Every finding on record at Wilton Meadows Health Care Center

Based on observations of the environment, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure the hallways and resident rooms on the 2nd floor were free from foul odors and failed to ensure the water temperatures in the 2nd floor shower room were warm enough to maintain resident comfort in the shower. The findings include:Observations on all days of the survey 5/13, 5/14, 5/18, 5/19 and 5/20/26 identified a foul smell in the 2nd floor hallways. The strongest smell was in the carpeted hallway that contained the main elevators and went down to the dining room. The hallway odor was foul and strong, but the foul odor was also strong in several of the rooms off of that main hallway. The hallway to the left of the nurses' station had a foul odor in the carpeted hallway with several of the rooms with foul smells. The carpeted hallway to the right of the nurses' station had a foul odor which was strong in some of the rooms, but not as strong as the elevator hallway. The far end of the elevator hallway, past the nurses' station had intermittent odors but was the least foul smelling on the 2nd floor. The rooms and hallways appeared clean. The floors looked clean, the bathrooms in the resident rooms looked clean. The resident beds had clean linen and the beds were made. There were no areas of excess garbage or dirty items. I was not able to pinpoint the etiology of the foul odor. Additionally, intermittently there was a short-lived floral smell that covered the foul smell.Interview with the ADNS on 5/18/26 at 8:40 AM identified a foul odor in the carpeted hallway on the second floor, and noted the odor was strongest in room [ROOM NUMBER]. The ADNS further identified that although the room appeared clean, he would have the room deep cleaned due to the presence of the odor. He also noted that there should not be any long-lasting foul odors in the facility.Observation of the 2nd floor hallway on 5/20/26 at 11:00 AM identified a very strong foul smell in the main elevator hallway that was stronger near room [ROOM NUMBER].Interview with Housekeeper #5 who was assigned to second floor on 5/20/26 at 11:22 AM, identified that she cleaned room [ROOM NUMBER] including the bathroom and indicated the mattress was changed but the foul odor persisted. Housekeeper #5 further identified that she used bleach to clean the bathroom. She pointed to a yellow-colored liquid in the mop bucket and noted that it was an all-purpose cleaner that she used to clean the rest of the room. In addition, Housekeeper #5 indicated that there was a particular chemical used to make things smell better. She noted that although she cleaned, the foul odor wouldn't go away.Interview with the Regional Housekeeping Supervisor on 5/19/26 at 1:45 PM identified the bacterial enzyme culture solution is an odor eliminator and is used to eliminate odors from bodily fluids such as urine, vomit and feces. He further identified that the housekeeping staff should only be using bleach products for cleaning all surfaces in the facility.Interview on 5/20/26 at 11:15 AM with the Regional Housekeeping Supervisor (in the presence of Housekeeper #1) identified he was unaware of all the solutions the facility was using because he thought the facility was only using bleach for cleaning. He further identified that the only product that have an EPA number are the bleach products because the other products they are using do not disinfect surfaces. The Regional Housekeeping Supervisor further identified that the bleach products should be used to clean because the other non-bleach products do not disinfect (kill germs) surfaces. In addition, he noted that the staff would be provided with training concerning the correct products to use to appropriately clean and disinfect surfaces and acknowledged that the staff had been inconsistent with using the correct cleaning products. Review of the Environmental Services Operations Manual identified that resident rooms, restrooms, offices, the isolation room, light covers, vent covers, wheelchairs, Geri-chairs, walls and handrails should be cleaned with a disinfectant cleaner. An observation on 5/20/26 at 11:30 AM of the 2nd floor shower room identified three shower stalls in the shower room and the water temperatures in the three stalls were as follows: the left side shower's hot water temperature was 89 degrees Fahrenheit (F), the middle shower stall's hot water temperature was 90 degrees F, and the right shower stall's hot water temperature measured at 100.8 degrees F. Interview with NA #8 on 5/20/26 at 11:36 AM identified that she has to let the water run for a while in order for it to be warm. NA #8 indicated that some residents complain about the water being too cold but not a lot. There was one resident who was refusing the showers because of the low water temperatures. The resident refused to talk to me about it but I decided to check and they were actually low. Then, during the investigation, I found that the maintenance was aware the temps were low and took temps for 10 days.Interview with Maintenance Staff #1 and Maintenance Staff #2 on 5/20/26 at 11:48 AM identified room sink temperatures are within accepted range. However, there was not any temperatures taken in the shower room.Re-temping of the shower room on 5/20/26 at 11:58 AM identified after the water had been allowed to run for about 10 minutes, the water in the left shower stall measured 94.4 degrees F, the middle shower measured 91 degrees F and the right-side shower measured 104.4 degrees F.Review of the facility temperature logs specific to the 2nd floor shower room identified temperatures were taken from 2/17/26 through 3/6/26 and ranged from 105 degrees F to 110 degrees F.Interview with the Administrator on 5/20/26 at 12:31 PM identified a new hot water tank was installed and brought in the documentation from the service company.Review of the facility invoices for replacement and service for hot water tank dated 3/5/26 identified service was completed for complaints of the hot water not reaching temperature. The service slip indicated the shut offs in the hallway were closed for cold water and the showers got hot. The receipt identified the customer will take care of the shower valves. The facility invoice identified that the facility would take care of the shower valves which would make the shower temperatures hotter. This was recommended by the hot water service company but not implemented by the facility.Interview with the Director of Maintenance on 5/20/26 at 12:32 PM identified that complaints regarding cold water were received at the beginning of the year and the shower temperatures were checked for 10 days. The Director of Maintenance indicated the facility go a new hot water storage tank and they were adjusting the temps due to the hot water running out fast. The Director of Maintenance indicated that he would have one of the maintenance workers adjust the water temp and identified the service company had been out to fix the temperature problem. The facility did not replace the shower valves as recommended by the hot water service company.The facility policy for bathing water temperatures identified safe water temperatures between 105 degrees F and 120 degrees F.

Based on observations, review of clinical record, review of facility policy, review of facility documentation, and interviews for one of three residents (Resident #128) reviewed for pressure ulcer/injury, the facility failed to place a resident with an open wound on Enhanced Barrier Precautions (EBP) to ensure the appropriate PPE was utilized when providing wound care; and two of two sampled residents (Resident #10 and Resident #90) reviewed for tube feeding, the facility failed to appropriately track and post appropriate signage for a resident with an indwelling medical device who required EBP; and one sampled resident (Resident #89) reviewed for the infection control program, the facility failed to utilize personal protective equipment (PPE) when entering a transmission-based precaution resident's room; and the facility failed to ensure appropriate disinfectant solution is used when cleaning areas and surfaces within the facility consistently by the housekeeping staff. The findings include: Resident #10's diagnoses included Alzheimer's Disease, dysphagia oropharyngeal phase, urinary tract infection (UTI) (4/10/26) and severe protein calorie nutrition. Physician's orders dated 4/11/26 directed enteral feeding through G-tube with directions to maintain enhanced barrier precautions every shift and directions for a foley catheter with directions to maintain enhanced barrier precautions every shift. The care plan dated 4/14/26 identified Resident #10 had a feeding tube with interventions to handle bag and change tube feeding following standards of practice, infection control precautions and manufacturer instructions. Additionally, the care plan identified Resident #10 was on enhanced barrier precautions related to a history of ESBL with interventions that a PPE located in the isolation cart placed outside of the resident room will be used by staff and identified staff will utilize enhanced barrier precautions, perform hand hygiene, don gown, gloves prior to care involving urinary catheter, feeding tubes and take off gloves, gown and hand hygiene after care. The Significant Change MDS assessment dated [DATE] identified Resident #10 had severely impaired cognition, was dependent on staff for toileting hygiene and transfers and substantial/maximal assistance with oral hygiene, had an indwelling catheter and a feeding tube in place, was at risk of developing pressure ulcers and was receiving non-surgical dressings. Observation of feeding tube care for Resident #10 on 5/18/26 at 6:36 AM with LPN #8 identified there was no precaution signage outside of the resident room and no precautions cart with supplies outside of the resident room. Observation of LPN #8 labeling feeding tube tubing and identified that he was asked by the nurse he took over for to label the tubing as it was new tubing. LPN #8 did not utilize any PPE when entering the room. Observation of feeding tube care for Resident #10 on 5/18/26 at 7:58 AM with RN #5 identified there was not any precaution signage or a precautions cart outside of the resident room. RN #5 prepared the feeding tube on the medication cart outside of the resident room with gloves on. RN #5 entered the room without any PPE in place but was holding gloves in her hand. RN #5 performs hand hygiene before entering the room and then used the bed remote to raise Resident #10's bed, stops the feed that was currently running and dropped the gloves she was holding onto the floor. RN #5 then goes into the resident bathroom and washes her hands and then leaves the resident room. When RN #5 returns to the room she brings two pairs of gloves and hands a pair of gloves to LPN #6, whom she is precepting this day, and puts a pair on herself. RN #5 resumed disconnecting the current feed and discards into the trash. Both LPN#6 and RN #5 use the draw sheet to reposition the resident and then RN #5 removes Resident #10's abdominal binder, noting there was not a dressing on the PEG tube where it meets the skin. RN #5 performed abdominal auscultation and performed checks for hanging the new feeding bag. RN #5 set the pump to the appropriate setting and attached the new tubing to Resident #10's G-Tube and replaced the abdominal binder. RN #5 then removed and discarded the gloves. RN #5 then left the resident room and performed hand hygiene with the sanitizer outside of the room. Observation on 5/18/26 at 8:16 AM identified RN #5 returned to Resident #10's room with items for the dressing that were supposed to be at the insertion of the G-Tube. RN #5 went into the resident bathroom and returned to the bedside with a garbage bag which she set up on the bed. RN #5 then put gloves on and cleaned the opening site. RN #5 noted fresh blood to the opening and changed gloves, without hand hygiene in between, and cleaned the site again. RN #5 then placed a new slit gauze dressing on the site and taped around the edges. RN #5 and LPN #6 then repositioned Resident #10 with the draw sheet and repositioned the abdominal binder. RN #5 went into the resident bathroom, discarded gloves and washed hands. RN #5 came back to the bedside and rechecked the feed setting and covered Resident #10 with a johnny. RN #5 then exits the resident room and uses hand sanitizer outside of the resident room. LPN #6 discarded his gloves and utilized the hand sanitizer outside of the resident room. Although RN #5 completed the tube feed orders and wound cleaning of the tub site as ordered by the physician, RN #5 and LPN #6, who assisted with care, did not wear a gown when providing care, did not perform hand hygiene between some glove changes, and performed some care without the use of PPE. RN #5 identified there was no precautions sign on the resident room and was not aware if Resident #10 was on precautions. Interview with RN #5 on 5/18/26 at 8:35 AM identified Resident #10 did have orders for EBPs and did not know why there was no signage or a precautions cart by the resident room. RN #5 indicated that the Infection Prevention nurse was usually the one to place signage and the carts but indicated that nursing should be aware if there was an order. Interview with the ADNS on 5/18/26 at 8:40 AM identified that Resident #10 should be on EBP for the catheter and the feeding tube and indicated that there should have been an EBP cart and signage outside of the resident room. The ADNS identified that although the infection prevention nurse is responsible for placing the EBP items, the nurses and nursing supervisor have access to the items if the IP is not available. Interview with the Infection Preventionist (IP) (LPN #2) on 5/18/26 at 2:00 PM identified that Resident #10 should have EBP signage and equipment based on the catheter, feeding tube and history of ESBL in the urine. Review of the facility policy for Enhanced Barrier Precautions (EBP) identified EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs. and indicate that gloves and gown are applied prior to performing the high contact resident care activities. Examples of high-contact resident care requiring this would include device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator etc. EBPS are indicated (when contact precautions don't apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization and stay in place until discontinuation of the indwelling medical device (inc. ESBL). Resident #128's diagnoses included fracture part of left femur, osteoarthritis, and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #128 had intact cognition, required moderate personal hygiene, ambulation, and maximal assistance with bed mobility, toilet transfer, and putting on/taking off footwear. The assessment further identified Resident #128 was at risk for pressure ulcer with treatments that included pressure reducing device for chair and bed. The care plan dated 4/27/26 identified Resident #128 at risk for alteration in skin integrity related to aging, skin mobility, incontinence, deconditioning and an open deep tissue injury (DTI) to left heel with interventions that included apply skin prep to bilateral heels as directed, offloading when in bed and report any skin issues when noted. The physician order dated 4/30/26 directed to cleanse left heel with normal saline apply skin prep to peri-wound and apply calcium alginate and cover with a clean dry dressing once a day. The wound progress note dated 5/14/26 at 3:14 PM written by APRN #1 identified in the wound assessment section Resident #128 had a deep tissue pressure injury (DTPI) measuring 1.0 centimeter (cm) by 0.6 cm by 0.2 cm with small amount of serous exudate. Observation of wound care treatment for Resident #128 on 5/18/26 at 11:30 AM with Charge Nurse (LPN #1) identified he reviewed the physician treatment orders for the left heel wound, performed hand hygiene, brought the treatment care to the resident's room entry way, performed hand hygiene, donned gloves and gathered supplies. The supplies included: normal saline, gauze, scissors, liquid skin prep pack, alcohol prep, calcium alginate, and a dry clean dressing. LPN #1 removed gloves, performed hand hygiene, then donned clean gloves to clean work surface area with a disinfectant wipe, then removed his gloves and performed hand hygiene. LPN #2 then place supplies onto the clean surface area performed hand hygiene, donned clean gloves, then removed the old dressing from the resident's left heel and noted a small amount of yellowish, tan color drainage. LPN #1 then removed his gloves, performed hand hygiene and donned a clean glove then proceeded to complete the treatment as directed by the physician/APRN. LPN #1, however, did not wear a gown when providing wound care to Resident #128. LPN #1 identified he did not wear a gown as the resident was not on Enhanced Barrier Precaution (EBP) as there was no signage outside of the room nor was there a physician order directing EBP. He further identified that it was the responsibility of the wound nurse to initiate the EBP precaution as the resident wound had drainage and the wound is monitored weekly by the wound nurse. Interview with the Infection Preventionist (IP) (LPN #2) on 5/18/26 at 1:50 PM identified she was responsible for placing residents on EBP and she was not aware that Resident #128 wound to the left heel had drainage. LPN #2 identified she complete the wound rounds with the wound APRN#1 weekly and did not see any drainage at the time. She reviewed APRN #1 note and identified the note as indicated the resident wound to the left heel had drainage. LPN #2 identified when the wound began to have drainage the resident needed to be placed on EBP. Review of the Enhanced Barrier Precautions policy identifies EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO (multi-drug-resistant organisms) status. The policy further identifies EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Resident #90's diagnoses included severe protein-calorie malnutrition, adult failure to thrive, and malignant neoplasm of nasopharynx. The admission MDS assessment dated [DATE] identified Resident #90 had intact cognition, was dependent on staff for toileting hygiene, bathing, transfers and maximal assistance with dressing, personal hygiene. The assessment further identified Resident #90 had a feeding tube. The care plan dated 4/21/26 identified Resident #90 is placed on enhanced barrier precautions related to G-tube with interventions that included staff will utilized enhanced barrier precautions, perform hand hygiene, don gown, gloves prior to the following care of central line, urinary catheter, feeding tube, dressing, bathing, showering, transfers, changing linens, providing hygiene care, changing briefs or assisting with toileting and take off [NAME], gown, and hand hygiene after care. The physician order dated 4/11/26 directed maintain enhanced barrier precautions for G-tube (gastrostomy tube). Observation and interview on 5/14/26 at 11:59 AM identified NA #6 wearing gloves while placing soiled linens in a plastic bag. NA #6 identified she had just provided care to Resident #90 and when asked if she had utilized a gown and gloves (PPE) while providing personal care to the resident, she responded she did not wear the gown because the resident was not on any precautions. NA #6 identified if the resident was on precautions, there would be a signage indicating the type of precaution on the outside of the room along with a cart containing PPE supplies. On observation with NA #6 of the entry way of Resident #90's room, there was no signage indicating EBP precautions nor was there a cart outside of the room. Observation and interview with LPN #1 on 5/14/26 at 2:10 PM failed to identify a posted signage outside the resident's room identifying the need for Enhanced Barrier Precautions (EBP) which noted the need for everyone to perform hand hygiene before entering and when leaving the room, providers, and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing, changing linens, changing briefs or assisting with toileting, showering, device care or care of a feeding tube. LPN #1 further identified staff uses the signage and the PPE supply cart outside the room to identify which resident is on precautions as well as the list posted at the nurse's station, which did not include Resident #90's name. LPN #1 further identified that he has not been using the PPE as he should, even though the resident had an order directing EBP, as they rely on the signage that is posted on the outside of the room, so he will be posting the EBP signage and placing a cart with PPE supplies outside of the room. Interview and review of the facility's current EBP list with the Infection Preventionist (LPN #2) on 5/18/26 at 12:20 PM failed to show that Resident #90 was placed on the EBP list. LPN #2 identified she was responsible for updating the EBP list and placing a copy at the nurse's station. She identified staff uses the EBP list at the nurse's station to identify which resident is on EBP and why they are on EBP, along with a posted EBP signage and a cart containing PPE supplies on the outside of the room. LPN #2 identified she was responsible for posting the EBP signage and the cart containing the PPE supplies outside of the resident's room and it should have been done. She further indicated that a resident would remove the signage, so she checks the rooms daily, but failed to state why this room did not have a sign nor a cart if it is being checked daily. Review of the Enhanced Barrier Precautions policy identifies EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO (multi-drug-resistant organisms) status. The policy further identifies EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required and PPE is available outside of the resident rooms. Resident #89's diagnoses included enterocolitis due to clostridium difficile, diarrhea, and chronic obstructive pulmonary disease. The admission MDS assessment dated [DATE] identified Resident #89 had intact cognition, dependent on staff for care with toileting hygiene, lower body dressing, chair transfers and moderate assistance with personal hygiene. The assessment further identified Resident #89 as non-ambulatory, utilizing a wheelchair and was always incontinent of bowel and bladder. The care plan dated 4/21/26 identified Resident #89 is placed on enhanced barrier precautions related to stoma and a history of clostridium difficile with interventions that included staff will utilized enhanced barrier precautions, perform hand hygiene, don gown, gloves prior to the following care of central line, urinary catheter, feeding tube, dressing, bathing, showering, transfers, changing linens, providing hygiene care, changing briefs or assisting with toileting and take off [NAME], gown, and hand hygiene after care. The physician order dated 5/12/26 directed contact precautions due to clostridium difficile every shift. Observation on 5/13/26 at 1:40 PM identified posted signage on the door frame of Resident #89's room which included a bolded stop sign and a contact precaution signage that identified everyone must clean their hands before entering and when leaving the room, and providers and staff must also put on gloves and gowns before room entry and discard gloves and gown before room exit. The signage also indicates use of dedicated or disposable equipment, clean and disinfect reusable equipment before using it on another person. Also, outside of the room directly underneath the sign was a cart containing PPE supplies such as gowns and gloves. Further observation identified Counselor #1 standing at Resident #89's bedside wearing a bookbag and holding a papers/notebook in hand while talking with the resident without the use of a glove and a gown. Counselor #1 then stood at the doorway while writing on papers/notebook, then proceeded to the next room, reached for the hand sanitizer dispenser on the wall and then knocked on the door, when the surveyor intervened. Interview with Counselor #1 on 5/13/26 at 1:46 PM identified she works with a company contacted by the facility to provide talk therapy for residents and is catching up on seeing residents. She further identified she had seen the signage posted on the doorframe prior to entering the room and had only performed hand hygiene. She further identified she did not see the gowns, and when asked what was in the cart directly underneath the signage, when she responded okay. Counselor #1 identified she did not ask any of the staff about the signage and had just performed hand hygiene, then entered the room. She identified that she should have followed the instructions on the signage as she had infection training at other places prior to last week when she first started to work at this facility. Interview with the Infection Preventionist (IP) (LPN#2) on 5/18/26 at 12:20 PM identified she does not provide in-services to the contract staff as the signage posted outside of the rooms when a resident is on precautions which clearly states what needed to be done before and after exiting the room. She further identifies because there are several residents with EBP signage outside of their rooms that she added the bold stop sign in addition to the contact precautions signage. LPN #2 further identifies she expects everyone to read and follow the instructions posted on the outside of a resident room before entering. LPN #2 further identified that after caring or contact with this resident it would require everyone to use soap and water for hand hygiene due to the clostridium difficile diagnoses. Review of the Procedures for Isolation: Initiation of Isolation Precautions policy identifies in addition to standard precautions, use contact precautions for a resident with known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact such as handling environmental surfaces or resident-care items. The policy further identifies to inform residents and staff for the needs of the isolation, provide education as appropriate, and obtain appropriate signage and post outside the door frame with no resident name or organism name should appear on the signage. Review of the Procedures for Airborne Contact, and Droplet Isolation policy identifies under the contact precautions sections private room is preferred, wear clean gloves when entering the resident's room or unit if a multibed room, wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items, or environmental surfaces or if the resident is incontinent. Remove gown carefully before leaving the room and wash hands and remove gloves before leaving the resident area. The policy further identifies to wash hands immediately with soap and water or alcohol-based hand rub and if the organism being isolated is clostridium difficile, soap and water is recommended. Review of the housekeeping supplies used to clean and disinfect the facility surfaces with the Housekeeping Supervisor (Housekeeper #1) and Housekeeper #2 on 5/18/26 at 9:30 AM identified the following solutions in Houskeeper #2's cart: bacterial/enzyme culture, lavender cleaner and deodorant, all-purpose cleaner, neutral cleaner, Clorox clean-up cleaner with bleach, and super Sani-cloth germicidal disinfectant wipes. Further observation identified some of the labels on the solution bottle did not show the EPA number (Environmental Protection Agency) which tracks hazardous materials to ensure regulatory compliance and public safety and the list of organisms which the solution kills. Housekeeper #1 identified she will provide the information as it is in her office and the housekeeper's closet. Upon entering her office, she was only able to provide information for the Clorox clean-up solution and the other Clorox products and indicated that she would have to contact her supervisor for the other information. Interview with the Regional Housekeeping Supervisor (Housekeeper #3) on 5/19/26 at 1:45 PM identified the bacterial enzyme culture solution is an odor eliminator and is used to eliminate odors from bodily fluids such as urine, vomit and feces. He further identifies that the housekeeping staff should only be using Clorox/bleach products for cleaning all surfaces in the facility. Interview with Housekeeper #1 on 5/19/26 at 1:58 PM identified they have been using these products for about 2 years now and the bleach products are used for the toilet and resident rooms with precautions, and the purple Sani-cloth wipes are used on the overbed tables and the dining room tables, as some resident does not like the smell of bleach. Interview with Housekeeper #2 and Housekeeper #4 on 5/19/26 at 10:38 AM and 11:10 AM identified that they use the purple top super Sani-cloth wipes to clean the dining room tables and the over bed tables; the Clorox product is used to clean the toilet; the bacterial enzyme culture or all-purpose cleaner is use to clean the bathroom sink; the bacterial enzymes culture is used to clean the bed, bed rails, walls and furniture; the neutral cleaner is used to clean the floor; and a glass cleaner to clean the mirrors in the room. Housekeeper #4 identified she uses the purple Sani-cloth wipes to clean the bed rails and other surfaces in the room but if she does not have the purple top Sani-cloth wipes she uses the bacterial enzyme culture or the all-purpose cleaner. Housekeeper #2 and Houskeeper #4 identified they were taught how to clean the facility's surfaces and what solutions to be used when cleaning by their supervisor when hired. Interview with Housekeeper #3 in the presence of Housekeeper #1 on 5/20/26 at 11:15 AM identified Housekeeper #3 had only started working approximately a year in his role and was unaware of what solution they were using as he thought they were using Clorox bleach for cleaning. He identified that the company does not supply the purple top Sani-cloth wipes but the other products they supply. He further identified that the only product that has an EPA number are the Clorox products as all the other products do not disinfect surfaces. Housekeeper #3 identified areas should be cleaned first then disinfect with the appropriate solution and the housekeeping staff should not be using the other products alone because they don't disinfect surfaces. He further identified that all housekeeping staff will be educated on the appropriate cleaning solution and disinfectant solution to use when cleaning and disinfecting, as the staff are improperly using the cleaning products and they are inconsistent with disinfecting surfaces. Review of the Environmental Services Operations Manual identifies for the following areas: resident rooms cleaning, restroom cleaning, office cleaning, admission/discharge cleaning, detail cleaning, isolation room cleaning, light covers and vent covers cleaning, wheelchair and Geri-chairs cleaning, walls and hand rail cleaning task includes to dust all flat surfaces with a cloth and disinfectant, and to wet mop the room using disinfectant.

Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure expired medications were removed from medication carts and medication rooms. The findings include:Observation of the Birchwood 3 medication cart with LPN #5 on 5/19/26 at 11:46 AM identified 1 full card of Mirtazapine 15 mg (30 pills) expired on 3/11/26.Interview with LPN #5 on 5/19/26 at 11:50 AM identified the pharmacy and the nurses are responsible for checking expiration dates and non-used medications and remove them from the medication cart.Observation of the Birchwood 2 medication cart with LPN #4 on 5/20/26 at 11:29 AM identified the following expired medications: Sertraline 25 mg tabs (8 remaining) expired 5/17/26, Divalproex Sodium 12.5 mg (14 capsules) with a use by date of 3/25/26, and Meclizine 25 mg tablets (29 tablets remaining) expired 12/31/25Interview with LPN #4 on 5/20/26 at 11:32 AM identified the pharmacist went through the carts and removed expired items and indicated that nurses were responsible for ensuring the medications are within use date. LPN #4 identified that although the medications were still active, there were additional, non-expired medications in use in the cart and indicated the Meclizine was an as needed medication.Interview with the ADNS on 5/20/26 at 1:13 PM identified that expired medications, or medications not in use should be removed from the medication carts by the nurses.The facility policy for medication storage identified expired of discontinued medications must be promptly removed and destroyed.

Based on review of clinical record, review of the facility policy and procedures, review of the facility documentation, and interviews for one of five sampled residents (Resident #57) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident. The findings include:Resident #57 was admitted to the facility in August 2025 and had diagnoses of chronic systolic heart failure, atrial fibrillation, and fracture of unspecified parts of lumbosacral spine and pelvis. The quarterly MDS assessment dated [DATE] identified Resident #57 had moderately impaired cognition. The assessment further identified Resident #57 pneumococcal vaccination was not up to date as the pneumococcal vaccine was not offered to the resident.Review of Resident #57's immunization record under the preventative health care section of the electronic records failed to identify that Resident #57 had any history of receiving/refusing the pneumococcal vaccine in the past or while at the facility. Review of the Resident Vaccine Consent and Education form for pneumococcal identified on August 18, 2025, the resident/resident representative gave the facility permission to administer the pneumonia vaccine (PCV20). The form further identified the resident had the PCV 20 vaccine in the past on 11/27/23. Interview with the Infection Preventionist (IP) (LPN #2) on 5/18/26 at 12:20 PM identified the vaccine consent form identified resident had the PCV 20 in the past on 11/27/23, however, LPN #2 identified that date was written by the previous IP nurse and somehow it was on the hospital records. LPN #2 then review the online vaccination record system (CTWIZ) (a system which tracks vaccine given to an individual) which identified that Resident #57 had no history of receiving the pneumococcal vaccine. LPN #2 further identified vaccine consent is obtained from resident/resident responsible party admission. LPN #2 identified it is responsibility of the IP nurse to review the vaccine consents and identify what vaccine the resident is eligible for then obtain a physician order and order the vaccine for what was selected.Interview on 5/19/26 at 10:40 AM identified she had searched Resident #57's hospital record and was unable to find any history that the resident had received the pneumococcal vaccine in the past. LPN #2 further identified that Resident #57 should have been given the pneumococcal vaccine (PCV 20) when it was requested. She further reviewed her resident vaccine audit/tracking record, and it identified that the resident had consented to receive the pneumococcal vaccine, but it was not given. Review of the Pneumococcal Vaccine policy identified prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessment of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. The policy further identified that pneumococcal vaccines are administered to resident (unless medically contraindicated, already given or refused) per our facility's physician-approved pneumococcal vaccination protocol.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #64) observed with medication at the bedside, the facility failed to ensure the resident was assessed for self-administration of a medication. The findings include: Resident #64's diagnoses included osteoarthritis, bilateral shoulder pain, bilateral, atopic dermatitis, and muscle spasms. The quarterly MDS assessment dated [DATE] identified Resident #64 had intact cognition, required moderate assistance with dressing, personal hygiene, toileting hygiene, transfers and ambulation. Observation with LPN #1 on 5/14/26 at 11:37 AM identified Resident #64 seated in a wheelchair and on the overbed table was a tube of Triamcinolone acetonide 0.1% cream that was dispensed by the pharmacy used by the facility.Interview with LPN #1 on 5/14/26 at 11:37 AM identified Resident #64 had a physician's order for the Triamcinolone acetonide 0.1% cream to be left at the bedside. LPN #1 identified the resident applied the cream that morning to his/her right 5th digit in his presence and could apply the cream if needed throughout the day. Upon review of physician's orders, LPN #1 identified the resident did not have an active physician order for the Triamcinolone acetonide 0.1 % cream as the order ended on 5/12/26 and was not renewed. He further identified the resident only had an order to leave the cream at the bedside but not to self-administer the medication. LPN #1 identified he was unable to identify a self-administration assessment completed prior to the medication being left in the room. LPN #1 further identified that he was the one who placed the medication cream in the room after receiving the physician's order to leave the medication at the bedside. Interview with the Nursing Supervisor (RN #2) on 5/14/26 at 11:45 AM identified a resident should have a physician order: for a medication treatment, for the medication to be self-administered, and for the medication to be stored at the bedside. RN #2 identified that an assessment should be completed to assess if the resident is able to self-administer the medication prior to leaving and obtaining the MD/APRN order. RN #2 identified that since working at the facility she has not seen a specific form/assessment for self-administration assessment, but she knows it must be completed prior to the resident self-administering a medication. RN #2 further identified when a medication is being stored at the bedside, it must be placed in a locked boxed to prevent other residents from having access to the medication. Interview with Resident #64 on 5/14/26 at 1:30 PM identified he/she applies the cream to his/her right 5th finger but had difficulty applying the medicated cream properly and would ask the nurse aide to assist him/her. Resident #64 identified he/she was not told how many times per day to use the cream when he/she was provided with the medication. Interview with the ADNS on 5/14/26 at 1:18 PM identified it is the facility's practice and policy to have a self-administration assessment completed prior to a resident self-administering medication; to have a physician order in place for the medication, a physician's order to leave the medication at the bedside and for the resident to self-administer the medication. The ADNS identified the facility does not have a separate self-administration assessment form, but the nurses are expected to document their assessment details in the progress notes. He identified the assessment should include the resident's cognitive abilities and their ability to self-administer the medication; however, an assessment was not completed for Resident #64. The ADNS further identified that any medication being left at the bedside should be stored in a lock box to prevent other residents from taking/using the medication. Interview with the Nursing Supervisor (RN #1) on 5/19/26 at 1:17 PM identified she obtained the order to leave the medication at the bedside but had not completed a self-administration assessment because she thought that it was done already by the APRN. RN #1 further identified she should have done the assessment prior to obtaining the order. Review of the Self-Administration of Medication for Skilled Nursing Facility policy identifies that a licensed nurse and/prescribing practitioner will assess the resident's ability to self-administer medications, and the assessment should include cognitive ability, physical ability, and behavioral/safety factors. The policy further identifies for a resident to self-administer medications it requires a written provider order authorizing the self-administration, the specification of which medications may be self-administered and any limitation or supervision requirements. The policy further identified the medication must be stored in a locked drawer, cabinet, or approved container and the medical record should include the assessment findings, the provider order, the resident consent, education provided, care plan updates, monitoring and reassessment documentation.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #5) reviewed for a skin condition, the facility failed to ensure an open area on the skin was assessed per the standard of practice, failed to ensure a physician's order was in place to address the open area on the skin, and failed to ensure an open area on the skin had weekly monitoring. The findings include: Resident #5's diagnoses included type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #5 had moderately impaired cognition, was dependent on staff for dressing, personal hygiene, putting on and/taking off footwear, transfers, bed mobility and was non-ambulatory.The care plan dated 3/24/26 identified Resident #5 had a risk for impaired skin integrity related to immobility, incontinence, diabetes and contractures. The care plan interventions directed to encourage/assist to turn and reposition resident frequently and as needed, pressure reducing mattress and chair cushion, weekly skin assessment and apply protective/preventative barrier to skin as indicated. The nurse's note dated 5/4/26 at 8:30 PM written by LPN #3 identified Resident #5 had a small opening on the coccyx area and the nursing supervisor was notified. Review of the nursing progress notes from 5/4/26 through 5/8/26 failed to identify that the open area was assessed by a Registered Nurse (RN) or an MD/APRN. According to the National Institutes of Health.An initial skin assessment of an open area should establish the wound's baseline by documenting its exact location, dimensions (length, width, and depth), tissue type in the wound bed, presence of tunneling, and the characteristics of the drainage (exudate) and surrounding skin (peri wound). Observation on 5/18 at 9:40 AM with LPN #8 identified Resident #5 had scabbed area on the coccyx and the surrounding skin appeared pink (like fragile skin in the healing process). LPN #8 applied barrier cream to the area and noted that it had previously been an open area. Interview with the Wound Nurse (LPN #2) on 5/18/26 at 1:58 PM identified that when an open area is identified the RN nurse/supervisor is responsible for assessing the area, obtaining a treatment order, documenting his/her assessment in the chart and notifying her of the open area. Interview on 5/19/26 at 11:48 AM with LPN #3 identified she reported the open area to Resident #5's coccyx to the nursing supervisor (RN #1). She noted that the opening was approximately the size of a dime. She further identified that she does not know if RN #1 assessed the open area, but she was told to apply barrier cream to the area. LPN #3 identified that the facility practice is that when an open area is identified, it is reported to the nursing supervisor who is responsible for assessing the area, calling the MD/APRN to obtain a treatment order and writing a note. Interview with RN #1 on 5/19/26 at 1:17 PM identified she did not recall being told that Resident #5 had an open area to his/her coccyx. She noted that if she were notified, she would have assessed the area, measured the wound, called APRN/MD to obtain a treatment order and documented her assessment. Review of the physician order for the period of 5/4/26, through 5/6/26 failed to identify a treatment directing care for the open area identified on Resident #5's coccyx on 5/4/26. The physician order dated 5/6/26 directed to apply zinc cream to MASD to coccyx every shift. Interview with LPN #2 on 5/18/26 1:58 PM identified that she was notified on 5/6/26 by either the charge nurse or the nursing supervisor that Resident #5 had an open area to the coccyx. She identified that she looked at the area and determined it was MASD (moisture-associated skin damage) and obtained an order from the APRN. She further identified that she thought that the APRN had written a note regarding the area but apparently no note was written. LPN #2 identified that when the area was first identified on 5/4/26, the supervisor on duty should have obtained a treatment order from the covering MD/APRN and the order should have already been in place prior to her seeing the wound. Additionally, LPN #2 identified that open areas including MASD are supposed to be seen weekly either by the in-house APRN or the Wound APRN and documented on at least weekly until the area is resolved. LPN #2 identified she did not notify the wound APRN of Resident #5's open area/MASD to the coccyx nor did she add the resident to her weekly wound documentation. Review of the weekly wound reports for the period of 5/4/26 through 5/20/26 failed to identify Resident #5's open area to the coccyx was assessed/monitored and/or documented on. Review of the Skin Integrity and Wound Management policy identifies the facility will implement evidence-based interventions to prevent pressure injuries, skin tears, moisture -associated skin damage, and other alterations in skin integrity while ensuring timely treatment and documentation of all identified skin conditions. The policy further identifies that the physician and responsible party will be notified upon the identification of a new wound. Wound documentation shall include location, measurements, stage/type, drainage, odor, peri wound condition, pain and treatment provided, treatment orders in place and wound monitoring weekly at a minimum.

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #59) reviewed for accidents, the facility failed to ensure the resident was properly supervised while eating. The findings include:Resident #59's diagnoses included sequela of cerebral, dysphagia following cerebral infarction, aphasia, cachexia and severe protein calorie malnutrition.Quarterly MDS assessment dated [DATE] identified Resident #59 had severely impaired cognition, had a mechanically altered diet (change in texture of food or liquids pureed) and required substantial/maximal assistance with eating. Physician's orders dated 5/1/26 directed aspiration precautions with head of bed upright for all meals, drinks, medications with special instructions to monitor for signs/symptoms of aspiration and document if noted. Additional instructions directed monitoring for pocketing of food, check oral cavity prior to reclining, with a diet consistency or puree with allowance for soft sandwiches as tolerated and thin liquids as tolerated with Provale cup (a specialized drinking aid designed for individuals with dysphagia (swallowing difficulties), it dispenses a fixed, controlled amount of thin liquid with each normal drinking motion, which helps prevent choking and aspiration while promoting independent drinking) only and special instructions for 1:1 feeding supervision. The care plan dated 5/13/26 identified Resident #59 had a swallowing problem related to dysphagia with interventions to follow Speech Language pathologist (SLP) as ordered and use aspiration precautions. Additionally, the care plan identified a potential for alteration in nutrition related to dysphagia, mechanically altered diet, advanced age, dementia, depression varied PO intake, dependence for nutrition/hydration, with interventions to encourage resident to drink with sippy cup (per SLP), diet as ordered regular diet, puree texture and added 4/28/26 OK for soft sandwiches (per SLP). SLP progress note dated 5/13/26 identified Resident #59 was discharged from SLP therapy services having med goals with recommended diet texture continuation of puree solids, thin liquids with an allowance for soft sandwiches as tolerated, maintain aspiration precautions, feeding supervision, encourage pacing/slow rate of intake, small bites/sips, alternate bites/sips and reconsult SLP as needed. Observation of Resident #59 on 5/13/2026 at 11:03 AM sitting in bed with a [NAME] gown on, and a large amount of a brown colored food residue on the front of the johnny and the resident's chest. There is not a meal tray in the room, nor any drinks. Interview with NA #7 on 5/13/26 at 11:07 AM identified she was assigned to Resident #59 but had not been able to see the resident that morning. NA #7 indicated that she did not assist Resident #59 with the breakfast meal nor provided any care. Observation of Resident #59 on 5/13/26 at 11:13 AM identified that the call bell was non-functional. This writer pushed the roommates call bell for assistance. The fire alarm was activated at 11:15 AM. At 11:18 AM, Maintenance Staff #2 entered the room of Resident #59 and reset the call bell and walked out of the room. Resident #59's roommate was asleep. Interview with NA #7 on 5/13/26 at 11:42 AM identified Resident #59 required 1:1 assistance for eating but indicated she did not pass out the trays and did not know if Resident #59 was fed by staff that morning. Interview with RN #5 on 5/13/26 at 11:45 AM identified Resident #59 usually self feeds and tended to spill food on himself/herself during mealtime. RN #5 could not identify what Resident #59's feeding status was or if Resident #59 was fed or self-fed this am or why Resident #59 would have so much residual food on the johnny. RN #5 additionally identified that she was not notified the call bell in the room was alarming, nor was she aware that Resident #59's call bell was not functioning but would put it in the maintenance book to be fixed. Observation of Resident #59 on 5/14/26 at 8:52 AM identified Resident #59 in bed with the head of the bed elevated and eating breakfast with regular silverware and regular plate unassisted and unsupervised. Observation of one sippy cup with lid, a regular clear cup with orange colored juice, a regular clear cup with white colored liquid, a plastic cup half filled with a clear liquid, a plate with pureed food (a brown colored food and a pale yellow colored food), a cup of yogurt (pink colored) and a spoon for the food on the plate and a spoon in a bowl of what appeared to be oatmeal. Resident #59 was eating unassisted and unsupervised and had a good amount of food on the green napkin that was tucked into the hospital johnny leaving a portion of the chest uncovered and food was noted on the resident's chest. Interview with NA #8 on 5/14/26 at 8:55 AM identified that she was not assigned to Resident #59 but had prepared and delivered the tray to Resident #59. NA #8 indicated that she was just passing trays and pointed me to the NA assigned to Resident #59 in an adjacent hallway. NA #8 could not identify the feeding status of Resident #59.Interview with NA #10 on 5/14/26 at 8:58 AM identified that he was the NA assigned to Resident #59 and that he had not gone into Resident #59's room that morning. NA#10 indicated that he was finishing care with another resident but identified he would know a resident's eating status by looking at the resident and seeing how they moved. A nurse walked by and prompted NA#10 to check the assignment sheet and NA #10 pulled a paper from his pocket and identified Resident #59 required 1:1 supervision while eating. Interview with LPN #4 on 5/14/26 at 9:05 AM identified Resident #59 was a 1:1 feed and that Resident #59's NA would have that information on the care card and that NA's assisting residents they are not assigned to should ask the nurse for confirmation of status.Interview with NA #8 on 5/14/26 at 9:08 AM identified that she gave Resident #59 a breakfast tray because she had seen the resident eating independently at other times. NA #8 indicated that Resident #59 was not on her assignment and that she did not check with anyone regarding Resident #59's feeding ability and identified she should have asked the nurse. Interview with SLP #1 on 5/14/26 at 1:26 PM identified Resident #59 had been discharged from SLP services yesterday, 5/13/26, and was a 1:1 supervision for feeding with cueing. SLP #1 indicated that if Resident #59 eats in the room, there needs to be a staff member with the resident while eating or drinking. SLP #1 identified that nurses and NAs are educated on the need for the 1:1 feeding and most meals should be eaten in the dining room related to cognition and need for supervision. SLP #1 indicated that if a resident is ordered a sippy cup, then all of the drinks should be in a sippy cup. Additionally, SLP #1 indicated that without the supervision in place, Resident #59 could choke or aspirate.Interview with the dietician on 5/14/26 at 1:38 PM identified that although adaptive equipment and meal consistency was listed on the meal slip, the slip does not tell staff how the meal should be supervised. The dietician indicated that Resident #59 had pureed consistency and a sippy cup and identified that seeing the sippy cup should indicate to staff how the drinks should be served. The dietician identified that the expectation for 1:1 supervision is that a staff member has their eyes on the resident at all times.The facility policy for Feeding the Resident (dependent eating) directed to assist the resident with feeding as necessary and to provide adequate nutrition and indicated to provide the diet as ordered and use of assistive devices as needed. The policy identified the procedure to include assisting the resident to proper sitting position and giving the resident small amounts at a time, alternate solid food and liquid and leave resident in a comfortable position with call light in reach if in bed.The policy for Choking Prevention and Care of Residents with Swallowing Disorders identified altered diet consistencies and appropriate feeding techniques will be utilized for all residents as indicated. The policy procedure identified that staff attend to residents who require supervision with meals and to have residents with swallowing trouble out of bed for meals whenever possible and indicated staff follow all recommendations/orders directed by the physician and /or speech therapist on food modifications and/or swallowing strategies.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of five sampled residents (Resident #3) receiving an anticoagulant and had a history of an indwelling catheter, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring of an anticoagulant medication and failed to ensure that the resident's care plan reflected the discontinuation of the indwelling catheter. The findings include: Resident #3's diagnoses included atrial fibrillation, cardiac arrhythmia and sequelae of cerebral infarction.The quarterly MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment, required moderate assistance with dressing, toileting hygiene, and transfers, required set-up assistance with ambulation and wheelchair mobility. The assessment further identified Resident #3 received anticoagulant medication (blood thinner) which the assessment noted to be a high-risk medication. A review of Resident #3's physician's orders for the time period of 9/6/25 through 5/20/26 identified an order for Eliquis (a blood thinner used to prevent blood clots) with directions to administer 5 mg by mouth twice daily for unspecified sequelae of cerebral infarction.Resident #3's care plan dated 3/18/26 failed to address the use of an anticoagulant medication and/or directions instructing staff what side effects to monitor the resident for such as bleeding, unusual bruising, blood in the urine, and tarry colored stools.According to Eliquis.com, the use of the medication poses a bleeding risk, in that it increases the risk of bleeding and can cause serious, potentially fatal bleeding.Interview with the MDS Director (RN #3) on 5/20/26 at 10:50 AM identified identified the care plan should have had interventions that monitor for signs and symptoms of bleeding and bruising. RN #3 identified that when nursing received the order for the anticoagulant medication, they should have added the care plan, however, if it was not added at the time, it should have been caught when the MDS assessment was completed. She further identified it is the responsibility of the MDS staff who completes the MDS assessment to review and ensure the appropriate care plan is implemented. RN #3 was unable to state why it was not completed as she was not the one who completed the MDS assessment and the staff who completed it is out on leave. Subsequent to surveyor's inquiry a care plan for the use of anticoagulant medication dated 5/20/26 was implemented with interventions that included administer anticoagulant as ordered, inspect skin with daily care to observe for bruising, to observed for active signs of bleeding such as but not limited to blood in urine, tarry colored stools, increased pulse, decrease blood pressure, abdominal pain and report signs/symptoms of bleeding to the physician. Review of the Care Plan, Comprehensive Person-Centered policy identified the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly, in conjunction with the required MDS assessment. Review of Resident #3's physician's order for the period of January 2026 through May 20, 2026, failed to direct the utilization of an indwelling urinary catheter and observation of Resident #3 failed to identify the presence of an indwelling urinary catheter. The care plan dated 3/18/26 identified Resident #3 requires a foley catheter (indwelling catheter) related to retention with interventions that included catheter size 16 French and 10cc balloon size as ordered, encourage resident to use leg bag during the day, and provide privacy cover for catheter bag. Interview with the MDS Director (RN #3) on 5/20/26 at 10:50 AM identified Resident #3's Foley catheter was discontinued in September of 2025 and at that time the care plan should have been revised to reflect the discontinuation of the Foley catheter. Review of the Care Plans, Comprehensive Person-Centered policy identifies that assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on review of facility documentation, review of facility policy, and staff interviews for one of three nurse aides (NA #1), the facility failed to complete an annual performance evaluation. The findings include:Review of NA #1's personnel file identified a hire date of 4/4/1988. Further review identified that the last performance evaluation was completed on 2/12/2019. The facility failed to ensure that annual performance evaluations were completed for 2024 and 2025.Interview with the administrator on 5/19/26 at 9:20 AM identified that each employee was required to have a performance evaluation completed annually based on their date of hire anniversary. He identified that the DNS had been responsible for ensuring that NA #1's performance evaluation was completed each year. He explained that the DNS had been attempting to complete performance evaluations for all nursing staff; however, the DNS had been unable to finish them before leaving the facility. He further identified that a Quality Assurance and Performance Improvement (QAPI) project had been initiated regarding performance evaluations because the facility had realized it was behind in completing evaluations for facility staff.The Employee Performance Evaluation Policy identified that employee performance evaluations were to be conducted on a regular basis for all employees. The performance evaluations assessed staff job performance, adherence to facility policies and procedures, attendance, professionalism, residents' rights, safety practices, and overall contribution to the facility.The evaluation schedule indicated that an introductory and/or probationary evaluation was to be completed within the first ninety (90) calendar days of employment and completed annually thereafter.

Based on clinical record review, facility documentation, facility policy, and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from verbal abuse. The findings include:Resident #1's diagnoses included dementia, depression, anxiety, dysphagia, difficulty walking, need for assistance with personal care, and generalized muscle weakness.The nursing admission assessment dated [DATE] by LPN #4 identified Resident #1 was alert and oriented to person, was incontinent of bowel and bladder, and required assistance with ADLs.A physician's order dated 8/20/2025 directed to provide complete assistance with ADLs.The Resident Care Plan (RCP) dated 8/20/2025 identified Resident #1 had the potential for alteration in elimination. Interventions directed to assist to the bathroom as needed, provide incontinent care as needed, bowel protocol per policy, bowel and bladder evaluation upon admission, and as needed.A facility reportable event (RE) form dated 8/20/2025 at 6:00 A.M. identified NA #2 reported she witnessed NA #1 yelling and swearing at Resident #1.The nurse's note dated 8/20/2025 at 9:30 A.M. by the Assistant Director of Nursing (ADON) identified it was reported that on 8/19/2025, NA #1, who worked the 11 P.M. to 7 A.M. shift, was witnessed yelling and swearing at Resident #1 during care. The ADON identified that Resident #1 reported that a girl was very mean h/her.The facility RE summary dated 8/28/2025 identified on 8/19/2025 during rounds on the 11 P.M. to 7 A.M. shift, NA #1 and NA #2 went to provide Resident #1 with incontinent care. NA #2 witnessed NA #1 yell at Resident #1 stating you are f***ing nasty because Resident #1 was incontinent of stool. The summary further indicated that Resident #1 was without distress from the incident and NA #1 was terminated.Review of NA #1's Corrective Action Record dated 8/25/2025, completed by the Director of Nursing (DNS), identified NA #1 was terminated for violations of company policy or procedures, rudeness to employees or customers, unsatisfactory work, and a verbal abuse allegation.Interview with the Director of Nursing (DON) on 9/17/2025 at 11:15 A.M. identified NA #1 was terminated because she was witnessed by NA #2 being verbally abusive towards Resident #1.Interview with the ADON on 9/17/2025 at 11:50 A.M. identified on 8/20/2025 at approximately 7:00 A.M., she was notified by the Director of Human Resources that NA #2 alleged NA #1 spoke inappropriately to Resident #1. The ADON indicated NA #1 was sent home, and she initiated an investigation. The ADON indicated the facility interviewed staff and Resident #1. NA #1 was terminated for verbal abuse.Interview with the Director of Human Resources on 9/17/2025 at 12:14 P.M. identified on 8/20/2025 between 6:15 and 6:30 A.M. NA #2 reported that during rounds NA #1 yelled at Resident #1 and stated what the f*** are you doing, you know better, you are f***ing nasty because Resident #1 was incontinent. The Director of Human Resources indicated that on 8/20/2025, she notified the corporate staff, the ADON, and suspended NA #1.Interview with NA #2 on 9/17/2025 at 12:42 P.M. identified on 8/20/2025 at about 6:00 A.M., she and NA #1 went to provide care for Resident #1. NA #2 indicated NA #1 started yelling at Resident #1 and after she and NA #1 finished providing care to Resident #1, she reported the incident to the Director of Human Resources. Review of the facility Abuse Prevention Policy dated December 2016, directed in part, residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes but is not limited to freedom from verbal abuse. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone, including facility staff.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure a resident was free from abuse resulting in a fracture. The findings include: a. Resident #1 had diagnoses that included dementia with other behavioral disturbance, depression, and anxiety. The significant change Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6) indicative of severely impaired cognition, was occasionally incontinent of bowel and bladder, required moderate assistance with transfers, and required supervision with ambulation. The Resident Care Plan (RCP) dated 2/26/2025 identified treatment with antipsychotic medication related to anxiety, depression, and dementia. Interventions directed to evaluate the effectiveness and side effects of medications for possible decrease or elimination, observe mood and behavior, refer to psych for medication and behavior management, and observe interactions with others for appropriateness. The physician's order dated 3/1/2025 directed to monitor behaviors of agitation and resistiveness every shift. b. Resident #2 had diagnoses that included dementia, anxiety, adjustment disorder with mixed anxiety and depressed mood, restlessness and agitation. The physician's order dated 2/3/2025 directed to monitor behaviors of restlessness and agitation every shift. The RCP dated 2/4/2025 identified Resident #2 had a new diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Interventions directed to engage in friendly conversations to help h/her feel welcomed and comfortable in the new environment, observe for signs of anxiety or distress if noted, provide additional support such as adjusting h/her environment, offering companionship, or notifying nursing staff for further intervention, offer access to preferred calming music through a radio, CD player, or digital device during relaxation times, ensure music is available in h/her room as per h/her request, and encourage family members to visit regularly and stay involved in her care to promote emotional well-being, and assist in coordinating visits. APRN #1's service note dated 2/6/2025 identified Resident #2 was seen for an initial encounter and was restless and wandering in the halls, with h/her son, discussing leaving. The note indicated staff denied increased behaviors and would continue to monitor. The admission MDS dated [DATE] identified Resident #2 had a Brief Interview for Mental Status score of five (5) indicative of severely impaired cognition, rejection of care behavior that occurred one to three days weekly, was frequently incontinent of bowel and bladder, required moderate assistance with transfers, and independent of with ambulation. SW #2's service note dated 2/11/2025 identified Resident #2 was alert to people only, pleasant, and cooperative and further identified an anxious and agitated mood. The note identified Resident #2 informed her that h/she was waiting for h/her son to take h/her home and that it was unclear if Resident #2 would be staying at the facility long term. APRN #1's service note dated 2/13/2025 identified behavioral concerns of restlessness with moderate severity. The note identified Resident #2 stated h/she was in good spirits and looking forward to going home and that, per staff, Resident #2's family decided not to tell Resident #2 that h/she was staying at the facility for long term care. A nurse's note dated 2/16/2025 at 2:30 A.M. by LPN #2 identified Resident #1 was restless through the night, continued to get out of bed and was redirected without a positive effect. The note identified Resident #2 removed h/her top and refused to put it back on, and further identified multiple attempts to redirect Resident #2 back to h/her room and Resident #2 refused. The note identified Resident #2 developed aggressive behaviors, the supervisor was notified, and a note was left in the APRN book. APRN #1's service note dated 3/3/2025 identified she was asked to evaluate Resident #2 with pertinent diagnoses of dementia, anxiety, and insomnia. The note identified Resident #2 was in the hall at the nurse's station crying, very upset, wanted to go home and Resident #2 was having increased moments of tearfulness and anxiety and was difficult to redirect. The note identified Resident #2 was more restless and agitated and APRN #1 ordered a onetime dose of Seroquel and would start Rexulti (a medication used to treat depression and agitation associated with dementia) 0.5 milligrams (mg) at bedtime. Physician's orders dated 3/3/2025 directed to administer Seroquel (a medication used to treat agitation, aggressive behaviors, hostility, and psychosis) 25 mg one time only and administer Rexulti 0.5 mg one time per day at 9:00 P.M. SW #2's note dated 3/5/2025 at 11:53 A.M. identified Resident #2's mood was depressed and Resident #2 appeared anxious due to confusion. A nurse's note dated 3/15/2025 at 6:24 P.M. by LPN #1 identified Resident #2 was confused, occasionally agitated and restless. APRN #3's telehealth visit note dated 3/16/2025 at 3:04 P.M. identified she was notified by RN #1 that Resident #2 assaulted another resident. APRN #3 identified that RN #1 reported Resident #2's behaviors had been escalating, and Resident #2 was evaluated by psych with changes made to h/her psychotropics. APRN #3 identified that Resident #2 struck another resident in the face and is being hostile towards nursing staff, Resident #2 is not redirectable, and requires transfer to the emergency department. The facility accident and incident report dated 3/16/2025 at 5:00 P.M. identified a resident-to-resident abuse incident with injury occurred on 3/16/2025 at approximately 3:00 P.M. Resident #2 was witnessed by a nurse aide (NA) leaving Resident #1's room, then the NA observed Resident #1 sitting on his/her room floor with an abrasion to h/her right eye lid, and both residents were transferred to the hospital for further evaluation. A review of Resident #1's emergency department documents dated 3/16/2025 identified that an X-ray of Resident #1's nasal bones identified cortical irregularity in the nasal bone suspicious for fracture and Resident #1 was diagnosed with a nasal fracture. The facility reportable event summary dated 3/19/2025 identified that at approximately 3:00 P.M. on 3/16/2025 Resident #1 was calling for help from h/her room, staff responded immediately, observed Resident #2 exiting Resident #1's room, and observed Resident #1 on the floor with a 0.5 centimeter periorbital abrasion with minor nasal bleeding. Resident #1 reported that Resident #2, who appeared to be confused, entered h/her room, claimed the room belonged to h/her, and became aggressive. Resident #1 alleged that Resident #2 punched h/her in the face and pushed h/her to the floor. The incident was unwitnessed. The attending physician was notified, and both residents were sent to the hospital. Resident #1's radiology report indicated a cortical irregularity in the nasal bone and Resident #2 underwent a psychiatric evaluation and was cleared to return to the facility. Resident #1 was relocated to a different unit. Resident #2 was re-evaluated by psych with medication adjustments and initiation of increased monitoring of aggression and behavioral changes was implemented. Interview with LPN #1 on 4/2/2025 at 9:20 A.M. identified on 3/16/2025 at approximately 2:30 P.M. she was sitting at the nurse's station completing her charting when she heard Resident #1 yelling 'help.' LPN #1 identified she observed Resident #1 was sitting on the floor in h/her room with NA #1 standing next to h/her, and Resident #2 was exiting the room. LPN #1 identified she notified RN #1 and directed NA #1 to stay one to one with Resident #2 until Resident #2 went to the hospital. Interview with NA #2 on 4/2/2025 at 10:20 A.M. identified during the morning of 3/16/2025 she attempted to provide personal care to Resident #2 and Resident #2 became combative and struck out in an attempt to hit her. NA #2 indicated she notified LPN #1 of the behavior. NA #2 identified that if Resident #2 did not want personal care h/she would usually say 'don't touch me.' Review of the clinical record identified there was no update to the RCP or further interventions after the combative incident with NA #2 on the morning of 3/16/25. Interview with the DNS on 4/2/2025 at 12:00 P.M. identified that prior to 3/16/2025 Resident #2 had behaviors which included agitation and anxiety. The DNS identified when Resident #2 returned to the facility after the 3/16/25 incident, h/she was monitored hourly for 48 hours and stop signs were placed on various resident doorways as a precaution. The DNS indicated she was not made aware of the combative incident between Resident #2 and NA #2 on 3/16/25. Review of facility policy titled, Abuse Prevention dated December 2016 identified as part of the resident abuse prevention the administration will protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on review of facility documentation and interviews the facility failed to have a qualified infection preventionist (IP). The findings include: Review of RN #13's employee file (previous IP) identified a hire date was 3/13/23. RN #13 no longer was employed by the facility effective 8/5/24. Review of facility documentation identified RN #1 was hired on 9/3/24 in the role of IP. Interview with RN #1 on 10/7/24 at 11:28 AM indicated she started at the facility on 9/3/24 as the IP. RN #1 indicated that she had taken the IP course online but she realized she only completed 92% of the course work and did not take and pass the post test for completion. Interview with the DNS on 10/8/24 at 6:20 AM indicated that she and the ADNS have not taken and are not certified as an IP. The DNS indicated that she assumed RN #1 had been certified in IP. Review of the facility infection control nurse job description identified the qualifications of a graduate of accredited school of nursing, bachelor's degree a plus, a current licensure as a registered nurse in the state of Connecticut, and working knowledge of applicable local, state, and federal regulations and standards.

Based on review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure nursing staff had completed the required annual skill competencies as identified through the facility assessment and for the only sampled resident (Resident #77) reviewed for enteral feeding, the facility failed to ensure an agency nurse had the required competencies to replace a feeding tube. The findings include: 1. Interview and review of facility documentation (Competency Book 2023) with the Staff Development Nurse (RN #2) on 10/8/24 at 8:19 AM failed to identify that the nursing staff had the required annual skills and competencies assessed in 2023. The Competency Book 2023 identified documentation supporting that hand hygiene and medication administration competencies were completed for a portion of the nursing staff. RN #2 further indicated that she was not employed at the facility in 2023 and began her role as the Staff Development Nurse in March of 2024. RN #2 indicated that on 7/18/24 she hosted a mandatory annual in-service which provided the nursing staff with the required annual education, in a poster board format, but did not include skill competencies. RN #2 further indicated that she is planning another mandatory in-service fair to evaluate skill competencies before the end of the year, for nursing staff. Interview with the DNS on 10/9/24 at 11:35 AM identified that she had worked at the facility for 7 weeks and was not aware that annual skill competencies for licensed nurses and nurse aides had not been evaluated in 2023, and she would expect specific skill competencies to be evaluated annually. The DNS further identified that since she began working at the facility, in collaboration with the Staff Development Nurse, they have completed 2 mock codes, planned an upcoming skills fair where nurses will demonstrate hands on assessments and treatments, and have planned monthly educational in-services/skill assessments on specific topics that relate to the patient population. The facility's Staffing policy directs that the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and the facility assessment. The Facility Assessment directs the following annual skill competencies for nurse aides: peri-care, turning and repositioning, mechanical lifts, donning and doffing personal protective equipment, electronic blood pressures, hand hygiene, and foley catheter care. The Facility Assessment further directs the following annual skill competencies for licensed staff: wound care and assessment, management of IV sites (for certified staff only), medication administration, and glucometer checks, cleaning, and testing. 2. Resident #77 was admitted to the facility on [DATE] with diagnoses that included tracheostomy status, gastrostomy status, restlessness and agitation. The quarterly MDS dated [DATE] identified Resident #77 had intact cognition, had no range of motion functional limitations to his/her upper body, and had a feeding tube while a resident, at the facility. The care plan dated 5/13/24 identified Resident #77 had the potential for an alteration in nutritional status related to tube feeding and hospital return. Interventions included administering tube feedings as ordered, checking placement every shift, and flushing tube feed, per order. The nurse's note dated 5/17/24 at 8:14 AM, written by LPN #19, identified Resident #77's feeding tube came out with the balloon inflated, the nursing supervisor was made aware and re-inserted the tube, placement was verified via auscultation, flushing was done with no issue, abdomen soft, non-tender, no respiratory distress noted. Review of the nurse's notes dated 5/17/24 failed to identify documentation from the nursing supervisor identifying the time and date of the procedure and the condition of the treatment area. Interview with LPN #19 on 10/8/24 at 9:42 AM identified that on 5/17/24 during the 11:00 PM-7:00 AM shift she entered Resident #77's room to flush the feeding tube and found the tube was dislodged and laying on top of Resident #19's abdomen. LPN #19 further identified that she called the nursing supervisor (RN #12), who was an agency nurse, to assess the area; RN #12 reinserted the feeding tube, confirmed placement via auscultation, and looked for a return. LPN #19 indicated that after placement was confirmed, she was told by RN #12 that the feeding tube could be used. Resident #77 was not scheduled for a tube feed during her shift, but the flush was completed. Although attempted an interview with RN #12 was not obtained. Interview with the DNS on 10/9/24 at 1:17 PM identified that she had been working at the facility for 7 weeks and was not the DNS at the time the feeding tube was replaced at the bedside, and she was not yet familiar with the facility's policy and procedure for a nurse to replace a feeding tube at the facility. The DNS further identified that she would expect that a licensed nurse replacing a dislodged feeding tube would have documentation of education and skill competency for the procedure on file. RN #12 was an agency nurse so education and competency validation would have been completed by the agency. The DNS indicated that she had reached out to the agency that employs RN #12 and was told that they did not have documentation that RN #12 had received education or demonstrated competency with feeding tube replacement. The DNS further identified, in the future, all agency nurses and nurse aides must arrive to the facility with a competency check list in hand, prior to starting their shift. The facility's G-Tube/PEG Tube: Replacement policy directs a G-tube replacement is performed by a licensed nurse to allow for the continuation of g-tube feedings/medication administration as per physician order. The policy further directs that the nurse document the time, date of procedure, and condition of treatment area.

Based on review of facility documentation, facility policy, and interviews for 5 of 5 certified nurse aide personnel files (NA #1, 2, 6, 7, and 8), the facility failed to ensure nurse aide performance evaluations were completed annually. The findings include: Review of NA #1's personnel file identified that she was hired on 10/25/2011 and failed to identify documentation that an annual performance evaluation was completed in the year of 2023 or to date, in 2024. Review of NA #2's personnel file identified that she was hired on 10/24/22 and failed to identify documentation that an annual performance evaluation was completed in the year of 2023 or to date, in 2024. Review of NA #7's personnel file identified that she was hired on 6/5/23 and failed to identify documentation that an annual performance evaluation was completed to date, in 2024. Review of NA #8's personnel file identified that she was hired on 8/2/04 and failed to identify documentation that an annual performance evaluation was completed in the year of 2023 or to date, in 2024. Review of NA #9's personnel file identified that she was hired on 6/17/13 and failed to identify documentation that an annual performance evaluation was completed in the year of 2023 or to date, in 2024. Interview and facility documentation review with the Payroll Manager on 10/9/24 at 12:45 PM identified that she had been working at the facility for approximately 3 weeks and that she was unable to locate any 2023 or 2024 annual performance evaluations for licensed nurses or nurse aides. Interview with NA #1 on 10/9/24 at 1:25 PM identified that she could not recall the last time her annual performance evaluation was completed. NA #1 indicated that performance evaluations were usually completed every year, but the facility had not completed them in the recent years. Interview with the DNS on 10/9/24 at 1:36 PM identified that she had worked at the facility for 7 weeks; after searching the prior DNS's paper files and hard drives she was unable to locate documentation identifying the 2023 and 2024 nurse aide annual performance evaluations were completed. The DNS indicated that she would expect nurse aide performance evaluations to be completed annually and stored in the employee's personnel file, copies would also be retained by the DNS and Human Resources. The facility's Annual Employee Evaluation policy directs that the purpose of the policy is to establish a standardized process for the annual evaluation of all employees, ensuring their performance aligns with the facility's goals and regulatory requirements, and to promote continuous improvement in job performance. The policy further directs that all employees will undergo an annual performance evaluation, which must be completed by the employee's anniversary dare or a designated time frame (e.g., every calendar year by a certain date) and all evaluation forms, ratings, and any supporting documentation will be stored in the employee's personnel file in accordance with confidentiality guidelines.

Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure that testing supplies used to ensure chemical sanitizing solution was at recommended concentration levels were not expired; and failed to ensure that the chemical sanitizing solution was maintained at the recommended sanitation level; and failed to ensure a policy was in place regarding testing and changing chemical sanitizing solution; and failed to ensure that unit nourishment refrigerators were maintained to the proper temperatures; failed to ensure that food items stored in the resident nourishment refrigerators were dated and labeled. The findings include: 1. Observations during a tour of the kitchen on [DATE] at 9:13 AM with the Dietary Supervisor identified that the chemical sanitizing solution used for cleaning and sanitizing kitchen surfaces, was being checked for proper levels with testing strips that were out of date. The Dietary Supervisor conducted a check of the sanitizer level with a test strip. The test strip appeared to be a blue tinged color upon removal from the test strip container and became a slightly darker shade of blue after submersion in the chemical sanitizer, which the Dietary Supervisor identified was the proper sanitizer level by referring the test strip bottle indicator label. The Dietary Supervisor identified that the square identifying ,d+[DATE] parts per million (PPM) was the test strip result. This observation also identified that the test strips used expired [DATE]. Interview with the Dietary Supervisor immediately following this observation identified that the chemical sanitizer was changed once daily at 6:00 AM, and at that time the sanitizer was checked with the test strips to ensure it was at the proper level by the Dietary Director. The Dietary Supervisor identified it was the responsibility of the Dietary Director to change the solution, check the levels, and log the results on the daily log sheets for the kitchen. Observation of the chemical sanitizer solution dispenser and test strips on [DATE] at 9:30 AM identified the facility utilized 'Smartpower Sink and Surface Cleaner Sanitizer' as the chemical sanitizing solution for the kitchen area and was a 2 chemical solution using DDBSA and Lactic Acid as the sanitizing components. The instructions on the sanitizer bottle identified that the sanitizer should be diluted for DDBSA to be between ,d+[DATE] PPM and Lactic Acid to be between ,d+[DATE] PPM. A review of the test strip bottle indicator label identified a large square around the target test colors for these ranges, and the test strip color previously identified by the Dietary Supervisor was below and outside these ranges. Review of the daily logs for the kitchen identified the chemical sanitizer was checked with test strips twice daily (AM/PM) and the sanitizer level should be between 200 - 400 PPM, and all documentation reviewed from [DATE] to [DATE] identified all test results were 400 PPM. Follow up observation on [DATE] at 7:04 AM identified the chemical test strips in the kitchen available for use were expired ,d+[DATE] and appeared to be the test strips from the [DATE] observation. Observation and interview with the Dietary Director on [DATE] at 8:15 AM identified that he was not typically responsible for changing or testing the chemical sanitizer in the morning, and that the staff member who arrived at 6:00 AM typically took care of this, but that he did test and change the solution sometimes. The Dietary Director identified that the solution was supposed to be changed every 2 hours, and that the facility used a quat (quaternary ammonium) based solution for sanitizing the kitchen. The Dietary Director identified he was not aware that the kitchen was using a lactic acid/DDBSA based solution, could not identify what the sanitizing ranges for this type of solution was, how often to change this type of solution, or why the test strips were expired. The Dietary Director identified that the facility had recently changed companies who provided the chemical sanitizer, and that the strips on hand were provided by the company at the beginning of the year, but he did not check the expiration date on the strips, and that the bottle on hand was the only test strips he had available but he had requested for an technician from the chemical sanitizer company to come to the facility regarding the solution and test strips. A request was then made for a policy regarding sanitization of the kitchen including testing of the sanitizer and when to change the sanitizer solution. Subsequent to surveyor inquiry, the Dietary Director provided in-service education on [DATE] at 2:21 PM regarding sanitizer buckets. The in-service documentation identified a policy effective date of [DATE] related to sanitizer bucket change and identified the buckets should be changed every 2 hours. Interview with the Dietary Director on [DATE] at 2:30 PM identified that the kitchen did not have any policies related to the chemical sanitizer buckets, testing, or changing of the solution prior to the survey team's entrance to the facility on [DATE]. The Dietary Director identified that the facility would be changing the chemical sanitizer solution from the DDBSA/lactic acid based to a quat based solution, which had sanitizer ranges from 200 - 400 ppm. A follow up observation and interviews on [DATE] at 1:10 PM identified the Dietary Director with Ecolab Technician #1 was onsite to change the chemical sanitizer solution. Person #2 identified that all sanitizer products for the kitchen would be qaut based and he was also posting signage regarding instructions of dilution levels and test strips ranges near the solution dispenser in the kitchen. Review of the manufacturer recommendations for Smartpower Sink and Surface Cleaner Sanitizer identified that the solution concentration should be between 272 - 700 PPM for DDBSA and 704 -1875 PPM for Lactic Acid, and that the solution should be checked with every change out. The recommendations also identified that the solution should be changed when it was visibly dirty or when the solution tested below the concentration range. The instructions also identified the test strips had a shelf life of 2 years. The facility policy on Sanitizer Bucket Change Protocol, effective [DATE], directed the purpose of the policy was to ensure the safety and cleanliness of the food service areas by maintaining effective sanitizing solutions and prevent cross contamination. The policy further directed that the sanitizer buckets must be changed every 2 hours to ensure the sanitizing solution remained effective and to minimize the risk of cross contamination. The policy also directed that staff were required to monitor the time of the sanitizing bucket preparation and the preparation would be according to the manufacturer's instructions. 2. Interview with the Dietary Director on [DATE] at 8:15 AM identified that the resident nourishment refrigerators were maintained by the nursing staff of the facility, including temperature logs and labeling. The Dietary Director identified that the dietary staff provided nourishment snacks and juices to the units and the kitchen items were labeled with use by dates. Observations conducted on [DATE] at of the resident nourishment refrigerators identified the following: Initial observation of the nourishment room located in the Deerfield unit was conducted at 1:59 PM. Review of the log located attached to the refrigerator door identified no logging of freezer temperatures, and observation of the freezer did not contain a thermometer. The log also included documented temperatures through 11:00 PM on [DATE] (a future time). The refrigerator contained three 2-quart clear pitchers, each half full, what appeared to be apple, orange and cranberry juices, however there were no labels on the pitchers. The refrigerator also contained a 48-ounce bottle of almond milk, a large container of microwavable prepacked macaroni and cheese; a clear plastic container with a white substance; partially full 20 oz water bottle, and large black and plastic white polka dotted lunch carrier taking up half of the bottom shelf. The freezer contained a second large black plastic lunch carrier and a partially full ice cream carton. All items observed had no labels to identify the date, item contained within the container, the resident the item belonged to, or the use by date. Observation of the Maple unit resident nourishment refrigerator located within the first floor lounge area was conducted at 2:03 PM. Review of the log located attached to the refrigerator door identified no logging of freezer temperatures, and the freezer did not contain a thermometer. The refrigerator contained three 2 quart clear pitchers, ,d+[DATE] full, what appeared to be apple, orange and cranberry juices, however there were no labels on the pitchers. The refrigerator also contained partially full container of [NAME] cream cheese, 6 containers of Chobani yogurts, a Walgreens brand protein drink with an expiration date of ,d+[DATE], and a probiotic yogurt bottle with an expiration date [DATE]. The freezer contained 13 freezer pops, an opened 5 lb. box of mozzarella sticks, and a partially full ice cream carton. All items observed had no labels to identify the date, item contained within the container, the resident the item belonged to, or the use by date. Observation of the Birchwood unit resident nourishment refrigerator located within the first floor lounge area was conducted at 2:39 PM. Review of the log located attached to the refrigerator door identified no logging of freezer temperatures, and the freezer did not contain a thermometer. The thermometer located within the refrigerator, on the top shelf near the door, had an observed temperature of 26 degrees F. The items observed in the refrigerator were not frozen or partially frozen during this observation. The refrigerator contained a 2 quart clear pitcher, ,d+[DATE]th full with what appeared to be orange juice. The refrigerator also contained partially full container of muscle milk protein drink. The freezer contained one small cup of ice cream. The items observed had no labels to identify the date, item contained within the container, the resident the item belonged to, or the use by date. Observation on all 3 refrigerators identified a large yellow sign with the following: This refrigerator is for Resident food only. Staff food must be stored in employee break rooms or staff development classroom. Review of the temperature logs for the Deerfield unit for ,d+[DATE] identified the following dates/times with no documentation: [DATE] no AM or PM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no AM or PM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no AM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no AM temperature. [DATE] no PM temperature. [DATE] no AM temperature. [DATE] no PM temperature. Review of the temperature logs for the Deerfield unit for ,d+[DATE] identified the following dates/times with no documentation: [DATE] no AM or PM temp [DATE] no AM temperature. [DATE] no AM temperature. [DATE] no AM temperature. [DATE] no AM temperature. [DATE] no AM or PM temperature. [DATE] no AM temperature. [DATE] no AM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no PM temperature. [DATE] no AM or PM temperature. [DATE] no AM or PM temperature. [DATE] no AM or PM temperature. [DATE] no PM temperature. [DATE] no AM temperature. [DATE] no AM temperature. [DATE] no AM or PM temperature. [DATE] no AM temperature. Interview with RN #1 (Infection Preventionist) on [DATE] at 2:48 PM identified that the dietary staff was responsible for all resident nourishment refrigerators, including cleaning and temperature logs. Interview with RN #2 (Staff Development) on [DATE] at 3:00 PM identified she believed the RN supervisor on 11:00 PM - 7:00 AM was supposed to check the nourishment refrigerators but was unsure if the logs included checking the freezer temperatures. Interview with the DNS identified on [DATE] at 3:02 PM identified that she was aware of an issue with the nourishment room temperature logs being maintained but was not aware the logs did not track the freezer temperatures. The DNS identified she only recently began employment at the facility, and in her review of the temperature logs, she was only able to locate one unit (Deerfield) of previous logs, and only going back to ,d+[DATE]. The DNS identified that the logs were an issue, and that the food in the refrigerators should be labeled with what the item was, the resident, and the use by date. The DNS also identified that the freezers should be checked along with the cooler portion of the refrigerator every shift. The DNS was unable to identify who was responsible for the cleaning of the refrigerators, but identified it was the responsibility of nursing staff to label the food items from outside the facility and to check the temperatures. Although requested, the monthly refrigerator logs for all resident nourishment refrigerators from ,d+[DATE] to ,d+[DATE] were not obtained. The facility policy on food brought by family/visitors directed that food items in the refrigerator would be labeled with the resident's name, item, and use by date. The policy further directed that the nursing staff would discard any perishable items on or before the use by date, and that the nursing and/or food service staff would discard any prepared foods for the resident that showed obvious signed of potential foodborne danger including mold and past package expiration dates. The facility policy on preventing foodborne illness directed that federal standards required that refrigerated foods be stored below 41 degrees and that freezers keep frozen food solid.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for hospitalization , the facility failed to convey appropriate information when the resident was sent to the hospital on 8/26/23. The findings include: Resident #7 was admitted to the facility in June 2023 with diagnoses that included dementia, acid reflux, and diabetes. The admission MDS dated [DATE] identified Resident #7 had moderately impaired cognition and required total assistance with transfers, bed mobility, dressing and toileting. The nurses note dated 8/26/23 at 5:34 PM identified Resident #7 was refusing to let the Intravenous (IV) technician insert an IV line for intravenous fluids the physician had ordered due to abnormal labs from this morning. Resident #7 continued to refuse IV insertion. The APRN was notified and Resident #7 was sent to the emergency room for evaluation. The facility transfer form dated 8/26/23 identified Resident #7 was being transferred to emergency room for abnormal labs. Resident #7 had refused an IV. The hospital emergency documentation dated 8/26/23 identified Resident #7 was brought to the emergency room per facility paperwork for abnormal labs. EMS reported concern for high potassium. ER charge nurse will call facility. At 7:15 PM the ER nurse called the facility, and nurse was unable to specify what lab work was abnormal but would fax lab results. At 7:25 PM ER nurse recontacted facility and nurse stated they do not have the lab work results that were reported as abnormal. They reported only having lab work from 8/17/23 and the results were on 8/23/23. At 8:00 PM received lab work from facility from 8/23/23 and potassium level was 4.3 (normal range 3.5 - 5.1 mmol/L), sodium of 159 (normal range 136 to 145 mmol/L), BUN of 23 (normal range HIGH), creatinine 1.01 (normal range .59 to 1.04 mg/dl), and normal LFT's. Gave 1 liter lactate ringers via IV in emergency room and transferred back to facility. Review of labs in chart dated 8/21/23, 8/23/23 and 9/27/23. Interview with RN #8 on 10/8/24 at 10:18 AM indicated that she does not recall transferring Resident #7 to the emergency roiagnom on [DATE]. RN #8 indicated that she would send with the resident to the emergency room their diagnosis list, current medication list, and call emergency room to inform them the reason for the transfer. RN #8 indicated she would write a progress note regarding who she spoke with at the ER. RN #8 indicated that she did not recall what the abnormal labs were but if she had the completed labs, she would have sent it with the paperwork. RN #8 indicated that there should be a copy of what was sent in the resident's medical record. Interview with the DNS on 10/8/24 at 11:40 AM indicated it is the responsibility of the charge nurse and supervisor to provide the hospital with the exact reason for the transfer to the hospital. After clinical record review, the DNS indicated the discharge paperwork dated 8/26/23 from the facility to the hospital does not identify the reason for transfer by just saying abnormal labs. The DNS indicated that her expectation was the nurse would have sent a copy of the labs and documented on the w-10 what the abnormal lab was. The DNS indicated that the nurse could have called the lab to get the results. The DNS indicated that the hospital should not have had to call the facility many times to try to get the labs or the reason for the transfer. The DNS indicated that she was not able to find labs dated 8/26/23 in the medical record and it was not in the MD or nurses progress notes if they had received a verbal from the lab of a critical lab. The DNS indicated she was not able to identify what was the abnormal labs were. Although requested a policy for hospital transfer documentation was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #274) reviewed for admission, the facility failed to ensure the baseline care plan was completed upon admission and included interventions related to the residents implanted cardiac defibrillator. The findings include: The hospital discharge summary dated 9/23/24 identified Resident #274 had an implanted cardiac defibrillator. Resident #274 was admitted to the facility in September 2024 with diagnoses that included cardiomyopathy and ventricular tachycardia. The baseline care plan, undated, was labeled with Resident #274's name, date of birth, physician name, and room number was not filled out. Observation 10/6/24 at 8:00 AM identified Resident #274 was lying in bed with a white box plugged into the wall on the nightstand within 2 feet from resident. Observation on 10/6/24 at 10:08 AM identified Resident #274 had a raised area on the left chest wall. Interview with Person #1 on 10/6/24 at 10:08 AM indicated that he/she had informed the nurse on day of Resident #274's admission and the day after admission that he/she had brought in and plugged in the implanted cardiac defibrillator monitor and it was sitting on the bedside table doing the continuous transmission. Further, Person #1 had placed the owner's manual for implanted cardiac defibrillator monitor in the top draw of the nightstand in the resident's room. Interview with the DNS on 10/7/24 at 6:49 AM indicated charge nurse or supervisor on the shift of admission was responsible to start the baseline care plan and the MDS coordinator was responsible to complete the baseline care plan the next business day. After review of the clinical record the DNS indicated the baseline care plan was blank, and did not reflect the implanted cardiac defibrillator. Although requested, a facility policy for baseline care plans was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #30 and 100) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the residents were provided a shower on scheduled shower days. The findings include: 1. Resident #30 was admitted to the facility in September 2024 with diagnoses that included heart failure, depressive episodes, and anxiety disorder. The physician's order dated 9/14/24 directed to provide a weekly body audit every week on the first shower day of the week. If the resident refuses shower or body audit update the supervisor and document in the progress notes. Shower once a day on Tuesday on the 7:00 AM - 3:00 PM shift. The care plan dated 9/14/24 identified Resident #30 had an Activity Daily Living (ADL's) functional deficit and needs assistance with mobility and self-care needs related to: weakness, dorsalgia, and advanced age. Interventions included to provide assistance and provide privacy to the extent needed. Allow extra time to perform tasks as needed. The unit shower & body audit schedule form identified Resident #30's shower days were Wednesday and Saturday on the 7:00 AM - 3:00 PM shift. The admission MDS dated [DATE] identified Resident #30 had intact cognition and required total assistance with shower. Review of the nurse aide flowsheet dated 9/14/24 - 9/30/24 failed to reflect documentation that Resident #30 had been provided a shower on his/her scheduled day Tuesday 9/17/24 during the 7:00 AM - 3:00 PM shift. Review of the nurse's note dated 9/14/24 through 9/23/24 failed to reflect documentation that Resident #30 had been provided a shower on his/her scheduled day Tuesday 9/17/24 during the 7:00 AM - 3:00 PM shift. The physician's order dated 10/1/24 directed to provide weekly body audit every week on the first shower day of the week. If resident refuses shower or body audit update the supervisor and document in the progress notes. Shower once a day on Tuesday on the 7:00 AM - 3:00 PM shift. Review of the nurse aide flowsheet dated 10/1/24 - 10/7/24 failed to reflect documentation that Resident #30 had been provided a shower on his/her scheduled day Tuesday 10/1/24 during the 7:00 AM - 3:00 PM shift. Review of the nurse's note dated 10/1/24 - 10/7/24 failed to reflect documentation that Resident #30 had been provided a shower on his/her scheduled day Tuesday 10/1/24 during the 7:00 AM - 3:00 PM shift. Review of the nurse aide care card failed to reflect documentation that Resident #30 shower days were scheduled for Tuesday during the 7:00 AM - 3:00 PM shift. Interview with Resident #30 on 10/6/24 at 11:40 AM identified he/she had not had a shower since she has been at the facility. Resident #30 indicated he/she had refused one shower in the month of September 2024 because he/she was not feeling well. Resident #30 indicated ever since that day the staff has not offer him/her a shower. Resident #30 indicated he/she was told his/her shower day are on Tuesdays on the 7:00 AM - 3:00 PM shift. Resident #30 indicated he/she has asked for a shower multiple times and the nurse aides have not given her a shower. Resident #30 indicated the nurse aides would say they are short of staff. Resident #30 indicated all he/she wants is a shower on his/her schedule shower day. Interview with the Administrator on 10/8/24 at 7:00 AM identified he was not aware that Resident #30 had not been receiving showers. The Administrator indicated that all nursing staff will be in-service regarding showers. Interview and review of the clinical record with RN #4 on 10/8/24 at 11:55 AM identified she was not aware that Resident #30 had not been receiving showers. RN #4 indicated Resident #30 has not complained to her that he/she has not received showers. RN #4 indicated going forward she will be in-servicing the nursing staff. Interview and review of the clinical record with the DNS on 10/8/24 at 1:49 PM identified she was not aware that Resident #30 had not been receiving showers. The DNS indicated the nurse aides should have provided Resident #30 with a shower on his/her schedule shower days. The DNS indicated the assigned nurse aide should have reported to the charge nurse if a shower was not given. The DNS indicated the assigned nurse aide should have documented if the shower was given or not. The DNS indicated that all nursing staff will be in-service regarding showers and documentation. Interview with LPN #15 on 10/11/23 at 1:34 PM identified she is a float nurse and works Per Diem only. LPN #15 indicated she signed the MAR on 10/1/24 on the 7:00 AM - 3:00 PM shift which indicated she performed a body audit and Braden scale. LPN #15 indicated she does not know if the nurse aide gave the resident a shower and she does not know when the residents shower day is and did not document whether Resident #30 had a shower or not. LPN #15 indicated being a float makes it very difficult to know the residents and their routine. Although attempted, an interview with LPN #14, and NA #3 was not obtained. 2. Resident #100 was admitted to the facility in July 2023 with diagnoses that included severe morbid obesity, atrial fibrillation, and chronic obstructive pulmonary disease. The unit shower & body audit schedule form dated 6/5/24 identified Resident #100 shower days were Tuesday and Friday on the 3:00 PM - 11:00 PM shift. The physician's order dated 8/1/24 directed to provide a body audit every week on the first shower day of the week. If the resident refuses shower or body audit update the supervisor and document in the progress notes. Once a day on Tuesday 3:00 - 11:00 PM. The quarterly MDS dated [DATE] identified Resident #100 had intact cognition and required supervision or touching assistance with shower/bathing, and personal hygiene. The care plan dated 8/28/24 identified Resident #100 would like to be offered and assisted with a shower on Tuesday and Friday on the 3:00 PM - 11:00 PM shift. Intervention included staff will offer Resident #100 a shower on Tuesday and Friday on the 3:00 PM - 11:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 8/1/24 - 8/30/24 failed to reflect documentation that Resident #100 had been provided a shower on his/her scheduled day Tuesday 8/6/24, 8/13/24, 8/20/24 and 8/27/24 during the 3:00 PM - 11:00 PM shift. Friday 8/2/24, 8/9/24, 8/16/24, 8/23/24, and 8/30/24 during the 3:00 PM - 11:00 PM shift. The physician's order dated 9/1/24 directed to provide body audit every week on the first shower day of the week. If resident refuses shower or body audit update the supervisor and document in the progress notes. Once a day on Tuesday 3:00 - 11:00 PM. Review of the September 2024 MAR and TAR reflected documentation that Resident #100 had a body and Braden scale audit performed on his/her scheduled shower day Tuesday 9/3/24, 9/10/24, 9/17/24 and 9/24/24 during the 3:00 PM - 11:00 PM shift. Friday 9/6/24, 9/13/24, 9/20/24, and 9/27/24 during the 3:00 PM - 11:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 9/1/24 - 9/30/24 failed to reflect documentation that Resident #100 had been provided a shower on his/her scheduled day Tuesday 9/3/24, 9/10/24, 9/17/24 and 9/24/24 during the 3:00 PM - 11:00 PM shift. Friday 9/6/24, 9/13/24, 9/20/24, and 9/27/24 during the 3:00 PM - 11:00 PM shift. The physician's order dated 10/1/24 directed to provide body audit every week on the first shower day of the week. If resident refuses shower or body audit update the supervisor and document in the progress notes. Once a day on Tuesday 3:00 - 11:00 PM. Review of the October 2024 MAR and TAR reflected documentation that Resident #100 had a body and Braden scale audit performed on his/her scheduled shower day Tuesday 10/1/24 and Friday 10/4/24 during the 3:00 PM - 11:00 PM shift. Review of the nurse's notes and nurse aide flowsheet dated 10/1/24 - 10/7/24 failed to reflect documentation that Resident #100 had been provided a shower on his/her scheduled day Tuesday10/1/24 and Friday 10/4/24 during the 3:00 PM - 11:00 PM shift. Interview with Resident #100 on 10/6/24 at 11:19 AM identified he/she has not had a shower since he/she moved from the 2nd floor to the 1st floor in October 2023. Resident #100 indicated he/she was told his/her shower day are Tuesday and Friday on the 3:00 PM - 11:00 PM shift. Resident #100 indicated when he/she asked the nurse aides about his/her shower the nurse aide would say they are short. Resident #100 also indicated the staff would tell him/her that they have to transfer him/her with a hoyer and they had too many resident with hoyers to take care of. Interview with the Administrator on 10/8/24 at 7:00 AM identified he was not aware that Resident #100 had not been receiving showers. The Administrator indicated that all nursing staff will be in-service regarding showers. Interview and review of the clinical record with RN #4 on 10/8/24 at 11:55 AM identified she has only been with the facility for approximately 1 month. RN #4 indicated she was not aware of Resident #100 had not been receiving showers. RN #4 indicated Resident #100 has not complained to her that he/she has not received showers. RN #4 indicated going forward she will be in-servicing the nursing staff. Interview and review of the clinical record with the DNS on 10/8/24 at 1:49 PM identified she was not aware that Resident #100 had not been receiving showers. The DNS indicated the nurse aides should have provided Resident #100 with a shower on his/her schedule shower days. The DNS indicated the assigned nurse aide should have reported to the charge nurse if shower was not given. The DNS indicated the assigned nurse aide should have documented if the shower was given or not. The DNS indicated that all nursing staff will be in-service regarding showers and documentation. Interview with LPN #13 on 10/8/24 at 3:30 PM identified she was aware Resident #100 refused showers. LPN #13 identified Resident #100 shower is on Tuesday and Friday on the 3:00 PM - 11:00 PM shift and indicated Resident #100 refuses care and showers. LPN #13 indicated on 9/10/24 on the 3:00 PM - 11:00 PM she had worked, and Resident #100 had refused to take a shower that day. LPN #13 indicated she did not document in the nurse's note that Resident #100 had refused his/her shower. LPN #13 indicated she signed the MAR on 9/10/24 because she had performed the body and Braden scale on Resident #100. LPN #13 indicated Resident #100 will allow the nurses to perform the body and Braden scale audit but will refuse the shower. LPN #13 indicated she had offered Resident #100 a shower on 9/19/24 on the 7:00 - 3:00 PM shift and Resident #100 had refused the shower. LPN #13 indicated she had documented in the nurse's note. LPN #13 indicated she does not know if Resident #100 has a care plan reflecting refusal of care. Interview with LPN #2 on 10/8/24 at 3:50 PM identified she was aware of Resident #100 not receiving his/her showers. LPN #2 indicated Resident #100 shower day are on Tuesday and Friday on the 3:00 PM - 11:00 PM shift. LPN #2 indicated Resident #100 refuses to take a shower on schedule shower days. LPN #2 indicated she signed the MAR because she did perform the body audit and Braden audits every Tuesdays on the resident schedule shower day. LPN #2 identified signing the MAR it indicated that the body audit was performed not that Resident #100 had a shower. LPN #2 indicated she thought she had documented when Resident #100 had refused his/her showers. LPN #2 indicated going forward she will document in the resident clinical record when Resident #100 refuses shower. LPN #2 indicated that she assists the nurse aides with hoyer transfers if needed. Subsequent to surveyor inquiry, Resident #100 was provided a shower on 10/8/24 on the 3:00 PM - 11:00 PM shift. Although attempted, an interview with NA #4 was not obtained. Review of the facility bath, shower/tub policy identified the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The date and time the shower/tub bath was performed. The name and title of the individual who assisted the resident with shower/tub bath. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. If the resident refused to the shower/tub bath, the reasons. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility activities of daily living policy identified residents will receive services to optimize their level of independence with activities of daily living and the assistance they need to complete activities of daily living. The resident will receive assistance daily with hygiene, dressing, bathing, feeding, transfer, ambulation, and elimination as necessary.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #87 and #378) reviewed for pressure ulcers, the facility failed to notify the physician and resident representative when new open areas were identified and 1 of 2 residents (Resident #274) reviewed for admission, the facility failed to notify the physician when a 2 glaucoma medications were not available and when a resident was admitted to the facility with an implanted cardiac defibrillator which required a bedside monitor. The findings include: 1. Resident #87 was admitted to the facility in December 2021 with diagnoses that included dementia and osteoporosis. The quarterly MDS dated [DATE] identified Resident #87 had severely impaired cognition, required maximum assistance with personal hygiene, and was totally dependent for transfers and rolling left to right. Additionally, Resident #87 was at risk to develop a pressure ulcer but did not have any pressure ulcers. The care plan dated 8/14/24 identified Resident #87 was at risk for skin breakdown. Interventions included to monitor skin when putting on and off compression stockings to bilateral lower extremities and position resident to offset pressure areas while awake. The nurse's note written by LPN #7 dated 9/10/2024 at 6:21 AM identified this writer was informed by a nurse's aide of a wound to the resident heel. This writer cleansed the wound site, offloaded the heel with pillow, and updated physicians book for the heel to be evaluated for a treatment. Review of the nurse's and physician's progress notes dated 9/10/24 to 9/11/24 failed to reflect the physician, APRN or resident representative had been notified of the new wound on the resident right heel. A progress note, written by MD #1 dated 9/12/24 at 2:48 PM indicated that staff reports a new right heel ulcer. Resident #87 is alert, confused and disoriented. There is a 4.5cm unstageable ulcer on the right heel with no exudate or tenderness. There is + 2 - 3 right pedal edema with no other clinical changes. MD #1 ordered a wound consult, bilateral heel boots, and a daily dressing with Santyl for chemical debridement. Interview with the DNS on 10/7/24 at 9:13 AM indicated that when a new pressure ulcer is noted, the nurse must notify the APRN or physician and resident representative that day and document the notification in the clinical record. After clinical record review, the DNS indicated the physician and resident representative were not notified until 9/12/24, 2 days later. The DNS it is not acceptable practice to place a notation of a new wound in the communication book for the physician. Interview with LPN #7 on 10/7/24 at 1:10 PM indicated that on 9/10/24 the nurse aide had informed him that the resident had an open area on the right heel. LPN #7 indicated he went and looked at it, cleansed it with normal saline, and placed a boarder gauze dressing over it. LPN #7 indicated that he had placed a notation of the wound in MD #1's book. LPN #7 indicated that he did not call the APRN, MD, or resident representative, or notify the RN supervisor because he had placed it in the physician book. Interview with MD #1 on 10/7/24 at 10:45 AM indicated that he had seen Resident #87 on 9/12/24 for his/her monthly visit. MD #1 indicated that he does not recall on that day how he learned about the new pressure ulcer and indicated that he would have expected someone to call him on 9/10/24 to let him know so he could have put a treatment in immediately. The policy on pressure injury risk assessment directed that the facility should notify the physician and resident representative if any new skin alternations were noted. 2. Resident #274 was admitted to the facility in September 2024 with diagnoses that included cardiomyopathy, ventricular tachycardia, and Glaucoma. a. The physician's order dated 9/23/24 identified to administer Brimonidine Timolol drops 0.2 -0.5%, 1 drop in each eye daily and Bimatoprost drops 0.01% administer 1 drop to both eyes every other day for Glaucoma. The care plan dated 9/24/24 identified Resident #274 had vision impairment. Interventions included to report any concerns or changes to the physician and resident representative as needed. Review of the September 2024 MAR identified from 9/24/24 through 9/27/24, 4 days, Brimonidine Timolol drops 0.2 - 0.5% was documented as not available (4 doses). Additionally, from 9/24/24 through 9/30/24, 7 days the Bimatoprost drops 0.01% were documented as not available (4 doses). Review of the physician and nurse's notes dated 9/23/24 through 9/30/24 failed to reflect that the physician had been notified that the glaucoma medications, Brimonidine Timolol and Bimatoprost and were not available. Interview with Resident #274 and Person #1 on 10/6/24 at 10:08 AM indicated they were upset that Resident #274 did not receive the 2 eye drops during for 4 - 7. Resident #274 indicated that he/she was not informed why the facility could not get them from the pharmacy. Person #1 indicated that he/she had brought in the eye drops when the nurse informed them that they were not available from the pharmacy and Person #1 offered again to bring in the eye drops from home and the nurse informed Person #1 that the facility could not use them. Person #1 indicated that he/she had brought in the vials with the pharmacy labels on them and showed them to a nurse, and was informed again that the facility could not use the resident's bottles of eye drops. Person #1 indicated that subsequently, Resident #274 miss 4 - 7 days of the eye drops when that was not necessary. Interview with the DNS on 10/7/24 at 7:07 AM indicated that if a medication is not available from the pharmacy the nurses could use the resident's personal medication with a pharmacy label on it, until the pharmacy medication arrives. The DNS indicated that the charge nurse should have notified the supervisor, and she would have expected the supervisor to call the pharmacy for a stat order for the 2 eye drops and if the medication was still not available to notify the physician. The DNS indicated that the supervisor could have received an order from the physician that Resident #274 could have used own medications until available from the pharmacy. The DNS indicated that the physician should have been notified immediately upon admission that the medications were not available and for each day that medications were missed. The DNS indicated that there were no nurse's notes that the supervisor or charge nurse had notified the pharmacy or the APRN/MD that the medications were not given because they were not available. b. The hospital discharge summary dated 9/23/24 identified Resident #274 had an implanted cardiac defibrillator. The physician's orders and progress notes and the nurse's notes dated 9/23/24 to 10/6/24 did not reflect that Resident #274 had an implanted cardiac defibrillator with a continuous monitor at the bedside. The care plan dated 9/30/24 did not reflect that Resident #274 had an implanted cardiac defibrillator with a continuous monitor. Observation 10/6/24 at 8:00 AM identified Resident #274 was lying in bed with a white box plugged into the wall on the nightstand within 2 feet from resident. Observation on 10/6/24 at 10:08 AM identified Resident #274 had a raised area on the left chest wall. Interview with Person #1 on 10/6/24 at 10:08 AM indicated that he/she had informed the nurse on day of Resident #274's admission and the day after admission that she had brought in and plugged in the implanted cardiac defibrillator monitor and it was sitting on the bedside table doing the continuous transmission. Further, Person #1 showed had placed the owner's manual for implanted cardiac defibrillator monitor in the top draw of the nightstand in the resident's room. Interview with LPN #16 on 10/6/24 at 10:30 AM indicated she was responsible for Resident #274's care today. LPN #16 indicated that she was not aware Resident #274 had a cardiac monitor or a defibrillator. Interview with the DNS on 10/9/24 at 8:33 AM indicated that after review of the clinical record, since admission on 9/23/24 until today 10/9/24 the cardiologist had not been updated about Resident #274's admission, nor was the primary physician at the facility notified that Resident #274 had an implanted cardiac defibrillator that required a monitor, which was at the bedside. The DNS indicated that this should have been done on the day of admission. The DNS directed RN #4 to call the cardiologist and the resident's primary physician for direction regarding the cardiac device and the monitor. After surveyor inquiry, interview with RN #4 on 10/9/24 at 9:20 AM indicated that she called the cardiologist and was informed the monitor must be at least 10 feet away from Resident #274 when resident is sleeping and frequent checks to make sure the monitor is on and functioning. RN #4 indicated that she put the order in place and was waiting for the cardiologist to fax over more information. RN #4 indicated that she would call MD #1 to notify him of the cardiac device and monitor once she received more information from the cardiologist today. The physician's order dated 10/9/24 directed to check cardiac monitor at 8:00 PM and 11:00 PM daily. Ensure the monitor is plugged in and functioning properly and at least 10 feet away from resident when sleeping. Review of the medication administration times policy indicated that medications were to be administered at the determined times per the physicians orders. Although requested, a facility policy for notification to physician when medications are not available from the pharmacy was not provided. Although requested, a facility policy for implanted cardiac devices with monitors was not provided. 46040 3. Resident #378 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, edema, and gout. The physician's order dated 9/17/24 directed to complete Braden scale and weight every week on the 1st shower day of the week (Monday 3:00 PM - 11:00 PM shift) for 4 weeks and then once monthly, update wound management weekly (every Tuesday) with measurements and details of the right upper back site and document a progress note every shift including reason for admission, treatments in progress, response to treatments, and any other pertinent information. The physician's order dated 9/19/24 directed to complete body audits every week on the 1st shower day of the month (Monday 3:00 PM - 11:00 PM shift) with special instructions to please check and update resident wound management observations. The care plan dated 9/19/24 identified Resident #378 was at risk to develop pressure ulcers. Interventions included to complete skin evaluations. A wound APRN note dated 10/3/24 identified Resident #378 was seen for wound follow up to the medial back. The note identified Resident #378 had 3 new areas assessed at this visit and included: a new penile wound identified as a laceration, measuring 4 cm x 5 cm x 0.3 cm with a small amount of serosanguinous drainage; a new coccyx wound, identified as a stage 3 pressure ulcer, measuring 4 cm x 1 cm x 0.2 cm with a moderate amount of serosanguinous drainage; and a new left buttock wound, classified as a stage 3 pressure ulcer, measuring 5 cm x 2.5 cm x 0.2 cm with a moderate amount of serosanguinous drainage. The treatment plan included bacitracin and zinc to the penile wound and calcium alginate to the 2 newly identified pressure ulcers. Interview with MD #1 on 10/7/24 at 10:52 AM identified that weekly body audits and Braden scales were standard orders and were usually done on a resident's shower day and that if anything was discovered going on with a resident's skin, the nurse aide should notify the nurse caring for the resident, and if the issue was related to a newly identified wound, the nurse should notify the wound nurse, as well as the APRN or MD to know that the next steps should be, and that the notification should happened the same day. Interview with LPN #4 on 10/9/24 at 8:35 AM identified that she was notified of a new open area on Resident #378's penile area and left sacrum on 9/29/24. LPN #4 identified she documented a nurses note but did not notify the RN supervisor or the resident representative. LPN #4 identified that the penile area previously had excoriation, and the left sacrum appeared to be a skin shear injury, however she did not assess either site any further. LPN #4 identified that she entered a request for wound care evaluation in the wound care communication book, which is what the facility used to notify the wound care APRN a resident needed to be seen. LPN #4 also identified that the facility's wound care nurse, RN #1, also made rounds on the units and was supposed to review the book for any issues. Interview with DNS on 10/9/24 at 10:10 AM identified that the facility did utilize a communication book but the licensed nurses, but newly identified wounds require direct notification to the resident's family, the APRN or the on-call provider or using the Third Eye (telehealth) providers to assess the resident for the next steps with treatments. The policy on acute condition changes directed that the nursing staff would contact the physician based on the urgency of the situation, that the nurse and physician would discuss possible causes of the condition change, and the physician would help identify and authorize appropriate treatments. The policy on pressure injury risk assessment directed that the facility should notify the MD and resident representative if any new skin alternations were noted.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #24, 39 and 87) reviewed for abuse and pressure ulcers, the facility failed to protect Resident #24 from physical abuse by Resident #19, who had a history of resident to resident altercations, failed to protect Resident #39 from physical abuse by Resident #24, who had a history of resident to resident altercations and the facility a failed to ensure the Resident #87 was not neglected when staff did not complete a daily dressing change to a pressure ulcer on the resident's heel for 4 consecutive days despite documenting that the dressing change had been done. The findings include: 1. Resident #24 was admitted to the facility in September 2022 with diagnoses that included dementia with behavioral disturbance, anxiety disorder, psychotic disturbance, and depressive episodes. The care plan dated 11/26/22 identified Resident #24 had physical aggression. Interventions included to report any verbal, physical, sexual or aggressive expressions to the charge nurse immediately three times a day on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. The physician's order dated 3/1/23 - 3/31/23 directed to monitor behavior for aggression and angry outburst on every shift night, day, and evening. The quarterly MDS dated [DATE] identified Resident #24 had moderately impaired cognition and required extensive assistance with personal hygiene. Additionally, Resident #24 had no behaviors of physical or verbal directed toward others. The reportable event form dated 3/16/23 at 5:00 PM identified staff witnessed Resident #19 throwing water at Resident #24 after having a verbal argument. Both residents were immediately separated, and an RN assessment identified Resident #24 had no injuries. Psychiatrist and social service consult requested. The resident representative, police, the physician, and the Administrator were notified, and an investigation was initiated. The nurse's note dated 3/16/23 at 10:33 PM by RN #9 identified at 5:00 PM a staff member reported that Resident #19 threw water at Resident #24. A written statement by NA #3 dated 3/16/23 identified she saw Resident #19 and Resident #24 fighting, and LPN #17 was between them, and she went to assist. A written statement by LPN #17 dated 3/16/23 identified she witnessed Resident #19 throwing water on Resident #24 which led to an altercation. LPN #17 indicated she and other staff were able to separate the two residents from each other. The nurse's note dated 3/17/23 at 1:08 AM by LPN #17 identified an altercation began between Resident #24 and Resident #19. LPN #17 witnessed Resident #19 throwing water at Resident #24 and a brief altercation took place. The residents were immediately separated. RN #9 was notified immediately. A written telephone interview (with no date) by the DNS with LPN #17 identified on 3/16/23 at 5:00 PM LPN #17 indicated she witnessed Resident #19 and Resident #24 having a verbal disagreement. LPN #17 indicated she heard one of the residents asking the other resident to move, however she was not sure who exactly said it. LPN #17 indicated she was walking towards the residents and observed Resident #19 throw water at Resident #24. LPN #17 indicated Resident #24 was angry and verbal towards Resident #19, however he/she did not retaliate. LPN #17 immediately intervened and separated the residents. The nursing supervisor was notified, and Resident #19 was placed on 1:1 monitoring. The social service note dated 3/17/23 at 12:02 PM identified Resident #24 indicated (Resident #19 threw a couple of punches at me, but it is no big deal). Resident #24 indicated he/she was not hurt and identified he/she has been to places with bigger guys/girls than him/her. Resident #24 indicated he/she was not scared and Resident #19 was a punk, and he/she should be scared. No emotional distress noted. Psychiatrist consult is schedule for today. Social service will continue to monitor. The psychiatrist note dated 3/17/23 identified Resident #24 had a recent alleged resident altercation with Resident #24 and tossed water at the resident. Resident #24 was alert and oriented times two, and brief response. Resident #24 was confused and preoccupied in finding a way to return back into the community. Resident #24 denies any harm, distress or concerns related to the negative interaction with Resident #19. Resident #24 noted feeling safe at the facility. Resident #24 was not in any distress/stable mood. Continue to monitor and support. The care plan dated 3/17/23 identified Resident #24 had physical aggression and attempted to move another resident's wheelchair. Interventions included to monitor for any signs of aggressive behavior. Report any behaviors to the charge nurse immediately. Social services and psychiatric consult requested post altercation with peer. Every shift night, day, and evening. A written statement by the Administrator dated 3/20/23 identified on 3/16/23 at 4:30 PM he was at the nurse's station and heard LPN #17 down the hallway yelling for help. The Administrator indicated he immediately went down the hallway and observed Resident #24 and Resident #19 getting close and yelling at each other. The Administrator indicated the residents started swinging, but he did not witness any physical contact. The Administrator indicated the staff separated the two residents. Resident #19 was placed on 1:1 monitoring. The police were notified and interviewed both residents. The Administrator indicated he notified the State Agency. A written report by the DNS, undated, identified Resident #19 had severely impaired cognition. On 3/16/23 at 5:00 PM LPN #17 observed Resident #19 and Resident #24 having a verbal argument. LPN #17 witnessed Resident #19 throwing water at Resident #24. LPN #17 immediately intervened and separated both residents and notified RN #9. Resident #19 was placed on 1:1 monitoring. An RN assessment revealed no physical injuries to either resident. A psychiatrist and social service consult was requested for both residents. Resident #19 was seen by the psychiatrist and 1:1 was discontinued. Resident #19 was seen by the physician with new orders obtained. Resident #19's care plan was updated to monitor for increase in agitation, confusion, paranoia, and aggressive behavior and to notify licensed staff immediately. Resident #24 was seen by the psychiatrist and was not in any distress/stable mood. Interview with Resident #24 on 10/6/24 at 11:25 AM identified he/she was not happy when Resident #19 threw the water at him/her. Resident #24 indicated he/she was angry when it happened. Resident #24 indicated he/she is not afraid of Resident #19. Although attempted, an interview with the Previous DNS and LPN #17 was not obtained. Interview and review of the clinical record with RN #5 on 10/8/24 at 1:55 PM identified Resident #19 was placed on 1:1 immediately until cleared by the psychiatrist. RN #5 indicated with each incident a behavior specific care plan was initiated or revised to prevent further behavioral issue. RN #5 indicated the staff were in-serviced. RN #5 indicated Resident #24 was seen by the psychiatrist and a behavioral care plan was initiated. 2. Resident #39 was admitted to the facility in July 2021 with diagnoses that included hemiplegia, hemiparesis affecting left -non-dominant side, anxiety disorder, major depressive disorder, and adjustment disorder. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition and required extensive assistance with personal hygiene. Additionally, Resident #39 had no behaviors of physical or verbal directed toward others. The reportable event form dated 5/8/23 at 4:30 PM identified Resident #39 was alert and oriented, calm, and cooperative. Resident #39 approached LPN #13 and reported that he/she was self-propelling in the wheelchair when Resident #24 exited his/her room, also in a wheelchair, and accidentally hit Resident #39's wheelchair. As they were attempting to untangle the wheelchairs, Resident #24 hit Resident #39 on the head and threaten to kill him/her. The residents were immediately separated and Resident #24 was placed on 1:1 and transferred to the hospital for psychiatric evaluation. Both residents were interviewed by SW #1. Resident #39 was seen by the psychiatrist APRN. The police, physician, psychiatrist APRN, the Administrator, and the resident representative were notified. The social service note dated 5/8/23 at 5:13 PM by SW #1 identified Resident #39 was alert and oriented times four. SW #1 was called to the unit by nursing to meet with Resident #39. Resident #39 indicated he/she was going down the hallway when Resident #24 came out and bumped into Resident #39 wheelchair. Resident #39 indicated the wheelchairs got stuck and he/she touched Resident #24's arm while trying to get away and that is when Resident #24 punched Resident #39 in the head. Resident #39 indicated Resident #24 threaten to kill him/her if they ever passed each other in the hallway again. Resident #39 was seen by the psychiatric APRN. SW #1 indicated she notified RN #9, the DNS, and LPN #13. No emotional distress was noted, and Resident #9 indicated he/she does not feel threaten or unsafe at this time. The nurse's note dated 5/8/23 at 7:11 PM by RN #9 identified at 4:50 PM the psychiatrist, APRN, and SW #1 reported that Resident #39 indicated Resident #24 punched him/her and threaten to kill him/her. Resident #39 indicated he/she was attacked by Resident #24 when he/she was coming down the hallway in the wheelchair. Resident #39 indicated he/she stopped to blow his/her nose and Resident #24 came out of his/her room and banged into Resident #39's wheelchair and they got stuck. Resident #24 blamed Resident #39 and punched Resident #39 on the right side of the head and later on threaten to kill Resident #39. An RN assessment was completed with no injury noted. The police, and the physician were notified. Message left for resident representative. The nurse's note dated 5/8/23 at 11:43 PM by LPN #13 identified Resident #39 came to the nursing station this afternoon and reported that he/she was in the hallway in Resident #24 bumped into his/her wheelchair when trying to get by. Resident #39 indicated Resident #24 got upset and punched him/her in the back of the head and threaten to kill him/her if this happens again. The incident was immediately reported to social service, the supervisor, and the psychiatrist APRN. Resident #39 was escorted to his/her room and assessed. A written statement by NA #5 dated 5/8/23 identified Resident #39 came to the nursing station and was very upset. NA #5 indicated Resident #39 reported that he/she was trying to get by when Resident #24 punched him/her on the head. NA #5 indicated she reported it to LPN #13 immediately. The psychiatrist APRN note dated 5/8/23 identified Resident #39 was seen after he/she approached the nursing station and stating that Resident #24 hit him/her on the head. Resident #39 is currently not a danger to self or others. Resident #39 appeared to be in behavioral control at this time. Will ask psychologist to see Resident #39 as a follow-up. No changes in medication. The care plan dated 5/8/23 identified Resident #39 was at risk for emotional distress and anxiety related to altercation with peer. Interventions included to monitor resident for any emotional or negative behavioral changes. Report to charge nurse or supervisor with any findings. Provide resident with emotional support. Although attempted, an interview with the Previous DNS, LPN #13, and NA #5 was not obtained. Interview with Resident #39 on 10/6/24 at 11:27 AM identified Resident #24's wheelchair and his/her wheelchair bumped into each other. Resident #39 indicated while trying to detangle the wheelchairs Resident #24 hit him/her on the head. Resident #39 indicated he/she was afraid when Resident #24 threaten to kill him/her. Resident #39 indicated the psychiatric APRN and SW #1 was right on the issue of making sure that he/she felt safe. Resident #39 indicated LPN #13, and the staff made sure that he/she was always safe from Resident #24. Resident #39 indicated he/she feel safe at the facility. Interview and review of the clinical record with the RN #5 on 10/8/24 at 1:55 PM identified Resident #24 was placed on 1:1 immediately, seen by the psychiatrist APRN, and was transferred to the hospital for psychiatric evaluation. RN #5 indicated with each incident a behavior pacific care plan was initiated to prevent further behavioral issue. RN #5 indicated the staff were in-service. RN #5 indicated Resident #39 was seen by the psychiatrist and a care plan was initiated Review of the facility abuse policy identified that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's symptoms. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful - means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse - is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Physical abuse - includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Resident to Resident altercation - is defined as a physical or verbal act between two residents with or without resulting injury. For altercations where the aggressor is cognitively impaired 42117 3. Resident #87 was admitted to the facility in December 2021with diagnoses that included dementia and osteoporosis. Physician's monthly orders for September 2024 (originally dated 8/19/23) directed to apply skin prep to bilateral heels daily on the 3:00 PM to 11:00 PM shift. The quarterly MDS dated [DATE] identified Resident #87 had severely impaired cognition, required maximum assistance with personal hygiene and bathing, and was totally dependent for transfers and rolling left to right. Additionally, Resident #87 was at risk to develop a pressure ulcer, did not have any current pressure ulcers, and had a pressure reducing device on the bed. The care plan dated 8/14/24 identified Resident #87 was at risk for skin breakdown. Interventions included to monitor skin when putting on and off compression stockings and position resident to offset pressure areas while awake. The Wound Assessment Report written by the Wound APRN, (APRN #2), on 9/26/24 identified a first evaluation of pressure ulcer to the right heel with measurements of 2.5 cm by 5.0 cm by 0.2 cm with 25 - 49% slough, 50 - 74% granulation tissue, moderate amount of serosanguineous drainage and a mild odor. Recommendations included to cleanse with normal saline, apply Santyl, Calcium Alginate, skin prep to the peri wound, dry clean dressing and off load boots. A physician's order dated 9/27/24 directed to cleanse the unstageable right heel pressure ulcer with normal saline, apply Santyl, Calcium Alginate, skin prep around the peri wound, secure with a dry clean dressing daily and as needed. A Wound Management Report, written by the Infection Control/Wound Nurse (RN #1) dated 10/4/24 (late entry for 10/3/24) identified the right heel pressure ulcer measured 2.5cm x 5.0 cm by 0.2 cm with slough in the wound bed and no tunneling. Review of the October 2024 TAR dated 10/3/24 to 10/8/24 identified the treatment to the right heel was signed as done on the following days by the following staff. 10/4/24 LPN #14 documented she completed the treatment to the right heel. 10/5/24 LPN #12 documented she completed the treatment to the right heel. 10/6/24 LPN #6 documented she completed the treatment to the right heel. Further, on 10/7/24 LPN #15 did not document if the treatment was completed as per the order on the (7:00 AM - 3:00 PM shift) and documented the treatment was not done on the 3:00 PM - 11:00 PM shift because it is scheduled for 7:00 AM to 3:00 PM shift. Interview with MD #1 on 10/7/24 at 10:45 AM indicated that his expectation was the nurses follow the physician's orders. Observation on 10/8/24 at 2:00 PM with LPN #14 identified when she removed the old dressing from Resident #87's right heel it was dated as 10/3/24, 5 days prior, and there were no initials to identify who completed the treatment on 10/3/24. Interview with LPN #14 at that time identified the treatment to the resident right heel is ordered to be done daily. Interview with the DNS and the VP of Clinical Operations (RN #5) on 10/8/24 at 3:00 PM indicated that Resident #87's had a wound on the right heel and the treatment was ordered to be done daily. Further, RN #5 identified the nurses are responsible to complete the dressing change daily, and date and initial the dressing itself, and sign their initials on the TAR. RN #5 indicated she would investigate to find out why the treatment was not done since 10/3/24. A written statement by LPN #14 dated 10/8/24 identified that on 10/4/24 she was orienting a new nurse, and that nurse was using her log in for the electronic medical record (EMR). There might have been a time that the dressing change to Resident #87's right heel was clicked off in the EMR as having been done but wasn't done yet. LPN # 14 indicated the dressing to the right heel was not changed on 10/4/24. An email from LPN #6 dated 10/8/24 identified she worked Sunday 10/6/24. LPN #6 identified she intended to do the dressing change to Resident #87's right heel but due to an overwhelming layer of pressure and distraction, she inadvertently overlooked the dressing change to Resident #87's right heel. LPN #6 did not identify why she documented on the TAR that the dressing change to Resident #87's right heel had been done. An email dated 10/9/24 from LPN #12 identified she worked 10/5/24 during the 7:00 AM -3:00 PM and she is not as familiar with that unit. LPN #12 indicated she inadvertently clicked the treatment to Resident #87's right heel as being done. A written statement dated 10/8/24 by LPN #15 who worked on 10/7/24 during the 7:00 AM - 3:00 PM shift identified at the end of her shift, she realized she did not have the time to complete the wound care. A statement by the ADNS identified LPN #15 did not document or complete dressing change to Resident #87's right heel and she left it for the following shift. This was an omission. Interview with the DNS on 10/9/24 at 6:42 AM identified LPN #15 forgot to notify the oncoming 3:00 PM - 11:00 PM nurse, LPN #9, that she had not done the dressing change. Further, LPN #9 did not do the dressing change because it was due on the 7:00 AM - 3:00 PM shift. Interview with the DNS on 10/9/24 at 6:42 AM indicated that all dressing changes are to be completed, and if they are not able to be completed, the nurses should not be documenting that they have been done. Further, the DNS indicated if a dressing change is not done, they are responsible to write a note as to why it wasn't done, and they should notify the supervisor because the supervisor can come and assist. The DNS indicated that the APRN/MD must be notified immediately if a dressing change is not done. Observation and interview with the DNS and RN #4 on 10/9/24 at 7:55 AM identified Resident #87's right heel pressure ulcer had an odor prior to removing the old dressing. The wound measured 2.1 cm by 1.2 cm by 0.4 cm with tunneling 0.6 cm from 9 o'clock to 1 o'clock. The wound bed was 75% slough and 25% purple color. Review of the Abuse Policy identified neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Any form of mistreatment or neglect is to be thoroughly investigated and reported.

Based on record review and interviews for one (1) of three (3) residents reviewed for medication errors (Resident #1), the facility failed to ensure that multiple nurses followed the five rights of medication administration in accordance with nursing standards of practice. Resident #1 was administered morphine (an opioid pain medication) at ten (10) times the prescribed dose on three separate occasions resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility in April 2024 under palliative care with diagnoses that included cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented to person place, time, and situation. The baseline care plan dated 4/19/24 identified Resident #1 at risk for reoccurrence of acute medical conditions with interventions directed to administer medications per MD orders and vital signs per facility protocol. Review of Resident #1's W-10 (a form sent from the hospital to the skilled nursing facility that includes medication orders) dated 4/19/24 directed to administer morphine (a narcotic pain medication) 2 milligrams (mg) per 1 milliliter (ml) oral solution, give 2.5 ml oral, every four (4) hours. The order did not specify the dosage in milligrams. (The order would equate to a 5 mg dose every 4 four hours). The physician's order dated 4/19/24 directed to administer morphine solution 2 mg/1 ml, total amount to be administered 2.5 ml, every four (4) hours around the clock. The order did not specify the dosage in milligrams. A nurse's note dated 4/19/24 at 11:31 P.M. written by Registered Nurse (RN) #3 identified the admitting orders (including the physician's order for morphine) were verified and approved by Advanced Practice Registered Nurse (APRN) #1. Review of Resident #1's Controlled Substance Disposition Record (a form that records how much of a controlled substance is administered) dated 4/20/24 identified that Omnicell House Stock morphine sulfate 100 mg/5 ml was retrieved on 4/20/24 by RN #3 and provided to Licensed Practical Nurse (LPN) #2. The narcotic disposition record identified that on 4/20/24 at 4:00 A.M. LPN #2 administered 2.5 ml's (100 mg/ 5 ml) to Resident #1. On 4/20/24 RN #4 administered 2.5 ml's (100 mg/ 5 ml) to Resident #1 at 8:00 A.M. and 12:00 P.M. Review of the Medication Administration Record (MAR) identified on 4/20/24 at 4:00 A.M. LPN #2 administered 2.5 ml's of 2 mg/1 ml morphine solution to Resident #1. On 4/20/2024 at 8:00 A.M. and 12:00 P.M. RN #4 administered 2.5 ml's of 2mg/1 ml morphine solution to Resident #1. Review of the facility's accident and incident report form dated 4/20/24 identified on 4/20/24 at 4:00 A.M, 8:00 A.M, and 12:00 P.M. erroneous morphine doses were administered to Resident #1. A nurse's note dated 4/20/24 at 8:28 P.M. written by RN #1 identified Resident #1 was assessed after a report of receiving the incorrect dose of morphine sulfate three (3) times at 4:00 AM, 8:00 AM, and 12:00 PM. RN #1 identified Resident #1 was on palliative care, lungs clear bilaterally with diminished sounds at bases. RN #1 identified Resident #1's oxygen saturation level was 88 % on room air (normal oxygen saturations are between 90-100%), the resident was placed on oxygen via nasal cannula at two (2) liters per minute, and oxygen saturation level increased to 95%. RN #1 indicated Resident #1 was offered to be sent to the hospital and refused. A nurse's note dated 4/21/24 at 2:25 AM indicated that the resident was nauseous, pale, diaphoretic, has slurred words, and vomiting. The physician was notified, and the resident was sent to the hospital. Interview with RN #3 on 5/22/24 at 8:53 A.M. identified that she was the nursing supervisor on the 11:00 PM to 7:00 AM shift on 4/19/24 into 4/20/24 and on 4/20/24 LPN #2 reported that she did not have morphine to administer to Resident #1. RN #3 identified she retrieved the morphine solution for Resident #1 from the Omnicell (an automated machine that dispenses medications) house stock and handed it to LPN #2. RN #3 could not recall if she looked at the strength/concentration of the morphine solution prior to giving it to LPN #2. Interviews with LPN #2 on 5/28/24 at 8:00 AM identified that she worked the 11:00 PM to 7:00 AM shift on 4/19 into 4/20/24 and she did not have the scheduled 4:00 AM dose of morphine to administer to Resident #1, as it had not come in from the pharmacy. LPN #2 stated that she informed the nursing supervisor (RN #3) that she needed the medication for Resident #1, and RN #3 retrieved the medication from the Omnicell. LPN #2 identified that RN #3 gave her the bottle of morphine from the Omnicell, and although she looked at the medication bottle and identified it was morphine prior to administration, she failed to identify that the concentration of the medication was 100 mg/5 ml instead of the 2 mg/1 ml as ordered by the physician. She administered 2.5 ml's of the 100 mg/5 ml concentration (50 mg) for the 4:00 AM dose to Resident #1, for a total dose of 50 mg instead of the ordered 5 mg. Interview with RN #4 on 5/28/24 at 7:34 AM identified she worked the 7:00 AM to 3:00 PM shift on 4/20/24 and administered the 8:00 AM and the 12:00 PM dose of morphine to Resident #1. RN #4 identified that she thought she looked at the label of the morphine solution concentration prior to administration, however she did not identify that the concentration of the morphine was 100 mg/5 ml prior to administration. RN #4 identified that she administered 2.5 ml's of the 100 mg/5 ml morphine solution instead of the ordered solution 2.5 ml's of morphine 2 mg/1 ml (which was two (2) doses of 50 mg instead of 5 mg, (10 times the ordered dose). Interview with LPN #1 on 5/22/24 at 3:45 P.M. identified that she worked the 3:00 PM to 11:00 PM shift on 4/20/24 and when counting narcotics with RN # 4 on 4/20/24 she identified by looking at the narcotic disposition form that the concentration of morphine given to Resident #1 was 100 mg/5 ml, and not 2 mg/1 ml as the physician's order directed. LPN #1 identified based on her calculations Resident #1 received 50 mg of morphine for each of the last 3 doses (the resident should have received 5 mg each dose according to the physician's order). LPN #1 identified she notified RN #1 that there was a medication error. Interview with RN #1 on 5/21/24 at 11:55 A.M. identified on 4/20/24 at approximately 4:00 P.M. she was notified by LPN #1 that a medication error was made, and Resident #1 received the wrong dose of morphine at 4:00 A.M., 8:00 A.M., and 12:00 P.M. RN #1 identified she assessed the Resident with an oxygen saturation of 88%. She applied oxygen, monitored the resident, and notified the physician. Interview with the Medical Director (MD #1) on 5/22/24 at 10:05 A.M. identified his expectations are that the nurses read the labels of all medications prior to administration to ensure the correct dose is administered in accordance with physician's orders. MD #1 identified LPN #2 and RN #4 should have read the label on the morphine solution and checked the strength/concentration prior to administering the morphine to Resident #1. MD #1 identified if the facility only had the 100 mg/5 ml of morphine on hand they could have called the on-call physician to obtain a new order to adjust the dose because the concentration was stronger than what was initially ordered for Resident #1. Interview with the Director of Nurses (DNS) on 5/21/24 at 11:00 A.M. identified LPN #2 and RN #4 administered the wrong dose of morphine to Resident #1 on 4/20/24 at 4:00 A.M., 8:00 A.M. and 12:00 P.M. The DNS identified the cause of the medication error was because LPN #2 and RN #4 did not read the concentration of the morphine prior to administration, and administered the 100mg/5ml concentration of morphine instead of the physician ordered concentration of 2 mg/ 1ml. The DNS identified that he expects the 5 rights of medication administration (right resident, right medication, right dose, right time, and right route) to be followed by all nurses. According to Fundamentals of Nursing: 11th edition, Mosby, [NAME] and [NAME], 2022: To prevent medication errors nurses must follow the five rights of medication administration consistently every time medications are administered. The five rights of medication administration include the right medication, right dose, right resident, right route, and right time.

Based on record review and interviews for one (1) of three (3) residents reviewed for medication administration (Resident #1), the facility failed to ensure the that the resident was free from a significant medication error. Two (2) nurses failed to check the strength/concentration of morphine (an opioid pain medication) prior to administration, and administered the medication at ten (10) times the prescribed dose on three (3) separate occasions, resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility in April 2024 under palliative care with diagnoses that included cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented to person place, time, and situation. The baseline care plan dated 4/19/24 identified Resident #1 at risk for reoccurrence of acute medical conditions with interventions directed to administer medications per MD orders and vital signs per facility protocol. Review of Resident #1's W-10 (a form sent from the hospital to the skilled nursing facility that includes medication orders) dated 4/19/24 directed to administer morphine (a narcotic pain medication) 2 milligrams (mg) per 1 milliliter (ml) oral solution, give 2.5 ml oral, every four (4) hours. The order did not specify the dosage in milligrams. (The order would equate to a 5 mg dose every 4 four hours). The physician's order dated 4/19/24 directed to morphine solution 2 mg/1 ml, total amount to be administered 2.5 ml, every 4 hours around the clock. The order did not specify the dosage in milligrams. A nurse's note dated 4/19/24 at 11:31 P.M. written by Registered Nurse (RN) #3 identified the admitting orders (including the physician's order for morphine) were verified and approved by Advanced Practice Registered Nurse (APRN) #1. Review of Resident #1's Controlled Substance Disposition Record (a form that records how much of a controlled substance is administered) dated 4/20/24 identified that Omnicell House Stock morphine sulfate 100 mg/5 ml was retrieved on 4/20/24 by RN #3 and provided to Licensed Practical Nurse (LPN) #2 in the amount of 15 ml's. The narcotic disposition record identified that on 4/20/24 at 4:00 A.M. LPN #2 administered 2.5 ml's (100 mg/ 5 ml) to Resident #1. On 4/20/24 RN #4 administered 2.5 ml's (100 mg/ 5 ml) to Resident #1 at 8:00 A.M. and 12:00 P.M. (Fifty (50) mg's of morphine was administered each time.) . Review of the Medication Administration Record (MAR) identified on 4/20/24 at 4:00 A.M. LPN #2 administered 2.5 ml's of 2 mg/1 ml morphine solution to Resident #1. On 4/20/2024 at 8:00 A.M. and 12:00 P.M. RN #4 administered 2.5 ml's of 2mg/1ml morphine solution to Resident #1. Review of the facility's accident and incident report form dated 4/20/24 identified on 4/20/24 at 4:00 A.M, 8:00 A.M, and 12:00 P.M. erroneous morphine doses were administered to Resident #1. A nurse's note dated 4/20/24 at 8:28 P.M. written by RN #1 identified Resident #1 was assessed after a report of receiving the incorrect dose of morphine sulfate three (3) times at 4:00 AM, 8:00 AM, and 12:00 PM. RN #1 identified Resident #1 was on palliative care, lungs clear bilaterally with diminished sounds at bases. RN #1 identified Resident #1's oxygen saturation level was 88% on room air (normal oxygen saturations are between 90-100%), the resident was placed on oxygen via nasal cannula at two (2) liters per minute, and oxygen saturation level increased to 95%. RN #1 indicated Resident #1 was offered to be sent to the hospital and refused. A nurse's note dated 4/21/24 at 2:25 AM indicated that the resident was nauseous, pale, diaphoretic, slurring words, and vomiting. The physician was notified, and the resident was sent to the hospital. Interview with RN #3 on 5/22/24 at 8:53 A.M. identified that she was the nursing supervisor on the 11:00 PM to 7:00 AM shift on 4/19/24 into 4/20/24) and on 4/20/24 LPN #2 reported that she did not have morphine to administer to Resident #1. RN #3 identified she retrieved the morphine solution for Resident #1 from the Omnicell (an automated machine that dispenses medications) house stock and handed it to LPN #2. RN #3 could not recall if she looked at the strength/concentration of the morphine solution prior to giving it to LPN #2. Interviews with LPN #2 on 5/28/24 at 8:00 AM identified that she worked the 11:00 PM to 7:00 AM shift on 4/19 into 4/20/24 and she did not have the scheduled 4:00 AM dose of morphine to administer to Resident #1, as it had not come in from the pharmacy. LPN #2 stated that she informed the nursing supervisor (RN #3) that she needed the medication for Resident #1, and RN #3 retrieved the medication from the Omnicell, LPN #2 identified that RN #3 gave her the bottle of morphine from the Omnicell, and although she looked at the medication bottle and identified it was morphine prior to administration, she failed to identify that the concentration of the medication was 100 mg/5 ml instead of the 2 mg/1 ml as ordered by the physician. She administered 2.5 ml's of the 100 mg/5 ml concentration (50 mg) for the 4:00 AM dose to Resident #1, for a total dose of 50 mg instead of the ordered 5 mg. Interview with RN #4 on 5/28/24 at 7:34 AM identified she worked the 7:00 AM to 3:00 PM shift on 4/20/24 and administered the 8:00 AM and the 12:00 PM dose of morphine to Resident #1. RN #4 identified that she thought she looked at the label of the morphine solution concentration prior to administration, however she did not identify that the concentration of the morphine was 100 mg/5 ml. prior to administration. RN #4 identified that she administered 2.5 ml's of the 100 mg/5 ml morphine solution instead of the ordered solution 2.5 ml's of morphine 2 mg/1 ml (which was two (2) doses of 50 mg instead of 5 mg, (10 times the ordered dose). Interview with LPN #1 on 5/22/24 at 3:45 P.M. identified that she worked the 3:00 PM to 11:00 PM shift on 4/20/24 and when counting narcotics with RN # 4 on 4/20/24 she identified by looking at the narcotic disposition form that the concentration of morphine given to Resident #1 was 100 mg/5 ml, and not 2 mg/1 ml as the physician's order directed. LPN #1 identified based on her calculations Resident #1 received 50 mg of morphine for each of the last 3 doses (instead of the 5 mg dose ordered by the physician) . LPN #1 identified she notified RN #1 that there was a medication error. Interview with RN #1 on 5/21/24 at 11:55 A.M. identified on 4/20/24 at approximately 4:00 P.M. she was notified by LPN #1 that a medication error was made, and Resident #1 received the wrong dose of morphine at 4:00 A.M., 8:00 A.M., and 12:00 P.M. RN #1 identified she assessed the Resident with an oxygen saturation of 88%, applied oxygen, and monitored the resident and notified the physician. Interview with the Medical Director (MD #1) on 5/22/24 at 10:05 A.M. identified his expectations are that the nurses read the labels of all medications prior to administration to ensure the correct dose is administered in accordance with physician's orders. MD #1 identified LPN #2 and RN #4 should have read the label on the morphine solution and checked the strength/concentration prior to administering the morphine to Resident #1. MD #1 identified if the facility only had the 100 mg/5 ml of morphine on hand they could have called the on-call physician to obtain a new order to adjust the dose because the concentration was stronger than what was initially ordered for Resident #1. Interview with the Director of Nurses (DNS) on 5/21/24 at 11:00 A.M. identified LPN #2 and RN #4 administered the wrong dose of morphine to Resident #1 on 4/20/24 at 4:00 A.M., 8:00 A.M. and 12:00 P.M. The DNS identified the cause of the medication error was because LPN #2 and RN #4 did not read the concentration of the morphine prior to administration. LPN #2 and RN #4 administered the 100 mg/5 ml concentration of morphine not the physician's ordered morphine concentration 2 mg/1 ml. The DNS identified that he expects the 5 rights of medication administration (right resident, right medication, right dose, right time, and right route) to be followed by all nurses. The facility medication administration policy last revised April 2019, directed in part, the individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, right method (route) of administration before giving the medication. Refer to F658.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #72) who had an unwitnessed fall, the facility failed to immediately send the resident to the hospital for treatment after the RN assessment demonstrated that the resident was exhibiting pain in the left leg including guarding. Further, the facility failed to adhere to professional standards of practice when staff log rolled the resident onto a sheet and carried the resident down the hall to his/her room approximately 50 feet away to put the resident to bed. Subsequently, the resident continued to exhibit pain, and vomited, and after physician notification was sent to the hospital, over 5 hours later, and diagnosed with a left intertrochanteric fracture which required surgery including an IM nail to correct. Further, for 1 of 5 residents (Resident #60) reviewed for unnecessary medications, the facility failed to ensure a medication was transcribed according to physician orders, for 1of 5 residents (Resident #68) reviewed for accidents, the facility failed to ensure an RN assessment after a skin tear was identified, and for 1 resident (Residents #120) reviewed for death, the facility failed to ensure the clinical record contained sufficient documentation regarding the residents end of life status and a RN may pronounce death order prior to the time of death according to professional standards. The findings included: Resident #72 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, staff to ambulate Resident #72 with rolling walker assist with 1 person as lib twice a day. The quarterly MDS assessment dated [DATE] identified Resident #72 had severely impaired cognition and required extensive assistance for bed mobility, transfers, walking in room and corridor, eating, dressing, and personal hygiene. Additionally, Resident #72 had wandering behaviors but no other behaviors present. The care plan dated [DATE] identified Resident #72 had a potential for falls due to wandering behaviors. Interventions included to monitor for steadiness of gait and update the physician with changes. The reportable event form dated [DATE] at 4:55 PM identified Resident #72 was observed lying on his/her left side on the dining room floor unable to verbalize incident. The fall was unwitnessed. The nurse's note dated [DATE] at 5:44 PM, written by RN #1, identified that she received a call from the charge nurse to assess Resident #72 who was on the floor. Upon arrival, Resident #72 was observed lying on his/her left side, unable to verbalize the incident: however, when assessed, the resident was guarding the left lower extremity. The APRN was notified and ordered an x-ray of leg 2 views immediately. The SBAR Communication Form dated [DATE], untimed, indicated Resident #72 had a fall and stat x-rays were ordered. Resident #72 had complaints of left leg and hip pain (8 out of 10) on the pain scale. A nurse's note dated [DATE] at 10:09 PM by RN #1 identified that Resident #72 had vomited once after the fall. MD #1 was notified and ordered Resident #72 be sent to the emergency room for further evaluation. Family updated. Resident An x-ray report dated [DATE] identified an acute angulated intertrochanteric fracture of the left hip. Electronically signed [DATE] at 1:10 AM. The emergency room physician documentation dated [DATE] at 11:32 PM identified EMS reports that Resident #72 was jumpy and flinching when his/her left side hip was palpated. Facility reports acute unwitnessed fall and left hip pain onset time prior to 4:55 PM today. Upon examination Resident #72's left hip was tender, and the leg was shortened and externally rotated. On [DATE] at 12:05 AM an x-ray showed a left intertrochanteric fracture. Resident #72 was treated with acetaminophen and [MEDICATION(S)]. On [DATE] Resident #72 underwent left hip IM nail and area was closed with sutures and staples. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #72 with a Sarita mechanical lift out of bed with assistance of 2 people. Interview with RN #1 on [DATE] at 8:21 AM identified Resident #72 was confused at baseline and could not verbalize what had happened and was in pain at the time of the incident. RN #1 knew there was something wrong with Resident #72 when she started her assessment. RN #1 indicated Resident #72 could not verbalize he/she was in pain but when RN #1 touched the residents left leg you could see he/she was in pain and was guarding the left leg and hip. Resident #72 did moan and had facial grimacing. RN #1 indicated she did not call 911 and indicated that she had to call the doctor and wait for the doctor to tell her what to do first before she could send Resident #72 to the hospital. RN #1 could not recall if she had moved Resident #72 off the floor and to his/her room then called the APRN or called the APRN while Resident #72 was on the floor. RN #1 indicated she had spoken with the APRN, and she was surprised she did not give orders to send Resident #72 to the emergency room , instead she had given orders for x-rays and RN #1 indicated she would not do things on her own. RN #1 indicated she had told the APRN exactly what had happened but did not recall exactly what she told the APRN at that time. RN #1 noted when she touched Resident #72's left hip, she knew there was something wrong. RN #1 indicated all she could recall was she and a couple of other staff members used a sheet and got Resident #72 off the floor and placed the resident onto the bed but did not recall the staff members names. Interview with the Medical Director, (MD #1) on [DATE] at 8:45 AM indicated if he had received a call that Resident #72 had an unwitnessed fall and was guarding the left leg and was in pain, he would have sent Resident #72 immediately to the emergency room . MD #1 indicated if the RN supervisor had called the APRN and the APRN did not give the order to send Resident #72 to the emergency room , his expectation was the RN would have called the primary physician or him as Medical Director, and he would have given the order to send Resident #72 to the emergency room and overridden the APRN's order. MD #1 indicated the on call APRN service do not really know the residents, they only go by what the nurse tells them. MD #1 indicated if Resident #72 was guarding the leg and had any signs of pain he/she should have been sent out right away. MD #1 indicated he remembers getting a call that Resident #72 had fallen and had vomited and he gave the order to send Resident #72 to the emergency room but did not realize that Resident #72 had fallen about 5 hours prior and had pain. Interview with LPN #1 on [DATE] at 11:05 AM indicated she remember she was passing medications when someone called out that Resident #72 was on the floor in the dining room, so she called for the supervisor. LPN #1 indicated she had observed Resident #72 lying on the floor. LPN #1 noted the RN did an assessment. LPN #1 noted the RN supervisor directed LPN #1 and a bunch of staff members to log roll Resident #72 onto a draw sheet and we carried Resident #72 from the dining room to his/her bed. LPN #1 could not recall the names of the 6 - 7 nursing staff that assisted RN #1 and herself in carrying Resident #72 from the dining room to his/her bed. LPN #1 indicated RN #1 made the decision to use the draw sheet and she felt carrying Resident #72 with a sheet was safer than using the hoyer because they were not sure what Resident #72's injuries were and wanted to prevent further injury. LPN #1 indicated she did not see RN #1 call the APRN so did not know if the call was before or after they had transferred Resident #72. LPN #1 indicated when the nursing assistant was providing bedtime care just before 10:00 PM, the nursing assistant reported Resident #72 had just vomited. LPN #1 indicated she had called RN #1 to come assess the emesis. LPN #1 did not recall if Resident #72 had eaten dinner, but if she had, the nursing assistant would have had to feed him/her in bed. LPN #1 indicated RN #1 came to the unit, assessed Resident #1, and called the physician and got an order to send Resident #72 to the hospital. LPN #1 indicated any resident that has a fall must be assessed by the RN before the resident is moved, and it was the RN's responsibility to direct whether to call 911, pick the resident up, or hoyer the resident. LPN #1 indicated in her judgement they did not know if Resident #72 was injured, and it was the RN's call to make. Interview with RN #1 on [DATE] at 11:30 AM indicated she had placed Resident #72 on a draw sheet and carried Resident #72 to his/her room and placed the resident on the bed for safety and because the resident was going to need x-rays done. RN #1 noted she had decided to use the draw sheet because Resident #72 was on the floor and she had to use her judgement and staff could not stand Resident #72 up because she did not know if Resident #72 had a broken bone. RN #1 noted Resident #72 complained by grimacing. RN #1 indicated she thought the APRN would say send Resident #72 to the hospital, but she said to do x-rays. RN #1 indicated she was surprised the APRN only ordered x-rays because RN #1 noted Resident #72 was confused but when she touched Resident #72 on his/her left side there was something wrong. RN #1 noted Resident #72 acted differently when she touched each hip and she felt there was something wrong there. RN #1 indicated the fall was after hours, so she did not call the primary physician, she called the APRN. RN #1 indicated after Resident #72 had vomited then she called MD #1. RN #1 indicated at the time of the fall she did not agree with the APRN but did not call the physician to override the decision. Interview and review of the clinical record with the DNS on [DATE] at 12:23 PM indicated Resident #72 was alert and confused. The DNS noted Resident #72 needs supervision for ambulation but can stand up on her own. The DNS noted if a resident falls the RN must analyze the situation and see what can be done to prevent another fall or prevent injury. The DNS noted his expectation would be to do an RN assessment prior to moving the resident. The DNS noted based on the RN assessment findings, the RN can decide to get the resident up, based on the resident's prior transfer status. The DNS noted then notify the APRN or MD and responsible party. The DNS indicated if Resident #72 was guarding his/her leg and was in pain it would depend on if the leg was externally rotated and the rest of the findings of the evaluation on whether or not he would move the resident. The DNS indicated it would be a judgement call for the RN that did the assessment. The DNS indicated he would never expect or recommend the nursing staff to carry a resident on a draw sheet. The DNS indicated he was not aware based on the documentation that was how the nursing staff transferred Resident #72 from the dining room to his/her bedroom. The DNS noted if you suspect an injury you don't want to move the resident off the floor, the expectation would be to send the resident to the hospital. Interview with NA #3 on [DATE] at 8:10 AM indicated on [DATE] at the time of the fall she was giving another resident a shower and did not assist with Resident #72. Interview with NA #4 on [DATE] at 9:23 AM indicated on [DATE] at the time of the fall she heard a loud noise in the dining room and as she entered saw Resident#72 on the floor. NA #4 noted LPN #1 and RN #1 were with Resident #72 and they tried to sit Resident #72 up and Resident #72 resisted, and the nurses laid him/her right back down. NA #4 noted that was when she left the room. NA #4 indicated she last saw Resident #72 on ding room floor and the next time she saw Resident #72 he/she was on his/her bed. Interview with LPN #5 on [DATE] at 10:30 AM indicated from the main dining room where the fall had occurred to Resident #72's room was at least 50 feet for Resident #72 to have been carried on a draw sheet. Although attempted, an interview with NA #5, NA #6, and NA #7 was not obtained. After surveyor inquiry, the in-service sheet dated [DATE] by the ADNS noted any fall whether witnessed or unwitnessed requires an RN assessment. Call the supervisor. Do not manually pick a resident up. If the RN suspects injury, do not move the resident. Call APRN/MD. If emergency, notify and send resident to emergency room . Notify the DNS. If a resident was unable to stand on their own, we must use a hoyer. Review of facility Fall Risk Observation Policy identified when a fall occurs, assessment for injury by a registered nurse is completed and the result documented in the nurse's notes and the 24-hour nursing report. Additional follow up will be performed according to the resident injury and adhering to acceptable standards of practice. Although requested, a facility policy for accident and incident reports and how to transfer a resident off the floor with suspected injury, was not provided. 2. Resident #60 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS dated [DATE] identified Resident #60 had severely impaired cognition and required extensive assistance with personal care. The corresponding care plan identified Resident #60 exhibited deficits in memory and behaviors of anxiety. Interventions included one instruction at a time and give medication as ordered. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders also noted the order was seen and approved by the APRN. A review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DNS on [DATE] at 1:50 PM identified orders from the psychiatric APRN were entered as recommendations and reviewed by the facility APRN. The order was approved and should have been transcribed correctly. 3. Resident #68 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] identified Resident #68 had severely impaired cognition and required extensive assistance for transfers. A reportable event form dated [DATE] at 9:15 AM, written by LPN #5, indicated Resident #68 had a skin tear to the dorsal left wrist. The area was cleansed with normal saline, approximated, and steri-strips applied. A wound management note dated [DATE] at 9:54 AM, written by LPN# 5, indicated Resident #68 had a left wrist skin tear which measured 3.0 cm by 1.0 cm. The nurse's note dated [DATE] at 9:59 AM, by LPN #5, identified that Resident #68 was noted walking in the hallway with some dry blood noted to the left wrist. Upon cleaning a skin tear was noted that measured 3.0 cm by 1.0 cm, skin flap was still intact and the area was able to be approximated with steri-strips. Supervisor, APRN, and family notified. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated [DATE] identified a skin tear left dorsal wrist. Interventions included to keep nails trimmed and filed and ensure no identification bracelet or jewelry on left arm until area healed. The nurses note dated [DATE] at 10:06 PM identified Resident #68 was alert and confused at baseline, did not have shortness of breath or pain this shift. The left wrist skin tear with flap intact steri strips replaced, no active running blood noted. Interview and review of the clinical record review with LPN #5 on [DATE] at 8:40 AM indicated Resident #68 was independent ambulating and was noted with a skin tear to the wrist. LPN #5 noted the policy was to report the new skin tear to the supervisor, which she did based on her progress note, and she had notified the APRN and the family member. LPN #5 did not recall seeing RN #2 come to the unit to assess the new skin tear and did not see a progress note from RN #2. LPN #5 noted the policy was for her to notify the LPN and the RN to do the assessment. LPN #5 noted there no RN assessment for the new skin tear in the electronic medical record. Interview and review of the clinical record with the ADNS on [DATE] at 8:55 AM identified the charge nurse or the supervisor would cleanse the area and then update the APRN or MD. The ADNS indicated there must be an RN assessment of a new skin tear which must be documented in a progress note or in the wound management section of the electronic clinical record. The ADNS noted in Resident #68's clinical record after review there was not an assessment noted by an RN for the new skin tear in the progress nots, under events, in observations or wound management section. The ADNS indicated it was her expectation that the RN supervisor would physically go and assess the skin tear and document the assessment. Although attempted, an interview with RN #2 was not obtained. Although requested multiple times, a facility policy for skin tears and reportable events were not provided. 4. Resident #120's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The history and physical dated [DATE] directed to continue coordinating care with oncology and will further clarify goals of care with the patient's overall condition fair. The admission MDS dated [DATE] identified Resident #120 had intact cognition and required extensive assistance with bed mobility, dressing and toilet use. The care plan dated [DATE] identified to provide comfort measures, palliative care only, family does wish to provide comfort measures only. Advance Directive: Do Not Resuscitate (DNR). Interventions included staff to anticipate and meet the resident's needs, observe for signs of pain, medicate per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The advanced directive declaration dated [DATE] and signed by Resident #120 and the APRN identified the resident's wishes were Do Not Resuscitate, Do Not Transfer to Hospital (unless needed for comfort). A nurse's note dated [DATE] identified Resident #120 was alert and oriented, continued on comfort measures, no complains of pain or any shortness of breath observed. Review of the February 2022 through [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated [DATE] at 9:35 PM and signed by RN #3 identified Resident #120 was observed lying in bed supine with oxygen in place. Absence of vitals, no pulse, respiration or blood pressure. Pupils fixed. Family was at bedside earlier this evening. Postmortem care was in progress. Message was sent to MD #2 and family was notified. Interview with the DNS on [DATE] at 1:30 PM identified that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS was not sure why the order was not in place. Interview with MD #2 on [DATE] at 4:10 PM identified that after consultation with Resident #120's pulmonologist, it was decided that the resident had very limited time. The resident was receiving palliative care and while continuing with pleural malignant effusion drainage the resident was being administered [MEDICATION(S)], Mucinex and [MEDICATION(S)] for comfort. MD #2 further identified that the APRN that assessed the resident and no longer working at the facility was responsible to write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #3 on [DATE] at 8:35 AM identified that in the State of Connecticut, an RN may pronounce death, but she was not aware that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #1 on [DATE] at 11:12 AM identified she was unable to remember the resident and signing the death certificate. RN #1 further identified that possibly she was helping RN #3 that evening, but she would never pronounce a resident without first checking for the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the RN Pronouncement policy identified the attending physician must document in the resident's medical record that the resident's death is expected due to illness, infirmity or disease and the attending physician must give written authorization for all Registered Nurses employed by the facility to pronounce death. The policy further directed the RN who had determined death shall attest to the pronouncement of death on the certificate of death, indicate on the certificate whether a contagious disease was known to be present at the time of death, note the date and time of death on the certificate and sign the certificate.

Based on clinical record review, interview and review of facility documentation for 2 (R#1, R#2) of 6 residents reviewed for allegations of sexual abuse the facility failed to ensure the residents were cared for in a safe environment free from abuse. The findings include: A. R#1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] indicated R#1 had intact cognition with no deficits in long and short term memory. The assessment further indicated R#1 was totally dependent on two staff members for transfer and bathing. According to a signed statement by NA#2 dated 11/14/16 at 1:45 PM and a signed interview dated 11/18/16 at 11:40 AM, NA#2 indicated that on 11/14/16 he/she witnessed NA#1 touch R#1's left breast and nipple area inappropriately while dressing R#1. NA#2 instructed NA#1 to stop. NA#1 responded that R#1 knew what NA#1 was doing and the act was consensual. In the statement NA#2 indicated R#1 was unaware of what was transpiring. A resident care plan (RCP) dated 11/14/16 indicated R#1 had allegedly been a victim of abuse. Interventions included to monitor for signs and symptoms of distress, social work would visit R#1 three times a week for two weeks, and psychiatry consult as needed. On 11/15/16 an additional intervention indicating R#1 was to be cared for by female staff only was added to the plan of care. A progress note dated 11/17/16 at 4:55 PM by Social Worker #1 indicated he/she and the Director of Social Services spoke with R#1 on 11/14/16 pertaining to the aforementioned incident and R#1 denied that a sexual abuse took place. B. R#2 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] indicated R#2 had severely impaired cognition with deficits in long and short term memory. The assessment further indicated R#2 required extensive assistance with activities of daily living including hygiene and bathing. A statement to local law enforcement, facilitated by the Director of Social Services, dated 11/15/16 at 11:30 AM indicated R#2 became upset and expressing increased anxiety at the mention of NA#1's name upon questioning. R#2 indicated NA#1 had hurt him/her when providing personal care however R#2 could not provide any details of the event and could not identify a date or period of time in which the event occurred. A RCP dated 11/15/16 indicated R#2 had allegedly been abused. Interventions included to monitor for signs and symptoms of distress, social work would visit R#2 three times a week and psychiatry consult as needed. A subsequent Social Service progress note dated 11/18/16 indicated R#2 was seen daily by the Director of Social Services since the incident of being hurt during care was identified. The note indicated R#2 exhibited no signs and symptoms of distress or changes in behavior. During an interview with Detective #1 on 11/16/16 at 1:20 PM Detective #1 indicated that NA#1 had been interviewed on 11/15/16 and admitted to touching R#1 in a sexually inappropriate manner. Upon further interview NA#1 additionally admitted to sexually assaulting R#2. Subsequently NA#1 was arrested and charged for the sexual abuse of R#1 and R#2. NA#1 was not available for interview. Facility Abuse Policy indicated the facility would protect residents from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds.

Based on review of the clinical record, review of facility documentation, and interview for one of for sampled residents reviewed for accidents (R#57), the facility failed to ensure a Hoyer transfer was conducted in accordance with the plan of care, and/or failed to ensure the environment was free from hazards. The finding include; 1. Resident # 57's [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] identified severe cognitive impairment, total dependence on staff for ADL's, and requiring the assistance of two for bed mobility and transfers. The RCP dated 2/17/14 identified the resident had significant ADL deficits related to diagnoses. Interventions directed the staff to provide ADL ' s with the assistance of two, transfer with the assistance of two staff via Hoyer lift, and observe for the presence of pain during care. Nurse ' s notes dated 5/4/14 identified NA#2 reported to the charge nurse that the resident's left upper arm was swollen and bruised. The charge nurse assessed the area and noted the resident's left arm was swollen from the shoulder and humerus measuring 17 x 15 cm with a ecchymotic area on the inner aspect of the left arm that measured 20 x 17 cm. The resident grimaced and said "no no" when the left arm was touched. The MD was notified. An X-ray report dated 5/4/14 identified a transverse fracture through the surgical neck of the humerus with marked displacement and lateral angulation. The physician was notified of the X-ray report and the resident was transferred to the ED for evaluation. The resident returned to the facility on [DATE] at 1:30 PM with a sling and swatch to left arm at all times, Percocet 5/325 every four hours for pain and to obtain an orthopedic follow up. Interview and review of facility documentation on 12/10/14 at 8:45 AM with NA#3, who provided care to the resident on 5/4/14 during the 11:00 PM to 7:00 AM shift identified that she/he provided incontinent care to the resident without the assistance of another NA. A draw sheet was used to turn the resident in bed. Interview and review of facility documentation on 12/10/14 at 8:47 AM with NA#1 (who was assigned to the resident 5/3/14 on the 3-11 PM shift) identified all the other NA ' s were providing care to other residents so he/she Hoyer lifted the resident back into bed without assistance. Interview, review of the clinical record, and interview on 12/10/14 at 1 PM with the DNS identified an investigation was conducted to determine the cause of the fracture. NA#3 provided incontinent care at 4:20 AM without assistance and NA#1 transferred the resident to bed with a Hoyer lift without the assistance from another staff member as directed in the RCP. 2. Observations during a tour on 12/9/14 at 9:30 AM noted the following: a. A handrail on the 1st floor adjacent to the housekeeping closet was noted to be broken with jagged exposed edges. b. In room 226, the corner of the wall adjacent to the closet was damaged with a sharp metal material exposed. c. In room 10 near the window, the metal baseboard heating element cover was damaged with exposed edges. An interview with RN # 2 at that time indicated although preventative maintenance is ongoing, these issues should have been reported to maintenance for repair.

Based on clinical record reviews, interviews, observations, and review of facility policy and procedures for two of six residents reviewed for pressure ulcers (R #120, 63), the facility failed to accurately assess and/or appropriately treat a pressure ulcer. The findings include: 1. Resident #120's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident had moderately impaired cognition, was totally dependent on staff for ADL's, was always incontinent of bowel and bladder, and at risk for skin breakdown/pressure sores. A care plan dated 6/24/14 identified a risk for alteration in skin integrity. Interventions included body/skin audits weekly according to house protocol, and Braden Scale per house protocol. Physician orders [REDACTED]. The open area was identified as healed 6/17/14 Physician orders [REDACTED]. Review of the clinical record failed to reflect documentation and/or any assessments of the left inner buttock and/or the right gluteal cleft wounds. Physician orders [REDACTED]. The wound was noted as healed on 8/4/14. Review of the clinical record failed to reflect documentation and/or any assessments of the left buttock wound. Physician orders [REDACTED]. Review of the clinical failed to reflect documentation and/or any assessments of the wound. Physician orders [REDACTED]. Nurse ' s notes dated 10/15/14 at 10:45 PM noted that the previously opened area to the left buttocks had re-opened, a [MEDICATION NAME] dressing was in place and a note was left for wound care to evaluate. Review of the clinical record failed to reflect that any assessment of the new open area had been completed when identified on 10/15/14. Physician orders [REDACTED]. Nurse ' s notes dated 11/7/14 at 4:28 PM noted an open area on the sacrum and a [MEDICATION NAME] dressing was applied. Review of the clinical record failed to reflect that any assessment of the new open area had been completed when identified on 11/7/14. Wound care specialist evaluation dated 11/26/14 noted R#120 with an " Incontinence Associated [MEDICAL CONDITION] (IAD) " of the buttocks. Recommendations included to apply a house barrier cream every shift. Physician orders [REDACTED]. Nurse ' s notes dated 12/8/14 at 4:39 PM noted the buttock wound opened measuring 7 CM x 5.5 CM and the left buttock open wound measuring 3 CM x 3 CM. The clinical record failed to reflect a complete assessment of the wounds was completed and/or documented when identified on 12/8/14 including color, periphery, type of tissue, etc. Review of facility weekly pressure ulcer log dated 6/5/14 through 11/6/14 failed to reflect weekly assessments were conducted until 11/11/14 when the area was described as moisture associated [MEDICAL CONDITION] (IAD). Additionally weekly wound rounds were not completed on R #120 from 11/13/14 through 12/4/14 because RN #3 was on vacation during that time. Observation of R#120's wound with LPN #1 and RN #4 on 12/9/14 at 11:30 AM identified the right buttock had an unstageable pressure ulcer measuring 7 CM x 5 CM noted with 100% slough, and maceration of the periwound. The left buttocks was noted with a pressure ulcer measuring 5 CM x 3 CM with 10% slough, and maceration of the periwound. Five denuded areas were also noted on the left and right buttocks. Facility policy and procedure for skin integrity and pressure ulcer prevention program identified a thorough skin/body check will be done on all new admissions and readmissions, weekly skin checks are done on the residents shower day and documented by the charge nurse. Weekly wound rounds will be done on residents with pressure and other ulcers directly by the wound team. Weekly documentation of the wound will include location and staging of the wound, size indicating the length, width and depth of the area, presence, location and extent of any undermining or tunneling/sinus tract, a description of the wound bed and wound edges including color and type of tissue. Interview with RN #2 on 12/9/14 at 11:45 AM indicated that due to the resident's incontinence status, he/she felt washing the wound with soap and water was appropriate for the cleansing of the wound. Interview with RN# 3 on 12/10/14 identified the use of soap and water to cleanse a pressure ulcer is not an appropriate cleansing agent. Additionally facility policy for wound cleansing directs to utilize normal saline and/or wound cleanser. Subsequent to surveyor inquiry, interview with the Wound Care Physician on 12/10/14 at 9:10 AM identified he/she completed an assessment of R#120 ' s wounds on 12/10/14 and identified an unstageble pressure ulcer located on the left upper buttocks measuring 3 CM x 3 CM, with light serous drainage, and 100% devitalized necrotic tissue. Another unstageble pressure ulcer was located on the left lower buttocks measuring 2 CM x 2 CM, with light serous drainage, and 100% devitalized necrotic tissue. A third unstageble pressure ulcer was located on the right buttocks measuring 5 CM x 5 CM, with moderate serous drainage, and 100% devitalized necrotic tissue. The wound care physician indicated the treatment for [REDACTED]. Subsequent to wound care physician's assessment on 12/10/14, new treatment orders were written directing to cleanse the areas with normal saline followed by Santyl daily. 2. Resident #63 ' s [DIAGNOSES REDACTED]. The hospital discharge summary dated 11/4/14 indicated that the resident had a new blister of the coccyx along with redness and a [MEDICATION NAME] dressing was applied. The initial care plan dated 11/5/14 identified that the resident was at risk for alteration in skin integrity related to decreased mobility and generalized deconditioning and weakness. Interventions included body/skin audit weekly, Braden quarterly, pressure reduction cushion to w/c, pressure reduction mattress to bed, skin barrier cream for incontinence and skin prep to bilateral heels. The care plan indicated that the resident had redness and an open area to right buttock. Interventions included to assess condition of surrounding skin, apply [MEDICATION NAME] dressing, weekly skin assessment and as needed, and to observe and report signs of infection,[MEDICAL CONDITION]. An undated care plan addition indicated the presence of moisture associated [MEDICAL CONDITION] with an " erosion " . No further assessments were noted from 11/4/14 through 11/14/14 when the area was assessed as moisture associated [MEDICAL CONDITION] with a 1.5 by 1.5 cm open area. Treatment orders were changed to calcium alginate with antifungal cream to surrounding area. No description of the " area " was documented other than " red " . The resident was discharged home on[DATE] with no subsequent assessments after 11/14/14. On 12/09/2014 at 11:26:06 AM, interview and clinical record and computer record review with RN#2 failed to provide documentation that the wound/area was assessed from 11/4-11/14 when it was noted to have declined. Further review noted that the assessment on 11/4/14 did not describe a "moisture associated [MEDICAL CONDITION]" and that the hospital noted a blister (pressure ulcer) present upon discharge on the discharge summary. RN#2 was unable to show documentation that the resident was re-assessed after 11/14/14 when the area was noted to have gotten worse.

Based on clinical record reviews and staff interviews for five of six residents in the survey sample reviewed for pressure ulcers (R #77, 150, 1, 165, and 115), the facility failed to implement interventions to prevent pressure ulcers and/or accurately assess a pressure ulcer on admission and/or weekly and/or assess and treat a stage 1 pressure ulcer. The findings include: 1. Resident # 77's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified severe cognitive impairment, total dependence on staff for ADL's including bed mobility and dressing, unable to ambulate, frequently incontinent of bowel and bladder, and at risk for pressure ulcers. The Braden scale assessment dated [DATE] identified R# 77 was at high risk for pressure ulcers. The care plan dated 11/23/12 identified the risk for skin breakdown related to impaired mobility and fragile skin. Interventions included to apply skin prep to both heels per protocol, pressure reduction mattress, turn and reposition every 2 hours, and weekly body audits. Nurse's notes dated 12/29/12 identified a deep tissue injury/scab (DTI) at the back of the left heel measuring 1.0 x 1.3 cm, and an open area, stage 2, on the left heel measuring 1.7 x 1.0 cm with small amount of drainage. Skin prep was applied to both heels and the heels were off loaded with pillows. Weekly body audits dated 12/3/12, 12/10/12, and 12/17/12 identified no new skin issues. On 1/2/13, the weekly body audit noted an area on the left heel. The body audits failed to be completed for 12/24/12. Review of December 2012 treatment kardex failed to identify skin prep had been applied and/or that the resident's heels had been off-loaded. Review of the January 2013 treatment kardex identified blue boots to both feet were initiated after the development of the DTI. Review of the weekly pressure ulcer documentation dated 12/31/12 identified a stage 3 "un-stageable" area to the left posterior heel measuring 1.0 x 2.0 x 0.3 cm. An interview with RN # 2, on 3/28/13 at 11:45 am identified that if a resident had an intervention of skin prep to heels per house protocol, then it is to be applied daily and documented on the treatment kardex. Review of the treatment kardex at that time with RN# 2 identified the December 2012 treatment kardexes failed to identify that skin prep and/or offloading had been provided. Additionally, review of the resident care plan failed to identify that the care plan was updated to reflect development of the wound on the heel and interventions until February 6, 2013. Further review of the clinical record with RN#2 failed to provide documentation that the resident's weekly body audit had been completed on 12/24/12. On 4/2/13 at 10 AM, RN#5 brought the resident's shoe/sneaker into the conference room and stated that the resident's shoe/sneaker was the cause of the pressure sore on the heel because the sneaker was "hard as a rock". When asked if the resident ambulated or could put own shoes on or off, the reply was no. 2. Resident #150's [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A significant change assessment dated [DATE] identified the resident was moderately cognitively impaired, required extensive assistance with ADLs, was at risk for pressure ulcer development , and had no skin conditions at that time. A long leg brace/splint was in place to stabilize the fracture. A nursing admission assessment dated [DATE] identified that R#150 was readmitted after a fall and hospitalization with a right femoral fracture. It further identified that his/her skin was warm and dry with redness and a scar located over the sacrum/coccyx area. An initial care plan dated 7/18/12 identified a right "hip" fracture and pressure ulcer/skin risk. Interventions included assisting to change position every two (2) hours. Nurse's notes dated 7/18/12 through 7/30/12 identified that R#150 was bed bound with an immobilizer on his/her right lower extremity and was experiencing pain. Further review failed to identify provision of any type of repositioning and/or off loading. Review of treatment records from 7/18/12 through 7/30/12 failed to document provision of turning and positioning and was lacking documentation that the physician ordered body audit for 7/24/12 had been completed. Despite numerous requests over several days, the ADNS was unable to provide the body audit documentation for July 2012 through August 28, 2012. A nurse's note dated 7/30/12 at 10:30 PM identified an "open area" to R #150's right buttock measuring 3.0 CM x 1.5 CM. The note further identified that the physician was made aware and ordered a treatment that included the application of a [MEDICATION NAME] dressing to be changed every three days and provision of an alternating air mattress. Physician orders [REDACTED]. During an interview and review of R #150's clinical record with the ADNS on 4/2/13 at 10:47 AM indicated that although she provided an interim/admission care plan that included every two hour repositioning she was unable to provide documentation that the plan of care included specific interventions for turning a resident with a fractured femur stabilized with a immobilizer (until 7/30/12). She additionally was unable to provide any documentation that repositioning to prevent the development of a pressure ulcer was provided to the resident and/or that the reddened area was closely monitored and/or treated on readmission. 3. Resident #1's [DIAGNOSES REDACTED]. An initial nursing assessment dated [DATE] identified no open areas on the heel. An MDS dated [DATE] identified the resident had severe cognitive deficits, required extensive assist with bed mobility and transfer, and had no pressure ulcers. A resident care plan dated 9/21/12 identified the resident was at risk for skin breakdown. Interventions included skin prep for 30 days and assess condition of skin over bony prominences and document changes. A physician order [REDACTED]. A weekly body audit dated 10/2/12 was blank. A nurse's note dated 10/5/12 noted the resident had a blister on the left heel. The Resident was assessed by the APRN and skin prep and off-loading were ordered. Weekly pressure ulcer documentation flow sheet dated 10/5/12 identified a circular blister (no measurements provided). Pressure ulcer documentation for 10/10/12 and 10/17/12 were blank, and the 10/2212 assessment indicated the left heel had a 6 x 7 cm area of dark discoloration. Review of the clinical record and interview on 4/1/13 at 10:45 am with RN #5 indicated it is the practice of the facility to off load and apply skin prep to heels on resident's with risk, such as [MEDICAL CONDITION]. Further review failed to provide documentation that the heels were off-loaded until 10/5/12 when the blister was identified and/or ordered by the APRN, and/or that weekly skin checks were performed, and/or that weekly comprehensive assessments of the pressure area had been performed and documented. Review of facility policy on prevention of pressure ulcers included relief/reduction of pressure as needed. Additionally, wound assessment documentation is completed at least weekly and as changes in the wound are apparent. 4. Resident #165's [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] identified a stage 1 pressure ulcer on the coccyx. The care plan dated 10/15/12 identified an alteration in skin integrity related to incontinence. Interventions included to assess condition of skin and document changes, provide incontinent care and reposition every 2 hours, utilize a pressure relief mattress and chair pad, and body audit weekly. A weekly body audit dated 10/16/12 identified the "same skin issues as on admission" but lacked a description, (color, size, depth) of the stage 1 area. A body audit dated 10/23/12 identified an open area to the buttocks. A nurse's note dated 10/23/12 identified an open area to the buttocks that measured 3 cm by 1.25 cm. A [MEDICATION NAME] dressing was applied until the APRN could assess the wound at a later date. A weekly pressure ulcer documentation flow sheet dated 10/24/12 identified the stage 1 pressure ulcer had deteriorated and was now identified as a stage III that measured 2.5 cm by 1.0 cm by 0.1 cm, with 85% granulation tissue, 15% slough and light serous drainage. A review of the clinical record and interview on 3/28/13 at 11:00 AM with the DNS failed to provide documentation that complete assessments had been done at least weekly, and/or that monitoring, assessment had been completed at least weekly and/or that treatment orders for the stage one pressure ulcer had been obtained/initiated to prevent decline to the area. 5. Resident # 115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] identified the presence of an open area on the right buttock. A resident care plan dated 1/9/13 identified a problem with skin integrity indicating the resident was admitted with an open area to the right buttock. Interventions included treatment to right buttock as ordered, body audit weekly, assess condition of skin over bony prominences, and document changes. A nurse's note dated 1/4/13 noted a skin opening on the right buttock. A nurse's note dated 1/7/13 noted a [MEDICATION NAME] was applied to the right buttock as ordered. Review of the nurse's notes from 1/8/13 through 2/10/13 (discharge) noted no further notes or assessments that addressed the open area on the right buttock. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Body audits dated 1/10/13 noted redness in the peri-area and open area on right buttock persists. 1/17/13 noted treatment continues on right buttock and peri-area. 1/24/13 noted buttock area improved. The body audits did not include size, description of wound bed and/or stage of open area. An interview and clinical record review on 3/27/13 at 2:15 PM with the DNS indicated the open area should have been assessed on admission (1/4/13) and the physician notified for an appropriate treatment order. Further review failed to provide documentation to indicate that the physician had been notified of the pressure sore for 3 days after admission. An interview on 4/1/13 at 2:55 PM with MD #1 indicated he would have expected to be notified by the nurse and/or the wound nurse of the open area on admission for an appropriate treatment. He further indicated there was a period when the facility was in-between wound nurses and the communication during that time was not good. A facility wound care and documentation policy indicated weekly documentation included a description of the area, including color, size, depth, location, extent of any drainage, condition of the wound area, as well as surrounding area.

Based on clinical record review and staff interview for 1 of 3 residents in the survey sample reviewed for hydration (R# 104), the facility failed to ensure the resident's fluid needs were being met and/or the physician was notified. The findings include: Resident #104's [DIAGNOSES REDACTED]. The Resident care plan dated 9/5/12 identified the resident was at risk for dehydration. Interventions included monitor for symptoms of dehydration, encourage fluids, monitor weights, and to record intake and output as per facility protocol. Review of the three day fluid assessment dated [DATE] identified R# 104's weight as 141 lbs and fluid needs to be 1692 cc per day. The resident' s intakes for 9/2-9/4/12 were 1080 cc, 1080 cc, and 1200 cc respectively. Intake and output (I&O) records from 9/5/12 through 9/27/12 when I &O was discontinued, identified R#104 never met the 1,692 cc fluid needs once during the 23 days. Documented fluid intakes during that time were between 240 cc- 1560 cc. Review of the resident' s documented meal intakes from 9/28/12 through 10/4/12 identified that out of 21 meals, 8 meals lacked any documentation of intake, 11 meals were consumed at 24% or less, and 2 meals at 25-50%. Laboratory data dated 9/6/12 identified the resident's BUN was 33 mg/dl (normal 7-25 mg/dl), and the Creatinine was 1.04 mg/dl (normal 0.6-0.88 mg/dl). Laboratory data dated 10/4/12 identified R #104's BUN was 172 mg/dl and the Creatinine was 9.14 mg/dl. Nurse's notes dated 10/4/12 at 3 PM identified R# 104 was lethargic, having trouble eating/swallowing, pocketing food and trouble ambulating. The APRN was notified and ordered labs and x-rays. Additionally, the note identified if a change in condition was noted to re-notify the APRN. Nurse' s notes dated 10/4/12 identified critical labs values were noted, the APRN was made aware, the family notified and the resident sent to the hospital for an evaluation. Review of a hospital summary dated 10/4/12 identified R #104 presented with altered mental status, decreased oral intake and poor appetite for about 1 week, as well as abnormal blood work. The resident was found to have acute [MEDICAL CONDITION] and was dehydrated. Laboratory Data dated 10/18/12 (after hospitalization ) identified the BUN had dropped to 19 and the Creatinine to 0.81 after hydration. Interview with the Corporate Nurse on 3/26/13 at 11:45 am identified all residents upon admission are placed on intake and output monitoring for 3 days. If the resident does not meet their fluid goals after 3 days they continue to have I & O monitored. Review of R # 104's clinical record at that time with the corporate nurse failed to provide documentation that R #104' s fluid intakes continued to be monitored when the resident did not meet his/her fluid goals repeated, and/or that documentation in the nurse's notes reflected the resident's decreased appetite, and/ or that the physician was notified of the resident's poor food and fluid intake, and/or that interventions to prevent dehydration were initiated when the resident' s fluid intakes were below needs, and/or that physical assessments were completed to check for signs and symptoms of dehydration in light of the poor fluid intakes. Review of R #104's clinical record, 24-hour report sheets, and interview with the ADNS on 3/27/13 at 2:00 PM noted that if a resident is not eating and/or taking fluids well the nurse aide is to report to the nurse. The nurse would then assess the resident, document in the clinical record, and report to the supervisor their findings. Additionally, review of the clinical record of R #104 and the 24-hour report sheets failed to identify that the physician was made aware of the resident's poor intake until 10/4/12 at which time the resident was admitted to the hospital with [REDACTED]. Review of the facility policy and procedure for hydration identified all residents will be placed on intake and output for 3 days and then evaluated. If residents are not meeting their fluid needs additional evaluation and monitoring will be initiated.

Based on clinical record review and staff interview for the only resident in the survey sample reviewed with a significant change (R#150), the facility failed to implement the physician's orders [REDACTED]. The findings include: Resident #150's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident was moderately cognitively impaired, required extensive assist with ADLs, had a fracture, was at risk for pressure ulcer development, and had no skin conditions present at that time. An Orthopedic follow-up consultation documentation dated 8/24/12 identified poor splint positioning and a two (2) cm [DIAGNOSES REDACTED] at the distal aspect of the knee. It further directed to "please maintain and do not change" the splint immobilizer. A subsequent orthopedic consult dated 9/25/12 identified a one (1) cm decubitus ulcer present on the knee area. The Orthopedic Physician directed the administration of Keflex 500 mg antibiotic every 6 hours for fourteen (14) days and to "leave" knee immobilizer and Jones dressing (in place) and follow up in 2 weeks. The follow up orthopedic consult dated 10/9/12 identified a one (1) cm full thickness decubitus ulcer. The physician ordered a wound consult for the full thickness decubitus pressure ulcer. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. A Physician's Assistant (PA#1) progress note dated 10/23/12 identified he/she was informed by staff that R #150's dressing and splint had remained in place without removal since the last follow-up appointment with the Orthopedic Surgeon on 10/9/12 (14 days prior) and that the wound MD had not assessed the wound. The note identified that upon examination (with nursing supervisor present) PA#1 observed an open area exposed to the bone above the patella and eschar (blackened skin) below the patella. The note identified that PA #1 spoke with the resident ' s primary care physician (PCP) who recommended sending R#150 to the hospital wound clinic instead of having the consultant wound physician see the resident. The note further identified that although the earliest appointment with the clinic was made for 10/30/12, it was rescheduled to 11/2/12 due to inclement weather. PA #1's progress note dated 11/1/12 identified that R#150's PCP examined the area again and identified additional new open areas and directed the resident to be transferred to the hospital emergency room . A hospital discharge summary dated 11/27/12 identified that R#150's hospital course included the [DIAGNOSES REDACTED]. Interview and review of R#150's clinical record with the ADON on 3/28/13 at 10:50 AM failed to provide documentation that nursing staff communicated with the orthopedic physician and/or the PCP for specific direction and/or plan of care related to the management of the developing ulcer under the resident's immobilizer. She was unable to determine why the resident did not see the consulting wound physician who comes to the facility weekly when it was ordered on [DATE]. An interview with the MD #1 (PCP & Medical Director) on 4/1/13 at 2:42 PM noted that when he ordered the consult for the wound doctor on 10/9/12, he expected the consult to be completed in a timely manner because the wound consultants were in the facility on a routine basis (weekly). He further indicated when the resident had still not been assessed by the wound doctor on 10/15/13, he ordered for the resident to be seen by the wound clinic at the hospital. MD #1 was unable to recall any communication with the nursing staff related to the plan of care to render wound care to the resident when it was first identified on 8/24/12 ([DIAGNOSES REDACTED]) and 9/25/12 (1 cm decubitus). He indicated that the orthopedic surgeon wrote not to touch the brace/splint and therefore the wound was left alone (no treatments).

Based on review of the clinical record and staff interview for two of six residents in the survey sample reviewed for accidents (R# 267, R # 42)), the facility failed to implement the care plan resulting in a fall with injury and/or transfill oxygen in a safe manner. The findings include: 1. Resident # 267 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] identified the resident with cognitive and behavioral symptoms, ambulation with difficulty, balance problems, and at risk for falls. A Bed Behavior Monitoring Form dated 8/2012 identified the resident "tries to get out of bed" and "tries to climb over side rails". The care plan dated 8/9/12 identified fall risk and directed the use of bed and chair alarms. An admission MDS dated [DATE] identified the resident had severe cognitive impairment and required extensive assistance with ADL's. Nurse' s notes dated 8/16/12 identified that at 6:45 PM, the resident was found lying on the floor positioned on his/her left side. The left leg appeared abducted and shorter in length than the right and the resident complained of pain in the left hip and groin area. The physician was notified and the resident was transferred to the emergency room for evaluation and was admitted . Review of a facility investigation dated 8/16/12 identified that at the time of the incident the side rails on the resident's bed were elevated and the resident was on the floor next to the bed. The resident attempted to get out of bed without assistance by climbing over the side rails. The nurse aide assigned to the resident had not followed the plan of care when he/she had raised the side rails on the bed. The nurse aide assignment sheet did not direct the use of side rails. A Hospital Discharge Summary dated 8/21/12 identified that the resident sustained [REDACTED]. The resident was readmitted to the facility on [DATE]. An interview on 3/28/13 at 12:50 PM with RN#1, supervisor on duty at the time of the fall, identified that full side rails were noted to be up on the bed at the time of the fall. The resident had climbed over the rails and landed on the floor. The resident did not have orders for the use of full side rails at that time. A review of the clinical record and facility documentation and interview on 3/28/13 at 11:00 AM with the DNS identified that as a result of the incident, the nurse aide was provided with counseling and education regarding the inappropriate use of side rails. 2. Resident # 42's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident had a BIMS score of 8 (moderately impaired cognition), and required extensive assist with transfer and toilet use. A fall risk assessment dated [DATE] identified the resident's fall risk was 26 (10 or higher = risk). A care plan dated 3/7/13 identified the risk for falls due to poor safety awareness. Interventions included moderate assist of 1 with toilet transfers. A physician order [REDACTED]. A nurse's note dated 3/15/13 at 12:30 PM indicated the resident was found supine on the bathroom floor with skin tears on the right hand and right elbow. The Resident indicated he/she should not have tried to go to the bathroom by him/herself. A facility investigation dated 3/15/13 indicated the resident was found supine on the bathroom floor. The resident sustained [REDACTED]. Steri strips were applied. The investigation indicated the hairdresser wheeled the resident to the bathroom, indicating the resident believed he/she did not need help with ambulation and transfers. An interview on 3/27/13 at 12:15 PM with the hairdresser indicated on 3/15/13 she was doing R # 42' s hair. When she was done, the resident started to stand up stating he/she had to go to the bathroom. The hairdresser indicated she wheeled the resident to the bathroom across the hall and closed the door. When she returned to the bathroom the resident was on the floor. She indicated she did not notify the staff that the resident needed to go to the bathroom because the resident indicated he/she could toilet him/herself and did not need help. She indicated she assumed the resident could toilet him/herself because the resident said he/she could. An interview on 3/27/13 at 1:30 PM with the DNS indicated she would have expected the hairdresser to notify a nursing staff member if a resident needed to use the bathroom. She further indicated it is not within the hairdresser's scope to know if a resident requires assist or is independent. The hairdresser was counseled post incident. 3. On 3/27/13 at 11:40 am, NA #3 was observed taking a portable oxygen tank to the trans- fill oxygen room and with the door open, began to fill the oxygen tank. Upon surveyor inquiry, NA #3 stopped filling the tank and stated that he/she was aware that the door needed to be closed but there was not a lot of room in the oxygen room. Further observation noted NA # 3 closed the door and continued filling the tank. Interview with LPN # 3 on 3/27/13 at 11:45 am noted that all staff had been inserviced on keeping the door closed when filling oxygen.

Based on clinical record reviews, observation, review of policies, and interviews for two (R#139, 227) of four sampled residents reviewed for hydration, the facility failed to assess the resident for dehydration when not meeting fluid expectations, and/or initiate interventions/care plan to prevent dehydration. The findings include: 1. Resident #139's [DIAGNOSES REDACTED]. The care plan dated 9/16/11 identified the risk for fluid volume deficit related to diuretic medication therapy. Interventions included to assess for signs and symptoms of fluid deficit include skin turgor, mucous membranes and level of consciousness, assess [MEDICAL CONDITION], encourage fluids, hydration assessment as needed and update physician, I&O as ordered and as needed. Physician admission orders [REDACTED]. The Nutrition Risk and Medical Nutrition Therapy assessment dated [DATE] identified the resident's estimated fluid needs were 2000-2400 cc daily. Review of lab work dated 7/30/11, prior to skilled nursing facility admission, identified a Blood Urea Nitrogen (BUN) of 27 (normal 7-25) and a creatinine 1.28 (normal 0.67-1.54). Review of laboratory results dated [DATE] identified a BUN of 40 and a creatinine of 1.45. Review of the Intake and output documentation dated 11/12/11 through 11/19/11 identified the resident failed to meet fluid needs with the 8 day average being 1575 ml. Nurse's notes dated 11/20/11 identified that the resident was restless and had an oxygen saturation of 74%. The resident was transferred to the hospital. Review of the hospital history and physical dated 11/20/11 identified R#139's daughter had visited the day prior to admission and found the resident very lethargic. The daughter indicated that the resident had been declining over the previous week, had behavioral issues and was not able to ambulate as well as prior. The H&P indicated that upon hospital admission, the resident was slightly distressed with labored breathing, "oral mucosa is extremely dry with cracked tongue and lips". The resident was "hypotensive, and systolic blood pressure was in the 70's which responded immediately to IV fluids". Review of laboratory data identified a BUN of 159 and a creatinine of 3.6. A urinalysis identified yellow urine, heavily turbid with 2+leukocytes. An assessment identified that the urine was grossly dirty after Foley insertion and the resident was determined to be septic with [MEDICAL CONDITION] severe dehydration. interview with the Dietician on 2/27/12 at 10:00 AM identified that the expectation is that a hydration assessment be completed and the physician notified when the resident is not meeting fluid needs. Interview and review of the clinical record with the Director of Nursing (DNS) on 2/27/12 at 11:00 AM identified that the expectation is for a hydration assessment to be completed after a resident has not met his/her fluid requirements for three days. Review of facility policy directs that if a resident did not meet his/her fluid goal an assessment of the resident should be completed for signs and symptoms of dehydration and the physician notified. Review of the clinical record at that time failed to provide documentation that the resident was assessed for signs and symptoms of dehydration when he/she repeatedly failed to meet the daily fluid needs and/or that interventions to prevent dehydration were initiated when the labs showed evidence of dehydration on 10/17/11 and/or when intakes failed to meet fluid needs. 2. Resident #227's [DIAGNOSES REDACTED]. An admission assessment dated 2/16/12 identified the resident had impaired cognition, required extensive assistance for eating and was frequently incontinent of bladder. The care plan dated 2/10/12 identified a potential for fluid volume deficit. Interventions included to assess for signs of dehydration. The dietitian's assessment dated [DATE] noted a fluid goal of 2000-2400 cc per 24 hrs. Review of the intake and output records for the period of 2/9 through 2/21/12 identified the fluid goal was not being met . The fluid intake was as follows: 2/10 960 cc 2/11 1060 cc 2/12 1440 cc 2/13 840 cc 2/14 900 cc 2/15 660 cc 2/16 820 cc 2/17 1920 cc 2/18 1220 cc 2/19 1620 cc 2/20 960 cc 2/21 780 cc Interview and clinical record review with the DNS on 2/27/12 at 10:45 am identified there should have been hydration assessments completed upon R #227 not meeting the fluid goals for the period of 2/9 through 2/20/12. She noted that the unit manager was responsible to complete assessments. Observation with RN#1 on 2/27/12 at 11:20 noted the resident in bed with the water pitcher on the nite stand out of reach of the resident. Interview with the Dietician on 2/27/12 at 11:30 am noted he/she was unaware that the resident was not meeting the fluid goals and if she had been made aware, she would have reviewed fluid preferences and offered jello with meals. Interview with LPN # 2 on 2/27/12 at 11:33 am noted that although R#227 required cueing with meals, he/she may drink from a cup if placed in front of her and LPN#2 was unaware that the pitcher was currently placed out of reach and she was going to immediately go offer fluids.

Based on clinical record reviews, observations and interviews for two of seven residents who required staff assistance for transfers (Residents #1 & #9) and/or for one of three residents residents observed for repositioning in bed (Resident #8), the facility failed to ensure that residents were transferred and/or that positioning devices were utilized in accordance with the plan of care to prevent injury. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. The assessment dated [DATE] identified that the resident did not have cognitive problems and required the assistance of two or more staff for transfers. The Resident Care Plan (RCP) dated 6/7/11 directed to transfer with the assistance of (2) two staff members. Nursing narratives dated 6/14/11 at 6:45 PM indicated that the resident was transferred to the bed by Nurse Aide (NA) #1, sustained an 8.0 centimeter (cm) by 12.0 cm laceration to the left lateral calf and was sent to the emergency department. Nursing narratives dated 6/14/11 11:50 PM noted that the resident returned from the ED and had nine (9) sutures in place to the left lateral calf with a dressing. Observation on 9/23/11 at 10:30 AM noted a healed, indented scar to the resident's left lateral, slightly posterior calf. Interview with NA #1 on 9/27/11 at 11:45 AM indicated that s/he did not usually work on the resident's unit, had observed other staff transfer the resident alone, and had not checked the resident's plan of care prior to transferring the resident. S/he further noted that s/he transferred the resident from the wheelchair (w/c) to the bed alone and the side of the resident's wheelchair " snagged" the resident's left leg. Interview with LPN #1 on 9/28/11 at 8:05 AM indicated that the resident sustained [REDACTED].#1 and that when s/he checked the RCP that was posted in the resident's closet, the RCP directed a 2 person transfer. The facility NA job description identified that an essential function of the NA included learning the care requirements of each assigned resident. 2. R# 9 was admitted to the facility on [DATE] for short term rehabilitation and skilled nursing after a hospitalization for muscle weakness. The Minimum Data Set ((MDS) dated [DATE] indicated that R#9 required the assistance of two or more staff for transfers and to walk in his/her room. Physician orders [REDACTED]. Nursing note dated 3/8/2011 at 12:00 PM indicated that Nurse Aide #10 (NA#10) was walking R#9 when the resident "started to go down" and NA#10 lowered the resident to the floor. During the initial assessment post fall, the resident denied any pain. However, nursing note dated 3/9/2011 at 12:20 PM indicated that R#9 stated he/she was having a headache, and a 1 centimeter (cm) discoloration was noted on the right side/back of the head which was tender to the touch. The resident was sent to to the emergency department. A Comuted Tomography (CT) scans on 3/9/2011 and a repeat CT scan on 3/14/2011 identified no acute findings. An interview with NA#10 on 9/28/2011 at 11:10 AM identified that, although the nursing care card in the resident's room directed an assistance of two for transfers and ambulation, NA#10 was not able to find additional help because other employees were assisting with lunch service. The facility's job description for a certified nursing assistant identified that the employee learn the care requirements of each assigned resident. 3. R#8's [DIAGNOSES REDACTED]. The Minimim (MDS) data set [DATE] identified an inability to obtain a Brief Interview for Mental Status score, short and long term memory deficits and requiring total assistance with bed mobility. The Resident Care Plan dated 6/3/11 identified the resident was at risk for alteration of skin integrity and deficits in activities of daily living (ADL) with directions to place pillow between the resident and siderails, utilize padded rails, turn and position every hour and when necessay and protect extremities during transfer. Review of the nurse aide assignment sheet directed to place pillow between resident and siderail and if resident becomes resistant -stop care and notify nurse. Review of the nurse's notes dated 7/15/11 at 5:40 AM identified the charge nurse called the nursing supervisor to assess R#8 and identified a hardened bony prominence to the left inner humerus proximal to the axilla. The nurse aide reported hearing a "pop" during positioning. The physician was notified. Review of radiology report dated 7/15/11 identified a segemental, comminuted fracture involving the distal diaphysis of the left humerus. Interview with MD# 1, radiologist on 9/26/11 at 2:00PM identified that this injury was a post-traumatic injury even though the resident has a history of osteoporosis. Interview with NA# 4 on 9/27/11 at 1:00 PM identified that he/she was not in the room at the time and was subsequently called in by NA#5. NA#5 stated that R#8 had become combative and when he/she tried to turn him/her something happened to the arm and he/she heard a noise. Interview with LPN#3 on 9/28/11 at 3:45PM identified that NA#5 called him/her to the room to observe R#8. At that time pillows were not observed between the resident and the siderails and sheepskin padding was not observed on the siderails. NA#5 reported that R#8's arm had gotten caught in the siderail and he/she heard a noise when he/she tried to get the arm out of the siderail. Review of the nurse aide job description directs that it is an expectation that nurse aides learn the care requiremtnsts of each assigned resident. Atempts to interview NA#5 were unsuccessful.

Based on clinical record review, observation and interview for one of three residents reviewed for injuries of unknown origin, the facility failed to ensure the resident remained free from injury. R#3's [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] identified an inability to complete the Brief Interview for Mental Status, short and long term memory deficits with inattention and altered level of consciousness. Review of the resident care plan dated 1/7/11 identified total care in activities of Daily Living with extensive assistance for transfers, ambulation, bathing, personal care and toileting. Review of the nurse's notes dated 1/11/11 identified that R#3 complained of shoulder pain and upon assessment, dimpling was noted and the resident developed increased pain on range of motion. Review of the clinical record identified an x-ray dated 1/11/11 which identified a slight anterior inferior displacement of the humerus in relationship to the glenoid fossa. Subsequently, R#3 was hospitalized and underwent a reduction of the right shoulder. Interview with NA#3 on 4/27/11 2:30PM at identified that he/she had positioned R#3 in the morning before breakfast and set him/her to feed self. When NA#3 returned, he/she observed that R#3 was unable to feed self and when attemptimng to wash R#3, he/she complained of pain and the Charge Nurse was immediately informed. The facility initiated an investigation of an injury of unknown origin which was inconclusive. Although the investigation was inconclusive, interview with the radiologist on 4/27/11 at 1:15PM identified that generally an anterior dislocation to the shoulder would not occur unless there was a direct blow to the shoulder, a fall or forceful tugging. This type of injury would not occur spontaneously unless the resident had a previous history with dislocation of this shoulder and would cause immediate pain.