Every finding on record at Whitney Rehabilitation Care Center

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who had established advanced directives, the facility failed to ensure a resident with the status of do not perform any life sustaining cardiopulmonary resuscitation (DNR) was honored and cardiopulmonary resuscitation (CPR) was not initiated on [DATE] in accordance with the care plan. The findings include: Resident #1's diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), asthma, depression, anxiety, anemia, muscle weakness, dementia with behavioral disturbance and hallucinations. A physician's active order as of [DATE] directed Do Not Resuscitate (DNR), Do Not Intubate (DNI) and Registered Nurse may Pronounce (RNP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living. The Resident Care Plan dated [DATE] identified Resident #1 and the authorized representative had elected to have a code status of DNR, DNI, RNP. Interventions directed code status options will be presented and explained to the resident and/or family recognized representative, in the event of a cardiopulmonary arrest or emergency, resident will not be intubated, and CPR and/or defibrillation via automated external defibrillator (AED) will not be administered in the event of a cardiopulmonary arrest or emergency. The nurse's note dated [DATE] at 7:17 PM identified the Nursing Supervisor, Registered Nurse (RN) #1, was called by a nurse aide, who reported Resident #1 was foaming at the mouth and RN #1 observed Resident #1 foaming at the mouth and holding excessive secretions in his/her mouth and throat. The note indicated Resident #1 was suctioned several times of a good amount of secretions. The nurse's note dated [DATE] at 7:42 PM identified the family and Advanced Practice Registered Nurse (APRN) were notified. The nurse's note dated [DATE] at 11:33 PM identified 911 was called and Resident #1 was transferred to the hospital. Interview with Resident #1's Responsible Party, Person #1, on [DATE] at 9:38 AM identified on [DATE] he/she received a call from the 3-11PM Nursing Supervisor, RN #1, stating Resident #1 had passed away then after hanging up, two (2) to three (3) hours later he/she received a second call from RN #1 stating Resident #1 had a pulse. Person #1 identified Resident #1 had an order for a DNR code status, and he/she believed on [DATE] the facility performed CPR. Interview with RN #1 on [DATE] at 1:03 PM identified on [DATE] she observed Resident #1 was not moving and receiving CPR by facility staff. RN #1 explained she went to verify Resident #1's code status and discovered Resident #1 had a DNR order and when she went back into Resident #1's room, Resident #1 had a pulse. RN #1 indicated CPR should not have been administered when Resident #1 was unresponsive as he/she had an advanced directive that directed DNR. Interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on [DATE] at 2:26 PM identified on [DATE], Resident #1 was found to be in respiratory distress that initially required suctioning of secretions from the airway. The ADON and DON identified Resident #1 had a physician's order that directed the code status as DNR. The ADON and DON identified all staff are responsible for ensuring each resident's code status was honored and Resident #1 should not have had CPR performed on him/her on [DATE]. Review of the facility policy titled Advanced Directives, dated [DATE], directed, in part, the facility will ensure that a resident's choice regarding advanced directives (code status) will be honored in accordance with state law and facility policy. Additionally, the policy directed, in part, the facility encourages the right of residents to prepare an advanced directive declaration or statement that clearly expresses their wishes regarding the use of life-prolonging measures and the declaration may designate another person to make treatment decisions in the event that the resident becomes incapable of communicating his/her choices or wishes. Although attempted, an interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1 was unsuccessful.

Based on interviews, review of clinical records, and facility policy for 1 of 5 sampled residents, (Resident #5) reviewed for accidents, the facility failed to provide adequate supervision with toileting resulting in a fall with major injury. The findings include:Resident #5's diagnoses included fracture of unspecified part of neck of right femur, difficulty in walking, weakness, reduced mobility, and need for assistance with personal care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment, required partial/moderate assistance with toileting hygiene and supervising/touching assistance with toilet transfers. A Morse Fall scale assessment dated [DATE] at 7:24 PM identified Resident #5 was at a high risk for falling. A Physical Therapy evaluation and plan of treatment evaluation dated 2/25/26 identified Resident #5 was an assist of two for transfers as his/her baseline. A Physician order dated 2/25/26 and in effect through 3/14/26 for Resident #5 directed an assist of two with toileting. The Resident Care Plan (RCP) dated 3/5/26 identified Resident #5 required assistance with activities of daily living related to decreased mobility and weakness. Interventions included an assist of one with washing, bathing, dressing, and toileting. Review of the facilities Certified Nurse Assistant resident assignment documented in effect on 3/14/26 for Resident #5 identified he/she was a fall risk and an assist of two for toileting. A Registered Nurse (RN) assessment note dated 3/14/26 at 10:41 AM for Resident #5 identified that while seated on toilet, resident suddenly got up, started to fall, and was lowered to the floor by the aide. Resident #5 stated I got up, my right leg gave out, and I lost balance. The note indicated that Resident #5 did not communicate or ask for help prior to the incident, had shoes on, denied hitting his/her head, and hit his/her right hip on grab bar during the loss of balance. The note indicated Resident #5 complained of right hip pain and had limited range of motion to the right lower extremity (right leg). The Advanced Practice Registered Nurse (APRN) was notified and an order for x-ray of right hip was obtained. A Situation, Background, Assessment, and Recommendation (SBAR) communication form and progress note dated 3/15/26 at 12:27 AM for Resident #5 identified that unilateral hip/pelvis x-ray results identified an acute right subcapital (beneath the head of long bone) hip fracture. The APRN was notified and a new order to transfer to the emergency room for evaluation and treatment was obtained.A RN assessment note dated 3/15/26 at 1:15 AM for Resident #5 identified that he/she was transferred to the emergency room. Review of the State Agency Reportable Event summary report dated 3/17/26 at 12:00 AM identified Resident #5 sustained a right femoral neck fracture after being lowered to the floor by his/her Nurse Aide (NA). Resident #5 was sitting on the toilet with the NA near him/her in the bathroom. Resident #5 suddenly stood up, losing his/her balance and bumped his/her right hip on the bar. The NA immediately lowered him/her to the floor. The RN supervisor was notified and assessed the resident. Resident #5 was noted to have right hip pain, and the right leg was externally (limb turning outward away from midline of body) rotated. Per NA, Resident #5 did not hit his/her head. APRN was notified and placed an order to have a right hip x-ray done at the facility. X-ray results showed a right femoral neck fracture. APRN was notified and placed orders to send to the ER for evaluation. Responsible party was notified and in agreement with plan to transfer to hospital. Review of the Hospital transfer handoff document dated 3/19/26 for Resident #5 identified a right hip imaging result of impacted transcervical right femoral neck fracture (fractured neck of femur is driven into the head). Interview with the DON on 5/5/26 at 9:29 AM identified that if a resident has a physician order for two persons assist for toileting then there should be two staff members present to help with getting the resident to the bathroom, onto and off the toilet, and back to their chair or bed. The DON indicated that after she was notified of the fall with major injury for Resident #5, she notified the state agency and started an investigation. The DNS indicated that NA #4 identified that she was the only staff member present when transferring Resident #5 to the bathroom and that while Resident #5 was on the toilet, he/she stood up and lost balance. NA #4 indicated to the DON that she was behind the resident after he/she lost balance and assisted the resident slowly to the floor, preventing him/her from falling to the floor. The DON indicated that their investigation found that NA #4 failed to review Resident #5's care card resulting in NA #4 not following the physicians order and improperly assisting him/her while toileting. The DON indicated that following the investigation, the facility initiated a QAPI and plan of corrective action which included in-servicing all staff on transfers and conducting random audits to ensure physician orders and resident care cards were followed. Interview and clinical record review with the facility Medical Director (MD) on 5/5/26 at 11:07 AM identified that Resident #5 had orders on 3/14/26 for an assist of two while toileting and that there should have been two staff present at the time Resident #5 was on the toilet and received the major injury. The MD indicated that Resident #5's diagnosis of a impacted transcervical right femoral neck fracture would most likely be due to a traumatic fall or direct blow to the area if the individual did not have osteoporosis (decreased density and strength in bones), which Resident #5 did not have. Additionally, the MD indicated that a individual would not typically receive that type of fracture while being assisted to the floor. Interview with the Director of Rehabilitation on 5/6/26 at 9:03 AM that Resident #5 was evaluated by Physical Therapy on 2/25/26 and was assessed as an assist of two for all transfers including toileting. He indicated that the expectation for residents who are an assist of two with toileting is that two facility staff assist the resident to the bathroom, onto the toilet, off the toilet, and are both present during the entire duration. Interview with NA #3 on 5/6/26 at 10:43 AM identified that she was working on 3/14/26 on the unit when Resident #5 had the fall with major injury. She indicated that she was not assigned to Resident #5 and was not present in the bathroom when the fall with major injury occurred. NA #3 indicated that when a resident is an assist of two for toileting, the assigned NA should not perform the transfer without the assistance of another staff member. Additionally, NA #3 indicated she was not asked to help transfer Resident #5 by NA #4 and should have been. Interview and clinical record review on 5/6/26 at 12:45 PM with the Hospital Radiologist identified that for the impacted right femoral neck fracture Resident #5 received 3/14/26 there would need to be some kind of impact to the area. Additionally, he indicated Resident #5's fracture is a very common type of fracture in falls for the elderly. Multiple attempts to contact NA #4 were unsuccessful. NA #4 is no longer employed by the facility. Review of the facilities Two Person Transfer policy, not dated, directed in part that when able transfer to the strongest side of the resident, both persons use gait/transfer belts as applicable, explain procedure and allow resident to assist with transfer as much as able, first person stands in front of resident assisting pivot or steps for transfer, and second person stands behind resident as needed for extra assistance. Review of the facilities Plan of Correction (POC) for not transferring and toileting per Medical Director (MD) orders identified that a resident who was transferred and toileted incorrectly sustained a right hip fracture. Any resident who has transfer and toileting orders of assist of two have the potential to be affected by the alleged deficient practice. Licensed and certified staff will be educated on transferring and toileting the residents what are assist of two per the MD orders, care plan, and NA care card. Random audits will be done weekly for four weeks, then monthly to observe that residents who are assist of two for transferring and toileting are transferred and toileted correctly. Findings and trends will be reported to QA committee with additional recommendations as necessary or until substantial compliance is met. Licensed and certified staff were in serviced between 3/16/26 and 4/3/26 with 155 staff signatures. The POC was reviewed at the facility QAPI meeting on 4/22/26 and identified that audits were completed weekly for four weeks and were in progress for monthly audits with no negative findings observed.

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 sampled residents (Resident #42, Resident #133, and Resident #159) reviewed for discharge, the facility failed to develop a discharge plan of care. The findings include: 1. Resident #42 's diagnoses included a non-displaced fracture of lateral malleolus of the right fibula, chronic myeloid leukemia, and anxiety disorder. The Resident Care Plan dated 2/16/26 identified Resident # 42 required assistance with Activities of Daily Living (ADLs) due to decreased mobility related to weakness. Interventions included providing the assistance from one staff with personal hygiene, bed mobility, toileting, transfers using a walker, ambulation, bathing, and dressing. The Resident Care plan failed to identify a discharge plan to return to the community. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 had a Brief Interview for Mental Status score of 15 indicating intact cognition and required total assistance with dressing and toileting, substantial assistance with bed mobility, transfers and ambulation, and independent with eating. The MDS further identified Resident #42 had an active discharge plan with a plan to return to the community and a referral was made to the local contact agency. Review of the physician, Advanced Practice Nurse Practitioner (APRN) notes dated 1/16/26 to 4/24/26 failed to identify a discharge plan. A nurse's note dated 5/4/26 at 7:04 AM identified Resident #42 was to be discharged home today. Review of the physician's orders on 5/6/26 failed to direct an order to discharge to the community. 2. Resident #133's diagnosis included Alzheimer's disease, morbid obesity and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #133 had a Brief Interview for Mental Status score of 13 indicating intact cognition, and was independent with hygiene, dressing, toileting, bed mobility, transfers and ambulation. The MDS further identified Resident #133 had an active discharge plan with a plan to return to the community and a referral was made to the local contact agency. The RCP dated 4/29/26 identified Resident #133 wanted to go home and had tried to leave the facility on several occasions, refused to wear a wander guard device, and went down the stairwell. Interventions included check the wander guard device for placement every 2 hours, staff to accompany the resident to another floor and return him/her to the unit, placing on 1:1 observation, changing the stair codes, social service to follow up, psych services as needed, add to the wanderer/elopement list, and reeducate the resident to notify staff when leaving the floor. The RCP failed to identify a discharge plan. Interview with Social Worker (SW) #1 on 5/6/26 at 12:40 PM identified that a discharge care plan is not always developed for every resident unless concerns or barriers to discharge are identified. Interview with the Director of Nursing (DON) on 5/6/26 at 1:25 PM identified she could not locate discharge care plans for Resident #42 and Resident #133. The DON stated she would expect a discharge care plan to be developed at the first care plan meeting, so the interdisciplinary team is aware of the resident's specific needs. The DON identified the Social Services Department was responsible for developing the discharge care plan and could not explain why it had not been completed. Review of facility Care Planning policy not dated, directed in part, for the care plan to be a good working tool, it should reflect the resident's current status. Interim problems, goals, and interventions should be added at any time after the conference if minor changes occur, which alter the care to be provided. Review of facility Discharge/Community Services policy not dated, directed in part, to initiate discharge planning upon admission to the facility. Social Services to coordinate discharge plans with the resident/responsible party. 3. Resident # 159's diagnoses included congestive heart failure, hypertension, and lower back pain. A social work progress note dated 11/13/2025 identified that Resident #159 was participating in therapy with the goal of discharging to the community at his/her prior level of function and social services would assist with discharge planning. The admission MDS assessment dated [DATE] identified Resident # 159 had a Brief interview for Mental Status score of 15 indicating intact cognition and required total assistance with toileting hygiene, lower body dressing, putting on and taking off footwear, and personal hygiene, substantial assistance with showering, and set-up assistance for oral hygiene and eating. The MDS further identified Resident #159 had an active discharge plan with a plan to return to the community. The RCP dated 11/18/2025 identified Resident #159 required assistance of one staff for ADLs to decreased mobility related to pain, weakness, and spinal stenosis. The RCP failed to identify a discharge plan. Review of the nursing notes from 11/11/25 through 2/10/26 failed to provide documentation to reflect a discharge plan or discharge teaching. The APRN facility Discharge summary dated [DATE] identified Resident #159 was stabilized and cleared for discharge home with services, medications, and a follow-up appointment with the primary care provider within two weeks of discharge. A social work progress note dated 2/11/26 identified that Resident #159 was discharged home with home health services and a follow-up appointment with the primary care provider. Interview with Social Worker (SW) #1 on 5/6/26 at 12:40 PM identified that a discharge care plan is not always developed for every resident unless concerns or barriers to discharge are identified. Interview with the Director of Nursing (DON) on 5/6/26 at 1:25 PM identified she could not locate a discharge care plan for Resident #159. The DON stated she would expect a discharge care plan to be developed at the first care plan meeting, so the interdisciplinary team is aware of the resident's specific needs. The DON identified the Social Services Department was responsible for developing the discharge care plan and could not explain why it had not been completed. Review of facility Care Planning policy not dated, directed in part, for the care plan to be a good working tool, it should reflect the resident's current status. Interim problems, goals, and interventions should be added at any time after the conference if minor changes occur, which alter the care to be provided. Review of facility Discharge/Community Services policy not dated, directed in part, to initiate discharge planning upon admission to the facility. Social Services to coordinate discharge plans with the resident/responsible party.

Based on observations, interviews, clinical record review, and facility policy for 1 of 2 sampled residents (Resident #14) reviewed for urinary catheters, the facility failed to provide a privacy cover for a urinary collection bag. The findings include:Resident #14's diagnoses included retention of urine, presence of urogenital implants and hydronephrosis with renal and ureteral calculous obstruction.The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #14 had a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment and was dependent on staff for toileting hygiene and transfers. Additionally, it identified Resident #14 had an indwelling catheter.The Resident Care Plan (RCP) dated 3/27/26 identified Resident #14 had an indwelling catheter related to retention and obstructive uropathy. Interventions directed to assess intake and output per facility policy, and position catheter bag and tubing below the level of the bladder and away from entrance room door.A physician's order dated 4/14/26 directed to change foley catheter every 4 weeks using a 24 French with 30 cubic centimeters (cc) balloon.Observation on 4/29/26 at 10:00 AM identified Resident #14 was in bed by the door with the urinary collection bag attached to the left side of the bed, fully visible from the hallway, containing 350 milliliters (mL) of yellow urine without the benefit of a privacy cover.Observation on 5/4/26 at 10:28 AM identified Resident #14 was in bed by the door with the urinary collection bag attached to the left side of the bed, fully visible from the hallway, containing 300 milliliters of yellow urine without the benefit of a privacy cover.Interview and observation with Licensed Practical Nurse (LPN) #2 on 5/5/26 at 6:38 AM identified per facility policy urinary collection bags must have a privacy cover. Observation with LPN #2 noted Resident #14 was in bed by the door, with the urinary collection bag attached to the left side of the bed, fully visible from the hallway, containing 300 milliliters of yellow urine without the benefit of a privacy cover. LPN #2 stated Resident #14's urinary collection bag should have had a privacy cover, and it was undignified for Resident #14 not to have one. LPN #2 indicated the facility urinary collection bags typically come with attached privacy covers, but the new supply did not. LPN #2 identified she was unable to locate a privacy cover. Subsequent to surveyor inquiry, LPN #2 moved Resident #14's urinary collection bag to the opposite side of the bed, out of view from the hallway and indicated she would notify her supervisor.Interview and observation with Registered Nurse (RN)# 1 on 5/5/26 at 6:54 AM identified urinary collection bags should always have privacy covers. RN #1 stated it is undignified if urinary collection bags are not covered. RN #1 identified the nurses on the unit are responsible for ensuring urinary collection bags have a privacy cover. RN #1 indicated privacy covers are stored in the supply room located in the basement. Observation of the supply room with RN #1 identified one box containing 3 privacy covers. RN #1 indicated although the facility normally provides urinary collection bags with attached privacy covers it was unacceptable a privacy cover was not present on Resident #14's urinary collection bag.Interview with the Assistant Director of Nurses (ADON) on 5/5/26 7:19 AM identified the facility policy requires that urinary collection bags hang attached to the bed below the level of the resident's bladder with privacy cover. The ADON identified all staff are responsible for ensuring urinary collection bags are covered. The ADON indicated that the supply clerk was recently hired and ordered the wrong type of urinary collection bags. The ADON indicated he would have the supply clerk order the urinary collection bags that come with a privacy cover.Review of facility Catheter Drainage System policy, not dated, directed in part that drainage bags are emptied by nursing personnel every shift and PRN and for staff to explain procedure to residents and provide privacy. Although requested, a catheter privacy bag policy was not provided.

Based on review of the clinical records, facility documentation, and interviews for 2 of 3 residents (Resident #42 and Resident #159) reviewed for discharge, the facility failed to notify the Office of the State Long-Term Care Ombudsman of discharges from the facility. The findings include:1. Resident #42 's diagnoses included a non-displaced fracture of lateral malleolus of the right fibula, chronic myeloid leukemia, and anxiety disorder. The Resident Care Plan dated 2/16/26 identified Resident # 42 required assistance with Activities of Daily Living (ADLs) due to decreased mobility related to weakness. Interventions included providing the assistance from one staff with personal hygiene, bed mobility, toileting, transfers using a walker, ambulation, bathing, and dressing. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 had a Brief Interview for Mental Status score of 15 indicating intact cognition and required total assistance with dressing and toileting, substantial assistance with bed mobility, transfers and ambulation, and independent with eating. The MDS further identified Resident #42 had an active discharge plan with a plan to return to the community and a referral was made to the local contact agency. A nurse's note dated 5/4/26 at 7:04 AM identified Resident #42 discharged home today. Interview with Social Worker #1 on 5/6/26 at 12:40 PM identified she only notifies the Ombudsman for discharges involving Against Medical Advice (AMA) or hospitalization bed-hold issues. SW #1 identified does not notify the Ombudsman when a resident discharges home. Social Worker #1 indicated the Director of Admissions was responsible for notifying the Ombudsman of residents discharged home. Interview with the Director of Admissions on 5/6/26 at 12:45 PM identified she did not notify the Ombudsman on 5/4/26 that Resident #42 was discharged home. The Director of Admissions identified she does not notify the Ombudsman of residents discharged home. The Director of Admissions indicated that if a resident leaves AMA or is transferred to the hospital the Ombudsman is notified. 2.Resident # 159's diagnoses included congestive heart failure, hypertension, and lower back pain. A social work progress noted dated 11/13/25 identified Resident #159 was participating in therapy with the goal for discharge to the community to their prior level of function and social services would assist with discharge plans. The admission MDS assessment dated [DATE] identified Resident # 159 had a Brief interview for Mental Status score of 15 indicating intact cognition and required total assistance with toileting hygiene, lower body dressing, putting on and taking off footwear, and personal hygiene, substantial assistance with showering, and set-up assistance for oral hygiene and eating. The MDS further identified Resident #159 had an active discharge plan with a plan to return to the community. The RCP dated 11/18/2025 identified Resident #159 had decreased mobility related to pain, weakness, and mobility with interventions that directed to provide the assistance of one staff for ADLs. The APRN facility Discharge summary dated [DATE] identified Resident #159 was stabilized and cleared for discharge home with services, medications, and a follow-up appointment with the primary care provider within two weeks of discharge. A social work progress note dated 2/11/26 identified that Resident #159 was discharged home with home health services and a follow-up appointment with the primary care provider. Interview with Social Worker #1 on 5/6/26 at 12:40 PM identified the Director of Admissions is responsible for notifying the Ombudsman. Interview with the Director of Admissions on 5/6/26 at 12:45 PM identified she did not notify the Ombudsman on 2/10/26 that Resident #159 was discharged home. The Director of Admissions identified she does not notify the Ombudsman of residents discharged home. The Director of Admissions indicated that if a resident leaves AMA or is transferred to the hospital the Ombudsman is notified. The facility Discharge/Community Services Policy not dated, directed in part, initiate discharge planning upon admission to the facility and Social Services to coordinate discharge plans with the resident/responsible party. The policy failed to direct Ombudsman notifications.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #161) reviewed for respiratory care, the facility failed to develop a baseline care plan for respiratory care including oxygen use and anxiety. The findings include: Resident #161 was readmitted to the facility on [DATE] diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), anxiety disorder and polysubstance abuse. An admission physician's note dated 4/21/26 indicated Resident #161's chief complaint upon admission was shortness of breath and flu-like symptoms with acute on chronic respiratory failure, a history of end stage COPD on chronic prednisone and 2 liters of oxygen. Resident #161 presented with shortness of breath and flu-like symptoms and a history of aspiration pneumonia. During a recent hospitalization in January 2026, the resident developed suspected pulmonary edema with right ventricular strain and was admitted to the Intensive Care Unit (ICU) for acute hypoxemic hypercapnic respiratory failure requiring bilevel positive airway pressure (BiPAP) support. The clinical course was complicated by COPD exacerbation, aspiration pneumonia and a small acute right upper lobe pulmonary embolism, requiring escalation to 5 liters of oxygen and aggressive diuresis with intravenous Lasix followed by intravenous Bumex for pulmonary edema management. The COPD exacerbation was treated with Solumedrol and prednisone taper and the aspiration pneumonia with antibiotics.Physician's orders, in effect on 4/21/26, directed continuous oxygen at 2 liters/minute via nasal cannula to keep oxygen saturation greater than 90% every shift.The baseline care plan dated 4/21/26 failed to identify the resident's recent respiratory failure with hypoxia, COPD or oxygen use. It also failed to identify respiratory monitoring including monitoring oxygen saturations and monitoring for anxiety. The admission MDS dated [DATE] identified Resident #161 had intact cognition and required continuous oxygen.Observation on 4/29/26 at 2:21 PM identified Resident #161 with eyes closed, head tilted back with deep breaths followed by 5-10 second periods of apnea. Nursing staff notified and woke Resident #161. Resident #161 was alert and oriented and verbalized concerns with anxiety and medications for anxiety. Resident #161 had oxygen on via nasal canula at 2 liters/minuteInterview with RN #2 (MDS Coordinator) on 5/5/26 at 1:59 PM indicated the baseline care plan was started on 4/21/26 without a plan for respiratory care, oxygen use or anxiety. RN #2 identified respiratory care, oxygen use and anxiety should be in the baseline care plan. RN #2 further indicated the baseline care plan is begun by the supervisor or admitting nurse and the comprehensive care plan is done by the MDS Coordinator. Interview and clinical record review with DNS and ADNS on 5/5/26 at 2:13 PM indicated that the supervisor is responsible for the baseline care plan and it was usually done within 24 hours. The DNS further indicated that there should be a care plan for respiratory care, oxygen use and anxiety. The DNS and ADNS indicated that the clinical record failed to reflect documentation of a baseline care plan for respiratory care, oxygen use or anxiety. The DNS and ADNS were unable to explain why the baseline care plan for respiratory care, oxygen use or anxiety was not completed.Review of the care planning policy directed upon admission, a brief interim plan shall be established to guide care givers until the full care plan was developed. This interim plan should include any problem and key approaches from each department involved in the resident's care. The plan is documented on the admission worksheet from the interdisciplinary team members. In order for the care plan to be a good working tool, it should reflect the residents' current status, interim problems, goals and interventions should be added at any time after the conference if minor changes occur which alter the care provided.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #3 and 126) reviewed for range of motion and positioning, for Resident #3, the facility failed to obtain a physician's order for a splinting device and failed to follow up on splinting device recommendations and for Resident #126 who had a contracture, the facility failed to apply palm guards to both hands per OT recommendations and physician's orders. The findings include:1. Resident #3 had diagnoses that included primary osteoarthritis, disorders of bone density and structure, and muscle weakness.The quarterly MDS dated [DATE] identified Resident #3 had severe cognitive impairment, was totally dependent on staff for all activities of daily living (ADL's) including eating, dressing and personal hygiene and received occupational and physical therapy at least 15 minutes a day on one or more days in the past 7 days. The Occupational Therapy (OT) Discharge Summary signed by OT #2 on 4/22/26 at 1:27 PM recommended that Resident #3 continue wearing a left palm guard and staff to pursue fitting of left resting hand splint.Observation on 4/29/26 at 10:35 AM and 5/4/25 at 10:49 AM identified Resident #3 with a palm guard on left hand. The care plan dated 5/1/26 identified Resident #3 required assistance with ADL's and had decreased mobility. Interview and record review with the Director of Rehabilitation (OT #1) on 5/5/26 at 11:38 AM identified it was facility policy for residents to be evaluated by therapy upon admission, and, if needed, skilled therapy services were initiated. OT #1 further identified that upon discharge from therapy services, the therapist writes orders reflecting the discharge summary recommendations, which are then transcribed by nursing. Review of Resident #3's clinical record with OT #1 identified that the resident received therapy services from 3/3/26 to 4/22/26. The discharge summary recommendations included continuation of the left palm guard and pursuit of a fitting for a resting left hand splint. However, further review with OT #1 failed to reflect that a physician's order for the left hand palm guard had been obtained, and there was no documentation that a fitting for a resting left hand splint had been set up. OT #1 indicated that the physician's order should have been entered at the time of discharge from therapy services on 4/22/26 and added that he would need to check with OT #2 regarding the status of the resting left hand splint fitting, since it requires an outside vendor.Review of physician's order failed to identify the recommendation for a resting left hand splint fitting or the palm guard. Interview and documentation review with OT #2 on 5/5/26 at 12:12 PM identified that the splint vendor was initially contacted on 4/15/26 via text message to perform a splint fitting for Resident #3 and was scheduled for 4/23/26, however, the vendor cancelled that appointment on 4/23/26. OT #2 stated the vendor was not contacted to reschedule until surveyor's inquiry on 5/5/26 (12 days later), and the fitting was rescheduled for 5/7/26. OT #1 was unable to explain why there had been no prior follow up. OT #2 identified that there should have been a physician's order for Resident #3's palm guard and that she would be entering that order. Subsequent to surveyor inquiry a physician's order dated 5/5/26 directed palm guard to the left hand, on after morning care, off after evening care and assess skin integrity every shift. Additionally, the nurse aide Resident Assignment sheet for Resident #3 dated 5/5/26 directed to apply left hand palm guard with morning care and take off with evening care. Review of the Splinting Policy directed that nursing staff was to follow therapeutic interventions including splinting and wearing schedule as indicated by therapy, nursing staff to document splinting application and notify rehabilitation of changes in resident condition regarding splinting (poor tolerance, increased or decreased range of motion in the joint, redness, change in edema).Review of the Therapy Orders Policy directed the purpose was to obtain accurate orders for therapy evaluation and treatment procedures to ensure services and treatments established in the plan of care or developed during the course of treatment will be accurately reflected in the medical record. Additionally, therapy orders will be entered by a therapist in the facility Electronic Medical Record upon completion of evaluation.2. Resident #126 diagnoses included weakness and unspecified dementia.The quarterly MDS dated [DATE] identified Resident #126 had severely impaired cognition and was totally dependent on staff for all activities of daily living including eating, dressing and personal hygiene. Additionally, the MDS identified Resident #126 had impairment of range of motion to both sides of the upper extremities (shoulder, elbow, wrist, hand) and failed to identify Resident #126 rejected care.The care plan dated 3/11/26 identified Resident #126 had actual alteration to skin integrity with potential for further alteration. Interventions included right hand palm pillow splint and geri-sleeves on at all times and treatments as ordered. Review of the Occupational Therapy Treatment Encounter Note dated 3/25/26 identified Resident #126 had a discharge assessment completed with instruction for daily wear of the right palm guard and left hand orthotic carrot. Resident #126 was compliant with treatment despite moderate cognitive impairment.The CNA Resident Assignment Card dated 3/31/26 directed for the right palm guard to be on at all times, removed for hand hygiene and left palm carrot to be applied after morning care and removed after hour of sleep care with photographs instructing proper placement of splints.Review of the April 2026 monthly physician's orders (original date 9/2/25) directed a right palm pillow to be on at all times, remove for hand hygiene and skin checks.A physician's order dated 4/9/26 directed left palm carrot to be on with morning care and removed at hour of sleep, check for skin. Observation on 4/29/26 at 12:05 PM identified Resident #126 sitting in the common area without the benefit of the ordered right palm pillow or left palm carrot. Resident #126's fingers were curled inward into fists.Observation on 5/4/26 at 9:40 AM identified Resident #126 sitting in common area without the benefit of the ordered right palm pillow or left palm carrot. Resident #126's fingers were curled inward into fists. Observation and interview with NA #1 on 5/4/26 at 12:05 PM identified Resident #126 was without the benefit of the ordered splinting devices to the right and left hands, fingers were curled inward into fists. NA #1 identified she was the regular nurse aide for Resident #126, and any special device instructions pertaining to care would be found in the care card book at the nurses station. Review of Resident #126's care card with NA #1 identified the resident should have a splinting carrot in left hand and a splinting palm pillow in the right hand. NA #1 indicated the therapist or the aide was responsible for application. Subsequent to Resident #126's care card review, NA #1 identified she had applied the splinting carrot, but the resident must have taken it out. A search for the left-hand splinting carrot by NA #1 identified it was in the closed nightstand drawer. NA #1 identified Resident #126 sometimes had another round splint in his/her right hand, but could not identify why she did not apply it.Subsequent to surveyor inquiry NA #1 applied the splinting carrot to Resident #126's left hand, by gently slowly uncurling the residents fingers, which were in a tight fist, fingers pressed into the palm. NA #1 indicated the resident will remove it by the time you come back.Interview with the Director of Rehabilitation, OT #1 on 5/4/26 at 12:25 PM identified splinting orders were provided by therapy after treatment, with the nursing department responsible for application and removal per orders. Review of Resident #126 physician's order with OT #1 identified the resident had 2 splinting devices; a right palm pillow to be on at all times and a left hand carrot to be worn in the morning, and off in the evening. Additionally, OT #1 identified failure to apply the splints could lead to skin break down, maceration and ultimately increase in contractures.Observation on 5/4/26 at 1:52 PM identified Resident #126 sitting in common area without the benefit of the right hand splint.Observation and interview with NA #2 on 5/6/26 at 9:06 AM identified Resident #126 fully dressed, in the process of being assisted with his/her meal in the dining area by NA #2, without the benefit of the left or right hand splints in place. NA #2 stated that the unit manager already brought to her attention that Resident #126 should have hand splints in place, she reported that she would apply the splints after the meal, adding there was a delay in her applying them because it is difficult due to the resident's contractures.Review of the Splinting Policy directed that nursing staff was to follow therapeutic interventions including splinting and wearing schedule as indicated by therapy, nursing staff to document splinting application and notify rehabilitation of changes in resident condition regarding splinting (poor tolerance, increased or decreased range of motion in the joint, redness, change in edema).

Based on observations, interviews review of clinical records and policy for 1 of 3 sampled residents (Resident #59) reviewed for respiratory care, the facility failed to ensure oxygen administration was set according to the physician order. The findings include: Resident #59 diagnoses included Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, and emphysema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had a Brief Interview of Mental Status score of 14, indicating the resident was cognitively intact. The MDS also identified that the resident required set-up, or clean-up assistance with oral hygiene, was dependent with personal hygiene, and required substantial/maximal assistance with transfers. The MDS also identified that Resident #59 experienced shortness of breath or trouble breathing when lying flat and required supplemental oxygen while he/she was a resident within the last 14 days of the assessment date. The Resident Care Plan (RCP) dated 5/6/26 identified Resident #59 had altered respiratory status/difficulty breathing related to COPD/Emphysema (a progressive, chronic lung disease making it difficult to breathe) with chronic oxygen use. Interventions included for staff to observe for signs and symptoms of respiratory distress and report them to the MD as needed. The RCP also identified that nursing staff administer oxygen as ordered, and document in the resident's medication administration record (MAR), or treatment administration record (TAR).A physician's order dated 5/6/26 directed to administer continuous oxygen at 3 liters per minute via nasal canula to keep oxygen saturation level greater than 90 percent.Observation on 4/29/26 at 11:15 AM, at 11:18 AM, and 11:54 AM identified Resident #59 sitting in his/her bed, with the head of bed (HOB) elevated and oxygen being administered via nasal cannula from an oxygen concentrator at 4 liters per minute (despite physician orders directing oxygen at 3 liters per minute). Interview and observation with Licensed Practical Nurse (LPN) #5 at 11:56 AM identified that the physician order for supplemental oxygen was for 3 liters per minute, and that the policy for checking oxygen administration settings was that the resident's on continuous oxygen, and the staff check his/her oxygen saturation, and it was 96-97 percent earlier that morning. Observation of the clinical record identified that the resident's oxygen saturation was documented on 4/29/26 as 96% and was documented as 97% by LPN #5 on 5/6/26. LPN #5 also identified that all staff should check the settings for the oxygen concentrator to make sure they reflect the orders placed by the physician, but it's the nurse's responsibility to change the oxygen administration settings on the oxygen concentrator. LPN #5 also indicated that she checked Resident #59's oxygen administration setting earlier this morning prior to surveyor interview. LPN #5 identified that Resident #59 was lying in bed wearing a nasal canula while having his/her oxygen administration was set at 4 liters per minute and stated the concentrator should be set at 3 liters per minute. The oxygen concentrator was observed behind Resident #59's bed, out of his/her reach, with the front of the concentrator that housed the control settings facing away from the patient towards the back wall of the room. LPN #5 indicated she wasn't sure who increased the resident's oxygen administration setting to 4 liters per minute, and why it wasn't set at 3 liters per minute. Interview with the Unit Manager (RN #5) on 5/6/26 at 12:05 PM identified the policy for supplemental oxygen administration was dependent on the physician's order, which would direct how much oxygen to administer, and how frequently it should be administered. RN #5 also identified that it's everyone's responsibility for checking residents' oxygen administration settings, although it's the nurses who can change the oxygen administration settings on the oxygen concentrator. RN# 5 identified that since the physician's orders directed staff to administer Resident #59's at 3 liters per minute, then the resident's oxygen administration setting should be set at 4 liters per minute. Interview with the ADNS on 5/6/26 at 12:25 PM identified that the policy for oxygen administration was dependent on the physician's order to direct how much oxygen was administered to the residents and how frequently the residents received supplemental oxygen. The ADNS further identified that all facility staff should check the settings on resident's supplemental oxygen concentrators, but nursing staff was responsible to change the oxygen settings if they're not correct. The ADNS also identified that he observed Resident #59's physician's orders directed staff to administer supplemental oxygen to the resident at 3 liters per minute, and indicated that based on those orders, the nursing staff should have administered Resident #59's supplemental oxygen at 3 liters per minute instead of 4 liters per minute as the oxygen was set. Review of the facility policy for Oxygen Administration directs, in part for staff to place the patient on a nasal cannula at 2 liters per minute unless otherwise instructed by the physician.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #36) reviewed for Hospice and End of Life, the facility failed manage the resident's pain according to professional standards. The findings include:Resident #36 was admitted to the facility in November 2020. Diagnoses included Alzheimer's Disease, anxiety disorder, and dementia with agitation.The quarterly MDS dated [DATE] identified Resident #36 had severely impaired cognition, required total assistance with all care, had impairment of range of motion of the upper extremity on one side, was at risk to develop a pressure ulcer/injury, had no current pressure ulcers, and had no reports of pain. The care plan dated 2/4/26 identified the resident was at risk for pain and was on hospice care due to progressive decline. Interventions included assessing, treating, and documenting pain every shift and as needed, identifying the cause of pain and treat accordingly, administering pain medications as ordered, meet/anticipate needs, notify the hospice company with a change in condition, and observe for signs and symptoms of pain/discomfort/anxiety and report/treat as ordered. The care plan also identified Resident #36 had a left-hand contracture with splinting. Interventions included to apply a resting left hand splint during morning care and off at evening care. The care plan also identified that the resident had the potential for alteration in skin integrity related to decreased mobility and incontinence which was updated on 2/25/26 to include that MASD on the gluteal cleft had deteriorated to an unstageable pressure ulcer to the coccyx. Interventions included an air mattress, provide incontinent care 4 times per shift, pressure reducing cushion to chair and weekly skin checks. Hospice care interventions included to notify the Hospice Care Company with changes in condition and observe for signs and symptoms of pain/discomfort/anxiety and report/treat as ordered.A wound care note dated 4/29/26, written by RN #3, identified the resident denied pain. Review of the May 2026 monthly physician's orders directed to administer Acetaminophen 650 mg every 6 hours as needed (prn) for temperature greater than 101 F or pain, directed to administer Morphine Sulfate (pain medication) 5 mg every 3 hours prn for shortness of breath and directed apply a left palm guard following morning care and remove after evening care; check the skin for any issues daily.Review of the May 2026 MAR dated 5/1/26 - 5/6/26 identified no documented reports of pain. Further, the MAR identified Morphine Sulfate 5mg was administered on 5/4/26 at 1:39 PM.Observation on 5/4/26 at 2:05 PM of RN #3 performing sacral wound care identified Resident #36 was on his/her side in bed, appeared tense, hands in fists, and had occasional labored breathing (deep inspirations and expirations). RN #3 was not observed to explain the procedure to the resident and was not observed to converse with the resident during the wound care. Interview with the Wound Nurse, RN #3, on 5/6/26 at 10:50 AM, identified Resident #36 exhibits pain during wound care. Interview with NA #5 on 5/5/26 at 1:30 PM identified Resident #36 has occasional grimacing when he/she is put in bed. NA #5 indicated reports Resident #36's pain to everybody.Interview with LPN #5 on 5/5/26 at 1:35 PM identified the resident is placed in bed in the afternoon to offload pressure to his/her sacral wound. LPN #5 reported Resident #36 shows signs of discomfort during transfers and when the palm guard is placed. Although RN #3, LPN #5 and NA #5 identified in interviews that Resident #36 exhibits pain when being put in bed (grimacing), during transfers, when the palm guard is placed, and when wound care is performed, the clinical record lacked documentation of such, including the administration of pain medications with the exception of the Morphine Sulfate administration on 5/4/26. Subsequent to surveyor inquiry, the updated care plan dated 5/6/26 included interventions to medicate for pain as needed prior to wound dressing changes. Review of the Pain Assessment Policy Item 3 noted to observe for non-verbal indicators of pain and Item 4 noted to provide for a pain intervention. Review of the Care Planning Policy Item 4 notes: In order for the care plan to be a good working tool, it should reflect the patient's current status. Interim problems, goals and interventions should be added at any time after the conference if minor changes occur which alter the care provided. These interim notes can be completed by any team member and should not be considered the sole responsibility of the RCC.Review of the wound care policy identified wound care is provided by a licensed nurse to any resident with a physician's order. The procedure included to explain the procedure to the resident.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #52) the facility failed to ensure hand hygiene was performed after providing personal care and failed to appropriately handle soiled linens. The findings include: Resident #52 had a diagnosis of dementia without behavioral disturbance. The nurse aide care card dated 2/2/26 identified Resident #52 required the assistance of 1 person for bathroom use. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #52 had severe cognitive impairment and required total assistance for toileting hygiene and personal hygiene. The Resident Care Plan dated 5/5/2026 identified the potential for alteration in skin integrity with an intervention for incontinent care/toileting 4 times per shift and as needed. Observation on 5/4/2026 at 10:40 am identified NA #8 exit Resident #52's bathroom with gloves on after providing personal care to the resident. NA #8 was noted to place soiled linens (towels, clothing) on the floor at Resident #52's bedside. NA #8 continued to touch the closet door, retrieved items from the nightstand, and touched the room door handle, all without the benefit or removing gloves, and washing hands. NA #8 also placed Resident #52's wig on the resident's head with the same soiled gloves in place. NA #8 then picked up the linens and discarded them in containers located outside of the room and then removed her gloves and washed her hands. Interview with NA #8 at 10:45 am on 5/4/2026 identified that she had assisted the resident with toileting hygiene in the bathroom and had not removed her gloves after assisting the resident in the bathroom. She noted that soiled linens should not be placed on the floor but should be placed directly in the receptacles in the corridor. NA #8 further noted that she should have removed the soiled gloves and washed her hands prior to touching on the closet, the door and placing Resident #52' wig. Interview with the Infection Preventionist (RN #4) on 5/6/2026 9:45 am identified that gloves should be removed after performing personal care and handling soiled linens. She also noted that clean surfaces should not be touched with soiled gloves and linens should not be placed on the floor but in the bins provided. She further noted that hand hygiene should be performed after providing personal care. Interview with DON 5/6/2026 10:15 am identified the same response as RN #4 regarding hand hygiene and disposal of soiled linens. The facility policy for Hand Hygiene directed, in part, that all personnel working in the long-term care facility are required to perform proper hand hygiene in the following situations: before and after resident contact, before and after performing any procedure, and after removing gloves.The facility policy for Standard Precautions directed, in party, that standard precautions include but are not limited to hand hygiene, the proper use of PPE personal protective equipment, and care of the environment, textiles, and laundry. Also, equipment or items in the resident environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents.

Based on interviews, observations, review of the clinical record, facility documentation, and facility policy for 1 of 4 residents (Resident #74) reviewed for pressure ulcers, the facility failed to correctly set and monitor an air mattress for a resident that resulted in the worsening of a pressure ulcer. The findings include: Resident #74's diagnoses included type 2 diabetes mellitus, anemia, and hyponatremia (low sodium in the blood). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #74 had intact cognition and required extensive assistance of two persons for transfers, toileting and bed mobility. Additionally, the MDS identified Resident #74 had an unhealed pressure ulcer and required a pressure reducing device for his/her bed. The Resident Care Plan (RCP) dated 8/7/24 identified an actual alteration in skin integrity due to a Stage 3 pressure ulcer to Resident # 4's left buttocks. Interventions included an air mattress to the bed but failed to include specific air mattress settings. Additionally, the RCP indicated to encourage assistance with turning and positioning every 2 hours and as needed (but there was no documentation that a turning and positioning schedule was implemented). The Nurse Aide Care Card identified Resident #74 was an assist of 1 for bed mobility but did not indicate any turning and positioning directives. The Wound Physician's (MD #1) progress note dated 8/7/24 at 1:02 PM identified a left buttock Stage 3 pressure ulcer with measurements of 3.0 centimeters (cm) by 4.0 cm by 0.1 cm. Wound status was indicated as improved. The Wound Physician's (MD #1) progress note dated 8/14/24 at 1:33 PM identified a left buttock Stage 3 pressure ulcer with measurements of 3.0 cm by 3.8 cm by 0.1 cm. Wound status was indicated as improved. The Wound Physician's (MD #1) progress note dated 8/21/24 at 6:54 PM identified a left buttock Stage 3 pressure ulcer with measurements of 3.0 cm by 3.8 cm by 0.1 cm. Wound status was indicated as improved, despite measurements. Observation and interview on 8/26/24 at 11:45 AM identified Resident #74 was lying in bed with the head of the bed elevated. Resident #74 indicated he/she was uncomfortable in the bed and that he/she was in pain due to the wound on his/her buttocks. An air mattress was observed in place on the bed and the dial was set at 150 lbs. LPN #1 was made aware of Resident #74's complaints of being uncomfortable and in pain. Observation and interview on 8/27/24 at 9:40 AM identified Resident #74 was sitting upright on the side of his/her bed with a bed pillow in place under his/her buttocks. Resident #74 indicated that the air mattress was very uncomfortable and that it felt like he/she was sitting on rocks. Resident #74 further indicated he/she was in pain due to the wound on his/her buttocks and the air mattress being like rocks. An air mattress was observed in place on the bed with the dial set at 150 lbs. Observation, interview and record review on 8/27/24 at 9:45 AM with the Wound Nurse (RN #1) identified that the air mattress was in place to help relieve pressure and promote healing for Resident #74's left buttock Stage 3 pressure ulcer. RN #1 indicated that the nursing staff were responsible for monitoring and setting the air mattress for Resident #74 every shift. RN #1 further identified that although Resident #74's current weight was 104 pounds (lbs), the air mattress dial was incorrectly set for a resident at 150 lbs. RN #1 then re-set the air mattress dial to the correct weight for Resident #74 and told the resident she would check on him/her later to see that the mattress was more comfortable after her adjustment. Review of the clinical record with RN #1 identified that a physician's order for setting and monitoring the air mattress was not in place for Resident #74. RN #1 indicated that the order should have been obtained from the physician when the air mattress was first initiated and that she would obtain a new order. On 8/27/24 at 1:00 PM observation of Resident #74 identified he/she was in his/her room, seated on a roho cushion in the wheelchair. Subsequent to surveyor inquiry, a physician's order dated 8/27/24, indicated to check setting and function of the air mattress every shift. Observation and interview with the Wound Physician (MD #1) on 8/28/24 at 1:11 PM identified Resident #74's left buttock Stage 3 pressure ulcer had worsened since her last assessment on 8/21/24 and that the wound had more depth, with tunneling and undermining noted from 11-2 o'clock. MD #1 further identified that the area of slough she removed from the wound was right over the bone and the wound was also deeper in that area which indicated the wound had been exposed to more pressure since her last visit. MD #1 indicated that the external components of pressure, due to the air mattress being set too firm, had caused worsening of Resident # 74's wound. Additionally, MD #1 identified that she was familiar with Resident #74's wound because she had treated him/her weekly since admission. MD #1 then directed RN #1 to communicate with the nursing staff regarding regularly monitoring Resident #74's air mattress to ensure the appropriate setting. The Wound Physician's (MD #1) progress note dated 8/28/24 at 1:44 PM identified a left buttock pressure ulcer now unstageable, with measurements of 3 cm x 3 cm x 1.5 cm with new undermining of the wound indicated from 11 o'clock to 2 o'clock which equaled 2 cm. Wound status was identified as stalled. The on-line manufacturer's manual for the air mattress applied to Resident #74's bed directed to determine the patient's weight and set the control knob to that setting on the control unit. Review of the facility Air Mattress policy, undated, indicated the use of an air mattress was for the prevention and treatment of wounds by providing pressure relief and/or redistribution of pressure. The policy further directed to observe the mattress each shift to make sure that the pump was functioning correctly and settings were accurate, reset as needed.

Based on interviews and a sample taste tray, the facility failed to ensure food was palatable. The findings include: Interview with Resident #45 on 8/26/24 at 11:30 AM identified he/she didn't like the taste of the food, and the food was of poor quality. Additionally, the cold food was not cold and there was not enough fresh fruit/vegetables provided. On 8/28/24 at 12:00 PM, a taste tray was conducted which consisted of cooked broccoli stems (no florets) and 2 manicotti (substituted for stuffed shells which were on the menu). Both items (broccoli stems and manicotti) were overcooked/mushy and extremely bland. Interview with the Food Service Director (FSD) at that time identified he was aware the broccoli was overcooked, and although there was a recipe to follow, the chef cooked the broccoli too long. He further identified although he doesn't conduct audits on the food quality, he does demonstrations with the cooks, but did not have any documentation to reflect what type of demonstrations he conducted. On 8/29/24 at 1:11 PM, during the Resident Council meeting Resident #53 indicated the food was of poor quality, the rice was uncooked, the fish was not edible, the minestrone soup was just pasta and peas, the burger bun top was tasty but the bottom was stale, there was a lack of fresh vegetables/fruit, and the food was salty. Additionally, Resident #106 indicated the macaroni and cheese was like a block and the ice cream was served melted and not frozen. Also, during the Resident Council meeting on 8/29/24 at 1:11 PM, Resident #29 indicated the salad was wilted, mushy and slushy. Facility policy for meat and vegetable cookery identified food items shall be prepared to conserve maximum nutritive value, to develop and enhance flavor and appearance.

Based on the tour of the Dietary Department, observations, interviews, facility policy, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure the ice scoop and ice scoop tray for the ice machine and the ice machine were kept in a clean and sanitary condition, failed to maintain clean vents in the dish room and failed to cover a garbage can on the clean side of the dish room. The findings include: Tour of the Dietary Department on [DATE] at 11:18 AM with the Dietary Manager identified the following: a. The walk in freezer #1 contained an open package with 7 chicken patties, no open date or expiration date was identified, and the chicken patties contained freezer burn. b. The walk in refrigerator #2 was observed with an opened package of ,d+[DATE] pound (lb) American cheese, a 1 lb open package of ham, 2 lb open package of ham and a 1 lb open package of roast beef, loosely wrapped with plastic wrap, without the benefit of an opened date and expiration dates. c. The ice machine scoop was stored in a visibly soiled holder which was adhered to the side of the ice machine. The vents on outside of the machine had soiled removable filters and the exterior vents were covered in a thick layer of dust. Review of the Monthly Ice Machine cleaning log identified the ice machine was last cleaned [DATE]. d. 2 dish room ceiling vents were found to contain a thick layer of dust. e. An observation on [DATE] at 9:14 AM identified an uncovered garbage can approximately ,d+[DATE] full with garbage was located on the clean side of the dish area of the dish room and not being utilized for food prep. f. An observation on [DATE] at 12:07 PM identified the storage of a staff members beverages in the kitchen juice refrigerator near the food service tray line. The contents of the staff members beverages included: ,d+[DATE] full 16 oz. plastic water bottle, ,d+[DATE] full plastic Coca-Cola bottle, and a teal colored reusable stainless steal water container. Additionally contained in the juice refrigerator were resident foods to include: 2 chef salads and 4 fruit plates. The chef salads were the lunch meal alternate. An interview with the Dietary Manager at the time of the tour identified whoever opened food items was responsible for covering and labeling food with an open date and that the food would be considered expired 3 days after opening. The Dietary Manager further indicated the facility would not know the expiration date of the opened food if not labeled with an open date. An interview with Dietary Aide (DA) #1 on [DATE] at 11:47 AM identified he did not notice that the ice machine was soiled, as it was last cleaned on [DATE] and was not yet cleaned for the month of August . An interview with the Dietary Manager on [DATE] at 9:14 AM identified the facility maintenance department was responsible for cleaning the ceiling vents and it would be the Dietary Manager's responsibility to identify the vents were dirty and notify maintenance. The interview further identified the trash on the clean side of the dish room should have been covered. An interview with DA #1 on [DATE] at 12:07 PM identified staff beverages should not be stored in facility kitchen refrigerators and could not indicate the reason he stored his beverage in there, despite knowing he should not. An interview with the Dietary Manager on [DATE] at 12:07 PM identified staff beverages were not to be stored in facility kitchen refrigerators and could not confirm the beverages were clean. Review of the facility policy titled Date Marking states, in part, Foods will be date marked with the name of the product, the date of the production or opening. Review of the facility policy titled Cleaning Ice Machine, Scoop and Tray states, in part, the ice machine and equipment (scoop and tray) will be cleaned on a regular basis to maintain a clean, sanitary condition and the ice scoop and tray will be washed and sanitized at least weekly in the dishwasher and allowed to air dry.

Based on observations, reviews of the clinical record, facility documentation, facility policy, and interviews for 3 of 7 residents (Resident #32, Resident #36, Resident #74) reviewed for Enhanced Barrier Precautions (EBP) the facility failed to ensure appropriate personal protective equipment (PPE) was donned (placed on) prior to personal care, for the only sampled resident (Resident #76) reviewed for Transmission Based Precautions (TBP), the facility failed to ensure the required signage had been placed to alert all persons of the need for PPE, and during a tour of the laundry room, the facility failed to ensure fans with debris were not blowing on clean laundry. The findings include: 1. Resident #32's diagnoses included unspecified macular degeneration, bilateral cataracts, cerebral infraction and artificial opening of the urinary tract. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was severely cognitively impaired, and required substantial/maximal assistance for eating, toileting and transfers. The Resident Care Plan dated 8/28/24 identified Resident #32 was on Enhanced Barrier Precautions relating to an illeal conduit (a surgical procedure that creates a new tube for urine to drain). Interventions included donning of a gown and gloves while bathing, showering, providing hygiene, dressing, transferring, and incontinent care (changing brief, assisting with toileting, changing linens, colostomy care, wound treatment, central line, urinary catheter, feeding tube). A physician's order dated 4/10/24 and currently in effect directed that every shift follow Enhanced Barrier Precautions for Clostridium Difficile (C-Diff), Methicillin Resistant Staphylococcus (MRSA) and an illeal conduit. The care card (NA Resident Assignment) identified Enhanced Barrier Precaution were in place. Observation on 8/28/24 at 9:23 AM identified Enhanced Barrier Precaution signage on Resident #32's room door directing to wear gloves and a gown for high contact resident care (dressing, bathing, changing linen, device care and wound care) and a precaution cart stocked with gloves and gowns. Observation on 8/28/24 at 9:24 AM identified Nurse Aide (NA) #2 in Resident #32's room emptying the illeal conduit urinary bag wearing gloves, without the benefit of a gown. Interview with NA #2 on 8/28/24 at 9:26 AM identified she received education on Enhanced Barrier Precautions, and signage posted on the door meant the resident had a bag or wound, and she should wear gloves and a gown when emptying the bag to protect all residents, however she forgot to put the gown on. Interview with Licensed Practical Nurse (LPN) #4 on 8/28/24 at 9:30 AM identified Enhanced Barrier Precautions signage on the door meant staff should wear personal protective equipment (gowns and gloves) with high contact activities such as providing personal care and transfers. The facility Enhanced Barrier Precautions policy dated 4/19/24 identified the required use of a gown and gloves for select residents during specific high-contact resident care activities in which there is an increased risk of transmission of multi drug resistant organisms. 2. Resident #36's diagnoses included dysphagia with a feeding tube, right-side hemiplegia, and a history of extended spectrum beta lactamase (ESBL) resistance infection. The annual Minimum Data Set assessment dated [DATE] identified that Resident #36 was severely cognitively impaired and dependent for toileting hygiene, upper body dressing, and received nutrition through a feeding tube. The Resident Care Plan dated 6/4/24 identified Resident #36 was on EBP related to the presence of a feeding tube. Interventions included donning of gown and gloves when providing hygiene, dressing, providing incontinent care, and assisting with the feeding tube. Review of the Resident Care Card (Individualized Resident Assignment) for Resident #36 included the need for Enhanced Barrier precautions due to presence of a feeding tube. A physician's order dated 8/14/24 directed to use EBP every shift due to Resident #36's feeding tube and history of ESBL infection. Observation of Resident #36's doorway indicated a sign to utilize PPE for EBP. Observation and interview with NA #4 on 8/28/24 at 2:50 PM identified that she was standing at Resident #36's bedside adjusting the blanket wearing gloves but no gown. NA #4 carried a bag that contained a dirty brief and paper towel, but no gown (PPE). NA #4 indicated that she had just completed incontinent care for Resident #36. Although NA #4 indicated that she was aware Resident #36 was on EBP and was aware of the sign outside the resident's door, Resident #36 didn't have anything. Additionally, NA #4 stated she was aware that she needed PPE (gown and gloves) when providing hands on care but didn't realize that hands on care included incontinent care. Interview with the Infection Preventionist, Registered Nurse (RN) #3, on 8/28/24 at 3:06 PM identified that per the EBP policy PPE (gown and gloves) needed to be worn when providing care to a resident requiring contact who was on EBP per the facility policy. RN #3 indicated that NA #4 should have worn the appropriate PPE when she provided care to Resident #36. RN #3 indicated that the staff have been educated that for residents on EBP, PPE is used to protect the residents from the staff. 3. Resident #74's diagnoses included type 2 diabetes mellitus, anemia, and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #74 was cognitively intact and required extensive assistance of two persons for transfers, toileting and bed mobility. Additionally, the MDS identified Resident #74 had an unhealed pressure ulcer. The Resident Care Plan dated 8/14/24 identified EBP related to wounds with interventions that included donning of gown and gloves when providing wound treatment. A physician's order dated 8/14/24 directed EBP to be maintained every shift for wound. A physician's order dated 8/21/24 directed Santyl External Ointment be applied to left buttock pressure area twice daily, cleanse the pressure area with wound cleanser, and pat dry with skin prep. Additionally, the physician order directed to apply Santyl Collagenase to the per-wound area followed by Calcium Alginate which was to be covered with a foam dressing. Observation of Resident #74's room on 8/28/24 at 1:10 PM identified EBP signage was posted on the door frame which directed staff must wear gloves and a gown for wound care. A cart containing disposable isolation gowns and other personal protective equipment (PPE) was located outside of Resident #74's room. Observation of Resident #74's left buttock wound care with the wound doctor (MD #1) and the wound nurse (RN #1) on 8/28/24 at 1:11 PM identified RN #1 was observed to enter Resident #74's room and completed wound care to the left buttock pressure area without the benefit of donning a gown throughout the treatment. Interview with Registered Nurse (RN) #1 on 8/29/24 at 2:38 PM identified residents on EBP, staff should wear gloves and a gown when care and treatments are provided for a resident with a wound. RN #1 indicated that she could not recall the reason she did not don a gown when she provided wound care for Resident #74 and that she must have thought she had donned a gown before she had started the wound care and then forgot. Review of facility education on EBP directed, in part, that a gown and gloves must be worn during high contact care activities, that these residents are not on isolation, but are being protected from any organisms staff may have on their clothes and hands, and to wear the gown and gloves when providing hygiene/incontinent care/changing briefs. It was further identified that NA #4 had received this education. Review of the facility EBP policy directed that use of gloves and a gown was required for certain residents during specific high-contact resident care activities in which there was an increased risk for transmission of multidrug-resistant organisms. High-contact resident care activities included bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care and that all staff will receive training on EBP upon hire and annually 4. Resident #76's diagnoses included Covid-19 infection, diabetes, hypertension, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #76 was severely cognitively impaired, required moderate assistance with bed mobility and transfers, and was dependent on staff for personal hygiene and toileting. The Resident Care Plan dated 8/20/24 identified Resident #76 with a Covid-19 diagnosis. Interventions included placing Resident #76 on droplet precautions, obtaining labs as ordered, encouraging fluids, and performing respiratory monitoring and assessments per the physician's order. Review of the clinical record identified Resident #76 had tested positive for a Covid-19 infection on 8/20/24 and was noted to be on the facility TBP list. Physician's orders dated 8/26/24 directed facility staff to place Resident #76 on isolation precautions and to provide meals, activities, rehab and care in his/her room from 8/20/24 until 8/31/24. Observations on 8/26/24 at 12:30 PM and 1:50 PM, failed to identify that the required signage used to alert staff and visitors of the need for additional instruction, prior to entering the room, was not posted. Observation and interview with Licensed Practical Nurse (LPN) #3 on 8/26/24 at 1:54 PM, identified Resident #76 had been recently diagnosed with a Covid-19 infection and was still being isolated. LPN #3 indicated that although there was no current signage on Resident #76's door, the sign had been taken down by the Infection Prevention Nurse (RN #3) that morning. LPN #3 indicated that RN #3 had stated that she would replace the sign. Interview with RN #3 on 8/28/24 at 10:00 AM, identified that the Infection Control Nurse (herself) and RN supervisors were responsible for posting signage in appropriate locations for residents on TBP. RN #3 stated that Resident #76 tested positive for a Covid-19 infection on 8/20/24 and isolation would continue for 10 days per the facility policy. RN #3 indicated signage was required to be posted outside Resident #76's door and should have been there according to the facility policy. Further RN #3 denied removing the required signage from Resident #76's door. Review of the Covid 19 Facility Assessment policy directed, in part that signage on the use of specific PPE (for staff) will be posted in appropriate locations in the facility (e.g., outside of a resident's room, wing, or facility -wide). 5. On 8/28/24 at 10:50 AM, tour of the laundry room identified a fan with a heavy accumulation of dust, was blowing on clean laundry that had been placed in front of the fan. On 8/28/27 at 11:00 AM an interview with the Director of Housekeeping identified that the fan was dirty, was unsure of when it was last cleaned and did not report the dirty fan to Maintenance. On 8/28/24 at 11:18 AM an interview with the Director of Maintenance identified that maintenance was responsible for cleaning the facility fan in the laundry room, that it was cleaned once a month and that maybe it should be cleaned twice a month to ensure cleanliness. Also, the Maintenance Director identified that he was not notified that the fan needed to be cleaned. Furthermore, the Director of Maintenance provided a log for the cleaning of the laundry room fan which was last done on 7/11/24. Review of the facility policy for Monthly cleaning for laundry room fan identified that the fan was to be cleaned by Maintenance Department on a regular basis to maintain a clean, and a sanitary condition. 50249 50250 51102 51183

Based on interviews, review of the clinical record, and facility policy for 1 of 2 residents (Resident #32) reviewed for positioning, the facility failed to follow physician's orders for proper positioning and documentation and for 1 of 4 residents (Resident #69) reviewed for pressure ulcers, the facility failed to follow a physician's order to obtain daily weights for a resident with Congestive Heart Failure (CHF). Additionally, for the only sampled resident (Resident #153) reviewed for anticoagulant therapy, the facility failed to address the continuation of an anticoagulant for a resident with a diagnosis of deep vein thrombosis (DVT) and for 1 of 3 residents (Resident #173) reviewed for closed records, the facility failed to perform blood glucose monitoring as directed by a provider and failed to initiate an intervention to prevent hypoglycemia for a resident experiencing hypoglycemic episodes. The findings include: 1. Resident #32's diagnoses included unspecified macular degeneration, bilateral cataracts, cerebral infraction and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was severely cognitively impaired, and required substantial/maximal assistance for eating, toileting and transfers. The Resident Care Plan dated 8/28/24 identified Resident #32 had an Activities of Daily Living (ADL) self-care performance deficit relating to confusion, Alzheimer's dementia and limited mobility. Interventions included transfer with assistance of 2 staff members and out of bed to a customized wheelchair per a 24-hour positioning plan. A physician's order dated 10/13/22 and currently in effect, directed Resident #32 to be out of bed per 24-hour positioning plan. A physician's order dated 4/15/23 directed to document on Resident #32's custom wheelchair comfort, positioning and pain in the nurses progress notes every 15th of the month. The 24-Hour Positioning Plan directed Resident #32 to be out of bed after morning (AM) care, out of chair or back to bed as needed for peri-care on the 7:00 AM to 3:00 PM shift, and out of bed as tolerated on the 3:00 PM to 11:00 PM shift. Clinical record review of Nursing progress notes dated 3/1/24 through 8/29/24 failed to reflect monthly custom wheelchair documentation on Resident #32's comfort, positioning or pain. Observations on 8/26/24 at 12:41 PM, 8/27/24 at 11:47 AM and 8/29/24 at 11:05 AM identified Resident #32 in bed after AM care (and not out of bed per the 24 hour positioning plan). Interview with the Occupational Therapist (OT) #1 on 8/29/24 at 10:42 AM identified the 24-hour positioning plan was individualized for each resident, and nursing staff was responsible for ensuring it was followed, as well as reporting issues to therapy. Furthermore, monthly notes were written by the nursing department, and quarterly notes for customized wheelchairs were written by the therapy department. OT #1 identified effects of not following the positioning plan for Resident #32 included increased weakness, pneumonia and everything that goes along with not getting out of bed. Interview and record review with Nurse Aide (NA) #5 on 8/29/24 at 11:21 AM identified that Resident #32's care card (NA Resident Assignment) sheet directed for Resident #32 to be out of bed to a custom wheelchair with a 24-hour positioning plan, offer for back to bed after lunch/dinner and offer to be out of bed if awake on the 3:00 PM to 11:00 PM shift. NA #5 identified that she usually gets Resident #32 up and out of bed 2 times a week, and since Resident #32 was up and out of bed yesterday, she was going to keep him/her in bed today. When questioned if Resident #32 wanted to stay in bed, NA #5 confirmed no that was my preference, since he/she was up all day yesterday. Interview and clinical record review with Licensed Practical Nurse (LPN) #6 on 8/29/24 at 11:30 AM identified the NA was responsible for getting the residents up and out of bed, and Resident #32 should have been out of bed. The clinical record failed to reflect documentation on Resident #32's customized wheelchair positing per physician's order. Interview and clinical record review with OT #1 on 8/30/24 at 10:49 AM identified the therapy department wrote quarterly customized wheelchair notes, however notes could not be provided because Resident #32 was technically in an adaptive wheelchair, and the two terms adaptive and customized should not be used interchangeably. Review of the Occupational Therapy Encounter note dated 11/15/23 signed by OT #1 identified Resident #32 would benefit from skilled OT to maximize functional endurance for self-feed and out of bed activities in custom wheelchair. Review of the Customized Wheelchairs policy directed to identify resident who will benefit from improved wheelchair positioning, additionally upon delivery of custom wheelchair the following will be done: complete therapy evaluation, establish a 24 hour positioning plan, complete nursing documentation monthly in PCC (the electronic health record program) using the template, complete therapy documentation quarterly in the therapy department, and request any necessary modification based on clinical review or as identified during daily care. 2. Resident #69 was admitted to the facility on [DATE] with diagnoses that included chronic systolic CHF, acute kidney failure, and hypertension (high blood pressure). A physician's order dated 7/7/24 directed to weigh Resident #69 one time a day for CHF and notify the physician or Advanced Practice Registered Nurse (APRN) if the weight was greater than or less than 3 pounds (lbs) per day, or greater than or less than 5 lbs per week. The admission Minimum Data Set assessment dated [DATE] identified Resident #69 was moderately cognitively impaired, required partial/moderate assistance with personal hygiene, and was dependent with toileting hygiene and to the sit to lying position. The Resident Care Plan dated 7/25/24 identified a potential for impaired nutrition/hydration due to chronic kidney disease, use of a diuretic, and weight loss. Interventions included diet as ordered and weights as ordered/as needed. Review of the Electronic Medication Administration Record (EMAR) identified that daily weights were signed off as completed on 7/11/24, 7/13/24, 7/16/24, 7/18/24, 7/20/24, 7/25/24, 7/27/24, 7/29/24, 8/2/24, 8/3/24, 8/4/24, 8/5/24, 8/7/24, 8/8/24, 8/9/24, 8/10/24, 8/12/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/21/24, 8/23/24, 8/25/24, 8/26/24, and 8/27/24, but the weight for each corresponding day was not documented in Resident #69's clinical record (despite being signed off as completed). Additionally, the clinical record failed to identify if Resident #69 refused to be weighed on any of these days. Interview with Nurse Aide (NA) #3 on 8/29/24 at 10:56 AM identified that the NAs were responsible for completing the weights on the residents. Additionally, the NAs would tell the nurse how much the resident weighed, and the nurse would document the weight in the resident's clinical record. The NAs would also advise the nurse if the resident refused to be weighed. NA #3 further indicated that she would know if a resident had to be weighed daily by referring to the NA care card. Interview with Licensed Practical Nurse (LPN) #7 on 8/29/24 at 11:07 AM identified that the NAs were responsible for completing the weights on the residents. The NAs would know if a resident had to be weighed daily by referring to their daily assignment sheet, the NA care card, and/or the nurse would verbally tell the NA. Additionally, the nurse was responsible for documenting the resident's weight in the clinical record as the NAs do not look at the EMAR. LPN #7 further indicated that it would be the responsibility of the nurse who transcribed the physician orders to also update the NA care card. Interview and clinical record review with Registered Nurse (RN) #1 on 8/29/24 at 12:05 PM identified that she had transcribed the physician order of daily weights into the EMAR. but identified that she did not add daily weights to the NA care card. RN #1 further indicated that the NAs would know if a resident had to be weighed daily by being told verbally by the nurse and/or by referring to their daily assignment sheet. Interview and clinical record review with LPN #6 on 8/29/24 at 12:15 PM identified that she had signed off on the EMAR that weights were completed for Resident #69 on 8/3/24, 8/4/24, 8/5/24, 8/9/24, 8/10/24, 8/12/24, 8/14/24, 8/15/24, 8/17/24, 8/19/24, 8/23/24, and 8/26/24 without documenting the weight. LPN #6 further indicated that the weights could either have not been completed or not documented on these days. Review of the NA care card (revised 7/8/24) failed to identify that Resident #69 had to be weighed daily. Review of the NA assignment sheet dated 8/29/24 failed to identify that Resident #69 had to be weighed daily. Additionally, a blank copy of the NA assignment sheet also failed to identify Resident #69 had to be weighed daily. Interview with the Assistant Director of Nursing Services (ADNS) on 8/30/24 at 8:42 AM identified that it was the responsibility of the charge nurse or supervisor to update the NA care card. Additionally, the ADNS identified that he would not add daily weights to the NA care card. The ADNS further indicated that the NAs would know if a resident had to be weighed daily by referring to their daily assignment sheet. Although requested, a facility policy for NA care cards was not provided. Review of the Weights/Re-weights Policy and Procedure updated 3/4/24 directed, in part, that for residents with CHF, the physician would be consulted for orders for daily weights and/or reporting parameters, or as ordered. Additionally, weights would be inputted into the medical record by the nurse. 3. Resident #153's diagnoses included acute embolism and thrombosis (blood clot) of the right femoral vein and bilateral lower extremities, surgical aftercare following surgery on the circulatory system (thrombectomy/blood clot removal) and presence of other vascular implants and grafts. An inter-agency patient referral form (W10) from Resident #153's initial admission to the facility on [DATE] indicated Lovenox (an anticoagulant medication) 100 milligrams/milliliter (mg/ml), inject 100 mg subcutaneously one time a day for status post deep vein thrombosis (blood clot in the legs, or DVT) with no end date. A physician's order dated 6/27/24 indicated anticoagulation medication, Enoxaprin Sodium injection Solution/Lovenox 100 mg/ml , inject 100 mg subcutaneously one time a day for status post DVT and directed to monitor for signs of bleeding, bruising, change in mental status or vital signs every shift. A physician's progress noted dated 6/28/24 at 4:15 PM identified Resident #153 was found to have an extensive clot burden in his/her bilateral lower extremities and was seen by hematology and neurology for anticoagulation recommendations. Additionally, the progress note indicated Resident #153 had been started on Lovenox for recurrent bilateral lower extremity DVT. Review of the W10 and hospital discharge summary from Resident #153's re-admission to the facility from the acute care hospital on 7/11/24 directed Lovenox 100 mg/ml, inject 100 mg subcutaneously one time a day for status post DVT and no stop date was indicated. Additionally, the hospital discharge summary dated 7/11/24 identified that Resident #153 had presented from the skilled nursing facility (SNF) on 6/30/24 as a stroke alert for altered mental status (AMS), confusion and dysphagia (difficulty speaking) and that neurology suspected the symptoms were due to an amyloid spell (brief neurological episode). A physician's progress note dated 7/12/24 at 9:12 PM identified recurrent bilateral lower extremity DVT with thrombectomy (clot removal) and to continue Lovenox. A medication order from the Advanced Practice Registered Nurse (APRN #1) dated 7/12/24 indicated Enoxaparin Sodium (Lovenox) 100 mg/ml, inject 100 mg subcutaneously one time a day for history of DVT until 7/28/24. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #153 was moderately cognitively impaired and required substantial/maximal assistance of 2 persons for transfers, toileting and bed mobility. Additionally, the MDS identified Resident #153's diagnosis of DVT with indication for an anticoagulant. A progress note from APRN #2 on 7/16/24 at 1:34 PM identified Resident #153 was readmitted to the facility following a hospitalization from [DATE]-[DATE] with recent bilateral lower extremity deep vein thrombosis (blood clot, or DVT) status post thrombectomy (clot removal) on 6/20/24 and a history of pulmonary embolism (blood clot in the lung, or PE) and inferior vena cava (IVC) filter. Additionally, the 7/16/24 progress note identified Resident #153 was on Lovenox with a prolonged hospitalization and to continue Lovenox. The Resident Care Plan dated 7/23/24 identified anticoagulation medications with interventions that included to administer relevant medications and monitor labs as directed. A progress note from APRN #2 on 7/29/24 at 1:32 PM identified recurrent bilateral lower extremity DVT, history of DVT and PE, status post IVC filter with recent bilateral lower extremity DVT and status post thrombectomy on 6/20/24. Additionally the progress note indicated that Lovenox was started with prolonged hospitalization and to continue Lovenox despite intermittent hematuria. Interview and record review with the Advanced Practice Registered Nurse (APRN) #1 on 8/28/24 at 1:51 PM identified that Resident #153 had not received Lovenox from 7/28/24 through 8/28/24 in error. The inter-agency patient referral form (W10) and discharge summary from 7/11/24 did not identify an end date for the Lovenox. APRN #1 indicated that for Resident #153's re-admission to the facility on [DATE], all medication orders should have been taken from the W10 and that the Lovenox order should not have been discontinued. APRN #1 was unable to identify the reason the 7/12/24 order for the Lovenox, with an end date of 7/28/24, was put into the electronic health record (EHR) under her name. APRN #1 further identified that with Resident #153's history of DVT and PE he/she should have been continued on an anticoagulant and that not being on an anticoagulant could cause non-dissolution of blood clots and a recurrence of a DVT or PE. Subsequent to surveyor inquiry on 8/28/24, APRN #1 entered a new order directing to administer Lovenox (Enoxaparin Sodium)100 mg/ml, inject 100 mg subcutaneously one time a day for history of DVT. Interview and record review with the ADNS on 8/29/24 at 9:30 AM indicated that for re-admissions to the facility it was the facility policy to follow the W10 for medication orders and that the discharge summary may be cross referenced. The medication orders are then verified with the MD or APRN. The ADNS identified that both the W10 and discharge summary from 7/11/24 for Resident #153 did not indicate an end date for the Lovenox. Interview with APRN #2 on 8/29/24 at 10:30 AM indicated that she was not aware that Resident #153 was no longer being administered Lovenox when she wrote her progress note on 7/29/24 noting Resident #153 continued on Lovenox. APRN #2 further identified that she did not recall an end date on the Lovenox order and that although her progress note from 7/29/24 was uploaded into the EHR, she was not sure if the nursing staff would have reviewed it, but that Resident #153 should have been continued on the Lovenox. Additionally APRN #2 indicated that, based on Resident #153's recent and recurrent history of DVT and PE, there was no reason for the Lovenox order to have an end date and that she had not discontinued it. Interview with LPN #10 on 8/29/24 at 11:32 AM indicated that she was familiar with Resident #153 but was unable to recall all of the medication orders or the reason the 7/12/24 Lovenox order was given an end date of 7/28/24. LPN #10 further identified that APRN #1 wrote the Lovenox order on 7/12/24 with the 7/28/24 end date. LPN #10 indicated that she confirmed and transcribed the Lovenox order, but did not initiate or change the Lovenox order on 7/12/24. Review of the facility Admissions Policy, undated, directed to review the W10 and hospital discharge summary and to transcribe all orders onto the physician's order sheet. Review of the facility policy, Verification of New Admission Medication Orders, dated 9/2022, directed that medication orders were to be transcribed from the hospital W10/Discharge summary upon admission and put into the residents EHR. Review of the facility policy, Anticoagulation Therapy, undated, directed the purpose of anticoagulation therapy was to treat someone who has a blood clot, such as a clot in the veins of the leg (a deep vein thrombosis, or DVT) or the arteries of the lung (a pulmonary embolus, or PE), and to prevent a blood clot in someone who is at high risk of getting one. 4. Resident #173 diagnoses included type II diabetes mellitus (DM), chronic kidney disease, and congestive heart failure. An admission physician order dated 6/5/24 directed blood glucose monitoring four times a day (before meals and at hours of sleep) with sliding scale Insulin coverage. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #173 had intact cognition and required extensive assistance for bed mobility and transfers. An Advanced Practice Registered Nurse (APRN) progress note dated 6/17/24 at 1:19 PM identified Resident #173 was seen for DM after experiencing hypoglycemia (low blood sugar), at times, in the morning. The Assessment and Plan section of the APRN progress note identified Humalog Insulin would be discontinued and directed to monitor blood sugars (Resident #173 was also to continue Glipizide 5 mg every day). An APRN progress note dated 6/20/24 at 1:22 PM identified Resident #173 was seen for DM after continued hypoglycemia in the morning/fasting blood sugar in the morning was 60-80 at times. The Assessment and Plan section of the APRN progress note directed to monitor blood sugars, decrease Glipizide to 2.5 mg by mouth every day and provide a nighttime snack as needed. Review of the June 2024 Order Summary Report identified Resident #173's Humalog Insulin was discontinued on 6/17/24 by APRN #2, attached to the Humalog Insulin order, in the electronic medical record (EMR), was the blood glucose monitoring action. The Humalog Insulin and the blood glucose monitoring were discontinued simultaneously. Additionally, there was no order in June of 2024 for providing a nighttime snack. Review of the Weights and Vitals Summary identified blood glucose monitoring 4 times per day from admission through 6/16/24 was completed. The last blood glucose documented was on 6/17/24 at 7:26 AM with no further blood glucose monitoring completed until a transfer to the hospital was initiated on 6/29/24, and a blood glucose level of 49 was identified. Review of the clinical record identified Resident #173 experienced a change in condition on 6/29/24. The facility document titled SBAR Communication Form and Progress Note dated 6/29/24 at 4:59 PM identified Resident #173 complained of chest pain, was diaphoretic, had an elevated blood pressure (170/80) and a blood glucose level of 49 requiring the administration of Glucagon (an emergency injection used to treat severely low blood sugar in people with DM). Resident #173 was transferred to the hospital. Review of the hospital discharge summary dated 7/9/24 at 3:59 PM identified Resident #173 was hypothermic upon arrival to the hospital and the hypothermia was felt to be related to the hypoglycemia. Interview and review of the clinical record with the ADNS on 8/28/24 at 2:48 PM identified there was no provider order to provide a nighttime snack as needed. The ADNS further identified there should have been an order if the APRN directed the intervention. The ADNS was unable to provide any form of documentation that Resident #173 received nighttime snacks. Interview with APRN #2 on 8/29/24 at 10:36 AM indicated blood glucose monitoring should be performed for a resident experiencing hypoglycemic episodes as well as for a resident requiring changes to medications used to treat DM. APRN #2 identified she was aware the blood glucose monitoring action, in the EMR, was at times attached to insulin orders and indicated it was not her intention to discontinue the blood glucose monitoring. APRN #2 further identified if she did not add an order for a nighttime snack but directed to provide a nighttime snack in her Assessment and Plan, she would have given a verbal order, to a nurse, who should have added the order in the EMR and did not know where she obtained the information that Resident #173 had hypoglycemia in the morning from her 6/20/24 progress note since there was no blood glucose monitoring results available. Interview with the Director of Nursing (DNS) on 8/29/24 at 11:34 AM indicated orders entered by a provider were presumed to be correct by the nursing staff. The DNS stated there was an order verification process but could not describe the process and further indicated nursing would not question the accuracy of a provider entered order. The inadvertently discontinued blood glucose monitoring omitted 50 instances of blood glucose monitoring over 13 days. Although requested, the facility was unable to provide a policy on order verification. 50249 50890 51102

Based on observations, interviews and policy review for 1 of 2 sampled residents (Resident #26) reviewed for dignity, the facility failed to return laundry in a timely manner to ensure Resident #26 had sufficient clothes and did not have to be dressed in a hospital gown. Resident #26's diagnoses included Type 2 Diabetes Mellitus, chronic venous hypertension with ulcer of bilateral lower extremity and cellulitis of right and left limbs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was cognitively intact, required partial to moderate assistance for transfers and upper body dressing and was dependent for lower body dressing and toileting. The Resident Care Plan dated 6/19/24 identified Resident #26 had an adjustment disorder. Interventions included encouragement to participate in activities of choice and providing the opportunity to communicate feelings regarding attending activities. Interview and observation of Resident #26 on 8/29/24 at 1:15 PM during the Resident Council meeting identified Resident #26 was wearing a hospital gown and stated it was because he/she had not received clothing back from laundry in 5 days. Interview with Resident #26 in his/her room on 8/30/24 at 11:20 AM identified he/she told everyone about the missing laundry and still not received it back. Interview with the Nurse Aide (NA) #7 on 8/30/24 at 11:20 AM identified and agreed that Resident #26 told everyone about the missing laundry items and she notified laundry on 8/27/24, adding there is a huge pile of clothing down there and I'm not looking through that. Interview and observation of Resident #26 on 8/30/24 at 11:42 AM identified he/she was seated in his/her wheelchair in a common hallway with the Physical Therapist, wearing a hospital gown with both lower extremities exposed and wrapped in ace bandages. Resident #26 identified it was 5 or 6 days that he/she had to wear a hospital gown, it bothered him/her not to have their own clothing, and that was the reason he/she was not doing therapy in the gym. Interview on 8/30/24 at 12:00 PM with the Director of Environmental Services identified the turnaround time for laundry was usually 2 to 3 days and today was the first time she heard of Resident #26 missing items. Additionally, the department was extremely short staffed, and the regular full-time employee whom it was most likely reported to worked her last day on 8/27/24. However, she was currently implementing easy to read labels and personalized bags to cut down on lost and missing resident clothing since that had been an issue. Interview with Social Worker #2 on 8/30/24 at 12:35 PM identified that she was not made aware of Resident #26's missing clothing until 8/30/24 (despite NA #7 being aware of Resident #26's missing clothing on 8/27/24). Interview with the Physical Therapist (PT) #1 on 8/30/24 at 12:40 PM identified that therapy was not done in the gym due to Resident #26 preference because it bothered him/her to be wearing a hospital gown when in the gym, but it did not impact the physical therapy progress. Observation of Resident #26 on 8/30/24 at 1:54 PM identified him/her wearing a hospital gown while sitting in the dining room waiting for lunch. Facility policy on Personal Items identified it was the responsibility of all staff members to report any missing items to the supervisor who will report it to the Social Worker and/administration.

Based on interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #36) reviewed for non-pressure skin conditions, the facility failed to notify the responsible party of the development of an open area requiring a treatment and for 1 of 4 residents (Resident #69) reviewed for pressure ulcers, the facility failed to notify the physician per the physician's order for a greater than 3 pound (lbs) weight loss in one day for a resident with congestive heart failure (CHF) and for 1 of 1 residents (Resident #476) reviewed for a lumbar brace, the facility failed to notify the physician/APRN of Resident #476's refusals to wear the lumbar brace. The findings include: 1. Resident #36's diagnoses included stroke, right-side hemiplegia, osteoporosis. The Annual Minimum Data Set assessment dated [DATE] identified Resident #36 was severely cognitively impaired and dependent for toileting hygiene, for putting on and taking off footwear, and required partial/moderate assistance to roll to the left and right. The Resident Care Plan in effect from 8/1/24 to 8/30/24 identified Resident #36 was at risk for an alteration in skin integrity related to decreased mobility. Interventions included use of a bed cradle, offloading both heels while in the bed or chair, and reporting of any areas of concerns identified during performance of skin checks with care. A weekly skin assessment dated [DATE] at 8:51 AM identified Resident #36's right toes were pink with a rash. A non-pressure wound weekly tracking assessment dated [DATE] at 3:15 PM identified Resident #36 had a superficial open area to the right great toe with measurements of 0.4 centimeters (cm) by 0.3 cm by 0.0 cm. The wound bed had 76% to 100% granulation, with a scant amount of bloody drainage. It was further identified that the treatment was to cleanse the right great toe with wound cleanser, pat dry, then apply Xeroform (yellow petroleum gauze) to the open area, and cover with a non-adherent pad followed by gauze wrap every day and as needed. A physician's order dated 8/5/24 directed to cleanse the right great toe open area with wound cleanser, pat dry, then apply Xeroform to the open area, and cover with a non-adherent pad followed by gauze wrap every day and as needed. A non-pressure wound weekly tracking assessment dated [DATE] at 1:37 PM identified that the superficial open area to the right great toe was resolved with a scab noted. It was further identified that the previous treatment was discontinued, and a new treatment initiated for skin-prep (protective barrier) to the right great toe. A physician's order dated 8/6/24 directed to apply skin-prep to the scab to the right great toe every day on the day shift. Clinical record review on 8/28/24 at 12:49 PM identified that from 8/2/24 when the open area to the right great toe was identified to 8/6/24 when the open area to the right great toe was documented as resolved, there had been no documentation that the responsible party for Resident #36 had been notified of an open area to Resident #36's right great toe which required a treatment. Interview with the Wound Nurse, (RN #1) on 8/29/24 at 2:45 PM identified that the nursing staff updated RN #1 with new skin issues that were identified. RN #1 stated that it was the responsibility of the nurse or unit manager who identified the skin issue or open area to call the responsible party and update them on the new finding, unless the wound was substantial and required detailed explanation by RN #1. RN #1 was unable to identify the reason the responsible party had not been notified. Interview with Person #1 on 8/30/24 at 9:40 AM identified that there had been no notification from the facility about the open area to Resident #36's right great toe documented by RN #1 on 8/2/24. A facility policy for family notification of change/new orders/wounds was requested and the Change in Condition policy was provided. This policy was reviewed and directed, in part, that the responsible party must be notified of changes in status and this notification is documented in the nurses' notes. 2. Resident #69's diagnoses included chronic systolic chronic heart failure (CHF), acute kidney failure, and hypertension (high blood pressure). A physician's order dated 7/7/24 directed to weigh Resident #69 one time a day for CHF and notify the physician or Advanced Practice Registered Nurse (APRN) if the weight was greater than or less than 3 pounds (lbs) per day, or greater than or less than 5 lbs per week. The Admission Minimum Data Set assessment dated [DATE] identified Resident #69 was moderately cognitively impaired, required partial/moderate assistance with personal hygiene, and was dependent with toileting hygiene and sit to lying position. The Resident Care Plan dated 7/25/24 identified a potential for impaired nutrition/hydration due to chronic kidney disease, use of a diuretic, and weight loss. Interventions included diet as ordered and weights as ordered/as needed. Review of Resident #69's weights identified that Resident 69's weight was 125.6 lbs on 7/21/24 and 120 lbs on 7/22/24 (a 5.6 lb weight loss/a greater than 3 lb weight loss in one day). Interview with LPN #7 on 8/29/24 at 11:07 AM identified the Nurse Aides (NA) were responsible for completing the weights on the residents, and that the nurses were responsible for documenting the resident's weight in the clinical record. Additionally, if there was a weight fluctuation of greater than or less than 3 lbs in one day, then it would be the responsibility of the nurse to notify the supervisor and APRN, and document it in a nursing note. Interview and clinical record review with APRN #1 on 8/20/24 at 9:43 AM identified that per the physician's order, she would have expected to have been notified when Resident #69 had lost more than 3 lbs in one day on 7/22/24. Additionally, APRN #1 identified that she would have assessed the change in weight further to determine the cause of the fluctuation and whether the resident needed to be evaluated. Review of the nurses' notes failed to identify that the physician or APRN was notified regarding the greater than 3 lb weight loss on 7/22/24. Review of the Weights/Re-weights Policy and Procedure updated 3/4/24 directed, in part, that for residents with CHF, the physician would be consulted for orders for daily weights and/or reporting parameters, or as ordered. 3. Resident #476's diagnosis included multiple vertebral compression fractures, pneumonia, and falls. Physician progress notes dated 8/13/24 directed Resident #476 to wear a thoracic lumbar sacral orthosis (TSLO) brace while out of bed. An Advance Practice Registered Nurse (APRN) progress note dated 8/14/24 identified that Resident #476 was to wear the TSLO back brace when he/she was out of bed. The admission Minimum Data Set assessment dated [DATE] identified Resident #476 was moderately cognitively impaired, required extensive assist of 1 for bed mobility, moderate assist for toileting, and personal hygiene, limited assist of 1 for transfers, and independent for eating. Observation on 8/26/24 at 1:50 PM noted Resident #476 coming out of the bathroom with the walker, sat him/her self in the wheelchair without the benefit of wearing the TSLO. Additionally, observation on 8/27/24 at 9:35 AM noted Resident #476 seated in the wheelchair without the benefit of wearing the TSLO. Further observation on 8/28/24 at 9:53 AM identified Resident #476 was seated in the wheelchair without the benefit of wearing the TSLO (the TSLO was observed to be on Resident #476's bed). On 8/28/24 at 12:12 PM, an interview with Nurse Aide (NA) #6 identified Resident #476 refused to wear the TSLO brace and she reported that to Licensed Practical Nurse (LPN) #1. On 8/28/24 at 12:15 PM an interview with LPN #1 identified that Resident #476 refused to wear the TSLO brace, and that she removed it all the time herself. LPN #1 also identified that she was unaware if the physician had been notified of the resident's refusal to wear the brace and if there was an order in place for refusals. Subsequent to surveyor inquiry, nursing notes dated 8/28/24 at 2:19 PM identified that LPN#1 had notified the APRN and spoke to the spine center that follows Resident #476 regarding the resident's refusal to wear the TSLO. On 8/30/24 at 9:42 AM, APRN #1 identified that she was unaware that Resident #476 was refusing to wear the TSLO brace and would expect to be notified of the resident's refusal to wear. Review of the facility policy for Refusal of Treatment was to determine the resident's cognitive capacity to decide refusal of treatment, if a resident continues to refuse, determine severity of the refusal, if the refusal will negatively affect the resident notify the Physician/ APRN of refusal if noted to be of significant importance. Subsequent to surveyor inquiry, the RCP was updated on 8/28/24 identifying Resident #476 may decline the use of the TSLO brace at times with interventions to encourage the resident to wear the TSLO brace, to reapproach as needed, and to document refusals. Furthermore, a follow-up appointment was made with the spine specialist. 51183

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #106) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #106's diagnoses included osteoarthritis. The admission assessment dated [DATE] identified Resident #106 was alert and oriented and self-mobile in his/her wheelchair. The Resident Care Plan (RCP) dated 8/9/2024 Resident #106 exhibited accusatory behaviors at times and had the potential to be verbally aggressive due to ineffective copying skills. Intervientions directed to guide away from sources of distress, engage calmly in conversation, if response is aggressive to staff walk away calmly and approach later. Review of the facility Reportable Event Form dated 8/16/2024 at 6:25 PM identified a staff to resident abuse without injury, Resident #106 alleged that LPN #12 swore at him/her. Review of Facility Summary Report dated 8/19/2024 at 12:00 AM identified the allegation was substantiated; LPN #11 observed the incident and intervened, the RN supervisor was immediately notified and Resident #106 had called the police. The summary indicated LPN #12's employment was terminated. Review of LPN #12's statement dated 8/16/2024 identified that he was providing care for another resident, when he looked at the door and saw his medication cart was being pushed away. LPN #12 stepped around the corner, saw Resident #106 and asked Resident #106 to not touch or move the cart, if he/she wanted it moved LPN #12 would move it. LPN #12's statement further indicated he then got into a verbal exchange with Resident #106, and he called Resident #106 an idiot and swore at him/her (called him/her a ****** ****er). Resident #106 then wheeled toward LPN #12 and LPN #12 stated go ahead and hit me as LPN #11 stepped between LPN #12 and the resident. The statement then indicated LPN #12 walked away, as Resident #106 called the police and reported that he/she had been threatened. Review of LPN #11's statement dated 8/16/2024 identified that she was passing medications when she heard arguing and observed Resident #106 and LPN #12 yelling at each another. The statement indicated both Resident #106 and LPN #12 were using profanities, she stepped between both parties in an attempt to diffuse the situation and she notified the supervisor. Interview and facility documentation review with LPN #12 on 9/3/2024 at 11:49 AM identified Resident #106 was moving his medication cart and he asked Resident #106 not to touch the cart, to ask for it to be moved. LPN #12 further indicated that Resident #106 turned his/her wheelchair toward LPN #12 and they had a verbal exchange. LPN #12 stated to Resident #106 that he was not going to be the resident's ****** ****er and as LPN #11 stepped between them, the resident ran over LPN #11's foot. LPN #12 stated he walked away as more words were exchanged between him and the resident. LPN #12 stated that he did swear and he did call the resident a swear word. Interview and facility documentation review with LPN #11 on 9/3/2024 at 1:55 AM identified that Resident #106 and LPN #12 were yelling at each other and she heard a lot of cursing between them, and she stepped between them to stop the incident. Interview, clinical record review and facility documentation review with the DON and ADNS on 9/3/2024 at 1:15 PM DNS identified on 8/16/2024 at 6:30 PM, LPN #12 and Resident #106 got into a verbal exchange, and LPN #12 swore at Resident #106. The exchange was witnessed by LPN #11, and LPN #12 admitted he swore at Resident #106. LPN #12 indicated that he felt provoked by Resident #106 and the DNS stated staff should not swear at any resident; the verbal exchange should not have occurred. The DNS stated no matter what a resident says or does, staff cannot respond back. The abuse was substantiated and LPN #12's employement was terminated. Review of facility Abuse/Retaliation Prohibition Policy, directed in part to ensure each resident has the right to be free from abuse, mistreatment, neglect. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents and to their families. Facility documentation review identified staff education was initiated on 8/16/2024 for all departments regarding abuse, resident rights, customer service, and retailation, and competency testing for staff was completed. Audits were initiated, to include staff-to-resident observations, on 8/16/2024, and a QAPI meeting and Resident Council meeting was held on 8/16/2024. Based on review of facility documentation, past non-compliance was identified.

Based on observations, interviews and record review for 1 of 2 residents (Resident #32) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure a dependent resident was provided with necessary assistance to maintain good grooming. The findings include: Resident #32's diagnoses included unspecified macular degeneration, bilateral cataracts, cerebral infraction and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was severely cognitively impaired, and needed substantial/maximal assistance for eating, toileting and transfers. The Resident Care Plan dated 8/28/24 identified Resident #32 had an ADL self-care performance deficit relating to confusion, Alzheimer's dementia and limited mobility. Interventions included assistance of one staff member for bathing/showering, dressing, personal hygiene, and oral care/grooming. Nursing notes dated 8/27/24 through 8/29/24 did not identify resident refusals of care. Observations of Resident #32 on 8/27/24 at 11:47 AM, 8/28/24 at 12:47 PM and 8/29/24 9:20 AM noted Resident 332 was unshaven with disheveled hair. Observation of Resident #32 on 8/28/24 at 12:46 PM identified Resident #32 was still unshaven with more facial hair since 8/27/24's observation. Interview with Nurse Aide (NA) #2 on 8/28/24 at 12:47 PM identified she did not shave Resident #32 because she had a hard time using the disposable razor since it did not catch all the hair, adding that facility policy was to shave Resident #32 on shower days (residents routinely receive weekly showers) and if unable to do so, report it to the nurse. Interview with NA #3 on 8/28/24 at 1:20 PM identified it was the facility policy to shave Resident #32 every day or every other day as needed and to let the nurse know if the resident refused. Interview with Licensed Practical Nurse (LPN) #4 on 8/28/24 at 1:23 PM identified it was facility policy that all shifts shave residents when needed, report any refusals to the nurse, who would reapproach then document the refusal, adding there's barely any refusals here 9/10 times the residents allow it. LPN #4 identified that no refusals were reported on Resident #32 that day. Review of the Grooming Policy directed that grooming is to be done to maintain a resident's dignity regarding hairstyle and facial hair, in addition if a resident is unable to express their personal preference socially acceptable and age-appropriate grooming should be provided.

Based on clinical record review, facility policy review, and interviews for one of three residents (Resident #375) reviewed for advanced directives, the facility failed to ensure advance directives were addressed timely after admission to the facility. The findings include: Resident #375 was admitted on [DATE] with diagnoses that included hypothyroidism and a fracture of the left femur. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #375 had moderately impaired cognition and required assist with ADLs. The Resident Care Plan (RCP) 2/21/2024 identified Resident #375 an alteration in skin integrity, femur fracture, and potential alteration in nutrition. Interventions directed to assist with ADLs. Record review identified Resident #375 had a Power of Attorney (POA) for health care decisions. The clinical record included a living will that directed life support systems the resident did not want which included artificial respiration, cardiopulmonary resuscitation and artificial means of providing nutrition and hydration. Record review identified Resident #375 was a full code. Interview and record review with the DON and ADON on 9/19/2024 at 1:15 PM identified advanced directives should be addressed upon a resident admission. Interview identified Resident #375's advance directives were not addressed during Resident #375's admission. The DON and ADON stated Resident #375's advanced directives should have been addressed, and they were unable to explain why it was not done. Review of facility Policy of Advanced Directives, dated 3/31/2023, directed in part to ensure a resident's choice regarding advanced directives will be honored in accordance with state law and facility policy. The care plan and face sheet will be updated.

Based on clinical record review, facility documentation and interviews for one of four sampled residents (Resident #252) reviewed for accidents, the facility failed to provide adequate supervision/assistance to prevent an accident with injury and/or maintain carpet in a safe and hazard free manner. The findings include: 1. Resident #252's [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] identified the resident had intact cognition and was totally dependent on two staff for bed mobility. The Resident Care Plan dated 10/10/16 identified the resident was at risk for falls related to gait/balance problems. Interventions included bed in low position at night and side rails as ordered. The Resident Care Plan further identified the resident had a self-care deficit with interventions including 2 half rails up to assist with bed mobility and the resident required the assistance of 2 staff members. The Physical Therapy Evaluation and Plan of Care dated 11/30/16 identified the resident required partial/moderate assistance with bed mobility. The Quarterly MDS dated [DATE] identified the resident had intact cognition and was totally dependent on two staff for bed mobility. Review of the C.N.A Resident Assignment identified the resident required the assistance of one staff member for washing, dressing and required a mechanical lift transfer with assist of 2 out of bed to the wheelchair. The C.N.A. assignment sheet further indicated the resident had fragile skin and required turning and repositioning every 2 hours. Directly above the line regarding turning and repositioning, Ax2 was indicated, however interview with DNS on 8/22/17 at 10:30 AM identified that the resident only required assistance of one for bed mobility. Review of the Resident Care Flow Sheets from January 1, 2017 through January 23, 2017 identified that the resident was dependent for bed mobility and was provided staff support of two person + physical assistance and from 1/1/17 -1/18/17 the resident was identified as oriented (except for one isolated shift on 1/12/17.) 1/20/17 11-7 oriented, 7-3 forgetful/confused and 3-11 oriented/forgetful. 1/21/17-11-7 oriented, 7-3 oriented, 3-11 oriented/ forgetful 1/22/17 oriented x 3 shifts 1/23/17 oriented on 11-7 shift. On the morning of 1/23/17, NA #3 documented the resident was forgetful and confused. The Reportable Event Form dated 1/23/17 at 6:15 AM identified that while C.N.A. #3 was providing AM care, he/she went to fix the bed linens and the resident rolled off the bed to the floor, landing face down with his/her right arm under him/her. The Mobilex Radiology Report dated 1/23/17 identified an acute fracture involving humeral neck with no displacement. A review of the clinical record failed to identify a nursing note for the shift the resident fell addressing the resident's mental status or any assessments. The physician's orders [REDACTED]. A review of NA #3's statement dated 1/13/17 identified that on the morning of the fall, the resident looked sleepy and was loopy. NA #3 referred to the resident as appearing loopy twice in his/her written statement. Interview with Nurse Aide #3 on 8/22/17 at 11:48 AM identified twice during the interview that the resident seemed sleepy. NA#3 indicated that he/she was regularly assigned to Resident #252 and the resident was an assist of one for bed mobility, indicating that the resident was able to routinely follow commands and hold onto the side rail while on his/her side. Subsequent interview with NA #3 on 8/22/17 at 1:25 PM regarding the statement referring to the resident being sleepy and loopy, identified that the resident was not a morning person and that was the resident's baseline therefore indicating he/she did not report a change in condition to the charge nurse. When shown the Resident Care Flow Sheets for the month of January and the documentation identifying the staff was routinely indicating the resident was oriented, however on the morning of the fall, per NA#3's documentation the resident was forgetful/confused which would appear as though the resident had a change in condition, NA #3 responded, yeah. When NA #3 was questioned as to why he/she documented the resident was totally dependent on 2+ person physical assistance for bed mobility on the morning of the fall, he/she indicated because there needs to be 2+ for a mechanical lift. NA #3 then indicated he/she was confusing bed mobility with transferring in and out of bed. A review of NA#3's employee file identified the facility provided NA #3 with written in-service education on recognizing and reporting a change in the resident's condition. Interview with the Director of Nursing Services on 8/23/17 at 11:01 AM identified that if a C.N.A. identified a change in the resident's condition, it would be their responsibility to report to the charge nurse. DNS further indicated that although Resident #252 had the tendency to be sleepy in the morning, if NA#3 observed that the resident was sleepy/loopy while providing care, he/she probably should have reported the change in condition and requested assistance with turning the resident the morning of the fall. The facility's Change in Condition Policy and Procedure identified that a change in condition is a significant clinical symptom or development which requires assessment and intervention. Policy and Procedure identified that a change in condition may be, but is not limited to the following; including changes in mentation. 2. During tours of facility on 8/21/17 through 8/24/17 carpet was noted lifted/bubbled at areas where carpet met wood flooring and loosely adhered to floor causing potential fall hazards located in (but not limited to) the following areas: 1. Resident bedrooms 233 and 234, carpeting at threshold loosely adhered to floor. 2. Entrance to second floor dining room adjacent to storage room and recreation office. 3. Area adjacent to second floor nurses station where carpet meets wood flooring lifted. 4. The third floor hallway from bedroom 334 through hallway to dining room. 5. Carpet lifted where meets wood flooring in front of social service office. 6. Carpet located at outpatient entrance loose adhered and lifted. Interview with administration on 8/23/17 at 1:36 PM indicated that the facility was in progress of purchasing and/or repairing the carpet and provided estimates dated 7/31/17.

Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Resident #3 and #4) who had sustained an injury, the facility failed to ensure Resident #3 was positioned properly in the bed when unattended and for Resident #4 the facility failed to ensure an assistive device was positioned properly before a transfer to prevent a fall with injury. The findings include: 1. Resident #3's [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified Resident #3 had severe cognitive impairment, exhibited no behavioral symptoms, required extensive two person assistance with bed mobility, was non-ambulatory, incontinent of bowel and bladder and received nutrition via a gastrostomy tube. The resident care plan dated 6/10/15 identified falls. Interventions directed to keep the side rails up, bed in a low position, and fall mats on both sides of the bed and keep the head of bed elevated at all times. A physician's orders [REDACTED]. The nurse's note dated 8/23/15 at 12:15 AM identified the nurse aide reported to the charge nurse Resident #3 had fallen out of bed and the supervisor was notified. The nurse aide stated he checked Resident #3 for incontinence, turned the resident onto the right side and went into the bathroom to get wet washcloths. The nurse aide identified while in the bathroom he heard a noise and when he looked out into the room Resident #3 was noted to be on the floor. The note identified Resident #3 had sustained a right parietal head laceration and was transferred to the hospital for an evaluation. The nurse's note dated 8/23/15 at 6:15 AM identified Resident #3 returned to the facility with a [DIAGNOSES REDACTED]. The Reportable Event Form dated 8/23/15 at 12:15 AM identified Resident #3 was found on the floor with a laceration to the right side of the head. The investigation identified that the 11-7AM nurse aide, Nurse Aide (NA) #2, went into check the resident for incontinence, the head of the bed was elevated, the floor mats were in place and the nurse aide raised the bed slightly. When questioned during the investigation, NA #2 stated Resident #3 had been incontinent and he went into the bathroom to get items to perform care. While at the sink, running the water NA #2 heard a noise and saw the resident on the floor. The resident was assessed and found to have a laceration to the right side of the head and was sent to the hospital and received 4 staples to the right side of the head. In an interview on 7/13/16 at 12:12 PM NA #2 identified he raised Resident #3's bed, turned the resident away from him and checked for incontinence. NA #2 stated when turned the resident was not positioned in the center of the bed but was closer to the side he/she fell out of the bed . NA #2 identified that when the head of bed was elevated, the resident was higher than the side rails. NA #2 stated that he left the resident to get supplies and while in the bathroom heard a noise and saw Resident #3 on the floor. NA #2 further stated that after the incident the resident's bed and side rails were changed. NA #2 identified he was counseled regarding the position of the bed should remain in the lowest position until care is rendered. Interview with the 11-7AM charge nurse, Licensed Practical Nurse (LPN) #1 on 7/13/16 at 11:40 AM identified that NA #2 told her Resident #3 was on the floor. LPN #1 stated she called the Nursing Supervisor, Registered Nurse (RN) #1, the resident was assessed and sent to the hospital for the laceration to the head. LPN #1 identified she spoke to NA #2 after the incident and was told that he left the resident on his/her side with the bed up while he gathered supplies. LPN #1 stated that after the incident the side rails were changed because the side rail height was equal with the mattress, therefore Resident #3 was higher than the side rails in the old bed. Interview with RN #1 on 7/13/16 at 10:10 AM identified she was called to the floor and observed the resident lying on the floor with a laceration to the right side of the head. RN #1 stated she assessed the resident, notified the physician and sent the resident to the hospital. RN #1 stated she spoke to NA #2 after the incident and was told that he had raised the bed, turned the resident on his/her side and left the resident to gather supplies. RN #1 identified that NA #2 stated the resident was above the side rail height with the head of bed elevated. 2. Resident #4's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #4 had no cognitive impairments, exhibited no behavioral symptoms, and required extensive one person assistance of with transfers, was non-ambulatory, had functional limitation in range of motion on both sides of the lower extremities and one side of the upper extremities, and no presence of pain. The Resident Care Plan dated 7/27/15 identified the resident had a decrease in activities of daily living function. Interventions directed to allow independence as able with activities of daily living, and occupational therapy as ordered. The Fall Risk assessment dated [DATE] identified that Resident #4 was a high risk for falls. A physician's orders [REDACTED]. The 7AM-7PM nurse's note dated 9/20/15 identified Resident #4 was lowered to the floor by a nurse aide, the supervisor was notified, assessed the resident, no injuries were noted, the resident denied pain at the time of the assessment and was Hoyer lifted off the floor to the chair. The note indicated at 12:00 PM Resident #4 complained of feeling achy and was medicated with Oxycodone IR 10 mg with fair effect. The Reportable Event Form dated 9/20/15 at 11:15 AM identified Resident #4 lost his/her balance and was lowered to the floor by a nurse aide while transferring from the bed to the wheelchair using a slide board. The investigation identified that at the time of the fall the resident was assessed and found to have no injuries. The investigation identified the 7-3PM Nurse Aide (NA), NA #1, had explained Resident #4 directed the staff in the placement of the slide board, position of the wheelchair and the height of the bed. The report indicated that although NA #1 had informed Resident #4 the slide board was not position properly because of the mattress, Resident #4 still wanted to be transferred out. NA #1 identified when the resident completed the transfer to the edge of the wheelchair, he/she shifted weight and had to be assisted to the floor because the resident started to fall. Review of the nurse's note from 9/22/15 at 3:00 PM through 9/22/15 at 3:00 PM identified Resident #4 complained of left hip pain, the APRN was made aware and an x-ray was ordered. The nurse's note dated 9/23/15 at 1:15 AM identified the x-ray results showed an acute non-displaced left hip fracture, the APRN was notified of the results and directed Resident #4 be transferred to the Emergency Department for an evaluation. Interview with NA #1 on 7/12/16 at 12:35 PM identified she was aware the slide board was not positioned correctly under the resident and the mattress before the transfer. NA #1 stated she did not fix the slide board because Resident #4 does not like to wait. NA #1 stated during the transfer the resident became shaky when he/she got into the wheelchair and started falling off the so she slide Resident #4 down her leg by holding onto the back of the pants. NA #1 demonstration the transfer and identified a gait belt was not utilized and she grabbed the resident's pants at the waistline to assist with sliding the resident across the board. Interview with the 7-3PM Nursing Supervisor, Registered Nurse (RN) #2, on 7/13/16 at 11:55 AM identified that after she assessed Resident #4 she spoke with NA #1. RN #1 stated that NA #1 told her that although the slide board had not been positioned properly under the resident, she, NA #1, continued with the transfer. RN #2 identified that a gait belt was to be utilized during a slide board transfer. Interview with the Director of Nursing (DON) on 7/13/16 at 1:30 PM identified that if a slide board was not positioned properly before the transfer, the nurse aide should not have completed the transfer but called for assistance to place the slide the appropriate way.

Based on review of the clinical records, facility documentation and interviews for two of six sampled residents reviewed for mistreatment (Residents #3 and #42), the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #3's [DIAGNOSES REDACTED]. The care plan dated 3/30/15 identified cognitive loss with interventions that included to approach the resident warmly and to explain before doing any tasks. The 14-day Minimum Data Set assessment dated [DATE] identified the resident was severely cognitively impaired, did not exhibit any behaviors, required supervision with eating and was totally dependent on staff for transfer, locomotion and dressing. The Reportable Event and facility investigation dated 4/27/15 identified multiple staff witnessed Nurse Aide (NA) #6 being rude, reprimanding the resident in a loud voice and arguing with the resident. The Behavioral Health progress note dated 4/27/15 identified the resident was treated rudely by the staff and a wait and watch approach will be taken to see if the resident reacts negatively over the next few days. The facility was to follow the resident for any untoward effects. Review of the clinical record on 7/21/15 at 10:30 AM failed to reflect documentation of the incident in the record and/or that assessments were conducted by nursing to determine if there was any effect from the incident on the resident. Interview with LPN #2 on 7/21/15 at 11:20 AM indicated she/he walked into the dining room and witnessed NA #6 moving the resident back and forth a little to hard in the customized wheelchair. NA #6 was shaking the resident and the resident was moving side to side which was concerning. NA #6 was talking to the resident in a loud voice, but I could not hear what was said. LPN #2 further indicated Resident #3 was agitated and after witnessing the event, NA #6 was immediately escorted out of the dining room. Interview with the Recreation Director on 7/21/15 at 12:25 PM identified he/she was in her/his office and overheard NA #6 yelling at the resident. The Recreation Director could not remember the exact words, but clearly the resident was getting angry and the resident's yelling increased. Interview with Director of Nurses (DNS) #2 (who was the DNS on 4/27/15) on 7/22/15 at 1:56 PM identified the investigation of the incident concluded that NA #6 was verbally abusive to Resident #3. NA #6 made inappropriate gestures and raised his/her fist to Resident #3. NA #6's inappropriate behaviors caused the resident to become upset and agitated. DNS #2 further stated that upon completion of the investigation verbal abuse was substantiated. Interview with Speech Therapist #1 on 7/23/15 at 9:25 AM identified he/she walked into the dining room on 4/27/15 and observed NA #6 grabbing Resident #3's wheelchair and shaking it back and forth, enough to make the resident visibly upset. Speech Therapist #1 further identified NA #6 made a fist, raised it to the resident and stated Come on you want some of this and Resident #3 threw ice cream towards NA #6. DNS #1 (current Director of Nurses) in an interview on 7/23/15 at 11:00 AM identified the resident was evaluated by Behavioral Health on 4/27/15 and suffered no apparent injuries and/or sign and symptoms of distress from the alleged abuse. Additionally, the DNS indicated NA #6 received disciplinary action and was terminated from the facility on 5/4/15 due to violation of the Resident Bill of Rights, disrespectful behavior to residents, reprimanding a resident, and using a tone of voice that was very loud to a resident. 2. Resident #42's [DIAGNOSES REDACTED]. The care plan dated 2/23/15 identified depressed mood with interventions that included provide emotional support, antidepressant as ordered, offer choices and psychiatry evaluation as needed. The care plan further identified decreased activities of daily living with interventions that included to cue the resident to walk slowly, transfer and/or ambulate with one assist and a rolling walker. The quarterly Minimum Data Set assessment dated [DATE] identified the resident had severe impaired cognition, required limited assistance for transfer and ambulation and did not exhibit any behaviors. The Behavioral Health Follow-up dated 4/22/15 identified the resident exhibited anxiety, memory impairment, anger, agitation and irritability. The evaluation further identified the resident was unable to articulating whether pain was present. The Reportable Event dated 4/27/15 identified Nurse Aide (NA) #6 was in the dining room at lunch time and was witnessed by multiple staff members being rude and inappropriate to Resident #42. The facility investigation identified Medical Record Person #1 provided a statement on 4/27/15 on the incident. Medical Record Person #1 identified NA #6 pushed the resident to another table and stated very loudly and rudely he/she had to remain at that table and could not move. Resident #42 stated she/he did not want to be there and NA #6 said very loudly You have to stay here. The Behavioral Health Follow-up dated 4/27/15 identified chief complaints of high anxiety, yelling and being reprimanded by a staff person. The concern/finding identified no trauma impact from staff reprimanding the resident and the facility supervising staff to address staff behaviors. The recommendation identified the resident needed gentle redirection, soothing words, calm, and acknowledging the resident's mood. Review of the clinical record on 7/21/15 at 1:00 PM failed to identify documentation of the incident that occurred on 4/27/15 and/or that a nursing assessment and follow up of the resident was conducted. Interview with the Recreation Director on 7/21/15 at 12:25 PM identified he/she overheard the resident calling out and requesting several times to go to her/his room. Resident #42 was upset and was escalating, getting louder and louder saying he/she wanted to go the her/his room. NA #6 said no to the resident not in a good way. Interview with Director of Nurses (DNS) #2 (who was the DNS on 4/27/15) on 7/22/15 at 1:56 PM identified NA #6 was verbally abusive to Resident #42. NA #6 spoke loudly to the resident and would not allow Resident #42 to go back to her/his room. NA #6's inappropriate behaviors caused the resident to become upset and agitated. DNS #2 further stated that upon completion of the investigation, verbal abuse was substantiated. NA #6 in an interview on 7/23/15 at 9:46 AM indicated he/she was joking around and having fun with the resident and denied speaking loud and/or refusing to assist the resident back to their room. DNS #1 (current Director of Nurses) in an interview on 7/23/15 at 11:00 AM identified the resident was evaluated by Behavioral Health on 4/27/15 and suffered no apparent injuries and/or sign and symptoms of distress from the alleged abuse. Additionally, the DNS indicated NA #6 received disciplinary action and was terminated from the facility on 5/4/15 due to violation of the Resident Bill of Rights, disrespectful behavior to residents, and reprimanding resident, tone of voice was very loud.

Based on medical record reviews, review of facility documentation, review of facility policies, review of manufacturer's recommendations and interviews for two of six residents, the facility failed to ensure side rail safety and/or for one of three residents who required total staff assistance for activities of daily living and/or the use of a mechanical lift for transfers (Resident #3), the facility failed to ensure that the resident remained free from serious injury. The finding incudes: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial side rail assessment dated [DATE] (by nursing) indicated that the resident required the use of a side rail as an enabler. The plan of care dated 6/4/15 directed two side rails up in bed. Nursing narratives dated 6/11/15 on the night shift identified that the resident's right leg was inserted into the right side rail gap and the leg was slowly released in a wider gap in the rail. The nursing narrative further indicated that the resident sustained [REDACTED]. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial side rail assessment dated [DATE] (by nursing) identified that the resident required two side rails up as an enabler. The plan of care dated 1/9/15 directed 2 side rails up. Nursing narratives dated 1/18/15 indicated that at 3:50 AM the resident was noted to have both lower extremities through the side rails. The wound investigation form, undated, indicated that as a result of the side rail entrapment, the resident sustained [REDACTED]. Although the intervention documented on the undated wound investigation form identified side rails padded as an intervention, the resident's plan of care did not identify the padding of the side rails until 1/23/15. An incident report dated 1/19/15 documented the resident's entrapment and lacked an investigation/assessment of the side rails that entrapped the resident's lower limbs. Facility documentation dated 6/15/15 identified that the same bed with middle side rail caused Resident #1 and #2's lower limb (s) to become entrapped. Review of facility documentation and interview with the Independent Nurse Consultant on 6/24/15 at 11:00 AM noted that measurements of the side rail gap on an angle instead of a vertical measurement for zone one of middle side rails was greater than 4 3/4 inches to almost 5 inches and the facility had 46 such beds in the facility of which 36 were in use on 6/15/15. Documentation by the Maintenance Director dated 6/17/15 noted that in January 2015 he/she was not informed that Resident #2's leg had been stuck in the side rail (did not measure side rail for gaps). According to the Food and Drug Administration, Hospital Bed Dimensional Limit Recommendations, 11/26/14, Zone 1 within the rail should measure less than 4 3/4 inches. 3. #3's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident had severe cognitive impairment, required the total assistance of two for bed mobility, and transfer via a mechanical lift. The plan of care dated 3/25/15 noted problems of altered mobility and potential for alterations in skin integrity. Care plan interventions for the identified problems included to turn and reposition every two hours, 2 staff for mechanical lift transfer and the presence of two nurse aides during care. Although the intervention of two nurse aides present during care was discontinued on 5/20/15 as an intervention for the resident's decreased function, the intervention remained in place for the resident's problems of potential for altered skin integrity and cognitive loss. Nursing narratives and/or facility documentation dated 6/1/15 identified that a red mark was observed in the center of the resident's forehead at 7:15 AM by NA #2. Facility documentation and/or nursing narratives dated 6/1/15 indicated that the resident screamed with pain when his/her left lower extremity was manipulated during A. M. care, complained of left leg pain again during the following evening shift and was transferred via mechanical lift twice without a complete assessment of the pain. The x-ray dated 6/1/15 identified mildly displaced left proximal femur (hip) fracture. Review of the facility investigation dated 6/1/15 and staff interviews conducted on 6/24, 6/25, and 6/30/15 were inconclusive as to the cause of the resident's injury. Interviews with NAs #1, #2, and #4 on 6/30/15 noted that the resident required only one staff member to provide care and/or they were able to provide personal care to the resident without another staff member present on 5/31/15 and/or 6/1/15. The facility NA job description identified a major responsibility to perform direct and indirect resident care activities as per the plan of care.

Based on review of clinical records, review of facility policy and procedures, review of facility documentation and interviews with facility personnel for one out of three residents who were at risk to fall, Resident #1, the facility failed to provide adequate supervision to prevent a fall that resulted in a fractured hip. The findings include: 1. Resident #1 (R #1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the readmission assessment, Minimum Data Set ((MDS) dated [DATE] identified that R #1 had a Brief Interview for Mental Status (BIMS) of twelve, indicative of moderate, cognitive impairment, required extensive assistance with transferring and toileting, was not steady and only able to stabilize with staff assistance. A fall risk assessment dated [DATE] identified that R #1 was at risk to fall with interventions that included a bed and an alarmed Velcro belt in the wheelchair. Review of the clinical record identified a history of a fall on 5/21/12 at the acute care hospital, resulting in a small subdural hematoma. Review of the Physical Therapy evaluation dated 5/30/12 identified that R #1 required bilateral upper extremity support while ambulating. Review of the Resident Care Plan (RCP) dated 6/9/12 identified that R #1 continued to be at risk to fall with interventions that included the assistance of two persons for all transfers. Review of facility documentation and interview with Nursing Assistant #1 (NA #1) on 4/22/13 at 1:10 PM identified that R #1 was transferred and toileted with assistance of two persons on 6/26/12 at 6:10 AM, however, NA #1 could not recall who assisted her/him with the transfer. NA #1 identified that R #1's roommate (Resident #8) became extremely restless and attempted to get out of bed on 6/26/12 at 6:10 AM and that she left R #1 alone on the toilet in the bathroom in order to assist with Resident #8. NA #1 identified that she subsequently heard a thud and found R #1 on the bathroom floor. R #1 was transferred to the Emergency Department (ED) where he/she underwent an Open Reduction/Internal Fixation (ORIF) of the right hip due to fracture.

Based on clinical record review and interview for 1 of 4 sampled residents (Resident #76) who was reviewed for the presence of pressure ulcers, the facility failed to ensure that the resident's plan of care was comprehensive in relation to preventative measures to treat a pressure ulcer. The findings include: R# 76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE] identified intact heels. A braden assessment on admitted d 5/31/11 identified the resident was a mild pressure sore risk. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance of 2 persons with bed mobility and totally dependent on staff with two persons for transfer. Further assessment identified range of motion impairment on both sides of the lower extremities, was a risk for pressure ulcer development and had no pressure ulcers. Review of the admission care plan dated 6/11/11 identified the problem of potential alteration in skin integrity with interventions that included in part, pressure reduction devices to bed and chair , turn and reposition every two hours, weekly skin checks and protective barrier cream to the buttocks. A nursing note dated 9/16/11 identified the resident was observed self-propelling around the unit in the wheelchair with noted bilateral lower extremity [MEDICAL CONDITION] and a prior existing blister on the left shin area. Further documentation on 9/16/11 identified the resident had a small blister to the left heel. Review of nursing note dated 9/18/11 identified that a new area was found during morning care to the left heel which was described as beefy red color. Review of the physician orders [REDACTED]. Physician order's dated 9/18/11 directed a topical debridement treatment to the left heel, keep heels off bed, elevate legs, and bilateral heel booties while in bed. Additionally, a physician order [REDACTED]. Physician order [REDACTED]. An initial wound assessment dated [DATE] identified a nosocomial acquired pressure ulcer on the left heel. Further documentation identified the area measured 6cm x 6cm, Stage 2 pressure ulcer which was described as a darkened flattened blister around an open area. Review of the Weekly Skin Tracking Form dated 9/20/11 identified an intact blood blister on the left heel. The wound care specialist initial evaluation dated 9/20/11 identified a stage 2 blood filled pressure ulcer to the left heel with a recommendation to float heels while in bed. Continued review of wound tracking identified on 9/29/11 a stage 3 pressure ulcer on the left heel with 50% necrotic tissue, sanguineous drainage and soft adherent necrotic type tissue. Interview and review of the initial care plan with the ICN on 4/26/12 at 12noon identified that the facility failed to identify any preventative measures to the heels on admission. Review of the clinical record identified that only after the left heel pressure ulcer developed were interventions of pressure off -loading and/ or pressure relief provided.

Based on clinical record review, observation and interview for 2 of 4 sampled residents (Resident #"s 76 and 118) who were reviewed for the presence of pressure ulcers, the facility failed to provide the necessary treatment and services to prevent the development of a pressure ulcer and/or assess an alteraton in skin integrity. The findings include: The findings include: 1. a. R# 76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE] identified intact heels. A braden assessment on admitted d 5/31/11 identified the resident was a mild pressure sore risk. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance of 2 persons with bed mobility and totally dependent on staff with two persons for transfer. Further assessment identified range of motion impairment on both sides of the lower extremities, was a risk for pressure ulcer development and had no pressure ulcers. Review of the admission care plan dated 6/11/12 identified the problem of potential alteration in skin integrity with interventions that included in part, pressure reduction devices to bed and chair , turn and reposition every two hours, weekly skin checks and protective barrier cream to the buttocks. A nursing note dated 9/16/11 identified the resident was observed self-propelling around the unit in the wheelchair with noted bilateral lower extremity [MEDICAL CONDITION] and a prior existing blister on the left shin area. Further documentation on 9/16/11 identified the resident had a small blister to the left heel. Review of nursing note dated 9/18/11 identified that a new area was found during morning care to the left heel which was described as beefy red color. Review of the physician orders [REDACTED]. Physician order's dated 9/18/11 directed a topical debridement treatment to the left heel, keep heels off bed, elevate legs, and bilateral heel booties while in bed. Additionally, a physician order [REDACTED]. Physician order [REDACTED]. An initial wound assessment dated [DATE] identified a nosocomial acquired pressure ulcer on the left heel. Further documentation identified the area measured 6cm x 6cm, Stage 2 pressure ulcer which was described as a darkened flattened blister around an open area. Review of the Weekly Skin Tracking Form dated 9/20/11 identified an intact blood blister on the left heel. The wound care specialist initial evaluation dated 9/20/11 identified a stage 2 blood filled pressure ulcer to the left heel with a recommendation to float heels while in bed.Continued review of wound tracking identified on 9/29/11 a stage 3 pressure ulcer on the left heel with 50% necrotic tissue, sanguineous drainage and soft adherent necrotic type tissue. Interview and review of the clinical record and facility documentation with the Infection Control Nurse (ICN) on 4/26/12 at 8:15 AM identified that standard prevention for heel pressure ulcers should include blue left boots and pillows to elevate heel off bed. Further interview identified that no prevention interventions to the heels could be found in the clinical record until after the development of the left heel pressure ulcer. The clinical record review included the care plan, nursing notes, and monthly treatment kardex from May 31, 2011 until September 18 2011 Review of the facility Heel Ulcer Prevention and Management policy identified that residents with impaired circulation are at the greatest risk for heel ulcers and need aggressive treatment and the most effective intervention for heel ulcers is to eliminate pressure. b. Intermittent observation of R# 76 on 4/25/12 from 1pm-6PM (total of 5 hours) identified the resident out of bed in a modified custom wheelchair. Although the resident was tilted once in the chair and incontinent brief change, no significant time of pressure relief was done for a resident with a stage 3 pressure ulcer of the coccyx/sacrum area and left heel. Observation of the resident sacrum 4/25/12at 4:30PM identified a large dressing to the area. Review of the Wound clinical record and Wound Care Specialist Evaluation identified a Stage 3 Pressure Ulcer of the sacrum. The wound documentation identified an 8cm x 5cm x 0.2cm pressure ulcer. The documentation identified 30% slough, moderate sero-sanuinous drainage with surrounding Deep Tissue Injury. Interview and review of the care plan with the Assistant Director of Nursing on 4/25/12 at 5PM identified that the resident should have been repositioned every two hours because of the stage 3 pressure sore of the coccyx/sacrum. 2. R#118 [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated that the resident was severely impaired cognitively and rarely exhibited cognitive skills for daily decision making. Additional review of the MDS indicated that the resident was an extensive assist with bed mobility and needed 2 nursing staff to assist with positioning when in bed. A review of the nursing notes dated 3/23/12 indicated LPN # 6 identified a reddened area to the buttocks and that he/she called the physician for an order. LPN #6 indicated that he/she could not recall if the nursing supervisor was informed. A review of the 3/23/12 nursing notes failed to show documentation that the wound was assessed by an RN. An interview with the Unit Manager on 3/25/12 indicated that he/she was not aware of the wound on 3/23/12. A review of the pressure ulcer log indicated that the RN nursing assessmet was not initated until 3/26/12. An interview with the Director of Nurses on 4/26/12 at 12:30PM indicated that the Registered Nurse supervisor should have assessed and co signed the LPN assessment as per the facility protocol. The DNS indicated that it was an oversight of the staff.

Based on clinical record reviews, interviews and review of facility documentation for one of four sampled residents (R#1), with injuries of unknown origin and/or who required assistance with transfers, the facility failed to ensure adequate supervision to prevent accidents. The findings include: a. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment ((MDS) dated [DATE] identified short and long term memory deficits, moderately impaired decision making ability, and was dependent on staff for transfers and hygiene. A care plan dated 1/18/12 identified impaired mobility requiring mechanical lift for transfers with interventions that included to ensure resident safety during transfer and to utilize 2 staff members to transfer using mechanical lift. Physician orders [REDACTED]. Nurse's notes dated 1/18/12 at 8:30 AM identified a bruise on the right shoulder and complaints of pain when repositioning R#1's hand. The Advanced Practice Registered Nurse (APRN) assessed R#1 and directed to send the resident to the emergency room for an evaluation. R#1 returned to the facility on [DATE] at 5:00 PM with a [DIAGNOSES REDACTED]. Interview with nurse aide (NA) #4 on 2/22/12 at 1:25 PM identified that he/she had given R#1 a shower on 1/17/12 during the 7-3 PM shift and had the assistance of NA#1 for the mechanical lift transfers without incident. NA #4 further identified that he/she was notified the following day that there was an injury to the resident's arm. Although NA #4 identified that he/she had the assistance of NA#1 for all transfers involving R#1, on 1/17/12, NA #1 identified in an interview on 2/22/12 at 2:00 PM that he/she did not provide assistance during the mechanical lift transfers on 1/17/12. Interview with the Director of Nurse's on 2/22/12 at 1:50 PM identified that due to the discrepancies in the nurse aide's statements, it could not be determined if the facility policy was followed regarding the utilization of two staff members for transfers with a mechanical lift resulting in an injury to the resident. b. Nurse's notes dated 2/6/12 at 2:00 PM identified R#1 fell out of the Hoyer lift onto the floor while being transferred from the bed to the wheelchair sustaining a laceration to the left side of his/her head. R#1 was transferred to the Emergency Department for an evaluation and returned to the facility with a fracture of the zygomatic arch. Interview with NA#2 on 2/22/12 at 1:00 PM identified that he/she was assisting NA #3 with a mechanical lift transfer involving R#1 on 2/6/12. NA#3 was operating the mechanical lift and NA#2 was guiding the resident during the transfer. NA#2 identified that he/she was moving around the bed to the wheelchair waiting for NA#3 to turn the resident in the lift in order to be positioned in the chair at which time the resident flipped out of the lift, landing on the floor. NA#2 further identified that when he/she was changing position from the bed to the wheelchair he/she was not in direct physical contact with the resident. Interview with the Director of Rehabilitation on 2/22/12 at 1:20 PM identified that annual competencies are conducted with nursing assistants regarding mechanical lifts. He/she further identified that the standard of practice is for one nurse aide to operate the controls of the lift and the other nurse aide to guide the patient, ensuring that direct contact is maintained throughout the transfer to provide a safe transfer and positioning.