Every finding on record at West Newton Healthcare

Based on records reviewed and interviews for two of three sampled residents (Resident #2 and Resident #3), who were at risk for developing Diabetes-related foot complications, the Facility failed to ensure they received proper care and treatment to maintain good foot health.Findings include:During an interview on 06/04/26 at 1:20 P.M., the Director of Clinical Operations said the Facility did not have a policy related to the care and services for a resident with Diabetes or a policy for Diabetic foot care.1) Resident #2 was admitted to the facility in December 2025 diagnoses included Diabetes Mellitus with diabetic neuropathy (damage or dysfunction to the nerves). Review of Resident #2's medical record indicated there was no documentation to support that the nursing staff obtained a physician's order to administer diabetic foot care to him/her nightly.Review of Resident #2's Treatment Administration Records for the months of February 2026 through June 2026, indicated there was no documentation to support diabetic foot care was being provided. 2) Resident #3 was admitted to the facility in October 2022 diagnoses included Diabetes mellitus with neuropathy.Review of Resident #3's medical record indicated there was no documentation to support that nursing staff obtained a physician's order to administer diabetic foot care to him/her nightly.Review of Resident #3's Minimum Data Set (MDS) assessment, dated 05/09/26, indicated Resident #3 was alert and oriented and had a Brief Interview for Mental Status (BIMS) score of 15 (0-7 suggests severe cognitive impairment, 8-12 suggest moderate cognitive impairment, and 13-15 suggest no cognitive impairment).During an interview on 06/04/26 at 12:10 P.M., Resident #3 said nursing did not wash or apply lotion to his/her feet nightly.During an interview on 06/04/26 at 2:26 P.M., Nurse #3 said that she often works the evening shift (3:00 P.M. through 11:00 P.M.) and provides diabetic foot care for the residents that have a physician's order. Nurse #3 said that all residents who have a diagnosis of Diabetes should have an order for daily diabetic foot care.During a telephone interview on 06/05/26 at 8:09 A.M., Nurse #1 said she provides diabetic foot care when the resident has a physician's order to do so.During an interview on 06/04/26 at 3:00 P.M., the Director of Nurses (DON) said it was his expectation that diabetic foot care should be done at least weekly and it should include a foot soak. The DON said he was working on a facility policy for diabetic foot care.

Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), who was readmitted to the facility from the hospital with a new diagnosis of seizures, the facility failed to ensure they developed and implemented a comprehensive individualized care plan specific to his/her associated risk of seizure activity, that included interventions, goals and outcomes. Findings include:Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, with a revision date of 01/2024, indicated the following:-A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial and functional needs and is developed for each resident.-Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's conditions change.Resident #1 was admitted to the facility in April 2026 diagnoses included dementia and chronic kidney disease.Review of Resident #1's Nursing Progress Note, dated 04/19/26, indicated that he/she had one episode of vomiting followed by shaking, facial twitching, and uncontrollable movements. The Note indicated Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment.Review of Resident #1's medical record indicated he/she was readmitted to the facility on [DATE].Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she had a primary discharge diagnosis of Seizures. The Summary indicated he/she sustained his/her first known seizure on 04/19/26 which lasted greater than 15 minutes in duration.Review of Resident #1's Comprehensive Care Plan indicated there was no documentation to support that he/she had an individualized care plan that included or addressed the following:-New diagnosis of seizures.-Monitoring and reporting seizure activity.-Interventions to maintain a safe environment during seizure activity.During an interview on 06/04/26 at 2:51 P.M., the Minimum Data Set (MDS) Coordinator said that she monitors resident care plans for completion and accuracy. The MDS Coordinator said she initiates a seizure precaution care plan for residents who have a diagnosis of a seizure disorder. The MDS Coordinator said the Unit Managers used to generate most of the resident care plans but two of them recently quit.During an interview on 06/04/26 at 3:00 P.M., the Director of Nurses (DON) said it was his expectation that nursing would have added or revised Resident #1's care plan following his/her hospitalization and new diagnosis of seizures.

Based on records reviewed and interviews, for one of three sampled Residents (Resident #1) who was experiencing an emergent change in condition, the facility failed to ensure quality of care was provided when multiple facility staff members did not know the access code to the elevator and Emergency Medical Services (EMS) were delayed in transporting him/her to the Hospital Emergency Department (ED) for evaluation and treatment. Findings include:Review of the Report submitted via the Health Care Facility Reporting System (HCFRS), dated 04/22/26, indicated that on 04/19/26 Resident #1 experienced a medical emergency and Emergency Medical Services (EMS) were unable to release the elevator in a timely manner due to code [series of numbers required to be enter into the keypad located inside the elevator] not being provided [by facility staff] in a timely manner. Resident #1 was admitted to the facility in April 2026, diagnosis included dementia. Review of Resident #1's Nursing Progress Note, dated 04/19/26, indicated he/she had an episode of vomiting, shaking, facial twitching and uncontrollable movements. The Note indicated a physician's order was obtained to transfer him/her to the Hospital ED for treatment and evaluation. During a telephone interview on 06/05/26 at 2:45 P.M., Nurse #1 said she was on duty on 04/19/26 when Resident #1 experienced a seizure. Nurse #1 said the keypad on the inside of the elevator was for the Wanderguard system (a system that alarms when a resident wearing a wanderguard bracelet is within the alarm's vicinity).Nurse #1 said the codes were supposed to be kept in the Resource Binder on the Unit, but when she and other staff members looked, the codes were not there. Nurse #1 said she called an off-duty employee to get the code. Nurse #1 said it took EMS about ten minutes to leave the facility. During an interview on 06/04/26 at 2:12 P.M., the Administrator said the codes should be in the Resource binder and he concluded that the problem was nursing staff didn't know where to look for the codes.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at increased risk for elopement, had cognitive impairment, and required supervision for ambulation, the Facility failed to ensure that they provided adequate staff supervision to maintain Resident #1's safety, when on 04/09/26, Resident was transported to the hospital for an out-patient medical appointment without an escort, he/she eloped from the hospital, and was later found at the police station approximately four miles away from the hospital.Findings include: Resident #1 was admitted to the Facility in November 2024, diagnoses included muscle weakness, depression, anxiety disorder, and mild cognitive impairment.Review of a Guardianship document (Decree and Order of Appointment of Guardian for an Incapacitated Person), dated 08/28/24, indicated that Resident #1 had a legal guardianship in place.Review of Resident #1's Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 required supervision for ambulation, and had moderate cognitive impairment, evidenced by a Brief Interview for Mental Status (BIMS) score of 12/15 (13-15 indicates intact cognition, 8-12 indicates moderately impaired, and 0-7 indicates severely impaired).Review of Resident #1's Activities of Daily Living Care Plan reviewed and renewed with the MDS Assessment, dated 02/26/26, indicated he/she required supervision for ambulation.Review of Resident #1's Elopement Care Plan, dated as initiated 03/02/26, indicated he/she was at risk for elopement, and a Wandergard bracelet was initiated on 03/02/26. Review of a report submitted by the Facility via Healthcare Facility Reporting System (HCFRS), dated 04/09/26, indicated that Resident #1 left for an appointment at the Hospital with a transportation service, was found elsewhere, and was returned to the Hospital's Emergency Department.Review of the Facility's Internal Investigation Report, undated, indicated that the Facility received a call from the Hospital at around 1:30 P.M. stating that Resident #1 was in the Emergency Department (ED). The Report indicated that Resident #1 had an appointment at the Hospital, had been transported to the appointment by a transportation company and handed over to Hospital staff. The Report indicated that the clinic that Resident #1 was supposed to be at indicated he/she had not been present for the appointment. The Report indicated that Police said Resident #1 arrived at the Police Station and said he/she was supposed to be at an appointment at the Hospital, so the Police requested Emergency Medical Services to transport Resident #1 to the Hospital's ED.Further review of the Facility's Internal Investigation Report indicated that a Facility escort was scheduled to attend the Hospital appointment with Resident #1, but the transportation company had left the Facility with Resident #1 without his/her escort.Review of the Facility's appointment calendar indicated that on 04/09/26, Resident #1 was scheduled for an appointment, was being picked up by the transportation company at 9:30 A.M, and Certified Nurse Aide (CNA) #1 was assigned to be his/her escort.Review of a Police Report, dated 04/09/26, indicated that on 04/09/26 at about 12:10 P.M., Resident #1 walked into the Police Station, reported that he/she was lost and wanted to go to the Hospital, so the officer requested Emergency Medical Services (EMS) to transport Resident #1 to the Hospital.During a telephone interview on 04/30/26 at 1:33 P.M., Certified Nurse Aide (CNA) #1 said she was not sure which resident she was supposed to escort that day, but Nurse #2 gave her paperwork and told her to go with Resident #1. CNA #1 said when she got downstairs, the transportation company had already left the Facility with Resident #1.During a telephone interview on 04/29/26 at 4:50 P.M., Nurse #1 said he was an agency nurse, and was not aware of the Facility's procedures for escorting residents to appointments. Nurse #1 said he was told that Resident #1 had an appointment, and so he thought nothing of it when the transport company came to pick him/her up.During a telephone interview on 04/30/26 at 12:22 P.M., Nurse #2 said Nurse #1 was assigned to Resident #1 that day, but when she saw Resident #1 leaving with a transport driver, she stopped them and asked where they were going. Nurse #2 said she checked the schedule and saw that Resident #1 had an appointment, so she found CNA #1, gave her the paperwork, and told her to go with Resident #1. Nurse #1 said that by the time CNA #1 got downstairs, the transport driver had left with Resident #1 without her. Nurse #2 said she told the Unit Manager and the Assistant Director of Nurses (ADON) that Resident #1 had left for an appointment with the transportation company without an escort. Nurse #2 said she could not remember the exact time but said Resident #1 left with the transport company sometime around 9:00 A.M. Nurse #2 said that the Hospital called one to two hours later and told staff that Resident #1 had been found wandering the streets.During a telephone interview on 04/30/26 at 1:48 P.M., the Unit Manager said that on 04/09/26, she showed up at the Facility at around 9:40 A.M., and Nurse #1 told her that Resident #1 had gone to a hospital appointment without an escort. The Unit Manager said she notified the ADON, but she was already aware. The Unit Manager said she could not remember the exact time, but said the Hospital called and reported to them that Resident #1 was found wandering, so she notified the Director of Nurses (DON).During a telephone interview on 05/01/26 at 10:06 A.M., (which included a review of her written witness statement), the Assistant Director of Nurses (ADON) said there had been several residents going out for appointments that morning and said Nurse #2 told her around 10:00 A.M. that Resident #1 had gone out for an appointment without an escort. The ADON said that Resident #1 always goes to medical appointments with an escort and should not have gone out that day without one. The ADON said even though she was notified immediately that Resident #1 went out without an escort, she didn't really process the information because she was trying to figure out other escorts for all of the appointments.During an interview on 04/23/26 at 2:25 P.M., the Director of Nurses (DON) said that she was notified by the Administrator on 04/09/26 in the afternoon that Resident #1 had gone out for an appointment with the transportation company without an escort. The DON said Resident #1 required an escort for appointments based on his/her cognitive status and that he/she was not safe to leave the Facility without one, but had, and was found wandering the streets.During an interview on 04/23/26 at 2:49 P.M., the Administrator said that on 04/09/26, he had been notified by Resident #1's Guardian sometime between 1:00 P.M t and 1:30 P.M., that Resident #1 was wandering the streets. The Administrator said that Resident #1 should not have gone out for an appointment without an escort. The Administrator said nursing should have notified him immediately when they noticed that Resident #1 went out for an appointment with the transport company around 9:30 A.M. without an escort, but they had not. The Administrator said Resident requires an escort for safety. The Administrator said Resident #1 somehow made it from the hospital to a police station (approximately four miles away) and EMS then transported him/her to the Hospital's ED. The Administrator said Resident #1 was unharmed but had not returned to the Facility per his/her guardian's request.On 04/23/26, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction, with an effective date of 04/18/26 which addressed the area(s) of concern as evidenced by:A. On 04/09/26 Resident #1 was transported to the Hospital' ED, was evaluated, and no injuries were noted. Resident #1 was not readmitted to the Facility per Guardian's request. B. On 04/09/26, the Administrator instituted immediate changes to their procedures for resident appointments, including how appointments are tracked on their electronic calendar, and how they communicate with the transport company to ensure no resident leaves the Facility without an escort if, one is required.C. On 04/09/26, Nursing Staff were educated by the ADON to notify Administration immediately if they realize a resident left for an appointment without an escort if required, as well as the procedures to ensure this does not recur.D. On 04/10/26, the DON tested all Wandergards to ensure they are all in working order.E. On 04/10/26, the DON began daily audits on the electronic resident appointment calendar to ensure resident appointments include information regarding resident escorts.F. On 04/13/26 the Administrator educated the Receptionist on the changes to the resident appointment procedures.G. On 04/13/26 and 04/15/26, the Administrator educated nursing administration and the receptionist that if a resident leaves the Facility without an escort, when they require one, they must notify the Administrator immediately.H. On 04/16/26 and 04/17/26, the DON completed new elopement assessments on all residents.I. On 04/17/26, the results of the audits were reviewed during an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to develop and institute a corrective action, and results of audits, and results of audits will be reviewed at monthly QAPI meetings to determine compliance.J. The Administrator and/or Designee are responsible for overall compliance.

Based on observation, record review, and interview, the facility failed to ensure four Residents (#5, #62, #98 and #9), out of a total sample of 27 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically: 1. For Resident #5 who had a stage 4 pressure ulcer (full Thickness and tissue loss appears as full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) the facility failed to consistently implement a physician's ordered air mattress.2. For Resident #62, who had a stage 3 pressure ulcer, the facility failed to ensure that the wound doctor's treatment orders were being followed as recommended.3. For Resident #98, the facility failed to ensure that the air mattress was set to 100 pounds as per the physician's order.4. For Resident #9, who is assessed to be at high risk for developing pressure ulcer/injuries, the facility failed to ensure weekly skin evaluations were completed weekly and timely. Findings include: Review of the facility policy titled, Prevention and management of Pressure Ulcers/Injuries, dated as revised 11/2024, indicated the purpose of this policy is to ensure a resident receives care consistent with professional standards of practice to prevent pressure ulcers and/or residents with pressure ulcers receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Risk Assessment: Develop the resident-centered care plan and interventions based on the risk factors identified, the condition of the skin, the resident's overall clinical condition. 6. Select appropriate support surfaces based on the resident's mobility, continence, body size, weight, and overall risk factors. 1. Resident #5 was admitted to the facility in October 2022 with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting the left non-dominant side, seizures, contracture of the left hand, and glaucoma. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/23/25, indicated that Resident #5 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS indicated Resident #5 did not reject care and was dependent on staff for upper and lower body dressing. This MDS indicated Resident #5 was at risk for developing pressure ulcers and had one stage four pressure ulcer. On 12/15/25 at 7:30 A.M., the surveyor observed Resident #5 in a room that was not assigned to him/her. He/she was on a standard mattress, and his/her heels were directly on the mattress. Nurse #1 said that Resident #5 was moved on Thursday 12/11/25 so his/her room could be painted. On 12/15/25 at 8:33 A.M., the surveyor observed the Hospice Home Health Aide (HHA) providing care to Resident #5. The HHA said that Resident #5 did not have his/her air mattress. The surveyor observed a dressing on Resident #5's left foot. On 12/16/25 at 6:50 A.M., 12/16/25 at 8:51 A.M., and 12/16/25 at 3:42 P.M., the surveyor observed Resident #5 on his/her air mattress. The air mattress was not plugged in and was not functioning, the power cord was observed to be disconnected from the device resting on the floor. Resident #5's air mattress was not inflated. Review of Resident #5's NSH Norton Scale for Predicting Risk for Pressure Ulcers - V2, dated 10/20/25, indicated Resident #5 scored an eight indicating that he/she was at high risk for skin breakdown. Review of Resident #5's physician's orders, dated 12/1/25, indicated: -Wound Care Stage IV (four) Left Medial Heel - wash with normal saline, pat dry, apply calcium alginate to wound bed and cover with abdominal pad, wrap with kerlix and secure with tape once daily and everyday shift, every other day. Review of Resident #5's physician's orders, dated 12/4/24, indicated: -Check air mattress setting every shift patient weights 107 pounds, setting #2. Review of Resident #5's plan of care related to pressure ulcer left heel related to immobility, dated as revised 10/10/25, indicated: -Special Mattress as ordered. Review of Resident #5's Treatment Administration Record (TAR), indicated that nursing documented Resident #5's air mattress was in place on: -Friday 12/12/25, all three shifts, -Saturday 12/13/25, evening and night shift, -Sunday 12/14/25, day and night shift, -Monday 1215/25, all three shifts, and on -Tuesday 12/16/25, all three shifts. Review of Resident #5's consultant wound note, dated 12/11/25, focused wound exam (site 5) stage 4 pressure wound of the left medical heel full thickness indicated: -2.2 x 2 x not measurable in depth due to presence of necrosis. Review of Resident #5's consultant wound note, dated 12/16/25, focused wound exam (site 5) stage 4 pressure wound of the left medical heel full thickness indicated: -2 x 1.1 x 0.1 centimeter (cm). During an interview on 12/17/25 at 7:43 A.M., Nurse #1 said that he moved Resident #5's room on Thursday morning (12/11/25) because Resident #5's room needed to be painted and Nurse #1 said he thought it was only going to be a day job. Nurse #1 said that he did not move Resident #5's air mattress because he didn't think Resident #5 would have been in the room for that long. Nurse #1 said that the air mattress is provided to Resident #5 because he/she has a pressure ulcer on his/her foot and that he is supposed to check for functioning and placement each shift. During an interview on 12/17/25 at 3:19 P.M., the Director of Nursing (DON) said nursing should have moved Resident #5's air mattress with the room move. The DON said that the air mattress is for pressure ulcer relief. 2. Resident #98 was admitted to the facility in September 2014 with diagnoses including type 1 and 2 diabetes mellitus, schizophrenia and age-related osteoporosis. Review of Resident #98's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Score of 10 out of 15 indicating moderate cognitive impairment. Further review of the MDS indicated that the Resident requires assistance from staff for Activities of Daily Living, has a current stage 3 unhealed pressure ulcer and is at risk of developing pressure ulcers/injuries. During an interview on 12/15/25 at 7:55 A.M., Resident #98 said he/she feels lousy and that his/her bottom hurts. The Resident said he/she has an open area on her buttocks. During a follow up interview on 12/16/25 at 8:26 A.M., Resident #98 said his/her backside hurts because of his/her open area on his/her skin. Review of Resident #98's Norton Scale for Predicting Pressure Ulcers evaluation (clinical tool used to assess a patient's risk of developing pressure ulcers) dated 11/24/25 indicated that the Resident scored a 6 indicating that he/she is at a high risk for developing pressure ulcers. Review of Resident #98's weekly skin evaluation dated 12/9/25 indicated the following: Left Ischium Wound, treatment order in place Review of Resident #98's physician's order dated 11/24/25 indicated the following: - Left ischium wound (the lower, back part of your left hip bone) – NS (normal saline) wash, apply hydrogel and xeroform gauze to wound, apply skin prep to surrounding intact skin, cover with foam dressing, every day shift Review of Resident #98's Wound Evaluation and Management Summary conducted by the wound physician on 11/19/25, 11/25/25, 12/2/25 and 12/11/25 indicated the following: - Summarized Wound Care Assessment and Individualized Treatment Plan: Stage 3 Pressure Wound of the Left Ischium. - Dressing Treatment Plan: Primary Dressing: Hydrogel w/ (with) silver apply once daily and as needed: if saturated, soiled, or dislodged. Xeroform gauze apply once daily and as needed: if saturated, soiled or dislodged. Review of Resident #98's physician's order dated 12/16/25 at 10:48 A.M., transcribed into medical record by Corporate Nurse #1, indicated the following: - Left ischium wound – NS wash, apply silvasorb gel and xeroform gauze to wound, apply skin prep to surrounding intact skin, cover with foam dressing. On 12/16/25 at 11:09 A.M., the surveyor observed a wound treatment on Resident #98's left ischium performed by Nurse #10, Corporate Nurser #1 was also observing the treatment. The 12/16/25 physician's order was used for the wound treatment – silvasorb gel and xeroform gauze. During an interview on 12/16/25 at 11:28 A.M., the surveyor asked Corporate Nurse #1 why the wound order was changed from hydrogel to silvasorb 21 minutes before the wound treatment observation, Corporate Nurse #1 said the facility ran out of hydrogel so she switched it to silvasorb. Corporate Nurse #1 said Resident #98 normally gets hydrogel for his/her stage 3 left ischium wound. The surveyor and Corporate Nurse #1 reviewed the Wound Doctor's recommendations indicated that Resident #98 should be getting hydrogel with silver. The surveyor and Corporate Nurse #1 then reviewed the Treatment Administration Record for December 2025 which indicated that staff have been applying hydrogel, not hydrogel with silver every day. Corporate Nurse #1 said she did not realize that Resident #98 was supposed to be getting hydrogel with silver and staff have been using the wrong treatment medication as recommended by the Wound Doctor. Corporate Nurse #1 said the silver decreases the chance of getting bacteria in the wound and not using hydrogel with silver can increase the chance of bacteria getting in the wound. Corporate Nurse #1 said the Wound Doctor comes in weekly and assesses Resident #98's wound and makes treatment recommendations which should then be applied to the Resident's orders. During an interview on 12/16/25 at 11:35 A.M., Nurse #10 said silver will improve the wound healing and it is different than just hydrogel. Nurse #10 said he follows the orders as written and he was unaware the written order was different than what the Wound Doctor recommended. During an interview on 12/16/25 at 11:53 A.M., the Physician Assistant (PA) said the facility should follow the Wound Doctor's recommendations, the PA then said the silver acts as an anti-bacterial. During an interview on 12/16/25 at 2:55 P.M., the Director of Nursing (DON) said the Wound Doctor comes in weekly and makes rounds and will make treatment recommendations which then get transcribed to himself. The DON then said he will confer with the Medical Director and then they will get entered as physician's orders for the Residents. The DON said Resident #98 should have been receiving hydrogel with silver, not just hydrogel. The DON continued to say that the silver acts as antibiotic and it helps with the bioburden of the wound and by not using silver could possibly cause the wound to not improve. 3. Resident #62 was admitted to the facility in September 2024 with diagnoses including dementia, adult failure to thrive and moderate protein-calorie malnutrition. Review of Resident #62's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that Resident #62 had a Brief Interview for Mental Status score of 0 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident was dependent on staff for activities of daily living and is at risk of developing pressure ulcers and at the time had one stage 3 pressure ulcer. The surveyor made the following observations: On 12/15/25 at 7:05 A.M. and 2:48 P.M., 12/16/25 at 6:50 A.M. and 12/17/25 at 7:17 A.M., Resident #62 was sleeping in his/her bed, Resident #62 was using an air mattress, and the air mattress pump was set to 250 pounds. Review of Resident #62's Weights and vital summary indicated that the Resident weighed 89.2 pounds on 12/9/25. Review of Resident #62's physician's order dated 9/25/25 indicated the following: Air Mattress: Set to 100 – Check and document setting every shift one time a day every 14 days for wound care Review of Resident #62's Norton Scale for Predicting Pressure Ulcers evaluation (clinical tool used to assess a patient's risk of developing pressure ulcers) dated 12/8/25 indicated that the Resident scored a 6 which indicated that the Resident is at a high risk for developing pressure ulcers. Review of Resident #62's weekly skin evaluation dated 12/14/25 indicated the following: coccyx area/groin area fragile, barrier cream applied. Review of Resident #62's skin breakdown care plan, dated and revised 9/23/25, indicated the following interventions: administer treatments as ordered and monitor effectiveness, Air mattress on bed. Review of Resident #62's Kardex (a form indicating the type of care a resident needs) indicated the following under the Resident Care section: administer treatments as ordered and monitor effectiveness, Air mattress on bed. During an interview on 12/18/25 at 9:04 A.M., Nurse #7 said air mattresses should be set to the weight of the resident or by physician's order. Nurse #7 said Resident #62's skin is fragile and he/she has had open areas in the past so we use the air mattress as a preventative measure. Nurse #7 said Resident #62's air mattress should not have been set to 250 pounds as it would be too firm. During an interview on 12/18/25 at 9:04 A.M., Unit Manager #2 and Corporate Nurse #1 said air mattresses should be set by what the Resident's weight is. Unit Manager #2 said she noticed yesterday that Resident #62's air mattress was at the incorrect setting, so she switched it to 100 pounds. Unit Manager #2 said if the air mattress is set too high it will be too firm for Resident #62. During an interview on 12/18/25 at 9:40 A.M., the Director of Nursing (DON) said air mattress settings should be set to the physician's order and the purpose of them is for pressure relief and they can be used as a preventative measure for pressure ulcers. The DON said Resident #62's air mattress should have been set to 100 pounds. 4. For Resident #9 the facility failed to ensure weekly skin evaluations were completed weekly and timely. Review of the facility's policy titled, Prevention and management of Pressure Ulcers/Injuries, revised 11/2024 indicated, Risk Assessment, 4. License nurse conducts a weekly skin evaluation. Resident #9 was admitted to the facility in June 2016 and has diagnoses that include but are not limited to unspecified dementia, type 2 diabetes mellitus, and chronic kidney disease. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #9 scored a 3 out of 15 on the Brief Interview for Mental Status Exam, indicating severe cognitive impairment. Further, the MDS indicated Resident #9 is at risk of developing pressure ulcers/injuries. During an observation on 12/15/25 at 8:58 A.M., Resident #9 was observed in the dining room eating his/her breakfast. Resident #9 was observed to be a person who requires care. Resident #9 smiled but was unable to participate in an interview. Review of Resident #9's clinical record indicated the following: -NSH Norton Scale for Predicting Risk of Pressure Ulcers dated 9/7/25 and 10/20/25 categorized Resident #9 as high risk for developing pressure ulcers, with a score of 4. -A care plan indicating Resident #9 as incontinent and has potential complications associated with frequent urinary and bowel incontinence, diminished perception, history of dementia, dated as revised 11/15/23 with the goal, Resident will have intact skin through next review, revised 10/17/25. -A care plan indicating Resident has potential for skin breakdown d/t (due to) frequent incontinence, dx (diagnosis) diabetes and quarterly Norton Score, revision date 5/14/25, interventions included license nurse to monitor skin weekly for alteration in skin integrity, dated initiated 3/21/20. Review of the physician's orders failed to indicate an order for a weekly skin evaluation. Review of the documented Weekly Skin Evaluations dated November 2025, failed to indicate a Weekly Skin Evaluation, was completed on 11/10/25 or within the week. Further, the last documented Weekly Skin Evaluation was documented on 12/1/25. During an interview of 12/17/25 at 9:35 A.M., Nurse #9 said all residents are assessed for risk for developing skin issues and a plan of care is determined by the risk level. Nurse #9 said all residents have a weekly skin assessment completed. Nurse #9 said Resident #9 is at risk for developing pressure areas because he/she is in a wheelchair and is diabetic. Nurse #9 reviewed Resident #9's medical record and said the Resident's weekly skin evaluation was missed and now is overdue. During an interview on 12/18/25 at 10:00 A.M., Unit Manager #2 said Resident #9 is high risk for developing pressure areas, and a weekly skin check is required to be documented on skin evaluation in the medical record weekly.

Based on observations, record review and interview, the facility failed to ensure dental services were provided for four Residents (#51, #81, #73, #72) out of a total sample of 27 Residents. Specifically, the facility failed to:1. Ensure Resident #51 was provided with consent to be seen by dental services resulting in the Resident not being seen by a dentist while residing in the facility for one year.2. Ensure Resident #81 was seen by dental services following a physician's order.3. Ensure Resident #73 had follow up as required following a dental visit.4. Ensure Resident #72 was seen by dental services following a physician's order. Findings include:Review of the facility policy titled Ancillary Physician Services, dated and revised March 2025, indicated the following: - Routine dental services are available to meet the resident's health needs. - Routine dental services are provided to our residents through: a contract agreement with a licensed Dentist that come to the facility routinely. - Social Services or nursing representatives will assist residents with appointments - Services are record in the resident's medical record. 1. Resident #51 was admitted to the facility in November 2024 with diagnoses including adjustment disorder and anxiety disorder. Review of Resident #51's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident has obvious or likely cavities or broken natural teeth and does not have dentures. During an interview on 12/15/25 at 7:43 A.M., Resident #51 was observed to have no bottom teeth and missing the majority of his/her teeth. Resident #51 told the surveyor that he/she has no teeth and has not seen the dentist since living in this facility but would like to. During a follow-up interview on 12/17/25 at 9:13 A.M., Resident #51 told the surveyor that he/she still would like to see a dentist because he/she has no teeth and that no one has ever approached him/her about it. The Resident continued to say he/she would like to get some information about dentures. Review of Resident #51's physician's orders indicated the following order: - Consults: Dental services as needed – Dated 11/18/24 Review of Resident #51's Care plan dated 12/1/25 indicated the following: - Focus: DENTAL: Resident #51 has no front teeth, he/she has rear teeth only - Interventions: Cut up meat as ordered, Refer to Dentist as needed Review of Resident #51's medical record indicated a Request for Service document indicating that the Resident consented to be seen by dental services. The form was signed on 12/16/25, one year after the Resident was admitted to the facility. Further review of the medical record failed to indicate that Resident #51 has ever been seen by the dentist or dental hygienist. The surveyor requested the most recent dental visitation logs dated for September 2025, and Resident #51 was not on the list. During an interview on 12/17/25 at 2:12 P.M., Nurse #7 said we obtain a consent form for dental services when a resident is admitted to the facility and then we fax it to the contracted dental services provided and then the Resident will be seen by the dentist. When asked why Resident #51's dental consent form was not obtained until a year after his/her admission Nurse #7 said she did not know about it and it should have been done when he/she was admitted to the facility so he/she could be seen by the dentist. Nurse #7 said she did not know Resident #51 wanted to see a dentist. During an interview on 12/18/25 at 9:03 A.M., Unit Manager #2 and Corporate Nurse #1 said consent to be seen by dental services is obtained upon admission to the facility and then it is faxed to the dental company. They then said if a resident expressed desire to be seen by a dentist we would arrange an appointment. Unit Manager #2 and Corporate Nurse #1 said they were not aware no dental consent was obtained until yesterday and Resident #51 should have been seen by the dentist by now. During an interview on 12/18/25 at 9:35 A.M., the Director of Nursing (DON) said consent for dental services is obtained on admission to the facility, the DON said he is still getting familiar with how the dental process works in the facility and they are trying to figure out a system. The DON then said Resident #51 should have been seen by the dentist by now. 2. Resident #81 was admitted to the facility in May 2025 with diagnoses including adult failure to thrive, major depression, and cognitive impairment. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/7/25, indicated that Resident #81 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS failed to indicate any dental issues. During an interview on 12/15/25 at 7:33 A.M., Resident #81 said he/she has a missing tooth and would like to see the dentist. During an interview on 12/17/25 at 9:00 A.M., Resident #81 said he/she does still have tooth pain and would like to be seen by the dentist. Review of Resident #81's physician's order, dated 8/2/25, indicated please put him/her on list for the dentist visit. Review of Resident #81's physician's progress note, dated 8/2/25, indicated resident is requesting dental visit, pain in tooth, missing tooth. Review of Resident #81's medical record indicated a Request for Service document indicating that the Resident consented to be seen by dental services. The form was signed on 8/6/25. Review of facility's dental visit list, dated 8/12/25, failed to include Resident # 81. Review of Resident #81's physician's order, dated 9/16/25, indicated left sided tooth pain, consult outpatient dentist for consult. Review of Resident #81's entire medical record failed to include any dental visits since admission. Review of Resident #81's care plan on 12/17/25 failed to include a plan of care related to dental. During an interview on 12/17/25 at 8:16 A.M. Unit Manager #2 said she was not aware that Resident #81 had an issue with his/her teeth or that there was an order to be seen by the dentist. She said the process for receiving ancillary services in the facility is to request consent when a resident is admitted and then fax to the ancillary service so the resident can be added to the next schedule. She said if there was an issue that needs attention prior to the next scheduled visit then the facility can contact a local provider for the resident to see. During an interview on 12/18/25 at 9:35 A.M., the Director of Nursing (DON) said that he has only been the DON since July and is currently trying to figure out a system for setting up ancillary services needed by the residents. He was unaware that Resident # 81 had dental issues or had an order to be seen by the dentist. He said that there had been some difficulty getting resident set up for ancillary services related to such things as insurance coverage, however, he would expect documentation of any attempts to set up these services. 3. Resident #73 was admitted to the facility in September 2024 with diagnoses including adult failure to thrive, cerebral infarct, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/5/25, indicated that Resident # 73 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS failed to indicate any dental issues. During an interview on 12/17/25 at 9:00 A.M., Resident #73 said that he/she had seen the dentist a few months ago and had been waiting to get dentures but had not heard anything. Review of Resident #73's plan of care related to dental, dated as revised 9/16/25, indicated is edentulous. He/she would like new upper and lower dentures. Review of Resident #73's physician's order, dated 9/4/24, indicated he/she has an order for a dental consult as needed. Review of Resident #73's dental group exam, dated 9/11/25, indicated patient has no teeth, patient would like full upper and lower dentures, full upper and lower dentures will aid in mastication. Nursing home staff were asked to have responsible party sign consent for denture form. During an interview on 12/18/25 at 9:18 A.M. Unit Manager #2 said that she was unaware of Resident #73's request for dentures or anything about the consent for denture form. Review of Resident #73's entire medical record failed to include a consent for denture form. During an interview on 12/18/25 at 9:35 A.M., the Director of Nursing (DON) said that he has only been the DON since July and is currently trying to figure out a system for setting up ancillary services needed by the residents. He was unaware about Resident #73 requesting dentures or where the consent form would be. He said he would expect documentation in the Resident's medical record to indicate any communication regarding this. 4. Resident #72 was admitted to the facility in October 2022 with diagnoses including severe protein-calorie malnutrition, anxiety, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/17/25, indicated that Resident # 72 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Further review of the MDS failed to indicate any dental issues. During an interview on 12/15/25 at 7:33 A.M., Resident # 72 said he/she would like to see the dentist as he/she had broken teeth. During an interview on 12/17/25 at 9:25 A.M., Resident #72 said he/she would like to be seen by the dentist as he/she had difficulty managing his food sometimes. Review of Resident #72's physician's order, dated 11/7/25, indicated needs to follow up with dentist broken tooth making hard for him to swallow. Review of Resident #72's medical record on 12/17/25 indicated a blank Request for Service (to receive ancillary services) over three years after Resident had been admitted to the facility and over a month after Resident had a physician's order to follow up with a dentist. Review of Resident #72's plan of care related to the teeth, dated as revised 2/17/2022, indicated care deficit pertaining to the teeth or oral cavity characterized by: altered oral mucous membrane; problems with dentures/ teeth/ gums. Interventions include: Refer to dentist as needed. Review of Resident #72's entire medical record failed to indicate any assessment of his/her oral cavity or contact with dentist to follow up with his/her broken tooth, failed to indicate any consent to receive dental services in facility or that he/she had received dental visits since admission. During an interview on 12/17/25 at 8:16 A.M. Unit Manager #2 said she was not aware that Resident #72 had an issue with his/her teeth or that there was an order to be seen by the dentist. She said the process for receiving ancillary services in the facility is to request consent when a resident is admitted and then fax to the ancillary service so the resident can be added to the next schedule. She said if there was an issue that needs attention prior to the next scheduled visit then the facility can contact a local provider for the resident to see. During an interview on 12/18/25 at 9:35 A.M., the Director of Nursing (DON) said that he has only been the DON since July and is currently trying to figure out a system for setting up ancillary services needed by the residents. He was unaware that Resident # 72 had dental issues or had an order to be seen by the dentist. He said that there had been some difficulty getting resident set up for ancillary services related to such things as insurance coverage, however, he would expect documentation of any attempts to set up these services.

Based on record review and interviews, the facility failed to have an effective immunization program in place for 11 Residents out of a total sample of 27 residents. Specifically, the facility failed to ensure the influenza vaccine was administered as soon as in became available. Findings include:Review of the facility policy titled Influenza Vaccine, dated as revised 11/5/20, indicated all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.-Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination.-Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated, or the resident has already been immunized.-Residents admitted to the facility between October 1st and March 31st shall be offered the vaccine.-Prior to the vaccination, the resident or resident's legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such educations shall be provided in the residents' medical record.- For the residents who receive the vaccine, the date of vaccination will be included in the resident's medical record.Review of the CDC guidelines titled Who Needs a Flu Vaccine, dated 9/18/25, indicated the following:-Everyone 6 months and older should get a flu vaccine every season with rare exceptions. Vaccination is particularly important for people who are at higher risk for serious complications from influenza.-Flu vaccination has important benefits. It can reduce flu illnesses, visits to doctor's office's .as well as make symptoms less severe and reduce flu-related hospitalizations and deaths in people who get vaccinated but still get sick.-Administration of the influenza vaccine when it becomes available rather than on a specific date.-vaccination is ideally recommended to occur in September or October to offer the best protection, before the season peaks.Review of the CDC guidelines titled People at Increased Risk for Flu Complications, dated 9/11/24, indicated some of the people at increased risk for complications of the flu are:-Adults aged 65 and older-People with Chronic lung disease-People with blood disorders-People with heart disease-People with a Body Mass Index (BMI) of 40 Kg (kilograms)/M (meters) or higher-People with a weakened immune system due to .chronic conditions requiring chronic corticosteroids or other drugs Review of 27 Resident medical records failed to indicate that 11 of the 27 Residents were offered/administered the influenza vaccination.During an interview on 12/18/25 at 9:45 A.M., the Director of Nursing (DON) said that the facility's influenza program includes everyone with consents will get immunized. An order must be obtained to administer the vaccine and then the order will be transcribed on the Medication Administration Record (MAR) and after the vaccine is administered it will also be recorded in the electronic record under the immunization tab.He said that in October the facility vaccinated the first wave of residents for everyone that had consents and wanted vaccines. He said that all new admits are offered the vaccine and medical record checked to see if they have already received. The DON said the influenza season starts in October and the facility did have the vaccine available at that time. He said there had been a lot of resistance from residents agreeing to receive the vaccine and from getting the consents returned from legal representatives.The DON said that there is no real excuse as to why some residents have not received the influenza vaccine despite having orders and consent since October.

Based on observations and interviews, the facility failed to ensure that Residents on the third-floor unit were provided with a dignified existence. Specifically, the facility failed to ensure that staff members were not using their personal cellphones in the Resident Dining Room while Residents were occupying it. Findings include: Review of the facility policy titled Resident Rights, dated and revised January 2024 indicated the following:- Employees shall treat all residents with kindness, respect and dignity- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence. During the survey period, the surveyor made the following observations:On 12/15/25 at 10:48 A.M., multiple Residents were observed sitting at the table in the dining room, a Certified Nursing Assistant (CNA) was standing, leaning against the counter with her cellphone in her hand not interacting with any Residents. On 12/16/25 at 10:30 A.M., multiple Residents were observed sitting at tables in the dining room, a Certified Nursing Assistant (CNA) was sitting in a chair documenting care on a tablet, while doing so she was texting on her personal cell phone in view of facility Residents.During an interview on 12/18/25 at 9:15 A.M., Unit Manager #2 and Corporate Nurse #2 said all residents are expected to have a dignified existence in the facility and staff members should not be on their phones in front of residents. During an interview on 12/18/25 at 9:46 A.M., the Director of Nursing said residents deserve a dignified existence in the facility and staff members should not be using their cell phones in front of residents in the dining room.

Based on record review, and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one Resident (#2), out of 27 sampled residents. Specifically, for Resident #2 the facility failed to code a fall with major injury (subacute L1 fracture, a bone in the lumbar spine). Findings include: Resident #2 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, abnormal posture, and a history of falling. Review of the Minimum Data Set (MDS) assessment, dated 10/10/25, indicated that Resident #2 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS indicated Resident #2 had one fall with minor injury. Review of the RAI manual, dated October 2025, indicated a major injury is a fall including bone fractures. Review of Resident #2's incident report, dated 7/30/25 at 9:30 P.M., indicated:-he/she was found with half his/her face on the floor and lying on his/her left side by certified nursing assistant while going to do a brief change. Has knot to left forehead. Director of Nursing made aware. Review of Resident #2's nursing note, dated 7/30/25, indicated he/she was found with half his/her face on the floor and lying on his/her left side by certified nursing assistant while going to do a brief change. Has knot to left forehead. Director of Nursing made aware. Review of Resident #2's nursing note, dated 7/31/25, indicated Resident #2 came back to the facility after sustaining a head strike from a fall in his/her room at the facility. Scans of the head are normal with a subacute compression fracture for L1 vertebra. Review of Resident 32's hospital Discharge summary, dated [DATE], indicated: -Seen in the emergency department after a fall. They did find a subacute fracture of your L1 vertebra. During an interview on 12/16/25 at 10:33 A.M., the MDS Nurse said that she codes falls based on the RAI manual and she should have coded the L1 fracture as fall with major injury, but she did not. During an interview on 12/16/25 at 10:30 A.M., the Director of Clinical Operations said that falls should be coded according to the RAI manual.

Based on observations, record review and interview, the facility failed to ensure that Activities of Daily Living were provided for dependent Residents for three Residents (#57, #88, #13) out of a total sample of 27 Residents. Specifically, the facility failed to:1. Ensure incontinent care was provided in a timely manner for Resident #57, who is assessed as incontinent of bladder and bowel, resulting in Resident #57 sitting in a soiled brief for an extended period. 2. Ensure that incontinent care was provided within a timely manner for Resident #88 who is assessed as incontinent of bowel and bladder resulting in Resident #88 sitting in a soiled brief for an extended period.3. Ensure that Resident #13 was supervised during mealtimes as indicated by the plan of care. Findings include: Review of the facility policy titled Activities of Daily Living (ADLS), Supporting, dated and revised November 2024, indicated the following: - Residents will be provided with care, treatment and services as appropriate to maintain or improve as able their ability to carry out activities of daily living (ADLs). - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Elimination (toileting), Dining (meals and snacks) 1) Resident #57 was admitted to the facility in July 2023 and has diagnoses that include but are not limited to muscle weakness, lupus (an autoimmune condition in which the body's immune system attacks its own tissues and organs and causes swelling and irritation, inflammation, that may affect joints, skin, kidneys, blood cells, brain, heart and lungs), spondylopathy cervical region (degenerative changes affecting the spinal column), and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #57 scored 15 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as cognitively intact. Further, the MDS indicated Resident #57 did not display behaviors and is dependent on staff for daily care activities including toileting, is incontinent of bladder and bowel and is at risk for developing pressure ulcer/injuries. During an interview on 12/15/2025 at 4:48 P.M., Resident #57 was greeted by the surveyor in the dining/activity room. Resident #57 said he/she has been out of bed since around 10:00 A.M. and has been asking to go back to bed. Resident #57 said he/she has not been changed since he/she got up and is soaked. Resident #57 became weepy and said 7 hours is too long to be out of bed. During an interview on 12/16/25 at 9:01 A.M., Resident #57 said he/she gets up on Mondays, Wednesdays and Fridays and on the days he/she stays in bed, he/she can use the call bell to be changed. Resident #57 said on the days he/she is out of bed; I drink and need to be changed, I know I am wet or sometimes soiled. Resident #57 voice wavered, said he/she is upset with being out of bed for seven hours at a time. On 12/17/25 at 10:01 A.M., Resident i#57 was observed being provided with care and Certified Nursing Assistant (CNA) #1 said Resident #57 was getting up today. On 12/17/2025 at 10:23 A.M., Resident #57 was out of bed in his/her wheelchair in the dining/activity room. On 12/17/25 the following observations and interviews were conducted by the surveyor: -At 11:13 A.M., Resident #57 was participating in an activity. When the activity was over Resident #57 was moved to his/her spot in the room where he/she remained through his/her lunch meal. -At 1:07 P.M., Resident #57 said he/she had not been changed, that he/she remained in the corner, and they (staff) know I have a diaper on. Resident #57 filled up with tears as he/she spoke to the surveyor. -At 1:55 P.M., Resident #57 remained in the same area in the activity/dining room. Resident #57 said he/she is wet and has not been checked or offered to be changed. -At 2:15 P.M., Resident #57 was provided an oatmeal cookie by a staff Certified Nursing Assistant. -At 2:34 P.M., Resident #57 eyes were closed, and he/she was observed dozing in his/her wheelchair. -At 2:42 P.M., Resident #57 was drinking a beverage left in front of him/her. -At 2:55 P.M., Resident #57 said he/she is wet and he/she wants to get back to bed. Resident #57 said now I will need to wait for the 3-11 staff. -At 3:26 P.M, Resident #57 remained in the same area in the activity/dining room. Resident #57 said he/she is wet, that he/she has not been asked to be changed and that after five hours he/she is tired and uncomfortable. -At 4:31 P.M., Resident #57 observed dozing in chair. He/she woke up and said no one had approached him/her about being changed, He/she said he/she is tired and just stuck here. -At 5:10 P.M., the Resident #57 remained in his/her wheelchair in the activity/dining room. During an interview on 12/18/25 at 8:30 A.M., Resident #57 said he/she got back into bed around dinner time on 12/17/25. Review of Resident #57's medical record indicated the following: -CNA task documentation of behavior monitoring and interventions dated 12/13/25, 12/14/25, 12/15/25, 12/16/25 and 12/17/25 indicated 'no behaviors observed'. -A care plan for potential alteration in skin integrity, immobility obesity, lupus, cervical spondylosis, incontinence of bladder and bowel, revised 7/15/25 Interventions include but are not limited to protect skin with incontinent care. -A behavioral care plan, Resident #57 has a behavior problem. He/she is reported to being verbally abusive, resistive to care etc. dated revised 10/13/25. Interventions included anticipate care needs and provide before the resident becomes overly stressed date initiated 7/12/23. -An incontinence care plan, resident has the potential for complications associated with bowel and bladder incontinence, revision date 7/15/25, goal, Resident #57 will be kept clean and dry and comfortable daily through next review, target date 1/16/26, Interventions included Check and change resident every 2-3 hours and as needed for incontinent episodes, date initiated 7/19/24. -A Kardex (a breakdown of the care plan and care requirements for each resident, used by care staff) printed and dated 12/18/25, Bladder/Bowel, check and change resident every 2-3 hours and as needed for incontinent episodes. During an interview on 12/17/25 at 4:37 P.M., Certified Nursing Assistant (CNA) #2, said Resident #57 is up in his/her wheelchair a few days a week when she comes in on the 3:00 P.M.-11:00 P.M., shift. CNA #2 said she will change Resident #57 when he/she gets transferred into bed. CNA #2 said Resident #57's requires two staff to transfer back to bed using the mechanical lift. CNA #2 said Resident #57's brief will be soiled with feces sometimes and is always wet and often his/her clothing is wet through. CNA #2 said Resident #57 is incontinent and needs to be checked and changed every 2 to 3 hours. During an interview on 12/18/25 at 8:42 A.M., CNA #1 said residents who are incontinent are to be changed every 2-3 hours. CNA #1 said Resident #57 is incontinent, drinks a lot and needs to be changed and asked to be changed when she is in bed. CNA #1 said Resident #57 uses a large brief. CNA #1 said Resident #57 has a schedule to be out of bed a few days a week. CNA #1 said she cared for Resident #57 yesterday (12/17/25) and that she did not nor did any other staff change Resident #57 once he/she was up in his/her wheelchair. CNA #1 said the next shift should have got him/her into bed to be changed around 3:00 P.M, or after. CNA #1 said Resident #57 should not be up for over four hours. CNA #1 said Resident #57 told her that on Monday (12/15/25) that he/she was up until 7:00 P.M. CNA #1 said she cares for the Resident and does not want him/her to get skin wounds for being up too long. During an interview on 12/18/25 at 9:07 A.M., Unit Manager #2 said residents who have incontinence should be checked and changed, and given appropriate incontinence care every 2 to 3 hours. Unit Manager #2 said Resident #57 could be transferred into bed to be provided with incontinent care and can get back up if he/she chooses to. During an interview on 12/18/25 at 9:28 A.M., Nurse #6 said to prevent skin breakdown for residents who are incontinent they should be checked and changed every few hours. Nurse #6 said Resident #57 does not exhibit behaviors, is incontinent and should be provided with incontinent care every few hours whether he/she is in bed or up in his/her wheelchair. Nurse #6 said Resident #57 is alert and oriented and does not always ask for assistance and should not have to ask for care. 2. Resident #88 was admitted to the facility in April 2020 with diagnoses including Alzheimer's disease, dementia, chronic kidney disease stage 3b, anxiety disorder and heart failure. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident requires substantial/maximal assistance with toileting hygiene, substantial/maximal assistance with toilet transfer, and staff assistance with walking. Review of Resident #88's Kardex (a form indicating the level of care a resident needs) indicated the following under the Resident Care section: - Bladder: incontinent, Bowel: incontinent - Toileting: assist to dependent Review of Resident #88's Activities of Daily Living (ADL) care plan, dated and revised 9/18/25, indicated the following: - Focus: Resident #88 has ADL self-care deficit as evidenced by incontinence of bladder and bowel -Interventions: Bladder: Incontinent, Bowel: Incontinent, Toileting: assist to dependent, Toileting – provide encouragement/supervision/assist/reminders. Provide incontinent care q (every) occurrence. Review of Resident #88's bowel and bladder care plan dated and revised 6/24/25 indicated the following: - Focus: Resident #88 is incontinent of bowel and bladder R/T (related to) decreased awareness of his/her needs d/t (due to) cognitive loss secondary to dementia, impaired mobility d/t muscle weakness and lack of coordination - Intervention: Assist with toileting and incontinence care, as needed Review of Resident #88's quarterly Nursing Evaluation, dated 12/1/25, indicated the following: Bladder: Continence/Incontinence – Incontinence is checked. Bowel: Continent of Stool? – No. Bowel Incontinence – frequently incontinent The surveyor made the following continuous observations of Resident #88 on 12/16/25: - At 10:10 A.M., Resident #88 was sitting in the corner of the dining room out of direct sight with his/her head down on a tray table. - At 11:07 A.M., Resident #88 was sitting in the corner of the dining room out of direct sight with his/her head down on a tray table. At no time during the observations did the surveyor observe staff check on or offer to change Resident #88. - At 12:40 P.M., Resident #88 was observed eating his/her lunch in the same spot in the dining room. - From 1:03 P.M. through 1:19 P.M., Resident #88 was still sitting in corner of the dining room out of direct sight. - At 2:08 P.M., just under four hours since the initial observation, the Occupational Therapist took Resident #88 to his/her room. The surveyor made the following continuous observations of Resident #88 on 12/17/25: - At 7:14 A.M., Resident #88 left his/her room using a rolling walker with a staff member and went into the corner of the dining room out of direct sight. - From 8:01 A.M. through 8:21 A.M., Resident #88 ate his/her breakfast in the same spot in the dining room. - At 9:10 A.M., Resident #88 was sitting in the corner of the dining room out of direct sight. At no time during the observations did the surveyor observe staff check on or offer to change Resident #88. - From 9:30 A.M., through 11:00 A.M., Resident #88 was sitting in the corner of the dining room out of direct sight with his/her head down on a tray table. At no time during the observations did the surveyor observe staff check on or offer to change Resident #88. - At 11:16 A.M., just over four hours since the initial observation, Certified Nursing Assistant (CNA) #4 began walking Resident #88 to his/her room. CNA #4 told the surveyor he was going to toilet and put Resident #88 to bed. As CNA #4 began changing Resident #88's brief, Nurse #7 took over changing his/her brief. Nurse #7 showed the surveyor Resident #88's brief and it was soiled and swollen with bright yellow urine. During an interview on 12/17/25 at 11:23 A.M., CNA #4 said he knows the Resident's level of care by looking at the care plan and by what the nurses tell him. CNA #4 then said incontinent residents should be checked by staff every two hours to see if they urinated or had a bowel movement. CNA #4 said he was not sure the last time Resident #88 was toileted, the surveyor told him he/she has not been offered since 7:14 A.M. and CNA #4 said Resident #88 should have been offered to toilet before right now. During an interview on 12/17/25 at 11:25 A.M., Nurse #7 told the surveyor incontinent residents should be checked for an incontinence episode every two hours and Resident #88 should have been checked for an incontinence episode prior to when he/she just was checked. During an interview on 12/17/25 at 1:41 P.M., CNA #3 said Resident #88 is dependent on staff for toileting and he/she should be checked every two hours for incontinence. Nurse #7 then said Resident #88 has dementia and he/she cannot voice his/her needs all of the time. During an interview on 12/18/25 at 9:07 A.M., Unit Manager #2 and Corporate Nurse #1 said CNA's should be checking if incontinent residents are wet every 2-3 hours. When asked about Resident #88, Unit Manager #2 and Corporate Nurse #1 said Resident #88 is incontinent of bladder and bowel and needs to be checked every 2-3 hours and should have been checked sooner. During an interview on 12/18/25 at 9:26 A.M., the Director of Nursing (DON) said incontinent residents should be checked every 2-3 hours and Resident #88 should have been checked sooner. 3. Resident #13 was admitted to the facility in March 2018 with diagnoses including schizophrenia, dementia and muscle weakness. Review of Resident #13's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident required supervision or touching assistance with eating. The surveyor made the following observations: - On 12/15/25 at 7:14 A.M., Resident #13 was sitting in his/her wheelchair eating his/her breakfast in his/her room. No staff were present in the room supervising the Resident or supervising from the hallway. Resident #13's room is the last room at the end of the hallway. - On 12/16/25 at 12:26 P.M., Resident #13 was sitting in his/her wheelchair eating his/her breakfast in his/her room. No staff were present in the room supervising the Resident or supervising from the hallway. Resident #13's room is the last room at the end of the hallway. - On 12/17/25 from 8:16 A.M. through 8:29 A.M., Resident #13 was sitting in his/her wheelchair eating his/her lunch in his/her room. No staff were present in the room supervising the Resident or supervising from the hallway. Resident #13's room is the last room at the end of the hallway. - On 12/17/25 at 12:18 P.M., Resident #13 was sitting in his/her wheelchair eating his/her breakfast in his/her room. No staff were present in the room supervising the Resident or supervising from the hallway. Resident #13's room is the last room at the end of the hallway. Review of Resident #13's Kardex (a form indicating the level of care a resident needs) indicated the following under the Resident Care section: - EATING: Supervision with set up help Review of Resident #13's Activities of Daily Living (ADLs) care plan dated and revised 9/9/20, indicated the following: Focus: Resident has ADL Self-Care Deficit as evidenced by needs assistance with bathing, dressing, feeding. - Interventions: EATING: Supervision with set up help, Resident #13 prefers to eat in his/her room. Eats meals supervised in the main dining room as tolerated During an interview on 12/17/25 at 1:41 P.M., Certified Nursing Assistant (CNA) #3 said she thinks Resident #13 is independent with meals and does not need supervision. During an interview on 12/17/25 at 2:12 P.M., Nurse #7 said we look at a Resident's care plan and Kardex for ADL care. Nurse #7 said Resident #13 is independent with meals and does not need supervision. Nurse #7 said she was unaware that Resident #13's medical record indicated supervision with meals. During an interview on 12/18/25 at 8:56 A.M., Unit Manager #2 and Corporate Nurse #1 said staff should follow the care plan and Kardex for what level of ADL care they need. Unit Manager #2 said supervision means someone needs to be watching Resident #13 while he/she eats but that is difficult if he/she eats in his/her room. During an interview on 12/18/26 at 9:26 A.M., the Director of Nursing (DON) said his expectation is that staff follows each Resident's care plan for ADL care.

Based on observations, record reviews and interviews, the facility failed to provide and implement an ongoing activities program for one Resident (#88) to meet his/her needs for engagement in meaningful activities, out of a total sample of 27 residents.Findings include:The surveyor requested a policy on Resident Activities, but the facility said they do not have a Resident Activities policy.Resident #88 was admitted to the facility in April 2020 with diagnoses including Alzheimer's disease, dementia, chronic kidney disease stage 3b, anxiety disorder and heart failure. Review of Resident #88's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicating that the Resident had a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident requires substantial/maximal assistance with toileting hygiene, substantial/maximal assistance with toilet transfer, and staff assistance with walking. Review of Resident #88's most recent Annual MDS dated [DATE] indicated the Resident enjoys reading books, newspapers or magazines, listening to music, doing things with groups of people, participating in favorite activities and spending time outdoors.Review of Resident #88's Kardex (a form indicating the type of care a resident needs) indicated the following under the Activities section: Invite to scheduled activities.Review of Resident #88's Care plans indicated the following dated and revised 10/28/25:Focus: Resident has previous recreational interest/patterns: Daily contact with close friends and/or relatives. Resident #88 Enjoys watching TV and listening to music. He/she will often engage in activities such as art projects. Even with the language barrier he/she enjoys being included and easy to understand activities. Resident #88 is currently a long-term care resident. He/she is at risk for social isolation due to language barrier, some physical limitations, and some cognitive impairment. However, Resident #88 is able to communicate through gestures and some limited English vocabulary, Resident #88 loves music, dancing, watching TV and enjoys one to one attention.Interventions: Introduce to other residents with similar interests, disabilities and/or limitations, invite to scheduled activities, offer to assist/escort resident to activity functions, offer variety of activity types and locations.Review of the Certified Nursing Assistant (CNA) documentation for December 2025 indicated that CNA's only documented activity participation for Resident #88 on 12/2/25 and 12/4/25 through 12/17/25.Review of Resident #88's quarterly Recreation Assessment conducted by the Activities Director dated 7/3/25 indicated the following:- Primary Language: Cantonese- Summary/Notes: Resident #88 participates in all of the music programs and enjoys singing! He/she also loves when family comes to visit him/her. The recreation department will continue to encourage Resident #88's social and cognitive progress.Review of Resident #88's quarterly Recreation Assessment conducted by the Activities Director dated 9/4/25 indicated the following:- Primary Language: Cantonese- Summary/Notes: Resident #88 spends a lot of time with other residents in the activities room. He/she enjoys watching TV, coloring and is frequently visited by family. The recreation department will continue to encourage and monitor Resident #88 in his/her social progress, accommodating for his/her language barrier.Review of Resident #88's quarterly Recreation Assessment conducted by the Activities Director dated 12/5/25 indicated the following:- Primary Language: CantoneseSummary/Notes: Resident #88 does not like larger groups and does not like group activities due to language barrier, but loves one on one visits with staff, He/she enjoys coloring and having his/her nails painted. When doing independent activities, he/she likes to watch TV in the living room with other residents. The recreation department will continue to monitorThe surveyor made the following observations in the third-floor dining room:- On 12/15/25 at 7:49 A.M., Resident #88 was in the corner out of direct sight of staff members, he/she had his/her head resting face down on a bedside table.- On 12/15/25 at 12:13 P.M., Resident #88 was in the corner out of direct sight of staff members, he/she had his/her head resting face down on a bedside table.- On 12/16/25 at 10:10 A.M., Resident #88 was in the corner out of direct sight of staff members, he/she had his/her head resting face down on a bedside table. Three Certified Nursing Assistants (CNAs) were in the dining room, one was documenting on an iPad and the other was on their personal cell phone not engaging with Resident #88.- On 12/16/25 at 11:07 A.M. and 1:03 P.M., Resident #88 was in the corner out of direct sight of staff members, he/she had his/her head resting face down on a bedside table., staff were not engaging with Resident #88.- On 12/16/25 at 1:19 P.M., the Activities Director came to the dining room to invite residents to live music on the second-floor dining room. The Activities Director did not attempt to speak to Resident #88 who was in the corner of the dining room.- On 12/17/25 at 7:14 A.M., staff were observed assisting Resident #88 out of his/her bedroom into the dining room where he/she was brought to the same corner seat in the dining room. At 9:10 A.M., Resident #88 was observed sitting in the same spot, on the bedside table was the daily activities calendar that was printed in English.- On 12/17/25 at 9:51 A.M., Resident #88 was in the corner out of direct sight of staff members, he/she had his/her head resting face down on a bedside table, the TV was on playing a show in English. Staff were not engaging with Resident #88. At 10:10 A.M., Resident #88 still had his/her head resting face down on a bedside table with no activities in front of him/her. From 10:10 A.M., through 11:16 A.M., CNAs and nurses entered the dining room but did not engage with Resident #88 nor provide him/her with any activities.During the surveyor's observations, none of the activities mentioned in his/her care plan and Recreation Assessment including art projects, music, TV in his/her language, coloring and nail painting were offered to Resident #88.Review of the facility's December activity calander indicated that Resident #88 did not participate in any of the scheduled activities from 12/15/25 through 12/17/25 from 9:00 A.M. through 2:00 P.M.During an interview on 12/17/25 at 1:41 P.M., CNA #3 said Resident #88 does not like to do anything, but staff should be offering him/her things to do.During an interview on 12/18/25 at 10:13 A.M., the Activities Director said she is in charge of the activities department, makes the facility's activity calendar, does individualized activities and completes each Resident's activities care plan. The Activities Director said we will talk to Residents who cannot read or comprehend a calendar, and we know the residents so we will know what activities each resident enjoys. The Activities Director said the facility has a lot of activity material for individual activities including puzzles, sorting materials and coloring supplies and she would expect staff to pass out activities to residents not involved in group activities. The Activities Director said Resident #88's cognition and communication is low and he/she has never been able to communicate in English to me. The Activities Director said Resident #88 loves to be greeted, likes to observe things, likes to interact with others, likes to color and likes to have his/her nails painted. The Activities Director said she would expect staff to offer Resident #88 activities and interact with him/her and hopes staff would be providing him/her material.During an interview on 12/18/25 at 12:41 P.M., Corporate Nurse #1 said Resident #88's Activities Assessment should be followed and staff should be engaging with him/her.

Based on observation, record review and interview, the facility failed to ensure professional standards in quality of care for one Resident (#87), out of a total sample of 27 residents. Specifically, for Resident #87, the facility failed to identify skin injuries on the soles of Resident #87's feet. Findings include: Resident #87 was admitted to the facility in March 2023 and has diagnoses that include but are not limited to iron deficiency anemia, furuncle unspecified (a pus-filled skin abscess of a hair follicle caused by a bacterial infection), an open abdominal wound, malignant neoplasm of the liver and bile duct, impulsiveness, adult failure to thrive, and dementia.Review of the most recent Minimum Data Set assessment dated as submitted 10/16/25 indicated Resident #87 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating he/she has severe cognitive impairment. Further the MDS indicated Resident #87 required partial/moderate assistance for lower body dressing, including footwear and displayed other behaviors 4-6 days in the look back period and rejection of care in 1-3 days of the look back period. The MDS did not code Resident #87 as having other wounds or skin problems. On 12/15/25 at 7:59 A.M., Resident #87 was observed lying in bed with both feet exposed and within view. Resident #87's left great toe was observed with small dark red areas on top of the toe and multiple scattered dark red areas were located on the sole of his/her left foot. Resident #87's right foot was observed with a few dark red areas. Resident #87 said there was no problem with his/her feet, and that they do not use any cream or treatment. Resident #87 said he/she just wanted food. During an observation on 12/15/25 at 11:27 A.M., the surveyors observed Resident #87, who was lying in bed with his/her feet exposed and visible. Resident #87's left great toe had dark red discoloration consistent with scabs and the sole of his/her left foot had a red open area with exposed layer of skin and other reddened scab like areas. The sole of his/her right foot had a few dark red scab-like areas. Resident #87 had an intact abdominal dressing dated 12/15/25. On 12/15/25 at 4:08 P.M., Resident #87 was observed walking in croc like shoes without socks. On 12/16/25 at 9:28 A.M., Resident #87 was resting in bed with his/her feet exposed and visible. Resident #87 was observed to have multiple red scab-like and open area on his/her left sole of his/her foot and great toe. Resident #87's right sole of foot had a few dark red scab-like areas. On 12/17/25 at 8:25 A.M., the surveyors observed Resident #87 lying on his/her back in bed. Resident #87 abdominal dressing was off, and his/her hands were stained blood colored. Resident #87 feet were exposed and visible. Resident #87's left foot had open areas and multiple dark red scab-like areas on the sole and dark red areas on the left great toe. Resident #87's right foot had red scab-like areas on the sole of his/her foot. Resident #87 asked what was wrong with his/her feet. Review of the progress notes dated from 12/1/25 through 12/16/25 in Resident #87's clinical record failed to indicate any documentation on the areas on Resident #87's left and right feet. Review of the weekly skin evaluations documented in the clinical record indicated on 12/12/25 Resident #87 refused the weekly skin evaluation. Prior to 12/12/25 the last documented weekly skin evaluation was dated 10/29/25. Review of the Norton Scale for predicting Risk of Pressure Ulcers dated 9/23/25 indicated Resident #87 as low risk with a score of 16. Review of Resident #87's physician's orders included the following:-Apply criticaid clear moisture barrier to heels and buttocks three times per day/PRN (as needed) for prevention, order date 5/12/25. -weekly skin check every evening shift every Tue. (Tuesday) Order dated 5/13/25 -wound prevention skin prep to bilateral heels every shift for skin prevention, order date 8/19/25. Review of the physician's orders failed to indicate an order to monitor or treat the open and red scab areas on the bottom of Resident #87's left and right feet. Review of the December 2025 Treatment Administration Record indicated the following: -Apply criticaid clear moisture barrier to heels and buttocks three times a day/PRN (and as needed) was signed off as administered 12/1/25 through 12/16/25 three times a day, thus indicating licensed nursing staff were in contact with Resident #87's feet three times a day and failed to note or identify the areas observed on Resident #87's feet. -Wound prevention: skin prep to bilateral heels every shift for prevention was signed off as administered all three shifts from 12/1/25 through day shift on 12/17/25, thus indicating licensed nursing staff were in contact with Resident #87's feet to provide the prevention treatment and failed to identify the areas on Resident #87's left and right feet. Review of Resident #87's care plans include the following:Behavior, Resident has a behavior problem. He/she is reported to neglect self-care, refuse care, scratch self, picking at self, spitting etc. contributing factors may include: Dx (diagnosis) of dementia, DX of other specified depressive episode, Dx of dysthymic (depression) DO (disorder), revised 9/25/25. Goal Resident #87 will not harm him/herself or others secondary to his/her behavior through next review, revision on 12/12/25 Interventions included but not limited to encourage resident to stop picking at abdominal wound. Review of the care plan failed to have interventions related to Resident #86 picking or causing injury to other areas of his/her body including his/her feet. During an interview on 12/17/25 at 1:34 P.M., Nurse #5 said Resident #87 has a wound and treatment on his/her stomach and has a prevention treatment to his/her heels. Nurse #5 said she was not aware of any other areas on his/her feet and that she did not receive report from staff that Resident #87 had areas on the soles of his/her feet. Nurse #5 said the Resident does walk around with no shoes on at times and is low risk for developing pressure ulcers and has weekly skin checks. Nurse #5 said if changes in a resident's skin are identified an incident report is completed, the Nurse Practitioner/Doctor are called to obtain orders to monitor or provide treatment as indicated. Nurse #5 said Resident #87 has a history of removing his/her abdominal dressing and picking at scabs and could reach his/her feet. Nurse #5 and the surveyor went to observe Resident #87, but he/she was unavailable and in the dining activity room. During an interview on 12/17/25 at 2:19 P.M., Certified Nursing Assistant (CNA) #1 said Resident #87 has behaviors of picking his/her skin including his/her feet. CNA #1 said the Resident refuses to let the nurses put cream on his/her feet. CNA #1 said the nurses know the Resident has areas on the bottom (sole) of his/her feet. CNA #1 said the areas on the bottom of the Resident's feet look worse right now.During an interview on 12/18/25 at 10:03 A.M., Unit Manager #2 said Resident #87 can be very non-complaint, but staff can create a rapport with him/her, especially if you provide a snack. Unit Manager #2 said if new areas are identified the doctor is notified to see if they want treatment for the area. Unit Manager #2 said nursing should be aware of new areas to monitor, put in interventions and that should be done to prevent the wounds from worsening or leading to possible infection.During an interview on 12/18/25 at10:08 A.M., the Director of Nursing said the nursing staff should be aware of new skin areas on a resident, even if they have known behaviors, to monitor provide treatment as indicated and prevent infection or worsening of the wounds.

Based on interview and record review, the facility failed to ensure that one Resident (#43), out of a total sample of 27 residents, received proper treatment to maintain vision ability. Specifically, the facility failed to implement Resident #43's ophthalmologist's recommendations for a prednisolone eye drop taper (medication used to treat non-infectious eye inflammations, including those caused by surgery) and to discontinue Cosopt (eye drop used to lower raised pressure in the eye and treat glaucoma, a disease that is caused by increased pressure inside the eye, resulting in vision loss if untreated) after eye surgery. Findings include: Review of the facility policy titled, Ancillary Physician's Services, dated 3/2025, indicated routine optometry, podiatry, dental and audiology services are available to meet the resident's health needs. 2. Residents have the right to select an optometrist of their choice when services are needed. 3. Selected optometrists will be available to provide follow up care per resident's request. Resident #43 was admitted to the facility in January 2024 with diagnoses including right eye cataract (clouding of the eye's lens, causing blurry, dim or faded vision) glaucoma, and lack of coordination. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/10/25, indicated that Resident #43 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #43 had adequate vision. Review of Resident #43's plan of care related to vision, dated as revised 7/16/25, indicated: - Arrange consultation with eye care practitioner as required. Review of Resident #43's physician's order, dated 11/23/25 and discontinued on 12/5/25, indicated prednisolone 1%, instill one drop right eye four times a day for glaucoma and post op (operation) right eye, unsupervised self-administration. Review of Resident #43's nursing note, dated 11/25/25, indicated:-Resident was seen for follow up for right eye. No new concerns in the post visit summary, resident to continue with original post op instructions and daily schedule prednisone 4x/daily and latanoprost to both eyes nightly. Ofloxacin should be continue 4x daily to right eye and discontinue on 12/7/25. During an interview on 12/15/25 at 8:44 A.M., Resident #43 said he/she was concerned about his/her follow up appointments for eye care. Resident #43 showed the surveyor eye care recommendations that were dated 12/2/25. Review of Resident #43's postoperative care for cataract hospital paperwork, dated 12/2/25, indicated: -STOP Cospt (eye drop, used to treat glaucoma)-Prednisolone eye drops 4x/day both eyes for one week, then 3x/day for one week, then 2x/day for one week, then 1x/day for one week. -Follow up on 12/23/25 at 1:15 P.M. Review of Resident #43's physician's orders, dated 12/2/25, indicated: -Appointment on 12/23/25 at 1:15 P.M., Ophthalmology. During an interview on 12/18/25 at 9:55 A.M., Nurse #4 said that on 12/2/25 Resident #43 had a follow up appointment for his/her eye, Nurse #4 said that Resident #43 returned from the appointment on 12/2/25 with paperwork, Nurse #4 said she reviewed the paperwork and she obtained an order for the next appointment on 12/23/25 and she said she put a copy of the paperwork in the medical record in the paper chart and she gave the paperwork back to the Resident. Nurse #4 said she did not notice any recommendations for eye drops. Review of Resident #43's Physician Assistant (PA) note, dated 12/4/25, indicated: -Continue Prednisone right eye four times daily. Review of Resident #43's Medication Administration Record (MAR) indicated that the prednisone eye drops were no longer ordered to be administered after 12/5/25 at 9:00 A.M., despite the recommendation for the taper on 12/2/25. Further review of Resident #43's postoperative care for cataract hospital paperwork, dated 12/2/25, indicated that the prednisolone eye drop should have been continued beyond 12/5/25. Review of Resident #43's nursing note, dated 12/4/24, indicated: -Resident complained about dizziness with bradycardia. Physician Assistant (PA) notified and wanted to notify ophthalmology regarding low heart rate and dizziness while on Cosopt due to concern for beta-blocker effect. Further Review of Resident #43's postoperative care for cataract hospital paperwork, dated 12/2/25, indicated that the Cosopt should have been discontinued. During an interview on 12/16/25 at 9:10 A.M., Unit Manager #1 said that Resident #43 recently had a vitrectomy (removal of gel in the back of the eyes) and he/she wears an eye patch. Unit Manager #1 said that when a resident goes out for an appointment, the resident is provided with paperwork for the consultant to write recommendations. Unit Manager #1 said that when the resident returns from outside appointments the nurse on duty is responsible to review the paperwork and to notify the provider of recommendations and obtain orders. During an interview on 12/16/25 at 10:19 A.M., the Physician Assistant said that Resident #43 recently had eye surgery. He said that all recommendations from the ophthalmologist should be implemented by nursing. During a follow up interview on 12/16/25 at 10:25 A.M., Unit Manager #1 said that there were no further orders for the prednisolone eye drops after 12/5/25, but there should have been. During an interview on 12/17/25 at 3:23 P.M., the Director of Nursing said that Resident #43 is very controlling with his/her paperwork, and he/she didn't turn over to the paperwork to the desk from the hospital on [DATE]. The DON said that follow up recommendations from the hospital should be reviewed by nursing and implemented.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#11) out of a total sample of 27 Residents. Specifically, the facility failed to obtain a re-weigh in a reasonable amount of time after a significant weight loss was identified.Findings include:Review of the facility policy titled Weight Measurement, dated and revised April 2019 indicated the following:- All Residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposed. If verification of weight indicates significant weight change (suggested parameters for evaluation significance of unplanned and undesired weight loss are: 5% in 30 days, 7.5% in 90 days and 10% in 180 days) the resident and/or family representative and IDT will be notified and plan of care will be revised as appropriate.Resident #11 was admitted to the facility in July 2025 with diagnoses including adult failure to thrive, dementia and type 2 diabetes mellitus.Review of Resident #11's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Further review of the MDs indicated that the Resident is fully dependent on staff for all activities of daily living. Review of Resident #11's weights summary indicated the following:9/2/25: 121.8 lbs. (pounds)9/4/25: 121.7 lbs.10/7/25: 122 lbs.11/6/25: 112.2 lbs.11/26/25: 113 lbs.12/1/25: 111 lbs.From 10/7/25 to 11/6/25, Resident #11 lost 9.8 pounds, indicating a 8.03% weight loss. The next documented weight was not obtained until 11/26/25, 20 days after the documented significant weight loss.Review of Resident #11's weight change progress note written by the Registered Dietitian dated 11/6/25 indicated the following:- question accuracy of 11/6 weight (112#(pounds)) of 10# wt loss x 1 month. Recommend reweigh to confirm. Diuretic noted.Review of Resident #11's physician's orders does not indicate an order for Resident #11 to be weighed.Review of Resident #11's care plan dated 12/2/25 indicated the following:- Focus: State of nourishment, potential for less than body requirement due to poor Po (by mouth) intake r/t (related to) refusal of meals, decreased appetiteGoal: Resident #11 will maintain or increase his/her weight through next reviewReview of Resident #11's Medical Nutrition Therapy assessment dated [DATE], documented by the Registered Dietitian, indicated that the Resident's last documented weight is 122 pounds and his/her weight has decreased within the past six months.Review of Resident #11's medical record failed to indicate that the Resident was re-weighed prior to 11/26/25 to confirm the 8.03% weight loss identified on 11/6/25.During an interview on 12/17/25 at 1:41 P.M., Certified Nursing Assistant (CNA) #2 said CNA's will weigh the residents when we are told to and we give the weight report to the nurses, and they input them into the medical system.During an interview on 12/17/25 at 12:32 P.M., the Registered Dietitian said if a significant weight loss is triggered then the best practice is to obtain a reweigh within 48 hours and if the weight loss is confirmed the resident should be assessed. The RD said reweighs should be obtained regardless of if a resident is on a diuretic medication or not. The surveyor reviewed Resident #11's weight change with the RD and she said that the Resident should have been reweighed a day or two after 11/6/25.During an interview on 12/18/25 at 8:59 A.M., Unit Manager #2 and Corporate Nurse #1 said CNAs will weigh residents and nurses will input the weights. They then said the RD will inform staff that a reweigh is needed and Resident #11's reweigh should have been done sooner than 11/26/25.During an interview on 12/18/25 at 9:31 A.M., the Director of Nursing (DON) said the facility will talk about significant weight changes in risk meeting and we will do a reweigh to confirm the weight change. The DON then said reweighs should be obtained within 24-48 hours of the identified significant weight change. Unit Manager #2 and Corporate Nurse #1 said Resident #11 should have been weighed sooner after the 11/6/25 weight change.

Based on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#56) out of sample of 27 residents. Specifically, for Resident #56, the facility failed to obtain physician's orders for oxygen use. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised 1/2024, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify there is a physician's order in place. Review the physician's order or facility protocol for oxygen administration. Resident #56 admitted to the facility in December 2025 with diagnoses including anoxic brain injury, tracheostomy (surgically created airway opening) status, and pressure ulcer of the sacral region. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/9/25, indicated that Resident #56 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. This MDS indicated Resident #56 was dependent on staff for activities of daily living and Resident #56 received oxygen therapy and tracheostomy care. Review of Resident #56's plan of care related to altered respiratory status and need for 6 liters of continuous oxygen via trach mask secondary to diagnosis of anoxic brain injury, dated as revised 12/11/25, indicated: - Oxygen settings as ordered. - Consult Respiratory Therapist as needed. Review of Resident #56's plan of care related to tracheostomy, Shiley size 6 cuffed (type of tracheostomy), dated as revised 12/11/25, indicated: - Oxygen setting: oxygen via trach mask at 6 liters per minute. Review of Resident #56's Respiratory Therapist (RT) note, dated 12/3/25, indicated that this writer has the following recommendation for the Resident: - Humidified oxygen at 6 liters per minute via trach mask, every shift. On 12/15/25 at 7:20 A.M., 12/15/25 at 8:36 A.M., 12/15/25 at 10:17 A.M., 12/15/25 at 12:21 P.M., 12/15/25 at 4:19 P.M., 12/16/25 at 6:49 A.M., 12/16/25 at 8:51 A.M., 12/16/25 at 12:27 P.M., 12/16/25 at 3:37 P.M., and on 12/17/25 at 6:50 A.M., the surveyor observed Resident #56 in his/her bed receiving oxygen at 5 liters per minute (LPM). On 12/16/25 at 12:32 P.M., the surveyor and Nurse #3 receiving oxygen at 5 LPM and he said that oxygen administration is based on the physician's orders. Nurse #3 said that the oxygen concentrator Resident #56 has cannot go above 5 LPM. Review of Resident #56's physician's orders on 12/17/25, failed to include an order for oxygen administration. During an interview on 12/17/25 at 7:45 A.M., Nurse #1 said that Resident #56 receives oxygen at 5 LPM and he said that oxygen use requires a physician's order. Nurse #1 reviewed Resident #56's physician's orders and he said that there was no order. During an interview on 12/17/25 at 3:08 P.M., the Director of Nursing said that Resident #5 receives oxygen therapy there should be a physician's order for oxygen use.

Based on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Resident #85 out of a total sample of 27 residents. For Resident #85, when the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) while providing direct care for the Resident on enhanced barrier precautions due to a suprapubic catheter (a flexible tube that drains urine directly from the bladder through a small opening in the lower abdomen). Findings include: Review of the facility policy titled, Infection Control Guidelines for Nursing Procedures, dated as revised 7/2024, indicated to provide guidelines for general infection control while care for residents.-Enhanced Barrier PrecautionsEnhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs).>EBP is indicated for nursing home residents with any of the following:-Infection or colonization with an MDRO when Contact Precautions don't otherwise apply.-Chronic wounds.-Indwelling medical devices, including but not limited to i.e. IV, feeding tubes, trach, drains/pleurex, urinary catheters.>PPE-Use of gown and gloves during high-contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing examples of high contact resident activities: are dressing, bathing, shower, transferring, changing linen, personal hygiene, toileting/ brief change, device care, PICC, Central line.-While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). Resident #85 was admitted to the facility in April 2025 with diagnosis including diabetes, dementia, and urine retention. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/3/25, indicated that Resident #85 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This MDS indicated Resident #85 required an indwelling catheter. Review of Resident #85's plan of care related to enhanced barrier precautions: suprapubic catheter, dated as revised 9/23/25, indicated: -18 French with 10 milliliter (mL) [NAME]. -Follow precautions as ordered. Monitor for changes and update provider as needed. Review of Resident #85's physician's order, dated 11/6/25, indicated:-Suprapubic catheter 16 French with 10 mL balloon continuous to catheter drainage bag while in bed. Review of the Resident #85 Physician Assistant note, dated 12/9/25, indicated:-Status post Levaquin (antibiotic medication) course for Proteus Mirabilis (gram negative bacteria) UTI (urinary tract infection), urine studies also grew vancomycin-resistant enterococcus faecalis (bacteria that is normally found in the intestines, that has become resistant to the antibiotic vancomycin) sensitive to Macrobid (antibiotic medication), Resident to start Macrobid twice daily. On 12/15/25 at 11:41 A.M., the surveyor observed Resident #85 in bed, his/her pants were pulled down below his/her knees, and the surveyor observed a 16 French 30 mL balloon catheter attached to a leg bag with yellow urine. Resident #85 said he/she was not sure why his/her pants were down. On 12/15/25 at 12:22 P.M., the surveyor observed Resident #85 in bed, his/her pants were pulled down below his/her knees, and the surveyor observed a 16 French 30 mL balloon catheter attached to a leg bag with yellow urine. Nurse #2 was bent down near Resident #85's catheter drainage bag, and she was not wearing PPE. Nurse #2 was observed obtaining Resident #85's vital signs with a multi-use blood pressure cuff. Nurse #2 said she was obtaining Resident #85's routine vital signs. While Nurse #2 was obtaining Resident #85's vital signs, Resident #85 requested to use the bathroom. The surveyor observed Nurse #2 transfer Resident from bed, she pulled up his/her pants, and she walked Resident #85 to the bathroom. The surveyor observed Nurse #2 lower Resident #85's pants and then assisted sitting him/her on the toilet. During an interview on 12/15/25 at 12:41 P.M., Nurse #2 said she should have worn PPE while providing care to Resident #85, but she did not. During an interview on 12/16/25 at 9:16 A.M., Unit Manager #1 said that she observed Nurse #2 providing care to Resident #85 without PPE, but she should have. During an interview on 12/17/25 at 3:15 P.M., the Director of Nursing said that Nurse #2 should have worn PPE while providing care to Resident #85.

Based on observation and interviews, the facility failed to post nursing staff data daily, at the start of each shift, as required. Specifically, the facility failed to ensure they consistently posted the staffing as required. Findings include: On 12/15/25 at 6:42 A.M., the surveyors observed the daily staffing posted as Friday 12/12/25 at 1:55 P.M., there were no additional staffing sheets under this one sheet. During an interview on 12/16/25 at 1:29 P.M., the Scheduler said that after last recertification survey she is supposed to update that daily staffing sheets Monday through Friday and post the sheets at the entrance of the facility. She said that during the weekends it is the responsibility of the person in charge to print the staffing sheets, and she does not print them on Friday because she does not know the facility census. The Scheduler said that she noticed on 12/15/25 the staffing sheet was still dated 12/12/25. During an interview on 12/16/25 at 2:29 P.M., the Administrator said that he is aware of the requirement to post the daily staffing sheets. The Administrator said that after the last recertification survey the plan was for the Scheduler to post the daily staffing sheets during the week and on the weekends manager on duty is supposed to post the daily staffing on the weekends. The Administrator said that the Scheduler should print the schedules for the weekend on Friday and she should leave them for the manager on duty to post during the weekend. The Administrator said that the manager on duty this past weekend was the Food Service Director (FSD) and the Housekeeping Supervisor. The Administrator said that the manager on duty roles and responsibilities is a work in progress. During an interview on 12/17/25 at 7:18 A.M., the FSD said he was the manager on duty on Saturday 12/13/25 and he said he was not aware he is supposed to hang up signs with the daily staffing information. During an interview on 12/18/25 at 8:52 A.M., the Housekeeping Supervisor said she was the manager on duty on Sunday 12/14/25 and she said she was not aware she was supposed to hang the schedule for the weekend.

Based on observations and interviews the facility failed to ensure a dignified dining experience for two Residents (#23, #50) out of a total sample of 24 residents and on 2 of 3 nursing units. Specifically: 1. For Resident #23, who is dependent on staff for feeding, the staff failed to ensure the resident was positioned properly to eat and was provided with the assist he/she needed, resulting in the resident eating with his/her hands and staring at meals without assistance. 2. For Resident #50, who is dependent on staff for feeding, the staff failed to ensure assistance with feeding was promptly provided when meals were served, resulting in the Resident watching others eat while he/she waited for long periods for assistance. 3a. In the 3rd floor unit dining room staff failed to provide a dignified dining experience and referred to residents as feeders, rather than by their name. 3b. In the 2nd floor unit dining room a Certified Nursing Assistant (CNA) sat on the arm of a chair in the dining room while feeding a resident lunch, rather than seated at eye level. Findings include: The facility policy titled Resident Rights, dated as revised 1/2024, indicated the following: -Employees shall treat all residents with kindness, respect, and dignity. 1. Resident #23 was admitted to the facility in November 2022 and has diagnoses that include Alzheimer's dementia and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/24, indicated that Resident #23 was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #23 is dependent on staff for eating and bed mobility. Review of the current ADL care plan, last revised 11/19/24, indicates the following: -Eating: assist to dependent. -Bed mobility-Ext (extensive) to Dep (dependent)-2 assist. -ADL performance ability fluctuates due to a decline in cognitive status and episodes of fatigue and weakness. Review of the Functional Abilities and Goals Assessment, dated 11/1/24, indicated Resident #23 is dependent on staff for eating and mobility. Review of the Medical Nutrition Therapy Assessment, dated 10/30/24, indicated need for assistance w/eating (sic). On 1/6/25 at 8:52 A.M., the surveyor observed Resident #23 laying flat in bed. A staff person delivered breakfast to the Resident's room, placed the tray on a tray table out of reach and exited the room to continue passing trays to other residents. The surveyor continued to make the following observation: -At 8:54 A.M., the surveyor entered Resident #23's room and observed Resident #23 laying awake in a flat bed, awake, able to see the breakfast tray, however unable to reach it. On 1/6/25 at 12:21 P.M., the surveyor observed Resident #23 in a recliner chair in the unit dining room. There was a lunch plate directly in front of him/her and Resident #23 was eating mac and cheese with his/her hands. The Resident then picked up a cup of milk, looked at it then placed it in the middle of his/her plate on top of the mac and cheese. The surveyor continued to make the following observations: -At 12:25 P.M., Resident #23 sat with the cup of milk in his/her food and watched other residents eating. -At 12:31 P.M., a Certified Nursing Assistant (CNA) asked Resident #23 are you not going to eat, then without offering assistance or waiting for a response sat down with her back to Resident #23 and began assisting a peer with their meal. Resident #23's hands had cheese on them, and his/her milk cup remained on top of the food. On 1/7/25 at 12:14 P.M., the surveyor observed Resident #23 in a recliner chair in the unit dining room. A CNA set up lunch on the tray table in front of Resident #23 and walked away. The surveyor continued to make the following observations: -At 12:19 P.M., Resident #23 started crying, and Nurse #1 walked over, told Resident #23 start feeding yourself and I will help you finish, I have to finish helping someone else first. Nurse #1 did not console Resident #23 who was visibly upset, but rather left him/her to sit and look at the meal in front of him/her. During an interview on 1/10/25 at 8:55 A.M., with Resident #23's Certified Nursing Assistant (CNA) #1 she said that Resident #23 is totally dependent for assistance including with feeding. CNA #1 said that the tray should stay in the cart for residents who require assistance with feeding until staff are ready to sit down and feed the resident. During an interview on 1/10/25 at 9:37 A.M., with Director of Clinical Operations #2 she said trays should remain in the food truck until staff are ready to feed dependent residents. As well, she said that if staff see a resident resorting to eating with their hands, they should intervene, call for a new tray and assist the resident with the meal. The Director of Clinical Operations #2 said it really makes me sad to hear this, if staff see Resident #23 crying, they should reassure and comfort him/her, apologize for not providing the assist and sit down and assist the Resident. 2. Resident #50 was admitted to the facility in August 2018 and has diagnoses that include dementia and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated Resident #50 was assessed by staff to have severely impaired cognition. The MDS further indicated Resident #50 requires partial to moderate assistance with eating. Review of the Nutrition Therapy Assessment, dated 10/15/24, indicated Resident #50 was at risk for nutritional decline due to a decreased self-feeding ability. The assessment further indicated in the summary: Resident #50 typically needs assistance at mealtime. Review of the Functional Abilities and Goals assessment, dated 10/19/24, indicated Resident #50 requires partial to moderate assistance with eating. Review of the current Activities of Daily Living (ADL) care plan indicated: -EATING: Limited assist-1. On 1/6/25 at 8:39 A.M., the surveyor observed Nurse #1 place a breakfast tray in front of Resident #50, leaving the cover over the food. Nurse #1 said to Resident #50 someone is coming to help you and walked away. Resident #50 sat looking at the tray of food in front of him/her and watched his/her tablemates eat their breakfast. The surveyor continued to make the following observation: -On 1/06/25 at 8:46 A.M., Nurse #1 sat down beside Resident #50, set up the breakfast in front of Resident #50, then stood up and walked away, leaving Resident #50 to look at the food. On 1/6/25 at 12:22 P.M., the surveyor observed Nurse #1 place a lunch tray in front of Resident #50, leaving the cover over the food and walk away to continue passing trays to other residents. Resident #50 sat at the table, looking at his/her lunch and watched his/her tablemates eat their lunch. The surveyor continued to make the following observations: -At 12:26 P.M., one of Resident #50's tablemates encouraged him/her to eat and said Aren't you hungry? to which Resident #50 responded yes. -By 12:30 P.M., no staff had offered Resident #50 assist, his/her table mate continued to encourage him/her to eat and Resident #50 watched the other residents present eating their meals. On 1/7/25 at 8:11 A.M., the surveyor observed a staff person place a breakfast tray in front of Resident #50, leaving the cover over the food and walk away to continue passing trays to other residents. Resident #50 was offered no assistance and sat looking at the covered breakfast tray. The surveyor continued to make the following observations. - At 8:17 A.M., Resident #50 leaned forward looking at the covered tray of food. -At 8:21 A.M., a Nurse uncovered Resident #50's food and walked out of the dining room, leaving Resident #50 to stare at the plate of food. On 1/9/25 at 8:45 A.M., a staff member delivered breakfast to Resident #50 and sat down to assist him. The surveyor continued to make the following observations: -At 8:49 A.M., while feeding Resident #50, the staff person was texting on her phone. During an interview on 1/9/25 at 11:42 A.M., with Nurse #6 she said that Resident #50 requires total care, including for eating. She said that it is the expectation that food remain in the truck until staff are ready to assist with feeding and that residents should not have to sit at a table looking at their tray while waiting for assist to be available. As well, Nurse #6 said that staff should never be on their phone while providing care. During an interview on 1/9/25 at 12:50 P.M., with the Director of Clinical Operations #2 she said that it is the expectation that food remain in the truck until staff are ready to assist with feeding because residents should not have to sit at a table looking at their tray while waiting for assist to be available. As well, Nurse #6 said that staff should never be on their phone while providing care. 3a. During an observation of the breakfast meal in the 3rd floor unit dining room on 1/6/25 beginning at 8:24 A.M., the following observations were made: There were 5 residents seated together at a table: -At 8:24 A.M., a Nurse placed a breakfast tray in front of a resident who was asleep. The nurse set up the breakfast in front of him/her and then walked away to continue passing trays to other residents. -By 8:32 A.M., 4 of 5 residents at the table had been served. The one resident without food watched the others eat while staff continued passing trays throughout the dining room. During an observation of the breakfast meal in the 3rd floor unit dining room on 1/07/25 the following observations were made: -At 8:09 A.M., a nurse placed a meal on a table for a resident who had not yet arrived at the dining room. -At 8:20 A.M., the resident arrived in the dining and sat down to eat the meal that had been served 11 minutes earlier. During an observation of the lunch meal in the 3rd floor unit dining room on 1/7/25 the surveyor made the following observation: -At 12:14 P.M., a Certified Nursing Assistant (CNA) walked into the dining room, gestured at a resident across the room and asked Nurse #1 if the resident was a feeder. Nurse #1 responded yes and failed to inform the CNA that residents should be referred to by their name, not as feeders. During an interview on 1/9/25 at 12:50 P.M., with the Clinical Director of Operations #2 she said that it is the expectation that food remain in the truck until residents are present and are ready to eat and that to it is a dignity issue to refer to residents as feeders. 36797 3b. On 1/7/25 at 12:22 P.M., the surveyor observed a Certified Nursing Assistant (CNA) sitting on the arm of a chair while assisting a resident to eat in the second floor dining room. During an interview on 1/7/25 at 12:22 P.M., Nurse #9 said that it was not appropriate for the CNA to be sitting on the arm of a chair while assisting a resident to eat. During an interview on 1/7/25 at 2:38 P.M., Director of Clinical Operations #2 said that it was not appropriate for the CNA to be sitting on the arm of a chair while assisting a resident to eat.

Based on observation, record review and interview, the facility failed to meet professional standards of practice for three Residents (#14, #35 and #74) out of a total of sample of 24 residents. Specifically: 1. For Resident #14 the facility failed to follow-up on rising abnormal PSA (prostate surface antigen). A potential indicator of cancer levels. 2. For Resident #35 the facility failed to ensure nursing clarified a physician's order for medications that were ordered orally and Resident #35 received medications via g-tube (tube inserted into the stomach). 3. For Resident #74 the facility failed to ensure nursing clarified a physician's order for g-tube flushes (two different frequencies in one order). Findings include: 1. Resident #14 was admitted to the facility in October 2022 with diagnoses including schizophrenia, stroke and diabetes. Review of the facility document titled Lab Results Report, dated 6/18/24, indicated a PSA level of 12.280. (Normal is below 5.4) Review of the facility document titled Consultation/Clinic Referral Urology, dated 10/16/24, indicated Resident #14 seems to have obstructive symptoms. The report further indicated for Resident #14 to have a PSA level obtained and for Resident #14 to return in one month. Review of the facility document titled Lab Results Report, dated 10/17/24, indicated a PSA level of 15.36. Review of the clinical progress notes indicated the following: 10/3/24- Elevated PSA await urology follow-up 10/16/24- Out for urology appointment. Resident returned from urology appointment, labs PSA free and total, NP (nurse practitioner) aware. 10/17/24-Lab result in PSA result, CH 15.36, NP aware, no new order. 10/24/24- Had recent PSA testing which was elevated at 15. 11/7/24- Had recent PSA testing which was elevated at 15. Urology consult scheduled. 11/20/24- Attempted to schedule urology consult. (Hospital) social worker will call back with appointment in 5 to 7 days. 11/21/24- Had recent PSA testing which was elevated at 15. 12/5/24- Had recent PSA testing which was elevated at 15. 12/12/24- Had recent PSA testing which was elevated at 15. 12/13/24- Had recent PSA testing which was elevated at 15. 12/24/24- Had recent PSA testing which was elevated at 15. 12/26/24- Had recent PSA testing which was elevated at 15. 12/29/24- Urology consult scheduled, await follow-up. (The appointment was not scheduled). 12/31/24- Had recent PSA testing which was elevated at 15. 1/1/24- Had recent PSA testing which was elevated at 15. 1/7/24-clarification for urology consult that was pending. Urology consult scheduled for 11/14/24, was canceled due to lack of communication with facility; Resident requiring labs 2 weeks prior to appointment. Appointment now re-scheduled. During an interview on 1/7/25 at 11:07 A.M., Unit Manager #1 said that she would have expected that a follow-up appointment would have been scheduled. Unit Manager #1 then said that treatment options regarding the PSA level of 15 should have been discussed with Resident #14's responsible party. 44095 2. Review of the facility policy titled, Administering Medications, dated as revised 9/24, indicated that medications are administered in a safe and timely manner, and as prescribed. b. Medications are administered in accordance with prescriber orders, including any required time frame. e. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #35 was admitted to the facility in October 2022 with diagnoses including anoxic brain damage, chronic respiratory failure, and tracheostomy status. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/24, indicated that Resident #35 was rarely/never understood and required a feeding tube. Review of Resident #35's current physician's orders, with a start date of 8/23/23, indicated: -NPO (nothing by mouth) Review of Resident #35's active physician's orders on 1/6/25, indicated the following were ordered to be administered by mouth: -aspirin 81 milligrams (mg) by mouth daily, initiated on 11/23/24. -atorvastatin 40 mg by mouth at bedtime, initiated on 11/14/24. -fenofibrate 145 mg by mouth at bedtime, initiated on 11/14/24. During an interview on 1/8/25 at 1:03 P.M., Nurse #3 said Resident #35 takes his/her medications via g-tube. Nurse #3 said she administers medications in accordance with the physician's orders. Nurse #3 reviewed Resident #3's physician's order for aspirin and Nurse #3 said that she administered the medication by g-tube today. During an interview on 1/9/25 at 9:00 A.M., the Director of Clinical Operations #2 said medications should be administered as ordered and that nursing should have clarified Resident #35's orders and administered medications via g-tube. 3. Review of the facility policy titled, Enteral Nutrition, dated as revised 9/18, indicated that enteral nutrition is provided to residents when deemed to be medically necessary and consented by the resident or durable power of attorney (DPOA) for healthcare using evidence-based practice and procedures to minimize complications and maintain or improve nutritional status to the extent possible. Gastrostomy tube (G-tube) is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube. 9. When the resident is fed by tube: iv. flushing with water at appropriate intervals. Resident #74 was admitted to the facility in January 2023 with diagnoses including traumatic brain injury, history of falling, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/24, indicated that Resident #74 was rarely/ never understood. The MDS further indicated that Resident #74 rejected care, was dependent on staff for activities of daily living and had a feeding tube. Review of Resident #74's nutrition progress note, dated 9/5/24, indicated: -Adjust water flushes to 250 milliliters (mL) four times daily. Review of Resident #74's current physician's order, with a start date of 10/13/24, indicated: -Enteral Feed, every 4 hours 250 milliliters (mL) flush 4 times daily. Scheduled every 4 hours at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. (6 times daily) Review of Resident #74's Medication Administration Record (MAR), dated January 2025, indicated nursing administered the physician's order and documented by nursing as administered every 4 hours (6 times daily). During an interview on 1/8/25 at 12:52 P.M., Nurse #4 said Resident #74's feeding tube is flushed according to the physician's orders. During an interview on 1/9/25 at 9:52 A.M., the Dietitian said that Resident #74 should receive water flushes of 250 mL four times daily. During an interview on 1/9/25 9:11 A.M., the Director of Clinical Operations #2 reviewed Resident #74's flush orders in the electronic health record and said that the order was not clear and should have been clarified.

Based on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Living (ADLs) were provided to three Residents (#23, #5, and #7) out of a total sample of 24 residents. Specifically: 1. For Resident #23 the facility failed to ensure assistance with bed mobility and dining was provided as needed. 2. For Resident #5 the facility failed to ensure assistance with positioning and feeding was provided as needed. 3. For Resident #7 the facility failed to ensure assistance with grooming was provided as needed. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, dated as revised 11/2024, indicated the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfers and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). 1. Resident #23 was admitted to the facility in November 2022 and has diagnoses that include Alzheimer's dementia and anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/24, indicated that Resident #23 was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #23 is dependent on staff for eating and bed mobility. Review of the current ADL care plan, last revised 11/19/24, indicates the following: -Eating: assist to dependent. -Bed mobility-Ext (extensive) to Dep (dependent)-2 assist. -ADL performance ability fluctuates due to a decline in cognitive status and episodes of fatigue and weakness. Review of the Functional Abilities and Goals Assessment, dated 11/1/24, indicated Resident #23 is dependent on staff for eating and mobility. Review of the Medical Nutrition Therapy Assessment, dated 10/30/24, indicated need for assistance w/eating (sic). On 1/6/25 at 8:52 A.M., the surveyor observed Resident #23 laying flat in bed. A staff person delivered breakfast to the Resident's room, placed the tray on a tray table out of reach and exited the room to continue passing trays to other residents. The surveyor continued to make the following observation: -At 8:54 A.M., the surveyor entered Resident #23's room and observed Resident #23 laying awake in a flat bed, awake, able to see the breakfast tray, however unable to reach it. On 1/6/25 at 12:21 P.M., the surveyor observed Resident #23 in a recliner chair in the unit dining room. There was a lunch plate directly in front of him/her and Resident #23 was eating mac and cheese with his/her hands. The resident then picked up a cup of milk, looked at it then placed it in the middle of his/her plate on top of the mac and cheese. The surveyor continued to make the following observations: -At 12:25 P.M., Resident #23 sat with the cup of milk in his/her food and watched other residents eating and a Nurse walked past him/her and out of the dining room without offering any assist with the meal. -At 12:31 P.M., a Certified Nursing Assistant (CNA) asked Resident #23 are you not going to eat, then without offering assistance or waiting for a response sat down with her back to Resident #23 and began assisting a peer with their meal. On 1/7/25 at 12:14 P.M., the surveyor observed Resident #23 in a recliner chair in the unit dining room. A CNA set up lunch on the tray table in front of Resident #23 and walked away without offering assist with the meal. The surveyor continued to make the following observations: -At 12:19 P.M., Resident #23 started crying, and Nurse #1 walked over, told Resident #677 start feeding yourself and I will help you finish, I have to finish helping someone else first. Nurse #1 did not assist the Resident with the meal in front of him/her. During an interview on 1/10/25 at 8:55 A.M., with Resident #23's CNA #1 she said that Resident #23 is totally dependent for care, including with feeding. During an interview on 1/10/25 at 9:37 A.M., with the Director of Clinical Operations #2 she said meal trays should remain in the cart until staff are ready to sit down and assist a resident who is dependent for feeding. She said that it is her expectation that dependent residents be fed their meals. 2. Resident #5 was admitted to the facility in November 2022 and has diagnoses that include dysphagia (difficulty chewing and swallowing) and contracture of the left and right hand. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/24, indicated staff did not assess Resident #5's cognition however that he/she is rarely or never understood. The MDS further indicated that Resident #5 has no behavior of rejecting care, has impairment on both sides of upper extremities, and requires supervision or touching assistance with eating. Review of the current Nutrition care plan indicates the following: -NUTRITION: at risk for decline r/t (related to) limited mobility, difficulty feeding self, dysphagia, h/o (history of) dysphagia, hypertensive HF (heart failure), hypothyroidism, etoh (Alcohol) dependence. Review of the Medical Nutrition Therapy Assessment, dated 10/30/24, indicated at risk for decline r/t limited mobility, difficulty feeding self, dysphagia. Review of the current Activities of Daily Living care plan indicates: Resident has ADL self-care deficit as evidenced by: needs assistance with all ADL care. Review of the Functional Abilities Assessment, dated 11/19/24, indicates that Resident #5 requires supervision or touching assistance with meals. On 1/7/25 at 8:08 A.M., a Certified Nursing Assistant (CNA) delivered a breakfast tray to Resident #5 who was seated in a recliner chair, tucked in a corner of the room out of eyesight of all others. The CNA set up the tray and walked away offering no supervision or assistance with the meal. The surveyor continued to make the following observations: -At 8:10 A.M., Resident #5 attempted to use a two-handle cup to drinking orange juice, however his/her hands were shaking, and Resident #5 was unsuccessful at drinking the beverage, but rather it spilled on his/her chest. -At 8:11 A.M., Resident #5 picked up another liquid, but his/her hands were shaking so much the liquid spilled all over the food on the tray. -By 8:15 A.M., Resident #5 had made no attempts to self-feed. The surveyor approached the Resident and asked how the meal was. Resident #5 appeared confused and smiled and nodded at the surveyor. On 1/7/25 at 12:12 P.M., a CNA set up Resident #5's lunch in front of him/her then walked away to continue passing meals to other residents without positioning Resident #5 in an upright position in the recliner and without offering assistance with the meal. Resident #5's recliner back was at a 45-degree angle and he/she had slid down in the chair, unable to reach the food. The surveyor continued to make the following observations: -At 12:16 P.M., Resident #5 said to Nurse #1 can you pick me up a little as he/she had slid down in the recliner chair and poorly positioned to reach the food. Nurse #1 and a CNA boosted Resident #5 then walked away offering no assist with the meal. -By 12:19 P.M., no staff had offered touching assistance with the meal and Resident #5 had made no attempts to self-feed. On 1/10/25 at 8:35 A.M., Resident #5 was observed in a recliner chair in the dining room with the head of the recliner at a 45-degree angle. Nurse #1 set up Resident #5's meal on a tray table in front of him/her and walked away without positioning him/her upright or offering assistance with the meal. Resident #5 shakily reached for his/her double handled cup and as he/she tried to drink the beverage it spilled on his/her chest. No staff were present in the room to supervise or assist the resident. During an interview on 1/10/25 at 10:14 A.M., with Certified Nursing Assistant (CNA) #3 she said that Resident #5 requires total assistance with care and when he/she cannot feed him/herself we help him/her. CNA #3 said that whenever a resident is struggling to feed themselves, assistance should be offered. During an interview on 1/10/25 at 10:26 A.M., with Nurse #6 she said that Resident #5 shakes when he/she eats which is why he/she has special cups and utensils. Nurse #6 said that Resident #5's chair should be put upright for meals, that staff should always be present in the room for meals and if they notice Resident #5 is struggling or spilling they should assist him/her. 44095 3. Resident #7 was admitted to the facility in July 2024 with diagnoses including dementia, tracheostomy, diabetes, and seizures. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that Resident #7 was comatose. The MDS further indicated Resident #7 was dependent on staff for activities of daily living. On 1/6/25 at 7:45 A.M., and at 3:08 P.M., 1/7/25 at 6:52 A.M., and at 1:10 P.M., the surveyor observed Resident #7 in his/her bed he/she had facial hair around 5 millimeters in length. Review of Resident #7's plan of care related to activities of daily living, dated as revised 9/11/24, indicated: - Grooming, dependent two assists. During an interview on 1/7/25 at 1:37 P.M., Certified Nurse Assistant (CNA) #1 said Resident #7 should be shaved once a week and she needs the nurse to assist with shaving needs. During an interview on 1/7/25 at 1:56 P.M., Nurse #2 said CNAs should shave Resident #7 during care. Nurse #2 said that Resident #7 has facial hair that is long, and the facial hair should have been shaved during care. During an interview on 1/9/25 at 9:06 A.M., the Director of Clinical Operations #2 said grooming such as shaving should be provided routinely during care.

Based on observations, record reviews and interviews, the facility failed to ensure physician's orders were followed for prevention of pressure ulcer development for one Resident (#91) out of a total sample of 40 residents. Specifically, the facility failed to implement heel booties as ordered resulting in a reddened area on the Resident's left heel and a deep tissue pressure injury on the right heel and failed to implement the correct setting for an air mattress. Findings include: Review of facility policy titled 'Pressure Ulcer/Injury Risk Assessment', last revised April 2018, indicated the following but not limited to: *Risk factors that increase a resident's susceptibility to develop, or to not heal, a pressure ulcer or pressure injuries include: a. Under nutrition, malnutrition, and dehydration deficits. b. Impaired/decrease mobility and decreased functional ability. Review of facility policy titled Support Surface Guidelines, last revised May 2018, indicated the following but not limited to: *Support surfaces are modifiable. Individual resident needs differ. *Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. Resident #91 was admitted to the facility in September 2023 with diagnoses including adult failure to thrive and severe protein-calorie malnutrition. Review of Resident #91's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #91 is cognitively intact. The MDS further indicated that the Resident was at a higher risk for developing pressure ulcers and was totally dependent for all activities of daily living.The Resident did not have any open pressure ulcer noted on the MDS. Review of Resident #91's physician's orders dated 12/27/23, indicated the following: *Bilateral heels booties on at 8 am and off at 8 pm. Every morning and at bedtime for pressure ulcer prevention related to unspecified severe protein calorie malnutrition. *Pressure redistribution mattress every shift for sacral wound care check for correct settings and function, dated 1/11/24. On 1/30/24 at 8:12 A.M., the surveyor observed the Resident lying in bed he/she did not have heels booties on, the air mattress was set at 200 lbs. (pounds). On 1/30/24 at 1:26 P.M., the surveyor observed the Resident lying in bed he/she did not have heels booties on, the air mattress was set at 200 lbs. On 1/31/24 at 6:34 A.M., the surveyor observed the Resident lying in bed he/she did not have have heel booties on, the air mattress was set at 200 lbs. On 1/31/24 at 11:10 A.M., the surveyor observed the Resident lying in bed he/she did not have heels booties on, the air mattress was set at 200 lbs. During an interview on 1/31/24 at 11:10 A.M., the Resident told the surveyor that he/she has been having ongoing heel pain to both feet and no one had done anything about it. The Resident further said that he/she has not worn any type of boots to his/her heels when in bed. Review of the weekly skin evaluation dated 1/16/24, indicated the skin intergrity was clean and intact. Healed stage three on coccyx no longer open. Review of the weekly skin evaluation dated 1/24/24, indicated the skin integrity was not clean and intact. Skin alteration noted, redness to sacrum. Review of the Norton Scale for predicating risk of pressure ulcer-V2 dated 1/16/24, indicated the Resident scored a 10 which indicated high risk for developing pressure ulcer. Review of the pressure ulcer care plan date revised 12/22/23, had the following interventions: -Follow facility policies/protocol for the prevention/treatment of skin breakdown. Review of the most recent documented weight for Resident #91 dated 1/4/24 was 120.4 lbs. During an interview on 1/31/24 at 11:30 A.M., Certified Nursing Assistant (CNA) #9 said she takes care of Resident #91 and that he/she has not had any heel booties. The surveyor asked if the CNAs were allowed to change the air mattress setting. CNA #9 said only nurses are allowed to touch the settings. She further said the Resident did not have any issues on his/her feet that she was aware of. During an interview and observation on 1/31/24 at 11:33 A.M., the surveyor and Nurse #7 observed Resident #91's heels, the left heel was red non blanchable (discoloration of the skin that does not turn white when pressed, indicating pressure injury). The right heel had a deep purple discoloration indicating a deep tissue pressure injury. Nurse #7 said she was not aware that the Resident had developed pressure injuries to the heels. Nurse #7 said the Resident should have the heel booties as ordered and she further said that Resident #91's air mattress was on the correct setting because the normal light indicator was on. When asked if she knew how much the Resident weighed and if the setting of 200 lbs. was correct. Nurse #7 said she believed the Resident weighed 160 lbs. when he/she was initially admitted to the facility. During an interview on 2/1/24 at 8:39 A.M., the Director of Nursing said the air mattress setting is set to residents' weight, physician orders should be followed for heel booties as ordered, she further said the red area to the Resident's left heel and the deep purple to the right heel were pressure injury areas.

Based on record reviews, policy review and interviews, the facility failed to alert the physician in a timely manner of a change in condition for 1 Resident (#58), out of a total of 29 sampled residents. Subsequently, Resident #58 was hospitalized with heart failure and pulmonary emboli (blood clots in the lung). Findings include: Review of the facility policy titled, Change in a Resident's Condition or Status, last revised 4/4/2019, indicated the following: *The Facility professional staff will communicate with physician, participants, and family regarding changes in condition. *A significant change of condition is a major decline or improvement in the resident's status that: *Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). *The nurse will notify the resident's Attending Physician/NP (Nurse Practitioner) or physician or NP on call when there had been a change in resident condition (but not limited to): *Accident or incident involving the resident *Significant change in the resident's physical/emotional/mental condition *Need to transfer the resident to a hospital/treatment center *Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: *There is a significant change in the resident's physical, mental, or psychosocial status Resident #58 was admitted to the facility in November 2022 with diagnoses that include chronic obstructive pulmonary disease, history of pleural effusion (fluid in the lungs) and pneumonia, muscle weakness, malignant neoplasm of oropharynx (throat cancer) and depression. Review of Resident #58's most recent Minimum Data Set (MDS) dated [DATE], indicated that the resident had a Brief Interview for Mental Status score of 13 out of a possible 15, which indicated that he/she is cognitively intact. Further review of the MDS indicated that Resident #58 requires extensive assistance with bed mobility, transfers, toileting, and personal hygiene. Review of Resident #58's medical record indicated the following: -A Medication Administration Note (MAR) note dated 11/20/2022 at 5:06 A.M.: Noted with SOB (shortness of breath). -A nursing progress note dated 11/20/2022 at 6:35 A.M.: Resident alert and verbally responsive, complaints of SOB, and constipation, during the night, resident assisted, head of bed raised and noted with long tubing, upon assessment O2 (oxygen) ranging between 65-70% on 2 liters/minute via nasal cannula. PRN (as needed) Combivent (an inhaler used to help relax and open the airways in your lungs) administered with effect. Resident continues O2 continuously. Will continue with care plan. The note failed to indicate that the physician or Nurse Practitioner were notified of the oxygen ranging between 65-70% on 2 liters of O2 via nasal canula. -A nursing progress note dated 11/20/22 at 11:27 A.M. (4 hours and 52 minutes after the previous progress note): Patient presenting with spO2 (oxygen saturation) 70% 2-liter O2 while laying. Denies SOB/resp. RR (respiratory rate): 28 HR (heart rate) 98 BP (blood pressure): 107/60 T (temperature): 97.4. Patient repositioned to sitting and became SOB with stomach breathing. Lung sounds + rhonchi throughout. Non re-breather placed and SpO2 increased to 92%. MD (medical doctor) notified. 911 called, patient left facility at approx. 11:25 A.M., via stretcher and transferred to the hospital. *A nursing progress note dated 11/27/22 at 8:30 A.M.: Reported by 3-11 agency nurse that resident returned from MLOA (medical leave of absence). Resident returned as a new admission from the hospital with diagnoses of chronic heart failure and pulmonary embolism. According to Resident #58's nursing notes, he/she was noted with shortness of breath at 5:06 A.M., an evaluation of the Resident was done at 6:35 A.M., 1 hour and 29 minutes later. At 6:35 A.M., Resident #58 was documented having an oxygen saturation level of 65-75%, the MD was not notified and 911 was not called until 11:27 A.M., 4 hours and 52 minutes later. Review of Resident #58's care plan, initiated on 11/10/2022, revised on 11/18/2022 indicated the following: *The resident has altered respiratory status/difficulty breathing related to COPD, pneumonia, and malignant neoplasm of oropharynx. Goal: The resident will be free from complications related to infection through the review date. *The resident has altered respiratory status/difficulty breathing related to COPD, pneumonia, and malignant neoplasm of oropharynx. Goal: The resident will have no complications related to SOB, no signs or symptoms of poor oxygen absorption, the resident will maintain normal breathing pattern as evidenced by normal respirations through the review date. Interventions: Monitor and report signs and symptoms of respiratory distress and abnormal breathing patterns to the MD. Review of Resident #58's Oxygen Saturation Summary indicated that his/her oxygen saturation was documented at 70% on 11/20/22 at 11:19 A.M. Review of Resident #58's Discharge/Transfer Evaluation, dated 11/20/22 at 11:31 A.M., indicated that the Resident was transferred to the hospital for shortness of breath and low oxygen saturation of 70%. Review of Resident #58's hospitalization after visit summary, dated 11/20/22 through 11/26/22 indicated that Resident #58 was admitted with shortness of breath and was diagnosed with heart failure and pulmonary embolisms (lung clots). During an interview on 12/15/22 at 11:35 A.M., Nurse #7 said if a change of condition is observed the nurse would first take vital signs, notify the MD and implement the orders from the MD. Nurse #7 said an acceptable oxygen saturation is between 90-100% and that if it fell between 80-90% the nurse should call the MD. Nurse #7 said if an oxygen saturation is in the 70%'s or lower that is critical and the patient could die and the expectation would be that the nurse would apply oxygen, call the MD and call 911 right away. During an interview on 12/15/22 at 11:48 A.M., Nurse #4 said for a change of condition the nurse should call the doctor, notify the family and send the resident to the hospital if it is something that can't be handled at the facility. Nurse #4 further said a normal oxygen saturation level is 92% or higher in general and 88% or higher for a resident with COPD and that if a resident's oxygen saturation is in the 60-70%'s, the nurse should first administer a non-breather oxygen mask, call 911 and then the MD. Nurse #4 said this should have been reported to the doctor and not passed on to the next shift. During an interview on 12/16/22 at 8:42 A.M., Nurse #6 said if the MD is notified it would be documented in the nursing progress notes. During an interview on 12/16/22 at 9:35 A.M., the Director of Nursing (DON) said if a change in condition is observed the expectation is that the nurse will take the resident's vital signs first, notify the MD and follow their orders and then notify the family. The DON said that when the MD gets notified, it should be documented in the progress notes. The DON further said that a normal oxygen saturation level is 94% or higher and 88% or higher if a resident has COPD and that if a resident's O2 saturation is in the mid to low 80%'s then the nurse should connect them to oxygen and call the MD immediately and if their oxygen saturation levels are in the 60-70%'s, 911 should be called immediately followed by notifying the MD. The DON reviewed Resident #58's progress notes with the surveyor and said that 911 should have been called and the MD should have been notified immediately upon discovering Resident #58's oxygen levels. The DON said what happened was concerning and unacceptable. During an interview on 12/16/22 at 10:24 A.M., Resident #58 said he/she remembers not being able to breath on the morning of 11/20/22. The Resident further said that he/she couldn't get any air into his/her body, and he/she was scared. The surveyor placed a call on 12/15/22 at 12:33 P.M. and did not hear back from the nurse who wrote the nursing note on 11/20/22 at 6:35 A.M.

Based on record reviews, policy review and interviews, the facility 1) failed to ensure treatment and services were provided in accordance with the plan of care after an acute change in condition for1 Resident (#58), resulting in a hospitalization , 2) failed to develop a comprehensive coordinated person-centered care plan with individualized interventions for hospice care services for 3 residents (#27 and #98) out of a total of 29 sampled residents. Findings include: 1. For Resident #58, the facility failed to ensure treatment and services were provided after an acute change in condition. Review of the facility policy titled, Change in a Resident's Condition or Status, last revised 4/4/2019, indicated the following: *The Facility professional staff will communicate with physician, participants, and family regarding changes in condition. *A significant change of condition is a major decline or improvement in the resident's status that: *Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). *The nurse will notify the resident's Attending Physician/NP or physician or NP on call when there had been a change in resident condition (but not limited to): *Accident or incident involving the resident *Significant change in the resident's physical/emotional/mental condition *Need to transfer the resident to a hospital/treatment center *Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: *There is a significant change in the resident's physical, mental, or psychosocial status Resident #58 was admitted to the facility in November 2022 with diagnoses that include chronic obstructive pulmonary disease, history of pleural effusion (fluid in the lungs), pneumonia, muscle weakness, malignant neoplasm of oropharynx (throat cancer) and depression. Review of Resident #58's most recent Minimum Data Set (MDS) dated [DATE], indicated that the resident had a Brief Interview for Mental Status score of 13 out of a possible 15, which indicated that he/she is cognitively intact. Further review of the MDS indicated that Resident #58 requires extensive assistance with bed mobility, transfers, toileting, and personal hygiene. Review of Resident #58's medical record indicated the following: -A Medication Administration Record (MAR) dated 11/20/2022 at 5:06 A.M.: Noted with SOB (shortness of breath). -A nursing progress note dated 11/20/2022 at 6:35 A.M.: Resident alert and verbally responsive, complaints of SOB (shortness of breath), and constipation, during the night, resident assisted, head of bed raised and noted with long tubing, upon assessment O2 (oxygen) ranging between 65-70% on 2 liters/minute via nasal cannula. PRN (as needed) Combivent (an inhaler used to help relax and open the airways in your lungs) administered with effect. Resident continues O2 continuously. Will continue with care plan. The note failed to indicate that the physician or Nurse Practitioner were notified of the oxygen ranging between 65-70% on 2 liters of O2 via nasal cannula. -A nursing progress note dated 11/20/22 at 11:27 A.M.: Patient presenting with spO2 (oxygen saturation) 70% 2-liter O2 while laying. Denies SOB/resp. RR (respiratory rate): 28 HR (heart rate) 98 BP (blood pressure): 107/60 T (temperature):97.4. Patient repositioned to sitting and became SOB with stomach breathing. Lung sounds + rhonchi throughout. Non re-breather placed and SpO2 increased to 92%. MD (medical doctor) notified. 911 called, patient left facility at approx. 11:25 A.M. via stretcher and transferred to hospital. -An Oxygen Saturation Summary indicated that his/her oxygen saturation was documented at 70% on 11/20/22 at 11:19 A.M. -A nursing progress note dated 11/27/22 at 8:30 A.M.: Reported by 3-11 agency nurse that resident returned from MLOA (medical leave of absence). Resident returned as a new admission from the hospital with diagnoses of chronic heart failure and pulmonary embolism. -A hospitalization after visit summary, dated 11/20/22 through 11/26/22 which indicated that Resident #58 was admitted with shortness of breath and was diagnosed with heart failure and pulmonary emboli (blood clots in the lung). Review of Resident #58's medical record indicated he/she was noted with shortness of breath at 5:06 A.M. and an evaluation of the Resident was not done until 6:35 A.M., 1 hour and 29 minutes after it was documented the resident was SOB. At 6:35 A.M., Resident #58 was documented having an oxygen saturation level of 65-75%, the MD was not notified and 911 was not called until 11:27 A.M., 4 hours and 52 minutes after the assessment. The facility failed to assess the Resident for 1 hour and 29 minutes after the Resident initially reported being SOB and failed to notify the physician or call 911 for 4 hours and 52 minutes after assessing the Resident and documenting his/her oxygen saturation level at 65-75%. Review of Resident #58's care plans initiated on 11/10/2022 and revised on 11/18/2022 indicated the following: *The resident has altered respiratory status/difficulty breathing related to COPD, pneumonia, and malignant neoplasm of oropharynx. Goal: The resident will be free from complications related to infection through the review date. *The resident has altered respiratory status/difficulty breathing related to COPD, pneumonia, and malignant neoplasm of oropharynx. Goal: The resident will have no complications related to SOB, no signs or symptoms of poor oxygen absorption, the resident will maintain normal breathing pattern as evidenced by normal respirations through the review date. Interventions: Monitor and report signs and symptoms of respiratory distress and abnormal breathing patterns to the MD. Review of Resident #58's Oxygen Saturation Summary indicated that his/her oxygen saturation was documented at 70% on 11/20/22 at 11:19 A.M. During an interview on 12/16/22 at 10:24 A.M., Resident #58 said he/she remembers not being able to breath on the morning of 11/20/22. The Resident further said that he/she couldn't get any air into his/her body, and I was scared. During an interview on 12/15/22 at 11:35 A.M., Nurse #7 said if a change of condition is observed the nurse would first take vital signs, notify the MD and implement the orders from the MD. Nurse #7 said an acceptable oxygen saturation is between 90-100% and that if it fell between 80-90% the nurse should call the MD. Nurse #7 said if an oxygen saturation is in the 70%'s or lower that is critical and the patient could die and the expectation would be that the nurse would apply oxygen, call the MD and call 911 right away. During an interview on 12/15/22 at 11:48 A.M., Nurse #4 said for a change of condition the nurse should call the doctor, notify the family and send the resident to the hospital if it is something that can't be handled at the facility. Nurse #4 further said a normal oxygen saturation level is 92% or higher in general and 88% or higher for a resident with COPD and that if a resident's oxygen saturation is in the 60-70%'s, the nurse should first administer a non-breather oxygen mask, call 911 and then the MD. Nurse #4 said this should have been reported to the doctor and not passed on to the next shift. During an interview on 12/16/22 at 8:42 A.M., Nurse #6 said if the MD is notified it would be documented in the nursing progress notes. During an interview on 12/16/22 at 9:35 A.M., the Director of Nursing (DON) said if a change in condition is observed the expectation is that the nurse will take the resident's vital signs first, notify the MD and follow their orders and then notify the family. The DON said that when the MD gets notified, it should be documented in the progress notes. The DON further said that a normal oxygen saturation level is 94% or higher and 88% or higher if a resident has COPD and that if a resident's O2 saturation is in the mid to low 80%'s then the nurse should connect them to oxygen and call the MD immediately and if their oxygen saturation levels are in the 60-70%'s, 911 should be called immediately followed by notifying the MD. The DON reviewed Resident #58's progress notes with the surveyor and said that 911 should have been called and the MD should have been notified immediately upon discovering Resident #58's oxygen levels. The DON said what happened was concerning and unacceptable. The surveyor attempted to contact the nurse who wrote the nursing progress note dated 11/20/22 at 6:35 and was unsuccessful. 36431 2. For Resident #27 the facility failed to develop a comprehensive coordinated person-centered care plan with individualized interventions for hospice care services. Review of the facility's policy titled Hospice Services, dated 4/2018 indicated the following: Guidelines: m) Coordinated care plans for residents receiving hospice services will include the most recent hospice plan f care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident #27 was admitted to the facility in 10/2022 with diagnoses that include dementia, adult failure to thrive, dysphagia, and chronic kidney disease. Review of the comprehensive Minimum Data Set Assessment (MDS) with an assessment reference date of 10/31/22 indicated Resident #27 was rarely understood or rarely understands and was assessed by staff as having moderate cognitive impairment. Further review of the MDS indicated Resident #27 was dependent on 2 staff for bathing, dressing, bed mobility and transfers. On 12/14/22 at 11:49 A.M. Resident #27's was resting in bed and observed to have thin, frail extremities and was slight in stature. Review of Resident #27's medical record indicated the following: * A physician order dated 10/25/22, do not weigh resident is on hospice. The physician's orders did not indicate an order for hospice services. Review of the care plans failed to indicate a care plan was developed for hospice services. During an interview on 12/15/22 at 11:19 A.M., the Minimum Data Nurse said the Resident was on hospice care services and it was not coded on the MDS, and a care plan was not developed for hospice care and should have been 3. For Resident #98 the facility failed to ensure a comprehensive person-centered care plan with individualized interventions was developed for hospice care. Review of the facility's policy titled Hospice Services, dated 4/2018 indicated the following: Guidelines: m) Coordinated care plans for residents receiving hospice services will include the most recent hospice plan f care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident #98 was admitted to the facility in 10/2022 with diagnosis of cerebral infarction and lung cancer. Review of Resident #98's comprehensive Minimum Data Set Assessment with an Assessment Reference date of 10/27/22 indicated Resident #98 scored a 9 out of 15 on the Brief Interview for Mental Status Exam, indicating moderate cognitive impairment and required extensive assistance from staff for hygiene and was dependent on staff for bathing. Further review of the MDS indicated Resident #98 was receiving service while a resident of the facility from a hospice program. During an interview of 12/14/22 at 4:34 P.M., Nurse #13 said the Resident (#98) has been at the facility a few months and is on hospice care services. Review of the medical record indicated a physician order for hospice services dated 10/21/22. On 12/15/22 review of the developed care plans failed to indicate a person-centered care plan with individualized interventions was developed for hospice services. During an interview on 12/15/22 at 11:42 A.M. the Minimum Data Set Nurse reviewed Resident #98's care plans and said a care plan for hospice was not present. The MDS nurse said a care plan for hospice should have been developed for Resident #98.

Based on interview, record review and policy review, the facility failed to provide the necessary treatment and services to prevent development of pressure ulcers for 2 Residents (#40 and #84) out of a sample of 5 residents with pressure injuries, out of a total sample of 29 residents. Findings include: Review of facility policy titled 'Prevention of Pressure Ulcers/ Injuries', revised 11/2017 indicated the following: *Policy: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. *Guidelines: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. *Risk Assessment: Assess the resident on admission (within eight hours) for existing pressure ulcer/ injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Review of facility policy titled 'Pressure Ulcer/Injury Risk Assessment', revised 4/2018 indicated the following: *Policy: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/ injuries. *General guidelines: 1. The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed and which will take time to modify. 2. Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs (Pressure Ulcers/Injuries) include, but are not limited to: a. Under nutrition, malnutrition, and hydration deficits; b. Impaired/decreased mobility and decreased functional ability; c. The presence of previously healed pressure ulcers/ injuries' d. Exposure of skin to urinary and fecal incontinence; e. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency; f. Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus; g. Drugs such as steroids that may affect healing; h. Cognitive impairment; and i. Resident refusal of some aspects of care and treatment. 3. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/ injuries. 4. Use only a facility approved risk assessment tool to obtain risk assessment data. 5. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. 6. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. *Steps in the procedure -Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Review of facility policy titled 'Pressure Ulcers/ Injuries Overview', revised 2/2019 indicated the following: *Purpose: -The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/ injuries and associated risk factors . *Definitions: -Pressure Ulcer/ Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. *A pressure injury will present as intact skin and may be painful. *A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. *Pressure ulcers/ injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. *Staging -Stage 2 pressure ulcer: Partial-thickness skin loss with exposed dermis. Appears as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. -Stage 3 pressure ulcer: full thickness skin loss. Appears as full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead or devitalized tissue) may be visible but does not obscure the depth of the tissue loss. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. -Unstageable Pressure Ulcer: obscured full-thickness skin and tissue loss. Appears as a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscure by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. 1. Resident #84 was admitted to the facility in October 2022 with diagnoses including muscular dystrophy, heart failure, type 2 diabetes and unspecified severe protein-calorie malnutrition. Review of Resident #84's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the Resident's MDS indicated he/she had no behaviors, did not reject care, was totally dependent with a two person physical assist for care activities, was always incontinent of bowel and bladder, had no pressure ulcers or injuries and was at risk for developing pressure ulcers/ injuries. On 12/14/22 at 9:50 A.M., Resident #84 was observed lying in bed. He/she was lying on a specialty air mattress. Resident #84 was wearing bilateral Prevalon boots (pressure relieving boots) and said he/she just got the boots within the past few days, but had been asking for them for a few weeks and was told staff was working on it. Resident #84 said he/she has an open area on his/her left foot and an open bedsore on his/her bottom. Resident #84 said he/she developed both issues after he/she was admitted to the facility and said he/she had no bedsores when he/she was admitted . Resident #84 said he/she sees the wound doctor every Monday and the doctor had repeatedly asked for booties for his/ her feet. Resident #84 was unable to say when he/she was given the specialty air mattress. Review of Resident #84's medical record on 12/14/22 at 12:45 P.M. indicated the following: -An admission nursing evaluation dated 10/25/22 which indicated the Resident had normal skin, no pressure injuries, no non-pressure skin issues and no foot problems. -A Norton scale for predicting risk of pressure ulcers dated 10/25/22 with a score of 10, which indicated the Resident was a high risk for developing a pressure ulcer. Further review of Resident #84's medical record failed to indicate any skin checks were completed after 10/25/22. -A Norton scale for predicting risk of pressure ulcers dated 11/01/22 with a score of 8, which indicated the Resident was a high risk of developing pressure ulcers. Further review of Resident #84's medical record failed to indicate any additional pressure ulcer risk assessments had been completed for the Resident after 11/01/22. -A nursing progress note written by Nurse #8 dated 11/25/22 (24 days after the last risk assessment and 30 days after the last skin assessment): During the 11-7 shift the Certified Nursing Assistant (CNA) went to change this resident and at that time this nurse was called to the room and the resident was observed to have an area on the left buttock and cream was applied to the area. Resident had no complaints of pain or discomfort. The note failed to indicate any measurements and failed to indicate if the physician was notified of the new skin issue or if any new treatment or orders had been implemented. -A skin/wound note dated 11/27/22 (2 days after the Resident was observed to have an open area on his/her buttocks): DTI (Deep Tissue Injury) measuring 1 centimeter (cm) x 0.7 cm noted to left lateral foot. Dark purple in color with dark red peri-wound. Center of DTI is hard. -A skin alteration report dated 11/27/22: DTI measuring 1cm x 0.7cm noted to left lateral foot. Dark purple in color with dark red peri-wound. Center of DTI is hard. Immediate action taken: skin prep applied to area and air mattress placed on bed. -An initial wound evaluation and management summary written by the wound MDS dated [DATE]: *Focused wound exam (site 1) unstageable DTI Sacrum full thickness- etiology: pressure; wound size 7cm x 1.5cm x not measurable; exudate: light serous; granulation tissue: 100%. *Focused wound exam (site 2) unstageable DTI of the left lateral foot partial thickness- etiology: pressure; wound size: 1.3cm x 0.6cm x not measurable cm -A wound evaluation and management summary dated 12/5/22: *Focused wound exam (site 1): Stage 3 pressure wound of the sacrum with full thickness with 90% thick adherent devitalized necrotic tissue 90% and granulation tissue 100%. The note further indicated the wound physician performed a surgical excisional debridement procedure (a procedure in which necrotic tissue is removed) to the sacrum. Site 1: Surgical excisional debridement procedure: Remove necrotic tissue and establish the margins of viable tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. *Focused wound exam (site 2): Unstageable DTI of the left lateral foot partial thickness measured 1.2cm x 0.9cm x not measurable and there was no change in the wound progress. Review of Resident #84's care plans indicated the following: -A care plan for potential alteration in skin integrity initiated 11/01/22 with a goal that skin will remain intact and the following interventions: dietary intervention/ evaluation; follow MD orders for skin care and treatments (utilize Best Practice Guidelines); protect skin with incontinent care; resident/ family education as needed; toileting assistance on toileting schedule or routine; turn and reposition as needed. During an interview on 12/15/22 at 10:01 A.M., the Director of Nursing said there is no specific skin check policy but said all residents should have a skin check upon admission and weekly. The Director of Nursing said there should be an order for weekly skin checks and the resident should be care planned for it. She said for any new skin issues identified the staff is expected to do an overall skin check and a skin investigation and said she was unable to locate an investigation for Resident #84's open area from 11/25/22. During an interview on 12/15/22 at 11:59 A.M., Nurse #4 said skin checks are done upon admission, and at that time orders for weekly skin checks should be populated automatically. Nurse #4 said she is familiar with the Resident and said there should have been weekly skin checks. Nurse #4 said Resident #84 had multiple risk factors for skin breakdown and that residents assessed to be a high risk for skin breakdown or pressure ulcer development should have specific interventions put in place. She said some interventions might be pressure reducing air mattresses and pressure relieving boots. Nurse #4 acknowledged there were no skin checks done for Resident #84 after admission. Nurse #4 said that if a nurse identifies any new skin issue there should be documentation and the physician should be notified. During a follow up interview on 12/15/22 at 1:57 P.M., the Director of Nurses said that the expectation would be that skin checks would be completed weekly for residents. The Director of Nursing said she would have to look into if there was an investigation into Resident #84's pressure injury on his/her sacrum. The Director of Nursing reviewed a skin incident report dated 11/27/22 for a DTI on Resident #84's left foot and acknowledged that it indicated an air mattress was placed on the bed after the Resident developed a pressure injury to his/her sacrum and after he/she was assessed to be a high risk for development of pressure injuries. The Director of Nursing was unsure of when the air mattress was implemented. The Director of Nursing said that all residents should have skin checks done weekly and said that her expectation would be that comprehensive care plans would be developed and implemented for pressure injuries and updates should be made accordingly. During an interview on 12/15/22 at 2:11 P.M., the Director of Maintenance said that he does not keep a log of which residents and rooms have air mattresses. He said he will bring an air mattress up when the nurse or Director of Nursing requests one. He said he thinks he set up an air mattress in Resident #84's room in late November, but was unsure of the date. During a follow up interview on 12/19/22 at 12:50 P.M., the Director of Nursing said the expectation is that orders will be followed and that if a resident is at risk for pressure injuries, comprehensive care plans should be implemented. The Director of Nursing acknowledged no skin checks were done after admission for Resident #84, despite being assessed as a high risk and that an air mattress was implemented 2 days after the first open area was identified, upon identifying an additional pressure injury. The Director of Nursing acknowledged the Resident developed 2 pressure injuries after admission to the facility. During a telephone interview on 12/21/22 at 3:07 P.M. Nurse #8 said she was familiar with the Resident. She said she does not think that Resident #84 was at risk for developing any pressure injuries and she believes he/she had orders for barrier cream to the buttocks that were put in when the Resident was admitted . Nurse #8 said she was notified of an open area to his/her buttocks after he/she was admitted by a CNA doing care. Nurse #8 said she did not measure the open area and that measurement is something the wound doctor will do. Nurse #8 said she wrote a progress note in the health record and notified the oncoming nursing shift of the new open area but did not communicate it to the physician directly and was unsure of when or if they were made aware. Nurse #8 said she is unaware of any additional documentation that needs to be completed for a new skin injury and said that weekly skin checks should be performed for all residents. Nurse #8 said she thinks an air mattress was put in place for the Resident a few days after the open area on his/her buttocks was identified. 2. Resident #40 was admitted to the facility in April 2020 with diagnoses including vascular dementia and diabetes mellitus. Review of Resident #40's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) exam and had short and long term memory problems. Further review of the MDS indicated he/she had no behaviors, did not reject care, was totally dependent for care activities, had no pressure ulcers/ injuries and was at risk for developing pressure ulcers/ injuries. On 12/14/22 at 1:30 P.M., Resident #40 was observed sleeping in bed. He/she appeared thin and frail. Review of Resident #40's medical record indicated the following: -A physician order dated 3/31/21 for weekly skin checks every Thursday. -A Norton Scale for Predicting Risk of Pressure Ulcers dated 10/18/22 which indicated the Resident was a high risk for developing a pressure ulcer. -A weekly skin evaluation dated 11/24/22 which indicated the Resident's skin was clean and intact. -An order dated 11/14/22 to apply zinc oxide (a barrier cream used to prevent skin irritation) to coccyx every shift. -Review of Resident #40's December 2022 Treatment Administration Record (TAR indicated) the zinc oxide barrier cream was applied as ordered -A nurse's note dated 11/30/22: Resident noted with bilateral buttocks excoriated, house barrier cream applied, to be seen by wound MD for evaluation. -An initial wound evaluation and management summary written by the wound MD and dated 12/5/22: Focused wound exam (site 1)- unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar DTI (deep tissue injury) sacrum full thickness. Etiology: pressure; Wound size: 6.3 centimeters (cm) x 6.5 cm x not measurable; exudate: moderate serous. Dressing treatment plan: Hypochlorus acid solution (Vashe-a cleanser), then apply calcium alginate (an absorbent dressing to help maintain a dry wound) followed by foam silicone border (an occlusive dressing) once daily for 30 days. Recommendations: Prevalon boots (pressure relieving boots). -A nurse's note dated 12/5/22: Resident seen by the wound specialist for sacrum wound. New order wash with hypochlorus acid solution (a cleanser), then apply calcium alginate (an absorbent dressing to help maintain a dry wound) followed by foam silicone border (an occlusive dressing) x 30 days Prevalon boots (pressure relieving boots). -An order dated 12/5/22 for Sacrum wound wash with hypochlorus acid solution (Vashe) then apply calcium alginate followed by foam silicone border dressing once daily x 30 days. -A nurse's note dated 12/06/22: Resident noted to have stage 3 on coccyx. Resident was seen by wound MD yesterday with new treatment orders and Nurse Practitioner (NP) to see resident today. -An NP note dated 12/6/22 which indicated the Resident has an unstageable DTI to his/her sacrum. Further review of Resident #40's medical record failed to indicate any documentation related to the Resident's skin or the wound deteriorating between 11/30/22 which indicated his/her buttocks were excoriated and 12/5/22 which indicated he/she had a full thickness unstageable DTI to his/her sacrum, despite zinc oxide cream being documented as being applied every shift. During an interview on 12/15/22 at 4:37 P.M., Nurse #1 said he was familiar with Resident #40 and that he/she recently came back to the unit after being on another unit. Nurse #1 said he/she developed the skin issues while on the other unit and he wasn't sure what happened. Nurse #1 said he would expect to see documentation if a Resident developed a new area of skin breakdown. During an interview on 12/19/22 at 12:50 P.M., the Director of Nursing said the expectation is that orders will be followed and that if a resident is at risk for pressure injuries, comprehensive care plans should be implemented. The Director of Nursing said weekly skin checks should be performed and acknowledged no skin checks were done after 11/24/22 for Resident #40. The Director of Nursing said that if any new skin issue develops, the expectation is that there will be a skin investigation completed. The Director of Nursing acknowledged there was no additional documentation regarding Resident #40's buttocks between 11/30/22, when it was documentation as being excoriated and 12/5/22 when it was documented as an unstageable DTI.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), on 5/31/19 the Facility failed to prevent an incident in which Certified Nurse Aide (CNA) #1 heated Resident #1's breakfast items in a microwave and served them to Resident #1 without checking the temperature and, oatmeal spilled onto Resident #1's leg and caused a painful second degree (partial thickness burn, involves the epidermis and part of the dermis layer of skin, appears red, blistered, may be swollen and painful) burn that required treatment with aloe vera. Findings include: The Facility's Microwave Oven and Safety Guidelines, undated, indicated that staff should rotate or stir foods to ensure even distribution of heat, allow foods to stand for two minutes after cooking to obtain temperature [MEDICATION NAME] and use a clean sanitized thermometer or temperature stick to ensure food has reached a safe internal temperature of 165 degrees. Resident #1's most recent Minimum Data Set (MDS) Assessment, completed 5/24/19, indicated that his/her cognitive patterns were intact and he/she ate independently. Resident #1 was discharged from the Facility prior to the Survey and did not respond to a letter sent by the Surveyor to his/her home on 7/5/19 for an interview. Review of CNA #1's written statement, dated 5/31/19, indicated that she brought Resident #1 oatmeal and some of it fell on him/her because of a tilting table. The Surveyor interviewed CNA #1 at 4:45 P.M. on 6/26/19. CNA #1 said that she did not recall an incident in which oatmeal spilled and burned Resident #1. Review of the Director of Nurse's notes from her interview with CNA #1 on 5/31/19, indicated CNA #1 told the Director of Nurses that she did not measure the temperature of Resident #1's oatmeal or stir it when she removed it from the microwave, before serving it to Resident #1. The Surveyor interviewed Nurse #1 at 1:45 P.M. on 6/24/19. Nurse #1 said that on 5/31/19 at approximately 9:00 A.M., CNA #1 asked her to come to Resident #1's room. Nurse #1 said CNA #1 told her that she reheated Resident #1's breakfast and Resident #1 spilled oatmeal on his/her leg. Nurse #1 said when she assessed Resident #1, he/she had already wiped the oatmeal from his/her leg. Nurse #1 said that Resident #1 told her that his/her leg was a little painful, said she applied a cold compress and notified the Director of Nurses. The Facility Non-Pressure Ulcer Evaluation Form, dated 5/31/19, timed at 10:00 A. M,. indicated Resident #1 sustained [MEDICAL CONDITION] his/her right leg. The Non-Pressure Ulcer Evaluation Form indicated Resident #1 sustained a 7.5 centimeter (cm) by 2.5 cm irregular burn on his/her right knee and [MEDICAL CONDITION] his/her right shin which measured 1.5 cm by 1 cm, 5.5. cm by 2.5 cm and a 4 cm by 1 cm. On 6/24/19, the Facility presented the Surveyor with a plan of correction which addressed the concern as evidenced by: A) Resident #1'[MEDICAL CONDITION] treated with aloe vera daily and when he/she discharged from the Facility on 6/5/19 the areas were described as pink. B) CNA #1 was disciplined for heating Resident #1's breakfast and educated on 6/10/19. C) All regular staff received training on microwaves, reheating food and taking food temperatures between 6/7/19 and 6/10/19. Additional staff were being trained at the start of their next scheduled shift. D) Postings were placed above the microwaves in the kitchenettes on 6/7/19 on the three units which provided guidance for the number of seconds to microwave different food items and the procedure for using single use cardboard thermometers. E) The Assistant Director of Nurses said that since 6/7/19 she rounded the units daily to observe that the postings were in place and to count the single use thermometers to be sure that staff were using them. F) The Assistant Director of Nurses said that since 6/7/19 nursing staff have observed CNAs using the microwave to ensure that the singe use disposable thermometers were used. G) The Facility to bring concerns to Quality Assurance Performance Improvement Committee, with results of monitoring, and assurance continued compliance with staffs use of microwaves, reheating food and taking food temperatures. H) The Director of Nurses and/or designee is responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 (who needed bed mobility assistance of two staff members) was provided with necessary services when Certified Nurse Aide (CNA) #1 performed care without the second staff member, Resident #1 rolled off the bed, fell on to the floor, was transferred to the Hospital Emergency Department, and was diagnosed with [REDACTED]. Findings include: The Facility's Policy titled, Abuse Prevention, dated 11/2017, indicated that the Facility will be proactive with measures to ensure that residents' freedom of risk of abuse, neglect, involuntary seclusion, and misappropriation of resident property, through assessment, care planning and monitoring of residents with needs and behaviors that may lead to conflict or neglect. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assistance of two persons during bed mobility and transfers. Review of Resident #1's Plan of Care related to falls prevention, dated revised 7/12/18, indicated Resident #1 was at risk for falls due [MEDICAL CONDITION] disorder, muscle weakness, cognitive deficits and impulsivity. Interventions included that Resident #1 should be assisted by two staff members during transfers and bed mobility. Review of Resident #1's Occupational Therapy Plan of Care, dated 04/11/19, indicated he/she was being treated for [REDACTED]. The OT plan of care indicated that Resident #1 has functional deficits with activities of daily living (ADLs) and that he/she was dependent and required assistance of two staff members. The Nurse Progress Note, dated 05/26/19, indicated that Resident #1 fell off the bed and sustained a bleeding laceration and a bump above his/her right eye during care. The Facility's Incident Report, dated 05/26/19, indicated that CNA #1 stated that she rolled Resident #1 away from her (CNA #1) during care, that the Resident #1 continued to roll further away from her, that she attempted to catch Resident #1 by the legs but that Resident #1 fell off the bed. The Report also indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation and that Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 12:00 P.M. on 06/07/19. CNA #1 said she was alone, did not have another staff member with her, when she provided care for Resident #1. CNA #1 said she repositioned Resident #1 by herself, and he/she rolled out of bed on to the floor. The Surveyor interviewed Nurse #1 at 12:30 P.M. on 06/11/19. Nurse #1 said she was unsure what Resident #1's plan of care indicated related number of staff members required for assistance with care. Nurse #1 said that he was in the hallway when he heard a loud sound come from Resident #1's room. Nurse #1 said he rushed to the room and could hear CNA #1 calling for help and that Resident #1 was on the floor with a bleeding laceration above his/her right eye. Nurse #1 said he assessed Resident #1 and said Resident #1 was in mild pain. Nurse #1 said Resident #1 was transferred to the hospital and was later diagnosed with [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 12:30 P.M. on 06/07/19. The DON said that the fall incident of 05/26/19 might have been prevented if Resident #1's plan of care was followed and implemented by two staff members as indicated, because Resident #1 was sometimes combative with care. The DON said that CNA #1 did not follow Resident #1's plan of care.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1's fall prevention plan of care interventions were implemented and followed by staff, when Certified Nurse Aide (CNA) #1 repositioned Resident #1 by herself while providing care despite his/her plan of care indicating he/she required the assistance of two staff member. Resident #1 fell out of bed, sustained a laceration to his/her head, and was transferred to Hospital Emergency Department for evaluation and was diagnosed with [REDACTED]. Findings include: The Facility's policy titled, Safety and Supervision of Residents, dated 04/2018, indicated that the Facility must ensure that Residents' care plan interventions are implemented correctly and consistently. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assistance of two persons during bed mobility and transfers. Review of Resident #'s Plan of Care, revised on 7/12/18, indicated he/she was at risk for falls due to his/her [DIAGNOSES REDACTED]. Interventions included that Resident #1 should be assisted by two staff members during transfers and bed mobility. Review of Resident #1's Occupational Therapy (OT) Plan of Care, dated 04/11/19, indicated he/she was being treated for [REDACTED]. The OT plan of care indicated that Resident #1 had functional deficits with activities of daily living (ADLs) and that he/she was dependent and required assistance of two staff members. The Nurse Progress Note, dated 05/26/19, indicated that Resident #1 fell off the bed on to the floor and sustained a bleeding laceration and a bump above his/her right eye during care provided by CNA #1. The Facility's Incident Report, dated 05/26/19, indicated that CNA #1 stated that she rolled Resident #1 away from her (CNA #1) during care, that the Resident #1 continued to roll further away from her, that she attempted to catch Resident #1 by the legs but that Resident #1 fell off the bed. The Report also indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation and that Resident #1 was diagnosed with [REDACTED]. The Surveyor interviewed Certified Nurse Aide (CNA) #2 at 1:30 P.M. on 06/07/19. CNA #2 said, even though she did not know where to locate care plans for residents prior to this incident, she knew Resident #1 required the assistance from two staff members because he/she could be combative and impulsive (turns quickly) during care. The Surveyor interviewed Nurse #1 at 12:30 P.M. on 06/11/19. Nurse #1 said CNAs usually provide care to Resident #1 alone. Nurse #1 said he was unsure what Resident #1's plan of care indicated related to staff assistance required for care. The Surveyor interviewed the Director of Nurses (DON) at 12:30 P.M. on 06/07/19. The DON said that the fall incident of 05/26/19 might have been prevented if Resident #1's plan of care was followed and implemented by two staff members as indicated because Resident #1 was sometimes combative with care. The DON said that CNA #1 did not follow Resident #1's plan of care.

Based on records reviewed and interviews for one of three sampled residents (Resident #1, who required the assistance of two staff members for bed mobility), the Facility failed to ensure Resident #1 was provided adequate staff assistance, when Certified Nurse Aide (CNA) #1 attempted to roll Resident #1 in bed, by herself, Resident #1 rolled out of the bed, on to the floor, sustained a laceration to his/her head and was transferred to the Hospital Emergency Department where he/she was diagnosed with [REDACTED]. Findings include: The Facility's Policy titled Safety and Supervision of Residents, dated 04/2018, indicated that the Facility will ensure that residents' care plan interventions are implemented correctly and consistently. Resident #1 was admitted to the Facility in (MONTH) (YEAR), [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assistance of two persons during care with bed mobility and transfers. Review of Resident #'s Plan of Care, revised on 7/12/18, indicated he/she was at risk for falls due to his/her [DIAGNOSES REDACTED]. Interventions included that Resident #1 should be assisted by two staff members during transfers and bed mobility. Review of Resident #1's Occupational Therapy (OT) Plan of Care, dated 04/11/19, indicated he/she was being treated for [REDACTED]. The OT plan of care indicated that Resident #1 had functional deficits with activities of daily living (ADLs) and that he/she was dependent and required assistance of two staff members. The Nurse Progress Note, dated 05/26/19, indicated that Resident #1 fell off the bed and sustained a bleeding laceration and a bump above his/her right eye during care provided by CNA #1. The Facility's Incident Report, dated 05/26/19, indicated that CNA #1 stated that she rolled Resident #1 away from her (CNA #1) during care, that the Resident #1 continued to roll further away from her, that she attempted to catch Resident #1 by the legs but that Resident #1 fell off the bed. The Report also indicated that Resident #1 was transferred to the Hospital Emergency Department for evaluation and that Resident #1 was diagnosed with [REDACTED]. Review of Certified Nurse Aide (CNA) #1's Written Statement, dated 5/26/19, indicated CNA #1 was providing care alone, and that she turned Resident #1 on his/her left side during care and he/she fell from the bed. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 12:00 P.M. on 06/07/19. CNA #1 said that she was alone in Resident #1's room, performed care with one assist and that Resident #1 fell when she attempted to repositioned him/her during care. CNA #1 said she grabbed Resident #1 by the leg to try to prevent the fall, but he/she fell from the bed and hit his/her head. CNA #1 said she usually assisted Resident #1 alone and that even though she knew his/her plan of care indicated that two staff members were required to assist with bed re-positioning, she said she knew Resident #1 well enough to provide care alone (one assist). CNA #1 said she only knew of where to find residents' plan of care after this fall incident on 05/26/19. Review of Nurse #1's The Written Statement, dated 5/26/19, indicated that Nurse #1 noted a bleeding laceration and a bump above Resident #1's right eye and that Resident #1 experienced mild pain when he/she fell . The Surveyor interviewed Nurse #1 at 12:30 P.M. on 06/11/19. Nurse #1 said that he was in the hallway when he heard a loud sound come from Resident #1's room. Nurse #1 said he rushed to the room and could hear CNA #1 calling for help and that Resident #1 was on the floor with a bleeding laceration above his/her right eye. Nurse #1 said he assessed, Resident #1 was in mild pain. Nurse #1 said Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with [REDACTED].#1 said, and his written statement indicated there were no other staff member in the room with Resident #1 except CNA #1, when he responded to the incident. The Surveyor interviewed the Director of Nurses (DON) at 12:30 P.M. on 06/07/19. The DON said that the fall incident of 05/26/19 might have been prevented if Resident #1's plan of care was followed and implemented, with two staff members providing care as indicated because Resident #1 was sometimes combative with care.

Based on record review, observation and staff interview, the facility failed to provide adequate supervision and effective fall prevention measures to prevent a fall with injury for one sampled resident (#8) in a total sample of 20. Findings include: Resident #8 was admitted in 2011 with [DIAGNOSES REDACTED]. On 7/15/14 at 8:40 A.M. during the initial tour of the facility, the surveyor observed the resident in bed. There were no staff present in the room at the time. A bed alarm was on the resident's bed, but it was not turned on. At 8:45 A.M., the surveyor interviewed the Assistant Director of Nursing Services (ADNS) at the nurses station about the bed alarm. The ADNS accompanied the surveyor to the resident's room and turned on the bed alarm. Record review on 7/16/14 revealed a 7/4/2013 quarterly Minimum Data Set (MDS) that indicated the resident required one person extensive assistance with transfer and one person limited assistance with ambulation in the room and the corridor. A 12/5/13 Significant Change MDS (minimum data set) indicated the resident had severe cognitive impairment, had a high risk for falls and no longer ambulated. The Care Area Assessment for Falls read: "2 falls major injury past 6 months: a pelvic fracture and right humerus fracture". The 6/5/14 quarterly MDS also indicated that the resident did not ambulate. Review of the current care plan for fall prevention included the following interventions "frequent monitoring" and "bed alarm". Record review indicated that the resident was found on the floor in his/her room by the bed on 5/24/13 at 6:00 A.M. The resident sustained [REDACTED]. At that time, imaging was negative for fractures. The 5/24/13 Incident Report indicated that the interdisciplinary team met about the fall and made the following recommendations: "will be seen by rehab" and "will put a bed alarm in place to alert nursing staff of unassisted transfer". On 6/2/13 the resident returned to the hospital due to complaints of left thigh pain and difficulty with ambulation. The hospital noted the resident's recent fall at the nursing home on 5/24/13 and that initial x-rays were negative. A follow-up scan on 6/2/13 showed an acetabular fracture. The hospital discharge summary read that the fracture would be managed non operatively and that a bed alarm was put into place during the resident's stay along with frequent checks for safety. Review of the 6/10/13 facility investigation of the fall read: "we have placed a bed alarm" on the bed. A physician order [REDACTED]. On 8/11/13 at 6:10 A.M. the resident sustained [REDACTED]. The 8/11/13 Incident Report indicated that the resident was found on the floor in the bedroom lying on his/her back with the walker by him/her. A CNA (certified nurses assistant) statement read that the resident was last seen at 5:00 A.M. in bed asleep. The resident told staff: "I was going to the bathroom, I don't know what happened". An x-ray of the right shoulder showed a moderate displaced fracture of the humerus. The resident was sent to the ER for further evaluation. The 8/11/13 Incident Report recommended a bed/chair alarm be put into place as a result of the fall. However, there was a physician order [REDACTED]. According to the 8/14/13 Post Fall Investigation Report there were no safety precautions and fall preventive measures in place at the time of the fall. On 7/17/14 at 4:45 P.M., the surveyor asked the Director of Nursing Services (DNS) if there was any additional information about the circumstances of the 8/11/13 fall including the use of a bed alarm that would have alerted staff to the resident's attempt to transfer unassisted to the bathroom. No further information was provided. The facility did not provide a bed alarm to alert staff that the resident attempted an unassisted transfer to the bathroom. The resident subsequently fell and sustained a fracture of the humerus.