Every finding on record at Wadsworth Glen Health Care and Rehabilitation Cent

Based on observations, interviews, facility documentation, and facility policy the facility failed to ensure that the dietician reviewed and approved menus and failed to ensure portion sizes were included on posted menus. The findings include:Observation on 8/4/2025 at 11:50 AM of the facility's posted menu in the kitchen area identified breakfast entrees included cream of wheat, a donut, and scrambled egg; lunch entrees included baked chicken with rice, baked ham with seasoned zucchini and onions, boiled potatoes with parsley, a dinner roll, and peaches and cream; dinner entrees included vegetable and cheese quiche with chef's vegetable, oven browned potatoes, and dinner roll , BBQ pork on a bun with coleslaw, and sherbet. The menu failed to include serving sizes for any of the posted meals.Observation on 8/4/2025 at 12:18 PM of the facility's second floor dining room posted menu failed to include serving sizes for any of the listed meals.Interview on 8/6/2025 at 11:15 AM with Regional Dietician #2 identified menus came from an agency and are reviewed by all the on-site dieticians. Further, she identified that she had not signed the menus before emailing them to the facility. Regional Dietician #2 indicated that it was the expectation of the Dietary Director to include portion sizes on the posted menus, she had spoken with him on several occasions previously regarding the absence of portion sizes and had shown him how to print the menus to include the portion sizes.Observation on 8/6/2025 at 12:10 PM of the facility's third floor dining room posted menu failed to include serving sizes for any of the listed meals.Interview on 8/11/2025 with the Dietary Director identified that the kitchen menus were not signed by the on-site dietician because there may be changes to the menu during the week. Further, he stated that he prints the menus for posting as they are sent to him by dietary and indicated that portion sizes were not included on the menu he received from dietary. Interview on 8/11/2025 at 10:33 AM with Dietician #3 identified she has not received any emails from Regional Dietician #2 with a facility menu. Further, she identified that she does not sign the menus after they are reviewed or print menus for the facility to post.Review of the Food First - Nutrition Policy identified, in part, that menus are posted in designated areas. The facility policy failed to identify that portion sizes should be included on posted menus.Review of the Food and Dining Service Policy identified, in part, that therapeutic diets are to be planned by a qualified registered dietician, and that necessary substitutions are made by the dietician and/or food service manager and documented on the appropriate form. The policy failed to include the facility's dietician should review the menus and maintain a signed and reviewed copy of the menu.

Based on observation, interviews, and a temperature test, for sampled residents (Resident #1, Resident #2, Resident #38, Resident #45, Resident #66, Resident #70 and Resident #76) reviewed for dietary services, the facility failed to ensure that food was palatable and failed to serve food at a safe and appetizing temperature. The findings included:1. Resident #1's diagnoses included fracture of the left patella, fracture of the left femur, and Type 2 diabetes mellitus.Interview with Resident #1 on 8/5/2025 at 10:48 AM identified he/she found the quality of the food to be terrible and that the food was served cold. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, was independent with eating, and required a mechanically altered diet.The Resident Care Plan (RCP) in effect on 8/4/2025 identified Resident #1 had a potential for impaired nutrition status due to unintentional weight loss, poor dentition, and a modified consistency diet. Interventions included providing supplements with meals, assisting with meals as needed, and assess and monitor the presence of factors interfering with nutrition status.A physician order in effect on 8/4/2025 identified Resident #1 was to receive a regular diet of mechanical soft ground texture, and thin (regular) liquid consistency.2. Resident 2's diagnoses included chronic kidney disease, chronic systolic and diastolic heart failure, and gastro-esophageal reflux disease.Interview with Resident #2 on 8/4/2025 at 2:57 PM identified he/she was concerned that the food was always cold.The quarterly MDS assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment, was independent with eating, and had no nutritional concerns.The Resident Care Plan in effect on 8/4/2025 identified Resident #2 was at risk for malnutrition. Interventions included providing supplements with meals, assisting with meals as needed, and assess and monitor the presence of factors interfering with nutrition status.A physician order in effect on 8/4/2025 identified Resident #2 was to receive a regular diet of regular consistency texture, and a thin (regular) liquid consistency.3. Resident 38's diagnoses included chronic systolic and diastolic heart failure, mixed lipidemia, and gastro-esophageal reflux disease.Interview with Resident #38 on 8/4/2025 at 2:57 PM identified many times he/she did not receive the substitute meal he/she requested, and that the food was always cold.The quarterly MDS assessment dated [DATE] identified Resident #38 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, required set-up with eating, and required a therapeutic diet.The Resident Care Plan in effect on 8/4/2025 identified Resident #38 was at risk for impaired nutrition status. Interventions included providing diet as ordered, obtain and update preferences as needed, and provide snacks as desired and in compliance with diet order.A physician order in effect on 8/4/2025 identified Resident #38 was to receive a low fat/low sodium diet of regular consistency texture, and thin (regular) liquid consistency.4. Resident 45's diagnoses included osteoarthritis, hyperparathyroidism, and gastro-esophageal reflux disease.Interview with Resident #45 on 8/04/2025 at 10:30 AM identified that the food was always cold, and that the food did not taste good.The quarterly MDS assessment dated [DATE] identified Resident #45 had a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment, was independent with eating, and required a therapeutic diet.The Resident Care Plan in effect on 8/4/2025 identified Resident #45 was at risk for malnutrition. Interventions included providing supplements with meals, provide snacks as desired and in compliance with diet order, and assess and monitor the presence of factors interfering with nutrition status.A physician order in effect on 8/4/2025 identified Resident #45 was to receive a low sodium diet of regular consistency texture, and thin (regular) liquid consistency.5. Resident #66's diagnoses included Type 2 diabetes, Stage 3 chronic kidney disease, and hyperlipidemia.Interview with Resident #66 on 8/4/2025 at 12:30 AM identified the food was delivered cold at all meals.The quarterly MDS assessment dated [DATE] identified Resident #66 had a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment, was independent with eating, and required a mechanically altered diet and a therapeutic diet.The Resident Care Plan in effect on 8/4/2025 identified Resident #66 had a potential for impaired nutrition status due to the need for a therapeutic diet and need for a texture modified diet. Interventions included assist with meals as needed, monitor weight as needed, and assess and monitor the presence of factors interfering with nutrition status.A physician order in effect on 8/4/2025 identified Resident #66 was to receive a controlled carbohydrate diet of regular consistency texture, and nectar thick liquid consistency.6. Resident #70's diagnoses included Type 2 diabetes, chronic diastolic heart failure, and hyperlipidemia.Interview with Resident #70 on 8/4/2025 at 11:45 AM identified the food did not taste good and there was not a variety of options for meals to choose from.The quarterly MDS assessment dated [DATE] identified Resident #70 had a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment, required set-up assistance with eating, required a therapeutic diet, and had a documented unintended significant weight loss.The Resident Care Plan in effect on 8/4/2025 identified Resident #70 was at risk for malnutrition due to the need for a therapeutic diet and history of weight variances. Interventions included obtain and update food preferences as needed, monitor weight as needed, and assess and monitor the presence of factors interfering with nutrition status.A physician order in effect on 8/4/2025 identified Resident #70 was to receive a controlled carbohydrate diet of regular consistency texture, and thin (regular) liquid consistency. 7. Resident #76's diagnoses included Type 2 diabetes, hypertension, and hyperlipidemia.Interview with Resident #76 on 8/4/2025 at 12:41 PM identified that many times the food was cold and did not taste good.The annual MDS assessment dated [DATE] identified Resident #76 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required set-up assistance with eating, and required a therapeutic diet.The Resident Care Plan in effect on 8/4/2025 identified Resident #76 had a potential nutritional problem related to obesity. Interventions included providing supplements as ordered, providing and serving his/her diet as ordered, and weigh at the same time of day weekly per physician orders.A physician order in effect on 8/4/2025 identified Resident #76 was to receive a controlled carbohydrate no added salt diet of regular consistency texture, and thin (regular) liquid consistency.On 8/6/2025 at 12:12 PM observation, interview and temperature check of the steam table was conducted with Kitchen Worker #1. The Director of Dietary was invited and declined to participate in the temperature check of the steam table, and instead he provided Kitchen Worker #1 his thermometer to use during the temperature check. Observation identified the lunch steam table contained breaded fish, chicken, mixed carrots and peas, mashed potatoes, and baked potatoes, and the steam table was plugged into a wall receptacle. The fish was noted to have a temperature of 122.0 degrees Fahrenheit (F), the chicken was 150.0 F. the mashed potatoes were 156.0 F, the carrots and peas were 160.0 F per the Dietary Director's thermometer. Kitchen Worker #1 stated that he would expect the food temperatures to be maintained between 150.0 and 160.0 F for both safety and for palatability of food. He was unable to identify why the low temperature of the fish was not maintained in the appropriate range of 150.0 to 160.0 *F. Kitchen Worker #1 indicated that the steam table may not have been working appropriately. On 8/6/2025 a test/temperature tray was conducted with the Dietary Director identified the lunch tray consisting of chicken, mixed carrots and peas, and gravy over mashed potatoes left the third floor steam table at 12:31 PM. The first tray on the third floor was delivered to residents starting at 12:32 PM. The last tray was delivered at 12:50 PM and, at that time, a temperature reading of the test tray was conducted with the Dietary Manager identifying the following: The chicken was 125.8 *F per the surveyor calibrated thermometer and 105 *F per the Dietary Manager's thermometer. The mixed carrots and peas temperature was 122.0 *F per the surveyor calibrated thermometer and 105.0 *F per the Dietary Manager's thermometer. The mashed potatoes and gravy temperature was 132.1 *F per the surveyor calibrated thermometer and 119.0 *F per the Dietary Manager's thermometer.Interview and observation with the Dietary Director on 8/6/2025 at 1:07 PM identified a safe temperature for all delivered food was 160 *F and a palatable temperature for the chicken, peas and carrots, and mashed potatoes should be 140 *F. Further, he stated there was no excuse that the temperature of the fish at the steam table was only 122.0 *F and it should have been higher. The Dietary Director identified he was aware of low food temperature issues prior to the temperature tray and stated he had previously notified the facility's Administrator about the low temperatures. He indicated no changes had been made to food service delivery since he reported the food service issues to the Administrator, and he was unable to identify why food was being served below safe and palatable temperatures.Subsequent to the identification of low food temperatures during the temperature tray inspection a taste tray sampling was conducted with the Dietary Director on 8/6/2025 at 1:19 PM by 3 surveyors. The test tray consisted of pureed chicken and gravy, mixed carrots and peas, and mashed potatoes and gravy. The chicken and the vegetables were seasoned well, and the mashed potatoes were bland and lacking flavor. The chicken and mashed potatoes were not palatable due to the unacceptable temperature.Interview with the Administrator on 8/7/2025 at 10:05 AM identified that she was aware of complaints of cold food and had directed food service to move the steam table into the hallway to serve residents. Further she identified that her directive had not been followed because there was no accessible outlet in the hallway in which to plus in the steam table resulting in cold food. The Administrator stated she was working with corporate offices to budget for and purchase additional steam tables.Review of the facility's Dietary Department Guidelines/Policy identified, in part, that hot cooked foods will be held at temperatures above 140 *F, and steam tables will keep food at proper temperature and will be maintained in safe and sanitary condition.

Based on observations, facility documentation, facility policy, and interviews the facility failed to ensure safe thawing of frozen foods, failed to ensure refrigerated foods were stored under sanitary conditions, failed to ensure open food items were dated to include opened/expired/use by dates, failed to ensure food was served/prepared under sanitary conditions, and failed to ensure proper handwashing was performed during food service. The findings include:1. Tour of the kitchen with the Director of Dietary on 8/4/2025 at 9:50AM identified the following:a. The kitchen cleaning log and temperature logs for 8/4/2025 were incomplete and missing signatures. The cleaning log contained no signatures for 8/4/2025 and the temperature log was missing temperatures and signatures for the walk-in freezer.b. Reach-in cooler #1 had food debris on the inside bottom of the coolerc. Fan in the dishwashing area over the clean dishes was plugged in but not running and thickly coated with dust and dirt.d. The wall behind where the clean dishes were stored had a brown substance that had dripped down the wall and dried.Interview with the Director of Dietary identified that dishes that are washed in the dishwasher do not always come out clean and he stated the brown substance was from leftover debris in the cleaned dishes.e. Dried food and debris was located around the kitchen's air compressor.f. Plastic lids, debris, and small plastic items were located under the bottom shelf of the air compressor on the floor. The floor had multiple dried brown spots from a liquid both under it and in front of it.g. The air handling unit for the kitchen's air compressor was caked with dust like substance, potentially impeding proper air flow.Interview with the Director of Dietary identified he was not responsible for the cleanliness of the air handling unit because an outside vendor was contracted for cleaning and servicing the unit. Further, he identified he had not contacted the vendor as that was the responsibility of the Maintenance Department at the facility, and they were already aware.h. The counter next to the coffee pot was found to have dried debris and a dead insect on it.i. The windowsill behind the coffeepot was visibly soiled, had cobwebs in the corner of the window, had dead bugs in and around the cobwebs, and had clean serving utensils directly set on top of the soiled windowsill.j. Crumbs of food and food splatter were located on the inside of the microwave.k. An opened and undated 7/8 full 16 oz container of turmeric was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.l. An opened and undated 2/5 full 14 oz container of ginger was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.m. An opened and undated 7/8 full 16 oz container of basil was stored under the stove on a shelf in unsanitary condition on a tray with debris both on and under the tray.n. An opened and undated 7/8 full 16 oz container of cinnamon was stored under the stove on a shelf in unsanitary condition on a tray with debris both on and under the tray.o. An opened and undated 5/8 full 16 oz container of pumpkin pie spice was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.p. An opened and undated 7/8 full 16 oz container of basil was stored under the stove on a shelf in an unsanitary condition on a tray with debris both on and under the tray.q. An opened and undated 2/5 full 16 oz container of pickling spice was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.r. An opened and undated 5/8 full 14 oz container of red pepper flakes was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.s. An opened and undated 7/8 full 16 oz container of paprika was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.t. An unidentified bag of food meal was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.u. 3 unopened paper boxes of [NAME] Sazon were stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.v. An opened and undated 16 oz bottle of imitation lemon juice was stored under the stove on a shelf in unsanitary conditions on a tray with debris both on and under the tray.w. A sheet of crumpled white paper was identified under the stove on a shelf with spices on a tray with debris both on and under the tray.An interview with the Director of Dietary identified that he did not use that particular stove so storing items under the cabinet under was permissible. He further identified the stove was in working order, but his staff did not use the stove, as they used a second stove to the left. The Director of Dietary stated he did not clean the cabinet as the spices were on trays, and he replaced the plastic trays with new ones when they became dirty. The Dietary Director was unable to identify the date that the trays were last taken out to be cleaned.x. The second six burner stove was found to be dirty. Dried food particles were in the burner areas and the splashguards around the stove were heavily coated with grease and grime.y. The counter next to the second six burner stove contained 10 covered bowls of soup, 1 metal container covered with plastic wrap of pureed peas, 1 metal container covered with plastic wrap of rice pilaf, 1 metal container covered with plastic wrap of gravy, 1 metal container covered with plastic wrap of pureed chicken, 1 metal container covered with plastic wrap of ground chicken, and 1 metal container covered with plastic wrap of ground ham.Interview with the Director of Dietary identified the food had been sitting on the counter since approximately 9:30 AM, when his Food Service Manager left the building, and had been removed from the walk in refrigerator before that time as part of preparation for lunch service. Further he identified the temperature danger zone for these food items was 40-41 *F.A temperature check, using the Director of Dietary's kitchen thermometer, performed on some of the items found: gravy was 69.8 *F, pureed chicken was at 78* F, ground chicken was at 80 *F, and ground ham was at 58 *F. Observation of the Dietary Director identified he was not as observed to clean the thermometer between temperature tests of the food items and indicated the risk of not cleaning his thermometer between putting it in different food items was cross contamination. He failed to identify why he didn't clean his thermometer between food items and stated the food was still safe to use as he would be bringing the temperature up to at least 150*F before serving it to residents.z. Two 32 oz opened containers of basil pesto were in the reach in refrigerator. The containers were not dated with an open date.Interview on 8/4/2025 at 10:00 AM with the Director of Dietary services identified the kitchen cleaning was his responsibility. The Director of Dietary failed to identify how he knew cleaning was being performed if staff did not initial the cleaning logs. Further, he failed to produce copies of the cleaning logs for the last 4 weeks upon request and stated the Kitchen Manager was responsible for filing them, but he did not know where they were kept.Although the Director of Dietary services was unable to locate copies of the cleaning logs requested, the Administrator was able to provide cleaning logs on 8/6/2025 from 6/29/2025 through 8/2/2025 which identified staff initials attesting that kitchen cleaning tasks had been performed daily.Interview on 8/6/2025 at 10:43 AM with the Kitchen Manager identified that she had signed all the initials on the weekly cleaning schedules yesterday (8/5/2025) for the previous two months. She further identified that she and the Dietary Director were responsible for ensuring staff sign the logs after cleaning, the logs had not been completed and initialed by staff, and she had signed the staff's initials on the log because she didn't want blank spots on the logs to be presented to the State Agency.Interview with the Administrator on 8/7/2025 at 10:05 AM identified the Director of Dietary was responsible for the cleanliness of the kitchen. She stated she was aware the kitchen was not clean, had spoken with the Director of Dietary in March and showed him what to clean, directed him to perform a thorough cleaning, but the kitchen had not been properly maintained by the Director of Dietary since the cleaning. Further, she stated she was not aware that the cleaning logs given to her on 8/6/2025 by the Kitchen Manager had been filled out and signed by the Kitchen Manager on 8/5/2025 because the logs had not been entirely filled out. 2. Observation of delivery of food to the kitchen from the food supplier was made on 8/5/2025 at 8:23 AM.An observation of the kitchen on 8/5/2025 at 10:05 AM identified the following:a. Two dirty pedestal fans were in the kitchen hallway. Both fans were visibly dusty, one fan was blowing onto clean dishes, the second fan was blowing into the main kitchen area where food was being preparedb. The three-bay sink next to the kitchen hood had frozen hamburgers in a dish of water to be thawed. There was no cold water running from the faucet into the dish of waterc. One multi-container box of single serve vanilla milkshakes, labelled refrigerate, was sitting on the kitchen prep counterd. One 6-pack box of frozen unshelled eggs in bags were sitting on the kitchen prep counterA second observation and interview on 8/5/2025 at 12:58 PM with the Director of Dietary services identified the following:a. One 6-pack box of frozen unshelled eggs in bags was sitting on the kitchen prep counter. The eggs inside the bags were not frozen solid and had a slushy consistency.b. One multi-box of single-serve vanilla milkshakes, labelled refrigerate, was sitting on the kitchen prep counter. The contents of the single-serve milkshake containers were not solid and could easily be squeezed.c. Two 32 oz opened containers of basil pesto were in the reach in refrigerator. The containers were not dated with an open date.The Director of Dietary identified the eggs and milkshakes were delivered earlier in the day and stated he was getting ready to put them in the fridge to thaw. He stated he believed that the boxes containing the perishable food items were still frozen, despite the delivery had occurred at 8:23 AM (4 and one half hours prior to the second observation). Further, he indicated he had forgotten to dispose of the opened and undated basil pesto containers identified on 8/4/2025, he was responsible for ensuring undated food items were disposed of, and subsequent to surveyor inquiry the items were discarded.3. Dietary serving observations identified the following:a. Observation and interview on 8/4/2-25 at 12:48 PM of the second floor dining room identified Nurse Aide (NA) #5 had long painted nails, was touching her hair repeatedly, was not performing hand sanitization after touching her hair and before serving resident's their food. Her nails made contact with multiple residents' plated food while she was serving. NA #5 stated she didn't use hand sanitizer before serving the Residents because she forgot but she should have hand sanitized, per the facility's policy.b. Observation on 8/4/2025 at 12:56 PM identified the Director of Dietary and his staff transporting uncovered plates of food to serve to the third floor residents in the dining room. The facility's Food First Nutrition policy identified, in part, that all dining rooms will have a hand washing area and/or hand sanitizer available. Staff members will wash their hands prior to serving/distributing food.The facility's Controlling Time and Temperature During Preparation policy identified, in part, that the facility will follow State or local Health Department requirements, use clean and sanitized equipment while preparing food, prepare foods as close to the serving times as the menu will allow, limit the time for preparation of any batches of food so that ingredients are not at room temperature for more than 30 minutes before cooking, serving, or being returned to the refrigerator, immediately return ingredients to the refrigerator if the anticipated preparation completed time is expected to exceed 30 minutes, and if potentially hazardous foods are not cooked or served immediately after preparation, quickly chill.

Based on clinical record review, interviews and facility policy for 2 of 2 sampled residents, (Resident #98 and Resident #99) reviewed for advance directives, the facility failed to ensure the advance directives consent and physician's order were in place. The findings included:1. Resident #98's diagnoses included muscular dystrophy, polyarthritis, and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #98 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition and was dependent on staff for dressing, personal hygiene, and transfers. The Resident Care Plan dated [DATE] identified Resident #98 had an established advanced directive and wished to receive cardiopulmonary resuscitation (CPR). Interventions included a review of advance directives with the resident and/or the healthcare decision maker quarterly, and to support the resident's decision for CPR. The physician's orders failed to direct an advance directive code status. A review of Resident #98's clinical record identified the Advanced Directives Declaration Health Care Wishes and Advanced Directives Declaration Code Status located in the front of the Resident #98's paper chart failed to include the resident's wishes for a code status, failed to include the resident/responsible party signature, and failed to include a physician's signature. Interview and clinical record review with Licensed Practical Nurse (LPN) #2 on [DATE] at 12:43 PM identified the facility policy for advanced directives was to review code status choices upon admission/re-admission and obtain a signature either from the resident or responsible party within 24 hours. Additionally, she identified that in the event of an emergency the nurse would check the physician orders in the electronic health record or the advance directives code status form in the chart. A review of Resident #98's electronic health record, and a review of the advanced directives code status form with LPN #2 failed to identify a code status choice. Although there was a code status form from [DATE] that was signed in the chart, LPN #2 identified there should have been an updated form since Resident #98 went to the hospital multiple times since [DATE]. Interview and clinical record review with the Director of Nursing (DNS) on [DATE] at 12:59 PM identified the facility policy on advance directives was for the admitting nurse to obtain a signature and physician's order for a code status the same day, or at least within 24 hours. A review of the clinical record with the DNS failed to identify a code status, and she could not identify why Resident #98's code status had not been reviewed upon readmission from the hospital. Subsequent to surveyor inquiry, the DNS made social services aware of the missing advanced directives and forms were sent to the responsible party for review and signature. 2. Resident #99's diagnoses included acute cystitis, mild cognitive impairment and depression. The Nursing admission assessment dated [DATE] identified Resident #99 was mildly cognitively impaired and required assistance of 1 staff for activities of daily living. The Resident Care Plan dated [DATE] did not address Resident #99's code status/advance directives. Physician's orders dated [DATE] did not direct Resident #99's choice for a code status/advance directive. LPN #1's nurse's note dated [DATE] at 3:47 PM identified Resident #99 and his/her responsible party had not decided on an advance directive status and had not signed the consent form. A review of nursing, social services, and practitioner (physician and APRN #1) documentation from [DATE] through [DATE] failed to identify that the facility had reapproached the issue of Resident #99's code since LPN #1's note dated [DATE] (6 days prior). Further, there was no resident/responsible person education documented to explain code status/advance directive information. Observations from [DATE] through [DATE] identified that Resident #99's responsible party was at the facility every morning visiting until after lunch. An interview with the DNS on [DATE] at 9:45 AM identified that advance directives should be addressed on admission and if no decision was made, to reapproach the resident/responsible party to make a decision. The DNS stated it was the responsibility of nursing to ensure advanced directives were signed. The DNS stated she was not familiar with the facility's policy as she was new to the facility and had only been in her role for a few weeks nor was she aware that Resident #99's code status/advance directives had not been readdressed. Subsequent to surveyor inquiry Resident #99's consent was signed, and a physician's order was obtained. An interview with LPN #1 on [DATE] at 12:00 PM identified that advance directives were to be addressed on admission and if, at that time, a resident was undecided, then it would have to be readdressed, but was unsure if this had occurred. LPN #1 indicated she had not provided any written educational material regarding code status to Resident #99 and/or the responsible party and that it would be a good idea to have something to provide on admission. LPN #1 stated she was unsure if Resident #99's code status/advanced directive had been readdressed by any staff until the advance directive was signed per the DNS directive on [DATE]. A review of Advance Directive Regarding CPR and DNR Policy dated 3/2019 directed, in part, prior to or at the time of admission, if possible, the facility will review and hand out Cardiac/Respiratory Arrest Explanation Sheet to the competent resident or responsible party. After review, the appropriate party will check off the appropriate box on the CPR/DNR Consent Form. Based on the CPR/DNR Consent Form, the nurse is responsible for obtaining a physician's order for the resident's code status.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 sampled residents (Resident #38) reviewed for personal property, the facility failed to follow their grievance policy to ensure the grievance was resolved. The findings include:Resident #38's diagnoses included congestive heart failure, mild cognitive impairment, and intellectual disabilities. Review of a concern form dated 3/19/2025 identified bleach issues with clothing. The Department Head Resolution area identified when resident's clothing gets soiled, the laundry has to wash the item in soil program which required washing with the addition of bleach. After the clothes get washed, the clothes would get discolored, or bleach stained. This was signed on 3/20/2025 by the Laundry Department Head but failed to be signed by the Resident Council President, the Administrator, or the Director of Recreation, and did not indicate the issue had been resolved. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #38 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required supervision for lower body dressing, and transfer and was independent with eating, upper body dressing and bed mobility. The Resident Care Plan in effect from 3/20/2025 through 8/4/2025 failed to address clothing concerns. An interview with Resident #38 on 8/4/2025 at 2:09 PM identified when he/she complained about the condition of a state college insignia sweatshirt, originally blue, returned from the laundry now purple, he/she was told nothing could be done. Resident #38 stated that this was communicated to the head of laundry. Observation and interview with Resident #38 on 8/7/2025 at 10:55 AM identified the purple state college insignia sweatshirt as well as another clothing item, a pair of sweatpants, that had been black and was now gray. An interview with the Director of Housekeeping/Laundry on 8/7/2025 at 11:45 AM identified that if a piece of resident's clothing was damaged during laundering, she would make administration aware and replace the item of clothing. The Director of Housekeeping/Laundry indicated she was aware of Resident #8's bleached state college insignia sweatshirt and black sweatpants. She stated that soiled linen was placed in a plastic bag and could not be separated if it was visibly soiled with fecal matter. The Director of Housekeeping/Laundry indicated that she did not fill out a grievance form for the damaged clothing items and could not replace all of the items all of the time when they were coming into the laundry area soiled with fecal matter. An interview with the Administrator on 8/7/2025 at 12:59 PM identified the process for damaged clothing is to fill out a grievance form and this would be sent to the Social Work Department for review and then sent to her and the facility would replace the damaged clothing. A re-interview with the Administrator on 8/11/2025 at 10:06 AM identified that she spoke to Resident #38 and would re-educate the resident about how to bag the personal laundry to avoid bleaching and would be replacing the damaged clothing items. Additionally, she spoke with Social Services and the Director of Housekeeping/Laundry related to following the grievance policy. The Administrator could not state why a grievance was not filed for Resident #38's bleached clothing items. Review of the Grievance policy directed, in part, the grievance officer will be responsible for overseeing the grievance process including reviewing and tracking grievances to conclusion, conducting any necessary investigations. Upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. The Director of Social Service has been appointed as the grievance officer. Review of the infection control policy and procedure laundry/handling linen directed, in part, all laundry in the facility will be treated as contaminated and handled using standard precautions. Contaminated laundry includes both the residents' linen and clothing and reusable protective equipment, The facility will wash all laundry with the appropriate mix of temperature and chemical as established by the chemical supply contractor.

Based on review of the clinical record, facility policy, and interviews for 2 of 2 sampled residents (Resident #14 and Resident #26) reviewed for abuse, the facility failed to ensure freedom from physical abuse. The findings include:The Accident and Incident Report dated 6/13/25 identified that on 6/13/25 at 1:10 PM Resident #26 hit another resident (Resident #14) while sitting next to each other on the second-floor hallway. 1. Resident #14's diagnoses included Alzheimer's disease, dementia, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was severely cognitively impaired, independent with eating, and required substantial/maximal assistance for transfers. The Resident Care Plan dated 4/2/25 identified Resident #14 was at risk for impaired communication due to dementia, Alzheimer's, and anxiety. Interventions included using simple, direct language or gestures as needed, observe for understanding, and give time to respond and repeat as necessary. A nurse's progress note dated 6/13/25 at 4:08 PM identified Resident #14 was struck by another resident on his/her cheek and grabbed by his/her wrists. There were no signs of distress or complaints of pain. Following the incident, Resident #14 displayed his/her usual behavior. 2. Resident #26's diagnoses included major depressive disorder, essential hypertension, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was moderately cognitively impaired and required setup help with transfers. The Resident Care Plan dated 5/26/25 identified Resident #26 was using psychotropic medications related to depression. Interventions included monitoring for side effects and monitoring for target behaviors. A psychiatric evaluation and consultation assessment dated [DATE] at 1:20 PM (following the incident) identified that Resident #26 was considered a danger to self or others and sent to the Emergency Department for further evaluation. A nurse's progress note dated 6/13/25 at 3:15 PM identified that Resident #26 was conversing with another resident, then hit the other resident with a backhanded punch to his/her left cheek and grabbed both of his/her wrists. Staff intervened and Resident #26 was immediately removed from the vicinity and was placed on 1:1 monitoring until transferred to the Emergency Department for evaluation. The summary of findings report submitted to the state agency dated 6/16/25 at 12:00 AM identified that on 6/13/25 at 1:10 PM, there was a resident-to-resident altercation. Resident #26 and Resident #14 were sitting in the hallway having a conversation. Resident #26 became agitated and struck Resident #14 with a backhand to the left cheek and then Resident #26 grabbed both of Resident #14's wrists and held them. Staff members who witnessed the altercation immediately separated the residents and Resident #26 was placed on continuous (1 to 1) observation. An investigation was initiated; the MD, local Police Department and POA/responsible party of both residents were notified. Both residents were assessed by psychiatry services immediately. Resident #26 was considered a danger to self or others and sent to the Emergency Department for further evaluation. Resident #14 did not have any recollection of the incident. Interview with Licensed Practical Nurse (LPN) #3 on 8/7/25 at 10:51 AM identified on 6/13/25 she was standing at the medication cart to the side of the nurse's station. LPN #3 heard residents yelling and immediately responded. Although she did not witness Resident #26 strike Resident #14, she did witness Resident #26 holding both of Resident #14's wrists and with the help of another staff member, separated the residents. LPN #3 indicated that Resident #26 stated that they were arguing over who is better at life. Resident #14 did not remember the incident happening. Interview with the Psychiatry Advanced Practice Registered Nurse (APRN) #2 on 8/11/25 at 10:25 AM identified that on 6/13/25 she was standing at the nurse's station on the second floor and heard yelling. APRN #2 stated when she turned around to intervene, she witnessed Resident #26 back hand Resident #14 on the left cheek and then grabbed both of his/her wrists. APRN #2 and LPN #3 immediately separated the residents and Resident #26 was placed on a continuous (1 to 1) observation. APRN #2 indicated that while evaluating Resident #26 after the incident, Resident #26 indicated that he/she would do it again. APRN #2 identified Resident #26 as being a danger to self and others and placed an order for transfer to emergency room for further evaluation. APRN #2 identified that Resident #14 had no recollection of the incident. Additionally, APRN #2 identified that Resident #26 did not have a history of hitting. Review of the Abuse, Neglect, and Exploitation policy, dated 2/2023, identified the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.

Based on review of the clinical record, facility policy and interviews for 2 of 5 sampled residents (Resident #1 and Resident #18) reviewed for nutrition, the facility failed to ensure daily weights were obtained per the physician's orders and for 1 of 2 sampled residents (Resident #90) reviewed for medication administration the facility failed to ensure a medication was available at the time of administration. The findings include: 1. Resident #1's diagnoses included chronic diastolic congestive heart failure, coronary artery disease, and atrial fibrillation. A physician's order dated 7/9/2025 directed to administer bumetanide (diuretic) 2 milligrams (mg) daily, obtain a daily weight and give an extra 2 mg of bumetanide for weight gain of greater than 2 pounds (lbs.) in a day or 5 lbs. in a week. The admission 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, required moderate assistance from staff for activities of daily living, and required a mechanical lift for transfers out of bed. A physician's order dated 8/1/2025 directed to decrease bumetanide to 1 mg once a day. The Resident Care Plan dated 8/5/2025 identified a history of congestive heart failure (CHF) and to monitor weights, administer diuretics as ordered, monitor for early signs of CHF such as fatigue and weight gain and monitor for swelling to his/her feet, legs and ankles. A review of the clinical record lacked documentation that weights had been obtained daily from 7/9/2025 through 8/6/2025. Out of 28 opportunities, Resident #1 had not been weighed 24 times. Interview with APRN #1 on 8/6/2025 at 11:00 AM identified that she was not aware daily weights had not been obtained. APRN #1 indicated that bumetanide parameters for administration were in place based on Resident #1's daily weight. APRN #1 stated that Resident #1 was on daily weights due to his/her significant cardiac history and recent hospitalizations. Further she identified that it was the nurse's responsibility to ensure that weights were obtained and documented as directed. APRN #1 indicated that she would be discontinuing the bumetanide parameters for Resident #1, but he/she would remain on daily weights. APRN #1 stated that Resident #1 had recently lost weight, but it was not related to his/her CHF, instead due to a general health decline and lack of appetite. APRN #1 identified that Resident #1 was being followed by the dietitian and receiving health shakes. Interview with LPN #1, the resident's nurse, on 8/7/2025 at 12:30 PM identified that she was not aware that Resident #1 had been placed on daily weights with bumetanide parameters in place. Although requested, a policy on congestive heart failure and daily weights was not provided. 2. Resident #18's diagnoses included dementia, gastroesophageal reflux disease (GERD), and depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 had a Brief Interview of Mental Status (BIMS) score of 1 indicating severely impaired cognition, and was independent for eating, transfers, and bed mobility. The Resident Care Plan dated 7/24/2025 identified Resident #18 had a potential for impaired nutrition/malnutrition related to dementia, dysphagia, cachexia (weakness and wasting of the body), sub-optimal meal intake, and weight loss. Interventions included monitoring meal intake and weights as needed. The physician's order dated 7/11/2025 directed for weekly weight monitoring on Mondays during the day shift. Review of Resident #18's weight monitoring documentation identified 1 weight of 117.4 lbs. that was obtained on 7/20/2025 since the physician implemented the order dated 7/11/2025. (weights were missing for 8/14, 8/21, and 8/28/25). Interview with Nurse Aide (NA) #2 on 8/6/25 at 10:05 AM identified it was the facility policy for the NA's to obtain a resident weight upon admission or monthly, and any other weights required needed to be communicated by the nurse. Interview and clinical record review with Licensed Practical Nurse (LPN) #1 on 8/6/25 at 10:13 AM identified it was the facility policy for the nurse to review the physician's order in the electronic health record, then highlight the residents who needed a weight taken on the daily NA vital sign and weight sheet for the NAs to obtain. The charge nurse would then enter the resident weight into the electronic health record. A review of Resident #18's clinical record with LPN #1 identified a physician order to obtain a weekly weight had been placed on 7/11/25. The only weight documented as obtained since then was 7/30/25 (3 missed opportunities to weigh). LPN #1 identified Resident #18 was scheduled to receive a shower on Mondays during the 3:00 PM to 11:00 PM shift and weight monitoring was supposed to coincide with the weekly shower schedule. LPN #1 indicated that the facility had not obtained Resident #18's weight, most likely, due to the order indicating the weight should have been taken 7:00 AM to 3:00 PM shift instead of the 3:00 PM to 11:00 PM shift, when the residents shower had been scheduled. Interview and record review with Registered Nurse Supervisor (RN) #1 on 8/11/25 at 11:00 AM identified that it was the facility policy for the NA to weigh the resident, then have the nurse confirm that it was accurate. If there was a discrepancy, the supervisor would be alerted to obtain a reweight. A review of Resident #18's clinical record with RN #1 identified he/she should have been weighed weekly as of 7/11/25 but was only weighed on 7/30/25. She identified that the weights would not be documented anywhere else and was unable to identify why the physician's order was not followed. Review of the Weights Policy dated 8/15 directed in part that weekly weights will be obtained per physician's order. 3. Resident #90's diagnoses included chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 had a BIMS score of 12 indicating moderate cognitive impairment and required the assistance of 1 staff for activities of daily living. A Physician's order dated 6/1/2025 directed to administer Trelegy Ellipta inhaler 200-62.5-25 MCG (micrograms) 1 puff once a day for COPD. The Resident Care Plan dated 6/3/2025 identified COPD with interventions to administer inhalers and nebulizer treatments as ordered, elevate the head of the bed, follow up with pulmonary as needed, and monitor for signs and symptoms of an exacerbation of COPD. Observation of Resident #90's medication administration with LPN #2 on 8/5/2025 at 9:26 AM and interview with Resident #90 identified that the Trelegy inhaler was unavailable for administration. Resident #90 stated that he/she had not received the inhaler for a couple of days and that it needed to be reordered. LPN #2 contacted the supervisor, the pharmacy, and APRN #1 to update them that the Trelegy inhaler was unavailable for administration. A physician order was obtained to administer the Trelegy inhaler when received at the facility from the pharmacy. A review of Resident #90's Medication Administration Record (MAR) identified LPN #2 had administered Resident 90's Trelegy inhaler on 8/5/2025 at 5:20 PM. Although Resident #90 indicated that the Trelegy inhaler had not been administered for the past few days, a review of the MAR identified that LPN #6 had signed the medication as being given on 8/1/2025, 8/2/2025, 8/3/2025, and 8/4/2025. Several attempts to contact LPN #6 were made by the DNS and surveyor but were unsuccessful. Interview with Pharmacist #1, the pharmacy manager, on 8/5/2025 at 1:10 PM identified that Resident #90's Trelegy inhaler had been ordered on 1/5/25, 1/30/2025, 3/9/2025 and last ordered on 4/3/2025. Pharmacist #1 stated each Trelegy inhaler provided 30 doses, and that based on the dates of delivery there would not have been enough medication to last for the time period indicated unless the medication had been obtained by another source. An interview with the DNS on 8/6/2025 at 9:15 AM identified that if a medication was unavailable, then it should not have been signed as given. The facility process for unavailable medications directed the nurse to indicate on the MAR that the medication was not available, contact the pharmacy, notify the supervisor, and notify the APRN for further instructions. The DNS indicated that if a medication was not administered and orders were not obtained from the practitioner then it would be considered to be a medication error. The DNS stated she had not received any medication error report for Resident #90 and was not made aware that his/her inhaler was unavailable until 8/5 when it was brought to her attention by the surveyor. A review of the policy Medications Unavailable directed, in part, in the event that medication is unavailable for any reason, the facility shall act promptly to notify the appropriate practitioner for orders to be followed and the pharmacy to obtain the medications in accordance with the updated order. Upon identifying that a medication is unavailable, the facility shall investigate all instances to assess whether appropriate actions were taken to ensure continuity of care.

Based on review of the clinical record, facility documentation, and interviews for 2 of 3 sampled residents (Resident #1 and Resident #24) reviewed for communication/sensory deficits, the facility failed to ensure services related to vision were provided and for Resident #24, the facility failed to revise the Resident Care Plan when a change in visual needs occurred. The findings include: 1. Resident #1's was admitted on [DATE] with diagnoses that included type 2 diabetes, anxiety disorder, and depression. An interview with Resident #1 on 8/5/25 at 10:51 AM identified that he/she was having trouble seeing due to broken eyeglasses. Resident #1 indicated that the lens was loose and the hinge on his/her glasses was broken so the temple of the glasses came off. Resident #1 stated it was difficult to see, and he/she was not even able to watch television on the wall across from his/her bed, adding that he/she had informed a Nurse Aid (NA) but did not recall which one. Review of the Nursing admission Assessments dated 6/26/25 and 7/9/25 identified Resident #1 was near sighted and had adequate vision with glasses. A physician's order dated 7/9/25 directed to administer Lutein (vitamin for the eyes) 20mg (milligrams) once a day. A readmission 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition, required moderate assistance from staff for activities of daily living and required a mechanical lift for transfers out of bed. The Resident Care Plan dated 7/26/25 failed to identify Resident #1 needed glasses. A review of APRN #1's progress note dated 7/28/25 identified Resident #1 had poor vision secondary to broken glasses. An interview with the unit secretary on 8/6/25 at 9:45 AM identified that she was responsible for having residents sign consents for ancillary services on admission regardless of payor type. She identified that Resident #1 not signing his/her consent since admission (41 days) must have been an oversight on her part. Additionally, the unit secretary indicated that she was not aware that Resident #1's eyeglasses needed repair. Subsequent to surveyor inquiry, Resident #1 signed consent for optometry services, and his/her eyeglasses were sent out for repair. Although requested, an Optometry Service Policy was not provided. 2. Resident #24's diagnoses included dementia, diabetes, and bipolar disorder. A review of the eye care group consultation note dated 9/11/2024 identified moderate nuclear cataracts in both eyes, cataract surgery recommended: ophthalmology consult, follow up in 4-5 months. Referral for ophthalmology consult cataract surgery evaluation, please refer to eye physician for evaluation. A review of eye care group consultation note dated 1/16/2025 identified moderate nuclear cataracts in both eyes, cataract surgery recommended: ophthalmology consult, follow up in 4-5 months. Referral for ophthalmology consult cataract surgery evaluation, Resident #24 wishes to have a cataract evaluation, please refer to outside ophthalmologist for evaluation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #24 had a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment and required assistance with eating and bed mobility substantial maximum to total assistance for transfers and was totally dependent on staff for dressing. The Resident Care Plan dated 8/5/2025 identified Resident #24 had glasses and could see small print. Interventions included assisting with cleaning glasses as needed, and vision consults as ordered. A review of nurse's notes dated 1/3/2025 through 8/11/2025 failed to identify an ophthalmology consultation for cataract surgery was scheduled. A physician's order in effect for July directed an ophthalmology consult, cataract surgery was recommended. An interview with Resident #24 on 8/4/2025 at 11:00 AM identified he/she needed cataract surgery, and the facility would not arrange transportation. Resident #24 indicated he/she had seen the facility eye physician and was told that cataract surgery was necessary. Resident #24 was unaware as to why the facility had not scheduled a consultation appointment. Interview with the unit secretary on 8/7/2025 at 12:30 PM identified she had not received any documentation indicating an ophthalmology consultation was requested for Resident #24. In an Interview and clinical record review with Registered Nurse Supervisor (RN) #1 on 8/7/2025 at 12:45 PM she was unable to identify that the recommendations for ophthalmology referral for cataract evaluation had been addressed. RN #1 indicated that Resident #24 currently was not enrolled in any insurance plan and had no active insurance. Further, RN #1 verified with the APRN that she was not aware of the need for an ophthalmology consultation. RN #1 was unable to identify why the Ophthalmology consultation was not completed. RN #1 placed a call to the Finance Department and identified Resident #24's insurance was inactive since October 2024 and that a state appointed conservator was working with the facility to apply for insurance for Resident #24. Interview with the Administrator on 8/7/2025 at 12:55 PM identified that she was unaware Resident #24 needed an ophthalmology evaluation for cataract surgery or that there was a problem with Resident #24's insurance. Further, the Administrator indicated that the nursing supervisor should have informed the unit secretary of the need for the evaluation, but due to Resident #24's inactive insurance, the appointment could not have been scheduled. Review of the consultant services policy directed, in part, a note should be recorded on the consultation form by any health care consultant who sees the resident at the request of the physician or family. The consultant should document findings and recommendations on this form. The charge nurse will then notify the attending physician of the findings, and he/she can then order the specific treatments as outlined by the consultant. A consultant's report or some form of documentation pertaining to the results will be retained in the clinical record.

Based on observations, interviews and record reviews for 1 of 2 residents, (Resident #98) reviewed for positioning, the facility failed to ensure a splint for contractures was applied per the physician's order. The findings included:Resident #98's diagnoses included muscular dystrophy, polyarthritis, and chronic pain syndrome.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #98 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition and was dependent on staff for dressing, personal hygiene, and transfers.The Resident Care Plan dated 6/30/25 identified Resident #98 had an ADL deficit related to generalized weakness, muscular dystrophy and poor dentition. Interventions included left hand splint applied with morning care and off with evening care. Check the skin for redness and bruising.The physician's order dated 8/1/25 directed left hand liter grip splint to be applied daily with AM care and taken off with PM care, every day.The Resident Care Card (NA care directive) dated 8/1/25 indicated that a left hand splint was to be placed on before lunch and taken off after dinner.Observations on 8/4/25 at 11:30 AM, 8/5/25 at 10:22 AM and 8/7/25 at 10:02 AM identified Resident #98 in bed without the benefit of the left-hand splint.Interview and observation with Resident #98 on 8/6/25 at 12:28 PM identified he/she was in bed without the benefit of the left hand splint, stating he/she wears it when the staff applies it because it makes his/her hand feel better. Additionally, Resident #98 stated he/she does not refuse to wear the splint, and that staff don't apply the splint consistently. Interview and observation with Nurse Aid (NA) #1 on 8/6/25 at 12:37 PM identified the facility policy for NA was to follow the directive of the Resident Care Card to apply the hand splint. Even though NA #1 identified the splint was in the room (on a chair under pillows and blankets), and the care card instructed splint application, she stated the splint was on hold and had not been applied since surgery due to Resident #98's arm swelling.Interview and clinical record review with the Director of Rehabilitation on 8/6/25 at 2:25 PM identified the facility policy on hand splints was that Occupational Therapy performed the evaluation, education was provided to staff on the unit, and from there a physician's order was written directing the nursing staff in the application and removal of the splint. Additionally, the splinting company came out annually in June to perform fit checks and identify any necessary replacements that were required for residents utilizing splints. Review of Resident #98's clinical record with the Director of Rehabilitation identified he/she had an order for a left hand splint to be on placed on in the AM and off in the PM due to the diagnosis of muscular dystrophy. The most recent evaluation had been completed upon a readmission dated 8/1/25 and an initial evaluation had been completed on the resident's admission to the facility dated 5/20/23. The Director of Rehabilitation identified that the splint was not on hold, and failure to utilize the splint could cause a loss in range of motion, decreased skin integrity, and increase in contractures that could lead to increased impairments.Subsequent to surveyor inquiry the Director of Rehabilitation retrained staff on the application and removal of Resident #98's left hand splint. An observation on 8/11/25 at 11:02 AM identified Resident #98 in bed with the left hand splint in place.Review of the Splints/Orthotics/Prosthetics Policy dated 4/15 directed in part that residents will receive splints/orthotics/prosthetic devices as deemed appropriate by the physician and rehabilitation services. Additionally, the nursing staff will apply/remove the designated splint/orthotic/prosthetic device during wearing times.

Based on review of the clinical record, facility policy, and interviews for 2 of 5 sampled residents (Resident #8 and Resident #50) reviewed for nutrition, for Resident #8 the facility failed to implement recommendations for a nutritional supplement for a resident with a significant weight loss, failed to obtain weights per physician orders, and failed to update the Resident Care Plan after a significant weight loss, and for Resident #50 the facility failed to assess and implement nutritional interventions for a resident with a pressure ulcer. The findings include:1. Resident #8's diagnoses included hemiplegia and hemiparesis on the right side, hypertension, and hyperlipidemia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status (BIMS) score of 7 indicating severely impaired cognition, was independent for eating and required supervision walking 50 feet with a walker and had no significant weight loss.A. The Resident Care Plan (RCP) in effect from 2/8/2025 identified Resident #8 was at risk for malnutrition due to multiple chronic conditions, the need for adaptive equipment, and polypharmacy. Interventions included assessing and monitor for the presence of factors interfering with nutrition status as needed, document the percentage of solids and fluids consumed, and monitor weights as needed.A quarterly Nutritional Evaluation dated 2/17/2025 identified Resident #8 had experienced reduced appetite, was on monthly weights, and noted he/she had experienced a non-significant weight loss. The dietician recommended to initiate 120 milliliters (ml) of Mighty Shake (calorie and protein supplement) twice a day and record the percentage completed.A quarterly Nutritional Evaluation signed 3/24/2025 identified Resident #8 had a supplement ordered for 120 ml of Mighty Shake twice a day, was consuming 50-75% of most meals, was on monthly weights, and that the results of the evaluation had been communicated, to nursing. The Nutritional Evaluation failed to address if the Mighty Shake recommendation dated 2/17/2025 had or not been implemented for Resident #8.A significant change Nutritional Evaluation dated 6/30/2025 identified Resident #8 had a weight loss of 8 lbs. (greater than a 5% weight loss), was eating 25-50% of his/her meals, had a decreased appetite, and indicated that Mighty Shakes had been ordered as well as the resident was being weighed weekly. The Nutritional Evaluation failed to address if the recommendations for Mighty Shake (dated 2/17/2025) or weekly weights had been implemented.Although the Nutritional Evaluations dated 2/17/2025, 3/24/2025, and 6/30/2025 indicated monthly, then weekly weights to be taken, a review of the clinical record identified weights had been recorded on the following dates: 1/21/2025, 4/10/2025, 5/2/2025, 5/4/2025, 5/7/2025, 5/8/2025, 5/9/2025, 5/10/2025, 6/3/2025, 6/4/2025, 6/5/2025, 6/6/2025, and 6/6/2025 with no weights being recorded for the months of February, March, July or August 2025 and no record of weights being taken weekly.Review of physician, Advanced Practice Registered Nurse (APRN) orders and notes and nursing notes from 2/17/2025 through 6/29/2025 failed to identify the dietician recommendation for Mighty Shake administration twice daily or that weekly weighing had been addressed and failed to identify that Resident #8 had experienced significant weight loss. Additionally, a review of Resident #8's Intake/Output record and Amount Eaten Flowsheets for 2025 failed to identify any documentation indicating the Mighty Shake had been given since the dietician's recommendation dated 2/17/2025.Interview and record review on 8/6/2025 at 11:15 AM with Regional Dietician #2 identified that the on-site dietician was notified by facility staff, during report, of any residents who experienced a significant weight loss. Further, she identified it was the expectation of dieticians to monitor resident weights at least monthly and follow-up on weight loss if not noted to be a beneficial weight loss. Regional Dietician #2 indicated the dietician documented in their nutrition note dated 3/24/2025 Resident #8's weights would be monitored, as well as weight trends and patterns of weight loss, however, the documentation failed to show weight monitoring or any notes for Resident #8 for the months of April 2025 or May 2025. Additionally, the facility dietician had failed to indicate Resident #8 had been seen again until 6/30/2025. Regional Dietician #2 indicated it was the expectation that the facility dietician would have followed up on the weights at some point during April 2025 and May 2025 but had failed to do so.B. A physician order dated 4/1/2025 directed to obtain monthly weights every shift on the first during the first 10 days of the month.Record review of Resident #8's weights identified the following weight entries: On 4/10/2025 a weight of 127.0 pounds (lbs.) was recorded, on 5/10/2025 a weight of 119.8 lbs. was recorded for a 7.2 lb. weight loss (5.7% in one month), and on 6/6/2025 a weight of 119.0 lbs. was recorded. The facility documentation failed to indicate a monthly weight was taken in July 2025 per the physician order.Interview and clinical record review on 8/7/2025 at 1:40 PM with Licensed Practical Nurse (LPN) #1 identified that Resident #8 was being weighed monthly and unless his/her favorite Nurse Aide (NA) was the NA asking to obtain the weight, he/she often refused. Review of the clinical record failed to indicate that Resident #8 had refused being weighed in July or August 2025. LPN #1 further identified that the facility practice required all residents to be weighed within the first 10 days of the month. LPN #1 stated that reviewing Resident #8 for weight loss was not her responsibility and that the dietician was the responsible staff member. Interview and record review on 8/7/2025 at 2:16 PM with Registered Nurse (RN) #3 identified that no weights had been taken for Resident #8 in July 2025 or as yet in August 2025. RN #3 indicated it was the expectation for NAs and LPNs to obtain resident weights according to the physician order and to notify her if any attempt to obtain a weight was refused. She indicated that her staff had not notified her that Resident #8 had refused being weighed. RN #3 stated she would instruct her staff to obtain a weight on the resident now and she would re-educate her staff that if a resident refused to be weighed, she was to be informed. Subsequent to surveyor inquiry, on 8/7/2025 a weight of 124.0 lbs. (a 5 lb. weight gain since June 2025) was recorded for Resident #8.Interview on 8/11/2025 at 10:18 AM with APRN #3 identified that nurses would notify her of any significant resident weight loss verbally, but she could not recall ever being notified of a weight loss for Resident #8. Further, she identified if a dietary recommendation for a supplement needed to be ordered, the dietician would text or call her. Upon reviewing her telephone log, APRN #3 indicated that she had not received any texts or calls from the dietician regarding weight loss, weekly weights, or a recommendation for a supplement for Resident #8.Interview and record review with the Regional DNS on 8/11/2025 at 11:07 AM identified that the current order for Resident #8 was to obtain a weight monthly. Given Resident #8's weight loss of 5.7% in a month, the facility should have implemented their weekly weight policy. The Regional DNS identified that Resident #8 had experienced a 1 month significant weight loss (7.2 lb. loss from 4/10/2025 to 5/10/2025, 5.7% in one month). The Regional DNS indicated the facility had not followed the policy or physician order to obtain a monthly weight for Resident #8 and had not implemented the weight loss policy for a significant weight loss which directed weekly weights be taken for 4 weeks following an unanticipated weight loss of greater than 5% in 1 month. Further she identified nursing should have notified the physician, dietician, and resident's family of the 7.2 lb. weight loss but had failed to do so.Review of the Weight Policy identified, in part, that residents with an unanticipated, unplanned weight loss of greater than 5% in one month are to be weighed weekly for 4 weeks. If a significant weight loss/gain is identified (> 5% in 30 days, or > 10% in 6 months), the interdisciplinary team, dietician, physician, and family are notified. All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly.C. Although a review of the Resident Care Plan (RCP) in effect from February 2025 through 8/7/2025 identified Resident #8 was at risk for malnutrition; the RCP failed to reflect that Resident #8 had a significant weight loss, failed to reflect the intervention for Mighty Shake administration per the dietician, and failed to indicate the facility policy to weigh a resident weekly when a significant weight loss had occurred. Interview and record review with the Regional DNS on 8/11/2025 at 11:07 AM identified that Resident #8's RCP failed to be updated with Resident #8's change in condition.Review of the Comprehensive Care Plans Policy identified, in part, that care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintaining a specific level of functioning and reflect resident preferences and the right to refuse certain services or treatment. Additionally, the care is evaluated and revised as needed, but at least quarterly. 2. Resident #50's diagnoses included idiopathic peripheral autonomic neuropathy (damage to nerves that control involuntary bodily functions), atherosclerosis of bilateral lower extremities, and chronic pain.A hospital Wound Care Consult note (during Resident #50's hospitalization from 5/3/2025 to 5/5/2025) dated 5/4/2025 identified a need to optimize nutrition per a hospital Registered Dietician recommendation due to left and right heel, pink, blanchable areas. readmission physician's order dated 5/5/2025 failed to direct supplementation for wound prevention.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was independent with eating, putting on/taking off footwear, bed mobility, transfers, and walking 150 feet using a walker. Resident #50 was noted to be at risk for pressure ulcer development.A nursing note dated 5/23/2025 identified that Resident #50 had self-reported a Stage 3 pressure ulcer, measuring 5.0 cm x 6.0 cm x 0.1 cm on his/her right foot that was caused by his/her shoe insert. (Resident #50 independently inserted shoe inserts designed for different footwear.) Further, the note indicated the APRN, charge nurse, and conservator were notified, and he/she was scheduled for an evaluation with the wound nurse (APRN #4) at the next visit. The Resident Care Plan (RCP) was updated on 5/23/2025 with interventions for the facility acquired pressure ulcer.Review of physician and Advanced Practice Registered Nurse (APRN) orders from 5/5/2025 through 5/23/2025 (date of pressure ulcer development) failed to identify orders for supplementation for wound prevention and from 5/23/2025 8/11/2025 failed to identify orders for Resident #50 to receive a supplement to assist with wound healing. Review of the APRN #4's wound notes dated 5/29/2025, 6/2/2025, 6/9/2025, 6/16/2025, 6/30/2025, 7/7/2025, 7/16/2025, 7/23/2025, 7/28/2025, and 8/4/2025 (10 visits) identified Resident #50 had a right heel Stage 3 pressure ulcer and had received wound care. Additionally, during each of the 10 evaluations the APRN had directed a Registered Dietician consultation for supplementation to aid wound healing.Dietician #3's re-admission Nutritional Evaluation dated 6/26/2025 (34 days after Resident #50's facility acquired pressure ulcer developed and 52 days since readmission from the hospital) failed to identify Resident #50 had a nutritional evaluation for pressure ulcer prevention or had been evaluated for a supplement before or after the development of his/her stage 3 pressure ulcer, or that Dietician #3 was made aware of a pressure ulcer.Interview on 8/11/2025 at 10:33 AM with Dietician #3 identified she was responsible to follow-up with all residents on a monthly basis and as needed. She indicated she had never been notified that Resident #50 required an assessment to provide a supplement upon his/her readmission 5/5/2025. Additionally, when Dietician #3 reviewed her facility communication, she indicated staff had never notified her of the development of Resident #50's pressure ulcer or that APRN #4 requested a consultation for supplementation. Dietician #3 indicated that her evaluation dated 6/26/2025 was for a routine, quarterly evaluation.Interview and record review on 8/11/2025 at 11:07 AM with the Regional Director of Nursing Services (DNS) identified that wound care nurse, APRN #4, was responsible for notifying the dietician for consultation or supplement requests. During a review of the clinical record, she failed to identify documentation indicating an evaluation by the dietician, and if Resident #50 had a supplement implemented when first requested, it would have aided in his/her wound healing. Interview with facility APRN #5 on 8/11/2025 at 2:35 PM identified that she had verbally ordered Resident #50 to be seen by the dietician for a nutritional evaluation and supplement to aid in wound healing and had documented the request in her notes. She stated that she personally did not place any electronic orders for supplements and that APRN #4 (the wound APRN) was responsible for ordering and entering supplement orders. Further, APRN #5 identified that a facility staff nurse accompanied APRN #4 during wound rounds and any requests for supplements made by APRN #4 were reported to the facility nurse. Attempts to reach APRN #4 (the wound APRN) were unsuccessful.The Prevention and Management of Pressure Injuries Policy identified, in part, that residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided with appropriate treatment to encourage healing and/or maintenance of skin integrity.

Based on observations, review of clinical records, facility policy, and interviews for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #49) reviewed for respiratory care, the facility failed to ensure that nebulizer tubing and masks were labeled, dated, and appropriately stored. The findings include:1. Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF).A physician's order dated 7/9/25 directed to administer Albuterol Sulfate inhalation treatment 1 vial every 3 hours as needed for wheezing and shortness of breath.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment and required moderate assistance from staff for activities of daily living and required a mechanical lift for transfers out of bed.The Resident Care Plan (RCP) dated 8/5/25 identified a history of COPD with interventions to administer oxygen and nebulizer treatments as needed, head of bed to be elevated, follow up with pulmonology, and monitor for signs of exacerbation.Observations on 8/5/25 at 11:02 AM, 8/6/25 at 8:30 AM, and 8/7/25 at 12:55 PM identified an undated and unlabeled nebulizer tubing. Additionally, the tubing was noted to be stored inappropriately, without a cover, and open to the environment.2. Resident #2's diagnoses included Congestive Heart Failure (CHF) and coronary artery disease (CAD).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 9 indicating moderately impaired cognition and required maximum assistance with activities of daily living. Physician's orders dated 6/28/25 directed to administer Albuterol inhalation 0.5-2.5 3 milligrams (mg)/3 milliliters (ml) administer 3 ml every 6 hours as needed for shortness of breath and wheezing.The Resident Care Plan dated 7/1/25 failed to identify Resident #2's respiratory status and did not identify the use of nebulizer treatments.Observations on 8/4/25 at 3:14 PM, 8/5/25 at 11:15 AM, and 8/6/25 at 1:00 PM identified undated and unlabeled nebulizer tubing. Additionally, the tubing was noted to be stored inappropriately, without a cover, and open to the environment.3. Resident #49 diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and atrial fibrillation.Physician's orders dated 6/23/25 directed to administer Albuterol Inhalation solution 0.5 milligram (mg)/1 milliliter (ml) give 3 ml inhalation every 4 hours as needed.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 had a BIMS score of 15 indicating intact cognition and required minimal assistance with activities of daily living.The Resident Care Plan dated 7/8/25 identified a history of COPD with interventions to administer oxygen and nebulizer treatments as needed, head of bed to be elevated, follow up with pulmonology, and monitor for signs of exacerbation.Observations on 8/5/25 at 11:00 AM and 1:30 PM and on 8/6/25 at 6:30 AM identified undated and unlabeled nebulizer tubing. Additionally, the tubing was noted to be stored inappropriately, without a cover, and open to the environment.Interview with the central supply staff on 8/6/25 at 10:10 AM identified that she was responsible for ordering nebulizer and oxygen tubing and bags for storage. She indicated she conducted an inventory of respiratory supplies at least weekly to ensure there was an adequate supply on all the units. Additionally, there was an inventory of master supplies kept in the main central supply room. She indicated that there was plenty of nebulizer tubing and bags available to use in the storage rooms.An interview with LPN #1 on 8/7/25 at 12:00 PM identified that it was the facility policy to date and label all nebulizer tubing and store nebulizer masks in a bag. LPN #1 indicated that the licensed staff on the 11:00 PM to 7:00 AM shift were responsible to ensure the tubing had been changed. LPN #1 stated many times that the masks were not in bags and indicated that she was not sure why the items were unlabeled, undated, and not stored appropriately, in a bag.An interview with the DNS on 8/6/25 at 12:30 PM indicated that she was not sure what the facility policy was for changing tubing as she was new to the facility, but the standard was to change the tubing weekly, and ensure the tubing was labeled, dated, and stored appropriately, not open to the environment.Although requested, a policy for nebulizer treatments/tubing was not provided.A policy on Oxygen Administration was provided that directed, in part, oxygen tubing should be changed weekly and when visibly soiled.

Based on review of the clinical record, and interview for 2 of 2 sampled residents (Resident #1) reviewed for dental services, the facility failed to ensure a consent to treat was signed in a timely manner in order to provide dental services to a resident with known dental issues. The findings include:Resident #1 was admitted on [DATE] with diagnoses that included protein calorie malnutrition, type 2 diabetes, and Gastroesophageal Reflux Disease (GERD).Review of Resident #1's nursing admission Oral Health assessment dated [DATE] and subsequent Oral Health assessment dated [DATE] identified Resident #1 had more than 4 missing and decaying teeth. A physician order dated 6/26/25 direct to provide a diet that was small bite size solids with thin liquids and while sitting upright 90 degrees.A Physician's order dated 7/9/2025 directed to give a mechanical soft, ground texture diet. (the resident diet was downgraded)The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition, was able to eat independently, perform oral hygiene independently after set up, had obvious or likely cavity or broken natural teeth and had mouth or facial pain, discomfort or difficulty with chewing. The Resident Care Plan in effect during June, and July 2025 failed to identify that Resident #1 had any dental issues.A review of APRN #1's progress note dated 8/1/2025 identified Resident #1 had a significant amount of weight loss since admission and poor intake was multifactorial including a recent readmission to the hospital.Interview and observation with Resident #1 on 8/5/2025 at 10:51 AM identified that he/she was scheduled for extractions of teeth and to be fitted for dentures prior to admission. Resident #1 indicated that he/she had many missing and broken teeth that were causing difficulty with eating. Observation of Resident #1's mouth when speaking showed several broken teeth on the top and bottom. Resident #1 indicated that he/she had informed staff he/she required a follow up dental visit, could not recall who he/she had told, and that no facility staff had offered any information related to dental services.A review of speech therapy notes dated 8/5/2025 identified that speech therapy was being discontinued as Resident #1 was not being appropriate for a diet upgrade due to requiring follow up dental work. Resident #1 was noted to have 8 remaining teeth that were broken and/or decaying.An Interview with the unit secretary on 8/6/2025 at 9:45AM identified that she was responsible for having residents sign consents for ancillary services on admission. She indicated that it is the normal process for her to offer the services on admission to all residents regardless of payment source. She indicated it was an oversight on her part, that Resident #1 was not offered to sign a consent for dental services on admission. She also indicated that she was not aware of Resident #1 needed to be seen by a dentist.Subsequent to surveyor inquiry, Resident #1 signed consent for dental services and would be added to the dental list for an upcoming visit once a date was scheduled.Review of the Consultant Services policy directed, in part, once the consultant is identified by the physician and after the family has been notified and given permission for the consultation, the staff will call the consultant to notify them of the request and document the response in the medical record.

Based on observations, review of the clinical record, facility policy, and interviews for 2 of 2 Residents (Resident #70) reviewed for dental services, the facility failed to ensure an outside dental provider appointment was scheduled and failed to update the Resident Care Plan for dental issues. The findings include: Resident #70's diagnoses included diabetes, bipolar disorder, and lesions of oral mucosa.A dental note dated 1/2/2025 identified crowns and bridges throughout mouth, and that a follow up visit was scheduled for 6/20/2025. The note did not identify a missing crown or lesion on Resident #70's tongue.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent when eating, and required set-up assistance for oral hygiene, and failed to indicate dental issues.A nurse's note dated 4/23/2025 at 11:04 PM identified Resident #70 informed LPN #5 that his/her third tooth on the top right side was very loose. Resident #70 indicated that his/her teeth were implanted, and he/she would like to be seen by a dentist. The note indicated that LPN #5 placed Resident #70's request in the appointment book and the supervisor was made aware.The Advanced Practice Registered Nurse (APRN) #6's note dated 5/19/2025 identified Resident #70 requested an evaluation for a dark spot on the lateral aspect of the right side of his/her tongue. Resident #70 reported the spot had not changed since first noticing it approximately 1 month ago.A Physician order dated 5/19/2025 directed Resident #70 to be seen by a dentist as soon as possible to evaluate a painless dark spot-on right side of his/her tongue.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #70 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment, required set-up assistance for eating and oral hygiene, and failed to indicate dental issues.APRN #1's note dated 6/16/2025 directed a follow up dental evaluation for Resident #70's tongue lesion.The Resident Care Plan dated 7/25/2025 identified a dark area on the tongue that was not painful and a history of cancer, chooses not to be seen by an in-house dentist at times. Currently, Resident #70 had been seen by the in-house dental services. Interventions included observing the dark area daily, ask Resident #70 if the area was painful or if they were having any difficulty chewing, and providing a dental consultation as soon as possible. The care plan failed to identify the missing crown or loose tooth.Interview and observation on 8/4/2025 at 11:45AM with Resident #70 identified that his/her front tooth crown had fallen off in April. Resident #70 indicated he/she needed to go to an outside dentist to have the crown repaired because the facility dentist could not repair a crown in house.An interview and clinical record review with the unit secretary on 8/7/2025 at 12:30 PM indicated she was responsible to schedule dental the consultation. The unit secretary was unable to locate a referral to an outside state dental provider.An interview on 8/7/2025 at 12:56 PM with the Administrator indicated she was unaware that Resident # 70 needed a state dental appointment with an outside dental provider. Subsequent to surveyor inquiry, the Administrator provided documents dated 8/8/2025 at 7:28 AM that had been sent to a state outside dental provider requesting an appointment as soon as possible. Review of the Consultant Services policy directed, in part, once the consultant is identified by the physician and after the family has been notified and given permission for the consultation, the staff will call the consultant to notify them of the request and document the response in the medical record. If the consultant will not come to the facility, the Physician will either identify a consultant who does make facility visits, or the social worker, nurse and family will arrange for consultation outside the facility. A note should be recorded on the consultation form by any health care consultant who sees the resident at the request of the Physician or family. The consultant should document findings and recommendations on this form.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for admission, the facility failed to ensure a comprehensive skin assessment was completed timely upon admission. The findings include: Resident #1's diagnoses included dementia and frontotemporal neurocognitive disorder. The RN admission assessment dated [DATE] identified that Resident #1 was alert, oriented to person, cooperative, aphasic (unable to communicate), unable to express ideas, incontinent of bowel and bladder and was dependent with ADL care. The Resident Care Plan (RCP) dated 12/28/2024 identified Resident #1 had the potential for pressure ulcer development related to immobility. Interventions directed follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of RN admission nursing note dated 12/28/2024 at 12:47 PM indicated Resident #1 arrived to 11:10 AM for respite stay, resident alert, was nonverbal and had contractures to upper and lower extremities. Review of the Norton Plus assessment score on admitted d 12/28/2024 indicated Resident #1 was at very high risk of developing pressure ulcers. Record review identified an admission assessment was completed by RN #1. Additional review identified RN #1 assessment included a Norton Plus skin risk with a score of 9 (high risk for alteration in skin). Additional review identified a skin assessment was not included in the admission assessment. Review of Pressure Injury Evaluation dated 12/30/2024 (2 days after admission), completed by LPN #1 (wound nurse), identified that Resident #1 had three (3) non-facility acquired pressure injuries staged as Deep Tissue Injuries (DTI's) to the proximal left lateral foot 1.0 x 1.0 centimeter (cm), left lateral mid foot 3.0 x 2.5 cm, and distal left lateral foot 4.0 x 3.0 cm. The evaluation identified the date of origin was on 12/28/2024. Nursing note dated 1/1/2025 identified notified by LPN that resident had a pressure ulcer DTI, and new orders were obtained to offload the area and keep foam dressing in place for support. Record review failed to identify a skin assessment was completed upon admission on 12/28/2024 (2 days prior to the DTI note). Additional review failed to identify an RN Assessment was completed for the newly identified alteration in skin integrity on 12/30/2024. Interview, review of clinical record and facility documentation with LPN #1 (wound nurse) 1/28/2025 at 12:34 PM identified that she evaluated Resident #1's skin on 12/30/2024 after reviewing the facility new admissions list. LPN #1 stated on 12/30/2024 Resident #1 had three (3) left lateral foot pressure ulcers that were present on admission. On 1/28/2025 at 1:49 PM interview, review of clinical record and facility documentation with the DNS identified that the facility prevention and management of pressure injuries policy directs on admission a comprehensive assessment of a resident will be completed which includes a head-to-toe skin assessment, and upon Resident #1's admission the nurse should have completed and documented the skin assessment. Interview failed to identify why an admission skin assessment was not completed, and why an RN assessment was not completed on 12/30/2024 when the DTI areas were identified. Review of facility Prevention and Management of Pressure Injuries Policy directed in part, residents with pressure injuries are identified, assessed and provided appropriate treatment, ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. On admission/readmission, a comprehensive assessment of the resident will be completed which will include the following: a head-to-toe skin assessment.

Based on clinical record reviews, review of facility documentation, review of facility policy and interviews for four of six sampled residents (Residents #8, #9, #10, and #12) reviewed for a potential allegation of verbal abuse, the facility failed to ensure the residents were treated in a dignified and respectful manner when a staff member used insensitive language when speaking to a resident and a staff member yelled in front of a resident. The findings include: 1. Resident # 8's diagnoses included overactive bladder, bipolar disorder, and paroxysmal atrial fibrillation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #8 was cognitively intact and required extensive assistance of one (1) staff person for most Activities of Daily Living. The Facility Reported Incident report dated 7/22/21 at 10:00 AM indicated Resident #8 alleged a staff member called Resident #8 a liar and turned off the call bell without toileting Resident #8. The report identified the facility substantiated that the charge nurse told Resident #8 that he/she used the bathroom too frequently and the nurse may have shut the call light off. The report indicated this caused emotional distress to Resident #8. The investigation identified the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #2, spoke in an undignified manner and used insensitive language toward Resident #8 when LPN #2 told Resident #8 that he/she used the bathroom too frequently and called Resident #8 a liar. The summary report dated 7/28/21 identified employment with LPN #2 was terminated. Interview and review of the Facility Reported Incident report with the Director of Nursing (DON) on 7/3/24 at 10:54 AM indicated although he was not at the facility at the time of the incident, based upon the facility documentation reviewed, the outcome of the investigation determined LPN #2 did not speak to Resident #8 in a respectful manner. The DON identified it was the expectation for all staff to treat all residents with respect while providing the care a resident needed. 2. Resident #9's diagnoses included osteoarthritis, bipolar disorder, and anxiety. The annual Minimum Data Set assessment dated [DATE] identified Resident #9 was cognitively intact and required limited one (1) person assistance with dressing and personal hygiene. The Facility Reported Incident report dated 11/17/23 identified NA #5 was in the hallway yelling at other staff. The report indicated Resident #9 became visibly upset by the behavior of NA #5 and was seen crying and shaking. Interview and review of the Facility Reported Incident report with the Administrator on 7/3/24 at 9:35 AM identified an investigation was conducted and determined NA #5 was in the hallway yelling at other staff about Resident #9's grievance and Resident #9 became upset by the behavior of NA #5. The Administrator identified NA #5 was not permitted back to the facility following the incident. 3. Resident #10's diagnoses included unsteadiness, need for assistance with personal care, and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 was cognitively intact and required limited one (1) staff person assistance with bed mobility, transferring, toileting, and personal hygiene. The Facility Reported Incident report dated 8/9/23 identified Resident #10 reported a nurse aide yelled at him/her on 8/8/23 on the 11PM-7AM shift after Resident #10 went to the bathroom on his/her own without waiting for assistance from a staff member. The investigation identified NA #6 communicated with Resident #10 in a manner that was unacceptable and not respectful of Resident #10. The report indicated NA #6 answered Resident #10's call bell on 8/8/23 on the 11PM-7AM shift, questioned Resident #10 why resident needed assistance and commented to Resident #10 that I was just in here ten (10) minutes ago. Interview and review of the Facility Reported Incident report dated 8/9/23 with the Director of Nursing (DON) on 7/3/24 at 10:58 AM identified although he was not at the facility at the time of the incident, based upon the facility documentation reviewed, the outcome of the investigation determined NA #6 did not speak to Resident #10 in a respectful manner. The DON identified it was the expectation that all staff members treat residents with dignity and speak to residents in a respectful manner. Review of the facility Resident's [NAME] of Rights dated 7/2021 directed residents had the right to be treated with consideration, respect, and full recognition of his/her dignity and individuality. 4. Resident #12's diagnoses included dementia and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #12 rarely made decisions regarding tasks of daily life, required substantial to maximum assistance with toileting, partial to moderate assistance with ambulating, utilized a wheelchair for mobility, was occasionally incontinent of bowel and bladder, and has a history of falls. The Resident Care Plan dated 1/29/24 identified Resident #12 was at risk for falls. Interventions directed to toilet early on first rounds, to provide frequent toileting throughout shift, keep wheelchair by the bed, and call bell within reach. The nurse's note dated 2/3/24 at 11:30 PM identified Resident #12 was found on the bathroom floor sitting on his/her buttock in front of the toilet and Resident #12 stated I had to go to the bathroom. The Facility Reported Incident form dated 2/4/24 identified Resident #12 sustained a fall in the bathroom without injury on 2/3/24. The report indicated the nurse aide upset with another staff member entered Resident #12's room using profanity in front of Resident #12. The investigation identified the 11PM-7AM nurse aide, Nurse Aide (NA) #7, and the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #3, had an argument at the nurse's station which carried into Resident #12's room when NA #7 went to assistance with getting Resident #12 up and off the floor. In an interview with the Administrator on 7/3/24 at 10:54 AM identified Resident #12 had fallen around the change of shifts, and LPN #3 asked NA #7 where she was and why Resident #12 had not been checked. The Administrator indicated the conversation took place at the nurse's station and NA #7 was swearing, NA #7 went into Resident #12's room and continued swearing, Resident #12 apologized to NA #7 for being an inconvenience and falling. The Administrator identified at the conclusion of the investigation NA #7 was terminated.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for the implementation of the care plan, the facility failed to ensure Resident #1 was transferred with the assistance of two (2) staff members. The findings include: Resident #1's diagnoses included fracture of the lateral condyle of the right tibia (lower leg), fracture of the left calcaneus (heel), unspecified head injury and arthritis. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time and required assistance of two (2) staff members with toileting, transferring, and ambulation with the use of a walker (a device to assist with ambulation) with partial weight bearing restrictions. The Resident Care Plan dated 8/27/21 identified a risk for activities of daily living deficit related to recent hospitalization for fall with fractures and non-weight bearing to the left lower extremity and toe touch weight bearing to the right lower extremity, impaired mobility, and pain. The care plan identified a left calcaneus fracture and right lateral tibial plateau fracture repaired with open reduction internal fixation (ORIF) and at risk for falls. Interventions directed to keep the call bell within reach, Occupational and Physical therapy evaluations and treatment as ordered, assist with position changes as needed, encourage elevation of fracture site, monitor circulatory motor sensation, non-weight bearing to the left lower extremity, toe touch weight bearing to the right lower extremity, orthopedic follow up as ordered, instruct in proper use of appliance and device to aid with balance/ and transfers and encourage use, and instruct to ask for assistance prior to attempting to transfer or ambulate as needed. A physician's order dated 8/28/21 directed the activity orders out of bed to chair as tolerated, ambulation with rehabilitation only, assist of two (2) staff members for transfers from bed to chair with rolling walker, assist of two (2) staff members to transfer to bedside commode for toileting, and assist of one (1) staff member for activities of daily living at bed or wheelchair level to resident's preference with precautions of non0weight bearing to left lower extremity and toe touch weight bearing to right lower extremity. The resident care card, undated, directed for transfer status with assist of two (2) staff members with toe touch weight bearing to the right lower extremity and non-weight bearing to the left lower extremity with pivot on right lower extremity. Interview and picture review with Person #4 on 7/3/24 at 7:57 AM identified Resident #1 was observed being transferred with only one (1) staff member. Interview, review of complainant pictures and clinical record review with the Director of Nursing (DON) on 7/3/24 at 11:03 AM identified the physician's order directed for Resident #1 to be out of bed to chair as tolerated, ambulate with therapy only, assist of two (2) staff members bed to chair with rolling walker, assist of two (2) staff members to bedside commode for toileting, assist of one (1) staff member for activities of daily living at bedside or wheelchair level with toe touch weight bearing to right lower extremity and non-weight bearing to left lower extremity. The DON identified there was also an order that directed for right lower extremity toe touch weight bearing, can use pivot with assistance of two (2) staff members. Although requested, a policy on weight bearing status was not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for pain management, the facility failed to ensure the hospital discharge order for ice to the lower extremities five (5) times a day for twenty (20) minute intervals was implemented. The findings include: Resident #1's diagnoses included fracture of the lateral condyle of the right tibia (lower leg), fracture of the left calcaneus (heel), unspecified head injury and arthritis. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time and required assistance of two (2) staff members with toileting, transferring, and ambulation with the use of a walker (a device to assist with ambulation) with partial weight bearing restrictions. The Resident Care Plan dated 8/27/21 identified a risk for activities of daily living deficit related to recent hospitalization for fall with fractures and non-weight bearing to the left lower extremity and toe touch weight bearing to the right lower extremity, impaired mobility, and pain. The care plan identified a left calcaneus fracture and right lateral tibial plateau fracture repaired with open reduction internal fixation (ORIF) and at risk for falls. Interventions directed to keep the call bell within reach, Occupational and Physical therapy evaluations and treatment as ordered, assist with position changes as needed, encourage elevation of fracture site, monitor circulatory motor sensation, non-weight bearing to the left lower extremity, toe touch weight bearing to the right lower extremity, orthopedic follow up as ordered, instruct in proper use of appliance and device to aid with balance/ and transfers and encourage use, and instruct to ask for assistance prior to attempting to transfer or ambulate as needed. Review of the hospital discharge summary dated 8/27/21 directed for Resident #1 to keep the extremities elevated and to apply ice five (5) times a day for twenty (20) minute intervals. A physician's order dated 8/27/21 directed to monitor pain every shift using the zero to ten (0-10) pain scale. Interview and clinical record review with the Director of Nursing (DON) on 7/3/24 at 11:03 AM identified the hospital discharge summary included an order to ice the lower extremities five (5) times a day for twenty (20) minute intervals, but this was not reflected in the physician orders or care plan. Review of the facility policy titled, Pain Management, dated April 2015, directed, in part, the facility will, to the extent possible, develop and implement interventions/approaches to pain management, both pharmacological and non-pharmacological.

Based on clinical record reviews, facility documentation, and interviews for one of three sampled residents (Resident #1) who was at risk for falls and aspiration and required one (1) to one (1) with meals, the facility failed to ensure the safety of Resident #1 who fell and sustained a laceration while attempting to walk to his/her meal tray that was across the room. The findings include: Resident #1's diagnoses included history of fall with neck fracture, right subdural hematoma, dysphagia (difficulty swallowing), and repeated falls. The Fall Risk assessment dated [DATE] identified Resident #1 was at high risk for falls. The Physical Therapy assessment dated [DATE] identified Resident #1 demonstrated a poor standing balance, was unable to perform ambulation, and was at risk for falls. A physician's order dated 2/9/24 directed to transfer with one (1) person assistance with rolling walker or two (2) person assistance as needed due to fatigue following dialysis, ambulate with rehab only, toileting assistance with one (1) at wheelchair level or with two (2) as needed due to fatigue following dialysis. Aspiration orders directed a pureed consistency with honey thick liquids, one (1) to (1) feed, teaspoon sips, consistent cues for throat clears/swallows after each bite or sip, slow rate, small bites, alternate liquids/solids, and withhold food or liquids by mouth if lethargic. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required maximum assistance with toileting, hygiene, bathing, dressing, and getting in and out of the bed and chair and was dependent on staff or eating. The Resident Care Plan dated 2/15/24 identified Resident #1 was at risk of falls. Interventions directed assistance of one (1) for getting in and out of the bed and chair, two (2) quarter side rails to aid with turning and repositioning, offer toileting on first rounds on the 11PM-7AM shift, gripper socks while in bed, instruct resident to ask for assistance before attempting to transfer or ambulate, call bell in reach, and offer to get the resident out of bed on the last rounds on the 11PM-7AM shift. The nurse's note dated 2/21/24 at 9:09 AM identified Resident #1 had fallen and was on the floor when the nurse entered the room. The note identified Resident #1 was bleeding from the forehead, complained of back pain, the Advanced Practice Registered Nurse (APRN) was notified and assessed Resident #1 after the fall, and the Emergency Medical Service (EMS) was called. The nurse's note dated 2/22/24 at 5:44 PM identified Resident #1 returned from the hospital, Resident #1 sustained two (2) black eyes and had 4 sutures in the middle of the forehead. The note indicated the nurse aide was instructed to not leave food at the bedside because Resident #1 would attempt to feed self. The facility's summary report dated 2/27/24 directed not to leave meal trays on the table until someone was there to assist the resident with the meal. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 3/19/24 at 1:20 PM identified she was the nurse aide assigned to Resident #1 on 2/21/24 and she placed Resident #1's breakfast tray across the room from where Resident #1 was seated, told Resident #1 she would be back to assist with the meal, and Resident #1 acknowledged her by saying, ok. NA #1 explained she left and was out of the room for approximately three (3) to five (5) minutes when Resident #1's call bell went off. NA #1 identified when she entered the room, Resident #1 was on the floor next to the table where she had left the food tray on which was approximately five (5) feet away from where Resident #1 had been sitting. NA #1 identified Resident #1's level of supervision for meals was a one (1) to one (1) which meant staff had to be present during mealtime and that was why she left the tray across the room.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled residents (Resident #1) who were reviewed for an allegation of neglect, the facility failed to ensure the resident was fed breakfast and failed to check and provide incontinent care during the 7AM-3PM shift. The findings include: Resident #1's diagnoses included Huntington disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up or clean-up assistance with eating, was dependent on staff with toileting, personal hygiene and was always incontinent of bowel and bladder. The Resident Care Plan dated 11/7/23 identified Resident #1 had activities of daily living self-care deficit related to Huntington's disease and restlessness. Interventions directed supervision with all meals (resident not to be left alone with any food), aspiration precautions and a total feed. The care plan identified Resident #1 was incontinent of bowel and/or bladder. Interventions directed to check and provide incontinent care approximately every two (2) hours and as needed. The nurse's note dated 12/27/23 at 11:02 AM (late entry for 12/24/23) identified Resident #1's family member met with the Director of Nursing to file a grievance against staff regarding Resident #1 not being fed breakfast on 12/24/23. The family member stated when he/she arrived at the facility Resident #1's breakfast tray was on the bedside nightstand and the meal had not been touched. The note indicated an investigation was initiated. The Facility Reported Incident form dated 12/27/23 at 1:00 PM identified Resident #1's family member reported and filed a grievance that Resident #1 was not fed breakfast on 12/24/23, Christmas Eve. The report identified Resident #1's family member arrived at the facility at approximately noontime and saw the breakfast tray at Resident #1's bedside untouched. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 1/17/24 at 10:40 AM identified she was an agency aide, it was her second time working at the facility and she was assigned to Resident #1. NA #1 indicated although she received a roster with resident names and room numbers, she did not receive a shift-to-shift report from the outgoing nurse aide, the 7AM-3PM nurse aide on the unit or the charge nurse. NA #1 identified she went into each room on her roster and Resident #1 was not in his/her room and the bed was made, so she assumed Resident #1 was either in the hospital or was discharged to home. NA #1 indicated she did not ask the facility staff if Resident #1 was in the facility or not and stated she was wrong not to ask questions regarding Resident #1's whereabouts. NA #1 identified she could not remember the exact time, however it was around lunchtime when Resident #1's family member arrived, came up to her and asked why Resident #1 was not fed breakfast today. NA #1 indicated she told Resident #1's family member that she was an agency aide, she did not know who his/her family member was and directed him/her to speak with the charge nurse. NA #1 identified she was unaware of who Resident #1 was due to Resident #1 being in a wheelchair in the hallway. NA #1 identified besides not feeding Resident #1, the first time she provided incontinent care to Resident #1 was around 12:45-1:00 PM (approximately six (6) hours) Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 1/17/24 at 10:58 AM identified NA #2 came up to her and stated Resident #1's family member had come up to her saying Resident #1 did not receive breakfast. LPN #1 indicated she had no idea about Resident #1 not being fed breakfast until that moment. LPN #1 identified she spoke with NA #1 who had Resident #1 on her assignment and NA #1 indicated she did not even know Resident #1 was on her assignment. LPN #1 indicated NA #1 had a list of residents that she was responsible for during the 7AM-3PM shift and NA #1 stated to her she just assumed Resident #1 was fed in the dining room. LPN #1 identified she did not give a report to NA #1 at the beginning of the shift and stated NA #2 did. Interview with a 7AM-3PM nurse aide, NA #2, on 1/17/24 at 11:45 AM identified the facility staff found out at lunch time when Resident #1's family member arrived that Resident #1 had not been fed breakfast because Resident #1's breakfast tray was still in Resident #1's room sitting on the nightstand. NA #2 indicated Resident #1 was a fall risk and the 11PM-7AM staff get Resident #1 up as they always did, and Resident #1 sits at the nurse's station most of the time. NA #2 identified Resident #1's family member fed him/her breakfast almost daily, however on 12/24/23 the family member did not show up to feed Resident #1 breakfast. NA #2 indicated she did not give NA #1 report because she had two (2) other agency nurse aides to give the report to, and she believed the charge nurse gave NA #1 report. Interview with the Director of Nursing (DON) on 1/17/24 at 2:10 PM identified it was brought to her attention by Resident #1's family member who came in on 12/27/23 to her office and told her that Resident #1 was not fed breakfast on 12/24/23. The DON indicated the family member stated the breakfast was on the nightstand, untouched, and it was almost lunch time. The DON identified LPN #1 should have been following up with what the nurse aids were doing and should have given NA #1 report at the beginning of the shift. The DON indicated the nurse aide leaving the 11PM-7AM shift should have given NA #1 a report and LPN #1 should have been checking to make sure it was being done. The DON identified Resident #1 did not receive incontinent care from 7:00 AM until noontime (five (5) hours) and should have received incontinent care approximately every two (2) hours or per the plan of care. The DON indicated she was unsure when Resident #1 received incontinent care last during the 11PM-7AM shift. Interview with the 11PM-7AM nurse aide, NA #4, on 1/17/24 at 3:25 PM identified Resident #1 was incontinent of bowel and bladder and was totally dependent on staff with the activities of daily living. NA #4 indicated the last time she provided incontinent care to Resident #1 on 12/24/23 was between 6:30-6:45 AM during her shift. Review of the Pressure Injury/Non-pressure Injury Wound Risk Management Policy directed to check resident for incontinence approximately every two (2) hours or per the individualized plan of care. The Resident's [NAME] of Rights directed the residents have the right to be treated with consideration, respect and full recognition of the resident dignity and individuality. The residents had a right to receive a quality care and services with reasonable accommodation of resident individual needs and preferences, except when resident health or safety or the health of safety of others would be endangered by such accommodation. Review of the Abuse, Neglect and Exploitation Policy and Procedure Manual directed neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record reviews, facility documentation, facility policies and interviews for one of four sampled residents (Resident #1) who were reviewed for an allegation of neglect, the facility failed to report the allegation to the Administrator or the Director of Nursing at the time the allegation was reported by a family member. The findings include: Resident #1's diagnoses included Huntington disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up or clean-up assistance with eating, was dependent on staff with toileting, personal hygiene and was always incontinent of bowel and bladder. The Resident Care Plan dated 11/7/23 identified Resident #1 had activities of daily living deficit related to Huntington's disease and restlessness. Interventions directed supervision with all meals (resident not to be left alone with any food), aspiration precautions and a total feed. The care plan identified Resident #1 was incontinent of bowel and/or bladder. Interventions directed to check and provide incontinent care approximately every two (2) hours and as needed. The nurse's note dated 12/27/23 at 11:02 AM (late entry for 12/24/23) identified Resident #1's family member met with the Director of Nursing to file a grievance against staff regarding Resident #1 not being fed breakfast on 12/24/23. The family member stated when he/she arrived at the facility Resident #1's breakfast tray was on the bedside nightstand and the meal had not been touched. The note indicated an investigation was initiated. The Facility Reported Incident form dated 12/27/23 at 1:00 PM identified Resident #1's family member reported and filed a grievance that Resident #1 was not fed breakfast on 12/24/23, Christmas Eve. The report identified Resident #1's family member arrived at the facility at approximately noontime and saw the breakfast tray at Resident #1's bedside untouched. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 1/17/24 at 10:58 AM identified when Resident #1's family member reported to her that Resident #1 was not fed breakfast, she did not report this incident to anybody because the family member seemed fine, and she thought it was pretty much handled. LPN #1 indicated she apologized to the family, asked if they needed anything, explained that the incident would not happen again and educated the nurse aide assigned to Resident #1. Interview with the Director of Nursing (DON) on 1/17/24 at 2:10 PM identified if there was an allegation of abuse or neglect the staff should have notified her or the Administrator immediately. The DON indicated staff should have called her or the Administrator on 12/24/23 and they did not. Review of the Abuse, Neglect and Exploitation Policy and Procedure Manual directed reporting of all alleged violations to the Administrator, state agency, adult Protective Services and to all other required agencies within specified time frames: immediately, but not later than two (2) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on clinical record reviews, observations, review of facility's documentation and interviews for one of three sampled residents (Resident #17) reviewed for facility acquired pressure ulcers, the facility failed to ensure interventions were consistently implemented to prevent the development and worsening of a pressure ulcers/injury. The findings include: Resident #17 had diagnoses that included cerebral infarction, hemiplegia and hemiparesis, paroxysmal atrial fibrillation, seizures, Parkinson's disease, congestive heart failure, iron deficiency anemia, dysphagia, type 2 diabetes mellitus, and protein calorie malnutrition. The Norton_Scale (used to predict risk for pressure ulcer development) dated 1/24/23 identified the resident was at high risk for pressure ulcer development. The physician's order dated 1/24/23 directed to offload heels every shift as tolerated. The RCP dated 1/31/23 identified the resident was at risk for skin breakdown with interventions that included inspect skin for redness, irritation or breakdown during care, off load heels, offer to turn and reposition every two hours and as needed, pressure reducing cushion and mattress, and wound physician to evaluate and treat. The Norton_Scale (used to predict risk for pressure ulcer development) dated 4/29/23 identified the resident was at high risk for pressure ulcer development. The quarterly MDS assessment dated [DATE] identified Resident #17 had severe cognitive impairment, depressed mood, no behavioral issues, required extensive assistance of two staff members for bed mobility, was non-ambulatory, required total assistance for transfers, locomotion, eating, dressing, and toilet use. The assessment further identified Resident #17 had a range of motion deficit of an upper extremity affecting one side, had experienced a weight loss that was not physician prescribed in the past month or the past six months, and was at risk for the development of pressure ulcers but did not have a pressure ulcer. Review of the weekly wound physician's notes for the period of April/2023 through 6/5/23 directed Resident #17's heels be offloaded per the facility's protocol, initiate pressure ulcer prevention protocol (the protocol identified that on admission or readmission, a comprehensive assessment of the resident will be completed which would include a head-to-toe assessment in a manner that respects the residents' dignity. A comprehensive clinical assessment to identify specific physical and functional risk factors associated with pressure injury development. The resident should be assessed for pressure injury risk factors, the resident's skin is observed daily with care, resident will have weekly body audit completed by licensed staff and pressure injuries are assessed and documented on at least weekly and with a significant change in the wound until it is resolved.) and apply a pressure redistribution mattress. The notes further identified that the plan of care would be discussed and coordinated with the wound treatment nurse. Review of the treatment administration record (TAR) from January 2023 to May 2023 identified the instruction to offload Resident #17's heels on every shift (day, evening, and nights). The documentation identified that the licensed staff were signing that the heels were being offloaded. The APRN's note dated 5/2/23 at 2:16 PM identified Resident #17 continued to have problems with eating and intake. He/she had labs based on history of IV fluid therapy needs, cardiovascular accident, poor intake and low Albumin which is now stable at 3.8. The note further identified that the resident's appetite continues to vary without acute worsening of condition and no acute kidney injury noted. The note further noted that the resident was stable but declining as expected. The nurse's note dated 5/13/23 identified that Resident #17 was noted with a DTI to left heel measuring 2.5 cm in length by 2.0 cm in width. Resident had no complaint of pain or discomfort, APRN notified, treatment was initiated as per protocol and a note was left for the wound MD. Responsible party updated. The Pressure Injury Evaluation dated 5/13/23 at 9:05 PM identified that the DTI was facility acquired and that Resident #17 was educated to keep legs offloaded. Responsible party educated on skin care/precautions. The wound physician's (MD #1) note dated 5/15/23 identified Resident #17 had a left heel deep tissue pressure injury with persistent non-blanchable deep red, maroon or purple discoloration. The note identified that the wound measured 3.0 centimeters(cm) in length by 3.0 cm in width with no depth and an area of 9.0 square(sq) cm. In addition, the note noted there was no drainage, and the resident reported a wound pain score level of zero out of ten (0 indicative of no pain and 10 indicative of extreme pain). The skin around the wound exhibited ecchymosis, and erythema. Further review identified that the resident's heels should be offloaded, apply a pressure redistribution mattress, and identified the plan of care was discussed and coordinated with the wound treatment nurse. Observation on 6/5/23 at 10:23 AM with MD #1 and RN #3 (Infection Control Nurse) identified Resident #17's heels were resting on the surface of the bed and were not offloaded. At 10:27 AM interview with MD #1 identified that staff were not offloading Resident #17's heels as ordered. MD #1 further identified that he had also recommended that Resident #17 have an air mattress, and one had not been provided. He identified that other than being immobile resident #17 did not have any current conditions that would directly contribute to the breakdown of the left heel. Interview with RN #3 at the time of the observation identified that she was unsure why the air mattress had not been provided and identified that she would investigate it. MD #1 further identified that if staff were offloading Resident #17's heels and had applied the air mattress as recommended, Resident #17 would not have developed a pressure injury to the left heel. In addition, MD #1 identified that he was going to recommend that staff be educated on the matter of prevention of pressure ulcers. MD #1's wound assessment dated [DATE] identified Resident #17's left heel wound had progressed to an unstageable pressure ulcer that measured 3.0 cm length by 2.5 cm width with depth, with an area of 7.5 sq. There was no drainage noted and the resident reported no pain. The wound bed had 76-100% eschar. Interview on 6/7/23 at 10:17 AM with LPN #7 who is the regular 3:00 PM to 11:00 PM shift (full time) on Resident #17's unit, identified that during her medication administration rounds, she would enter Resident #17's room and elevate/offload the resident's heels with pillows placed under the resident's legs. She further identified that she always tries to check because the nurses' aides often forget to do it. Interview on 6/8/23 at 2:21 PM with NA #1(who is frequently assigned to provide care to Resident #17) identified that she was aware that Resident #17's heels were to be elevated when in bed. She further identified that not all nurses' aides assigned to provide care to Resident #17 remember to offload the resident's heels, but she always elevated Resident #17's heels when the resident was on her assignment. Interview on 6/8/23 at 2:53 PM with RN #2 (7-3 pm nursing supervisor) identified that prior to February 2023, the wound nurse reported all the wound MD orders to the ADNS and the ADNS would follow up. RN #2 noted that now the orders are usually communicated to the supervisor on shift, who is responsible for ensuring the orders are either included in the plan of care and/or implemented as prescribed. RN #2 further identified that she was never made aware of an order for Resident #17 to be provided an air redistribution mattress. RN #2 further identified that the wound nurse could update the care plan and ensure the implementation of physician's orders regarding ordering the specialty mattress. RN #2 conveyed that she would be ordering the air mattress immediately. A review of the facility's prevention and management of pressure injuries policy identified that the facility is dedicated to preventing pressure injuries and to developing a preventative plan of care based on individual needs. The policy further identified that residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The policy described an avoidable pressure injury as a pressure injury that the resident developed that the facility did not do one or more of the following: implement interventions that are consistent with the resident's needs, goals, or recognized standards of practice, monitor and evaluate the impact of interventions or revise the interventions as appropriate. The facility failed to consistently ensure that interventions were in place to prevent and/or treat a pressure ulcer/injury, resulting in the development of a left heel deep tissue injury that progressed to an unstageable pressure ulcer.

Based on clinical record review, review of facility's documentation and interviews for one sampled resident (Resident #194) reviewed for pain management and was assessed as having a severe level of pain, the facility failed to ensure the resident was provided pain medication within a reasonable timeframe. The findings include: An entry tracking MDS identified Resident #194 was admitted to the facility from an acute care hospital on 4/11/22. Resident #194's diagnoses included effusion of the left and right knee, pyothorax, type 2 diabetes, hypothyroidism, nontoxic goiter, malignant neoplasm of the pancreas, iron deficiency anemia, pain, and Lyme disease. The hospital discharge summary dated 4/11/22 identified Resident #194 was seen for a fall sustained at the resident's home. It noted no severe injuries, but contusions to face and both anterior knees were noted. The summary further identified that Oxycodone HCL 5mg was administered at 10:06 AM and 1:27 PM for pain related to resident's cancer diagnosis. The summary contained a recommendation for Oxycodone (ROXICODONE) 5 mg immediate release tablet one tablet by mouth every four hours as needed for moderate pain and two tablets by mouth every four hours for severe pain as needed. The admission nursing assessment dated [DATE] at 9:00 PM identified Resident #194 had no cognitive impairment, speech or hearing issues. The assessment further identified that Resident #17 was partial weight bearing, independent with eating, required supervision with bed mobility and required the assistance of one person with toileting, transferring, and ambulation. A review of Resident #194's pain evaluation assessment dated [DATE] identified Resident #194 was assessed at a pain score of ten out of ten (depicting severe unbearable pain) on a scale of one to ten. The assessment further identified that Resident #194 reported that an acceptable pain level for him/her was a level four (4) on the scale. Resident #194 complained that he/she was experiencing pain all over his/her body and noted the pain was intermittent and affected his/her ability to sleep, appetite and ability to perform activities. In addition, the assessment identified Resident #194 also identified the quality of pain as throbbing and nagging and that his/her pain was relieved by pain medication. A late entry nurse's note dated 4/11/22 10:55 PM identified that the medication list from the hospital was sent via fax to the facility and reviewed with the registered nurse (RN) at the hospital emergency department (ED). The ED RN reported that Resident #194 was discharged with Oxycodone 5mg by mouth every four hours as needed for moderate pain and Oxycodone 10 mg by mouth every four hours as needed for severe pain. The note further identified that the medication list was passed on to the 11:00 PM to 7:00 AM nursing supervisor to verify with the on call APRN. Review of the nurses' notes and the medication administration record failed to identify that Resident #194 was offered pain medication when the resident's pain level was evaluated at a level 10 on a scale of 1-10 with 10 indicating severe pain at 9:00 PM. A discharge MDS tracking form identified the resident had an unplanned discharge to the acute care hospital on 4/12/22. A grievance filed by Resident #194's family member dated 4/12/22 identified that the night nurse did not provide care to Resident #194 and withheld pain medication that was due at 5:30 AM until the family member called the facility at 6:37 AM. Further review of the grievance identified a statement by the former facility Administrator dated 4/27/22 that identified Resident #194 asked for pain medication at approximately 10:00 PM but due to issues with the medication list provided from the hospital, the pain medication was not administered until approximately 2:00 AM. The letter further identified Resident #194 had concerns that the pain medication was usually ordered to be administered every two hours. The APRN orders directed for the pain medication to be every four hours as needed, so Resident #194 received another dose as requested at 6:30 PM. A review of Resident #194's medication administration record (MAR) for 4/2022 identified an order for Oxycodone HCl Tablet 5 MG Give one tablet by mouth every four hours as needed for moderate pain and Oxycodone HCl Tablet 10 MG to give be administered every four hours as needed for severe pain. The MAR further identified that the order should start on the following day (4/12/22) in the morning. The MAR did not reflect any signatures indicating that the medications were given during Resident #194's stay at the facility. Interview with APRN #1 on 6/5/23 at 12:18 PM identified that nursing staff were expected to call the on call APRN after hours if any resident was experiencing pain and/or if an order for pain medication was not clear. APRN #1 further identified that the on call APRN could place an immediate one-time order so that a resident's pain is controlled until the issue is resolved. Interview and clinical record review with the current facility DNS on 6/8/23 at 3:11 PM identified that the nursing staff are expected to call and report severe complaints of pain to the on call APRN or physician who can prescribe an interim pain medication until any issues with the medication list have been resolved. Efforts to contact the staff that worked on the evening of 4/11/22 and the night shift on 4/11/22 into 4/12/22 were unsuccessful. The RN that worked the 3:00 PM to 11:00 PM shift no longer works at the facility, and the 11:00 PM to 7:00 AM RN was on a medical leave of absence. Review of the clinical record and the MAR failed to identify that the resident was medicated, the grievance identified that the resident was medicated at 2:00 AM, which was five hours after the resident was assessed at 9:00 PM as having a severe level of pain. Review of the facility's pain policy directed in part that the facility was committed to assisting residents attain or maintain their highest practical mental and psychosocial wellbeing. This is done by evaluating pain and using interventions to prevent pain from interfering with activities of daily living. The resident's acceptable pain level will be determined during Resident interview and evaluation. The policy identified that the facility would assess pain using standardized pain scale of zero to ten (0-10) and or non-verbal pain scale, develop and implement interventions or approaches to pain management both pharmacologic and non-pharmacologic as well as use pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of adverse reactions. For admitting and readmitting residents, the admitting MD is notified and the appropriate orders for pain relief are obtained. The facility failed to ensure that a resident who was assessed at a severe level of pain was responded to in a timely manner. The resident was admitted to the facility on [DATE] and decided to return to the acute care hospital on 4/12/22 due to the facility not managing the resident's pain and not consulting with the physician to address the resident's severe pain level.

Based on clinical record review, review of facility documentation, review of the hospital record, interviews, and policy review, for 1 of 3 sampled residents reviewed for pressure ulcers (Resident (R) #1) the facility failed to assess a heel wound on an ongoing basis and failed to follow the resident's care plan which resulted in hospitalization and an emergent above the knee amputation which resulted in immediate jeopardy. The findings include: Resident # 1's admission nursing assessment dated [DATE] identified the resident's skin, including both feet were intact. The interim care plan dated 8/11/21 identified the resident was at risk for skin breakdown related to impaired mobility, [CONDITION(S)], diabetes, and [CONDITION(S)]. Interventions included to inspect for redness, irritation, or breakdown during care, off load heels, offer turning and repositioning every 2 hours, pressure relieving mattress and weekly skin inspections. The admission Minimum Data Set (MDS) dated [DATE] identified the resident was alert and oriented, required extensive assistance of one staff for bed mobility, dressing, and personal hygiene, and the resident was without pressure ulcers. Review of the treatment Kardex's during the period of 8/11/21 through 9/2/21 identified on 6 occasions there was no documentation that the resident's heels were off-loaded, in accordance with the care plan. Review of the pressure injury evaluation and the Wound MD notes dated 9/2/21 noted a stage 2 pressure ulcer on the left heel measuring 1.0 centimeter (cm) by 1.0 cm by 0.1cm with a scant amount of sero-sanguineous drainage. The note identified treatment recommendations, offload pressure to heels, and reposition every two hours. Resident #1 was hospitalized on [DATE] unrelated to skin problems and was readmitted on [DATE]. Review of the readmission/weekly skin audit sheet dated 9/7/21 identified a 1.0 cm by 1.0 cm stage 2 partial thickness wound to the left heel. And the weekly skin audit dated 9/9/21 identified a stage 2 pressure ulcer to the left heel measuring 1.0 cm by 1.0 cm by 0.1 cm with a small amount of drainage noted. The resident's clinical record failed to identify that pressure ulcer education was provided to the resident. Physician orders dated 9/7/21 and 9/9/21 directed treatments to the wound, off load heels every shift as tolerated, and to apply a left heel float boot while in bed. The care plan initiated on 9/9/21 identified the resident had a stage 2 pressure ulcer to the left heel with interventions including heel float boot while in bed, monitor nutritional status, follow facilities policies for the prevention /treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of weekly wound sheets dated 9/16/21 identified a facility acquired unstageable area to the left heel measuring 1.5 cm by 1.5 cm and with 50% unhealthy (slough) tissue. Review of the clinical record for 9/16/21 failed to identify that the APRN, MD or Wound MD were updated on the unstageable left heel wound. Review of the APRN progress notes dated 9/17/21 failed to identify the unstageable left heel pressure ulcer. APRN notes dated 10/1/21, 10/6/21, 10/7/21, 10/13/21, 10/22/21 and 10/25/21 identified the resident's skin as fragile, denies rash or wound changes and to see nursing skin documentation. Review of the nurse's notes dated 9/17/21 through 10/5/21 failed to include documentation of weekly wound assessments to include wound size, odor, or presence of drainage. The nurse's note dated 10/5/21 at 3:54 PM noted that the dressing was changed, a photo taken and sent to Wound MD and awaiting further orders. Physician orders dated 10/8/21 directed a new treatment to the wound, 3 days after request. Nurses notes dated from 10/10/21 to 10/15/21 identified that heel dressings were changed, there was a small amount of drainage with good granulation, and that dressings were clean, dry and intact. The nurse's note dated 10/18/21 at 10:17 PM identified the resident was seen by the wound MD and new orders were received (for treatment to the right great toe and left heel). A physician's order dated 10/18/21 directed to cleanse the right great toe with NS followed by medi-honey and dry clean dressing daily and to cleanse the left heel with NS followed by [MEDICATION(S)] and dry clean dressing daily. Review of the clinical record and treatment record from 10/19/21 until 10/26/21 (7 days) failed to identify that the physician's order to apply [MEDICATION(S)] to the resident's left heel was completed. The APRN progress note dated 10/27/21 at 4:22 PM identified nursing reports that the left foot wound was worsening, no [CONDITION(S)] or symptoms of [CONDITION(S)] at this time, and awaiting wound physician to evaluate on 10/29/21. The nurse's note dated 10/27/21 at 10:18 PM noted that the wound MD was contacted (by phone), updated on the resident's wound, and identified that he would see the resident on 10/29/21 to assess the left foot. The APRN note dated 10/28/21 at 2:40 PM identified the resident was currently having left wound dressing changed and nursing requested an evaluation. The note identified several necrotic areas to the left foot, redness without warmth to top of foot and per nursing some areas improving. The note further identified to continue current treatments to resident's foot and follow up with the wound doctor. Review of the care plan dated 10/29/21 identified the plan was revised to reflect a right great toe wound (11 days after treatment was initiated) and noted the left heel to be necrotic. Review of nursing notes during the period of 10/28/21 through 11/2/21 at 3:45PM identified one entry on 10/30/21 at 3:35 AM identifying the left heel dressing was clean dry and intact. There was no other documentation of the wound status. The APRN progress note dated 11/1/21 at 8:52 PM noted the resident had loose stools, the left foot had necrotic areas, and laboratory blood work was ordered and identified a high white blood cell count of 19.3 ml/L (normal 5.0 to 10.0). The APRN progress note dated 11/2/21 at 1:48 PM identified the resident was transported to the hospital related to high WBC, co-morbidities, and question of metastatic cancer. The nurse's note dated 11/2/21 at 3:45 PM noted the resident was sent to the emergency room for evaluation related to elevated WBC's, question metastatic cancer, and to rule out [CONDITION(S)]. The resident was afebrile at the time of discharge. Review of the Interagency referral form (W-10) dated 11/2/21 noted worsening wounds to right toe and left foot. Review of the hospital admission history and physical dated 11/2/21 identified that Resident #1 presented with a fever of 102.8 degrees and wounds on bilateral feet. The note identified a significant malodor, the left extremity had a necrotic heel with marked surrounding [CONDITION(S)] that extended up the posterior calf, crepitus, and ulceration along the Achilles location. Additionally, the right great toe had an open necrotic ulcer with subcutaneous tissue exposed. Labs were drawn and the WBC was noted at 25.1 ml/L (normal 5.0 to 10.0). The hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the vascular surgeon's operative report identified the patient underwent an emergent left leg above the knee amputation. A vascular consult dated 11/3/21 at 9:28 AM noted the resident will most likely require amputation of the right great toe. Interview with the DON on 11/9/21 at 10:15AM and review of the clinical record and treatment record from 9/16/21 through 11/2/21 identified that the clinical record failed to describe an assessment of the left heel wound including location, measurements, stage, presence of tunneling, drainage, color, odor, appearance of wound bed and edges, pain and the effectiveness of treatment. The DON stated that the last time the left heel was assessed was on 9/16/21 when it was identified as unstageable. The DON stated that the right great toe which started a treatment on 10/18/21 had never been assessed. The DON stated that he was first made aware the resident had a wound on the right great toe when the resident was sent to the hospital on 11/2/21. The DON further stated that all wounds are to be assessed by a RN or the wound doctor on a weekly basis. The DON stated that because Resident #1 was out of the facility when the wound doctor was here, it was the RN's responsibility to assess the wound weekly and update the APRN or wound MD with any changes. Interview with MD #1 (wound MD) on 11/9/21 at 11:00 AM stated that he recalled assessing Resident #1 in the beginning of September when the resident first developed the wound on the left heel. MD #1 stated that in the beginning of October he was sent a picture of the wound by nursing, and he ordered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #1 stated he was again made aware of the wound at the end of October and told the staff he would stop in and see the wound quickly on 10/29/21. MD #1 stated he saw the wound quickly but did not assess it at that time or direct any further treatment orders. MD #1 stated that he would see the resident the following week. MD #1 stated that because this resident was out of the facility at the times, he was in the building he would expect nursing to do weekly assessments and notify him of any changes. Review of the clinical record and interview with the Acting DON on 11/8/21 at 10:50 AM failed to identify that the right great toe wound was assessed or documented on since it was first identified on 10/18/21. The Acting DON stated that the resident had picked the skin off the toe and the area was red. The Acting DON texted the wound MD for a treatment, but the wound MD had not seen the toe, because the resident was out of the facility when the MD was onsite. Interview with LPN #1 on 11/8/21 at 1:30 PM stated that she assisted the resident in the shower and saw a band-aid on the right great toe and was told by the resident he/she put it there. LPN #1 stated that she removed the band-aid and saw an open blister with the skin picked off, brownish drainage and the wound bed had some slough. LPN #1 stated that she told the Acting DON about it who then texted the wound MD for a treatment. Interview with APRN #1 on 11/9/21 at 2:10 PM and 11/10/21 at 9:35 AM stated that on 10/28/21 she was asked to look at the left heel wound and saw the left heel was necrotic and the top of the foot was red but did not see the right great toe wound. APRN #1 stated that she did not fully assess the left heel but directed the nurse to have the resident seen by the wound MD. APRN #1 stated that she did not change the treatment or implement any new interventions. APRN #1 stated that she again saw the resident on 11/1/21 and 11/2/21 but did not look at either wound. APRN #1 stated that when she received the resident's labs back and the WBCs were elevated to 19.3, she sent the resident to the hospital for an evaluation when he/she returned from [CONDITION(S)]. Interview with the Corporate RN on 11/9/21 at 11:15AM stated that weekly wound assessments are to be completed and sent to the corporate wound nurse. The Corporate RN stated that she had not received weekly wound assessments on any residents since the previous Infection Preventionist nurse left on 9/18/21. Interview with LPN #1 on 11/10/21 at 12:00 PM stated that she signed the weekly wound documentation as being complete. She would just sign the treatment record because she assumed it was getting done but was not sure who was doing the weekly assessment. LPN #1 stated that she did not do the assessments and that the resident was out to [CONDITION(S)] when the wound MD was in the building. LPN #1 stated that with the resident's permission, pictures were taken once of the heel wound on 10/5/21 and sent to the wound MD by the Acting ADON. Interview with the Acting ADON on 11/10/21 at 12:10PM stated that she would do rounds with the Wound MD when she was here and available, but there were several times the wound MD would do rounds on his own. The Acting ADON stated that although she took pictures of the left heel wound to send to the wound doctor, she did not ever see or assess the resident's heel wound or right great toe. Interview with the DON on 11/10/21 at 1:20 PM stated that after the IP nurse left in September, he was relying on the charge nurses to assess and report any issues to the RNs for further assessment. The DON stated that any resident who had a wound or skin issue is to be assessed by the RN and documented in the clinical record including location, size, stage, odor, surrounding tissue and notify the MD to have a treatment implemented. Interview with RN #2 (RN Supervisor) on 11/10/21 at 2:30 PM stated that she was aware the resident had a heel wound, but the day she sent the resident to the hospital she did not assess it. Review of the facility policy for Prevention and Management of Pressure Injuries identified pressure injuries are assessed and documented at least weekly until the wound is resolved. The policy identified the assessment should include location measurements, stage, presence of tunneling, drainage amount and color, odor, appearance of wound bed and edges, pain, and effectiveness of treatment. Immediate Jeopardy was identified on 11/10/21 at 11:14AM. During the onsite visit on 11/10/21, it was verified that the Facility had completed body audits on all residents, conducted facility wide staff education of the Facility's wound policy, and an auditing process was established. As a result of this survey it was determined the Immediate Jeopardy for F686 was abated as of 11/10/21.

Based on review of clinical records, review of facility policies, review of facility documentation, and interviews for one of three residents reviewed for falls, (Resident #19) the facility failed to ensure that a safety measures in the resident's environment were implemented and/or for one of three residents reviewed for transfers, (Resident #189), the facility failed to ensure that a mechanical lift transfer was performed in a safe manner. The findings include: 1. Resident #19 (R #19) had [DIAGNOSES REDACTED]. Review of the care plan last updated on 8/10/15 identified that R #19 had impaired physical mobility and was at risk for falls with interventions that included to provide assistance of one person for functional mobility, functional transfers and with cues to lock/unlock rollator, to observe frequently for compliance with safety plan. The initial minimum data set assessment dated [DATE] identified that R#19 had a Brief Interview of Mental Status (BIMs) score of one out of fifteen, indicative of severe cognitive impairment, required extensive physical assistance with activities of daily living including transfers, ambulation, and personal hygiene, and was only able to stabilize with staff assistance. Interview with Occupational Therapist#1 on 2/3/16 at 1:30 PM indicated that R#19 had poor safety awareness and that the resident had demonstrated an inability to sequence tasks and that R #19 could not remember to lock and/or unlock his/her rollator. OT #1 indicated that the staff had been instructed to provide assistance with all ADL's because of the resident's inability to complete tasks safely. A review of facility documentation dated 8/22/15 identified that R #19 stood up from the shower chair unassisted, the shower chair slid out and the resident fell . Review of the facility's investigation identified that at the time of R #19's fall, the shower chair was not locked and the resident's seat belt was not secured. Interview with NA#1, who was providing care to R #19 at the time of the fall, on 2/3/16 at 10:15 AM indicated that he/she did not lock the shower chair in error. NA#1 stated that he/she turned away from the resident to obtain the resident's clothing after the shower, and that the resident attempted to stand without the benefit of the staff assistance and fell . Interview with the Director of Nurses on 2/2/16 at 1:45 PM and review of the facility transfer policy indicated that the staff was responsible for ensuring that shower chairs are locked. As a result of the fall from the shower chair on 8/22/15, R #19 sustained a non-displaced fracture of the distal left radius. Review of facility policy on safety standards directed in part that residents are not to be left unattended in a shower chair and that seat belts are to be fastened at all times. The policy further indicated that the seat belt was to provide added safety during transportation and showering though do not make it safe to leave the resident in the shower chair for even a short time. 2. Resident #189 (R #189) was admitted to facility 1/22/16 with [DIAGNOSES REDACTED]. A nursing admitted d 1/22/16 identified R #189 as alert and oriented, incontinent of bowel and bladder, was non-ambulatory and required two (2) staff persons for transfers with a mechanical lift. The resident care plan dated 1/22/16 identified that R #189 was at risk for falls due to decreased mobility with interventions that included as identified in the nursing admission assessment dated [DATE], transfer with the assistance of two persons with a mechanical(Hoyer) lift. Review of a mobility/transfer nursing assessment dated [DATE] identified that R #189 required transfer with the assistance of two persons via a mechanical lift utilizing a medium sized lifting pad. Review of facility documentation dated 1/26/16 at 5:00 PM identified that R#189 was lowered to floor during a transfer via a mechanical lift from his/her bed to wheelchair. The investigation identified that R#189 was transferred into a wheelchair via mechanical lift and that due to utilization of a Hoyer lift pad that was too large, the resident began to slide out of the wheelchair and was lowered to the floor. The investigation documentation further identified that the correct size lift pad was utilized to safely transfer the resident back to the wheelchair. R #189 did not sustain injury as a result of the incident. Interview with RN #1 on 2/3/16 at 11:45 AM identified that although R#189 was requesting to be lowered because he/she was slipping off the wheelchair, it was determined through the investigation that the incorrect size mechanical lift pad was utilized during the transfer and was the cause of the incident. Interview with the Director of Nursing on 2/4/16 at 12:11 PM identified that that mechanical lift pad sizes are color coded and determined by the individualized resident's weight. The DNS further indicated that R#189's appropriate size was a medium and that the investigation determined that a large size pad was inadvertently used.

Based on clinical record reviews, review of facility documentation and staff interviews for three of six sampled residents ( Residents # 90, # 119 and # 141 ) at risk for pressure ulcer development , the facility failed to ensure that the residents skin integrity were consistently monitored and /or failed to place interventions in place to prevent the development of a pressure ulcer. The findings included: 1. Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The RCP for urinary incontinence resident has a Foley catheter in place due [MEDICAL CONDITION] dated 10/23/13 included an interventions to notify the nurse if the resident's skin is red/open and to keep the Foley catheter tubing kink free. The admission MDS dated [DATE] identified that the resident's cognition and memory were intact, that the resident required extensive assistance with two person physical assistance for bed mobility and transfers. Additionally, the assessment noted that the resident had a Stage 2 Pressure Ulcer and directed the facility staff to apply pressure relieving devices to the resident's bed and wheelchair and noted the utilization of an indwelling catheter. The physician's orders [REDACTED]. The Braden Scale Evaluation dated 1/19/14 identified a score of 18 which directed interventions to be in place. Interventions include pressure reducing mattress and pressure reduction cushion for the resident's chair. A quarterly MDS assessment dated 1/22/14 identified that the resident's decision making was reasonable and consistent, required extensive assistance with ADLS, utilization of a Foley catheter and at risk for skin impairment. The physician's orders [REDACTED].# 119's inner right thigh with a wound cleanser, to pat dry and apply skin prep to the perimeter of the wound, followed by Santyl Ointment. A review of Resident # 119 Weekly Pressure Area flow record identified on 2/24/14 the resident was identified with a stage 3 ( facility acquired ) pressure ulcer on the thigh area that measured 13.8 Cubic Centimeter (CM) by 1 CM with 80 percent granulation and 20 percent slough. However, the nurse's note dated 2/24/14 identified that the resident had stage 3 pressure ulcer that measured 16 CM by 2 CM by 2 CM with 20 percent slough and 10 percent eschar and indicated that staff was educated on catheter Foley placement. Review of Wound Care Specialist documentation dated 2/27/14 noted a stage 3 pressure wound on the right superior thigh with at least one day duration. The wound lacked exudate and the resident denied pain to the area. The physician's orders [REDACTED]. A review of Resident # 119's weekly body audits dated 10/23/14 to 3/1/14 identified that the resident's first body audit was not conducted until 3/2/14 and the clinical record lacked documentation of an RN assessment . Observation and interview with Medical Doctor ( MD #1) on 3/6/14 at 10:45 A.M. identified Resident # 119's right thigh stage 3 pressure ulcer wound was most likely due to pressure of the Foley Catheter tubing. MD #1 indicated that the wound measured 15.5 CM from the 2/24/14 measurement. Observation of the wound on 3/6/14 identified that the wound measured 7.5 CM and stage 2 on 3/6/14. MD #1 stated that pressure ulcers occurred as a result of ill-fitting briefs. Interview with NA#5 on 3/6/14 at 10:30AM. indicated that she/he had reported Resident # 119's opened area to LPN #4 three to four weeks ago during the day shift. The interview further noted that NA # 5 verbalized that the area " looked like it looked now but indicated that the wound was not as opened or as long. " Interview with Licensed Practical Nurse ( LPN #4) on 3/6/14 at 10:45 A.M. indicated that she/he did not remember if NA#5 had reported an opened area to her/him. LPN #4 also stated that she/he provide treatment to Resident #119's buttocks daily, however, indicated that she/ he had not noticed the opened area on the thigh. Interview with the DNS on 3/6/14 at 1:36 P.M. indicated physician's orders [REDACTED]. The first weekly body audit was completed on 3/2/14. The interview also identified that the RN assessment for the readmission was not in place. 2. Resident # 90's was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The RCP for alteration in skin integrity dated 12/27/13 for I have a stage 1 pressure ulcer area to the coccyx , stage 2 pressure ulcer by my right buttocks , I have boggy heels and scabby areas to my abdomen, thighs, buttocks and back included interventions to apply treatment to my buttocks as ordered, to apply my Sarna cream as ordered for itching as needed, to perform a weekly body audit , NA to please ensure that my feet are elevated off the bed when in bed, to offer to assist me with turning and repositioning and to provide incontinent care every two hours and when needed. The physician's orders [REDACTED].# 90's heel of the bed every shift and to apply skin prep to bilateral boggy heels twice a day ( 7- 3 P.M. and 3-11 P.M. ), Additionally, directed the licensed staff to cleanse the resident's bilateral buttocks /coccyx area with warm soapy water, to pat dry and to apply Dimethicone cream every shift and when needed . The physician's orders [REDACTED].# 90's heels while in bed and in the wheelchair every shift. The readmission MDS assessment dated [DATE] identified that the resident was moderately cognitively impaired , had memory problems, noted feeling tired or having little energy, that the resident was an extensive assistance with bed mobility and required two people to assist with bed mobility. Additionally, noted fracture, no pressure ulcer reducing and/ or relieving devices for the resident's bed and / or chair and noted recommendations for staff to assist with turning and repositioning. The physician's orders [REDACTED]. Review of the facility documentation of Pressure Ulcer Tracking identified on 1/13/14 that Resident# 90 developed a( facility acquired) unstageable pressure ulcer on the right heel. A review of the the treatment kardex , nurses notes and ADL flow sheets dated December 27, 2013 through January 12, 2014 lacked documentation and / or evidence that the facility had assisted Resident # 90 with turning and repositioning and / or failed to identify intervention to off load the resident's heels in the wheelchair prior to 1/13/14. The treatment kardex for January 2014 identified that on 1/13/14 the licensed staff was instructed to off load Resident # 90's heels in bed and in the wheelchair. Additionally, the treatment kardex directed the licensed staff to cleanse the resident's blister on the right heel with a wound cleanser, followed by skin prep, to apply Calcium Ag ( Wound Debridement ) followed by dry clean dressing every other day. Facility documentation of Pressure Ulcer Tracking dated 1/13/14 identified that Resident # 90 developed a facility acquired unstageable pressure ulcer on the right heel. The facility's Pressure Wound Evaluation documentation dated 1/14/14 identified that Resident # 90 had an unstageable suspected deep tissue are on the right heel that measured 4 CM in length and 5.0 CM in width and 0.1 CM depth that was slightly macerated due to dependent [MEDICAL CONDITION]. Interview with the DNS and the ADNS on 3/7/14 at 10:00 A.M. identified that they were unaware that Resident # 90 had boggy heels and indicated that LPN # 5 failed to communicate to the ADNS Resident # 90's boggy heels and /or open area on the heel until until 1//14/14. Additionally, the DNS and the ADNS indicated that although they could not provide documentation and / or evidence that the facility staff assisted Resident # 90 with turning and repositioning in accordance to the plan of care , the facility practice is to turn and reposition residents every two hours. 3. Resident # 141's [DIAGNOSES REDACTED]. The nursing assessment dated [DATE] identified that Resident # 141 had a stage 1 area that did not appear to be pressure related. The admission MDS assessment dated [DATE] identified that the resident was moderately cognitively impaired, had memory problems and that the resident required extensive assistance for bed mobility, transfers and personal hygiene, noted no pressure ulcer development but directed the facility staff to provide a pressure reducing device for Resident # 141's bed and chair. The RCP dated 7/30/13 and 8/12/13 for irritation to my buttocks secondary to excessive/aggressive self wiping included interventions to report any changes in my skin integrity to the nurse, to offer to take to the bathroom before meals and going to bed, to offer to assist me with turning and repositioning , to provide incontinent care every two hours and when needed, to provide a pressure reducing mattress and to offload my heels when I am in bed. The annual Minimum Data Set ((MDS) dated [DATE] identified that the resident required extensive assistance with with bed mobility and transfers and noted no pressure ulcer development. A review of the facility's weekly wound monitor dated 8/12/13 to 2/19/14 identified no pressure ulcer development until 2/20/14 when Resident # 141 was noted with a stage 3 pressure ulcer area on the coccyx that measured 2.5 CM by 2 CM , the physician was notified and the licensed staff was directed to cleanse the coccyx/buttocks re-opened area with Normal Saline , to apply an Allevyn GB dressing every other day . Further review of facility documentation of wound tracking and monitor dated 2/21/14 noted that Resident # 141 developed a stage 2 ( facility acquired) pressure ulcer on the medial coccyx area. Record review and interview with the DNS and Assistant Director or Nursing ( ADNS on 3/6/14 at 4:30 P.M. identified that they could not explain how and why Resident # 141 developed a pressure ulcer on the coccyx . Additionally, stated that although the facility could not provide documentation and/or evidence that staff assisted the resident with turning and repositioning, the facility practice is to turn and reposition residents every two hours. LPN # 5 was unavailable for interviews The facility's Skin Care Prevention and Management of Pressure Ulcers policy and procedures notes that the facility is dedicated to preventing pressure ulcers and developing risk based prevention system reflecting individualized plan of care. Residents receive the care and services they needed according to the established practice guidelines, so that a resident who enters the facility without pressure ulcers does not develop one unless the individuals clinical condition demonstrates that they were unavoidable . Additionally, notes that the necessary treatment and services will be provided to promote healing , prevent infection and prevent new pressure ulcers from developing. The facility policy notes for Protocol Assessment: Ulcer/ Risk Factors notes on admission/ readmission , a skin assessment is completed on each resident by completing a heat to toe skin assessment, comprehensive assessment to identify risk factors associated with pressure ulcer development and noted that the resident's skin is observed daily with care. According to the National Pressure Ulcer Advisory Panel for pressure ulcer notes for pressure ulcer prevention and treatment to continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual's response. 3. Inspect the skin for additional damage each time the individual is turned or repositioned while in bed. Do not turn the individual onto a body surface that is damaged or still reddened from a previous episode of pressure loading, especially if the area of redness does not blanch. 4. Limit head-of-bed elevation to 30 degrees for an individual on bedrest, unless contraindicated by medical condition. Encourage individuals to sleep in a 30- to 40-degree side-lying position or flat in bed if not contraindicated. Category/Stage I and II Pressure Ulcers Note: Selection of support surfaces is complex and cannot be determined solely on the basis of the category/stage of the ulcer. While in Bed 1. Consider higher-specification foam or similar nonpowered pressure-redistribution support surfaces for Category/Stage I and II pressure ulcers. 2. Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. While in a Chair 1. Use a pressure-redistribution cushion in the chair for individuals with Category/Stage I or II pressure ulcers. 2. Minimize seating time and consult a seating specialist if pressure ulcers worsen on the seating surface selected. 3. Ensure that the feet are properly supported either directly on the floor, on a footstool, or on footrests when sitting (upright) in a bedside chair or wheelchair. 4. If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer.

Based on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled residents reviewed for behaviors (R#67) and/or for 1 of three sampled residents that required extensive assistance with ADL's (R#103) the facility failed to provide adequate supervision and/or assistive devices to prevent an accident . The findings include: 1. Resident #67's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with short and long term memory problems, moderately cogntively impaired, requiring extensive assistance with ADL's and other skin lesions. A RCP dated 10/21/11 identified a [DIAGNOSES REDACTED]. A Psychiatric progress note note dated 12/27/11 identified the resident with increased irritability, increased loud outbursts and increased behavioral problems. Review of facility investigation dated 1/1/12 at 5:45 AM identified R#67 was noted with a 6.0 cm by 0.8 cm skin tear to the right upper wrist and a 4.0 cm by 0.0 cm skin tear to the left posterior hand. The outcome of the investigation identified that the resident became agitated during care, and the resident's arms hit the siderails when being turned. The investigation further identified that NA#1 did not wait for assistance before providing care. Interview with NA#1 at 11:15 AM failed to identify why he did not wait for assistance when the resident became agitated and/or why he did not notify the nurse of R#67's behaviors. Interview with the DNS on 3/08/12 at 1:40 PM identified nursing staff were educated to wait for assistance, allowing time for the resident to calm and reporting behaviors to the nurse when attempting to provide care. 2. Resident #103's [DIAGNOSES REDACTED]. A RCP dated 9/20/11, identified the resident required frequent toileting. Review of facility investigation dated 9/20/11 identified R#103 was given a Fleet enema at 3:15 PM, was observed to be sleeping in bed at 4:30 PM and was found on the floor at 5:20 PM with loose stool. R#103 was transferred to the hospital and found to have an acute T-6 compression fracture. The investigation identified that the resident had attempted to get out of bed unassisted and NA#6 was provided on the job training regarding bowel regimen and enema administration. The RCP was updated to include toileting the resident within 30 minutes of administration of an enema. Although attempts to reach NA#6 were unsuccessful, on 3/6/12/ at 3:00 PM LPN#2 identified that NA#6 was aware R#103 was given an enema. Interview with the DNS on 3/08/12 at 1:40 PM identified that a resident should be checked on shortly after administration of an enema.

Based on review of the clinical records, facility documentation and interviews for two of three sampled residents reviewed for accidents (Residents #3 and #33), the facility failed to provide the appropriate supervision and/or assistance to prevent falls with injuries. The findings include: 1. Resident # 3's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified severe cognitive impairment and total dependence for bed mobility with assist of two. The care plan dated 3/9/10 identified impaired mobility however, failed to identify that interventions for bed mobility were implemented. The Reportable Event dated 3/27/10 identified the resident rolled out of bed onto the floor while receiving care from Nurse Aide (NA) #4. The nurse's note dated 3/27/10 at 9:45 AM identified the nurse aide was turning the resident onto his/her side in the bed when the resident rolled out of bed and onto the floor. The initial nursing assessment identified no injury. A subsequent nurse's note dated 3/27/10 at 12:44 PM identified the resident exhibited grimacing and yelling upon movement. The physician was notified and directed to transfer the resident to the Emergency Department for an evaluation and was admitted with a right tibia-fibula fracture. NA #4 in a written statement dated 3/27/10 identified she was standing on the upper part of the side of the bed and rolled the resident toward her to provide care. NA #4 noted the resident was not positioned at the top of the bed and when turned his/her legs and hips rolled to the edge of the bed. NA #4 indicated she was unable to prevent the resident from rolling off the bed and falling to the floor. Interview with the Director of Nurses (DNS) on 2/24/11 at 2:25 PM identified the resident required two staff for bed mobility. The DNS indicated NA #4 was aware the resident required two staff for bed mobility and could not explain why she did not seek assistance. The DNS further indicated NA #4 was terminated from the facility after the incident. An attempt to contact NA #4 was unsuccessful. 2. Resident #133 was admitted to facility on 12/10/10 with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified R #133 was alert and forgetful and required assistance of one person for toilet use. The care plan dated 12/11/10 identified impaired physical mobility and a recent fall in the hospital that resulted in rib fractures with interventions that included providing assistance. The physical therapy assessment dated [DATE] identified fall precautions secondary to a recent fall and limitations due to confusion that required assistance of one person for all care and mobility. The physician's orders [REDACTED]. The nurse's note dated 12/11/10 at 11:48 PM noted the resident fell in the bathroom and was bleeding from a posterior scalp laceration and a skin tear was noted on the left elbow. The physician was notified and directed to transfer the resident to the Emergency Department for an evaluation. The Emergency Department progress note dated 12/11/10 identified two staples were required to approximate the posterior scalp laceration and steri-strips were applied to the left elbow skin tear and the resident was returned to the facility. The Reportable Event dated 12/11/10 identified R #133 was left unattended on the toilet and fell sustaining a 2.0 centimeter (cm) x 0.4 cm laceration to the posterior scalp and a 3.0 cm skin tear on the left elbow. Review of the clinical record and interview with Registered Nurse (RN) #2 on 2/24/11 failed to reflect that a nurse aide resident care card was initiated and/or was available for staff use on 12/11/10. RN #2 indicated the charge nurses provide verbal reports to communicate a resident's care needs and/or precautions to the nurse aides. Interview with Nurse Aide (NA) #1 on 2/24/11 at 12:03 PM indicated that on 2/11/10 she was reassigned from a different nursing unit just before the evening meal to provide care to R #133. NA #1 indicated she did not receive a written and/or verbal report from the charge nurse to identify the resident's care needs and did not know the resident could not be left alone on the toilet. Interview with the Assistant Director of Nurses on 2/24/11 at 12:25 PM indicated nurse aides receive continuing education related to resident safety and noted that a resident who required assistance must be supervised and cannot be left unattended on the toilet. Review of facility "safety standards" which "impact quality of resident care" identified in part "any resident who does not ambulate ad lib (independently) and who must be assisted to the toilet will not be left alone on the toilet". It further identified "someone must remain within touching distance to prevent the possibility of a fall".