Every finding on record at Willowbrooke Court Skilled Care Center Fairhaven

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure that dignity was maintained for a Resident with non-pressure wounds. This was evident in 1 (Resident #39) of 1 reviewed for dignity. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. The information collected informs Resident care planning decisions. An observation on 7/20/26 at 10:01 AM showed that several residents were sitting in their wheelchairs and had congregated in front of the nurses' station. The observation also showed Resident #39 sitting among the other residents, wearing shorts, with multiple red, weepy-looking wounds on both legs and no wound dressings on the wounds. In a follow-up observation on 7/20/26 at 10:40 AM, Resident #39 was sitting in a common room on the unit with other residents participating in an activity program, and the Resident's wounds remained uncovered. Record review for Resident #39 on 7/20/26 at 10:45 AM showed an MDS assessment dated [DATE], which noted that the Resident had severe cognitive impairment and relied on staff for all self-care needs. A continued review noted that Resident #39 had chronic wounds on both lower extremities. The review also included a treatment administration record (TAR) for Resident #39 for July 2026, which indicated that the Resident's wounds were to be cleaned daily and covered in the morning. The TAR documented that the Resident's wound treatment had been completed; however, earlier observations did not show that Resident #39's wounds were covered with dressings while he/she was sitting in common areas. During an interview on 7/21/26 at 11:56 AM, staff #5, a licensed practical nurse, explained that the dressing on Resident #39's wounds had been removed to give him/her a shower and should have been replaced after the shower, before bringing the Resident out of his room to the common area with other residents. In an interview on 7/22/26 at 9:11 AM, the director of nursing and the assistant director of nursing stated that they expected Resident #39's wounds to be covered with a dressing before bringing Resident #39 out of the room to the common areas with other residents.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that residents were informed of their right to formulate an advance directive. This was evident in 1 (Resident #6) of 2 residents reviewed for advance directives during the survey. The findings include:An advance directive is a legal statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor because of illness or incapacity. The Minimum Data Set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information about each Resident's strengths and needs. The information collected informs Resident care planning decisions. A medical record review on 7/20/26 at 1:04 PM showed that Resident #6 had lived in the facility since 2017. Further review included a document completed by the Resident's attending provider on 9/13/18, which indicated that the Resident could make his/her own decisions. The review also included an MDS assessment dated [DATE] for Resident #6, which indicated that the Resident had intact cognition. However, the review failed to show that Resident #6 had been informed of his/her right to formulate an advance directive or that the facility had periodically reviewed the advance directive with the Resident. In an interview on 7/21/26 at 1:42 PM, staff #3, the social services coordinator, indicated that the team discussed with residents who could make their own decisions their right to formulate an advance directive during their care plan meetings. However, an earlier review of Resident #6's latest care plan meeting notes, dated 6/9/26, did not show that there was a discussion with Resident #6 about developing an advance directive. In a follow-up interview on 7/21/26 at 2:08 PM, staff #3 reported that she lacked supporting documentation confirming that an advance directive had been discussed with Resident #6.

Based on record reviews and interviews, it was determined that the facility failed to notify a resident's attending provider and responsible party in a timely manner after a significant medication error occurred. This was evident in 1 (Resident #39) of 5 residents reviewed for unnecessary medications during the annual survey. The findings include:A PT/INR test measures how long it takes for your blood to clot, checks normal clotting times, monitors blood-thinning medicine like Coumadin, and evaluates liver function. A review of Resident #39's medication administration record for July 2026 showed that the Resident was to receive Coumadin 3 mg (a blood thinner) daily for chronic blood clots, starting on 6/26/26. Further review included a nurse's progress note dated 7/10/26, which reported that a covering attending provider reviewed Resident #39's lab results and increased the Resident's Coumadin from 3 mg to 4 mg each evening. This means Resident #39's previous Coumadin order of 3 mg daily was to be discontinued on 7/10/26, as the attending provider intended the Resident to start receiving 4 mg. However, the review showed that Resident #39 continued to receive Coumadin 3 mg in addition to Coumadin 4 mg, totaling 7 mg daily on 7/12/26, 7/13/26, 7/14/26, and 7/15/26. The review also noted that on 7/15/26 at 10:53 PM, staff #1, a licensed practical nurse, discontinued Resident #39's order for Coumadin 3 mg daily. However, the review lacked supporting documentation to show that Resident #39's attending provider and representative had been notified that Resident #39 had received Coumadin 7 mg on 7/12/26, 7/13/26, 7/14/26, and 7/15/26 instead of 4 mg on those days. A subsequent review showed that Resident #39's therapeutic goal for the blood thinner was 2-3. However, Resident #39's PT (Prothrombin Time) and INR (International Normalized Ratio) laboratory results dated [DATE] showed a critical result of 7.55. (A PT/INR test measures how long it takes for your blood to clot, checks normal clotting times, monitors blood-thinning medicine like Coumadin, and evaluates liver function.) An interview with the director of nursing on 7/22/26 at 12:59 PM revealed that she had not been informed of the significant medication errors involving Resident #39 on 7/12/26, 7/13/26, 7/14/26, and 7/15/26. An interview with Resident #39's attending provider on 7/23/26 at 10:45 AM indicated that she learned of the significant medication error involving the Resident's blood thinner only after the surveyor's intervention on 7/22/26. During a follow-up interview with staff #1, she explained that she discontinued the Coumadin 3 mg order for Resident #39 only on 7/15/26, based on her nursing judgment after noticing that the Resident had been receiving 7 mg of Coumadin daily for 4 days instead of 4 mg. She also confirmed that the Resident's attending provider and representative were not notified when she identified the significant medication error on 7/15/26.

Based on record reviews and interviews, it was determined that the facility failed to ensure residents were free of significant medication errors. This was evident in 1 (Resident #39) of 5 residents reviewed for unnecessary medications during the annual survey. The findings include:A review of Resident #39's record on 7/21/26 at 11:18 AM included an attending physician's visit note dated 6/3/26, which indicated that the Resident had a chronic blood clot in the left femoral vein (the large vein in the leg that carries blood back to the heart) and was to receive Coumadin daily.Continued review of Resident #39's medication administration record for July 2026 showed that Coumadin 3 mg daily was initiated for the Resident on 6/26/26. Further review included a nurse's progress note dated 7/10/26, which reported that a covering attending provider reviewed Resident #39's lab results and increased the Resident's Coumadin from 3 mg to 4 mg every evening, meaning the Resident's previous Coumadin order for 3 mg daily was to be discontinued on 7/10/26.However, the review showed that Resident #39 continued to receive Coumadin 3 mg in addition to Coumadin 4 mg, for a total of 7 mg daily on 7/12/26, 7/13/26, 7/14/26, and 7/15/26.A subsequent review showed that Resident #39's therapeutic goal for the blood thinner was 2-3. However, Resident #39's PT (Prothrombin Time) and INR (International Normalized Ratio) laboratory results dated [DATE] showed a critical result of 7.55. (A PT/INR test measures how long it takes for your blood to clot, checks normal clotting times, monitors blood-thinning medicine like Coumadin, and evaluates liver function.)During an interview with the director of nursing on 7/23/26 at 10:33 AM, she reported that following the surveyor's intervention, the facility reported the medication error involving Resident #39 to the state office on 7/22/26.In an interview with Resident #39's attending provider on 7/23/26 at 10:45 AM, she explained that the Resident's Coumadin had been increased from 3mg to 4mg on 7/10/26 due to a low therapeutic INR result on 7/10/26. She expected Resident #39's previous order for 3mg to be discontinued on 7/10/26 and not given together to the Resident on 7/12/26, 7/13/26, 7/14/26, and 7/15/26.

Based on record reviews and interviews, it was determined that the facility failed to implement its written agreement with the hospice provider to ensure the development and maintenance of a current, coordinated plan of care for 2 (Resident #4 and Resident #5) of 2 residents reviewed for hospice services. The findings include: On 7/21/26 at 10:40 AM, a review of the written Hospice Service Agreement between the facility and BridgingLife Hospice Care revealed that the Hospice Plan of Care was defined as an individualized, written interdisciplinary plan containing an assessment of the hospice patient's needs, identifying the services to be provided, and describing in detail the scope and frequency of hospice services and supplies necessary to palliate and manage the resident's terminal illness. The agreement required BridgingLife to furnish the facility with a copy of the hospice plan of care for integration into the nursing facility plan of care.The agreement further required one plan of care to be developed collaboratively between facility and hospice staff and periodically reviewed and modified collaboratively. The facility was required to provide services to each hospice resident in accordance with the hospice plan of care and the nursing facility plan of care. The agreement also required the facility and hospice provider to prepare and maintain complete and detailed clinical records concerning each hospice resident, including services provided and events concerning the resident.1. Resident #4Review of Resident #4's electronic clinical record revealed a physician's order dated 5/19/26, to admit the resident to BridgingLife Hospice.On 7/21/26 at 11:30 AM, review of Resident #4's hard-copy clinical record on the [NAME] View unit revealed a section designated for BridgingLife documentation. The record contained documentation of the resident's election of the Medicare hospice benefit, consent for hospice treatment, a Hospice Plan of Care Coordination Tool, and handwritten hospice progress notes dating from the resident's admission to hospice through 7/21/26.The Hospice Plan of Care Coordination Tool identified scheduled hospice Registered Nurse (RN) and hospice aide visits twice weekly. It contained general checkmarks assigning certain services to the hospice provider, the facility, or both. However, the tool did not contain the resident's comprehensive hospice assessment, individualized hospice interdisciplinary goals and interventions, a common problem list, or detailed identification of the disciplines and providers responsible for the resident's current palliative care needs.Review of the handwritten hospice progress notes revealed entries from hospice nursing, social work, aide, and chaplain services. Multiple entries did not identify the time of the visit. Several entries contained only a signature, without a printed name or completed discipline designation. The documentation did not include the hospice interdisciplinary group's current plan of care, interdisciplinary group review documentation, or subsequent updates to the hospice plan of care.On 7/21/26, at 11:38 AM, further review of Resident #4's hard-copy and electronic clinical records revealed no evidence of the hospice provider's individualized interdisciplinary plan of care.On 7/21/26 at 11:55 AM, a review of Resident #4's facility comprehensive care plan revealed that the facility developed a hospice-focused care plan area on 5/22/26. The care plan identified that the resident had a terminal prognosis related to senile degeneration of the brain and established a goal that the resident's comfort would be maintained. Interventions included observing the resident for pain, administering medications as ordered, working cooperatively with the hospice team, and working with nursing staff to provide maximum comfort.The facility comprehensive care plan did not incorporate the twice-weekly hospice RN and hospice aide visits identified on the coordination tool, the hospice interdisciplinary group's individualized palliative interventions, or a specific delineation of which services and functions were the responsibility of the hospice provider and which remained the responsibility of the facility.2. Resident #5Review of Resident #5's electronic clinical record revealed an order dated 4/22/26, for a BridgingLife Hospice consultation and an order dated 4/25/26, to admit the resident to hospice.On 7/20/26 at 10:50 AM, during a telephone interview with Resident #5's family member, they stated that the hospice provider regularly communicated with the resident's family. The family member stated that the hospice nurse provided follow-up telephone calls after visits and that the hospice social worker and chaplain also provided routine updates. The family member stated that she/he and their other family member, who were the resident's primary contacts, lived out of state and commended the hospice provider for its regular communication.On 7/21/26 at 11:30 AM, review of Resident #5's hard-copy clinical record on the [NAME] View unit revealed a section designated for BridgingLife documentation. The record contained documentation of the resident's election of the Medicare hospice benefit, consent for hospice treatment, a Hospice Plan of Care Coordination Tool, and handwritten hospice progress notes dating from the resident's admission to hospice through 7/21/26.The Hospice Plan of Care Coordination Tool identified scheduled hospice RN and hospice aide visits twice weekly. It contained general checkmarks assigning certain services to the hospice provider, the facility, or both. However, the tool did not contain the resident's comprehensive hospice assessment, individualized hospice interdisciplinary goals and interventions, a common problem list, or detailed identification of the disciplines and providers responsible for the resident's current palliative care needs.Review of the handwritten hospice progress notes revealed entries from hospice nursing, social work, aide, and chaplain services. Multiple entries did not identify the time of the visit. Several entries contained only a signature, without a printed name or completed discipline designation. The documentation did not include the hospice interdisciplinary group's current plan of care, interdisciplinary group review documentation, or subsequent updates to the hospice plan of care.On 7/21/26 at 11:38 AM, further review of Resident #5's hard-copy and electronic clinical records revealed no evidence of the hospice provider's individualized interdisciplinary plan of care.Review of Resident #5's facility comprehensive care plan revealed that the facility developed a hospice-focused care plan area on 5/8/26. The care plan identified that the resident was under the care of BridgingLife Hospice and established a goal of maintaining the resident's comfort. Interventions included assessing the resident's coping strategies, monitoring the resident for signs of pain, administering comfort medications as ordered, and working cooperatively with the hospice team to meet the resident's spiritual, emotional, intellectual, physical, and social needs.The facility comprehensive care plan did not incorporate the twice-weekly hospice RN and hospice aide visits identified on the coordination tool, the hospice interdisciplinary group's individualized palliative interventions, or a specific delineation of which services and functions were the responsibility of the hospice provider and which remained the responsibility of the facility.Although the family interview supported that hospice visits and family communication were occurring, the facility could not produce the hospice interdisciplinary plan governing those services or demonstrate how the hospice plan was coordinated with the facility's comprehensive care plan. On 7/21/26 at 11:59 AM, during an interview with Staff #1, a Licensed Practical Nurse (LPN), they stated that hospice aides communicated with facility staff regarding morning care provided to residents and that hospice nurses communicated about services provided and concerns identified during their visits. Staff #1 stated that most hospice documentation was maintained on paper. Recommendations and orders received from the hospice provider were entered into the facility's electronic clinical record. Staff #1 did not identify where the current hospice interdisciplinary plans of care or interdisciplinary group updates for Residents #4 and #5 were maintained.On 7/21/26 at 1:42 PM, during an interview with Staff #3, the Social Services Coordinator stated that hospice representatives and resident representatives were invited to facility care-plan conferences and that hospice plan-of-care updates were communicated through the nursing department. Staff #3 stated that when the facility received a resident's hospice plan of care or determination of terminal illness, the documentation was maintained in the resident's electronic clinical record. Review of the electronic and hard-copy clinical records for Residents #4 and #5 did not reveal the hospice interdisciplinary plans of care. On 7/21/26 at 3:19 PM, the Director of Nursing and Assistant Director of Nursing were informed that the current hospice interdisciplinary plans of care could not be located in either resident's hard-copy or electronic clinical record. The Director of Nursing and Assistant Director of Nursing acknowledged that the hospice plans of care for Residents #4 and #5 were unavailable. Specifically, the facility failed to obtain and make available the hospice provider's current interdisciplinary plans of care. It failed to demonstrate that the facility's comprehensive care plans were coordinated with the hospice plans of care and identified the current palliative interventions, responsible disciplines and providers, and respective responsibilities of the facility and hospice provider for Resident #4 and Resident #5.On 7/23/26 at 1:50 PM, during an interview with the Nursing Home Administrator and the Director of Nursing, they were informed that current hospice interdisciplinary plans of care for Resident #4 and Resident #5 were not available in electronic or hard-copy format. They acknowledged the surveyor's concern, and no additional evidence was provided before the end of the survey.

Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 of 2 kitchen observations and 1 of 2 unit refrigerators observed during the recertification survey. The findings include:1) An initial tour of the facility's kitchen with staff #6, director of culinary and nutrition services, on 7/20/26 at 8:54 AM revealed the following:Observation of the facility's walk-in refrigerators revealed the following:-6 cartons of Farmland reduced cultured buttermilk with a use-by date of July 14, 2026. Staff confirmed the use-by dates and said, I will dump them all right now.- 3 bags of unopened parmesan cheese and 1 bag of cheddar cheese with labels stating the received date was 7/17/26 but had no use-by dates.-3 multi-serve pouches of Yoplait Parfait Pro low-fat yogurt with a best-by date of 6/11/26. Staff confirmed the best-by date and disposed of them. 2) An observation on 7/20/26 at 10:37 AM of the 1st floor Unit refrigerator with staff #7, a nursing supervisor, showed the following ready-to-eat boxed meals:-Goat cheese & tomato cream ground turkey with a use-by date of 7/8/26-Garlic herb roasted barramundi with a use-by date of 7/3/26.-[NAME] olive & tomato barramundi with a use-by date of 7/4/26.-Lemon butter steelhead [NAME] with a use-by date of 7/4/26. Staff #7 explained that typically residents' personal food items that are ready to eat or leftovers are kept for 3 days. However, unopened boxed meals were kept until their expiration dates. Staff added that she would speak to the Resident and discard the food items after the surveyor's intervention. During an interview on 7/22/26 at 9:18 AM, the director of nursing (DON) and the assistant director of nursing (ADON) explained that the night shift staff were responsible for checking and cleaning the unit refrigerators daily. They added that for boxed, unopened residents' meals kept in the unit refrigerators, staff were to follow the expiration dates on the boxes. The DON also reported that the expired meals were discarded after the surveyor's intervention.

Number of residents sampled: Number of residents cited: Based on observation and interview, it was determined the facility failed to provide food at an appetizing temperature. This was evident for 1 out of 1 observation of a meal and test tray. The findings include:On 07/17/2025 at 12:02 PM, the surveyor observed the start of the lunch meal on the first floor pine view unit dining area. The plates were prepared in the kitchenette within the dining area, from prepared food that was kept on steam tables.On 07/17/2025 at 12:47 PM, the surveyor observed the dining staff prepare the test tray plate.On 07/17/2025 at 12:49 PM, the test tray left the kitchenette on a cart with other trays, which belonged to residents who were eating lunch in their rooms. On 07/17/2025 at 12:51 PM, the test tray arrived in the prospective hallway. The staff began to deliver the trays which belonged to residents, which were on the same cart as the test tray.On 07/17/2025 at 12:52 PM, the last resident tray had been delivered. The surveyor requested Medical Dietary Aide (Staff #8), who was present at the time, to take the temperature of the food on the test tray. The spaghetti was 107.2 degrees Fahrenheit and the beef soup was 120.5 degrees Fahrenheit. On 07/17/2025 at 12:54 PM, the surveyor tested the spaghetti and beef soup, which were room temperature to taste.On 07/17/2025 at 1:03 PM, the surveyor reviewed the concern with the Nutrition Services Manager (Staff #11). She indicated that the facility realized their steam tables were not working correctly after the test tray temperature result.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, it was determined that the kitchen failed to ensure food items were stored to maintain the integrity of the specific items. This was evident for the initial observation of the kitchen upon facility entry. This failure has the potential to affect all residents.The findings include:On 07/15/2025 at 7:41 AM, an observation of the kitchen revealed the first of three walk-in refrigerators, which had opened and unlabeled bologna and opened and unlabeled salami.On 07/15/2025 at 7:43 AM, an observation of the second of three walk-in refrigerators revealed opened and unlabeled feta cheese, opened and unlabeled parmesan cheese, and opened and unlabeled yellow american cheese.On 07/15/2025 7:48 AM, an observation of the dry storage room revealed opened and unlabeled linguine pasta, opened and unlabeled graham cracker crumbs, an opened container of brown rice labeled use by 9/17/24, an opened container of panko bread crumbs labeled use by 2/1/25, and an opened bag of pecans dated 7/8/25.On 07/15/2025 at 7:53 AM, an interview with [NAME] (Staff #13), revealed that the expectation of kitchen staff was when they opened or prepared items, to use the machine that creates a label for various food items.On 07/15/2025 at 7:56 AM, further observation of the kitchen revealed opened canola oil, red wine vinegar, soy sauce, powdered sugar, cooking wine, and light corn syrup. All of the cooking items had a single date on them, which was written on the containers. On 07/15/2025 at 8:11 AM, an interview with the Director of Culinary Services (Staff #12) revealed that the expectation of staff was to label every item upon opening, whether it was a cooking ingredient, seasoning, refrigerated item, or dry storage item. Further interview with Staff #12 revealed the staff were expected to use the label machine on all products, and not write in one singular date on items.

Based on resident and representative interviews, record reviews, and staff interview, it was determined the facility failed 1. to include the resident or their representative in the care planning process, 2. update and revise the care plan to accurately reflect the resident's current interventions and treatments. This was evident in 4 (Resident #3, #31 #35, and #44) out of 12 residents reviewed for care planning. The findings Include: 1a. On 7/15/2025 at 8:56 AM, An interview was conducted with Resident #35. The resident stated that they cannot remember if they have been to a care plan meeting. On 7/15/2025 at 10:24 AM, Record review of Resident #35's electronic health record was conducted. No documentation found regarding care plan meetings in the year of 2025. Latest care plan meeting signature sheet found in the resident's record was from October 2024. On 7/16/2025 at 11:18 AM, An interview was conducted with the Assistant Director of Nursing (ADON). When asked when the facility conducts care plan meetings, the ADON stated that typically after the care plan is revised Quarterly (Every 3 months). The ADON stated that Resident #35 had their last care plan revision in April. When asked if a care plan meeting was conducted with the resident or the representative, ADON stated that they will see if they have any notes or meeting signatures for the 2025 year. On 7/17/2025 at 8:55 AM, An interview was conducted with Resident #35's Representative. The Resident Representative stated they had not had a Care Plan meeting in roughly 6 months. On 7/17/2025 at 8:56 AM, A review of Minimum Data Set (MDS) assessments and Care Plan Revisions was conducted. Revisions to care plans were noted to have been made on 1/3/2025 and 4/18/2025. MDS Quarterly Assessment was completed on 12/7/2024, 3/9/2025, 6/8/2025. The Minimum Data Set (MDS) is a standardized, comprehensive assessment tool used in nursing homes to evaluate residents' functional abilities and healthcare needs. On 7/17/2025 at 9:29 AM, the ADON stated that they could not provide evidence of a care plan meeting with the resident or the resident's representative since the last care plan meeting signatures from October 2024. 1b. Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). On 7/15/25 at 8:37AM An interview with Resident #44 was conducted. They stated that they have not been invited for a care plan meeting in a long time. On 7/16/2025 at 9:31 AM, A review of Resident #44's medical record was conducted. The review revealed that the resident's last care plan meeting was 3/21/25. Additionally, the review revealed a completed quarterly MDS dated [DATE]. On 7/16/2025 at 11:03 AM A review of the facility's care plan policy indicated that a care plan meeting must be developed within 7 days after completion of MDS. On 7/16/2025 at 11:18 AM An interview with the social worker was conducted. The social worker stated that the Resident did not receive an invitation for her 90-day care plan meeting. On 7/16/2025 at 11:20 AM The Assistant Director of Nursing (ADON) was notified of care plan meetings concern. 1c. On 7/15/2025 at 9:52 AM An interview with Resident #31's representative was conducted. They reported that they have not attended a care plan meeting recently. On 7/15/2025 at 10:25 AM A review of Resident #31's medical record was conducted. The review indicated that the resident was admitted into the facility on 1/27/25 and had a care plan meeting on 3/14/25. This was the last care plan meeting the Resident or Resident Representative attended. Further review of the record indicated that the resident had a quarterly MDS completed on 5/3/25. On 7/16/2025 at 11:18 AM, An interview with the Social Worker was conducted. Per Social Worker the Resident #31 did not have a quarterly care plan meeting as required. On 7/16/2025 at 11:20 AM The ADON was notified of the concern. 2. On 7/15/2025 at 07:45 AM, Resident #3 was observed receiving oxygen via a nasal cannula. On 7/16/2025 at 08:45 AM, a review of Resident #3's medical records revealed that on 5/5/2025 an order was placed by Physician #7 that stated, “Administer Oxygen at 2 liters per minute via nasal cannula. every shift for COPD.” Further review of the resident's medical records, on 7/16/2025 at 9:05 AM, revealed the resident's care plan dated 7/12/2025 had a focus that stated, “I use oxygen as needed for SOB or POX below 92% r/t history of hypoxia”. The care plan failed to address the current order for continuous oxygen. During an interview with the ADON on 07/16/2025 at 1:53 PM, she stated that the expectations are that care plans would be updated to reflect current treatments that the residents are receiving. At this time the ADON was made aware of the findings and again at exit.

Based on observation and interview, it was determined that the facility failed to ensure that a resident was free from abuse. This was evident for 1 of several observations made on the first floor pine view unit during an annual survey.The findings include:On 07/15/2025 at 9:59 AM, an observation on the first floor pine view unit revealed Resident #43 had his/her room call light on. On 07/15/2025 at 10:03 AM, further observation revealed Geriatric Nursing Assistant (Staff #6) walk into Resident #43's room. At the same time, the surveyor overheard Staff #6 indicate that he/she had just used the restroom with therapy. The surveyor then observed Staff #6 walk out of Resident #43's room.On 07/15/2025 at 10:08 AM, an interview with Resident #43 revealed that he/she needed to use the restroom, but no one would take her. On 07/15/2025 at 10:51 AM, an interview with Staff #6 revealed that the resident often would put his/her call light on to use the restroom, but then would not actually go. She further said that therapy services had just left the room and took the resident to use the restroom.On 07/15/2025 at 1:10 PM, an interview with the Acting Director of Nursing revealed that staff were expected to take residents to the restroom, even if they had just been taken. The surveyor reviewed the concern.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to report an allegation of abuse in a timely manner. This was evident for 1 (Incident #358045) of 9 Facility Reported Incidents (FRIs) reviewed during an annual survey.The findings include:On 7/17/25 at 10:35 AM, review of investigation documentation provided by the facility revealed that Resident #2 informed Occupational Therapist (Staff #14) on 4/4/25 at 9:12 AM that a care giver the evening prior was rough with him/her and in result caused his/her knees pain.On 7/17/25 at 10:37 AM, further review of the investigation documentation revealed that the facility failed to report the incident to the Office of Health Care Quality until 4/4/25 at 5:07 PM.On 7/18/25 at 10:57 AM, an interview with the Nursing Home Administrator revealed he was unaware that the facility needed to report all allegations of abuse within two hours. The surveyor reviewed the concern with the Nursing Home Administrator.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that written notification of transfer was provided to the resident and or resident representative upon transfer and failed to ensure the comprehensive care plan goals were sent with the resident upon transfer. This was evident for 1 (Resident #46) of 1 resident reviewed for hospitalizations during an annual survey.The findings include:1a) On 07/16/2025 at 8:55 AM, review of Resident #46's medical record revealed he/she was hospitalized on [DATE].On 07/16/2025 at 9:38 AM, an interview with Registered Nurse (Staff #5) revealed that verbal notice of reasoning for transfer was given to the resident or representative, and that it was not in written form.On 07/16/2025 at 10:52 AM, the facility was unable to provide documentation that written notification of transfer with reasoning was provided to the resident and the resident representative. The concern was reviewed with the Acting Director of Nursing. 1b) On 07/16/2025 at 9:38 AM, interview with Registered Nurse (Staff #5) revealed that resident care plan goals were not sent with the residents upon a transfer. She showed the surveyor a binder that had a checklist of documents, which failed to include comprehensive care plan goals.On 07/16/2025 at 10:52 AM, the surveyor reviewed the concern with the Acting Director of Nursing.

Based on record review and interviews, it was determined that the facility failed to code the resident's status accurately on the Minimum Data Set (MDS). This was evident for 1 (Resident #5) of 11 residents reviewed for accuracy of assessment. The findings include:The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.Benign Prostatic Hyperplasia (BPH), also known as an enlarged prostate is a common condition in older men where the prostate gland grows larger, potentially causing urinary problems by pressing on the urethraOn 7/16/2025 at 10:05 AM A review of Resident #5's medical record was conducted. The review revealed that the resident was admitted into the facility on 2/3/25. The resident's hospital discharge notes dated 1/21/25 indicated that the resident had BPH as an active diagnosis. Further review of Resident #5's MDS section I (active disorders) that was completed on 5/5/25, failed to indicate that the resident had BPH. Furthermore, the record revealed an active order dated 4/24/25 for a foley catheter insertion due to urinary retention,On 7/17/2025 at 12:46 PM The Assistant Director of Nursing (ADON) was asked to provide documentation on when Resident #5 first had a foley catheter insertion. On 7/17/2025 at 2:40 PM The ADON provided a progress note dated 2/19/25 that indicated resident had a foley placed secondary to underlying BPH.On 7/18/2025 at 12:02 PM A review of resident records revealed a provider's note entered on 4/28/25 that indicated active diagnosis that included acute urinary retention with underlying history of BPH, staff to continue foley catheter. On 7/18/2025 at 12:32 PM An interview with the MDS coordinator was conducted. When asked where she obtains information to code active diagnosis, the MDS coordinator stated that it needed to be from a doctor's progress note and to be considered active, the Resident needed to be receiving active treatment or intervention. The MDS was notified of the failure to code BPH despite the available information on the resident's record.On 7/18/2025 at 12:32 PM The ADON was notified of concern with MDS coding accuracy.

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice related to 1. documentation of treatment administration and 2. documentation of a resident's current diagnosis. This was evident for 3 (Resident #8, #3, #50) out of 12 residents reviewed during the annual recertification survey.The findings include: 1a. On 07/16/2025 at 9:23 AM, review of Resident #8’s medical record revealed an active order for hipsters (cushion belt to protect hips) to be worn at all times. On 07/16/2025 at 9:30 AM, an observation of Resident #8 revealed the resident was in their room recliner eating breakfast, but failed to reveal the hipster brace was on. On 07/16/2025 at 9:44 AM, an interview with Registered Nurse (Staff #5) revealed that the resident was supposed to wear the hipster brace at all times, but that he/she refused it that morning and it would be put on at a later time. On 07/16/2025 at 9:46 AM, review of the administration record for Resident #8’s order revealed that the hipster order was signed off as completed on 07/16/25 at 8:37 AM. On 07/16/2025 at 10:54 AM, an interview with the Acting Director of Nursing revealed that the expectation of staff was to not sign off an order as completed unless it was done. She said that if a resident refused, the staff had a way of signing off on the order as refused. The surveyor reviewed the concern. 1b. On 7/17/2025 at 9:43 AM, Complaint #358047 was reviewed. The complaint alleged that the facility was not placing Resident #50's sling on the resident as ordered. On 7/17/2025 at 1:36 PM, a review of the Treatment Administration Record (TAR) and progress notes was conducted. The TAR indicated that nursing staff had marked the order, Wear Sling to left shoulder at all times every shift for Sling, as held on 5 shifts in the month of August 2024. There was no progress notes explaining why the order was held. On 7/17/2025 at 2:36 PM, An interview with the Assistant Director of Nursing (ADON) was conducted. When asked what the expectation for staff documentation when a treatment is held in the Treatment Administration Record, the ADON stated that there should be an accompanying note to describe why the treatment was held. When asked if there should have been a note for staff holding Resident #50's order for a sling, the ADON stated that there should have been an order. 2. On 7/16/2025 at 8:45 AM, a review of Resident #3’s medical records revealed an order to administer oxygen at 2 liters per minute via nasal canula every shift for COPD. (Chronic obstructive pulmonary disease) On 7/16/2025 at 9:05 AM, a review of the resident’s care plan revealed that the facility had failed to identify a diagnosis of chronic obstructive pulmonary disease (COPD). On 7/16/2025 at 9:25 AM, a review of Resident #3’s medical records revealed that the resident was hospitalized on [DATE] and discharged back to the facility on 5/5/25. The discharge summary from the hospital revealed a discharge diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 7/16/2025 at 9:30 AM, a review of Physician #7’s progress notes from 5/7/25, for readmission follow up, failed to address Resident #3’s hospital discharge diagnosis of COPD. During an interview on 7/16/25 at 1:40 PM, Physician #7 stated that when a resident is readmitted to the facility following a hospitalization, she would review the discharge summary and the notes from the hospitalization. She said that she would then update the care plan and resident’s diagnoses according to the findings. She stated, if a resident was diagnosed with something new at the hospital then it should be reflected in their diagnosis at the facility. On 7/16/2025 at 1:45 PM, the ADON was made aware of the findings and again at exit.

Based on observation, review of the medical record and interview with staff it was determined the facility staff failed to provide appropriate care for a resident with an indwelling urinary catheter. This was evident for 1 (Resident #5) of 2 residents reviewed for urinary catheter.The findings include:An indwelling urinary also known as a foley catheter, is a flexible tube inserted into the bladder to drain urine. It's held in place by a balloon inflated in the bladder. Indwelling catheters are used when patients are unable to urinate naturally due to various medical conditions. Foley Catheters are associated with an increased risk of urinary tract infection and therefore, proper catheter care and monitoring is crucial to avoid poor health outcomes.On 7/15/2025 at 8:16 AM Resident #5 was observed with a foley catheter. The catheter tube had cloudy urine draining. Additionally, the foley catheter bag had no date of when it was last changed.On 7/16/2025 at 10:16 AM A review of Resident #5's medical record was conducted. The review revealed a progress note dated 7/9/25 that indicated Resident #5 had a chronic foley catheter secondary to urinary retention with obstructive uropathy. Review of records also revealed an order to change the foley drainage bag monthly and as needed, every night shift every 1 month(s) starting on the 1st for 1 day(s) and as needed for infection control.On 7/16/2025 at 10:26 AM A review of Resident #5's Treatment Assessment Record (TAR) for July 2025 was conducted. The review failed to show documentation that the foley drainage bag was changed.On 7/16/2025 at 10:30 AM The review of the resident's care plan revealed an intervention that stated staff should monitor, record, and report to the Medical Doctor signs and symptoms of Urinary Tract Infection (UTI). The signs and symptoms included deepening of urine color, urine cloudiness and foul-smelling urine.On 7/16/2025 at 12:49 PM Another observation was conducted alongside Staff #10. Cloudy urine was noted to be draining in the foley catheter bag. Staff #10 acknowledged that the urine was cloudy and was draining into a catheter bag that had no date. Staff #10 proceeded to notify the charge nurse (Staff #4) that the resident's urine looked milky. On 7/16/2025 at 12:54 PM An interview was conducted with Staff #4 and Staff #10. When asked who was responsible to document urine catheter changes, staff #10 stated that it was nursing responsibility. Staff #4 further stated that nurses are responsible for reporting to the Resident's Provider any concerns with foley including change in color. Both staff members acknowledged that there was no documentation of changes in urine color and the provider was not notified.On 7/16/2025 at 2:02 PM The surveyor reviewed all the concerns related to urinary catheter care with the Assistant Director of Nursing (ADON) and the facility's Administrator.

Based on observations, record reviews and interviews, it was determined that the facility failed to change the humidification bottle for a resident who is on continuous oxygen therapy. This was evident for 1 (Resident #11) of 2 residents reviewed for respiratory care.The findings include:On 7/15/2025 at 9:07 AM surveyor observed Resident #11 on 3L of oxygen via nasal cannula. The humidification bottle was dated 7/7/25.On 7/15/2025 at 12:41 PM A review of record revealed that Resident #11 had a history of pulmonary fibrosis and required continuous oxygen therapy. The review also revealed an order to change oxygen humidification bottle every night shift, every Sun for respiratory comfort per manufacturers recommendation. Further review of records revealed a care plan for altered respiratory status related to pulmonary fibrosis with an intervention that stated, Oxygen per MD orders. On 7/15/2025 at 1:12 PM Another observation was made by the Surveyor and Staff #4 who confirmed that the humidification bottle was dated for 7/7/25. On 7/15/2025 at 1:14 PM A brief interview with Staff #4 was conducted. When asked what the expectation of changing oxygen humidification bottles for residents on oxygen was, the staff responded that for Resident #11, his/her humidification bottle should have been changed last week on Sunday.On 7/15/2025 at 3:00PM The Assistant Director of Nursing (ADON) and Facility Administrator were made aware of the surveyor's findings and concerns.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that all Medication Regimen Review (MRR) recommendations were addressed by the physician and that medications were adjusted when a recommendation was accepted. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during an annual survey.The findings include:A MRR is completed monthly by a pharmacist to ensure that each resident's medications that they take are safe (including the amount of the medication and the reason for it, along with making sure the medications do not have a negative effect being taken with other medications). The physician reviews the recommendations and decides whether they want to adjust the medications, or not.1a) On 07/16/2025 at 7:42 AM, review of Resident #7's medical record revealed an MRR document dated 2/7/25 which indicated the resident was on several medications that increase the risk for falls and fractures, and listed the medications. Further review of the MRR revealed indication for the physician to reevaluate the combination of medications.On 07/16/2025 at 7:43 AM, review of the response from the Physician (Staff #7) failed to reveal indication that she 1) accepted the recommendations, 2) did not accept the recommendations, or 3) accepted the recommendation with a modification.Further review of the document at the same time revealed written note by Staff #7 that read, will consult with psychiatry services to follow, but failed to reveal indication that the physician addressed the medications that were not psychiatric medications (which are medications that can help with mental health), such as Oxycodone, Oxycontin, and Flexaril.Flexaril is a muscle relaxer, Oxycodone is a strong pain medication that is closely controlled, Oxycontin does the same thing as oxycodone, except it works for an extended amount of time.1b) On 07/16/2025 at 7:42 AM, review of Resident #7's medical record revealed an MRR document dated 5/15/25 which indicated the resident was on Tylenol medication and to document the daily amount based on the medication label. The second half of the recommendation revealed for the physician to clarify that the Oxycodone medication was for severe pain. Further review of the document at the same time revealed that the physician accepted both of the medication recommendations noted above from the pharmacist. On 07/16/25 at 7:46 AM, review of Resident #7's medical record failed to reveal that the facility acted upon the oxycodone recommendation once it was accepted by the physician.On 07/16/2025 at 1:28 PM, an interview with Physician (Staff #7) revealed that the expectation was to review each MRR, and address and act upon the recommendations.Further interview with Staff #7 revealed that the pharmacists often list several medications on the MRR, and she notes the medications that she accepts to adjust at the time, and the others she may address over time, but may not note it on the MRR/medical record. The surveyor asked if the expectation was to address each medication in the MRR, whether she accepts or declines the recommendation, she did not know, and asked the surveyor if she should be doing that.On 07/17/2025 at 7:14 AM, the surveyor reviewed the concern with the Nursing Home Administrator and the Acting Director of Nursing.

Based on a facility reported incident, reviews of a medical record, and staff interview, it was determined that the facility staff failed to: 1) follow Resident #15's plan of care and prevent injury to a resident during incontinence care. This resulted in harm to Resident #15; 2) provide adequate supervision of Resident #17 to prevent unsafe wandering/elopement. Although this noncompliance resulted in no actual harm Resident #17, it has a potential for more than minimal harm if the practice is not corrected. This occurred for 2 of 8 residents reviewed during a Long-Term Care Survey Process annual recertification survey. The findings include: A review of facility-reported incident MD 591 on [DATE] revealed that Resident #15 while being cared for on [DATE] at 1:20 AM, rolled out of bed onto the floor. X-rays were obtained and confirmed a right arm fracture and pelvic fracture. Review of the medical record on [DATE] revealed Resident #15 was admitted to the facility in [DATE] with diagnoses that included a stroke with left-sided weakness, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. A review of Resident #15's ADL self-performance care plan on [DATE] revealed that Resident #15 was assessed by the staff on [DATE] and noted to require total assistance by 2 staff members to turn and reposition in bed and 2 staff members for toileting/incontinence care. The interventions were added to Resident #15's care plan. A review of the facility policy, Lifting/Transferring/Repositioning, L-05, Resident Safety, on [DATE], revealed that the purpose of the policy is: To strive to establish the requirements for safe resident lifting, transferring and repositioning techniques, reduce ergonomic hazards, help prevent injuries to employees, and to promote safe work practices. The policy indicates: Each employee will utilize a mechanical lift device when lifting or transferring a resident who has limited ability to assist. The determination is made by nursing or therapy staff who will determine the percentage of assistance each resident requires. Staff will not lift anything heavier than thirty-five (35) pounds without using the assistance of some lifting device. In an interview with Geriatric Nursing Assistant (GNA) #37 on [DATE] at 4:40 PM, GNA #37 stated that s/he was alerted to Resident #15 on [DATE] at 1:20 AM, by Resident #15 calling GNA #37 on the telephone to report that s/he needed help. GNA #37 then stated that s/he went to Resident #15 ' s room and raised the head of the bed that is when Resident #15 asked for his/her incontinence brief to be checked. GNA #37 stated that Resident #15 indicated that no other staff member had been in his/her room since 12 noon on [DATE]. GNA #37 stated that Resident #15 ' s brief was soaked with urine and that s/he had a bowel movement. GNA #37 stated that s/he lowered Resident #15 ' s head of the bed and raised the entire bed as high as it could be raised into the air. GNA #37 stated that s/he then positioned Resident #15 to perform incontinence care. GNA #37 stated that s/he was cleaning Resident #15 with one hand and holding onto Resident #15 with the other hand. GNA #37 stated this is when Resident #15 started to slide out of the bed. GNA #37 stated that s/he could not hold onto Resident #15. GNA #37 stated that s/he was never shown, during new employee training in [DATE], how to look up a resident ' s care guide on the IPAD. The staff care guide/IPAD is where staff can review every resident care plan and what individualized nursing interventions, like the number of staff members needed for resident transfer/care. In an interview with the facility director of nurses (DON) on [DATE] at 11:45 AM, the facility DON stated that s/he was unable to locate any of GNA #37 ' s checklists that indicated GNA #37 had received training on the use of the IPAD/Care tracker and how to access all residents care plans since being hired in [DATE]. The DON stated that GNA #37 did receive one on one education with the staff education nurse on [DATE], including, reviews of the orientation checklist for a nursing assistant, charting in the electronic health record, and how to look up all residents ' care plans on the electronic health record. In an interview with Resident #15 on [DATE] at 12:51 PM, Resident #15 stated that s/he recalled falling out of bed in February 2022 and having a fractured right arm. Resident #15 stated that ' s/he called GNA #37 to provide incontinence care. Resident #15 stated that GNA #37 is six foot 7 inches tall, so GNA #37 did have to raise my bed into the air. Resident #15 stated that s/he slide out of bed onto the floor and that GNA #37 was alone when providing care on [DATE] at 1:20 AM. Resident #15 stated that 2 staff members come in now to provide any type of care for me. Resident #15 stated that his/her right arm is his/her functioning arm and that the left arm is weak. 2) Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of or has the potential to experience heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. (State Operations Manual appendix pp Long Term Care Facilities.) A Wander guard bracelet is used to keep residents at risk of wandering/elopement comfortable and protected. It is discreet yet powerful, it triggers alarms and can lock monitored doors to prevent the resident leaving unattended. A review of the facility incident investigation record for MD 383, was conducted on [DATE] at 8:35 AM. The report stated that staff on Willow View observed Resident #17 walking in the common area and hallway then at approximately 9:17 AM on [DATE] they noticed that resident #39 wasn't there. At about 9:35 AM, Resident #17 was located at the top of the back staircase of Willow view hall. The report added that the resident was standing with walker in the stairwell, pants were down around lower leg, and wearing a wander guard on left wrist. The resident was described as oriented to person, confused and with impaired memory. Further review of the report revealed staff written statements that indicated the alarm did not go off. Review of the medical record on [DATE] at 10:30 AM, revealed Resident #17 was admitted in [DATE] with diagnoses that included Dementia, Anxiety, Depression, [CONDITION(S)], [CONDITION(S)], Macular degeneration, [CONDITION(S)], Diabetes, [CONDITION(S)], Hypertension, history of falling. On [DATE] at 1:45 PM, Resident # 17 was observed sitting in a wheelchair in the common area. Resident was alert and oriented to person only. He could say his/her first name but was not interviewable. Surveyor observed resident wearing a left wrist wander guard bracelet. On [DATE] at 11:40 AM, in an interview with the Maintenance Technician (Staff #22), he/she stated they conducted weekly maintenance checks on all the facility alarm doors. Staff #22 further stated that the Wander guard bracelet prevents the door from opening. When the alarm goes off it rings on all the pagers and alerts staff to the specific location of the door/stairwell. Pagers are specific to each floor and assigned to the nursing staff. The alarm will not go off if there was a problem with the system or if the wander bracelet battery died . Staff #22 added that the system was installed a couple of years ago and was working properly. On [DATE] at 12:10 PM, interview with Licensed Practical Nurse (LPN # 7). LPN # 7 stated she was working on the day Resident #17 was found in the long hallway stairwell of the second-floor unit. LPN #7 stated that the alarm did not go off even though the resident was wearing a wander guard bracelet. She/he further stated that they checked the resident ' s transmitter was checked and it was functional, and maintenance checked all the doors, and they were functioning properly. LPN #7 added that the nurses and the GNAs (Geriatric Nursing Assistant) all carry pagers that will ring when a resident with a wander guard bracelet went close to any of exit doors. When asked how the resident got into the stairwell, LPN #7 stated they were told by maintenance that if the alarmed door was pushed hard enough, the door will open, so the resident might have pushed the door open. On [DATE] at 8:39 AM, in an interview with the Assistant Director of Nursing (ADON), she stated that immediately following the incident, all the doors and the wander guard system including the resident ' s bracelet were checked and found to be functioning properly. When asked how the resident got into the stairwell, the ADON stated she was going to look into the report and come back with information. On [DATE] at 9:10 AM, the Administrator, the DON, and ADON respond to the question of how the resident got into the stairwell undetected. The Administrator stated that they could not determine how Resident #17 got in there because the wander guard alarm did not go off. He further stated that the fire alarm did not go off as well (that would have released the doors). He said they immediately brought in a company to check the Willow View Long Hall doors and the wander guard system on [DATE], all functioned without fail. Additionally, the resident ' s transmitter was checked and was functional, however, the transmitter was changed to a new wander guard transmitter to ensure no interruption in service. He advised staff education on door alarms, door checks, stairway checks, pagers, elopement precautions, resident engagement/diversional activities was completed. The resident ' s care plan was reviewed and updated. When asked if the alarm door could be pushed opened, the Administrator stated the door could be pushed opened if force is applied on it for 15 to 30 seconds. However, the Administrator stated that the alarm would go off if the door was forced open, which was not what happened in the above incident. On [DATE] at 2:25 PM, the monitoring log for the facility elopement deterrent system from [DATE], through [DATE], was requested and reviewed. Surveyor noted the following activity on the Willow View (WV) Long Hall Fire Stairwell on [DATE]; door open, door alarm signal was noted at 9:16 AM and shortly after that another signal picked up the resident at 9:17 AM and 9:19 AM respectively. There was a door access, no description, noted at 9:19 AM and 9:32 AM through 9:35 AM. On [DATE] at 4:20 PM, in an interview with one of the surveyors, the Administrator stated that door access, no description, noted on the monitoring log for the facility elopement deterrent system meant a staff member accessed the door. On [DATE], surveyors were able to verify that example #2 for Resident #17 was corrected prior to the survey start date. On [DATE] at 5:00 PM, all concerns were addressed with the Administrator, the Director of Nursing, and the Assistant Director of Nursing prior and during the survey exit.

Based on surveyor observation, interviews, and reviews of the facility medication administration policy, it was determined that the facility staff failed to follow (1) the infection prevention and control program by failing to dispense medications without touching with bare hands. This was evident for 2 (Resident #31, #39) of 4 residents observed during the Long -Term Care Survey Process (LTCSP) medication pass task during an annual recertification survey. Additionally, (2) it was determined that the facility failed to have an effective system in place to help prevent the development and transmission of disease by failing to follow infection control guidelines during the laundry process. This was evident for random observations made during the tour of the facility. This deficient practice has potential to affect all residents. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: 1). On 05/19/22 at 08:50 AM, LPN #4 administered medication to Resident # 31. LPN #4 did not place gloves on his/her hands. LPN #4 was observed dispensing Resident #31's pills from a bubble pack into his/her hand and then dropping the medications in the medication cup. LPN #4 was observed pouring 2 of 10 of Resident #31's medications into his/her hand before dropping the medications into the medication cup. On 05/19/22 at 09:06 AM, LPN #4 administered medication to Resident # 39. LPN #4 did not place gloves on his/her hands. LPN #4 dispensed Resident #39's pills from a bubble pack into his/her hand and then dropped the medications into the medication cup. LPN #4 was observed pouring 7 of 9 of Resident #39's medications into his/her hand before dropping the medications into the medication cup. A review of the facility policy, Medication Administration & Management, updated and reviewed by the facility staff in January 2022, revealed a procedure, #3c, that instructed the nursing staff to avoid touching the medication when opening a bottle, unit dose package, or bubble pack. These concerns were reviewed with the facility Administrator and Director of Nursing on 06/02/22 at 5:15 PM during the exit conference. 2) Observation was made of the laundry room on 5/31/2022 at 9:40 AM. Staff #27 (laundry aide) was in the clean side of the laundry room folding clean laundry when the surveyors walked into the laundry room. Observed, on top of the folding table, were the following food items next to the clean laundry: 2 cups with straws containing juice, a [NAME], banana, orange, and a small food container with bacon. Noted on one side of the room was a bin containing clean white folded linen. On top of the clean white linen, surveyors observed a set of keys and a phone connected to a charger that was plugged into a socket on the nearby wall. Staff #27 stated during an interview on 5/31/2022 at 9:45 AM, that no food or drinks were allowed in the laundry room. She/he further stated that staff had a break room where they were supposed to keep their food, drinks, and personal belongings. Staff #27 stated the keys and phone belong to the other laundry aide, Staff #28. While the surveyor was still interviewing Staff #27, Staff #28 walked into the room and picked up the keys and phone but left the charger dangling into the bin with the clean linen. On 5/31/22 at 9:50 AM, Surveyor interviewed the Director of Environmental Services, Housekeeping, and Laundry (Staff # 19). She/he stated that No eating and no drinking was allowed in the laundry room. Staff #19 was made aware of surveyors' observation. She immediately removed the phone charger that was dangling into the bin with clean linen, and stated she was going to re-educate staff. The Director of Nursing (DON) was made aware of the observation on 5/31/2022 at 10:00 AM. DON stated that she/he was going to take care of it right away. On 5/31/22 at 11:49 AM, the DON brought to surveyor copies of the facility policies and procedures for Laundry and Linens, and for Sorting/Folding. The DON also brought a copy of a staff sign-in sheet for In-service started on proper laundry procedure for clean folding area: Effective 5/31/2022 - No Food, drinks, or personal items on folding table. No personal items are to be touching clean folded linens, such as cell phones or charger. No eating meals in clean area side of laundry. The Nursing Home Administrator was informed of all concerns on 6/2/2022, at 5:00 PM during the exit conference.

Based on observation and reviews of the facility policy, it was determined that the facility failed to ensure each resident was treated in a dignified manner regarding urinary catheter care. The facility failed to ensure the urine collection bags had privacy covers in place. This was evident for 1 (Resident #37) of 4 residents reviewed for urinary catheters during the Long Term Care Survey Process (LTCSP) recertification survey. The findings include: During an initial tour of the facility on 05/19/22 at 8:50 AM, Resident #37 was observed sitting at the nurses' station in a wheelchair with a urine collection bag that was hooked and hanging underneath the wheelchair frame. Resident #37's urine collection bag was observed without a cover. Upon an observation of the second-floor nursing unit on 05/19/22 at 10:30 AM, Resident #37's urine collection bag was again observed without a cover. A third observation of the second-floor activity area where a group of residents were waiting for a music program to start on 05/19/22 at 1:40 PM, Resident #37's urine collection bag was again observed without a cover. A review of the facility Catheter Care policy on 05/24/22 at 3:27 PM which was last revised in March 2015, under line #9, staff are to place a cover over a resident's urinary collection bag to maintain the resident's dignity. These findings were shared with the facility Administrator and Director of Nursing during the exit conference on 06/02/22 at 5:15 PM.

Based on review of facility investigation documentation and medical records, observations and interviews it was determined that the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. More specifically, the facility failed to: 1) Properly assess that a resident was at risk for wandering and failed to re-assess when a resident showed increased signs of confusion and wandering, 2) provide adequate supervision to prevent cognitively impaired residents from exiting the facility unsupervised and 3) have a system in place to ensure that all staff were educated and aware of residents assessed to be a wandering risk. This was evident for 2 (Resident #2, #1) out of 7 residents reviewed for elopement/wandering during a complaint survey. On 2/26/2020 at 10:46 AM a determination of Immediate Jeopardy was made regarding risk for elopement related to the facility failing to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. The facility submitted 3 plans to abate, one on 2/26/2020 at 3:54 PM, one on 2/26/2020 at 4:55 PM and the last plan was submitted via email on 2/26/2020 at 7:37 PM. On 2/26/19 at 8:02 PM the facility's abatement plan was accepted by the Office of Health Care Quality. On 2/28/2020 at 3:49 PM, after validation of the acceptable plan, the Administrator was informed the Immediate Jeopardy was lifted. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all remaining residents at a scope and severity of D. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Review of the medical record on 2/24/2020 at 9:45 AM revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dysarthria is a speech deficit caused by problems controlling the muscles involved in speech production. Anarthria is the most severe form of dysarthria, resulting in the inability to produce clear, articulate speech. Review of the physician's admission history and physical dated 7/12/19 documented that Resident #2 had cognitive deficits and poor insight. The admitting nurse documented on 7/12/19 at 9:04 PM that the resident was admitted from another long term care facility, was alert and oriented times 1-2 and appeared confused. Review of transfer paperwork from the long term care facility included a July 2019 physician's orders [REDACTED]. On 7/12/19 a BIMS (Brief Interview of Mental Status) assessment was done by the social worker and documented Resident #2 had a BIMS of 3. The BIMS test is used to get a snapshot of how well someone is functioning cognitively at that time. A score of 13 to 15 indicates intact cognition. A score of 8 to 12 indicates moderate impaired cognition and a score of 0 to 7 indicates severely impaired cognition. Resident #2 was assessed to have severe cognitive impairment. The Elopement Risk Evaluation dated 7/13/19 documented that Resident #2 was not an elopement risk, however the nursing staff failed to include contributing factors, which should have included wandering in the previous facility and wearing a wander guard as noted in the forms that were sent to the facility from the transferring facility. A 7/13/19 at 10:51 PM nursing note documented, resident remains very confused. Nurse found resident walking down the hallway around 10:30 PM, detached self from tube feeding, feeding pole lying on the floor in the room. A 7/17/19 at 12:24 PM nursing note documented, it was reported to this writer that Resident #2 has wandered to residents' rooms and to the hallway. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/19/19, Section E coded wandering occurred 1 to 3 days and answered yes to at risk of getting into a potentially dangerous place and intrude on privacy of others. A 7/21/19 at 7:43 PM nursing note documented, resident ambulatory with rolling walker. Refused assistance with ambulation. When approached, increased agitation noted along with hurried sprint with walker. A 7/22/19 at 10:16 AM nursing note documented, Resident was assisted to walk with his/her walker and gait belt. Once walking down one hall he/she could not be redirected to sit down in chair and take a break. He/she took off walking very fast and unsteady and ambulated down the short hall and then turned around on his/her own. The note continued, very resisted to care or direction. Has wander guard on leg from previous facility but is non-functioning for ours. A 7/23/19 at 10:02 AM nursing note documented, non-functioning wander guard removed from resident's left ankle. Care plan updated. A care plan that was created on 7/23/19 for resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety) had the approaches approach from the front, walk in step with resident first before redirecting, assess resident for placement in a specially designed therapeutic unit, avoid over-stimulation, maintain a calm environment and approach to the resident, remove resident from other resident rooms and unsafe situations and when resident begins to wander, provide comfort measures for basic needs. A second Elopement Risk Evaluation was done on 7/23/19 and was completed by the Director of Nursing (DON). The evaluation documented that the reason for evaluation was resisting direction. The evaluation documented the resident's cognition was severely impaired, resident resisted direction, had recent move to the facility and a wander guard from the previous facility was removed. The resident was assessed, no risk for elopement. The assessment failed to include risk factors such as having a wander guard on from the previous facility, history of wandering in the past 60 days and wandering with no rational purpose after admission to the facility. Review of a facility reported incident dated 8/19/19 documented that on 8/18/19 at 8:00 PM, Resident #2 was witnessed sitting outside of the front, side door of the facility. The self-report documented the resident was brought back by an off-duty employee. Interview of Licensed Practical Nurse (LPN) #1 on 2/24/2020 at 11:51 AM revealed LPN #1 was the supervisor on 8/18/19 and was working on the first floor due to being short of nurses. LPN #1 stated, I took my break and the night shift nurse told me the patient went outside. Resident #2 had a sitter, but she left. He/she was confused and trying to elope and had a sitter. I only work weekends and I came in and knew he/she had a sitter because he/she was confused because he/she went in other rooms. The sitter came from the agency. We only had 2 GNAs (geriatric nursing assistants) and just kept checking on him. LPN #1 continued, we sometimes work short. I have to get on the cart, and it stops me from doing the supervisor things. The Assistant Director of Nursing (ADON) was asked on 2/25/2020 at 10:09 AM if agency staff were brought in to sit with the resident. The ADON stated that there was no agency staff in the building that evening, so she was assuming it was staff that were already working. An interview of Staff #9 (Assisted Living Manager for sister facility) was conducted on 2/25/2020 at 12:33 PM. Staff #9 stated that she saw Resident #2 come out of the door in a wheelchair. She stated she was there to pick up her son who worked at the facility. It was a Sunday evening at 8:00 PM. She stated, I asked my son if the resident looked familiar because we do have independent residents and the resident did not look like an independent living resident. I got out of my car as a reaction to go over to try and assist and I was fearful he/she was going to fall and get hurt. The resident was trying to go down the sidewalk where there wasn't a wheelchair ramp. I was afraid he/she was going to tumble forward. I got the wheelchair turned around. The resident stated, 'I want to see my brother.' The resident could not state his/her name. My husband helped me get the resident back in the building and we took the resident to the first floor nurse's station. Staff #9's written statement at the time of the incident on 8/19/19 documented, I attempted to wheel Resident #2 back inside, but he/she was resistant and started swinging his/her hand to hit me. Resident #2 stated he/she was looking for his/her brother. Because Resident #2 was so resistant I could not push the wheelchair. The resident was leaning forward and at risk for falling out of the wheelchair. The note continued that the resident was yelling, cursing and flailing hands to strike out at us. On 2/26/2020 at 8:48 AM the DON and ADON were interviewed and asked if the MAR (Medication Administration Record) that was sent over from the transferring facility should have been looked at by the admitting nurse and if the nurse should have questioned the wander guard order. The response was yes. The DON and ADON (Assistant Director of Nursing) were asked if after doing full body assessments for admission and full body skin assessments if the nurses should have seen the wander guard on the left ankle. The response was yes. Resident #2's admission assessment dated [DATE] was reviewed on 2/24/2020 at 9:45 AM. There was no documentation on the admission assessment that the resident had a wander guard on the left leg/ankle. The DON and ADON were asked if GNAs (Geriatric Nursing Assistants) who gave personal hygiene care to Resident #2 should have seen the wander guard on Resident #2's left ankle/leg, the response was yes. The DON stated, we tried to make the resident comfortable in this environment and he/she was closer to his/her son, so we didn't consider Resident #2 a risk to elope because the environment was different. 2) Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 2/24/2020 at 10:15 AM a review of the Transfer Summary from the hospital dated 1/29/2020 documented, the hospital course as dementia behavioral disturbance: per patient daughter, patient for the last 1 year developed worsening memory. Review of the medical record on 2/24/2020 at 10:20 AM revealed a wandering risk assessment was done on 1/29/2020 and it was determined the resident was at low risk for elopement. Review of Resident #1's medical record on 2/24/2020 at 10:21 AM revealed a Physician's Certification of Incapacity to make an informed decision due to cognitive impairment likely due to underlying dementia which was signed on 1/31/2020 at 11:30 AM. A nursing note dated 1/30/2020 at 12:54 PM documented, noted wandering in the hallway, redirected back to his/her room. Subsequent nursing notes from 1/30/2020 to 2/2/2020 documented the resident had intermittent confusion. Review on 2/24/2020 at 10:30 AM, of a facility reported incident dated 2/2/2020 documented that Resident #1 exited the facility and was found in the parking lot by the security guard. A 2/2/2020 written statement by the security guard documented that he was patrolling the campus and spotted an individual and felt it wasn't the right place for the individual. The security guard documented that the individual did not appear to know where they were and was asked where they were going, and the individual stated he/she was looking for his/her daughter. The guard stated the individual was outside about 20 minutes. The security guard called the nurse and the nurse came outside and said it was a resident and took the resident back inside. Review on 2/24/2020 at 10:33 AM of a statement dated 2/2/2020 from RN #10 documented that the resident was last seen at 5:05 PM standing next to the resident's bedroom door and the resident told the writer he/she wanted to go home. The writer redirected the resident to the resident's room and told Resident #1 that this was Resident #1's new home. Resident stated he/she wanted to see his/her daughter. The writer left the resident in his/her room and went to assist in the dining room. At 5:40 PM the writer received a call from the administrator informing her that the resident was observed outside next to the chapel. Security noticed the resident and sat with the resident by the entrance into the health care center until the nurse got there. Review of the medical records for Resident #2 and Resident #1 on 2/24/2020 at 9:45 AM revealed both resided on the first floor skilled unit when they were first admitted to the facility. Observation of the first floor skilled unit on 2/24/2020 at 8:45 AM revealed the residents on the first floor could go anywhere in the facility. There were no doors that were locked and there was a hallway that led to an unlocked side door by the wellness center. The other hallway led to the front of the building where the main lobby was located. An interview was conducted with the receptionist on 2/24/2020 at 1:45 PM. The receptionist was located at the main entrance in front of the glass doors that led to the parking lot. When asked if there was an elopement book of residents at risk for elopement or pictures of residents at risk, the answer was no. The receptionist stated that the doors were able to be opened from the inside 24 hours a day, every day. The receptionist stated that the doors are locked from the outside by the security guard at 11:00 PM, but anyone on the inside could still go out the door. At the time of the survey, there was no one to monitor the doors. Observation of the area surrounding the facility on 2/24/2020 at 1:45 PM revealed the exits that were accessible to residents lead to open areas in which a resident could proceed to wander into a dangerous area,: several parking lots, fields and a main thoroughfare that is heavily traveled for cars traveling between counties with a speed limit of 50 miles per hour and weather hazards. On 2/24/2020 at 1:35 PM RN #7, the nurse on the 2nd floor secure unit was asked how she knows which residents wander. RN #7 said she would have to check because she didn't normally work on the unit and did not know where the information would be located. When asked how she checks the wander guard that certain residents wore to make sure it was working RN #7 stated, I'll have to ask the GNAs how it is done. Random Treatment Administration Records (TARS) were reviewed on 2/25/2020 and it was noted that residents who wore wander guard bracelets had areas on their individual (TAR) for nurses to initial when the wander guard was checked for working. On 2/24/2020 at 1:59 PM the DON provided the surveyors with a copy of the elopement policy. Procedure number 9 documented, the elopement deterrent system itself is to be checked weekly by the Maintenance/Security department to ensure proper functioning of the equipment. It was noted, documentation of system checks will be kept in an anti-elopement service logbook. The weekly system check can be documented using the Anti-Elopement System Testing Record. On 2/24/2020 at 2:20 PM the DON was asked how the staff knew which residents were a wandering risk. The DON stated that they had a list. The DON stated, visitors and staff know who wanders. We have every staff looking out. We have to protect the patient's information and [DIAGNOSES REDACTED]. The DON continued that the second floor had a wander guard system and it would alarm when a resident, who wore a wander guard bracelet, would get close to the elevator or exit doors. On 2/24/2020 at 2:30 PM the Director of Maintenance (DM) was interviewed, with the DON and ADON present, and was asked how often the wander guard system was checked. The surveyor also asked to view the logbook where the wander guard checks were to be documented. The DM asked the secretary where the information was documented, and the secretary stated that she didn't have any documentation. The DM then called Staff #25 from maintenance who stated, maintenance does not test the alarm and haven't done anything after having it installed years ago. Nursing should know how to reset the panels. A second interview was conducted with the DON on 2/24/2020 at 3:10 PM and the DON stated, can't lock everyone up if confused. An interview was conducted with RN #26 on 2/25/2020 at 8:18 AM. RN #26 stated she had concerns with residents on the first floor unit with confusion. RN #26 stated, sometimes we don't get the full picture before they come here and we don't know if they were displaying features of wandering prior and when the census is low, they will pretty much take anybody. Since we changed to (Corporate name) in July 2019 it was overwhelming with all the training. I don't know if there is a plan for residents with confusion. On 2/25/2020 at 12:25 PM Staff #22, #23 and #24 from the therapy department were interviewed. The therapy department was located in the hallway leading up to the first floor skilled nursing unit. The staff members were asked if they had a list of residents that wandered, and the answer was no. When asked if they were in-serviced after the 2/2/2020 elopement of Resident #1, the answer was no. During the survey, on 2/26/2020 at 10:46 AM, an Immediate Jeopardy was called related to the facility failing to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. The facility submitted three plans to abate, one on 2/26/2020 at 3:54 PM, one on 2/26/2020 at 4:55 PM and the last plan was submitted via email on 2/26/2020 at 7:37 PM. On 2/26/2020 at 8:02 PM the facility provided an abatement plan which was accepted by the Office of Health Care Quality. This plan included the following: -The facility implemented 24-hour supervision and monitoring of the entrance/exit area to/from first and second floor of the long term care unit and the skilled nursing unit by staff trained by nursing leadership. The 24-hour supervision will continue until a new, enhanced elopement deterrent system is installed and operational. -A team under the direction of the Regional Clinical Director were assembled to conduct BIMS assessments and Wandering Risk Scale assessments of all current residents from both units to determine other residents potentially at risk for elopement/wandering. Any resident identified at risk for elopement will be relocated to the second floor secure unit. -An elopement binder was created to include the name, picture and room number of those residents identified as at risk for elopement. The binder will be placed at the nurse's station on both units, the wellness center, the main reception desk and the security guard area. -On an ongoing basis, facility personnel will receive annual training on elopement and policy review and the facility will conduct an annual elopement drill. -Training to all staff that have contact with the healthcare center on Elopement Risk Protocols, Elopement/Wandering Risk Assessment, Elopement, Unescorted Exit. -An audit process that was set up for residents to be assessed for wandering upon admission and re-assessed 72 hours later, within 30 days of admission, quarterly and/or if a change in behavior occurred.