Caleb Hitchcock Health Center

Based on observations, interviews, facility documentation and facility policy for 1 of 1 supply closets observed, the facility failed to ensure the nursing supply closet on the secured Memory Care unit was locked/secured. Review of the Resident Listing Report dated 11/18/25 indicated there were 12 residents living on the facility's secured Memory Care unit.An observation on the secured Memory Care unit on 11/18/25 at 10:30 AM identified the nursing supply closet was unlocked and contained 20 bottles of peri wash (8.1 ounces (oz) each), 24 bottles of non-alcohol mouthwash (4 oz each bottle), 22 bottles of body cream (5 oz in each bottle), 12 tubes of barrier cream, 25 bottles of body lotion (8 oz in each bottle). 40 fingernail clippers, 8 disposable razors, 2 containers of Sani cloth bleach wipes with 75 wipes in each, 5 containers of Sani cloth PDI- germicidal wipes with 160 wipes in each, 5 cans of shaving cream (11oz in each can), and 17 bottles of Purell hand sanitizers (12 oz. in each bottle).A second observation on 11/18/25 at 3:00 PM identified that the nursing supply closet was still unlocked with the above items still present from the 11/18/25 observation.The Safety Data Sheet (SDS) dated 3/15/18 identified that the PDI Germicidal Wipes identified product hazards as they may be harmful if swallowed and may cause eye irritation. The SDS dated 8/12/2016 identified that the PDI Sani-Cloth Bleach Germicidal Wipes identified may cause eye and skin irritation and if excessive amounts inhaled or ingested seek medical attention. The SDS dated 8/9/16 for body cream and barrier moisture protection identified may cause eye irritation and if ingested rinse mouth, drink 3 to 4 glasses of water and seek medical attention if any gastrointestinal (GI) symptoms persist. The peri wash (SDS) dated 2/25/15 identified that may cause slight irritation to the skin and eyes. Lastly, Purell Instant Hand Sanitizer SDS dated 2/16/18 identified that eye contact required immediate flushing of the eyes for at least 15 minutes and seek medical attention. If swallowed, do not induce vomiting, rinse mouth with water and obtain medical attention.Observation and interview with Registered Nurse (RN) #4 regarding the nursing supply closet on 11/18/25 at 3:10 PM identified that the supply closet was supposed to always be locked and that the Nursing Supervisor, Maintenance Director and Housekeeping Director had keys to the closet. Nurse Aides and/or any staff member must ask for the supply closet key to obtain supplies and ensure the door was locked upon exiting. RN #4 could not indicate the reason the door was unlocked and the length of time it had been unlocked. Interview with NA #5 on 11/19/25 at 9:25 AM identified that the nursing supply closet was to be always locked. Staff must ask the nurse on the unit to unlock the supply closet due to safety concerns with the residents. NA #5 stated that if the door was found unlocked then it needed to be reported to the nurse. NA #5 stated she did not realize the nursing supply closet was not locked.Interview with Facility Operations Manager on 11/20/25 at 9:00 AM identified that he was made aware by the second shift nurse a little after 3:00PM on 11/18/25 that the nursing supply closet door was not locked. He indicated that it was the first time he was made aware and that there were no repair requests in the maintenance repair portal. Furthermore, he indicated that the door had an automatic lock and was unsure when and how it broke.Subsequent to surveyor inquiry, the Facility Operations Manager replaced the lock on the nursing supply door on 11/18/25 in the afternoon to automatically lock. Review of the facility policy Secured Storage Closets (clean and dry), dated 11/2025 directed, in part, all storage closets within the skilled nursing facility, whether designated as clean, dirty, equipment, chemical, linen or general storage must always remain locked when not actively in use. Only authorized personnel may have access to these areas. This is to ensure the safety of residents, staff and visitors by maintaining secure control of all storage areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy, and interviews regarding the facility Infection Control program, the facility failed to document Covid-19 staff effected on a line list, failed to document and complete Covid-19 testing per facility policy, and failed to provide facility-initiated education to non-nursing personnel related to Covid-19, The findings include: Review of a Department of Public Health (DPH) Facility Licensing and Investigations Section (FLIS) Resolution Report dated [DATE] identified the facility had a COVID -19 outbreak which was declared as resolved on [DATE] and involved 2 residents (Resident #6 and Resident #66) and 2 staff members.a. Review of the facility COVID-19 outbreak documentation for [DATE]-[DATE] failed to identify a line list for staff members. The nurse aide (NA) and Life Enrichment Director who tested positive for COVID-19 during the outbreak were not documented on a staff line list which would have documented their age, gender, primary floor assignment, symptom onset date, symptoms (fever, cough, body aches, headache, shortness of breath, loss of appetite, chills, and sore throat), chest x-ray (if done), type of test performed (PCR or antigen), pathogen detected (COVID-19), symptom resolution date, hospitalized (Y/N), died (Y/N).Interview with the DNS on [DATE] at 12:50 PM identified she did not have an employee line list for the COVID-19 outbreak. The DNS identified she was unsure of exactly everything that needed to be done specifically in regards to the outbreak, but that she had notified the local and state DPH and had documented the line list information for the residents. (please refer to F 882).b. Review of the facility COIVD-19 outbreak documentation for [DATE]-[DATE] failed to identify documentation of resident testing completed in response to a COVID-19 positive resident/staff member.Interview with the DNS on [DATE] at 12:50 PM identified that resident testing completed in response to a COVID-19 positive resident/staff member would be found in the individual resident charts. The DNS identified that she did not have a list of residents tested with the dates and results of those tests, but she indicated that testing would be done on all exposed residents on days 1, 3, and 5 after exposure.Interview and facility documentation review with the DNS on [DATE] at 1:30 PM identified in response to a COVID-19 positive resident/staff member during an outbreak all residents on the affected neighborhood (unit) would be tested.c. Review of the clinical record for residents listed on the census list for the affected unit(s) (neighborhoods) with a COVID-19 positive resident test on [DATE] and [DATE] failed to identify that COVID-19 testing was completed per policy on days 1, 3, 5 following identification of exposure to a COVID-19 positive staff/resident.Review of the facility COVID-19 outbreak documentation for [DATE]-[DATE] identified there were 11 residents on the affected neighborhood on [DATE] when Resident #66 tested positive. Review of the clinical record for the 10 remaining residents (not including Resident #66) identified that 1 out of 10 residents were tested for COVID-19 on [DATE], 1 out of 10 residents were tested for COVID-19 on [DATE], 2 out of 10 residents were tested for COVID-19 on [DATE], 0 out of 10 residents were tested for COVID-19 on [DATE] which contradicts that Resident #6 was listed on the resident line list as testing positive on [DATE]. The clinical record further identified 8 out of 9 residents (not including Resident #6 and Resident #66) were tested for COVID-19 on [DATE], 0 out of 9 residents were tested for COVID-19 on [DATE], 2 out of 9 residents were tested for COVID-19 on [DATE]. The clinical record failed to identify any testing of residents on the affected neighborhood from [DATE]-[DATE]. The clinical record further identified 1 out of 9 residents were tested for COVID-19 on [DATE] which was the date the COVID-19 outbreak was declared resolved.Interview with the DNS on [DATE] at 1:30 PM identified the licensed nurses on the affected neighborhood would know which residents required testing based on education that goes out to staff following identification of a positive resident/staff. The DNS identified she did not obtain a specialized order for testing on days 1, 3, and 5 to trigger the nurse to obtain the test on the applicable day, that the nurse would utilize the as needed (PRN) order for COVID-19 testing in each resident's orders and the nurse would administer tests using that PRN COVID-19 test order, and the results would be documented in the electronic medical record.d. Review of the facility COIVD-19 outbreak documentation for [DATE]-[DATE] failed to identify documentation of staff testing completed in response to a COVID-19 positive resident/staff member.Interview with the DNS on [DATE] at 1:30 PM identified the facility does not perform staff testing in response to a COVID-19 positive resident/staff member. The DNS identified that the staff could test themselves if they chose to, but it was not required for staff to test in response to exposure. The DNS indicated that staff were expected to wear surgical masks when working in response to the facility outbreak so testing was not required for them.e. Review of the Respiratory Season In-Service education provided on [DATE] that was initiated in response to the facility COVID-19 for [DATE]-[DATE] identified 62 staff signatures all of which were nurse aides or licensed nurses. The education signature sheets failed to identify signatures from any non-nursing departments. (please refer to F 882).Review of the Respiratory Season In-Service education initiated in response to the facility COVID-19 for [DATE]-[DATE] failed to identify symptoms of infection for COVID-19, information related to personal protective equipment required when treating COVID-19 positive residents including an N95 mask, and when isolation precautions was warranted. The education directed to follow facility policy for isolation precautions but failed to include that policy with the education.Interview with the DNS on [DATE] at 1:00 PM identified she had provided the Respiratory Season In-Service education to non-nursing departments and had provided those signature sheets on [DATE] but that she would provide the signature sheets again.Subsequent to surveyor inquiry review of Respiratory Season In-Service education identified 78 staff signatures which included only 13 non-nursing staff member signatures.Review of the Infection Outbreak Response and Investigation policy directed, in part, a single case of COVID-19 would trigger declaration of an outbreak. The policy directed staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures which includes special environmental infection control measures that are warranted based on the organism. The policy directed surveillance activities will increase to daily for the duration of the outbreak. The policy directed in the absence of the Infection Preventionist, the DNS will assume responsibility for all reporting requirements and outbreak investigations. The policy directed a line list about each person affected by the outbreak will be maintained.Review of the [NAME] Communicable Disease Reporting Policy reviewed by the DNS on 10/2025 directed, in part, the facility will identify, document, and report all suspected or confirmed communicable diseases as required by state and local health authorities. The policy directed COVID-19 was immediately reportable (within hours). The policy directed the outbreak would be reported via the state reporting system, phone or fax and the date and time of the report to local/state health departments would be documented. The policy directed to maintain line listings and daily surveillance. The policy directed that annual training on communicable diseases, signs/symptoms, transmission-based precautions, and reporting requirements would be provided and additional training provided during outbreaks.Review of the Coronavirus Testing directed, in part, the facility will conduct testing through the use of rapid point of care testing (antigen test) and anyone with even mild symptoms of COVID-19 should receive a viral test as soon as possible. The policy directed in response to an outbreak investigation, outbreak testing will be performed either through contact tracing or broad-based (facility wide) testing, and the facility may choose to conduct focused testing based on known close contacts if they have the ability to identify close contacts of the individual with COVID-19, but if the facility does not have the expertise, resources, or ability to identify all close contacts, the facility should instead investigate the outbreak at a facility-wide or group-level (affected neighborhood). The policy directed that testing would be performed on days 1, 3, and 5 (with the exposure as day 0). The policy directed the facility may elect to initially expand testing only to healthcare personnel and residents on the affected units as opposed to the entire facility. The policy directed for documentation of testing for symptomatic residents and staff, document: date and time of signs and symptoms, date when testing conducted, date when results obtained, actions facility took based on results. The policy directed upon indemnification of a new positive case during an outbreak the document: date the case was identified, date other staff and residents are tested, dates that staff and residents who tested negative are retested, results of all tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #4) reviewed for positioning and mobility, the facility failed to obtain a physician's order, develop a plan of care and provide staff education for a resident's lower extremity brace. The findings include: Resident #4 was admitted to the facility in January 2024 with diagnoses that included difficulty in walking, unsteadiness on feet and unspecified abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #4 had no cognitive impairment and was independent with toileting, bed mobility and transfers. The MDS further indicated Resident #4 required partial/moderate assistance with lower body dressing and had a diagnosis of weakness and difficulty in walking. The Resident Care Plan (RCP) dated 8/27/25 identified Resident #4 required assistance with activities of daily living and had an AFO (Ankle-Foot-Orthosis) for the right lower extremity. The RCP failed to indicate directives for application of the AFO, goals, or interventions for the AFO brace. Observations on 11/18/25 at 11:57 AM, 11/20/25 at 8:38 AM, and 11/21/25 at 11:22 AM noted Resident #4 with shoes on both feet and an AFO brace on his/her right lower extremity. The brace had metal bars on both sides and was secured with a black strap that wrapped around the resident's ankle/calf area. The brace rested inside a black rubber soled shoe, went under the resident's right foot and extended up the leg, ending at Resident #4's right mid-calf area. Interview and review of facility documents on 11/21/25 at 11:36 AM with Nurse Aide (NA) #4 identified although she puts Resident #4's AFO brace on every morning, she had not received any education or instruction as to how to put the brace on or what the brace was for. NA #4 indicated Resident #4 came to the facility with the brace and would ask her to put it on for him/her every day. Review of the Nurse Aide (NA) care card (Individualized Resident Assignment) with NA #4 failed to identify that Resident #4 utilized a AFO brace and lacked directions for application of the AFO brace (when the AFO was to be worn and removed). Interview with Resident #4 on 11/21/25 at 11:37 AM identified he/she had the AFO brace for over 30 years and was prescribed the brace by a podiatrist because his/her arch was starting to collapse. Resident #4 indicated the brace was to be put on his/her right lower extremity every morning and removed at night and was kept in his/her shoe. Resident #4 identified he/she came to the facility with the brace and was last seen by the prescribing podiatrist a couple of years ago. Resident #4 further indicated the nursing staff at the facility would put the AFO brace on his/her right lower extremity daily. Interview and review of the clinical record and facility documents on 11/21/25 at 11:42 AM with RN #6 identified although the NA's have been putting the AFO brace on Resident #4's right lower extremity daily, there was not a physician's order for the brace nor was it listed on the NA care card. RN #6 indicated it was an error, she would contact the physician to obtain an order for the brace and make sure the NA care card was updated. RN #6 was unsure of the reason this was not done when Resident #4 came to the facility with the brace and would notify therapy to educate the NA's as well. Interview and review of the clinical record at 11/21/25 at 11:58 AM with the Occupational Therapist (OT) #1 identified she had worked with Resident #4 for toileting and mobility and the resident had the AFO brace since he/she came to the facility. OT #1 indicated she was unsure what the brace was for and had never evaluated the resident for the brace. OT #1 identified although the nursing staff have been putting the AFO brace on Resident #4 daily, it was not indicated in the resident's physician's orders or on the NA care card. OT #1 indicated a physician's order should have been obtained, education should have been provided to the nursing staff for Resident #4's AFO brace and she was unsure of the reason that was not done. Additionally, OT #1 indicated she would need to ask the Physical Therapist (PT) about it. Interview and review of the clinical record with PT #1 on 11/21/25 12:58 AM identified although he was aware Resident #4 came to the facility with the AFO brace and was wearing it daily to the right lower extremity, he was unsure of the purpose of it and was unaware there was not a physician's order for the brace. PT #1 indicated it would have been his responsibility to assess and evaluate the resident for the brace and provide education and training for the nursing staff. PT #1 further identified there should have been a physician's order and a plan of care in place for Resident #4's AFO brace and he was unable to indicate the reason that was not done. Subsequent to surveyor inquiry on 11/21/24, the NA Care Card was updated and directed application of a right ankle support for Resident #4. Subsequent to surveyor inquiry on 11/22/25 the RCP identified Resident #4 was to wear a brace to the right ankle with an intervention that included education for direct care staff on proper application of the brace. The RCP interventions further indicated Resident #4 should be monitored for changes in functional status and monitored for abnormalities in skin integrity with therapy services to evaluate the brace quarterly and as needed. Interview with the DNS on 11/24/25 at 9:40 AM identified Resident #4 was admitted to the facility with the AFO brace and should have had an OT evaluation with education for the staff as well as a physician's order for use of the right lower extremity brace. The DNS was unsure of the reason that was not done, and it would have been the responsibility of nursing to notify the PT or OT of the brace after admission. The OT would have been responsible for evaluating and educating staff and continuing to monitor the use of the brace. The DNS indicated the specifics of the AFO brace should have been in Resident #4's care plan and on the NA care card as well. Interview with Person #2 on 11/24/25 at 1:34 PM identified Resident #4 was prescribed the AFO brace over 30 years ago by a local podiatrist and the resident wore it every day. Person #2 indicated the tendons in Resident #4's right ankle were weak, identified he/she was unaware the facility had not evaluated the brace or educate the staff as the resident has had therapy on multiple occasions and she thought it would have been addressed. Person #2 indicated he/she did not bring the AFO brace into the facility and Resident #4 had been admitted with the brace. Person #2 further identified Resident #4 last saw the prescribing podiatrist in 2023 and he/she was going to let the facility know he/she wanted another follow-up scheduled. Review of the facility policy, Orthotic Device Policy, dated 1/25, directed a splint was an orthopedic device used to support a body part and a physician or qualified therapist must provide a written order specifying use and goals of treatment. The policy directed a comprehensive assessment shall be conducted and staff applying the splint must be properly trained and competent in the correct application and care procedures. The policy further directs application and responses must be documented in the resident's medical record and the need for the splint would be regularly reassessed by the physician or therapy team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to ensure Resident #6 who exhibited self-injurious behaviors (biting, gnawing and sucking), had a comprehensive care plan developed and interventions implemented to minimize the risk of injury. The facility's failure to develop a comprehensive care plan with individualized interventions to address self-injurious behaviors resulting in the development of an open area, progressing to osteomyelitis (a bone infection) and gangrene which required a partial right third finger amputation. These failures resulted in the finding of immediate jeopardy. Additionally, for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident care plan was comprehensive for Resident #1's history of fractures and seizures. The findings include: 1.Resident #6 was admitted to the facility from the hospital on [DATE] with diagnosis that included a urinary tract infection, hypertension and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was moderately cognitively impaired, was dependent on transfers, and toileting, required partial to moderate assistance for eating, personal hygiene, and showering. Additionally, the MDS identified Resident #6 did not exhibit any abnormal behaviors.The Resident Care Plan (RCP) dated 10/10/25 identified a problem with behavioral symptoms, being easily agitated with occasional verbal abusive/aggressive behavior and Resident #6 did not fully understand what was happening. Interventions included to establish and maintain familiar routines, psych referral as needed, monitor for changes in mood/behavior and report to the nurse. The RCP failed to identify the behaviors of gnawing, biting and sucking of the fingers to the right hand or interventions to discourage the behavior and protect the skin from breakdown.The Resident Care Plan dated 10/15/25 identified Resident #6 was at risk for skin breakdown related to decreased mobility and incontinence with interventions directed to conduct a systematic skin inspection weekly, keep skin clean dry, and report any signs of skin breakdown. Nursing notes dated 10/18/25 at 10:48 PM and written by Registered Nurse (RN) #3 identified Resident #6 continued to bite/suck on 3 fingers of his/her right hand (did not specify which 3 fingers), the areas were bloody with no signs and symptoms of infection. RN #3 also identified she placed a dry protective dressing to the areas (but failed to document an assessment/description of the open area/location where the blood was originating from). Advanced Practice Registered Nurse (APRN) #1 notes dated 10/20/25 at 5:44 PM identified Resident #6 was COVID-19 positive.Advanced Practice Registered Nurse (APRN) #1 notes dated 10/22/25 failed to identified Resident #6's skin was warm and dry and failed to document the skin breakdown to the right 3 fingers that was observed by RN #3 on 10/18/25. Nursing notes dated 10/26/25 (8 days after Resident #6 was noted with 3 right hand fingers that were bloody) at 1:37 PM and written by Registered Nurse (RN) #4 identified she was called to the unit by the charge nurse who reported to her that Resident #6's right 3rd finger looked infected. RN #4 identified she completed an assessment of Resident #6's right middle finger and the surrounding area, which was noted with redness, swelling, being warm to touch, the top of the 3rd finger was dark in color with a white patch at the tip. RN #4 also identified she called MD #1 and obtained an order to send Resident #6 to the emergency room for evaluation. Resident #6 was sent to the emergency room at 1:43 PM. Nursing notes (written after Resident #6 was transferred to the Emergency Room) dated 10/27/25 at 4:54 PM and written by RN #5 identified Resident #6's right 3rd finger was reddened, warm to touch, and swollen. Resident #6 denied pain or discomfort. RN #5 further noted that the finger was not like that on Saturday (on 10/25/25, but no assessment of the right hand was documented) and Resident #6 was afebrile. A hospital Discharge summary dated [DATE] identified Resident #6 was being transferred back to the long-term care facility status post gangrene, osteomyelitis and partial amputation of the right 3rd finger.Nursing notes dated 10/30/25 at 11:27 PM written by RN #3 identified Resident #6 was readmitted to the facility from the hospital with a diagnosis of right middle finger osteomyelitis with a partial amputation. Interview and RCP review with the DNS on 11/19/25 at 2:59 PM identified although there was a care plan for behaviors of being anxious, agitated and aggressive, the care plan failed to include the behaviors of gnawing, biting and sucking his/her fingers which therefore interventions were not implemented to discourage the behaviors and protect the skin to the fingers from breakdown. Additionally, the DNS identified the RCP should have included Resident #6's behaviors of gnawing, biting and sucking of the fingers with appropriate interventions.Interview on 11/19/25 at 3:09 PM with RN #3 (the RN that observed Resident #6's right hand to be bloody on 10/18/25) identified she was the full time 3:00 PM to 11:00 PM nurse on Resident #6's unit and was familiar with Resident #6. RN #3 also identified Resident #6 had the habit of sucking/gnawing/picking at his/her right-hand fingers but did not include that behavior in the Resident Care Plan and therefore interventions to discourage Resident #6 from sucking/gnawing/picking at his/her right-hand fingers and interventions to protect/monitor the skin to the right hand were not in place. RN #3 further indicated all nursing staff were responsible to up-date the care plan as changes occur and noted it was an oversight that she did not include that behavior with interventions in the care plan.Interview on 11/20/25 at 12:25 PM with Nurse Aide (NA) #3 identified she observed Resident #6 putting his/her fingers in his/her mouth, noticed blood at times and she reported to the nurse on the unit but was unsure of who and when she reported it to. Interview on 11/20/25 at 2:40 PM with Person #1 identified Resident #6 had a history of biting and picking at his/her fingers before and during admission to the facility, and the fingers were scabbed. Person #1 further indicated he/she did not see Resident #6 until 10/26/25 (because Resident #6 had Covid) and indicated the fingers were very discolored and red. Interview on 11/21/25 at 1:23 PM with MD #2 noted that Resident #3 had a history of vascular disease, but it was not noted in the resident electronic medical record. Also, identifying if Resident #6 had history of gnawing, bleeding to his/her fingers, the expectation would for Resident #6's fingers to be monitored at least daily. Interview and care plan review with RN #1 (MDS Coordinator) on 11/24/25 at 1:54 PM failed to identify the RCP was comprehensive to include Resident #6's behaviors of gnawing, biting and picking at his/her fingers. Additionally, RN #1 identified the RCP was updated on 10/31/25 (after Resident #6 returned from the hospital) to include Resident #6's behaviors of picking of the skin with his/her fingers and mouth but failed to include interventions to discourage the behavior and prevent the skin from breakdown. Additionally, RN #1 further indicated that although she was responsible for developing resident care plans, any nurse can develop and initiate a care plan. Although a policy regarding care plans was requested, only a care plan policy pertaining to the baseline care plan was provided. The above deficiency resulted in the finding of Immediate Jeopardy (IJ). The facility Administrator was provided with the IJ template on 11/20/25 at 2:00 PM and submitted a removal plan which was approved by the State Agency on 11/21/25.The removal plan noted in part, a comprehensive audit was conducted for all care plans and behavior monitoring practices to confirm care plans were accurate and discrepancies were corrected. The Interdisciplinary Team was engaged, and direct care staff were educated on updated care plans to reinforce continuity of care. To prevent recurrence, the removal plan also indicated systems were strengthened through policy reviews related to behaviors, quality of care, clinical monitoring, escalation and documentation. Staff were in-serviced regarding to ensure understanding of behavior recognition and documentation in the electronic medical record and care plans. 2. Resident #1's diagnoses included epilepsy (seizure disorder), left ulna (forearm/wrist bone) fracture with routine healing, and fracture of the right side of the skull and facial bones.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, was independent with eating, bed mobility, chair/bed transfers and walking. The Resident Care Plan (RCP) dated 2/4/25 identified Resident #1 was at risk for falls related to physical deconditioning and required assistance with activities of daily living (ADLs). Interventions included keeping personal items and frequently used items within reach, leave a night light on in the room, and providing toileting assistance every 2 hours.A progress note written by the physician (MD) #1 and dated 2/28/25 at 1:40 PM identified Resident #1 was hospitalized for an episode of hypotension (low blood pressure) and having a large blood-filled stool. While at the hospital Resident #1 had 2 tonic-clonic seizures (seizure with muscle stiffness and rhythmic jerking of limbs) and was started on Keppra (anti-seizure medication). The progress note further identified imaging was obtained during the hospital workup which showed multiple facial fractures and a periorbital hematoma.A physician order dated 3/4/25 directed to administer 7.5 milliliters (ml) of Keppra solution 100 milligrams (mg) per ml for a dose of 750 mg by mouth twice a day. A nursing note written by Registered Nurse (RN) #7 on 5/27/25 at 6:21 PM identified Resident #1 was sent to the hospital for evaluation following an x-ray report addendum received 5/27/25 which indicated Resident #1 may have a left intertrochanteric fracture following an unwitnessed fall on 5/22/25. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility and was dependent with chair/bed transfers. The MDS assessment identified Resident #1 had a fracture related to a fall in the 6 months prior to readmission and had active diagnoses that included, in part, epilepsy and a hip fracture. The Resident Care Plan (RCP) dated 9/17/25 identified Resident #1 had pain related to having a left hip fracture with surgical repair. Interventions included to administer medications as ordered and position for comfort with physical support as needed. The RCP failed to include Resident #1's history of seizures, being on anti-seizure medication and therefore did not identify interventions if seizure activity were to occur. Furthermore, the RCP failed to include Resident #1's recent left ulna fracture and recent history of facial fractures.A Reportable Event (RE) form dated 9/30/25 at 7:00 AM identified Resident #1 presented with a swollen, bruised, painful left hand, and had x-rays performed which revealed an acute distal ulna fracture. The RE form further identified Resident #1 was sent to the hospital for evaluation and treatment.A physician order dated 11/13/25 directed to apply a left hand/forearm splint for non-weight bearing (NWB) to left upper extremity (LUE) when out of bed (OOB) twice a day (7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM) with special instructions to remove splint at bedtime.Interview and clinical record review with RN #1 on 11/21/25 at 2:45 PM identified Resident #1's RCP failed to include a care plan for seizures and facial fractures identified in February 2025 and failed to include a care plan related to his/her ulna fracture identified on 9/30/25. RN #1 identified she had missed entering seizures into Resident #1's RCP and that it should be included because Resident #1 was on anti-seizure medication. RN #1 identified she had not realized the RCP should include Resident #1's history of ulna and facial fractures.Subsequent to surveyor inquiry on 11/21/25, RN #1 initiated a care plan addressing Resident #1 having a history of seizures and receiving antiseizure medication. Interventions included if Resident #1 had a seizure ensure a safe environment by cushioning the head, removing sharp objects, loosening tight clothing, and turning Resident #1 to his/her side, and to report any seizure like activity to providers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to follow professional standards of practice for the monitoring of neurological assessments following an unwitnessed fall. Additionally, for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to follow professional standards of practice regarding completing a skin assessment when Resident #6 was observed to sustain bloody areas to the fingers of the right hand caused by the behaviors of sucking, biting and picking and failed to ensure routine skin assessments were completed by a Registered Nurse (RN) and not a Licensed Practical Nurse (LPN). The findings include:
1.Resident #1 had diagnoses that included epilepsy (seizure disorder), vascular dementia, and fracture of right sided skull and facial bones with routine healing.
The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, was independent with eating, bed mobility, chair/bed transfers and walking.
The Resident Care Plan (RCP) dated 2/4/25 identified Resident #1 was at risk for falls related to physical deconditioning and required assistance with activities of daily living (ADLs). Interventions included keeping personal items and frequently used items within reach, leave a night light on in the room, and to provide toileting assistance every 2 hours.
A nursing note written by Registered Nurse (RN) #7 on 2/20/25 at 6:45 PM identified at 5:30 PM Resident #1 was observed lying on his/her back next to a pool of blood. The nursing note identified Resident #1 was alert but unable to describe what happened due to his/her dementia. The nursing note further identified pressure was applied to the right eyelid and left side of the nose to stop the bleeding and neurological (neuro) checks were within normal limits. The note further identified Resident #1 was sent to the hospital for evaluation and treatment and left the building at 6:05 PM.
A physician order dated 2/20/25 directed to obtain neurological checks (neuros) (neurological assessment including mental status, pupillary exam, hand grasps)/vital signs (vitals) after an unwitnessed fall every 15 minutes for 4 times (5:30 PM, 5:45 PM, 6:00 PM, and 6:15 PM), every 30 minutes x 2 (6:45 PM and 7:15 PM) with special instructions: if neuros/vitals are not at baseline, document in a progress note and notify the physician (MD).
A physician order dated 2/20/25 directed to obtain vital signs every hour for 2 times after an unwitnessed fall (8:15 PM and 9:15 PM).
A physician order dated 2/20/25 directed to obtain vital signs every 4 hours for 4 times after an unwitnessed fall (1:15 AM, 6:15 AM, 11:15 AM, and 4:15 PM).
A physician order dated 2/20/25 directed to obtain vital signs every shift for 7 days for an unwitnessed fall starting on 2/21/25 (temperature, pulse, respirations, blood pressure, oxygen saturation).
The Medication Administration Record (MAR) dated 2/20/25 noted although neuro checks were signed off as completed on 2/20/25 at 5:30 PM and documented as being within normal limits (WNL), documentation failed to show what information was obtained during the neuro check to allow for comparison to previous/future neuro checks. The MAR failed to identify neuros were completed on 2/20/25 at 5:45 PM or 6:00 PM prior to Resident #1 being transported to the hospital at 6:05 PM.
A nursing note dated 2/21/25 at 4:26 PM identified Resident #1 had returned from the hospital at 8:30 AM and had bruising to both eyes, face, right neck, left knee, and the left chest. The nursing note identified vital signs were obtained on readmission and at 1:30 PM. The note failed to identify neuro checks were obtained.
The Medication Administration Record (MAR) dated 2/21/25 identified vital signs were obtained at 11:15 AM and 4:15 PM.
A nursing note written by RN #4 on 5/22/25 at 2:49 PM identified at 2:00 PM Resident #1 was observed lying on the floor in the common area and identified Resident #1 was last seen sitting in a chair. The note identified Resident #1 denied hitting his/her head and neuro checks were stable.
A physician order dated 5/22/25 directed to obtain neuros/vitals after an unwitnessed fall every 15 minutes for 4 times (2:00 PM, 2:15 PM, 2:30 PM, and 2:45 PM), every 30 minutes for 2 times (3:00 PM and 3:30 PM), with special instructions: if neuros/vitals are not at baseline, document in a progress note and notify the MD.
A physician order dated 5/22/25 directed to obtain vital signs every 4 hours for 4 times after an unwitnessed fall (4:00 PM, 9:00 PM, 2:00 AM, and 7:00 AM).
A physician order dated 5/22/25 directed to obtain vital signs every shift for 7 days for an unwitnessed fall starting on 5/21/25 (temperature, pulse, respirations, blood pressure, oxygen saturation).
The Medication Administration Record (MAR) dated 5/22/25 identified neuro checks were completed at 2:00 PM, 2:15 PM, 2:30 PM, 3:00 PM, and 3:30 PM and were documented as being at baseline, but documentation failed to show what information was obtained during the neuro check to allow for comparison to previous/future neuro checks. The MAR failed to identify neuros were completed at 2:45 PM on 5/22/25 per physician order.
Interview with MD #1 on 11/24/25 at 1:10 PM identified she was unsure of the specific neuro check policy without looking at it, but that it would direct nursing to obtain neuro checks every 15 minutes for a span of time, every 30 minutes, then hourly and so forth for a 3-day span of time. MD #1 was unaware that the facility policy directed to obtain neuro checks every 15 minutes for 4 times, then every 30 minutes for 2 times only (a total of 2 hours of neuro checks monitoring) with no further neuro checks required to be obtained. MD #1 identified she would revisit the policy.
Review of the [NAME] Fall Prevention Program policy directed, in part, following an unwitnessed fall the facility will initiate neuro checks every 15 minutes for 4 times, and every 30 minutes for 2 times. The policy failed to identify what components of the neuro checks are evaluated when the neuro checks are conducted.
2. Resident #6 was admitted to the facility from the hospital on [DATE] with diagnosis that included a urinary tract infection, hypertension and chronic obstructive pulmonary disease.
The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was moderately cognitively impaired, was dependent on transfers, and toileting, required partial moderate assistance for eating, personal hygiene, and showering. Additionally, the MDS identified Resident #6 did not exhibit any abnormal behaviors.
a. The Medication Administration Record (MAR) for October 2025 identified on 10/13/25 and 10/20/25 weekly skin assessments were completed by a Licensed Practical Nurse (LPN) #1 and not a Registered Nurse (RN).
Interview on 11/24/25 at 9:53 AM with Licensed Practical Nurse (LPN) #1 identified on 10/13/25 and 10/20/25 she performed a skin assessment for Resident #6 and that she usually performed skin assessments for residents on their shower day.
Interview and record review on 11/24/25 at 10:20 AM with the DNS identified an LPN completed the skin assessments on 10/13/25 and 10/20/25. The DNS further identified LPN's cannot complete skin assessments and the facility policy stated that. The DNS also identified she was responsible for making sure a Registered Nurse performed the assessments and did not know the reason LPN #1 completed skin assessment in lieu of a RN.
b. The Resident Care Plan dated 10/15/25 identified Resident #6 was at risk for skin breakdown related to decreased mobility and incontinence with interventions directed to conduct a systematic skin inspection weekly, keep skin clean dry, and report any signs of skin breakdown.
Nursing notes dated 10/18/25 at 10:48 PM and written by Registered Nurse (RN) #3 identified Resident #6 continued to bite/suck on 3 fingers of his/her right hand, the areas were bloody with no signs and symptoms of infection. RN #3 also identified she placed a dry protective dressing to the areas (but failed to document an assessment noting a description of the open area/location where the blood was originating from).
Advanced Practice Registered Nurse (APRN) #1 notes dated 10/20/25 at 5:44 PM identified Resident #6 was COVID-19 positive and did not document an assessment of Resident #6's right fingers.
Nursing notes dated 10/19/25 through 10/25/25 failed to identify any monitoring or assessments of Resident #6 's fingers to the right hand where blood was observed on 10/18/25.
A hospital Discharge summary dated [DATE] identified Resident #6 was being transferred back to the long-term care facility status post gangrene, osteomyelitis and partial amputation of the right 3rd finger.
Nursing notes dated 10/30/25 at 11:27 PM written by RN #3 identified Resident #6 was readmitted to the facility from the hospital with a diagnosis of right middle finger.
Review of the policy for Documentation in the Medical record dated February 2025 identified that each Resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Also, identifying all licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to protect the skin of a resident with known behaviors of picking and gnawing at his/her fingers, failed to monitor the fingers after gnawing caused skin deterioration of the finger, failed to document an assessment when the fingers were noted with breakdown which resulted in Resident #6 developing osteomyelitis (a bone infection),and gangrene requiring a partial right third finger amputation. These failures resulted in the finding of Immediate Jeopardy. Resident #6 was admitted to the facility from the hospital on [DATE] with diagnosis that included a urinary tract infection, hypertension and chronic obstructive pulmonary disease (there was no admitting diagnosis of peripheral vascular disease (PVD), diabetes or neuropathy). A progress note written by MD #3 prior to Resident #6's admission to the facility, obtained by the facility subsequent to surveyor inquiry and dated 7/14/25 identified in 2022, Resident #6 developed a nonhealing infection of the left toe, underwent angioplasty for critical left lower extremity ischemia with amputation of the 2nd left digit of the foot due to dry gangrene. Resident #6 also required amputation of the 3rd left toe related to gangrene in February 2023. A physician's admission progress note dated 10/6/25 and written by MD #2 failed to identify any history of peripheral vascular disease (PVD), although the physician's admission progress note did list a past history of amputation of replicated toes (a congenital condition of having extra toes). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was moderately cognitively impaired, was dependent on transfers, and toileting, required partial/moderate assistance for eating, personal hygiene, and showering. Additionally, the MDS identified Resident #6 did not exhibit any abnormal behaviors. The Resident Care Plan dated 10/15/25 identified Resident #6 was at risk for skin breakdown related to decreased mobility and incontinence with interventions directed to conduct a systematic skin inspection weekly, keep skin clean dry, and report any signs of skin breakdown. Nursing notes dated 10/18/25 at 10:48 PM and written by Registered Nurse (RN) #3 identified Resident #6 continued to bite/suck on 3 fingers of his/her right hand (did not specify which 3 fingers), the areas were bloody with no signs and symptoms of infection. RN #3 also identified she placed a dry protective dressing to the areas (but failed to document an assessment/description of the open area/location where the blood was originating from and failed to notify the physician). (refer to F 658) Advanced Practice Registered Nurse (APRN) #1 progress notes dated 10/20/25 at 5:44 PM identified Resident #6 was COVID-19 positive and failed to document the skin breakdown to the right 3 fingers that was observed by RN #3 on 10/18/25. . Nursing notes dated 10/19/25 through 10/25/25 failed to identify any monitoring, physician notification or assessment of Resident #6 's fingers to the right hand where blood was observed on 10/18/25, despite RN #3 applying a dry, protective dressing on 10/18/25. Advanced Practice Registered Nurse (APRN) #1 notes dated 10/22/25 identified Resident #6's skin was warm and dry and failed to document the skin breakdown to the right 3 fingers that was observed by RN #3 on 10/18/25. Review of physician orders from 10/18/25 when skin breakdown to Resident #6's right 3 fingers was observed by RN #3 through 10/26/25 failed to reflect a treatment was obtained for Resident #6's right 3 fingers. Nursing notes dated 10/26/25 (8 days after Resident #6 was noted with 3 right hand fingers that were bloody) at 1:37 PM and written by RN #4 identified she was called to the unit by the charge nurse who reported to her that Resident #6's right 3rd finger looked infected. RN #4 identified she completed an assessment of Resident #6's right middle finger and the surrounding area, which was noted with redness, swelling, being warm to touch, the top of the 3rd finger was dark in color with a white patch at the tip. Also identifying she called MD # 1 and obtained an order to send Resident #6 to the emergency room for evaluation. Resident #6 was sent to the emergency room at 1:43 PM. Nursing notes (written after Resident #6 was transferred to the Emergency Room) dated 10/27/25 at 4:54 PM and written by RN #5 identified Resident #6's right 3rd finger was reddened, warm to touch, and swollen. Resident #6 denied pain or discomfort. Also identifying that the finger was not like that on Saturday (on 10/25/25, but no assessment of the right hand was documented) and Resident #6 was afebrile. A hospital Discharge summary dated [DATE] identified Resident #6 was being transferred back to the long-term care facility status post gangrene, osteomyelitis and partial amputation of the right 3rd finger. Nursing notes dated 10/30/25 at 11:27 PM written by RN #3 identified Resident #6 was readmitted to the facility from the hospital with a diagnosis of right middle finger osteomyelitis with a partial amputation. An interview on 11/19/25 at 2:17 PM with RN #2 identified that if a resident had a wound the documentation would be found in the wound management section of the electronic medical record (EMR), however he was unable to provide any documentation contained in the wound management section of the EMR. RN#2 further identified he worked on 10/19/25 (1 day after Resident #6's right hand was bloody) and there were no treatment orders for Resident #6's fingers. Additional RN#2 indicated the 24-hour shift report dated 10/18/25 failed to identify any concerns with Resident #6. Interview and clinical record review with the Director of Nursing (DNS) on 11/19/25 at 2:59 PM failed to identify an assessment of Resident #6's right hand at the time it was observed to be bloody on 10/18/25 until 10/26/25 identifying Resident #6's right 3rd finger and the surrounding area had redness, swelling, being warm to touch, and the top of the 3rd finger was dark in color with a white patch at the tip. The DNS further identified documentation of the wound to the fingers should have been completed in EMR of the wound management section, the care plan should have been updated, and the physician should have been notified, and a treatment should have been obtained by RN #3 on 10/18/25 when the area was observed. Interview on 11/19/25 at 3:09 PM with RN #3 (the RN that observed Resident #6's right hand to be bloody on 10/18/25) identified she was the full time 3:00 PM to 11:00 PM nurse on Resident #6's unit and was familiar with Resident #6. RN #3 also identified Resident #6 had the habit of sucking/gnawing/picking at his/her right hand fingers, but did not include that behavior in the Resident Care Plan and therefore interventions to discourage Resident #6 from sucking/gnawing/picking at his/her right hand fingers and interventions to protect/monitor the skin to the right hand were not in place. RN #3 further indicated all nursing staff were responsible to up-date the care plan as changes occur and noted it was an oversight that she did not include that behavior with interventions in the care plan (please refer to F 656). An interview on 11/20/25 at 10:30 AM with RN #4 identified she evaluated Resident #6 on 10/26/25 after being notified by RN #5 with concerns about Resident #6's fingers. RN#4 also, identified there was no dressing in place to the resident's right hand. Additional RN#4 indicated the right-hand middle finger was greenish, black in color, no odor, no drainage, felt it was infected and was not aware of any behavioral concerns of gnawing, biting or sucking of the fingers. Interview on 11/20/25 at 12:25 PM with NA #3 identified she observed Resident #6 putting his/her fingers in his/her mouth, noticed blood at times and she reported to the nurse on the unit but was unsure of who and when she reported it to. Interview on 11/20/25 at 12:52 PM with RN #5 identified Resident #6 had a dressing in place to Resident #6's fingers because he/she was picking at them but couldn't identify when the dressing was in place. Interview on 11/20/25 at 2:40 PM with Person #1 identified Resident #6 had a history of biting and picking at his/her fingers before and during admission to the facility, and the fingers were scabbed. Person #1 further indicated he/she did not see Resident #6 until 10/26/25 (because Resident #6 had Covid) and indicated the fingers were very discolored and red. Interview on 11/21/25 at 11:44 AM with RN #4 (the wound care nurse) identified RN #3 should have notified the provider on 10/18/25 regarding the breakdown of the resident's fingers, obtained an order for treatment and updated the care plan to include wound care interventions. RN#4 identified the policy for open skin areas was to notify the provider of any changes to the skin. RN #4 provided a video of Resident #6's right 3rd finger that she provided to MD #1 on 10/26/25 to relay the condition of the 3rd right finger, identifying she did not think the wound could have deteriorated that quickly in just 1 day and had interventions been in place the infection could have been avoided. A progress note obtained by the facility on 11/21/25, dated 7/14/25 and written by MD #3 prior to Resident #6's admission to the facility identified in 2022, Resident #6 developed a nonhealing infection of the left toe, underwent angioplasty for critical left lower extremity ischemia with amputation of the 2nd left digit of the foot due to dry gangrene. Resident #6 also required amputation of the 3rd left toe related to gangrene in February 2023 and underwent revascularization. The clinical record failed to identify Resident #6's history of lower extremity ischemia or toe amputation prior to the facility obtaining prior MD progress notes on 11/21/25. Interview on 11/21/25 at 1:23 PM with MD #2 indicated that Resident #3 had a history of vascular disease (PVD) and amputation of some toes, but it was not noted in the EMR upon Resident #6's admission on [DATE]. MD#2 identified if Resident #6 had history of gnawing, bleeding to his/her fingers, the expectation would for Resident #6's fingers to be monitored at least daily due to the history of PVD. Interview on 11/24/25 at 9:53 AM with Licensed Practical Nurse (LPN) #1 identified on 10/13/25 and 10/20/25 she performed a skin assessment for Resident #6 documenting the resident's skin was intact and that she usually performs skin assessments for residents on their shower day. The assessment was not completed by an RN.Interview on 11/25/25 at 12:25 PM with MD #1 (Medical Director) identified Resident #6 had a diagnosis of PVD which made Resident #6 more at risk for delayed healing or no healing at all, risk for infection and risk for ischemia (low or no blood flow) of any extremities with open or emaciated areas identified. MD #1 identified Resident #6 had poor vasculature, blood flow and circulation due to PVD. MD #1 identified Resident #6 was at risk due to poor circulation, had gnawed, emaciated fingers, Resident #6 skin should have been monitored at least daily, the wound care nurse should have been notified with a treatment plan put in place, including monitoring, daily assessment with documentation having occurred daily in the progress notes. Review of the policy for Skin integrity dated 10/7/25 directed, in part, the facility was to provide proper treatment and care to maintain skin integrity. Also, identifying the attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, or any changes in the resident's medical condition. Further, identifying interventions will be modified in the resident's care plan as needed and report assessment and changes in condition to the provider. The above deficiency resulted in the finding of Immediate Jeopardy (IJ). The facility Administrator was provided with the IJ template on 11/20/25 at 2:00 PM and submitted a removal plan which was approved by the State Agency on 11/21/25.The Removal Plan noted in part, when the concern was identified on 10/26/25 the DNS and charge nurses performed a thorough skin assessment of Resident #6, documented the findings and conducted a comprehensive audit for all resident care plans and behavior monitoring practices for accuracy. The removal plan also indicated staff education was conducted related to resident behaviors, clinical monitoring, escalation, documentation and physician notification. Additionally, the removal plan identified staff participated in education training and competency to ensure understanding of policies related to resident behaviors, quality of care, clinical monitoring, escalation and documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, interviews and facility policy for 1 of 3 sampled residents (Resident #12) reviewed for pressure ulcers, the facility failed to ensure the alternating pressure mattress was set correctly. The findings include: Resident #12 was admitted to the facility in January 2024 with diagnoses that included dementia, osteoporosis, and mobility impairment. The quarterly Minimum Data Set, dated [DATE] identified Resident #12 was severely cognitively impaired, was dependent on staff for all of activities of daily living, required assistance of 2 for transfers with a mechanical lift, and was at risk for developing pressure ulcers/injuries. Additionally, the MDS identified Resident #12 did not have a pressure ulcer.The physician's orders (undated) directed to apply Triad paste (a zinc-based sterile wound dressing in paste form) to the coccyx two times a day, skin prep to bilateral heels twice a day, mechanical lift for transfers and weekly skin checks. The physician's orders lacked an order for the alternating pressure air mattress (that Resident #12 was observed to be lying on), as directed per the facility policy.The Resident Care Plan dated 11/3/25 identified Resident #12 as being at risk for skin breakdown related to incontinence and decreased mobility. Interventions included applying Triad paste to coccyx twice a day, skin prep to bilateral heels twice a day, inspect the skin weekly, transfer using a stand lift, and incontinent care after each incontinent episode and as needed. The care plan failed to reflect the use of an alternating pressure mattress as a preventive measure for skin breakdown. Observation on 11/18/25 at 10:45 AM (during the initial tour of the facility) noted although Resident #12 was not in bed, an alternating pressure mattress was present on the bed and set at 240 pounds (lbs.). Resident #12's clinical record identified that Resident #12's weight was 100 lbs. Observations on 11/19/25 at 2:35 PM and 11/20/25 at 8:49 AM noted Resident #12's was lying in bed on his/her back with the alternating pressure mattress set at 240 lbs. (despite Resident #12's weight of 100 lbs.). Interview and review of the clinical record with RN #1 (Resident Care Plan Coordinator) on 11/20/25 at 12:35 PM identified that Resident #12 did not have the alternating pressure mattress in his/her care plan nor were there any settings established for alternating pressure mattress. RN #1 indicated that the alternating pressure mattress was in place as a preventive intervention to prevent skin breakdown. Furthermore, RN #1 indicated that the Nurse Aide (NA) care card did not reflect that Resident #12 was on an alternating pressure mattress and the mattress should be set by Resident #12's weight. RN #1 indicated that the charge nurse and NA should know how to set the air mattress according to Resident #12's weight and was not sure of the reason the mattress was set at 240 lbs. Interview with NA #4 on 11/20/25 at 1:00PM indicated she was unaware of Resident #12's alternating pressure mattress setting. In addition, NA #4 was unsure where to obtain the information.Subsequent to surveyor inquiry, the alternating pressure air mattress setting was changed to reflect weight of 100 lbs and Resident #12's care plan was updated to include the alternating pressure air mattress.The manual for the alternating pressure mattress utilized on Resident #12's bed, printed in 2021, directed to set the air mattress according to the weight and height of the patient, adjust the weight setting to the most comfortable level without bottoming out. The pressure in mattress will slowly increase to the weight settings displayed on panel, approximately 45 minutes. Once fully inflated the air mattress is ready to use. May set the cycle time if needed.The facility Air Mattress Policy dated 3/15/25 directed, in part, the facility shall provide appropriate pressure-redistribution surfaces, including air mattress systems, when clinically indicated for residents who are at risk for or have existing pressure injuries. Air mattresses will be ordered based on individualized assessment, provider order and Interdisplinary team review. All use must comply with standards of practice, manufacturer recommendations, and state/federal regulations.

Based on review of facility documentation, facility policy and interviews regarding the employment of an Infection Preventionist, the facility failed to designate an individual with the required training and certification to oversee the Infection Control Program. The findings include: Interview with the Director of Nursing Services (DNS) on 11/19/25 at 2:00 PM identified that she was designated as the Infection Preventionist (IP) in October 2025 until a new IP was hired to the position.Interview with Registered Nurse (RN) #8 on 11/24/25 at 10:30 AM identified she was a full time RN-Designee at the Assisted Living Services Agency (another entity of the Long Term Care Facility) and was not actively a facility employee. RN #8 identified she had assisted the previous IP in the past around 2 times a week with training on support in her IP position but since the DNS took over coverage for the IP position, she only helped to answer questions periodically when the DNS called her. RN #8 identified that she did not review infection prevention documents and reports at the facility, and that the last time she assisted with the creation of reports was when the previous IP was in the position. Interview with the DNS on 11/24/25 at 1:00 PM identified that she contacted RN #8 at times with questions but that she managed all the Infection Preventionist duties including surveillance, antibiotic stewardship, reports, etc. on her own. The DNS identified she had not started or completed specialized training for Infection Prevention because it had not been her intention to cover the IP position for any length of time, and she was not aware of the free online training offered by the Centers for Disease Control and Prevention (CDC). The DNS further identified the facility had just posted an advertisement for a part-time (24 hour) infection preventionist.Review of the Infection Prevention and Control policy directed, in part, the designated IP is responsible for the oversight of the program and serves as a consultant to the staff on infectious diseases, surveillance, implementing isolation precautions, staff and resident exposures, and investigations of exposures of infectious disease. The policy failed to identify the specialized infection prevention training requirements of the designated IP that were necessary to meet federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided gently when staff repositioned Resident #1 and staff pulled on Resident #1's wrist to turn him/her in the bed. The findings include:Resident #1's diagnoses included dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of one out of fifteen, indicative of severe cognitive impairment, was incontinent of bowel and bladder, was dependent on staff for personal hygiene, and required maximal assistance with bed mobility. The Resident Care Plan (RCP) dated 9/17/2025 identified incontinence, alteration in mobility, becomes easily agitated with occasional aggressive outbursts. Interventions directed two (2) staff for personal care, wrap a bath towel around quarter side rails to prevent injury when resistive or combative with care, use a calm approach and an unhurried manner when dealing with Resident #1. The facility reportable event dated 9/30/2025 at 10:00 PM identified during morning care, Resident #1 was noted to flinch when his/her left hand was touched. On assessment, the left hand was mildly swollen with scattered bruising. The APRN assessed Resident #1, and an x-ray was obtained. X-ray results identified a distal (away from the arm) ulnar (larger of the two lower arm bones) fracture with mild displacement. Resident #1 was transferred to the hospital and returned to the facility on [DATE] with a splint in place. Review of hospital x-ray results dated 10/1/2025 identified a left wrist minimally displaced oblique fracture of the distal ulnar diaphysis (bone near the wrist that is angled and only slightly out of alignment). Narrowing of the radiocarpal joint (forearm bone on the thumb side) with negative ulnar variance (condition where the ulna bone is shorter than the radius bone) (smaller arm bone) may represent sequelae (caused by) of remote trauma. Soft tissue swelling of the distal forearm, impression: minimally displaced distal ulnar fracture. Review of the facility summary report dated 10/3/2025 identified Nurse Aide (NA) #1 and NA #2 provided incontinent care for Resident #1 on 9/30/2025 at 5 AM and NA #1 grasped Resident #1's shoulder and wrist and pulled him/her toward her (toward NA #1). A facility interview was conducted with NA #1, and NA #1's responses were erratic, stated I'm there for the heaviness and stated, she tossed him/her to me, and I tossed him/her back. NA #1 further described the resident as fussing and did not answer which part of Resident #1's body she grabbed or pulled. On 10/29/2025 at 3:25 PM voicemail message from MD #1 (facility contracted radiologist) at [JA1] 3:12 PM identified the cause of Resident #1's fracture was most likely caused by trauma. Interview and record review with NA #2 on 10/29/2025 at 12:46 PM identified on 9/30/2025 about 5 AM, she and NA #1 provided incontinence care for Resident #1. NA #2 stated Resident #1 was awake, smiling but not following commands, and was slightly resistive to turning, and as she turned Resident #1 toward NA #2 NA #1 grabbed the resident by the (left) wrist and shoulder and turned the resident towards her (NA #1). NA #2 stated NA #1 was getting frustrated, seemed to be in a hurry, and grabbed the resident's left hand hard and pulled him/her to roll over. NA #2 stated that when NA #1 grabbed Resident #1's wrist, he/she did not make any noise, but Resident #1 grimaced. Review of NA #1's statement dated 10/2/2025 at 11 AM obtained via phone by the DNS and Administrator, NA #1 identified NA #1 was waiting for the call because of the resident's arm, made erratic statements such as I'm there for the heaviness, and stated, she tossed him to me, and I tossed him back. NA #1 further stated Resident #1 was fussing, and did not provide information regarding where she grabbed or pulled Resident #1. 'Interview with NA #1 on 10/29/2025 at approximately 12:45 PM identified that NA #1 assisted NA #2 with care for Resident #1 on 9/30/2025, however, NA #1 declined to provide any additional information about the care provided. Interview with the DNS and Administrator on 10/29/2025 at 1:45 PM identified that the facility interview with NA #2 identified NA #1 was in a rush during care. When NA #2 and NA #1 turned Resident #1, he/she was not turning fast enough, so NA #1 yanked Resident #1 by the shoulder and wrist and NA #2 saw Resident #1 grimace. The DNS stated NA #1 should not have yanked Resident #1 over or grabbed Resident #1 by the wrist/hand to turn him/her over, and subsequent to the incident, NA #1's employment was terminated. The DNS stated at times Resident #1 was resistive and frightened during care, and NA #1 and NA #2 should have left the resident when he/she was not cooperating and reapproached later. Review of facility undated Abuse, Neglect and Exploitation Policy directed in part to prevent resident abuse. Abuse was defined as the willful infliction of injury resulting in harm or pain. Physical abuse was defined as including, but not limited to, hitting, slapping, and punching. Mistreatment was defined as inappropriate treatment of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include:Resident #1's diagnoses included dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of one out of fifteen, indicative of severe cognitive impairment, was incontinent of bowel and bladder, was dependent on staff for personal hygiene, and required maximal assistance with bed mobility. The Resident Care Plan (RCP) dated 9/17/2025 identified incontinence, alteration in mobility, becomes easily agitated with occasional aggressive outbursts. Interventions directed two (2) staff for personal care, wrap bath towel around quarter side rails to prevent injury when resistive or combative with care, use a calm approach and an unhurried manner when dealing with Resident #1. The facility reportable event dated 9/30/2025 at 10:00 PM identified during morning care, Resident #1 was noted to flinch when his/her left hand was touched. On assessment the left hand was mildly swollen with scattered bruising. The APRN assessed Resident #1, and an x-ray was obtained. X-ray results identified a distal (away from the arm) ulnar (larger of the two lower arm bones) fracture with mild displacement. Resident #1 was transferred to the hospital and returned to the facility on [DATE] with a splint in place. Record review identified Resident #1 returned to the facility on [DATE]. Review of hospital x-ray results dated 10/1/2025 identified a left wrist minimally displaced oblique fracture of distal ulnar diaphysis (bone near the wrist that is angled and only slightly out of alignment). Narrowing of radiocarpal joint (forearm bone on the thumb side) with negative ulnar variance (condition where the ulna bone is shorter than the radius bone) (smaller arm bone) may represent sequelae (caused by) of remote trauma. Soft tissue swelling of the distal forearm, impression: minimally displaced distal ulnar fracture. Review of facility summary report dated 10/3/2025 identified Nurse Aide (NA) #1 and NA #2 provided incontinent care for Resident #1 on 9/30/2025 at 5 AM. NA #2 reported she positioned Resident #1 on his/her left side and turned him/her towards NA #1. NA #2 reported NA #1 grasped Resident #1's shoulder and wrist and pulled him/her toward her (toward NA #1). Facility interview with NA #4 identified Resident #1 was pleasant and cooperative during the 3 to 11 PM shift and had no signs of distress. Facility interview with NA #2 identified about 5 AM, she and NA #1 provided incontinent care, and she positioned Resident #1 on his/her left side and turned him/her toward NA #1. NA #1 grasped Resident #1's shoulder and wrist and pulled Resident #1 toward her. Facility interview with NA #1 indicated she was waiting for the call (from the facility) because of the resident's arm. The Summary indicated NA #1's responses were erratic, stated I'm there for the heaviness and stated she tossed him/her to me, and I tossed him/her back. further, NA #1 described the resident as fussing and did not answer which part of Resident #1's body she grabbed or pulled. The Summary indicated Resident #1 sustained a left distal ulna fracture, and NA #1's employment was terminated. Interview, and facility documentation and record review with NA #2 on 10/29/2025 at 12:46 PM identified she was assigned to Resident #1 on 9/30/2025, and about 5 AM, she and NA #1 provided incontinence care for Resident #1. NA #2 stated she was on the left side of Resident #1 and turned Resident #1 toward NA #2. NA #2 stated Resident #1 was awake, smiling but not following commands, and was slightly resistive to turning and NA #1 grabbed the resident by the (left) wrist and shoulder and turned resident towards her (NA #1). NA #2 stated NA #1 was getting frustrated, seemed to be in a hurry and grabbed the residents left hand hard and pulled him/her to roll over. NA #2 stated when NA #1 grabbed Resident #1's wrist, he/she did not make any noise, but Resident #1 grimaced. NA #2 stated she and NA #1 should have stopped providing care when Resident #1 was not listening/following directions and should have returned and reapproached Resident #1 later. NA #2 stated she should have notified the nurse of the incident when it occurred. Review of NA #1's statement dated 10/2/2025 at 11 AM obtained via phone by the DNS and Administrator, NA #1 identified NA #1 was waiting for the call because of the resident's arm, made erratic statements such as I'm there for the heaviness, and stated, she tossed him to me, and I tossed him back. NA #1 further stated Resident #1 was fussing, and did not provide information regarding where she grabbed or pulled Resident #1. Interview with NA #1 on 10/29/2025 at approximately 12:45 PM identified that NA #1 assisted NA #2 with care for Resident #1 on 9/30/2025, however, NA #1 declined to provide any additional information about the care provided. Interview with the DNS and Administrator on 10/29/2025 at 1:45 PM identified the facility investigation included an interview with NA #2. NA #2 indicated NA #1 was in a rush during care and when she and NA #1 wanted Resident #1 to turn, he/she was not turning fast enough, so NA #1 yanked Resident #1 by the shoulder and wrist and NA #2 saw Resident #1 grimace. The DNS stated NA #1 should not have yanked Resident #1 over, or grabbed Resident #1 by the wrist/hand to turn him/her over, and subsequent to the incident NA #1's employment was terminated. The DNS stated at times Resident #1 was resistive and frightened during care, and NA #1 and NA #2 should have left the resident when he/she was not cooperating and reapproached later. The DNS stated the incident should have been by reported by NA #2 immediately when she witnessed NA #1 grab Resident #1 and the resident grimacing. Review of facility undated Abuse, Neglect and Exploitation Policy directed in part, to prevent resident abuse. Abuse was defined as the willful infliction of injury resulting in harm or pain. Physical abuse was defined as including, but not limited to, hitting, slapping, punching. Mistreatment was defined as inappropriate treatment of a resident. The Policy further directed staff to immediately report allegations of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #17 and Resident #36) reviewed for nutrition, for Resident #17 the facility failed to assess the resident's nutritional needs following a significant weight loss and for Resident #36, failed to follow a dietician's recommendation for nutritional supplements The findings include:
1. Resident #17's diagnoses included dementia with behavioral disturbances, chronic kidney disease, and iron deficiency anemia.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #17 as severely cognitively impaired and required set up assistance for eating, mechanical lift for transfers, and supervision for bed mobility.
A Quarterly Registered Dietician Review dated 10/5/23 identified that Resident #17's intake was variable but frequently 50% or less of meals were consumed. A recommendation for Medpass 2.0 (a nutritional supplement) 120 milliliters (ml) three times daily was given and was accepted by the physician.
The Resident Care Plan dated 10/11/23 identified that Resident #17 was at risk for a reoccurrence or worsening of congestive heart failure, weight loss related to diuretic (fluid reducing medication) use, and poor intake. Interventions included to provide assistance with meals as needed, offering alternative meal selections, notify the Dietician of any weight loss, and the Dietician was to follow up and reassess Resident #17 as needed.
Review of Resident #17's clinical record identified a weight of 105.6 pounds on 10/10/23 and a weight of 98.2 pounds on 11/14/23, which indicated a loss of 7.01% (7.4 pounds). An additional weight loss was noted on 1/16/24 when Resident #17 measured 86.0 pounds indicating a total weight loss of 18.56% over 3 months (19.6 pounds).
Review of the Dietician progress note dated 12/8/23 identified that Resident #17 had a 4 pound weight loss in the past month and 12.6 pound weight loss in the past 6 months for an 11.7% weight loss which was significant. Although the Dietician identified a significant weight loss, she failed to document a recalculation of Resident #17's nutritional needs for calories, protein requirements, usual body weight, and desired weight range.
A Registered Dietician Quarterly Review dated 1/5/24 identified that Resident #17's meal intake was poor, s/he had a significant 6% weight loss over the past month and a significant 13% weight loss in the past 6 months due to illness and overall decline. After discussion with the interdisciplinary team, it was decided to continue the regular diet and supplements, and that staff was to encourage the resident's intake.
A Dietician progress note dated 1/12/24 identified a physician order dated 1/11/24 directed the addition of house milkshakes, per a DNS request, to assist with improvement of overall intakes, calories, and protein.
In an interview and clinical record review with the Dietician on 1/23/24 at 10:57 AM, she indicated she had failed to recalculate Resident #17's nutritional needs since 7/25/23. The Dietician identified the facility policy directed calories, protein, usual body weight, and desired weight range be calculated on admission, annually, and with any significant change. The Dietician stated that she had not completed the calculations on the Quarterly Dietary Assessments dated 10/5/23 and 1/5/24 due to the implementation of a new EHR, in August of 2023 which eliminated the prompt to do so. The Dietician indicated that she would calculate and add the information manually in the future.
Interview with the DNS and Administrator on 1/23/24 at 11:17 AM indicated that the facility switched over their EHR in August of 2023, which was physically built by them, but they were not aware that the nutritional needs analysis was omitted. The DNS stated she reached out to the EHR supplier on 1/22/24 and that subsequent to surveyor inquiry, a template for nutritional analysis would be added to future Dietician assessments.
Review of the Nutritional Management policy dated 9/2023 directed, in part, that a comprehensive nutritional assessment would be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. The Dietician would use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether the intake was adequate to meet those needs.
2. Resident #36 was admitted on [DATE] with a diagnosis of Parkinson's disease, dementia, and depression.
The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #36 had severe cognitive impairment. Resident #36 required setup or clean-up assistance with eating and supervision or touching assistance with picking up objects. The admission assessment also indicated Resident #36 weighed 100 pounds (lbs.)
A review of the resident's documented weights identified that Resident #36 had a significant weight loss of 6.2%. On 12/6/23, Resident #36 weighed 100 lbs. On 1/3/23, the resident weighed 95 lbs. On 1/12/24, the resident weighed 93.8 lbs. (a 6.2 lb. weight loss).
A Dietician progress note dated 1/12/24 identified that Resident #36's documented weights were variable, and that the resident's oral intake was also variable. Additionally, the Dietician's progress note indicated that a house milkshake supplement twice a day was recommended due to possible weight loss.
The Resident Care Plan dated 1/12/24 indicated that Resident #36 was at risk for poor oral intake and at risk for weight loss. Interventions included maintaining a regular diet, checking weekly weights, and recommending a house milkshake twice per day.
A review of the January 2024 physician orders failed to identify a nutritional supplement had been ordered.
A review of the resident's documented oral intake record from 1/12/24 to 1/24/24 failed to identify a nutritional supplement was given.
A review of the Medication Administration Record (MAR) identified that Resident #36 did not receive a nutritional supplement from 1/12/24 to 1/22/24.
An interview with RN#3 on 1/22/24 at 2:40 PM identified that RN#3 did not give Resident #36 any supplements because the resident did not have a nutritional supplement ordered. RN #3 indicated that she would know if a resident received any nutritional supplements because a physician's orders would have been in place and the order would appear on the MAR. RN #3 indicated that house milkshakes came from the kitchen with the resident's meals. RN #3 also indicated that nurses documented the amount of nutritional supplement a resident consumed under a supplements category on the flowsheet and that supplements would not be documented under meals or snacks.
An interview with the Hospitality Dietary Manager on 1/22/24 at 2:55 PM indicated that the kitchen provided the house milkshakes and that either nurses or the Dietician would inform the kitchen of residents who required a house milkshake. The Hospitality Dietary Manager indicated that the kitchen has a list of residents who receive house milkshakes for each nursing unit. A review of the list for the Cedar unit identified that Resident #36 was included.
An interview with the Dietitian on 1/23/24 at 10:55 AM indicated that when recommendations were made during clinical rounds, the Director of Nursing (DNS) would have placed an order for the supplement. The Dietitian indicated that the recommendation for house shakes twice a day for Resident #36 was made during a clinical rounds meeting on 1/12/24 involving the DNS and the Assistant Director of Nursing but was unable to identify why there was no order for supplements for Resident #36. The Dietitian indicated that multiple supplements were available such as house shakes, Ensure, pro-source, and Medpass. The Dietitian stated she had recommended house shakes twice daily for Resident #36 and that each 4 ounce house shake would have provided the resident with 220 calories and 6 grams of protein.
In an interview, medical record review, and observation with RN #2 on 1/23/24 at 11:40 AM she identified that she had given Resident #36 the nutritional supplement Medpass 2.0 after breakfast and lunch. RN#2 indicated that she knew the resident needed a supplement because she has taken care of the resident often and that there was also a physician's order for supplements. A medical record review with RN #2 identified that there was no physician order for supplements, and she was unable to explain how she knew what supplement to give or how often the supplement should have been administered. RN #2 indicated that the supplement was stored in the nursing unit supply room. An observation of a carton of Med-Pass 2.0 with RN #2 identified that one serving of Med-Pass 2.0 was 8 ounces and provided 480 calories and 20 grams of protein per serving.
An interview with the DNS on 1/23/24 at 12:15 PM indicated that nutritional supplements were not discussed with the Dietitian during the clinical meeting on 1/12/24. The DNS indicated that if supplements had been discussed, they would have been reflected on the minutes taken during the meeting. The DNS also identified that a supplement order would have been placed by nursing after a discussion with the physician or provider. Additionally, the DNS indicated that nurses were expected to document nutritional supplements in the electronic MAR and that nurses were also expected to document the amount of the supplement the resident consumed.
The facility's Nutritional Management policy indicated that part of the process for optimizing a resident's nutritional status was to develop and consistently implement pertinent approaches, including weight-related interventions and offering real food before supplements.

Based on observation of the Dietary Department, staff interview, and facility policy, the facility failed to ensure cleanliness of the kitchen, a food items were labeled when opened, contained an expiration date, failed to failed to perform hand hygiene, and adequately store a chemical solution away from food. The findings include:
Tour of the Dietary department on 1/18/24 at 10:32 AM and 1/23/24 at 12:16 PM with the Director of Dietary identified the following:
1a. A 1 gallon container that was 1/4 full of fresh, peeled garlic was observed to be located inside the reach in cooler and was noted to be opened but not labeled with the date of opening, contained a green substance inside the container and lacked an expiration date.
b. A five gallon plastic container containing loose flour (almost full) was not dated to identify when the flour was placed into the container and failed to identify the expiration date.
c. A five gallon plastic container containing loose sugar (approximately 3/4 full) was not dated to identify when the sugar was placed into the container and failed to identify the expiration date.
d. The ceiling tiles, plastic molding strip on the wall above the spice rack, and the light covering above the steam table where food was being plated was noted to have a heavy accumulation of dust/debris.
e. A red container (approximately 3 gallons) containing a chemical solution (which he later identified as Multi-Quat Sanitizer) was stored adjacent to food items during the plating of food.
On 1/18/24 at 10:32 AM, interview with the Director of Dietary identified he did not know and does not know the reason the fresh peeled garlic was not dated after opening and could not locate an expiration date on the container. Additionally, the Director of Dietary identified being unaware that containers were to be dated when opened (flour and sugar). He also identified being unaware that a sanitizing chemical solution adjacent to food items should not be stored next to food.
Additionally, the Director of Dietary identified Housekeeping was responsible for cleaning the dust off the ceiling because Dietary did not have the tools reach the ceiling.
2a. Observation of the tray line on 1/23/24 at 12:16 PM, identified the Director of Dietary was plating food from the steam table and a red 3 gallon plastic container which contained a liquid substance (which he later identified as Multi-Quat Sanitizer) with 3 knives was located on a metal cart adjacent to steam table where food was being plated. Upon further observation, the Director of Dietary was noted to take a knife out of the Multi-Quat Sanitizer container, bring it across and over the steam table, wiped the knife with a towel and cut a sweet potato, which caused the potential for the liquid substance to drip sanitizer solution from the knife into the food on the steam table.
Additionally, the ceiling tiles and the light covering above the steam table where food was being plated was still noted to have a heavy accumulation of dust/debris, although the plastic molding strip on the wall above the spice rack was cleaned.
b. Observation of the tray line on 1/23/24 at 12:43 PM, identified the Director of Dietary picked up a piece of chicken with his gloved hands, place it on the steam table prep area, held the chicken with his gloved hands, cut the chicken with a knife, and placed it on a plate. The Director of Dietary then took his gloves off but did not wash his hands before putting new gloves on. Additionally, he was observed to take a piece of fish with a utensil, use his gloved hands to hold the fish to cut it up and transfer onto a plate with his gloved hands without handwashing in between the glove changes.
Interview with the Director of Dietary on 1/23/24 at 1:10 PM identified he knew to wash his hands after touching the chicken with his gloved hands and before donning new gloves and thought he did.
Facility policy regarding Maintaining a Sanitary Tray Line identified wash hands before and after wearing or changing gloves.
Facility policy regarding Food Safety Requirements identified labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen/ discarded; and keeping foods covered or in tight containers.
The Safety Data Sheet regarding Multi-Quat Sanitizer identified do not ingest, may be harmful if swallowed.

Based on observations, facility documentation, and interviews for 11 of 11 residents (Resident #'s 1, 7, 16, 22, 27, 29, 42, 44, 46, 401, and 402) interviewed during the Resident Council meeting, the facility failed to ensure survey results were accessible to residents. The findings include:
An observation on 1/23/24 at 9:35 AM identified the state survey inspection results were located in the lobby at the entrance to the facility. Access to the lobby from the nursing units was noted to be key coded (locked) for exit.
An interview with the Resident Council members, Resident #'s 1, 7, 16, 22, 27, 29, 42, 44, 46, 401, and 402 on 1/22/24 at 3:25 PM indicated they were unaware of the state survey results location.
Interview with Receptionist #1 on 1/23/24 at 10:01 AM indicated that family members and staff were the only individuals that have the code to gain access from the nursing units to the front lobby. Receptionist #1 denied residents had the exit code.
Interview with the ADNS on 1/23/24 at 10:44 AM indicated that staff and the receptionist were the only individuals who have the exit code from the nursing units to the lobby.
Observation on 1/23/24 at 10:45 AM identified a sign located on the ASH unit bulletin board indicating that copies of the state inspection reports were available in the lobby and the great room (within the resident units).
Observation on 1/23/24 at 10:55AM in the great room failed to identify state survey inspection results.
Interview with the Life Enhancements Director on 1/23/24 at 11:00 AM indicated that she was unable to locate the state survey inspection results in the great room. Additionally, she was not aware that the survey results were required to be readily accessible to residents without requesting assistance.
Although requested, the facility failed to provide an access to survey results policy.

Based on observations, review of facility policy and interview for 2 of 5 resident living units, the facility failed to ensure that all residents, except those assessed to require a secured unit, were allowed to freely move off the unit or about the facility resulting in the finding of a pattern of involuntary seclusion. The findings included:
Observation during tour on 1/18/24 noted that the exit doors to the resident care units, Elm, and Fir, were always locked and exiting required a security code. Although it was noted that some alert and oriented residents had been provided with the code to open the doors, other residents were unable to independently exit the unit.
Interview with the Administrator and Director of Nursing on 1/24/24 at 11:40 AM identified the facility lacked policies and procedures for assessing which residents required living on a secure unit and that there was no facility documentation, in any resident's clinical record, for those residents residing on the locked units, indicating criteria for secured/locked area placement. The Administrator indicated the doors were locked for safety. The DNS indicated that, in the past, the facility had a key card available at the door allowing exit, but when an exit seeking resident learned to use the key card, approximately 1 year ago, a keypad was installed. Further, the Administrator identified that the residents/resident representatives for residents unable to independently exit the units, were never informed that residents placed on the Elm and Fir Units were being housed in a locked unit. Although the Administrator identified the facility had an elopement policy assessing residents for wandering and elopement the facility did not have a policy that directed facility staff to assess residents to meet a criterion for being placed on a locked unit, and/or to notify resident/resident representatives of locked unit placement.
Subsequent to surveyor inquiry, the keypad to the resident Elm and Fir Units was unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Resident #6 and #19) reviewed for unnecessary medications, the facility failed to initiate a care plan for an anticoagulant (blood thinning) medication. The findings include:
1. Resident #6 had diagnoses that included heart failure, atrial fibrillation, and falls.
The Quarterly MDS (minimum data set) assessment dated [DATE] identified Resident #6 was without cognitive impairment and required partial/moderate assistance with transfers and supervision/touch assistance with ambulation. Additionally, the MDS had anticoagulation coded for consideration for care planning.
The physician's order dated 8/1/23 directed facility staff to administer Eliquis (an anticoagulation medication) 2.5 milligrams (mg) twice daily.
Review of the Resident Care Plan failed to identify a care plan related to the use of an anticoagulant medication.
Review of the NA care card (care plan) failed to identify that NA staff were to monitor for bruising/bleeding (due to blood thinner use)
Review of the nurse's notes from 6/7/23 to 1/22/24 failed to identify that the facility was monitoring Resident #6 for signs and symptoms of bleeding due to anticoagulation therapy.
Interview and review of facility care plan from 6/7/23 to 1/22/24 with RN #1 (MDS coordinator) failed to identify the facility had developed a care plan for the use of the anticoagulant medication.
2. Resident 19's diagnoses included dementia with behavioral disturbance, insomnia, and atrial fibrillation.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was severely cognitively impaired and required supervision with personal hygiene. Additionally, the MDS had anticoagulation coded for consideration for care planning.
The physician's order dated to 8/1/23 directed the administration of Eliquis (apixaban)(a blood thinner) 2.5 mg 1 tab every day.
Review of the Resident care plan failed to identify a care plan related to the use of an anticoagulant.
Interview and review of facility care plan from 3/27/23 to 1/22/24 with RN #1 (MDS coordinator) failed to identify the facility had developed a care plan for the use of the anticoagulant medication. Further, RN #1 indicated that care plans were used to direct facility nursing and NA staff how to care for residents. RN #1 indicated that the charge nurse as well as herself were responsible to update the care plan and that a care plan for the anticoagulant use should have been in place for both Resident #6 and Resident #19. RN #1 was unable to explain why there were no Resident Care Plans related to anticoagulant use.
Review of facility Comprehensive Resident Care plan policy dated 10/11/22 directed, in part, that the comprehensive care plan would be developed within 7 days after completion of the comprehensive MDS assessment. All care assessment areas triggered by the MDS would be considered in developing the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for the only sampled resident (Resident #10) reviewed for hearing loss, the facility failed to review and revise the care plan when a hearing aid was unavailable. The findings include:
Resident #10's diagnosis included dementia, age related cognitive decline, and anxiety.
The MDS assessment dated [DATE] identified Resident #10 had moderate hearing loss, was severely cognitively impaired, and required assistance with eating, personal hygiene, and transfers.
The Resident Care Plan dated 1/10/24 identified Resident #10 had hearing loss and required bilateral hearing aids. Interventions included assisting with proper care and maintenance of hearing aids, audiology consults as ordered, and use simple and direct communication.
A nurses note dated 12/2/23 at 6:52 PM identified that Resident #10 was transferred to the hospital with his/her right hearing aid.
A re-admission nursing observation document dated 12/7/23 identified bilateral hearing aids.
A physician's order dated 12/21/23 directed nursing staff to confirm Resident #10 was wearing the left hearing aid.
Observations on 1/19/24 at 12:19 PM and 1/22/24 at 9:12 AM identified Resident #10 was wearing a left hearing aid but no right hearing aid.
Interview with RN #4 on 1/22/24 at 11:09 AM identified she was told Resident #10's right hearing aid was lost at the hospital and because she had not been working at the time, it had not been her responsibility to revise the care plan.
Interview with Social Worker #1 on 1/22/24 at 1:12 PM identified she was aware that Resident #10's right hearing aid was missing but failed to document the incident or update the care plan.
Interview with the DNS on 1/23/24 at 11:17 AM indicated that the current care plan had not been updated to reflect the loss of Resident #10's hearing aid at the hospital, however it was her expectation for facility staff revise resident care plans when resident needs changed.
Subsequent to surveyor inquiry, the Resident Care Plan was revised by Social Worker #1.
Review of the Comprehensive Care Plans policy dated 10/11/22 directed, in part, that comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observations, review of facility documentation, facility policy, and interviews, the facility failed to ensure laundry was handled in a clean manner. The findings include:
During a tour of the soiled laundry area on 1/22/24 at 12:00 PM, two barrels, used to contain dirty linen, were in direct contact with a clean rack of personal clothing items that were under a mesh cover. In the clean laundry folding areas, two of the three ceiling intake valves were coated with a gray substance. Additionally, in the clean laundry area, one running fan, coated with a gray substance on the blades and the grill, was blowing directly on the table where clean linen was folded.
Interview, observation, review of facility documentation, and review of facility policy on 1/22/24 at 12:08 PM with Laundry Operator #1, indicated that the facility policy was to keep clean and dirty laundry items separated (dirty laundry barrels from the clean personal clothing rack) and clean items should not be stored in the soiled linen area. Laundry Operator #1 identified that the gray substance on the ceiling vents and on the fan was lint from the dryers, that according to the facility policy fans should have been cleaning monthly, and that there was a cleaning log which recorded laundry cleaning responsibilities when completed. Review of the laundry cleaning log identified the last time staff had completed the log for the laundry area had been in March and April of 2023 (8 months prior). Laundry Operator #1 indicated all laundry staff were responsible for cleaning, he was unsure why clean and soiled linen were together in the soiled area but may have been due to a lack of clean area storage space, and he was unable to indicate why the cleaning policy had not been followed since April of 2023.
Interview on 1/24/24 at 11:36 AM with Director of Facilities identified laundry staff should be looking at the vents and fans and initiating cleaning when the items were identified as dirty. The Director of Facilities indicated that the daily cleaning log failed to include fans, but he would be revising the form to include fan cleaning. Further, he stated clean and dirty laundry should always be stored in separate areas, clean laundry should not be stored in the soiled receiving area, and that subsequent to surveyor inquiry, the staff had moved the clean laundry from the soiled area.
Review of the Laundry policy dated 1/27/22, directed, in part, soiled laundry shall be kept separate from clean laundry at all times.
Although requested, a facility policy for environmental cleaning of the laundry room was not provided.

Based on interviews, review of employee files, and facility policy for 3 of 3 Nurse Aides (NAs) reviewed (NA #4, NA #5, and NA #6), the facility failed to complete an annual performance appraisal for NA #4, NA #6 and failed to complete a 90 day evaluation for NA #5 per facility policy. The findings include:
1. NA #4 was hired on 3/10/10, had an annual evaluation last completed on 7/2/19 but failed to reflect subsequent annual performance appraisals had been completed.
2. NA #5 was hired on 12/4/20, was due for a 90 day evaluation on 3/4/20 which had not been completed as of 10/27/21.
3. NA #6 was hired on 9/1/04 with a last annual performance evaluation completed on 5/1/19 but failed to reflect subsequent annual performance appraisals had been completed.
Facility policy regarding Performance Review stated the performance reviews are completed annually on the date designated by the facility each year and are to be conducted after the first 90 days of employment and annually on the date designated.
Interview with the Human Resource Specialist identified that all evaluations/appraisals were put on hold due to COVID-19. Upon further inquiry, Person #2 also stated that a new process for evaluations was in the process of being developed and that she was directed by management to suspend completing annual employee performance appraisals in 2020 and 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for 1 of 4 sampled residents (Resident #263) reviewed for accidents, the facility failed to ensure a mechanical transfer was provided according to the plan of care. The findings include:
Resident #263's diagnoses included Diabetes Mellitus, osteoporosis, osteoarthritis, muscle weakness and cervical spondylosis.
A Resident Care Plan (RCP) dated 4/4/19 identified a problem with a self-care deficit, generalized weakness, difficulty with transfers and needing assistance. Interventions included to provide assistance of 2 for transfers, toilet use, bathing, grooming, and dressing. Additional interventions included to encourage maximum level of performance and adequate time for self-performance, asses for decline in function, and rehabilitation screens as needed.
A physician's order dated 5/6/19 directed to transfer Resident #263 with assistance of 2 using a Sara lift, including toilet use and showering and to discontinue stand pivot transfers.
An activities of daily living daily care list audit trail document dated 5/6/19 identified Resident #263 RCP intervention for transfers was changed to a Sara lift (sit to stand mechanical lift) with assistance of 2 staff.
The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #263 with moderate cognitive impairment, extensive 2 person assistance with bed mobility, transfers, dressing and personal hygiene. The MDS further identified Resident #263 was non ambulatory and utilized a wheelchair.
Nurse's notes dated 9/29/19 at 3:57 PM identified Resident #263 was alert, at approximately 11:30 AM complained of right shoulder pain during a Sara lift transfer and was unable to raise his/her arm above his/her head. Resident #263 was assessed promptly, was crying out, could not perform range of motion, and no swelling or redness was present. Resident #263 was encouraged to place his/her arm in a comfortable position, the on call physician was notified and directed Tramadol 50 mg to be given immediately and a stat x-ray was ordered. Resident #263 was kept in safe and comfortable position.
A portable x-ray report of the right shoulder dated 9/29/19 identified a recent moderately displaced fracture of the right humerus and moderate osteoarthritis of the right shoulder joint.
A nurse's note dated 9/29/19 at 5:43 AM identified Resident #263's x-ray results were reported to the Advanced Practice Registered Nurse (APRN #1) and was directed to send Resident #263 to the Emergency Department (ED) for evaluation and treatment. Resident #263's family member was at the bedside and accompanied Resident #263 to the hospital. The ambulance arrived approximately 6:40 PM and Resident #263 was transferred to the ED at approximately 7:20 PM. Resident #263 returned to the facility at 11:30 PM with a full right arm cast in place, the Nursing Supervisor was updated, and Resident #263's family member was in presence. Resident #263 was resting in his/her room with safety precautions maintained and the call bell in reach.
An After Visit summary from the ED dated 9/29/19 identified that Resident #263 was seen in the ED and found to have had moderate swelling above the mid humeral shaft region and mild ecchymosis surrounding the area as well. X-ray of the right shoulder two views identified there was a spiral fracture of the mid to distal right humerus with lateral displacement of the distal fracture fragment.
A Reportable Event form dated 9/29/19 identified that Resident #263 complained of pain to the right shoulder and was unable to raise his/her arm during a Sara lift transfer.
A physician's progress note dated 9/30/19 at 9:05 PM identified Resident #263 had a closed spiral fracture through the mid to distal right humerus with lateral displacement of the distal fracture fragment without trauma superimposed on moderate glenohumeral arthrosis. Additionally, the physician's progress note identified Resident #263 was suspected of having osteoporosis due to chronic use of prednisone, post-menopausal and impaired mobility; in addition, bony demineralization seen on prior x-ray.
Interview with the DNS on 10/26/21 at 11:00 AM identified Resident #263 was previously living at an Assisted Living facility (ALSA) that was associated with the Long Term Care facility. The DNS further identified NA #2 was a private duty NA who was hired for Resident #263 by his/her family while Resident #263 was at the ALSA and continued to assist with Resident #263's care in the nursing home.
Additionally, the DNS identified that NA #2 did not follow Resident #263 plan of care as Resident #263 required assistance of 2 with a Sara lift and NA #2 provided the transfer alone (without the assistance of another staff member). The DNS did not recall if NA #2 received specific training related to the duties of a NA in the nursing home as NA #2 previously worked for the ALSA section and prior to Resident #263 requiring a Sara lift.
In an interview with NA #2 on 10/26/21 at 12:26 PM identified that she was hired by the ALSA section in January of 2018, was familiar with Resident #263 and went to the nursing home side with Resident #263 as his/her private duty NA. NA #2's duties for Resident #263 included all activities of daily living (ADL's) including transferring Resident #263 in and out of bed. NA #2 identified that she was assisting Resident #263 on 9/29/19 by lifting him/her alone from the bed into the wheelchair using the Sara lift when Resident #263 started yelling and saying his/her arm hurt and could not move it. NA #2 indicated that she had always assisted Resident #263 with ADL's and that she was waiting for someone to assist her with transferring Resident #263, but that Resident #263 was getting agitated and wanted to get out of bed right away. NA #2 further identified that she knew mechanical transfers required 2 staff members but decided to transfer Resident #263 via the Sara lift by herself. NA #2 indicated that she did some type of orientation at the ALSA, but she did not remember ever having an orientation or competency review for any equipment since Resident #623 began utilizing a mechanical type lift (Sara lift).
In an interview with NA #3 on 10/27/2021 at 10:00 AM identified that she recalled Resident #263 was on her assignment for 9/29/19 but that NA #2 did not request any assistance to help with care or to transfer the resident. NA #3 identified that Resident #263 required two people with assistance out of bed utilizing a Sara lift
Facility employment separation documentation identified that NA #2 was terminated on 9/29/10 due to violation of facility mechanical lift transfer policy.
Facility policy related to Safe Resident Handling/Transfer directed that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guideline. The policy further directed that mechanical lifts may include equipment such as full body lifts (Hoyer) and sit to stand lifts (Sara lift) and that two staff members must be utilized when transferring residents with a mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and staff interview for 5 residents (Residents #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for resident assessment, the facility failed to ensure the Discharge assessment-return not anticipated MDS' were transmitted to the CMS System according to established timeframes. The findings include:
1. Resident #1 was admitted to the facility on [DATE] and discharged on 5/6/21. The Discharge assessment-return not anticipated MDS was completed on 5/7/21. Interview with the MDS Coordinator, RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 5/18/21 however, was not transmitted per the validation report.
2. Resident #2 was admitted to the facility on [DATE] and discharged on 5/10/21. The Discharge assessment-return not anticipated MDS was completed on 5/12/21. Interview with the RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 5/18/21 however, was not transmitted per the validation report.
3. Resident #3 was admitted to the facility on [DATE] and discharged on 5/10/21. The Discharge assessment-return not anticipated MDS was completed on 5/12/21. Interview with the RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 5/18/21 however, was not transmitted per the validation report.
4. Resident #4 was admitted to the facility on [DATE] and discharged on 6/17/21. The Discharge assessment-return not anticipated MDS was completed on 6/21/21. Interview with the RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 6/22/21 however, was not transmitted per the validation report.
5. Resident #5 was admitted to the facility on [DATE] and discharged on 6/17/21. The Discharge assessment-return not anticipated MDS was completed on 6/22/21. Interview with the RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 6/22/21 however, was not transmitted per the validation report.
Interview with the MDS Coordinator, RN #1 on 10/25/21 at 2:45 PM identified the Discharge assessment-return not anticipated MDS should be transmitted within 14 days of the completion date. Additionally, RN #1 indicated Discharge assessment-return not anticipated MDS' for Residents #1, 2, 3, 4 and 5 were not transmitted. RN #1 indicated although the MDS' were were batched to go, they did not transmit. RN #1 could not explain why the MDS' were not transmitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #63) reviewed for accidents, the facility failed to ensure timely notification of Resident #63's physician and responsible person when a change in skin integrity was identified. The findings include:
Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, encephalopathy, atrial fibrillation and history of a cerebral vascular accident.
A physician's order dated 5/1/19 directed to administer Eliquis (a medication to treat and prevent blood clots) 2.5 mg twice a day.
The quarterly MDS assessment dated [DATE] identified Resident #63 had moderately impaired cognition, required extensive two-person physical assistance with mobility and transfers and utilized a wheelchair.
The Resident Care Plan (RCP) dated 2/21/20 identified Resident #63 required assistance with activities of daily living and was unsteady with transfers. Interventions included to encourage maximum level of performance, assess for decline in function, and rehabilitation screens as needed.
Additionally, the RCP dated 2/21/20 indicated Resident #63 had the potential for injury related to the use of Eliquis. Interventions included to avoid straining with blowing nose, assess for bone, abdomen or joint pain, and to observe for active bleeding.
A monthly nursing summary dated 3/18/20 identified Resident #63 utilized a wheelchair and was dependent for transfers with a mechanical lift.
A Reportable Event form dated 3/30/20 at 11:00 AM identified Resident #63 was found to have bruising/skin tear to his/her bilateral shin area. The Reportable Event form also identified MD #1 and the resident's representative were notified of Resident #63's injury on 3/31/21 (more than 24 hours after the change in skin integrity was identified).
A Post Incident Assessment/Evaluation form dated 3/30/20 identified Resident #63 got agitated at times and used a Sara lift. Additionally, staff were unable to explain how the injury occurred, and there were no witnesses.
A statement obtained by the facility from Nurse Aide (NA) #1 dated 3/30/20, identified that when she cared for Resident #63 on 3/30/21 during the 3:00 PM to 11:00 PM shift, she observed dry healing areas on Resident #63's legs and the resident did not report pain.
A nurse's note dated 3/31/20 at 12:30 PM identified bruises to Resident #63's bilateral shins and house moisture was applied.
A skin evaluation form dated 3/31/20 at 1:37 PM identified Resident #63 had a friction shear skin condition that had the treatment of Bacitracin twice a day for 7 days.
A nurse's note dated 3/31/20 at 3:20 PM identified Resident #63 had discolored areas on lower the shins with small patches of dry skin that looked like scabs. Subsequent to MD #1's notification, a treatment was ordered. Additionally, the note indicated the resident's representative was notified (more than 24 hours after the change in skin integrity was identified).
Physician's order dated 3/31/20 directed to cleanse left and right shin with Normal Saline, pat dry and apply a small film of Bacitracin ointment. Additionally, the physician's order directed to apply Tubigrips to both lower legs at all times for protection.
A physician's progress note, written by MD #1 dated 3/31/20 at 11:26 PM identified Resident #63 had anterior skin abrasions on both shins that were healing. The resident was unable to state the circumstances surrounding the event. Skin abrasions didn't appear infected at the time of the evaluation, topical Bacitracin twice daily was ordered.
A statement obtained by the facility from LPN #1 and dated 3/31/20 identified that on 3/30/20 at approximately 9:30 AM, Resident #63's private duty Nurse Aide reported that Resident #63 had bruising on both shin areas. Subsequently, LPN #1 observed the resident's legs and noticed the bruising was yellow and faded. LPN #1 indicated that on 3/31/21 she notified the physician.
Although a call was placed to LPN #1, an interview was not obtained.
Although a call was placed to MD #1, an interview was not obtained.
The resident monitoring for Reportable Events policy (accidents/injuries) identified all residents will be assessed and monitored following a Reportable Event (accident/injury). The policy directs that the supervisor, physician and resident's family will be notified. Further, the policy directs documentation in the clinical notes to include a description of the incident, injury sustained and the notification of the physician and family and measures and/or treatments.
Although the Reportable Event form dated 3/30/20 identified Resident #63 was found to have bruising/skin tears to the bilateral shin areas, MD #1 and the resident's representative were not notified until more than 24 hours later on 3/31/20.