Meadowview Health & Rehab Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#3) of 3 sampled residents.Findings: Policy:Pressure Injury Prevention Program (Reviewed and Revised date of 06/27/2025)Standard: All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries.3. The following is a list of commonly used interventions to possibly prevent the development of pressure injuries- c. Keep residents clean and dry d. Provide incontinent care as appropriateReview of Resident #3's medical record revealed Resident #3 had an initial admission date of 07/07/2018 with a readmission date of 09/18/2025 with the following diagnoses in part: Multiple sclerosis, pressure ulcer of the sacral region - Stage 4, altered mental status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Review of Resident #3's annual MDS (Minimum Data Set) assessment dated [DATE] revealed in part, a BIMS (Brief Interview of Mental Status) score of 04, indicating severe cognitive impairment and Resident #3 was dependent on staff for toileting and personal hygiene.Review of Resident #3's physician order dated 11/10/2025 revealed clean sacrum with wound cleanser, apply Ioplex, cover with super absorbent dressing three time weekly and as needed if soiled or dislodged.Review of Resident #3's person centered care plan revealed Resident #3 had a pressure ulcer to the sacrum with interventions which included in part, clean with wound cleanser, apply Ioplex, cover with super absorbent dressing three times weekly and as needed if soiled.An observation of wound care on 01/05/2026 at 11:30 a.m. revealed S6 Treatment Nurse removed a saturated bandage from Resident #3's sacral area. S6 Treatment Nurse continued wound care leaving the soiled brief in place. S6 Treatment Nurse completed wound care, secured the soiled brief back in place, and placed the bed linens back over Resident #3. During an interview on 01/05/2026 at 11:35 a.m. S6 Treatment Nurse acknowledged Resident #3's brief was soiled during wound care treatment. During an interview on 01/05/2026 at 2:15 p.m. S1 DON (Director of Nursing) reported Resident #3's soiled brief should have been changed prior to starting wound care and the soiled brief should not have been left on Resident #3 after wound care was complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident was seen face to face by a physician at least once every 60 days for 1 (#1) of 3 sampled records reviewed.Findings:Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with the following diagnoses which included, in part: Chronic respiratory failure, osteomyelitis of vertebra, lumbar region, complete paraplegia, pressure ulcer to the sacral region and an encounter for attention to a tracheostomy.Review of Resident #1's medical record revealed one face to face physician visit dated 05/06/2025 from the admission date on 04/11/2025 to discharge date on 11/22/2025. Further review of Resident #1's medical record found no other documentation of a face to face physician visit with Resident #1.During an interview on 01/06/2026 at 3:18 p.m. S1 DON (Director of Nursing) confirmed Resident #1 only had one face to face physician visit from 04/11/2025 to 11/22/2025. S1 DON acknowledged a face to face physician visit should have been done every 60 days thereafter the initial visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure oral care was provided for 1(#2) of 3 sampled residents.Findings:Review of Resident #2's record revealed an initial admission date of 02/04/2025 with the following diagnoses in part, other sequelae of cerebral infarction, acute respiratory failure with hypoxia, aphasia, encounter for attention to tracheostomy and encounter for attention to gastrostomy.Review of Resident #2's care plan revealed in part: ADL self-care performance deficit related to a diagnosis of cardio vascular accident and respiratory failure with hypoxia. Further review of Resident #2's care plan revealed interventions which included oral care routine in the morning and at night: Brush teeth, clean gums with toothette and rinse mouth with wash.Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed in part, BIMS (Brief Interview of Mental Status) score of 00, indicating severe cognitive impairment. Further review of functional abilities revealed Resident #2 was dependent on staff for oral hygiene.An observation on 01/06/2026 at 8:07 a.m. revealed Resident #2 with a tracheostomy and her lips covered with white debris. During an interview on 01/06/2026 at 8:21 a.m. S2 RT (Respiratory Therapist) acknowledged the white debris on Resident #2's mouth and oral care was needed. S2 RT further reported the CNAs (Certified Nursing Assistant) are responsible for providing oral care to residents and oral care should have been provided to Resident #2.During an interview on 01/06/2026 at 8:32 a.m. S5 LPN (Licensed Practical Nurse) reported she took care of Resident #2 and Resident #2 did not received oral care yesterday (01/05/2026) and was not sure how often CNAs provide oral care. During an interview on 01/06/2026 at 8:34 a.m. S3 CNA, reported she did not provide oral care because the Respiratory Therapist provided oral care to Resident #2. During an interview on 01/06/2026 at 8:38 a.m. S4 ADON (Assistant Director of Nursing) reported Resident #2 should have received oral care every shift and oral care was in Resident #2's plan of care. S4 ADON confirmed the responsibility of CNAs was to provide oral care to residents every shift and Resident #2 should have received oral care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the provider failed to ensure ADL (Activities of Daily Living) Care was completed for 1 (Resident #1) of 3 sampled residents. Findings:Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and was discharged from the facility on 09/02/2025. Resident #1's diagnoses included Multiple Sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness and agitation, polyosteoarthrits, Schizoaffective disorder, bipolar type. Review of Resident #1's Minimum Data Set, dated [DATE] revealed Resident #1 required substantial/maximal assistance for bathing. The definition of substantial/maximal assistance meant the helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Resident #1's BIMS (Brief Interview for Mental Status) score was 15, which would indicate the resident was cognitively intact. Review of Resident #1's Documentation Survey Report for August 2025 revealed no documentation of evidence of bathing being completed on August 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st, of 2025. On the days there was no documentation of evidence of bathing being completed Resident #1 had code 97 entered on the Documentation Survey Report which indicated not applicable.During a telephone interview on 09/22/2025 at 12:50 p.m., Resident #1 reported that she did not receive a bath for two weeks. During an interview on 09/23/2025 at 2:45 p.m., S1DON (Director of Nursing) verified Resident #1 did not receive a bath on August 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30, and 31st of 2025. She further reported code 97 meant not applicable. During an interview on 9/23/25 at 3:30 p.m., S2Corporate Nurse reported the code 97 means not applicable, and that code should not be used. S2Corporate Nurse verified that code 97 should be the same as not getting bathed. During an interview on 09/25/2025 at 11:55 a.m., S3CNA (Certified Nursing Assistant) reported Resident #1 required assistance for bathing. During an interview on 09/25/2025 at 12:20 p.m., S4CNA reported Resident #1 required assistance for bathing. During an interview with observation on 09/25/2025 at 1:15 p.m., S5CNA reported they use a Kiosk for documenting all care that resident's receive. Observation with S5CNA revealed several different options to select for bathing according to resident's needs. Further review revealed an option of Not Applicable. During an interview on 09/25/2025 at 1:40 p.m. S1DON verified the staff uses the Kiosk to document what they have completed for each resident they are responsible for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation for 1 (#1) of 3 sampled residents reviewed to ensure safe and orderly transfer or discharge from the facility. The facility failed to provide Resident #1 with a discharge instruction form.
Findings:
Review of Facility's - Transfer or Discharge, Facility Initiated (2001) Policy and Procedure: Policy Statement - Once admitted to the facility .require resident/representative notification and orientation, and documentation as specified in this policy.
Orientation for Transfer or Discharge (Planned) - 1. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility.
Review of Resident #1's medical records revealed an admit date of 01/30/2025 and discharge date of 02/20/2025 with the following diagnoses, including in part: acute respiratory failure with hypoxia, other pneumonia/unspecified organism, other cerebral infarction, acute kidney failure/unspecified, acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral, essential (primary) hypertension, type 2 diabetes mellitus with other specified complication, heart failure/unspecified and encounter for attention to colostomy.
Review of Resident #1's Progress Notes revealed the following entry on 02/20/25 16:54 - ambulance picked up resident at 4:05 p.m. phoned daughter to inform her that resident was on her way home .
Review of Resident #1's medical record failed to reveal documentation resident or responsible party was provided discharge instructions.
During a telephone interview on 03/25/2025 at 8:49 a.m. S8 Complainant reported the resident did not receive any discharge instructions to include a follow-up appointment prior to or upon discharge.
During an interview on 03/25/2025 at 10:55 a.m. S1 Administrator acknowledged a discharge instruction form was not provided to Resident #1 or her responsible party upon discharge on [DATE] and should have been.
During an interview on 03/25/2025 at 2:00 p.m. S4 LPN (Licensed Practical Nurse) acknowledged she did not complete a discharge instruction form for Resident #1 when she was discharged home on [DATE] and should have.
During an interview on 03/26/2025 at 10:35 a.m. S2 DON (Director of Nursing) acknowledged Resident #1 did not receive a discharge instruction form on 02/20/2025 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure 1 (#2) out of 3 sampled residents reviewed received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers. The facility failed to:
1. Complete a head to toe assessment prior to discharge to hospital, and
2. Notify staff of change in skin status/injury.
Findings:
Review of Facility's Skin Integrity Prevention and Treatment Program Policy and Procedure revised 09/2024: Standard: All residents will be assessed for the risk of pressure development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Procedure: All residents will have a head to toe assessment (skin check) completed on a weekly basis by the licensed nurse. 5. If a pressure injury/skin breakdown is identified, the following will be done - a. if pressure injury - complete new wound evaluation/assessment. d. notify RP or family .
Review of Facility's Investigation Report (259708) for Resident #2 revealed: Discovered: 01/31/2025 at 12:07 p.m. Witness Statement: S5 CNA (Certified Nursing Assistant) - I changed resident on 01/30/2025 and noticed a red spot on her bottom and a blister. I was rushing to get her ready to be sent to the emergency room and I forgot to report it to the nurse.
Review of Resident #2's medical records revealed an admit date of 10/06/2022 with the following diagnoses, including in part: type 2 diabetes mellitus without complications, unspecified open wound/right ankle/initial encounter, and dementia in other diseases classified elsewhere/unspecified severity with other behavioral disturbance.
Review of Resident #2's comprehensive care plan revealed: Potential for impairment of my skin integrity - report abnormalities .
During an interview on 03/26/2025 at 9:40 a.m. S6 LPN (Licensed Practical Nurse) reported S5 CNA did not inform her of any skin issues for Resident #2. S6 LPN acknowledged a head to toe assessment was not completed on Resident #1 prior to being discharged from the facility and should have been.
During an interview on 03/26/2025 at 10:35 a.m. S2 DON (Director of Nursing) acknowledged S6 LPN did not complete a head to toe assessment on Resident #2 prior to her discharge to the hospital on [DATE] and should have. S2 DON further acknowledged S5 CNA did not report Resident #2's new skin injury discovered on 01/30/2025 to the nurse and should have.

Based on record reviews and interviews, the facility failed to ensure 1 (#1) of 13 sampled residents reviewed was free from unnecessary drugs. The facility failed to monitor Resident #1's edema while receiving a diuretic.
Findings:
Review of Resident #1's medical records revealed an admit date of 01/30/2025 with the following diagnoses, including in part: acute respiratory failure with hypoxia, other pneumonia/unspecified organism, acute kidney failure/unspecified, and heart failure/unspecified.
Review of Resident #1's comprehensive care plan revealed: resident has hypertension - monitor for and document any edema/notify Medical Director.
Review of Resident #1's Physician's orders revealed an order dated 01/30/2025 for Furosemide oral tablet 40mg (milligram); give 1 tablet by mouth two times a day related to edema.
Review of Resident #1's February MAR (Medication Administration Record) failed to reveal edema was monitored while receiving diuretic.
During an interview on 03/25/2025 at 2:10 p.m. S7 LPN (Licensed Practical Nurse) while reviewing Resident #1's February MAR, acknowledged there was no monitoring for edema. S7 LPN confirmed Resident #1 was receiving a diuretic.
During an interview on 03/25/2025 at 2:35 p.m. S3 Corporate Nurse acknowledged Resident #1 was not monitored for edema while receiving a diuretic for the month of February and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers 1 (#1) of 3 (#1, #2, #3) residents reviewed for pressure ulcers. The facility failed to have documented evidence of turning and repositioning resident #1 to help prevent pressure ulcers.
Findings:
Review of the facility`s policy and procedure related to pressure injury prevention with a revision date of 09/2024 revealed in part:
3. The following is a list of commonly used interventions to possibly prevent the development of pressure injuries-
a. Turning and positioning to include but not limited to: during and after care- activities of daily living, skin audits/dressing changes, transfers between surfaces and as needed.
Record review for resident #1 revealed an admission date of 10/13/2023 with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, non-traumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia. Resident#1 also had a right hip fracture and right wrist fracture diagnosis added on 08/12/2024.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment.
Review of the active care plan for resident #1 revealed it was initiated on 10/24/2023 which included the following: The resident has bowel and bladder incontinence. Goal: resident will have intact skin and be free from odors. Interventions: incontinent care as needed, skin checks weekly by licensed vocational nurse or treatment nurse, turn and reposition every 2 hours. The plan of care further revealed resident #1 required 2 person assistance for bed mobility after re-admission to the facility on [DATE].
On 10/08/2024 at 2:49 p.m., an interview with S4Registered Nurse (RN) (Wound Care Nurse) revealed she assessed resident #1 on re-admission from the hospital to the facility on [DATE] and she had no pressure ulcer to her sacrum. S4RN reported a Certified Nursing Assistant (CNA) reported an abnormal area to resident #1`s sacrum on 08/15/2024. S4RN completed a wound assessment on 08/15/2024. The wound was assessed to be a facility acquired stage 2 pressure ulcer to the sacrum.
Record review revealed there was no documented evidence of the nursing staff turning and repositioning resident #1 every 2 hours on 08/13/2024 for the morning shift (6 a.m.- 2 p.m.) and the evening shift (2 p.m.- 10 p.m.) and on 08/14/2024 for the evening shift (2 p.m.-10 p.m.) and the night shift (10 p.m.- 6 a.m.) as directed by the plan of care.
On 10/08/2024 at 11:25 a.m., an interview with S3Director of Nursing confirmed there was no documented evidence of resident #1 being turned every 2 hours on 08/13/2024 for morning shift (6 a.m.- 2 p.m.) and evening shift 2 p.m.-10 p.m.) and on 08/14/2024 for the evening shift (2 p.m.-10 p.m.) and the night shift (10 p.m.-6 a.m.) as directed by the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care to assist resident safety and maintain the highest practical physical, mental, and psychological well-being of each resident for 1 (#2) of 3 (#2, #4, and #5) residents sampled for accidents.
The facility`s failed practice was evidenced by a Certified Nurse Aide's (CNA) failure to follow the facility's Incident/Accident policy and procedure when resident #2 was found on the floor on 08/06/2024.
Findings:
Review of the Policy for Resident Incident and Visitor Accident Report, revised 07/23/2018, reviewed June 2024, revealed the following, in part:
B. Resident Incidents/Accidents:
1. If you witness an incident/accident, you must:
-Immediately summon help
-DO NOT move the resident until he/she has been assessed by a licensed nurse
Review of the record revealed resident#2 had an admission date of 10/13/2023 with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia.
Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living.
Review of resident #2's current care plan dated 10/24/2023 revealed resident#2 was at risk for falls with the following interventions in place prior to the fall on 08/06/2024 as follows: anticipate and meet resident's needs, be sure call light is within reach and encourage resident to use it for assistance as needed, provide prompt response to all requests for assistance, ensure resident wearing appropriate footwear when ambulating or mobilizing in wheelchair.
Review of the incident report for resident #2 dated 08/06/2024 at 12:24 a.m. revealed S4Licensed Practical Nurse (LPN) was notified by S5CNA that she heard a thump and a door slam and she found resident #2 lying on the floor in her room.
A telephone interview on 08/27/2024 at 8:55 a.m. with S5CNA revealed she worked on 08/06/2024 on the 10:00 p.m.-6:00 a.m. shift, and worked with resident #2. S5CNA reported about midnight she heard a thump and a door slam and she went to resident #2's room and found her lying on the floor on her stomach with her head facing the door. S5CNA reported she assisted resident #2 back into the bed, and then notified S4LPN of resident #2 being on the floor.
A telephone interview on 08/26/2024 at 12:40 p.m. with S4LPN revealed she was notified on 08/06/2024 by S5CNA that resident #2 had fallen in her room. S4LPN reported when she was notified she went to assess the resident and the resident was in the bed. S4LPN reported that during the assessment of resident #2, the resident was moaning and had facial grimacing with touching or movement of the right leg. S4LPN reported she notified the resident's physician and an order for a x-ray to the right hip and the right leg was obtained.
An interview on 08/28/2024 at 10:15 a.m. S3Director of Nursing (DON) confirmed that S5CNA should not have moved resident #2 back to the bed on 08/06/2024 when she found the resident on the floor. S3DON confirmed S5CNA should have notified S4LPN of the fall immediately, and S5CNA did not follow the facility's policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#2) of 3 (#2, #4, and #5) residents reviewed for accidents. The facility failed to ensure fall risk assessments were completed quarterly, specific interventions were implemented based on the results of the risk assessments, and careplan interventions were implemented on readmission on [DATE].
Findings:
Review of the facility's Fall Prevention Program Policy and Procedure, last revision dated 06/10/2024, policy and procedure revealed in part the following:
Policy:
All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls, and minimize falls resulting in significant injury.
A. Procedure
1. All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall and upon significant change in condition.
2. Residents identified at being at risk will have interventions identified in their plan of care to minimize falls.
4. The resident's plan of care will be updated to reflect risk for falls, and appropriate interventions.
Review of the record revealed resident#2 had an admission date of 10/13/2023 with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia.
Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living.
Review of resident #2's current care plan dated 10/24/2023 revealed the resident was at risk for falls with the following interventions in place prior to the fall on 08/06/2024 as follows: anticipate and meet resident's needs, be sure call light is within reach and encourage resident to use it for assistance as needed, provide prompt response to all requests for assistance, ensure resident wearing appropriate footwear when ambulating or mobilizing in wheelchair. Further review of the care plan revealed an actual fall with injury on 08/06/2024 (fracture proximal right femur) and interventions dated 08/08/2024 were to visit resident often to ensure location, provide visual/verbal cueing as needed to ensure safety.
Review of the facility reported incident for resident #2 dated 08/06/2024 revealed resident #2 had a fall at 12:17 a.m. on 08/06/2024. Further review revealed resident #2 had moaning and facial grimacing to her right leg during the assessment by S4Licensed Practical Nurse (LPN). S4LPN notified the physician of the findings and the physician ordered an x-ray of her right leg and right hip. S4LPN notified mobile x-ray, and they performed x-rays at 8:00 a.m. on 08/06/2024. S6LPN was notified of the results of the x-ray including a right femur fracture on 08/06/2024 at 9:55 a.m.
Review of the record revealed no documented evidence the facility completed a fall risk assessment for resident #2 quarterly on 05/23/2024.
Review of resident #2's record revealed a fall risk assessment was completed on 04/11/2024 and resident #2 was assessed to be high risk for falls. Further review of the record revealed a fall risk assessment was completed on 08/06/2024 and resident #2 was assessed to be at moderate risk for falls.
An interview on 08/27/2024 at 10:45 a.m. with S2Corporate Nurse revealed the facility completes fall risk assessments on admit, readmit, with significant change, and with each fall. S2Corporate Nurse revealed resident #2 was assessed to be high risk for falls. S2Corporate Nurse reported the facility does not implement specific interventions for residents at risk for falls.
An interview on 08/27/2024 at 12:45 p.m. with S1Administrator confirmed specific interventions are not implemented when residents are assessed to be at risk for falls.
An interview on 08/28/2024 at 10:20 a.m. with S2Corporate Nurse confirmed the facility did not have documented evidence of interventions including - visit resident often to ensure location or provide visual/verbal cueing as needed to ensure safety when resident #2 returned from the hospital on [DATE].
An interview on 08/28/2024 at 4:00 p.m. with S2Corporate Nurse confirmed the fall risk assessment was not completed quarterly on 05/23/2024 for resident #2, confirmed previous fall risk assessment on 04/11/2024 was the last fall risk assessment/evaluation done prior to resident #2's fall on 08/06/2024. S2Corporate Nurse further confirmed the facility did not follow the Policy and Procedure for the Fall Prevention Program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#2) of 5 (#1, #2, #3, #4, and #5) sampled residents.
Findings:
Review of the record revealed resident #2 had an admission date of 10/13/2023 with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia.
Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living.
Review of the Discharge Summary from the hospital dated 08/12/2024 revealed resident #2 was admitted after a fall with a right hip fracture, pneumonia, sepsis, and was found to have a right radius fracture, right wrist fracture, and right hip fracture. Resident#2 had an open reduction internal fixation of right hip surgery on 08/08/2024, and was discharged back to the facility on [DATE].
Review of the current care plan for resident #2 revealed alteration in musculoskeletal status history other displaced fracture of 2nd cervical vertebra sequela dated 10/24/2023. Interventions included - monitor cast to right lower arm, stabilizer with ace bandage to right leg, ankle and toes dated 08/13/2024.
Review of the record revealed no documented evidence the interventions were implemented as stated on the careplan on 08/13/2024.
An interview on 08/28/2024 at 12:00 p.m. with S2Corporate Nurse confirmed the facility failed to implement the following interventions listed on resident #2's care plan including monitoring of the cast to the right lower arm, and a stabilizer with ace bandage to the right leg, ankles, and toes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state agency for 1 (#2) of 2 (#1 and #2) residents sampled with facility incident reports.
Findings:
Review of the Abuse Prohibition Policy and Procedure with revision date of 05/17/2024 revealed the following, in part:
Reporting/Response:
2.) The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within 2 hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.
Review of the record for resident #2 revealed an admission date of 10/13/2023 with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage without loss of consciousness, contusion and laceration of cerebrum, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia.
Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living.
Review of the facility reported incident for resident #2 dated 08/06/2024 revealed resident #2 had a fall at 12:17 a.m. on 08/06/2024. Further review revealed resident #2 had moaning and facial grimacing to her right leg during the assessment by S4Licensed Practical Nurse (LPN). S4 LPN notified the physician of the findings and physician ordered an x-ray of her right leg and right hip. S4LPN notified mobile x-ray, and they performed x-rays at 8:00 a.m. on 08/06/2024. S6LPN was notified of results of x-ray including a right femur fracture on 08/06/2024 at 9:55 a.m. S6LPN notified S1Administrator on 08/06/2024 at 10:00 a.m. of resident #2 having a right femur fracture from her fall on 08/06/2024.
Review of resident #2's right femur 2 view x-ray dated 08/06/2024 revealed an acute complex impacted fracture proximal right femur.
An interview on 08/28/2024 at 9:40 a.m. with S1Administrator revealed she was notified on 08/06/2024 at 10:00 a.m. that resident #2 had a fall on 08/06/2024 around 12:15 a.m. and the portable x-ray results revealed resident had a right femur fracture. S1Administrator revealed she entered the facility reported incident to state office on 08/06/2024 at 10:16 p.m. for resident #2. S1Administrator confirmed she should have reported to the state office within 2 hours of notification for resident #2's injury of unknown source with serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 (#102,#118) of 3 (#10, #102,#118) residents reviewed for position and mobility. The facility failed to apply splints for Resident #102 and Resident #118 as ordered.
Resident #102
Review of Resident #102's Medical Records revealed an admit date of 10/12/2023 with the following diagnoses, in part: anoxic brain damage/not elsewhere classified, muscle wasting and atrophy/right upper arm/left upper arm, contracture of muscle, and personal history of sudden cardiac arrest.
Review of Resident #102's MDS (Minimum Data Set) assessment dated [DATE] revealed Section G Functional Status - total dependence/2 person - bed mobility, toilet use, eating, and transfer.
Review of Resident #102's Physician's Orders revealed orders dated 05/03/2024 for resident to receive restorative nurse program seven days per week for splinting to bilateral hands with roll resting hand splints, on in a.m. and off in the p.m. with skin checks before and after use related to weakness and decreased mobility secondary to anoxic brain injury.
Review of Resident #102's May 2024 Documentation Report (flowsheet) failed to reveal resting hand splints were placed on Resident #102 on May 4, 5, 7-10, 13 and 14th.
Observation on 05/13/24 at 9:00 a.m. revealed Resident #102 with a rolled up washcloth in the left hand and none in the right hand.
Observation on 05/13/24 at 2:16 p.m. revealed Resident #102 with a rolled up washcloth in the left hand and none in the right hand. No other splints noted.
Observation on 05/14/24 at 11:00 a.m. revealed Resident #102 with a rolled up washcloth in the left hand and none in the right hand. No other splints noted.
Observation on 05/15/2024 at 9:20 a.m. revealed Resident #102 lying in bed with heel protectors on and splints to both arms. Resident positioned on side.
During an interview on 05/15/2024 at 2:20 p.m. S2 Corporate Nurse acknowledged Resident #102's splints were supposed to be placed daily in the a.m. and removed in the p.m. and they were not.
Resident #118
Review of Resident #118's Medical Records revealed an admit date of 03/18/2024 with the following diagnoses, in part: Parkinson's disease, acute and chronic respiratory failure with hypoxia, muscle weakness, muscle wasting and atrophy to the right and left upper arm, encounter for attention to tracheostomy, dependence on respirator status, and other secondary parkinsonism.
Review of Resident #118's MDS assessment dated [DATE] revealed Section GG: Functional abilities - upper and lower impairment to both sides and was dependent on dressing, undressing and hygiene.
Review of Resident #118's Physician Orders dated 05/03/2025 revealed resident to receive restorative nurse program 7 days per week for splinting with resting hand splint to right hand with skin checks before and after use, on in the morning and off in the afternoon.
Review of Resident #118's May 2024 Documentation Report (flowsheet) failed to reveal Resident #118's resting right hand splint was placed on May 4, 5, 7-12, and 14th.
An observation on 05/13/2024 at 9:00 a.m. revealed Resident #118 did not have on hand splints.
An observation on 05/13/2024 at 2:11 p.m. revealed Resident #118 did not have on hand splints.
An observation on 05/14/2024 at 12:30 p.m. revealed Resident #118 did not have on hand splints.
During an interview on 05/14/2024 at 12:40 p.m., S11 LPN (Licensed Practical Nurse) reported Resident #118 got restorative services and hand splint should be applied in the morning and off in the evening. S11 LPN further confirmed Resident #118's right hand splint should be on his hand now and is not.
During an interview on 05/15/2024 at 10:38 a.m., S2 Corporate Nurse reviewed Resident #118's clinical record and confirmed there was no documentation of the right hand splint being placed and removed from Resident #118's on the May 2024 flowsheet on the following dates May 4, 5, 7-12, and 14th.

Based on record review, observation, and interviews the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding by failing to change enteral feeding container at appropriate interval for 1 (#37) out of 3 (#37, #42, #67) residents reviewed for tube feedings.
Findings:
Review of medical diagnosis revealed the following:
Cerebral infarction
Facial weakness from cerebrovascular accident
Dysphagia
Lack of coordination
Unspecified dementia
Review of resident #37's physician's orders revealed an order for Enteral feeding: every night shift give Jevity 1.5 or equivalent formula at 60 cc (cubic centemeter) per peg tube (1080 calories, 46 grams protein and 1656 cc fluid) order dated 04/27/2023.
An observation on 05/13/2024 at 8:30 a.m. revealed peg tube feeding tubing and enteral feeding Jevity 1.5 were dated 05/09/2024.
During and interview on 05/13/2024 at 9:00 a.m., S4 LPN (Licensed Practical Nurse) acknowledged resident #37's enteral feeding was dated 05/09/2024 and should have been changed every 24 hours.
During an interview on 05/13/2024 at 1:30 p.m., S2 Corporate Nurse acknowledged resident #37's enteral feeding was dated 05/09/2024 and should be changed every 24 hours.
During an interview on 05/15/2024 at 9:50 a.m., S3 ADON (Assistant Director of Nursing) acknowledged enteral tube feeding should be changed every 24 hours.

Based on record review and interview, the facility failed to ensure a performance review had been completed at least every 12 months for 3 (S5CNA [Certified Nursing Assistant], S6CNA, S7CNA) of 5 (S5CNA, S6CNA, S7CNA, S8CNA, S10CNA) personnel records reviewed.
Findings:
Review of S5CNA's personnel records revealed a hire date of 08/09/2022. Further review of S5CNA's personnel records failed to reveal evidence that a performance review had been conducted every 12 months.
Review of S6CNA's personnel records revealed a hire date of 02/23/2023. Further review of S6CNA's personnel records failed to reveal evidence that a performance review had been conducted every 12 months.
Review of S7CNA's personnel records revealed a hire date of 02/28/2023. Further review of S7CNA's personnel records failed to reveal evidence that a performance review had been conducted every 12 months.
During an interview on 05/15/2024 at 4:40 p.m. S1Administrator reported she could not find evidence that performance reviews had been conducted every 12 months for S5CNA, S6CNA, or S7CNA.

Based on observation and interview the facility failed to ensure garbage was disposed properly.
Findings:
Observation on 05/13/2024 at 8:40 a.m. with S13 Maintenance Director revealed multiple trash bags and loose trash were scattered all around the perimeter of the dumpster outside of the facility. Lids to the dumpster were not closed.
During an interview on 05/13/24 at 8:41 a.m. S13 Maintenance Director verified the trash should not be outside of the dumpster and dumpster lids should be closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #98
Based on record review and interviews the facility failed ensure a discharge assessment was completed for 1 (Resident #98) of 4 (Residents #6, #98, #103, #106) residents reviewed for hospitalizations.
Findings:
Record review of Resident #98's progress notes from 04/24/2024 revealed the following:
General Nurse's Note- Writer notified by Wound Care NP (Nurse Practitioner) that Resident #98 needs to go to ER (Emergency Room) to be evaluated at this time due to worsened wounds and abnormal vital signs .
General Nurse's Note- Ambulance arrived and transported Resident #98 to acute hospital .
Record review of Resident #98's MDS (Minimum Data Set) failed to reveal a discharge assessment was completed after Resident #98 was sent to an acute hospital on [DATE].
During an interview on 05/14/2024 at 4:30 p.m. S12 MDS RN (Registered Nurse) verified she did not do a discharge assessment for Resident # 98 when he was discharged to the hospital on [DATE].
During an interview on 05/14/2024 at 4:35 p.m. S2 Corporate Nurse verified a discharge MDS should have been completed by S12 MDS RN when Resident # 98 was discharged to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to accommodate the needs of 1 (#38) of 39 sampled residents. The facility failed to ensure Resident #38 had a call light within reach.
Findings:
Review of Resident #38's medical record revealed Resident #38 was admitted to the facility on [DATE] and had diagnoses that included, in part, Alzheimer's disease unspecified, essential (primary) hypertension, chronic atrial fibrillation, other seizures, non-traumatic intracerebral hemorrhage, cognitive communication deficit, major depressive disorder, and unspecified psychosis.
Review of Resident #38's 02/06/2024 Annual MDS (Minimum Data Set) revealed Resident #38 had a BIMS (Brief Interview Mental Status) of 09 which indicated moderate cognitive impairment.
Review of Resident #38's Care Plan revealed Resident #38 had an alteration in musculoskeletal status including interventions, in part, anticipate and meet needs and be sure call light is within reach and respond promptly.
Observation on 05/13/2024 at 9:15 a.m. revealed Resident #38's call light was on floor behind the bed and not within Resident #38's reach.
During an interview on 05/13/2024 at 11:25 a.m. Resident #38 reported he could not reach his call light.
Observation on 05/13/2024 at 11:26 a.m. revealed Resident #38's call light was on floor behind the bed and not within Resident #38's reach.
During an interview on 05/13/2024 at 11:26 a.m. S9 CNA (Certified Nursing Assistant) observed the call light behind Resident #38's bed and confirmed Resident #38's call light was not in Resident #38's reach and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents out of a total sample of 5 received treatment and care in accordance with professional standards of practice by:
1.
Failing to provide needed care and services when a resident's physical condition changed, and
2.
Failing to notify the resident's attending physician of emergency transfer.
Findings:
Review of the facility's Transfer or Discharge, Emergency Policy revealed in part: Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s).
Policy Interpretation and Implementation
4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's attending physician.
During an interview on [DATE] at 6:14 p.m. resident #1's RP (responsible party) reported when she arrived to the facility [DATE] 2:00 between 2:00 - 3:00 p.m. she found resident #1 wet, sweaty, breathing hard and unresponsive. Resident #1's RP reported she immediately went to the nurse's station to get the nurse. RP reported the nurse came and took his blood pressure (BP), heart rate and his oxygen level on his finger. RP reported the nurse informed her resident #1's heart rate was low and his oxygen level had dropped. RP reported she requested the nurse send resident #1 to the emergency room and the nurse refused.
During an interview on [DATE] at 10:30 a.m. resident #1's roommate, resident #5{according to the most recent MDS (minimum data set) a BIMS (brief interview of mental status) Score 15 - cognitive intact} reported when resident #1's responsible party came to visit she was unable to resident #1 to answer her. Resident #5 further reported the daughter asked him to call resident #1's name and he was unable get him to answer. Resident #5 reported resident #1's daughter went to the nurse's station and got the nurse to come down and see about him. Resident #5 reported the first shift did nothing for resident #1. Resident #5 further reported resident #1 was not sent to the hospital until the second shift got there. Resident #5 reported he thought resident #1 should have been sent out when he had got weak and stopped talking and eating. Resident #5 reported it was just not right.
During an interview on [DATE] at 12:45 p.m. S4 LPN (Licensed Practical Nurse) reported she did not have resident #1. S4 LPN reported she cannot go in this room. S4 LPN reported resident #1's RP came to the nurse's station and asked a nurse to come and check on resident #1. S4 LPN reported S5 LPN went to the room to get resident #1's vital signs. S4 LPN reported she did not see anything abnormal about resident #1 or his vital signs. Surveyor asked S4 LPN how could she evaluate resident #1 and she did not go in the room. S4 LPN reported she peeped in the room. At this time S4 LPN became verbally augmentative and surveyor ended the conversation.
During an interview on [DATE] at 1:15 p.m. S5 LPN reported resident #1's daughter came to the nurse's station and asked that he be assessed. S5 LPN reported she went to his room and assessed resident #1. S5 LPN reported resident #1 was not her resident, he was S4 LPN's resident and she was not allowed in the room. S5 LPN reported she took resident #1's vital signs. S5 LPN reported she did not remember the vital signs or the assessment and she did not document anything.
Review of resident #1's medical records on [DATE] at 11:30 a.m. with S3 ADON (Assistant Director of Nursing) failed to reveal any documentation of an assessment performed by S5 LPN or S4 LPN for resident #1. S3 ADON confirmed there was only documentation to confirm resident #1 wasn't assessed until the next shift and sent out to the emergency room.
Review of S6 LPN Progress Notes dated [DATE] at 7:22 p.m. revealed she documented evening assessment of resident #1 and yielded a blood pressure of 63/50, pulse of 50, respiration 32 and blood glucose of 192. 7:15 ___ EMT's (emergency medical technician) arrived; 7:18 p.m. Responsible party notified of resident's status; and 7:22 p.m. Resident transferred via stretcher to ______ hospital.
During an interview on [DATE] at 12:30 p.m. S6 LPN reported she obtained vital signs for resident #1 and did an assessment because something about him just did not look normal. S6 LPN reported resident #1's vital signs were abnormal and he was lethargic so she sent him out. S6 LPN reported she did not notify resident #1's physician before she sent him out. S6 LPN denied she notified the resident's attending physician of him being transferred out to the ER (emergency room).
Review of resident #1's Hospital emergency room notes revealed diagnoses of anemia, unspecified hypoglycemia, unspecified hypotension, unspecified sepsis, and unspecified organism. Presentation: [DATE]
19:42 presenting complaint: EMS (emergency medical services) states: EMS called for report of patient having left side facial droop and hypotension of 60/40.
19:42 Acuity: Urgent (3)
Triage Assessment:
19:48 General: Appears malnourished. Plan: Denies pain. At worst, pain level was 2 out of 10 on a pain scale. Neuro: Level consciousness is lethargic, listless, does not follow commands or respond to verbal stimuli. Neuro: Facial droop on left. Cardiovascular: Heart tones present S1 S2 Rhythm is sinus rhythm. Chest pain denied. Respiratory: Breath sounds are clear. GI (gastrointestinal): Reports normal bowel habits. Musculoskeletal: patient BLE (bilateral lower extremities) contracted.
Review of resident #1's Hospital admission History and Physical revealed : Date of Services: [DATE] at 0413
admitted : [DATE]
discharged : [DATE]. 2023 (expired)
Addendum: Pt has been received his 3rd unit of PRBC (pasked red blood cells) with no complication. Nurse at bedside performed digital disimpaction with retrieval of large amount of nonblood bowel movement. Will start patient on bowel movement program.
Chief Complaint: Left side facial droop and low blood pressure.
HPI (history of present illness)/Subjective: Upon arrival to the ED (emergency department), CT (computed topography) head was negative for acute findings. He was noted to be hypotensive with BP 71/49 and tachypneic with RR (respiratory rate) 32. He was started on IVF (intravenous fluids) with mild improvement in his pressure. Lab was significant for increased BUN (blood urea nitrogen)/creat 45/1.7, increased WBC (white blood cell) of 12.5, decreased H/H (hemoglobin/hematocrit) of 4.9/16.8, and increased lactic of 5.2. CXR (chest x-ray) showed left basilar airspace disease suggestive of atelectasis or pneumonia. CT Chest/Abd/pelvis showed no PE (pulmonary embolus), extensive colonic fecal burden, and bibasilar
During an interview on [DATE] at 4:30 p.m. S2 DON (Director of Nursing) acknowledged S4 LPN did not assess resident #1 as requested by his responsible party. S2 DON reported there was no documentation to confirm S4 LPN or S5 LPN working had assessed resident #1 earlier during the day as requested by his responsible party. S2 DON reported documentation revealed resident #1 was not assessed until the evening shift arrived and sent out to the hospital emergency room. S2 DON and S1 Corporate Nurse confirmed there was no documentation of assessment or skill notes to verify an assessment was done for resident #1 prior to the evening shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to thoroughly investigate an allegation of misappropriation of funds/exploitation for 1 (#36) of 3 (#32, #36, #104) sampled residents reviewed for abuse. Findings:
Review of the facility's Abuse Prohibition Policy dated 03/2023 revealed, in part, the facility will thoroughly investigate all alleged violations and take appropriate actions. Procedure for the investigation will include, but is not limited to the following: interviews and or written statements from individuals, (residents, visitors or staff), who may have firsthand knowledge of the incident. Written statements should be in the handwriting of the witness, signed, and dated.
Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of non-traumatic intracerebral hemorrhage, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, psychosis, neuromuscular dysfunction of bladder, convulsions, incomplete C1 - C4 quadriplegia, gastrostomy, tracheostomy, heart failure, hypertension, schizophrenia, and anxiety disorder.
Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #36's BIMS (Brief Interview Mental Status) score was 15 which indicated she was cognitively intact. Further review revealed the resident required two person total assistance with bed mobility, dressing, toilet use, and transfer. The resident required two person extensive assistance with personal hygiene.
An interview with the resident and her husband on 06/05/2023 at 12:15 p.m. revealed about 2 weeks ago she had $105 come up missing. The resident revealed only 2 staff members knew where she hid her coin purse. She reported that she received $125 from her 2 sons for Mother's day, 05/14/2023. The resident reported that her husband noticed the money was missing on Thursday, 05/18/2023. The resident revealed she reported the missing money to her nurse.
An interview with the resident on 06/07/2023 at 9:05 a.m. revealed S6CNA (Certified Nursing Assistant) and S5Hospitality Aide were in her room on Wednesday, 05/17/2023. The resident revealed both staff members knew where she hid her money.
Review of the facility's investigation documentation revealed S6CNA and S5Hospitality Aide were not interviewed about the allegation of misappropriation of funds/exploitation for resident #36.
An interview with S1Administrator on 06/07/2023 at 4:15 p.m. confirmed the facility did not interview S6CNA and S5Hospitality Aide. S1Administrator confirmed the facility did not conduct a thorough investigation.

Based on record review and interviews the facility failed to ensure adequate supervision and assistance was provided to prevent accidents. The facility failed to implement the plan of care for 1(#57) of 4(#27, #57, #102, #104) residents reviewed for accidents.
Findings:
Review of the facility's Incident Log revealed Resident #57 had an unwitnessed fall on 05/18/2023.
Review of Resident #57's admission MDS (Minimum Data Set) dated 04/25/2023 revealed the functional status of the resident required support with two person physical assistance with transfers between surfaces including to or from the bed.
Review of Resident #57's Care Plan dated 04/18/2023 revealed Resident #57 has an ADL (Activities of Daily Living) self-care performance deficit due to a cerebral vascular accident and hemiplegia. As of 04/25/2023, Resident #57 needs 2 persons assistance for bed mobility and transfers. Further review of Resident #57's care plan revealed Resident #57 was at risk for falls.
Review of the Incident Description dated 05/18/2023 revealed S12 CNA (Certified Nursing Assistant) reported while attempting to transfer Resident #57 from the wheelchair to the bed, resident stood up, but it appeared that her legs gave out and Resident #57 started to fall. S12 CNA sat Resident #57 on floor and left the room to get assistance. S12 CNA reported upon re-entering the room, resident was laying on her back.
During an interview on 06/05/2023 at 12:37 p.m., Resident #57's daughter reported Resident #57 had a fall and went to the local hospital to be evaluated. She fell in her room when a staff member was helping her in bed.
During an interview on 06/07/2023 at 11: 14 a.m., S2 DON (Director of Nursing) reported Resident #57 was sent to the local emergency room for an evaluation on 05/18/2023 after a fall. S12 CNA was transferring Resident #57 from the wheelchair to the bed when the resident's leg started to give out and S12 CNA eased Resident #57 to the floor. S12 CNA then left the room to get help. When S12 CNA reentered the room, Resident #57 was on her back on the floor stating she hit her head.
During an interview on 06/07/2023 at 11:25 a.m., S11 PT (Physical Therapist) reported Resident #57 should be a 2 person assist.
During an interview on 06/07/2023 at 11:33 a.m., S9 CNA reported transferring Resident #57 by herself. S9 CNA confirmed she does not get assistance to transfer Resident #57 between surfaces.

Based on observation and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary condition by having a leak in the apple juice concentrate tubing of the drink station. This had the potential to affect 118 residents who received meals from the kitchen.
Findings:
On 06/05/2023 at 11:00 a.m., an observation of the drink station in the kitchen revealed there was old clear tape wrapped around the tubing about five inches below where it connects to the apple juice concentrate bag. The apple juice concentrate bag was inside the manufactures cardboard box that was sitting on a stainless steel shelf under the drink station. Further observation revealed apple juice concentrate had pooled on the stainless steel shelf and also on the tile floor in front of the stainless steel shelf.
On 06/05/2023 at 12:35 p.m., interview with S3 Dietary Manager revealed she was aware of the leak in the apple juice concentrate tubing yesterday, but thought it had stopped leaking. S3 Dietary Manager confirmed that the apple juice concentrate tubing was still leaking and needed to be fixed.
On 06/05/2023 at 12:45 p.m., surveyor informed S1 Administrator of the issue with the apple juice concentrate tubing leaking onto the stainless shelf and onto the tile floor in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure alleged violations of abuse and misappropriation of resident property were reported no later than 24 hours to the State Survey Agency for 2 (#32 and #36) of 3 (#32, #36, #104) residents reviewed for abuse. Findings:
Review of the facility's Abuse Prohibition Policy dated 03/2023, in part:
Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Physical abuse includes, hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment.
The facility will thoroughly investigate all alleged violations and take appropriate actions.
The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.
Resident #32
Record review revealed Resident #32 was admitted to the facility 08/16/2013. Resident #32 diagnosis include but not limited to the following: Parkinson's disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, type 2 diabetes mellitus with hyperglycemia, essential hypertension, unspecified convulsions, constipation, muscle wasting and atrophy left upper arm, contracture of left hand, essential tremor, other specified bilateral hearing loss, and presence of external hearing aid.
Review of the quarterly MDS (Minimum Data Set) dated 03/14/2023 revealed Resident #32's BIMS (Brief Interview Mental Status) score 15 which indicated she was cognitively intact. Resident #32 required supervision and set up assistance with ADLS (Activities of Daily Living). Further review revealed she wears hearing aids and had moderate hearing loss.
On 06/05/23 at 03:45 p.m. interview with Resident #32 revealed S7 LPN (Licensed Practical Nurse) pulled the pillow from underneath her head and hit her in the head with the pillow and left the room leaving the door open. Resident #32 reported S7 LPN then returned and pulled the pillow from beneath her head and hit her in the head with the pillow again. Resident #32 reported S7 LPN then returned a 3rd time and pulled the pillow from beneath her head and hit her in the head with the pillow. Resident #32 reported that she could not hear what S7 LPN said because she did not have her hearing aids on at the time. Resident #32 reported that this occurred one evening last week and she notified the S2 DON (Director of Nursing) the next day after it occurred.
Review of the SIMS (Statewide Incident Management System) report revealed the incident was discovered on 05/31/2023 at 10:00 a.m. and entered on 06/01/2023 at 5:11 p.m.
On 06/06/23 at 1:00 p.m. an interview with S2 DON (Director of Nursing) revealed on 05/31/2023 around 9:30 a.m. she was notified by Resident #32 of the incident involving S7LPN hitting her with a pillow multiple times.
On 06/07/23 at 8:40 a.m. an interview with S1 Administrator revealed she was called on 05/31/2023 at 10:00 a.m. and notified of Resident #32's allegation of S7 LPN jerking the pillow from under her head and hitting her in the head with the pillow 3 times. S1 Administrator reported she is responsible and the only one at the facility that able to submit and complete SIMS reports. S1 Administrator reported that they were made aware of the allegation on 05/31/2023 at 10:00 a.m. S1 Administrator agreed that she submitted the information to the State Agency on 06/01/2023 at 5:11 p.m. which was past the 24 hour window of reporting allegations of abuse without serious bodily injury. S1 Administrator confirmed that the SIMS report should have been entered within the 24 hours.
Resident #36
Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of non-traumatic intracerebral hemorrhage, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, psychosis, neuromuscular dysfunction of bladder, convulsions, incomplete C1 - C4 quadriplegia, gastrostomy, tracheostomy, heart failure, hypertension, schizophrenia, and anxiety disorder.
Review of the Minimum Data Set, dated [DATE] revealed the resident was cognitively intact. Further review revealed the resident required two person total assistance with bed mobility, dressing, toilet use, and transfer. The resident required two person extensive assistance with personal hygiene.
An interview with the resident and her husband on 06/05/2023 at 12:15 p.m. revealed about 2 weeks ago she had $105 come up missing. The resident revealed only 2 staff members knew where she hid her coin purse. She reported that she received $125 from her 2 sons for Mother's day, 05/14/2023. The resident reported that her husband noticed the money was missing on Thursday, 05/18/2023. The resident revealed she reported the missing money to her nurse.
Review of the SIMS (State Investigation Management System) Report revealed the incident was discovered on 05/19/2023 at 3:00 p.m. and entered on 05/19/2023 at 8:56PM. Review of a statement dated 05/18/2023 from S10LPN (Licensed Practical Nurse) revealed she went into the resident's room and the resident reported that she had $115 missing out of her purse. S10LPN reported the missing money to her supervisor.
An interview with S1Administrator on 06/07/2023 at 4:50 p.m. confirmed she entered the discovery date as 05/19/2023 and it should have been 05/18/2023. S1Administrator confirmed the SIMS report was initiated later than 24 hours following the discovery of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure adequate supervision was provided for 1 (#72) of 5 (#61, #67, #72, #119, #233) residents reviewed for accidents. The facility failed to conduct an elopement assessment utilizing the Wander Data Collection Tool each quarter for Resident #72, as per facility policy.
Findings:
Review of the facility's Wanderer Management, Monitoring System & Resident Elopement Protocol revealed:
Purpose
-To monitor safety of residents at risk for elopement.
-To provide a system to alert staff that a resident may be attempting to leave the facility.
Policy
-It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.
.
Procedures
Identification & Prevention of Elopement
1. Elopement risk is determined by use of the Wander Data collection tool. The assessment should also include review of the resident's medical and social history. The Wander Data collection tool is to be completed on admission, quarterly, upon change of condition, or post elopement incident.
.
Review of Resident #72's medical Record revealed Resident #72 was initially admitted to facility on 3/8/2012 with a readmission on [DATE] and had diagnoses that included Major Depressive Disorder single episode, anxiety disorder, vascular dementia without behavioral disturbance, atherosclerosis of native arteries of extremities, essential hypertension, other sequelae of cerebral infarction, Epilepsy unspecified intractable with status epilepticus, hemiplegia affecting right dominant side, peripheral vascular disease, unspecified abnormalities of gait and mobility, and insomnia.
Review of Resident #72's medical record revealed an incident on 11/23/2021 in which Resident #72 went out of the facility main entrance front door. Review of medical record further revealed an elopement incident on 12/11/2021 in which Resident #72 left the facility's premises.
Review of Resident #72's medical record failed to reveal an elopement risk assessment utilizing the Wander Data Collection Tool was conducted quarterly, between 4/5/2021 in which Resident #72 had a low risk for wandering and 12/29/2021 in which Resident #72 had a High Risk for Wandering.
During an interview on 5/18/2022 at 2:02pm S2 DON (Director of Nursing) reviewed #72's medical record and reported Resident #72 had not been assessed for elopement risk utilizing the Wander Data Collection Tool between 4/5/2021 and 12/29/2021 and should have been assessed for elopement risk quarterly.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by:
1.) Having food items in the dry pantry that were not labeled with date when opened.
2.) Having food items in the dry pantry that contained insects.
3.) Failing to ensure dishwasher was in proper working order through temperature/chemical check.
This had the potential to affect 89 resident who received trays out of the kitchen as per S11 Dietary Manager.
Findings:
1.)
Review of Food Receiving and Storage policy revealed:
Foods shall be received and stored in a manner that complies with safe food handling practices.
Policy and Interpretation
.
7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in -first out system.
Observation of dry storage area on 5/16/2022 at 9:15am revealed the following items were open and not labeled with any date:
-Large rolling metal bin filled approximately 1/4 full with rice.
-16 ounce bag of Fritos approximately 1/2 full.
-24 ounce bag of lime flavored gelatin approximately1/2 full.
During an interview on 5/16/2022 at 9:15am S11 Dietary Manager observed the metal bin with rice, the open bag of Fritos, and the open bag of lime gelatin and reported they do not have an open date and should have.
2.)
Review of Food Receiving and Storage policy revealed:
Foods shall be received and stored in a manner that complies with safe food handling practices.
Policy and Interpretation
.
5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean.
Observation on 5/16/2022 at 9:40am revealed a large bag of onions in a net type bag on the floor in the dry pantry storage area and insects that appeared to be gnats were flying around the bag of onions.
Observation on 5/17/2022 at 3:20pm revealed S11 Dietary Manager open a sealed plastic bin of onions in the dry pantry area and multiple small insects that appeared to be gnats flew out.
During an interview on 5/17/2022 at 3:20pm S11 Dietary Manager indicated the large bag of onions in the dry pantry had been received last Friday (5/13/2022) and had been placed in the sealed plastic bin earlier today and should not have been discarded due to the gnats in them
3.)
Review of Sanitization Policy revealed:
The food service area shall be maintained in a clean and sanitary manner.
Policy Interpretation and Implementation
.
8. Dishwashing machines must be operated using the following specifications:
.
Low-Temperature Dishwasher (Chemical Sanitization)
a. Wash temperature (120 degrees Fahrenheit);
b. Final rinse with 50 parts per million (PPM) hypochlorite (chlorine) for at least 10 seconds.
During an interview on 5/17/2022 at 10:15am S11 Dietary Manager performed chemical check of dishwashing machine and reported the chemical strip check revealed less than 50PPM and should be 50 PPM.
Review of the May 2022 Dishwasher temperature/chemical checks log failed to reveal dishwasher temperature/chemical check had been conducted for the breakfast meal dishes on 5/17/2022.
During an interview on 5/17/2022 at 10:25am S11 Dietary manager observed the May 2022 dishwasher temperature/chemical checks and reported the dishwasher temperature/chemical checks for the breakfast dishes on 5/17/2022 had not been done and should be done with each meals' dishes.

Based on observation, record review and interviews, the facility failed to ensure a resident being fed by enteral means received the appropriate treatment and services by failing to label a resident's feeding bag properly according to facility policy for 2 (#21, #55) of 2 (#21, #55) resident's reviewed for tube feeding.
Findings:
Review of Facility Policy Enteral tube feeding via continuous pump revealed in part:
-Initiate Feeding:
--5. ON the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.
Resident #21:
Observation on 5/16/22 at 11:30 am revealed resident #21's Isosource enteral feeding infusing per pump at 60 milliliters per hour. Further observation of the Isosource feeding bag label failed to reveal documentation of the initials of the nurse that hung/administered the feeding.
Resident #21's medical record revealed an admit date of 2/17/2022 with diagnoses that included, in part, cardiac arrest, acute and chronic respiratory failure with hypoxia, convulsions, cerebral edema, gastrostomy, tracheostomy and ventilator dependence status.
Review of Resident #21's current physician orders revealed:
-4/20/202 enteral feed every shift Isosource 1.5 at 60 milliliters (ml)/hour (hr) for 22 hours per day.
Review of May 2022 Medication Administration Record for resident #21 revealed documentation for enteral feedings of Isosource at 60 milliliters per hour daily as ordered.
During an interview on 5/16/22 at 3:00 pm S5 ADON (Assistant Director of Nursing) CVU (Critical Vent Unit) acknowledged all formula/feeding bag labels should contain the date, time and initials of the person administering the medication and resident #21's feeding formula label did not contain the initials of the nurse that hung/administered the feeding.
Resident #55:
Observation on 5/16/22 at 10:30 am revealed resident #55's Isosource enteral feeding infusing per pump at 55 milliliters per hour. Further observation of the Isosource feeding bag label failed to reveal documentation of the date and initials of the nurse that hung/administered the feeding.
Review of resident #55's medical record revealed an admit date of 7/26/2021 with diagnoses that included, in part diffuse traumatic brain injury with loss of consciousness of unspecified duration, acute and chronic respiratory failure with hypoxia, neuromuscular dysfunction of bladder, joint derangement, tracheostomy, and gastrostomy.
Review of resident #55's current physician orders revealed:
--4/1/22 enteral feed every shift Isosource 1.5 at 55 cubic centimeter per hour per peg (percutaneous endoscopic gastrostomy) tube for 22 hours/day.
Review of resident #55's May 2022 Medication Administration record revealed documentation of enteral feedings administered daily as ordered by the physician.
During an interview on 5/16/22 at 3:00 pm S5 ADON CVU acknowledged all formula/feeding bag labels should contain the date, time and initials of the person administering the medication and resident #55's feeding formula bag label did not contain the date or initials of the nurse that hung/administered the feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good grooming, and personal hygiene for 3 (#95, #101, #234) of 3 (#95, #101, #234) residents observed for ADL care in a total sample of 49 residents. The facility failed to (1) ensure Resident # 101 and Resident #234's fingernails were trimmed and clean, and (2) Resident #95's face was clean.
Findings:
Resident #101
Review of resident #101's medical record revealed a diagnosis of but not limited to, Multiple Schlerosis.
Observation on 5/16/2022 at 8:30 am revealed resident 101 had long dirty finger nails on his right hand with a dark brown substance underneath nail beds.
Observation on 5/18/2022 at 8:50 am with S10 LPN revealed resident 101 had long dirty finger nails on his right hand with a dark brown substance underneath nail beds
Review of resident #101's Minimum Data Set, dated [DATE] revealed resident #101 was assessed to require total one person physical assist with personal hygiene.
Review of resident #101's Comprehensive Care Plan revealed the following problem and approaches: resident has an ADL self care performance deficit with approaches for nail care weekly.
During an interview on 5/18/2022 at 8:50 am S10 LPN confirmed the certified nuring assistants should have done nail care and trimmed resident #101's nails when resident #51 was bathed.
.
Resident #95:
Observation on 5/16/22 at 11:00 am revealed Resident #95 lying in bed with dry cracked and peeling lips and areas of dry blood with dried bloody drool coming from the left corner of her mouth down to her neck. Resident #95 was also noted with a dried white streak of tears from the outer corner of her left eye down her cheek.
Review of Resident #95's medical record revealed an admit date on 9/14/2021 with diagnoses that include in part cerebral infarction, acute and chronic respiratory failure with hypoxia, type 2 diabetes, dysphagia following cerebrovascular disease, essential hypertension, epilepsy, tracheostomy, gastrostomy, anxiety disorder, contracture right hand, schizoaffective disorder bipolar type and history of malignant neoplasm of breast.
Review of Resident #95's comprehensive care plan revealed Resident #95 required total assistance with ADL care due to her mental and physical deficits.
During an interview on 5/17/22 at 3:00 pm S5 ADON (Assistant Director of Nurses) and manager on the CVU (Critical Vent Unit) confirmed that staff should have cleaned resident #95's face and did not.
Resident #234:
Observation on 5/16/2022 at 9:00 am revealed Resident #234 had bilateral hand splints in place and Resident #234's fingernails were long past his fingertips, jagged with brown and black substance underneath.
Review of Resident #234's medical record revealed an admit date of 5/6/2022 with diagnoses that include in part cardiac arrest, respiratory failure, anoxic brain damage, type 2 diabetes mellitus with other specified complications, essential hypertension, gastrostomy, tracheostomy, dependence on respirator ventilator status, dysphagia, epilepsy and ventricular tachycardia.
Further review of Resident #234's medical record revealed the baseline care plan and MDS (Minimum Data Set) were still in progress.
Review of Resident #234's admit progress notes dated 5/6/22 revealed in part Resident #234 had no visual tracking or any awareness of his surroundings and rolled his eyes without knowing. Resident #234 was nonverbal and required total care.
During an interview on 5/17/22 at 3:00 pm S5 ADON and manager on the CVU reported CNA's (Certified Nursing Assistants) should clean resident's fingernails during their bath and as needed. S5 ADON assessed Resident #234's fingernails and confirmed that Resident #234's fingernails had not been trimmed or cleaned and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the plan of care was revised for 1 (#51) of 3 (#51, #94, #133) residents reviewed for hospitalizations. The facility failed to ensure resident #51's plan of care was revised to reflect new onset seizures.
Findings:
Review of resident #51's nurses notes dated 3/9/22 revealed resident #51 was transferred to a local hospital due to being found unresponsive with hands clinched and in an altered mental state.
Review of resident #51's nurses notes dated 3/10/2022 revealed the facility was notified of resident #51's diagnosis of Recurrent Seizures via a phone call from a local hospital. Further review revealed resident #51 returned to the facility on 3/11/2022.
Review of resident #51's hospital records from a local hospital revealed the following: [AGE] year old nursing home patient with .and new onset seizures continue Keppra for new onset seizures, to return to the nursing home on tomorrow.
Review of resident #51's Comprehensive Plan of Care failed to reveal a problem with approaches for seizures.
During an interview on 5/18/2022 at 4:09 pm S3 Care Plan Nurse confirmed resident #51's plan of care was not revised or updated to reflect a diagnosis of new onset seizures after a hospital admission.

Based on observations, record review and interviews the facility failed to ensure the plan of care was followed for 2 (#51 and #101) of 3 (#51, #94, #101) residents reviewed for position and mobility. The facility failed to ensure residents #51 and #101 wore splint devices according to their plan of care.
Findings:
Resident #51
Review of resident #51's medical record revealed a diagnosis of, but not limited to, Cardiovascular Accident; Traumatic brain injury; protein calorie malnutrition, Dysphagia, Unspecified convulsions
Review of resident #51's May 2005 Physicians Orders revealed an order for Occupational Therapy to treat 3 times a week for 4 weeks for range of motion, simple reaching with left upper extremity splinting and restorative nurse program education.
Review of resident #51's Occupational Therapy's Evaluation and Plan of Treatment revealed the following;
Current Referral: Occupational Therapy to address splinting needs on left upper extremity and right hand.
Objective Progress/Short-Term Goal:
Patient will tolerate 2 hours of wearing L extension splint with no redness, pain or discomfort.
Patient will tolerate B palm protectors times 2 hours with no distress, redness, pain or swelling.
New long term goal: Patient will tolerate 4 hours L extension splint with no redness, pain or discomfort.
Observation on 5/16/2022 at 9:00 am revealed resident #51 had a contracture to left upper extremity without a splint device in place. Further observation also failed to reveal a splint device on lower extremities.
Observation on 5/17/2022 at 11:30 am revealed resident #51 had a contracture to left upper extremity without a splint device in place. Further observation also failed to reveal a splint device on lower extremities.
Observation on 5/18/2022 at 2:00 pm revealed resident #51 had a contracture to left upper extremity without a splint device in place. Further observation also failed to reveal a splint device on lower extremities.
Observation on 5/19/2022 at 9:00 am with S6 LPN revealed resident #51 had a contracture to left upper extremity without a splint device in place. Further observation also failed to reveal a splint device on lower extremities.
During an interview on 5/19/2022 at 9:00 am S6 LPN confirmed the aides were supposed to put resident #51's splints on after giving him a bath. S6LPN confirmed resident #51 did not have splints in use.
Review of resident #51's Comprehensive Plan of Care failed to reveal a problem and approaches related to resident #51's left upper extremity contracture.
During an interview on 5/19/2022 at 10:30 am S3 Care Plan nurse confirmed a problem and approaches for contractures should have been included in resident #51's plan of care.
During an interview on 5/19/22 at 9:38 am S7 Occupational Therapy Assistant reported palm protectors and a left arm splint should have been used on resident #51 as occupational therapy plan of care stated.
Resident 101
Review of resident #101 revealed a diagnosis of Multiple Sclerosis.
Review of resident #101's May 2022 Physician Orders revealed the following orders
Resident to receive RNP (Restorative Nursing Program) with static knee splinting to both knees on before breakfast and off before lunch or as tolerated with skin checks before and after use and passive range of motion to Bilateral lower extremities related to decreased mobility and weakness secondary to Multiple Sclerosis
Nurse to check skin to both knees before application of splints and document
Nurse to check skin to both knees after removal of splints and document
Review of resident #101's Comprehensive Plan of Care revealed the following:
Resident to receive Restorative Nursing Program 7 days per week for splinting with static knee splint to both knees on before breakfast and off after lunch or as tolerated with skin checks before and after use and passive range of motion to bilateral lower extremities related to decreased range of motion and weakness secondary to multiple sclerosis: nurse to check skin to both knees after removal of splints and document; nurse to check skin to both knees before application of splints and document; Restorative Aide/staff to apply static knee splints. apply large splint to left knee and small splint to right knee.
Observation on 5/18/2022 at 8:50 am of resident #101 failed to reveal static knee splints in place at that time.
During an interview on 5/18/2022 at 8:50 am resident #101 reported he did not have any braces or splints on today and reported no one came in to put them on this morning.
During an interview on 5/18/2022 at 12:00 pm S8 Restorative Aide confirmed resident #101's splints were not put on this morning before breakfast as they should have been according to resident #101's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to accommodate the needs and preferences for 2 (#67, #119) of 5 (#61, #67, #72, #119, #233) residents reviewed for accidents. The facility failed to ensure:
1. Resident #67's wheelchair had leg rests in place.
2. Resident #119's right hand assist rail was tightly secured to the bedframe and the left hand assist rail was not present.
Findings:
1.)
Review of Resident #67's diagnoses revealed the following, but not limited to, generalized muscle weakness, muscle wasting and atrophy, lack of coordination, and abnormal posture.
Review of admission MDS (Minimum Data Set) dated 3/22/2022 revealed Resident #67 used a wheel chair for mobility.
Observation on 5/16/2022 at 11:30 AM revealed Resident # 67 sitting up in wheel chair with feet not touching the floor. Further observation of Resident #67 sitting up in wheel chair failed to reveal leg rests on wheel chair.
Observation on 5/18/2022 at 12:00 PM revealed Resident # 67 sitting up in wheel chair with feet not touching the floor. Further observation of Resident #67 sitting up in wheel chair failed to reveal leg rests on wheel chair.
Observation on 5/18/2022 at 1:00 PM with S9 CNA (Certified Nurse Assistant) observed Resident # 67 sitting in wheel chair with feet not touching the floor. Further observation of Resident #67 sitting up in wheel chair failed to reveal leg rests om wheel chair.
During an interview on 5/18/2022 at 1:00 PM S9 CNA confirmed Resident #67 should have had leg rests on wheel chair.
During an interview on 5/18/2022 at 1:15 PM S10 LPN (Licensed Practical Nurse) observed Resident # 67 sitting in wheel chair without leg resst and confirmed Resident # 67's wheel chair should have leg rests in place.
During an interview on 5/19/2022 at 8:45 AM S7 Occupational Therapy Assistant confirmed Resident # 67 was not able to propel the wheel chair with her legs and feet; therefore Resident #67 wheel chair should have leg rests in place.
2.)
Review of Resident #119's medical record revealed Resident #119 was admitted to the facility on [DATE] and had diagnoses that included, in part, heart failure, Type 2 Diabetes Mellitus, primary pulmonary hypertension, lack of coordination, abnormalities of gait and mobility, muscle wasting and atrophy of right and left upper arm, and peripheral vascular disease.
Review of Resident #119's 5/3/2022 Quarterly MDS revealed Resident #119 required supervision with bed mobility and transfers and was total dependence with toilet use.
Observation on 5/16/2022 at 9:15 AM revealed Resident #119 lying in bed slightly toward his right side and hand assist rail on Resident #119's right side was attached to bed but noted to be loose and leaning toward the mattress. Further observation revealed no hand assist rail was present to Resident #119's left side.
During an interview on 5/16/2022 at 9:15 AM Resident #119 shook the hand assist rail to his right side vigorously and reported This needs to be fixed! and further indicated the hand assist rail on the left side had fallen off and had never been replaced. Resident #119 further indicated staff had been informed about the hand assist rails and the rails had not been fixed.
During an interview on 5/18/2022 at 8:25 AM S4 LPN observed the loose right hand assist rail and lack of hand assist rail on the other side of Resident #119's bed and reported the right rail was loose and should not be. Further agreed the opposite side of Resident #119's bed did not have an assist rail in place.