Every finding on record at Westhaven Nursing Home

Based on record review and interview, the facility failed to ensure an allegation of abuse was immediately reported for 1 (#1) of 3 sampled residents reviewed for abuse.The administrator identified 60 residents resided in the facility. Findings:An undated policy titled Patient Abuse, read in part, It is strictly prohibited for any employee fail to immediately report an incident of patient abuse to the Administrator, or DON.An admission assessment for Resident #1, dated 01/25/26, showed the resident's cognition was severely impaired with a BIMS score of 03. The assessment showed the resident was dependent on staff for transfers and required substantial/maximal assistance from staff for wheelchair use. The assessment showed the resident had diagnosis which included dementia.An incident report for Resident #1, dated 02/12/26, showed an allegation of abuse on 02/11/26. The report showed on 02/11/26 at approximately 11:00 p.m., RN #1 observed CNA #1 behave in an abusive manner toward Resident #1. The report showed RN #1 did not report the abuse allegation until 6:00 a.m. on 02/12/26 to the DON.On 02/18/26 at 1:21 p.m., family member #1 stated they had been called to the facility on [DATE] from approximately 10:30 p.m. to 11:00 p.m. because Resident #1 was being combative with care. Family Member #1 stated they asked for the resident to be transferred to the couch where they had been sleeping recently. Family Member #1 stated CNA #1 yanked the resident up from the wheelchair and dropped them down on the couch with force. Family Member #1 stated they felt the CNA's actions were abusive.On 02/18/26 at 1:52 p.m., RN #1 stated they had asked CNA #1 to transfer Resident #1 from the wheelchair to the couch in the common area. RN #1 stated CNA #1 was mad and aggressively transferred the resident to the couch. RN #1 stated they spoke with family member #1, and both felt the CNA's actions were abusive to the resident. RN #1 stated they were busy with their duties for their shift and did not report the incident to the DON until the next morning at 6:00 a.m.On 02/19/26 at 9:40 a.m., the administrator stated they reported the abuse allegation and started an investigation as soon as they were made aware of the incident by RN #1.On 02/19/26 at 10:30 a.m., the DON stated the incident should have been reported to them or the administrator immediately by RN #1. The DON stated RN #1 had been terminated for not reporting an allegation of abuse and CNA #1 was terminated due to their behavior.

Based on record review and interview, the facility failed to immediately protect a resident from the potential for further abuse for 1 (#1) of 3 sampled residents reviewed for abuse.The administrator identified 60 residents resided in the facility.Findings:An undated policy titled Patient Abuse, read in part, To protect the resident from employees during an abuse investigation, the employee will be suspended during the investigation process.1.An admission assessment for Resident #1, dated 01/25/26, showed the resident's cognition was severely impaired with a BIMS score of 03. The assessment showed the resident was dependent on staff for transfers and required substantial/maximal assistance from staff for wheelchair use. The assessment showed the resident had diagnosis which included dementia.An incident report for Resident #1, dated 02/12/26, showed an allegation of abuse on 02/11/26 at approximately 11:00 p.m., for CNA #1 towards Resident #1. The report showed RN #1 did not report the abuse allegation until 02/12/26 at 6:00 a.m. to the DON. The report showed CNA #1 was suspended after the abuse allegation was reported to the DON.2. A timesheet for CNA #1, dated 02/01/26 through 02/15/25, showed CNA #1's last day to work was 02/12/26. The timesheet showed CNA #1 clocked out at 6:15 a.m. on 02/12/26.On 02/18/26 at 1:52 p.m., RN #1 stated the allegation of abuse was not reported to the DON until 6:00 a.m. on 02/12/26. RN #1 stated they did not send CNA #1 home after the abusive behavior was witnessed. RN #1 stated they did not know the facility's abuse procedure and waited till the next morning to report it.On 02/19/26 at 10:30 a.m., the DON stated CNA #1 should have been sent home immediately by RN #1 while an abuse investigation was conducted. The DON stated CNA #1 should not have been allowed to finish the shift.

Based on record review and interview, the facility failed to ensure a comprehensive assessment was accurate for 1 (#35) of 12 sampled residents reviewed for accurate comprehensive assessments.The DON identified 62 residents resided in the facility. Findings: An undated weight summary showed Resident #35 weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26. A Physician's Order, dated 01/17/26 showed Resident #35 was to be given a bolus feeding of Jevity 1.5 (a tube feeding formula), five times daily. An admission MDS, dated [DATE], showed Resident #35 was admitted to the facility on [DATE] with diagnoses which included malnutrition, gastrointestinal hemorrhage, and dysphagia. The admission assessment showed Resident #35 required nutrition through a feeding tube, weighed 195 pounds, and had not had a weight loss of 5% or more in the last month. Resident #35's weight loss totaled 8.66% between 12/24/25 and 01/23/26. On 02/09/26 at 11:59 a.m., LPN #2 was asked what interventions were in place for Resident #35's weight loss. They stated Resident #35 was placed on five bolus feedings daily for a few days. On 02/09/26 at 12:05 p.m., the MDS coordinator stated they looked at resident assessments to obtain weight information. They were asked to review Resident #35's weight summary between 12/24/26 and 01/23/26. The MDS coordinator stated the admission assessment should have showed Resident #35 had a weight loss of over 5% in one month.

Based on record review and interview, the facility failed to update and implement a care plan for 1 (#35) of 12 sampled residents reviewed for care plan implementation.The DON identified 62 residents resided in the facility. Findings: An undated weight summary showed Resident #35 weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26. A Care Plan, dated 12/29/25, showed Resident #35 required nutrition through a feeding tube. Interventions in place included the registered dietitian to evaluate quarterly and as needed. There was no update to the care plan showing Resident #35 had significant weight loss. A Physician's Order, dated 01/17/26 showed Resident #35 was to be given a bolus feeding of Jevity 1.5 (a tube feeding formula), five times daily. An admission MDS, dated [DATE], showed Resident #35 was admitted to the facility on [DATE] with diagnoses which included malnutrition, gastrointestinal hemorrhage, and dysphagia. The admission assessment showed Resident #35 required nutrition through a feeding tube, weighed 195 pounds, and had not had a weight loss of 5% or more in the last month. Resident #35's weight loss totaled 8.66% between 12/24/26 and 01/23/26. On 02/09/26 at 11:59 a.m., LPN #2 was asked what interventions were in place for Resident #35's weight loss. They stated Resident #35 was placed on five bolus feedings daily for a few days. On 02/09/26 at 12:05 p.m., the MDS coordinator stated they looked at resident assessments to obtain weight information. They were asked to review Resident #35's weight summary between 12/24/25 and 01/23/26. The MDS coordinator stated the care plan should have showed Resident #35 had a weight loss of over 5% in one month and included interventions to prevent further weight loss.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted in a prominent place readily accessible to residents, staff, and visitors for 2 of 2 observations. The DON identified 62 residents resided in the facility.Findings:On 02/01/26 at 7:15 p.m., the daily nurse staffing information sheet was observed posted on a bulletin board partway down hall 4, not clearly visible to all visitors and residents. On 02/02/26 at 9:30 a.m., the daily nurse staffing information sheet was observed posted on a bulletin board partway down hall 4, not clearly visible to visitors and residents.On 02/10/26 at 11:47 a.m., the DON stated the daily nurse staffing information sheet was not posted in the main lobby area and was not visible to all residents and visitors if they did not know where it was located. They stated, It has always been down hall 4 on the bulletin board.On 02/10/26 at 12:36 p.m., the administrator stated the daily nurse staffing information sheet was not posted at the front entrance and was not visible to all residents and visitors if they did not know where to look.

Based on observation, record review, and interview, the facility failed to ensure expired medications/supplies were removed from 1 of 4 medication carts and 1 of 1 medication supply room observed.The DON identified 62 residents resided in the facility. Findings: On 02/10/26 at 9:20 a.m., the medication supply room was observed with LPN #1. The following medications/supplies were observed to be expired: a. four packages of IoFlex iodophor foam dressings with an expiration date of 12/31/23, b. seven packages of IoFlex iodophor foam dressings with an expiration date of 12/28/25, c. two boxes of 10 count Maxorb II alginate wound dressing with an expiration date of 03/01/23, d. five packages of Maxorb II alginate wound dressing with an expiration date of 02/01/23, e. one box Sorbalgon calcium alginate dressing with an expiration date of 10/20/24, f. three boxes Sorbalgon calcium alginate dressing with an expiration date of 06/19/25, g. one box Sorbalgon calcium alginate dressing with an expiration date of 01/02/26, h. three packages of 10 count Tegaderm film with an expiration date of 12/26/22, i. one pack of Zetuvit Plus silicone border with an expiration date of 01/06/25, j. one pack Optifoam heel foam non-adhesive dressing with an expiration date of 09/2021, k. one Tubersol vial with an opened date of 01/02/26, and l. one Tubersol vial opened with no date of when it was opened. On 02/10/26 at 10:10 a.m., the medication cart for hall #3 was observed with CMA #1. One box of Naloxone hydrochloride spray 4 milligrams had an expiration of 05/2025. A policy titled Expired Medications and Medications with Shortened Expiration Dates, dated 01/2026, read in part, Ensure that all medications in the facility are rotated and/or reviewed on a constant basis to prevent expired medications. On 02/10/2026 at 9:50 a.m., LPN #1 stated the expired medication/supplies should have been removed from the medication/storage room. They stated the Tubersol vial should have been dated when opened and the other vial should have been removed after 30 days. On 02/10/26 at 10:18 a.m., CMA #1 stated the Naloxone should have already been removed from the cart. On 02/10/26 at 10:20 a.m., the DON stated the expired medications/supplies should have been removed.

Based on observation, record review, and interview, the facility failed to ensure staff implemented proper infection control practices after performing incontinent care for 1 (#10) of 2 sampled residents observed for incontinent care. The director of nursing identified 56 residents resided in the facility. Findings: On 06/18/25 at 1:33 p.m., CNA #1 and #2 were observed to enter Resident #10's room to provide incontinent care. CNA #2 explained each step to Resident #10 as they performed the incontinent care. CNA #1 removed blankets from Resident #10 and then removed the pillow from under the resident's legs. CNA #1 was observed to assist Resident #10 to their right side, wipe their peri area with four wipes using each one time and disposing of the wipe. CNA #1 then assisted Resident #10 to their back and wiped the resident's peri area with three wipes using each wipe one time. CNA #1 replaced the pillow, one by one pulled up each of the four blankets, and used a remote to raise the head of the bed. CNA #1 then placed the remote on the blankets nearest Resident #10's left arm. Once incontinent care was completed, CNA #1 did not remove their soiled gloves or sanitize their hands. A Perineal Care policy, revised February 2018, read in part, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Put on gloves .Remove gloves and discard into designated container .Wash and dry hands thoroughly .Reposition the bed covers. On 06/18/25 at 1:42 p.m., CNA #1 stated the policy for glove use for providing incontinent care was to remove the gloves before touching clean areas. CNA #1 stated they did not remove their soiled gloves prior to replacing the clean items.

Based on record review and interview, the facility failed to complete a discharge summary of the residents' stay for three (#60, 67, and #69) of three sampled residents reviewed for discharge. The DON reported 66 residents resided in the facility. Findings: 1. Res #60 was discharged from the facility on 08/22/24. A review of the resident's record did not contain a discharge summary. 2. Res #67 was discharged from the facility on 05/29/24. A review of the resident's record did not contain a discharge summary. 3. Res #69 was discharged from the facility on 05/31/24. A review of the resident's record did not contain a discharge summary. On 08/28/24 at 10:56 a.m., the DON reported the discharge summary's were not completed.

Based on observation, record review, and interview, the facility failed to ensure the removal of expired medications and supplies were removed from the medication storage room. The DON reported 66 residents resided in the facility. Findings: On 08/28/24 at 9:20 a.m., a tour of the medication room was completed with the DON. The following medications and supplies were observed to be expired or passed the use by date. 2- boxes of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 04/10/24, 1- box of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 07/19/24, 2- boxes of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 11/23/24, 1- box of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 11/25/24, 6- collection and transport swab packets with an expiration date of 02/01/24, 1- bottle Lantus insulin opened and not dated, 1- bottle Milk of Magnesia with a use by date of 05/14/24, 2- bottles Milk of Magnesia with a use by date of 03/22/24, 1- bottle Milk of Magnesia with a use by date of 08/03/24, 1- bottle Milk of Magnesia with a use by date of 05/30/24, 1- bottle Milk of Magnesia with a use by date of 06/05/24, 1- Box Narcan nasal spray with a use by date of 11/02/13, 1- Box Narcan nasal spray with a use by date of 12/07/23, 1- Box Narcan nasal spray with a use by date of 11/02/23. On 08/28/24 at 9:35 a.m., the DON reported the insulin should have been dated when opened and the other medication and supplies should have been removed before the use by date.

Based on record review and interview, the facility failed to ensure: a. an as needed psychotropic medication had a 14 day stop date for one (#14), and, b. a MRR psychotropic reduction request was acted upon for one (#37) of five sampled residents reviewed for unnecessary medications. The DON identified 66 residents resided in the facility and 55 residents received psychotropic medications. Findings: 1. Res #14 had diagnoses which included anxiety. A physician order, dated 03/25/24, documented to administer lorazepam 1mg/1ml topically every four hours as needed. The order documented the physician was to re-evaluate on 04/08/24. The order was discontinued on 05/21/24. A physician order, dated 07/15/24, documented to administer lorazepam 1mg/1ml topically every four hours as needed. The order documented the physician was to re-evaluate on 07/29/24. The order was discontinued on 08/05/24. A physician order, dated 08/05/24, documented to administer lorazepam 1mg/1ml topically every four hours as needed. The order documented the physician was to re-evaluate on 08/19/24. The order was discontinued on 08/26/24. On 08/26/24 at 1:46 p.m., Corp. nurse #1 stated when the orders were entered they should have been entered with a set stop date instead of the notation in the body of the order. 35749 2. Res #37 had diagnoses which included anxiety and depression. Physician's orders, dated 09/29/23, documented to administer: a. Lorazepam Tablet 0.5 mg every 6 hours related to anxiety, and b. bupropion extended release 150 mg daily for depression. A Medication Regimen Review, dated 01/05/24, read in part, .The following medications are due for consideration of gradual dose reduction per state and federal guidelines: bupropion xl 150 mg qd, lorazepam 0.5mg q6h. Do you feel this resident is stable enough to tolerate a trial dosage reduction of either of the above medications at this time . On 08/27/24 at 10:19 a.m., the DON was asked to locate a physician response to the 01/05/24 MRR request to physician. On 08/27/24 at 10:28 a.m., the DON stated they could not locate the MRR request.

Based on record review and interview, the facility failed to ensure a MRR pharmacy request to physician had been sent to the physician to be acted upon for one (#6) of five sampled residents reviewed for unnecessary medications. The DON identified 55 residents received psychotropic medications. Findings: A Drug Regimen Review policy, dated 2024, read in part, .The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the .Director of Nursing .the Primary Physician .physician provides a written response of the report to the facility within one month after the report is sent . Res #6 had diagnoses which included diabetic neuropathy. A physician's order, dated 04/14/21, documented to administer Gabapentin 600 mg TID. A Medication Regimen Review, dated 06/11/24, read in part, Current orders include Gabapentin 600 mg tid. Based on the resident's renal function the maximum recommended dosage is 700 mg bid .Do you feel a dose reduction would be beneficial at this time . There was no documentation in the resident's clinical record the recommendation had been acted upon. On 08/28/24 at 9:12 a.m., the DON was asked to locate the physician response to the MRR pharmacy recommendation letter to the physician. On 08/28/24 at 10:56 a.m., the DON stated they were unable to locate the MRR.

Based on observation, record review, and interview, the facility failed to ensure medications were not left at bedside for one (#49) of six sampled resident reviewed for medications. The DON identified 66 residents resided in the facility. Findings: An Administering Medications policy, dated December 2012, read in part, .Medications shall be administered in a safe .manner . An Inservice Education report, dated 11/06/23, read in part, .Medications are not to be placed in residents' room for them to take later. You are to take medication with you, put name and date and placed in medication cart until resident is ready to take medication . On 08/25/24 at 8:33 a.m., Res #49 was observed sitting in their room eating breakfast. Two medication cups were observed on the resident's bedside table. One medication cup contained two white tablets, and the other contained 12-15 tablets/capsules. On 08/25/24 at 8:40 a.m., RN #1 was asked what the policy was for administering medications. They stated staff would check the physician's orders, punch the medications out, initial the MAR, and administer the medications. RN #1 stated they would stay with the resident until they swallowed the medications. On 08/25/24 at 8:43 a.m., RN #1 was shown the two medication cups sitting on Res #49's bedside table. RN #1 told Res #49 they needed to take their medications. Resident #49 informed RN #1 they would take them after they ate breakfast. RN #1 told Res #49 they were going to take the medications and would bring them back after breakfast. Res #49 stated, Why. RN #1 left the two medication cups on the bedside table and left the resident's room.

Based on observation, record review, and interview, the facility failed to notify the physician of a new pressure ulcer for one (#4) of one sampled resident reviewed for pressure ulcers. The CMS 802 resident matrix documented two residents had pressure ulcers. Findings: Res #4 had diagnoses which included Alzheimer's disease and dementia. A progress note, dated 07/27/24 at 5:33 a.m., documented Res #4 had an open area measuring 0.5 cm by 0.5 cm with red tinged drainage. The note documented the wound was cleaned, patted dry, and calazime (barrier cream) was applied. The note did not document the physician was notified. On 08/27/24 at 10:23 a.m., wound care for Res #4 was observed. On 08/27/24 at 11:51 a.m., the DON stated the physician should be notified of new wounds the day they are discovered. They stated they could not see any documentation the physician was notified.

Based on observation, record review, and interview, the facility failed to ensure EBP were implemented during incontinent care and indwelling catheter care for one (#120) of five sampled resident reviewed for infection control. The DON identified nine residents with foley catheters and 23 with EBP's in place. Findings: An undated, Enhanced Barrier Precautions policy, read in part, .EBP .are an infection control intervention designed to reduce transmission of multidrug-resistant organisms .Enhanced Barrier Precautions involve gown and glove during high-contact resident care activities .High-contact resident activities include .Changing briefs .urinary catheter . An Enhanced Barrier Precautions sign, posted on the outside of Resident #120's door, documented staff must wear gloves and a gown during transfers and urinary catheter activity. On 08/25/24 at 9:23 a.m., Res #120 was observed sitting in a wheel chair with a lift sling under them. A urinary drain bag was hooked under the wheel chair. CNA #4 and CMA #1 brought a lift into the room, cleaned their hands, and donned gloves. They attached the sling to the lift and transferred the resident to their bed. CMA #1 provided peri care and indwelling catheter care to Res #120. Resident #120 was turned to their left side and CNA #1 provided incontinent care to the resident's bottom. CMA #1 and CNA #4 did not wear gowns during the incontinent care or indwelling catheter care. On 08/25/24 at 11:06 a.m., CMA #1 was asked what the policy was for EBP. They stated staff would use EBP for residents with COVID, respiratory issues, wound care, skin conditions, scabies, breathing treatments, and for c-diff. CMA #1 was asked if EBP should be implemented during incontinent care and urinary catheter care. They stated they thought it should be.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for antidepressant medications for one (#55) of 15 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 39 residents received antidepressant medications. The census was 68. Finding: Resident #55 had diagnosis which included fracture of sacrum and depression. A Care plan policy, revised November 2010, read in part, .an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . A Care plan, dated 06/24/23, did not address the use of antidepressant medications. A Admission Assessment, dated 06/29/23, noted Resident #55 had received antidepressant medications. On 07/25/23 at 3:52 p.m., the DON was asked if a resident was on a psychotropic/antidepressant medication, would the care plan need to reflect that medication. They stated, of course it should. The DON was then asked, who makes the changes or up dates a care plan when a resident's medication or status changes. The DON stated, the whole team does, it depends on was here when something needs to be added to the careplan.

Based on observation, record review, and interview, the facility failed to ensure insulin and insulin supplies were not left unattended and in the presence of licensed/qualified staff during medication observation for one (#272) of three residents observed for medication administration. The DON identified three residents that wander about the facility. Findings: A Storage of Medications policy, revised April 2007, read in parts, The facility shall store all drugs and biologicals in a safe, secure .manner .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in clean, safe, and sanitary manner .Compartments (including, but not limited to .carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Resident #272 admitted with diagnoses which included osteomyelitis and type 2 diabetes. On 07/25/23 at 12:05 p.m., RN #1 was ready to be observed for an insulin injection, stating they had to use a different cart as theirs was in use by a physician. They presented with a rolling cart with insulin and supplies for injection inside three different boxes on top of the cart. RN #1 did not have the computer or order visible with them. On 07/25/23 at 12:10 p.m., RN #1 stated they needed to go and check Resident #272's order for the insulin dose. RN #1 walked away from the rolling cart with the insulin and supplies on top. Inside of the three boxes were two vials of insulin, one insulin pen, insulin syringes and alcohol pads. On 07/25/23 at 12:11 p.m., RN #1 returned to the cart with their laptop. They were asked what the policy and procedure was for medication and supplies storage. They stated that usually in a cart with a lock and have boxes for them and leave them in the cart. RN #1 was asked when they went to look at the order, was the medication and supplies left unattended by qualified staff. They stated that if by themselves then yes, but you were here. You count right? On 07/25/23 at 12:37 p.m., the DON was asked what the policy and procedure was for medication storage. They stated to be kept in the cart and the unopened went in the fridge. They were asked if the cart was to be locked. They stated yes. On 07/25/23 at 12:39 p.m., The DON was asked if it was okay for the insulin and supplies to be left unattended on a rolling cart in the hallway. They stated, No. The DON further stated that they already heard about it and that they knew better than that and would be in-serviced that day.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed as ordered for one (#3) and failed to ensure an oxygen concentrator had a filter for one (#11) of three sampled residents who utilized oxygen. The DON identified 17 residents who utilized oxygen. Findings: The facility's undated Maintenance of O2 Equipment policy, read in parts, .Change cannula .every 2 weeks on night shift .Date cannula and connective tubing when changed .Clean concentrator filters .every 2 weeks on night shift . 1. Res #3 was admitted on [DATE] with diagnoses which included cardiomyopathies and edema. A Physician Order, dated 04/20/23, read in parts, .Oxygen at 2-3 L/MIN via nasal cannula .Change O2 set up on the 10th and 25th of each month . On 05/12/23 at 1:31 p.m., 05/16/23 at 8:10 a.m., and 05/17/23 at 6:23 p.m., Resident #3 was observed receiving oxygen via nasal cannula. Resident #3's oxygen tubing was dated 04/25/23. The nasal cannula prongs were observed to be a yellowish color instead of clear. On 05/17/23 at 6:23 p.m., the DON observed Resident #3's oxygen nasal cannula. They stated the oxygen nasal cannula prongs were usually clear. They stated Resident #3's were yellowish. The DON stated the nasal cannula was supposed to be changed two times a month. The DON stated the tubing was dated 04/25/23. The resident reported to the DON the nasal cannula had not been changed since they were admitted to the facility. 2. Resident #11 had diagnoses which included shortness of breath, heart failure, anxiety, and dementia. Resident #11's physician's order, dated 10/04/22, documented to clean the filter on the oxygen concentrator with warm water every other Wednesday and allow to air dry before replacing. Resident #11's physician order, dated 01/24/23, documented to administer oxygen at three liters via nasal cannula continuous. On 05/17/23 at 5:45 p.m., Resident #11 was observed with oxygen in use at three liters via nasal cannula. The oxygen concentrator was observed to be missing a filter on the right side. On 05/17/23 at 6:29 p.m., the DON observed Resident #11's oxygen concentrator and stated the filter was missing on the right side of the machine. On 05/17/23 at 6:40 p.m., Resident #11's family stated they visited the resident each evening and noticed the oxygen filter had been off for at least a week.

Based on record review and interview, the facility failed to ensure the resident's representative was notified the resident had falls and was sent to the hospital and failed to ensure the physician was notified of weight loss for one (#2) of three residents who were reviewed for falls and weight loss. The DON identified 70 residents who resided in the facility and four residents who had weight loss. Findings: The facility's undated, Fall Management Program policy, read in parts, .Notification of Changes .A facility must immediately .notify the resident's legal representative or an interested family member when there is . An accident involving the resident which results in injury and has the potential for requiring physician intervention . The facility's Nutrition(Impaired)/Unplanned Weight Loss policy, dated 09/2017, read in parts, .The staff will report to the physician significant weight gains or losses .For individuals with recent or rapid weight gain or loss (for example, more than a pound a day) . Resident #2 was admitted on [DATE] with diagnoses which included heart failure, diabetes, Parkinson's disease, muscle wasting, neuropathy, osteoarthritis, and UTI. An incident report, dated 04/20/23 at 10:30 a.m., read in parts, .Res observed on floor next to sink .Res stated that she was washing her hands from using the restroom and was going to visit with roommate and lost balance and fell . The incident report did not document Resident #2's family and/or representative had been notified of the fall. Resident #2's incident report, dated 04/20/23 at 12:15 p.m., read in parts, .Res was observed on floor in room in door way of bathroom. Res was laying supine with walker in front of her .Res stated that she was up talking to her roommate and noticed that there was paper laying around and was cleaning up and fell .Res taken to [hospital] r/t head injury .Laceration .Back of head .Res A&O x 4 [person, place, time, and situation] following fall Res became more AMS as time passes . The incident report did not document Resident #2's family or representative had been notified the resident had fallen or had been sent to the hospital. On 05/17/23 at 11:20 a.m., LPN #1 stated Resident #2 had fallen around 10:00 a.m., and at 12:15 p.m., on 04/20/23. The LPN stated they had not notified the family the resident had fallen or was sent to the hospital. On 05/17/23 at 4:34 p.m., LPN #2 was asked if they were aware Resident #2's family had not been notified the resident had fallen twice and was sent out to the hospital on 04/20/23. They stated, Yes. LPN #2 stated the employee involved had been counseled in writing and the staff had been in-serviced on family notification. Resident #2's weight was documented as 237.2 on 04/12/23 and 229.4 on 04/19/23. Resident #2 had a weight loss of 7.8 pounds in seven days. There was no documentation the physician had been notified of the weight loss. On 05/17/23 at 11:20 a.m., LPN #1 was asked if the physician had been notified Resident #2 lost 7.8 pounds in one week. They stated, No. LPN #1 stated they had documented the weight in the computer but had not received an alert and was not aware Resident #2 had lost 7.8 pounds in a week. On 05/17/23 at 4:34 p.m., The quality assurance RN was asked if the physician should have been notified of Resident #2's weight loss. They stated yes, according to the policy.

Based on interview and record review, the facility failed to follow infection control practices to help prevent the development and transmission of a communicable disease (scabies) for two (#2 and #4) of four residents reviewed for communicable diseases. The Infection Preventionist (IP) identified nine residents who acquired scabies. This had the potential to affect all 63 residents who resided in the facility. Findings: A policy, updated August 2016, titled, Scabies Identification, Treatment and Environmental Cleaning documented, Purpose: The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A significant change assessment, dated 06/05/21, documented the resident's cognition was severely impaired, required extensive assistance for all ADLs and required an application of ointments to skin other than the feet. Skin assessments dated 11/10/21, 11/11/21 and 11/24/21, read in parts, rash, initiation and treatment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An 11/16/21 nursing communication note, read in parts, Spoke with [name withheld] r/t scabies infection and treatment plan . A care plan, updated 12/06/21, read in parts, .Focus: Resident has potential for impaired skin integrity d/t requiring extensive assistance with her bed mobility .Intervention(s) Administer treatments as ordered and monitor for effectiveness . 2) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised 12/04/2020, read in parts, .Focus: Resident is at risk for impaired skin integrity .Intervention(s) .nursing staff to provide any treatments as prescribed, monitoring for effectiveness . A quarterly assessment, dated 09/05/21, documented the resident's cognition was moderately impaired, required extensive assistance with ADLs and received an application of ointments to skin other than feet. Skin Observation Assessments, dated 11/11/21 and 11/12/21, documented, Abdomen - Rash, Groin - Rash. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing communication note, dated 11/16/21, read in parts, Spoke with [name withheld] r/t scabies infection and treatment plan . A review of the facilities infection prevention program tracking and trending contained no documentation to indicate the facility had investigated the residents with active scabies and complete effective training to prevent the further spread of scabies. On 12/21/21 at 8:09 a.m., the infection preventionist was asked how many residents in the facility acquired scabies. She stated, Nine. The infection preventionist provided no additional documentation of measurers taken to prevent the spread of scabies.

Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent the potential spread of infection for four (#1, 2, 3, and #4) of four sampled residents. The facility failed to ensure the staff: a) stored and used gloves from appropriate sources, not from the staff's uniform pocket; wore face shields when providing care; b) wore N-95 mask correctly; and c) changed gloves and completed hand hygiene as required. Findings: The Center for Disease Control guidance titled, Preparing for Covid-19 in Nursing Homes, .Reinforce adherence to standard IPC (infection prevention control) measures including hand hygiene and selection and correct use of personal protective equipment (PPE) .Remove and discard gloves before leaving the patient room or care area and immediately perform hand hygiene . 1. On 10/07/20 at 11:02 a.m., on hall two, certified medication aide (CMA) #3 put gloves in her pocket, she put an isolation gown on, then reached into her pocket and retrieved a pair of gloves and put them on. She did not don a face shield. She entered resident #3's room to provide care; after she left the room she was asked what she had done for the resident. She stated she helped the resident remove her jacket. The CMA did not wear a face shield while providing care to the resident. At 11:08 CMA #3 put on an isolation gown and again retrieved gloves from her pocket and donned the gloves, she did not put on a face shield prior to entering resident #4's room with certified nurse aide (CNA) #2. CNA #2 stated they assisted the resident to bed. The CMA did not wear a face shield when she provided care to the residents and obtained gloves from her pocket under her isolation gown rather than from a box of gloves. At 2:00 p.m., CMA #3 stated she did not normally put gloves in her pocket. She stated she did not wear a face shield because she left it on the other hall. At 4:36 p.m., the infection preventionist (IP) stated the staff should not get gloves and put in their pocket to use. The IP stated the staff were encouraged to wear face shields. 2. On 10/07/20 at 12:03 p.m., on hall one, licensed practical nurse (LPN) #2 was wearing a surgical mask under an N-95 mask. The LPN stated he had been fit tested for the N-95 mask and had received education on how to wear the mask. At 4:36 p.m., the IP stated a surgical mask should not be worn under the N-95 mask. 3. On 10/07/20 at 11:31 a.m., on hall one, LPN #1 wiped down a stick (An assistive device used to help her don/doff shoe covers.) she used to apply her shoe covers; donned gloves without cleaning hands; entered resident #2's room. She moved some food containers on the bedside table; reached into her pocket under her isolation gown and pulled out the keys to the treatment cart and asked an employee in the hall to get her something out of the cart. The LPN did not change her gloves or perform hand hygiene and continued to obtain the resident's finger stick blood sugar. The LPN placed the glucometer outside the resident's room on the handrail; she removed her PPE and picked up the glucometer took it to the treatment cart; put on one glove and cleaned the stick she was using to don and doff her shoe covers, cleaned her shield, removed the one glove she had on and touched her scrubs, the keys to the cart and got into the treatment cart and retrieved a paper barrier and placed it on top of the treatment cart. The LPN did not perform hand hygiene when she left the resident's room or after cleaning her face shield or assistive device. She did not clean/disinfect the handrail she had placed the glucometer on in the hall. At 11:43 a.m., LPN #1 stated she should not have gotten in her pocket with her gloves on and handed the keys to the other employee. She stated she should have performed hand hygiene when she left the resident's room before she touched anything else. At 12:27 p.m., on the COVID unit, CNA #1 left resident #1's room; removed PPE, used hand sanitizer and donned a new pair of gloves and disinfected her face shield with Clorox wipes, removed her gloves. She did not perform hand hygiene. The CNA poured drinks for resident #1 and donned PPE and entered resident #1's room. The CNA removed the PPE prior to exiting the resident's room. She did not wash or use hand sanitizer upon leaving the resident's room. She donned new pair of gloves, disinfected the face shield, removed gloves, and did not perform hand hygiene with either hand sanitizer or soap and water. She touched a cabinet in the nurses' station and a mask she was given to give to another employee. At 12:48 p.m., CNA #1 stated she did not clean her hands because she only handed the resident a cup of coffee and turned off her call light. She stated she did not think about cleaning her hands after disinfecting her face shield.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure one (#5) of three sampled residents was transferred safely with two person physical assistance. This resulted in actual harm to the resident. This had the potential to affect eight residents who required two person physical assistance with transfers. Resident #5 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 11/10/11, documented, "Category MOBL (Mobility) Problem(s) Requires 2 persons physical assist for all transfers at all times Goal(s) Will be safely transferred from bed to chair and back to bed without injury/accident Approach(s) 2 assist for all transfers..." A bed safety assessment, dated 12/01/11, documented, "1. (Checked) Yes... Condition(s) present that may affect judgement and/or cause involuntary movement that puts the resident at risk for falls ...(checked) Seizure Disorder ...(checked) Other: COPD 2. (Checked) Yes... Are medical conditions present that indicate the need for bed safety measures? ... (checked) Reduced muscular coordination 3. (Checked) Yes... Medical symptom(s) impacts or potentially functional status of the resident? 4. (Checked) Yes... Exhibits alteration in safety awareness due to cognitive decline or fluctuation in level of consciousness? 5. ...Current medications that would require increased safety precautions? ... (checked) Other: Seizure meds ...7. (Checked) Yes... Exhibits difficulty with balance and/or trunk control? 8. ...Transfer Code assigned to the resident? Code: 2 9. (Checked) Yes... Is there a history of falls? Explain: prior to admit Based upon the above assessment, the appropriate bed safety measure(s) is/are indicated: ...2 Two Person transfer (highlighted)..." A quarterly assessment, dated 04/29/12, documented the resident was moderately impaired in his cognitive skills for daily decision making. He required extensive assistance with transfers with a two plus person physical assist. His balance was not steady during transitions and walking. He was only able to stabilize with staff assistance. Monthly physician orders, dated June 2012, documented, "(original order date) 02/25/12 - 2 x Assist with All Transfers." The resident was hospitalized [DATE] to 06/08/12. An Admission/Start-Up sheet, dated 06/08/12, documented, "...(Checked) Re-Admission. cont all meds and previous orders..." An admission nursing evaluation, dated 06/08/12 at 3:00 p.m., documented, "... Physical Functioning I = Independent S = Supervised A = Assist D = Dependent ...Transfer (checked) A ...Assistance required (checked) 2 person..." A nurse's note, dated 06/28/12 at 1:30 p.m., documented, "Resident had to be lowered to floor due to feet got tangled up et got too tired p cleaning up, rec #2 skin tears #1 RFA 2.2 cm edges approx. #2 (L) shin 3.2 cm x 1.8 cm abrasion areas cleaned NS viscopaste applied secured c hypofix (physician) notified..." A nurse's note, dated 06/28/12 at 8:00 p.m., documented, "...C/O pain to LLE, pain med given..." An accident/incident report, dated 06/28/12 (untimed), documented, "... Resident... (checked) Physically impaired... Type of Incident (checked) Fall (checked) observed... Was person involved seen by a physician? Yes (checked)... Was first aid administered? Yes (checked) If Yes, Type of Care Viscopaste to ST Q 3day... Was person involved taken to a hospital? yes (checked)... By Whom? EMS Date 6/30/12 Time 0830 AM (checked)... Recommended steps to prevent recurrence: Change resident to a 2 person transfer due to decline..." Describe exactly what you observed or heard: (Name deleted) CNA (#3) reported to this nurse that during transfer back to bed from BSC resident had to be lowered to floor due to feet became tangled up, res was tired because had to stand to bee (sic) cleaned up A post falls assessment and root cause investigative report, dated 06/28/12, documented, "...b. Does the resident receive any of the following medications? Anti-psychotics, anti-anxiety/hyponotics, anti-depressants, cardiovascular medications or diuretics? If yes, list these medications and last dosage administered: Paxil 0800... h. Was the resident doing usual or unusual activity? Usual (up) BSC... r. Was the resident wearing appropriate foot wear? No (circled). If no, explain barefoot... s. Did resident have alarm in place? ...no being transferred by staff (not) needed... v. When was the resident last toileted? was getting off BSC Circumstances of Fall: Time of Day 130 (PM) Description of Occurrence: (include location, activity at time of fall, etc.): lowered to floor during transfer from BSC to bed Conclusion of findings: residents feet became tangled during transfer & was tired from standing too long during peri care Interventions instituted: resident currently a 1 person transfer make resident a two person transfer..." An OSDH Incident Report Form, documented, "...Incident Date 06/28/12... Certain Injuries (checked)... Part B Description of Incident. Please include injuries sustained as well as measures taken to protect the resident(s) during investigation. On 06/28/12 at approximately 1330 (1:30 p.m.), (resident) was lowered to the floor by the CNA during care because his legs got tangled up and (resident) felt to weak to stand. (Resident) received skin tear to right forearm - 2 x 0.5 cm and left shin - 4 x 2.5 cm - dressings applied... On 06/29/12, (Resident) began to c/o left knee and ankle pain - no redness, swelling or bruising noted to L knee - small amount of swelling to L ankle... (Name deleted) in house to perform x-ray - results from x-ray - results from x-ray received on 06/30/12 and were inconclusive. ...(Resident) was transferred to (hospital) for eval... Part C (Resident) returned from the (hospital) with a splint to left leg and a [DIAGNOSES REDACTED]. A nurse's note, dated 06/29/12 (untimed), documented, "...Pain to Left ankle + knee from assisted fall... Morphine given per order Resident states pain is okay just hurts to move toes, skin tear to left shin left foot + R forearm + R upper arm... some min swelling noted to left ankle will continue to monitor... @ 1700 (5:00 p.m.) Received order (name deleted) x-ray of Left ankle + left knee, called in will come ASAP in morning..." A nurse's note, dated 06/29/12 (untimed), documented, "... (Name deleted) came did x-rays..." A nurse's note, dated 06/30/12 at 8:30 a.m., documented, "EMS here to transport via ambulance to ER for further eval... 1315 (1:15 p.m.) Returned from hospital, fractured patella new order for immobilizer..." On 08/22/12 at 10:00 a.m., CNA #3 was asked to describe what occurred during the incident on 06/28/12 when the resident was lowered to the floor. She stated, "I was putting the resident on the port-a-potty and then to bed. His feet slid during transfer to the bed." She stated, "I lowered him to the floor." She was asked how the resident received an abrasion to his left shin. She was shown the incident report. She stated, "I guess he hit his leg on the side of the bed." She was asked if she knew the resident required two person physical assistance. She stated she did not. She was asked how she determined the transfer needs of the residents. She stated, "We put numbers in the little slip on the head of the bed. It was a one." She was asked who was responsible for putting the numbers on the bed. She stated, "The DON and the ADON." At 10:15 a.m., a request was made to the ADON for a copy of the facility's transfer policy. She stated, "We are using the bedside assessment." She provided the surveyor with a blank copy of the assessment. She stated, "He has improved and declined and improved and declined. The doctor comes and rounds with us. The doctor's orders and care plan was reviewed. She stated, "Ok. Alright." The residents record was reviewed by the ADON for the bedside assessments. The last assessment, located in the residents clinical record prior to the fall was dated 12/01/11. There were no assessments which documented the resident was a one person assist with transfers. There were no physicians orders which documented the resident was a one person assist with transfers. There was no care plan which documented the resident was a one person assist.

Based on observation, clinical record review, policy and procedure review, and staff interview, it was determined the facility failed to safely transfer three (#1, 4 and #5) of three sampled non weight-bearing residents. This deficient practice resulted in actual harm for resident #1. It had the potential to affect three non weight-bearing residents identified by the facility who were transferred in the last six months. Findings: A policy and procedure, titled Gait Belt Policy and Procedure, documented, "...To assist the resident from sitting to standing grasp the belt at the patient's back and the patient's right or left side and gently lift... Transfer Belt:...Should be used with every transfer when patient is in a weight-bearing or upright posture... Pivot Transfers...Weight-bearing through the patient's legs, during the transfer, will lighten the transfer and help the patient maintain functional strength... Bed to Wheelchair Transfer. When transferring a patient from bed to wheelchair, the patient usually can help by pushing with arms and extending legs...On signal, move patient to standing position from edge of bed with rocking motion..." A policy and procedure titled, Mechanical Lift Policy & Procedures, documented, "...The following will provide a guideline that will indicate the necessity of using the mechanical lift: physical debility, inability to support any weight, morbid obesity..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 11/11/10, documented the resident was severely impaired in cognitive skills for daily decision-making and was totally dependent on two staff for transfers. The assessment also documented the resident did not ambulate and was never moved from a seated to a standing position. A care plan, last updated on 02/10/11, documented the resident was at risk for falls and fractures due to dementia and rigidity during transfers. Approaches to deal with this problem included gentle assistance with activities of daily living and 1-2 person assistance with transfers. The care plan did not include how the resident should be transferred and what devices should be used to transfer the resident. A monthly summary, dated March 2011, documented the resident was bed or chair bound and needed repositioning by staff every two hours. The summary also documented the resident had generalized muscle weakness and had contractures of the arms and legs. A facility accident/incident report form, dated 04/30/11, documented, "... (8:45 p.m.)...called to room by CNAs who were assisting c (with) nightly care. Upon assessment by RN and 2 LPNs noted (right lower extremity) swollen in (upper) thigh outer aspect. Slight swelling below knee, pain c movement & palpation. (No) bruising noted..." A final incident report to the OSDH, dated 05/05/11, documented, "...Relevant resident history: ... requires two CNAs for transfers... is not a fall risk and has not had a fall this year... is non weight-bearing... Summary of the investigation: ... (an x-ray report dated 04/30/11) identifies '... there is an acute fracture deformity of the distal half of the right femur with mild overriding of the fracture fragments'... Interviews and statements reveal that CNAs transfer 1 or 2 assist with a gait belt... (A CNA) interview revealed at times upon transferring, (the resident's) feet drag the ground and following the transfer (on 04/30/11) from her wheelchair to bed, 'noticed her right leg looked a little different and reported it to the nurse'... Staff report (the resident) is a 1 person assist with gait belt use. She weighs approximately 146 pounds but when she becomes rigid or stiff, they utilize 2 staff members for transfers. Although the statements don't address any difficulties with (resident) transfers, it is possible that while being assisted by 2 CNAs on 04/30/11, with the contractures and crossing of her lower extremities,... that transferring and pivoting her and subsequently dragging her feet may have resulted in the 'twist' that correlates with the spiral fracture..." On 09/14/11 at 10:30 a.m., the restorative aide was asked when a gait belt could safely be used to transfer a resident. She stated all residents could be transferred using a gait belt. She stated, "With a two person transfer, you can use a gait belt on any non weight-bearing resident." She was asked when a mechanical lift should be used. She stated, "With a heavy resident, or one that is non weight-bearing." She was asked if she was familiar with the resident. She stated that when she worked with the resident for restorative services, the resident would keep her legs crossed and flexed at the knees and hips. She stated, "She was very resistant to passive range of motion exercises." She was asked if the resident could bear weight on her lower extremities. She stated, "No." She was asked why the mechanical lift was not used for the resident. She stated, "She wasn't that heavy." At 10:40 a.m., the physical therapy assistant was asked if a gait belt could be used to transfer all residents. She stated, "95 percent of the time you can use a gait belt to transfer a resident. All residents newly admitted start out coded to be transferred with a gait belt." She was asked if a gait belt should be used to transfer a resident if the resident could not bear weight and could not pivot. She stated, "No, it shouldn't." At 11:00 a.m., MDS coordinator #1 was asked if the resident could bear weight and pivot. She stated, "At times she could be made to pivot, but it was unpredictable. We could never trust that she could do it." She further stated, "She had contractures of her hips and knees. Sometimes she would pull up her legs spontaneously during a transfer. So then the CNAs would have her suspended by the gait belt." MDS Coordinator #2 stated, "(The resident) could not follow directions. She could not move her own legs and could not pivot." She was asked when a mechanical lift should be used to transfer a resident. She stated, "It depends on size. You should use it on a large, non weight-bearing resident." At 12:15 p.m., the physical therapist stated, "A gait belt should not be used if the resident cannot bear any weight, and cannot pivot." He further stated, "Weight is not the only factor in determining when to use a Hoyer lift. Each resident needs to be assessed for appropriate and safe transfers. A resident may be too frail for a gait belt." 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 03/14/11, documented for approaches, "...Transfer per limited lift code..." The care plan did not document what type of assistance or extent of assistance the resident required for transfers. A quarterly assessment, dated 06/10/11, documented the resident was moderately impaired in cognitive status for daily decision making, required extensive assistance of two persons for transfers and did not ambulate. On 09/14/11 at 10:10 a.m., resident #4 was observed as she was transferred from her bed to her wheelchair by CNA #1 and CNA #2. Both CNAs assisted the resident to a sitting position on the side of the bed. The CNAs then applied a gait belt around the resident's waist. The CNAs then picked the resident up by one hand on the gait belt and one arm underneath the resident's arm. The resident was lifted in the air and off of her feet. The resident was non weight bearing. The resident was carried several steps to the wheelchair and lifted up and into the chair. Not at any time did the resident's feet touch the floor. 3. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 12/17/10, documented, "Fall...3/10/11 Unable to ambulate, can stand for transfers, require 2 persons assist... ADLs...Transfer per limited lift code..." The care plan did not document the current level of assistance the resident required for transfers, as the resident was non weight bearing and could no longer stand for transfers. A quarterly assessment, dated 06/08/11, documented the resident was moderately impaired in cognitive skills for daily decision making, was totally dependent for transfers which required the assist of two persons, and was unable to ambulate. On 09/14/11 at 12:05 p.m., resident #5 was observed as she was transferred from her bed to her wheelchair by CNA #3 and CNA #4. Both CNAs assisted the resident to a sitting position on the side of the bed. The CNAs then applied a gait belt around the resident's waist. With each CNA with an arm under the resident's arms and a hand on the gait belt, the resident was lifted off the bed. The resident was non weight bearing and had her knees bent. The resident was carried several feet to the wheelchair. The resident was low to the ground and her feet were sweeping the floor. The CNAs had to lift the resident up high to enable them to place the resident in the wheelchair. At 2:30 p.m., the corporate nurse was asked if residents should be carried by a gait belt during transfers. She stated, "No." She stated the resident should never be carried by a gait belt.