assessment dated [DATE] identified that R #2 had a BIMS score of 2 (severe cognitive impairment), was unable to identify the correct day of the week, month or year, or recall words, had no behaviors, and required supervision for walking in the hall. The Resident Care Plan (RCP) dated 5/9/19 identified a risk for elopement with interventions directed to utilize a wander guard bracelet, and check every shift for placement and nightly for function. Review of the clinical record identified that the wanderguard was checked for function in accordance with the plan of care. The facility incident report dated 6/14/19 at 4 PM identified R #1 and R #2 walked down the sidewalk to the hospital and returned without any injury. Review of the facility investigation identified that Receptionist #1 saw R #2 in the lobby near the front door with a person she did not recognize, and the wander guard alarm was sounding. Receptionist #1 asked the person she did not recognize if the floor nurse knew they were going out and if she had signed R #2 out with the nurse, and the person responded yes. Receptionist #1 then entered the code to silence the alarm, unlocked the door and allowed Resident #2 leave the building with this unknown person. Review of facility documentation and interview with the Administrator and Receptionist #1 on 6/28/19 at 10:29 AM identified that on 6/14/19, R #2 and a person she did not know came to the lobby. They went to the front door, and the alarm went off. Receptionist #1 asked if the person signed out on the nursing unit, and the person said yes, so she put in the code to open the door and allowed the person and R #2 to leave. Further interview with Receptionist #1 indicated that she did not call the nurse to check who the person was, did not ask the person what their name was, and later learned that it was Resident #1. Receptionist #1 indicated that about five to ten minutes later, she was alerted that R#1 had fallen outside and she called the supervisor. The Administrator identified that Receptionist #1 should not have disabled the alarm to let R #2 and the unknown person out the door, and she should have checked with the nurse on the unit. Further interview with Receptionist #1 on 6/28/19 at 1:06 PM identified there was an elopement book located at the receptionist desk and included R #2's name and photo, however, R #1's name and photo was not included in the book until after the elopement. Interview with the Scheduler on 6/28/19 at 11:20 AM identified she had left the building and was notified by Dietary Aide #1 (DA) that R #1 and #2 were in front of the hospital, and that DA #1 had observed R #1 fall. The Scheduler alerted staff in the building and then went to get R #1 and #2. Observation of the location where R #1 and R #2 were located identified they would have had to walk in the road in front of the facility, cross a paved alley next to the building, cross a gated parking lot entrance for the hospital and cross the paved hospital ambulance driveway, then walk in the road in front of the hospital approximately 49 steps before reaching the sidewalk ramp where R #1 was observed sitting on his/her buttocks. R #2 was observed walking on the adjacent sidewalk (totaling 175 steps from the front of the facility to where R #1 was found on the ground). Interview and observation with the Administrator on 6/28/19 at 12:33 PM identified the exit doors and the elevators have wander guard systems in place that lock when a resident who wears a wander guard gets close to the door or elevator door, and if they are too close an alarm sounds. The Administrator indicated that all the wander guard alarms were checked immediately after the incident and all were functioning correctly. Review of clinical records and facility documentation with the Administrator, DON, and Regional RN #1 on 6/28/19 at 1:45 PM identified although R #1 was identified as an elopement risk, the elopement book failed to identify R #1 was at risk for elopement on 6/14/19. Interview further identified R #1 and #2 could not have used the elevator close to the receptionist desk, as it was in the process of being repaired at the time of the incident, and they would have had to use the back elevator. The elevator's wander guard alarm would have sounded and the elevator locked in place when R #1 and #2 got on the elevator on the fourth (4th) floor, and when they exited the elevator on the ground floor. The Administrator stated the facility was unable to identify who silenced the alarms and allowed the elevator to go to the ground floor. Further interview with the Administrator identified that the elevator alarm should not have been silenced and the elevator should not have been released to go to the ground floor. Interview and review of facility video tape dated 6/15/19 with Regional RN #1 on 6/28/19 at 2:39 PM identified the video tape time stamp was off by one day. Regional RN #1 stated the time stamp on the tape records the date as one day ahead, so the date of 6/15/19 occurred on 6/14/19. Observations identified at 3:26:29 PM, R #1 and R #2 exited through the front doors of the facility with R #2 using his/her walker. Both residents were observed to proceed to the stairs leading onto the street and go down the stairs with R #2 carrying his/her walker in front of him/her down the stairs. Further observation of the video tape indicated that while R #1 and R #2 went down the stairs, two cars traveled past the residents, each at a separate time going in opposite directions. At 3:56:45 PM, the Scheduler exited the building. At 4 PM, staff were observed to exit out of the building, and at 4:09 PM staff returned to the building with R #1 and R #2 in wheelchairs. Review of facility documentation identified that the facility implemented a plan of correction 6/15/19 and included the following: Receptionists were in-serviced regarding when a resident leaves the facility to go on a leave of absence to call the nurse to confirm, to obtain a copy of the person's photo identification, and to test the wander guard on the front door at the end of their shift. Department heads, maintenance, recreation and all other staff were in-serviced regarding the elopement policy, updating the elopement book, and what to do when an alarm sounds. New procedure was also implemented that directed staff if a wander guard alarms, staff are to look for the resident who may have triggered the alarm, if they don't see a resident with a wander guard bracelet they need to do a head count to account all residents in the house. Nursing Supervisors are to ensure the reception desk are up to date with pictures of those at risk for elopement. Audits were initiated on 6/17/19. The elopement policy defined elopement as an unauthorized absence of a resident from the facility who is unable to make decisions due to mental capacity or guardianship. Residents will be accounted for at all times. The facility will assess and identify residents who are at risk for elopement from the facility by completing an elopement risk assessment form. A photo of residents that are identified at risk will be placed at the reception desk.

Based on clinical record reviews, review of facility documentation, and interviews for one of six sampled residents reviewed for accidents ( Resident # 16), the facility failed to follow the plan of care to prevent an accident and /or for (Resident #472) who was dependent on staff assistance with transfers and was reviewed for a fracture, the facility failed to ensure the resident was transferred in accordance with the plan of care to prevent an injury. The findings include: 1. Resident # 16's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified severe cognitive impairment, required limited assistance of one person for locomotion on the unit, utilized a wheelchair and noted the resident had one fall with injury since the prior assessment. The care plan dated 8/24/17 identified a risk for falls secondary to physical decline, cognitive deficit and poor safety awareness with an intervention to apply leg rests on wheelchair when the resident was being pushed. A nurse's note dated 10/15/17 identified the resident fell forward on his/her head while being transported by a nurse aide; the resident sustained [REDACTED]. A physician's orders [REDACTED].# 16 to the ED for evaluation status [REDACTED]. A Reportable Event dated 10/15/17 identified on 10/15/17 at 2:00 P.M. Resident # 16 fell on to the floor from his/her wheelchair and landed on his/her head sustaining a laceration to the left temporal area measuring 1.0 Centimeter (CM) x 0.5 CM x 0.0 CM. Facility documentation dated 10/15/17 of the investigation of the incident identified the resident was being pushed in a wheelchair by a nurse aide when the resident fell to the floor. Facility follow up investigation dated 10/20/17 noted the resident had suddenly leaned forward and placed both feet on the floor, causing the wheelchair to stop abruptly; as a result the resident fell and sustained a laceration to his/her forehead and sutures. A review of the facility Re-enactment Form dated 10/15/17 identified Resident # 16 was observed on the floor in the hallway with lacerations to the left forehead next to the wheelchair. Additionally, noted the Nurse Aide (NA) # 7 was propelling the wheelchair and Resident # 16 did not lift her/his feet and the resident fell forward hitting his/her head. Further review of the Re-enactment Form dated 10/15/17 identified Resident # 16's wheelchair did not have a leg rest due to the fact the resident use to self-propel at times and would suddenly place his/her feet on the floor while being wheeled. Subsequent to the re-enactment NA # 7 received education on the importance of ensuring that leg rests are applied when transporting a resident in the wheelchair. The hospital ED provider note dated 10/15/17 identified the resident was being pushed in a wheelchair and apparently her/his feet was caught on the floor and the resident tumbled forward, striking his/her head on the floor and received a laceration. The hospital laceration note dated 10/15/17 identified the resident's laceration was closed with six sutures. Interview with the DNS on 2/16/18 at 10:54 A.M. identified the resident fell because staff pushed the resident in a wheelchair without the benefit of leg rests in accordance to the plan of care. The DNS also indicated it is a standard practice to use leg rests when staff are pushing residents in the wheelchair. NA # 7 failed to attach the wheelchair leg rests prior to transporting Resident # 16 which resulted in the resident sustaining an injury to the head. The resident was evaluated at the hospital and required six sutures to the laceration. The DNS was unable to locate any policy regarding transportation of resident in the wheelchair or other related policy. On 02/16/18 during interview with NA #7 on 2/16/18 11:01 A.M. identified he/she was the NA transporting Resident # 16 on 10/15/17 when the resident fell . NA #7 indicated at the time of the incident she/he was transporting the resident in a wheelchair without leg rests to his/her room from the nurse's station in order to provide incontinence care. NA #7 also indicated she/ he told Resident # 16 to pick up his/her feet and the resident did, then midway to the resident's room Resident # 16 put her/his feet down and fell forward at which time she/he called the nurse and stayed with the resident. The resident had a cut on his/her head. NA #7 identified he/she was not told before transporting Resident # 16 to use leg rests because the resident self-propels. NA #7 was directed afterward to use leg rests all the time for the resident when pushing in the wheelchair. NA #7 indicated he/she normally looks at the care card or asks the nurse if a resident needs leg rests and uses leg rests unless told not to apply. NA # 7 indicated she/he could not recall if the care card directed to use leg rests. 2. Resident #472's [DIAGNOSES REDACTED]. The Resident Care Plan dated 8/10/17 identified Resident #472 had a self-care performance deficit with mobility. Interventions directed two (2) person assistance with transfers to the wheelchair and/or when toileting. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #472 had poor decision making skills, poor short and long term recall, required extensive two (2) person assistance with transfers, ambulating and toilet use, utilized a walker and/or wheelchair for mobility and had a history of [REDACTED]. The nurse's note dated 9/12/17 at 1:06 AM identified Resident #472 was medicated with Tylenol 650 milligrams (mg) for a complaint of left upper hip pain, and upon assessment had no [MEDICAL CONDITION], redness and/or warmth was noted. The nurse's note dated 9/12/17 at 12:31 PM identified Resident #472 complained of left hip pain with any type of movement and upon palpation, and a slight discoloration was noted to the right side of the forehead. The note identified the resident was unable to recall if any incident occurred and/or when the pain started, Tylenol when administered was ineffective and the physician was notified. A physician's orders [REDACTED]. The x-ray report dated 9/12/17 identified an acute comminuted intertrochanteric [MEDICAL CONDITION] femur. The Reportable Event Form dated 9/12/17 identified Resident #472 complained of left hip pain, etiology unknown. In a written statement, the 3-11PM primary care nurse aide, Nurse Aide (NA) #1 identified on 9/11/17 she transferred Resident #472 three (3) times from the wheelchair to the toilet, from the toilet to the wheelchair and then from the wheelchair into bed without additional staff assistance and she did not use a gait belt. The investigation identified NA #1 denied Resident #472 fell during one of the three (3) transfers. At the conclusion of the investigation NA #1 was terminated for failure to follow the resident care plan and violation of the policy and procedure. Interview with NA #1 on 2/13/18 at 1:10 PM identified on 9/11/17 she transferred Resident #472 onto the toilet, off the toilet, and into bed without any other staff assistance. Interview with the Director of Nursing (DON) on 2/14/18 at 8:40 AM identified NA #1 did not follow the plan of care when she transferred Resident #472 three times without additional staff assistance. The DON stated Resident #472 was at risk for fractures due to [MEDICAL CONDITION] and debility. Interview with NA #5 on 2/14/18 at 11:31 AM identified she worked the 3-11 PM shift on 9/11/17 and NA #1 did not ask her to assist with transferring Resident # 472. Interview and review of x-ray report results with the radiologist, MD #1, on 2/15/18 at 10:02 AM identified that a comminuted fracture was common and the fracture could have been caused by a fall, a twisting motion, and/or by a normal step. Review of facility Resident Transfer Policy directed in part, before any transfer is completed, the NA will check the assignment to ensure the proper transfer is performed, and all transfers will utilize a gait belt.

Based on clinical record review, staff interview, and review of facility documentation for one of two residents in the survey sample reviewed for accidents (Resident #54), the facility failed to provide care to a combative resident in a safe manner. The findings include: Resident #54's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had short and long-term memory problems, no mood or behaviors concerns, required physical help in part of bathing with one person, and received an antianxiety and antidepressant medication daily. A resident care plan dated April 2015 identified a problem with cognitive loss related to Alzheimer Disease. Interventions included to approach and speak in a calm, positive, reassuring way, and explain what you are about to do. Although the care plan identified a cognitive loss problem, it failed to reflect aggressive/resistive behaviors with care were exhibited. A nurse's note dated 7/9/15 at 4:30 PM indicated Resident #54 sustained a laceration to the right hand 2.5 cm x 1.0 cm between the thumb and first finger while in the shower. A sterile pad was placed on the injury with a small amount of bloody drainage noted. The resident had no complaints of pain/discomfort. At 5:30 PM the resident was sent to the emergency room for evaluation and treatment. A review of the reportable event form and investigation dated 7/9/15 at 4:30 PM indicated while receiving assistance with bathing Resident #54 sustained a laceration to the right hand between the thumb and index finger measuring 2.5 cm x 1 cm. The Physician was notified and directed to send the resident to the emergency room for evaluation. The resident returned to the facility with eight sutures to the right hand. The facility investigation indicated the resident was calm and cooperative, but became agitated during the shower. The resident grabbed the shower head and while swinging the shower head sustained a laceration to the right hand. An inservice program dated 7/10/15 and 7/13/15 indicated staff were inserviced to stop a shower and attempt at another time if a resident becomes combative during a shower. Review of the nurse notes' dated 4/28/15 through 7/10/15 did not note any aggressive/resistive behaviors had occurred. Review of the 24-hour report sheets dated 7/1/15 through 7/13/15 did not note any aggressive/ resistive behaviors had occurred. Review of an APRN note dated 8/5/15 indicated Resident # 54 was seen for cellulitis of the right hand s/p laceration. The resident was started on antibiotics that week and the dressing orders were changed. An interview on 2/10/16 at 10:00 AM with LPN #2 indicated Resident #54 was confused and alert and had the potential for agitated behaviors with increased anxiety. The resident sundowned on 3 PM- 11 PM shift at times. An interview and review of the reportable event form and investigation dated 7/9/15 on 2/10/16 at 10:15 AM with the DNS indicated when the resident exhibited agitation and/or resistive to care in the shower NA # 1 should have stopped the shower and reported it to the nurse. Additionally, NA #1 should not have turned the shower water on/off while providing the shower. An interview and review of the reportable event form and investigation dated 7/9/15 on 2/10/16 at 12:00 PM with NA #1 indicated while providing a shower to Resident #54, the resident started to get agitated when the shower water touched him/her. Nurse aide # 1 turned the shower water off and continued to wash the resident. The resident grabbed the shower head in anger and attempted to hit NA #1. Nurse aide # 1 indicated he/she continued with the shower and/or care even while Resident #54's agitation increased. He/she noticed blood on the resident's hand when he/she was drying the resident with a towel, but did not know the cause of the laceration. Nurse aide # 1 indicated looking back on the incident he/she should have stopped providing care when the resident had increasing agitation.

Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Resident #1 and #2) the facility failed to ensure residents were free from verbal and/or physical abuse. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2 had severe cognitive impairments, difficulty focusing attention, disorganized thinking, psychomotor [MEDICAL CONDITION] and required one to two person extensive assistance with activities of daily living. The resident care plan dated 2/6/14 identified a potential for decrease in activities of daily living. Interventions directed to assist with activities of daily living and provide a constant daily routine. The Reportable Event Form dated 4/21/14 identified that "a nurse aide reported verbal abuse against Resident #2." The incident had occurred on 4/18/14 at 5:00 PM and was not reported to the charge nurse until 4/21/14, three days later. Upon notification NA #3 was sent home pending the investigation. The monitoring for psycho-social well-being documentation dated 4/21/14 through 4/23/14 identified that Resident #2 did not recall the 4/18/14 incident and did not display signs of agitation or sadness. Review of NA #7's written statement dated 4/21/14 identified that NA #7 overheard NA #3 say to Resident #2 "stop being an a_ _ _." Review of NA #5's written statement dated 4/21/14 identified that she had assisted NA #3 toilet Resident #2. When the resident acted out, NA #3 stated to Resident #2 "if you weren't such an a_ _ _hole we would be done with this already " Resident #2 grabbed NA #3 by the shirt and yelled at her. At that point the resident started to stand up and NA #3 pushed Resident #2 back into the chair causing the resident to hit his/her head on the toilet paper dispenser and landed on the arm of the wheel chair. Review of the facility's conclusion in the investigation dated 4/23/14 identified that NA #5 received disciplinary action for failure to report witnessed abuse immediately and NA #3 was terminated on 4/29/14 for substantiated abuse. Interview with NA #5 on 8/12/14 at 12:00 PM identified that she assisted NA #3 toilet Resident#2. When Resident #2 attempted to help pull up his/her pants making things more difficult NA #3 yelled at the resident and said if he/she "wasn't such an a_ _ _hole we would be finished." Resident #2 became agitated grabbed NA #3's shirt and NA #3 pushed Resident #2 back on the toilet causing the resident to hit his/her head on the toilet paper holder. Interview with NA #3 on 8/14/14 at 12:15 PM she denied that the interaction occurred. Interview with NA #7 on 8/14/14 at 1:30 PM identified that while she was caring for another resident nearby in the shower room, she heard NA #3 swear at Resident #2. 2. Resident #1's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly dated 7/17/14 identified that Resident #1 had poor decision making skills and required cues and supervision, difficulty thinking, required total one person assistance with dressing, extensive one person assistance with personal hygiene and extensive two person assistance with bed mobility, transfers and toileting. The resident care plan dated 4/18/14 through 7/22/14 identified an alteration in activities of daily living related to a neurological deficit medulla [DIAGNOSES REDACTED]. Interventions directed to set up supplies and assist as needed, explain all procedures prior to care, offer verbal cues and choices and speak in a calm gentle tone. The Reportable Event Form dated 7/23/14 at 7:45 AM identified that Nurse Aide (NA) #1 came forward regarding an inappropriate verbal statement made by NA #2 to Resident #1. NA#2 was immediately sent home and an investigation initiated. Review of NA #1's written statement dated 7/23/14 identified that NA #2 stated to Resident #1 "it's time to get up b_ _ _ _ _." The statement indicated that NA #2 told NA #1 that she and another nurse aide (NA #4) gang up on the resident and Resident #1 doesn't say anything because NA #4 would tell the resident "to shut his/her f_ _ _ _ing mouth." NA #1 stayed with Resident #1 until morning care was completed and the resident was brought to the dining room. The social service note dated 7/23/14 at 4:15 PM identified that when Resident #1 was asked about how NA #2 treated him/her, Resident #1 indicated that the nurse aide called him/her names and cussed. Review of the notes from 7/24/14 through 8/7/14 identified that the resident did not recall the 7/23/14 incident. Review of the facility's investigation dated 7/31/14 identified that verbal abuse was substantiated and NA #2 was terminated. Interview with NA #1 on 8/12/14 at 11:30 AM identified that on 7/23/14 she assisted NA #2 with getting Resident #1 out of bed. NA #2 said good morning and then said to the resident "it's time to get up b_ _ _ _ _." NA #1 stated that she reported the incident immediately and NA #2 was sent home pending facility investigation. Review of facility policy identifies that each resident has the right to be free from verbal, sexual, physical and mental abuse. Each resident will be treated with respect and dignity at all times.

Based on clinical record reviews, review of facility documentation and interviews for one of two sampled residents (Resident #1) who were new admissions, the facility failed to ensure that the correct hospital discharge medications prescribed for the resident were transcribed on the physician's orders [REDACTED]. Resident #1 was admitted to the long term care facility on 6/7/13 with had [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified that Resident #1 was alert and oriented to person, place and time, independent in decision making, and the initial vital signs were temperature 97.4, blood pressure 132/58, pulse 80, respirations 22, and the oxygen saturation level was 98% on room air. A physician's orders [REDACTED]. Review of the nurse's note dated 6/9/13 at 2:00 PM identified that Resident had a poor appetite, vomited once 400 cubic centimeters, blood was noted in the urine and the covering physician was notified. A physician's orders [REDACTED]. The nurse's note dated 6/9/13 at 5:30 PM identified that Resident #1's blood pressure was 107/63, pulse 72 , respirations 20, pulse oximetry 95% and the resident's appetite was poor. At 8:30 PM, Resident #1 complained of not feeling well and had refused the 5:00 PM medications. The note indicated that Resident #1 had voiced concern that he/she was not usually on all these medications before and this information was reported to the Nursing Supervisor. The resident's vital signs were blood pressure 103/66, pulse 74, respirations 14-18 per minute and the oxygen saturation was 88-89% for which oxygen was applied. At 7:00 PM Resident #1 was transferred to the hospital. The hospital history and physical dated 6/9/13 identified that Resident had no significant past medical history and did not take any medications. The hospital course included intravenous fluids for gentle hydration, cardiac monitoring, and [MEDICATION NAME] for the nausea. The discharge summary dated 6/11/13 identified [DIAGNOSES REDACTED]. Interview with the ADON on 2/24/14 at 1:38 PM identified that she did not review the name at the top of each page, therefore she did not realize the two medication sheets had different resident names. Subsequent to the incident the plan of correction is for the name on the paperwork to be highlighted and the medications reviewed with another nurse. The Reportable Event Form dated 6/11/13 identified that Resident #1 was admitted on [DATE] and on 6/9/13 the resident complained of nausea and questioned the medications he/she was receiving. A review of Resident #1's discharge paperwork from the hospital revealed that a different patient's list of medications was included with Resident #1's discharge packet and the medications were erroneously transcribed onto Resident #1's physician's orders [REDACTED]. The facility's investigation identified that the hospital discharge packet had two pages of discharge medications that were not stapled together but were one after another. The Assistant Director of Nurses (ADON) on 6/7/13 checked the name on the first page but did not check the name on the second page and the medications were written on the physician's orders [REDACTED].

Based on clinical record review, observation and staff interview for one of three sampled residents (Resident #46) who was reviewed for pressure ulcers, the facility failed to provide pressure relief to a foot deformity to prevent pressure ulcer development. The findings include: Resident #46's [DIAGNOSES REDACTED]. The care plan dated 5/16/11 identified skin was intact, but the resident was at risk for breakdown due to over lapping toes. The care plan dated 11/3/11 identified the resident had a hammer toe. Interventions included to observe for signs and symptoms of pain, ensure proper fitting shoes and podiatry consult as needed. The care plan failed to direct staff on any protection of the overlapping toes and/or pressure/friction relief. Physician orders [REDACTED]. A wound/skin condition report dated 1/1/12 identified a 1 cm by 1 cm wound on the resident's left foot/second toe. On 1/3/12, the wound was documented as a stage III pressure ulcer that measured 1 cm by 1.5 cm with 40% slough. On 1/19/12, the area was documented as unstageable with 100% necrosis. Observation on 1/25/12 at 2:05 PM identified the residents toes were deformed and overlapping with no pressure relief. The current ulcer was visualized and appeared necrotic and red, and another ulcer was noted on the third toe. The care plan dated 1/12/12 directed to apply lamb's wool between the 1st and 2nd toes on left foot.

Based on clinical record review and staff interview for one of five residents in the survey sample reviewed for accidents (R # 45), the facility failed to transfer a resident with a mechanical lift safely. The findings include: Resident # 45's [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] identified R # 45 with no memory problems, total care for transfers, and did not ambulate. A resident care plan dated 2/15/10 identified a problem with transfers. Interventions included mechanical lift transfer with the assist of 2 staff. A nurse aide assignment sheet dated 2/17/10 directed to transfer the resident with the assistance of 2 staff with a mechanical lift. An updated nurse aide assignment sheet dated 3/17/10 indicated, in part, may transfer with mechanical lift with 3 people (assisting); tilt wheelchair back and remove leg rests. Nurse's notes dated 3/15/10 at 11:15 AM indicated the mechanical lift tipped over when R #45 was being transferred. The resident complained of right knee pain and the right foot was outwardly rotated. The note indicated the physician was notified and the resident was sent to the emergency department for evaluation. A hospital x-ray report dated 3/15/10 indicated R #45 had acute fractures of the distal femur, proximal tibia and a lateral patellofemoral dislocation. An interview on 12/8/10 at 11:10 AM with the Staff Development Director indicated that mechanical lift inservices and/or competencies including the need to remove wheelchair legs prior to transferring a resident in a lift had been completed. An interview on 12/8/10 at 12:30 PM with NA# 7 who participated in the transfer of the resident on 3/15/10, indicated that when they transferred R #45 in the mechanical lift on 3/15/10, the wheelchair leg rests were on the resident's wheelchair. She further indicated that the legs on the mechanical lift would not widen all the way and had to be kicked open. She indicated the nurse was not notified at that time. An interview on 12/8/10 at 3:30 PM with NA #8 indicated he did not remove the leg rests from R # 45's wheelchair prior to transferring the resident in the mechanical lift. He indicated the legs of the lift were placed in-between the front wheels of the wheelchair because the legs of the lift would not widen. He noted the resident's wheelchair was very large and there was not much room between the wheelchair and the resident's dresser. An interview on 12/8/10 at 1:50 PM with the Rehab Director indicated that although she had not assessed R # 45 for safe transfer with the mechanical lift, wheelchair leg rests should be removed prior to transferring with a lift. An interview on 12/9/10 at 7:40 AM with Person #1 (medical supplier of the mechanical lift) indicated he examined the lift after the incident on 3/15/10 and found no mechanical problems. He noted there is no manufacturer procedure on where to place the lift when transferring into a wheelchair and noted each resident should be assessed for proper placement of the lift to assure the legs and/or wheels of the lift are not impeded during the transfer. He further noted that even with the lift not opened, the lift was designed not to tip over.