Hamden Rehabilitation & Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documents and staff interview for 1 of 3 residents (Residents #71) reviewed for abuse, the facility failed to ensure staff documented clinical findings of the resident's condition for 2 shifts during the 72-hour post fall period. The findings include: Resident #7's diagnoses included Alzheimer's disease, cervical vertebrae fracture and history of back pain. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 as severely cognitively impairment, required partial to moderate assistance with a walker for transfer and ambulation, noted no falls since admission, had a fall in the last month and fall with a fracture in the last 6 months. The care plan dated 5/08/2025 indicated Resident #71 was at risk for falls due to a history of falls weakness impaired mobility and safety awareness. Interventions included: to ensure resident is positioned in the center of the bed during rounds, encourage not to get up alone, ensure resident is wearing nonskid socks, explain all tasks, encourage use of the call bell and to place commonly used items within reach. A progress note dated 8/2/2025 at 10:49 AM indicated the Registered Nurse supervisor was called to the unit and noted Resident #71 lying on his/her right side on the floor, the resident was able to move all extremities without complaints of pain and no injuries noted. The Advanced Practice Registered Nurse (APRN) was notified, and no new orders were obtained at that time. The progress notes dated 8/02/2025at 12:36 PM written by the charge nurse on duty identified Resident #71had an unwitnessed fall reported to him/her at 8:36 AM. The resident was noted on the floor at the entrance to the bathroom verbally denying pain, once the resident was cleared upon standing. The resident complained of some back pain and received Tylenol as scheduled for back pain with some positive effect and the RN supervisor was updated. Vital signs and neurological checks were initiated after the fall and Resident #71 required constant redirection and reminders not to get up on her/his own. A nursing progress note written by the 7-3 PM supervisor on 8/02/2025 at 3:17 PM identified Resident #71 was noted grimacing from pain of the lower right back and hip area and to the left swollen ankle. The APRN was notified with new orders for portable x-rays and noted family member had been updated. A nursing note dated 8/02/2025 at 5:16 PM indicated the x-rays had been completed at 4:45 PM and Resident #71 had tolerated the procedure well. At 9:36 PM results of the left ankle and the lumbo-sacral spine noted osteoarthritis. A nursing progress notes dated 8/02 2026 at 9:40 PM indicated Resident #71 had no signs of discomfort, bedtime care was completed and vital signs, including neurological signs were within normal limits. The next nursing progress note was entered on 8/03/2025 at 8:29 PM (no 11-7 AM shift or 7-3 PM shift notes on 8/03/2025). A nursing progress note dated 8/04/2025 at 4:09 PM indicated it was day 2 post fall and the resident voiced no signs or symptoms of distress or discomfort and appears to be sleeping. The 8/04/2025 Occupational Therapy progress note dated 11:00 AM indicated Resident #71 had been at physical therapy, had difficulty bearing weight when standing, and complained of left hip pain. The note indicated the session was stopped and the supervisor was updated. A nursing note dated 8/04/2025 at 1:10 PM written by the nursing supervisor indicated she/he observed the same complaint upon examination and the APRN was notified and an order for a left hip x-ray was obtained. A nursing note written on 8/04/2025 at 7:47 PM indicated the left hip x-ray results were obtained and noted a left hip fracture. A physician's order from the APRN was obtained to send Resident #71 to the hospital for further evaluation and treatment. A later note written at 8:03 PM indicated the resident left for the hospital at 8:00 PM with 2 ambulance attendants. An interview with the Director of Nursing Services on 2/11/2026 from 10:45 AM through 11:06 AM indicated documentation after a fall should occur every shift for 3 days and the clinical record noted missing documentation which she/he would follow up on. On 2/11/2026 at 12:02 PM identified although the DNS was unable to provide the documentation missing from the clinical record on the 2 shifts for 8/03/2025 for 11-7 AM and the 7-3 PM shift s/he was able to provide the shift-to-shift nursing report sheet (not part of the clinical record) and the neurological documentation sheet including vital signs, neurological and comfort status during the 2 shifts. The facility policy labeled Falls Management notes once the resident had been identified stable, neurological signs for an unwitnessed fall where the resident is a poor historian will be documented on the neurological flow sheet for 72 hours. In addition, documentation is required for 72 hours to assess latent injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy review and interview for 1 of 3 residents (Resident #16) reviewed for Advanced Directives, the facility failed to ensure the physician's orders accurately reflected the resident/responsible party's documented wishes. The findings include: Resident # 16's diagnosis included heart failure and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 had severe cognitive impairment. A physician's order dated [DATE] directed Full Code status (provide Cardiopulmonary Resuscitation). The care plan dated [DATE] indicated the Advanced Directive code status was Full Code or (Do Not Resuscitate (DNR) and to provide Cardiopulmonary Resuscitation (CPR) or not, based on the responsible party wishes. Resident #16's Advanced Directive Communication Form indicated on [DATE] a conference with the Conservator of Person (COP) indicated not wanting Cardiopulmonary Resuscitation or Do Not Intubation (DNI), and the physician signed the form on [DATE]. A physician's order dated [DATE] directed Do Not Resuscitate (DNR). On [DATE] at 10:29 AM, an interview and clinical record review with the nursing supervisor, Registered Nurse (RN #3) identified the physician's order for Advanced Directives dated [DATE] indicated Do Not Resuscitate (DNR), Resident #16's signed Advanced Directive paperwork which indicated DNR, DNI. RN #3 indicated the paperwork was not transcribed correctly for writing the physician's order and she/he would correct the order immediately. The facility policy labeled Advanced Directives indicated the resident/responsible party's advanced directive wishes will be incorporated into treatment care and services. Once the advanced directive form is completed by the resident or responsible party the physician will sign the form and a physician's order will be obtained.

Based on observations and staff interviews for 1 of 2 residents (Resident #154) reviewed for environment, the facility failed to ensure housekeeping staff reported a soiled privacy curtain for cleaning and replacement. The findings include: An observation on 2/05/2026 at 11:01 AM identified Resident #154's bedside curtain opened fully between the two beds in the room. At the level of the tray table behind the curtain on Resident #154's side an approximate 2-3 feet long and 1-foot-high soiled area noted at the middle of the privacy curtain.An observation on 2/11/2026 at 10:14 AM identified Housekeeper #1 working in Resident #154's room with the door to the room open and the privacy curtain between the beds was still noted to have a soiled area noted on 2/05/2026 at 11:01 AM (6 days ago).Once Housekeeper #1 exited Resident # 154's room on 2/11/2026 at 10:18 AM an interview was attempted. However, she/he indicated the need to contact the housekeeping supervisor and in Spanish asked Houskeeper #2 to do so.An interview and observation on 2/11/2026 at 10:22 AM with the Housekeeping Supervisor indicated privacy curtains are to be removed, replaced with a clean curtain, and the soiled curtains sent to be laundered on a schedule for complete room cleaning called room of the day and daily any soiled curtains are added to a list by the housekeeper on duty, given to the housekeeping supervisor who would have the privacy curtain removed and replaced. The Housekeeping Supervisor provided a handwritten list given to him/her 2 days prior by Housekeeper #1 which indicated resident rooms with privacy curtains needing replacement due to soiled area. Several rooms noted privacy curtains with soiled areas were on the list except Resident #154's. The Housekeeping Supervisor indicated all the privacy curtains on the list and Resident #154's would be changed immediately, and housekeeping staff would be re-educated on the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policies and staff interviews for 1 of 4 residents (Resident #103), the facility failed to consistently conduct completed weekly pressure wound assessments that included wound measurements within accordance with facility practice. The findings included: Resident #103 's diagnoses included End-Stage Renal Disease (ESRD), pressure ulcer of the sacral region, gastroparesis, nausea with vomiting, metabolic encephalopathy, type 2 diabetes mellitus with diabetic neuropathy, Peripheral Vascular Disease (PVD), and chronic systolic Congestive Heart Failure (CHF).A Resident Care Plan (RCP) dated 6/11/24 identified Resident #103 was at risk for skin breakdown related to inability to respond to pressure-related discomfort, impaired mobility, bowel and bladder incontinence, and the presence of a wound. Interventions included encouraging frequent repositioning, assisting with repositioning every 2 hours, and using pressure-relieving devices.A quarterly MDS assessment dated [DATE] identified Resident #103 had a Stage 3 pressure ulcer and remained at risk for further skin breakdown, noted pressure-relieving devices and nutritional interventions were in place.A nursing progress note dated 12/14/24 documented Resident #103 returned from a hospital admission with redness noted on her/his coccyx. A subsequent nursing progress note dated 12/16/24 documented the resident returned to the hospital from a specialized treatment due to hypotension and lethargy.The RCP dated 12/19/24 directed weekly wound measurements to the coccyx and treatment as ordered.A nursing progress note dated 12/19/24 documented Resident #103 returned from hospitalization with an open sacral wound measuring 1.5 Centimeter (CM) x 0.5 CM x 0.5 CM.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #103 was severely cognitively impaired; required set-up assistance with eating and oral hygiene; required substantial to maximum assistance with toileting, showering, and dressing; and required partial to moderate assistance with transfers. The MDS further identified the resident was receiving specialized treatment, was at risk for pressure ulcers, and had one unstageable pressure ulcer and noted pressure-relieving devices and treatment interventions in place.The clinical record identified that although nursing staff documented wound treatments frequently, staff failed to complete weekly wound measurements as ordered for 1 of 2 expected weeks in December 2024.A review of the clinical record from January 2025 through November 2025 identified documentation of wound treatment. However, the clinical identified staff failed to document weekly wound measurements as required for the following: 3 of 5 weeks in January 2025, 4 of 4 weeks in February 2025; 4 of 4 weeks in March 2025, 3 of 5 weeks in April 2025, 3 of 4 weeks in May 2025, 2 of 4 weeks in June 2025, 4 of 5 weeks in July 2025, 3 of 4 weeks in August 2025, 3 of 4 weeks in September 2025, 5 of 5 weeks in October 2025 and 2 of 4 weeks in November of 2025.Further review of the clinical record from December 2025 through February 13, 2026, identified staff failed to document weekly wound measurements for: 4 of 4 weeks in December 2025, 5 of 5 weeks in January 2025 and 1 of 2 weeks to date in February 2026.On 2/11/26 at 9:57 AM, the Director of Nursing Services (DNS) identified she/he expects staff to measure resident wounds weekly. The DNS reported that Resident #103 was frequently absent from the facility on Fridays during scheduled wound rounds for her/his specialized treatment appointment. The DNS identified that a registered nurse should complete wound measurements when the resident is absent during wound rounds and indicated she could not identify a reason why the measurements were not completed. The DNS identified licensed nurses have been trained to complete wound measurements.On 2/11/26 at 12:35 PM Licensed Practical Nurse (LPN #3) (wound care nurse) identified wound measurements are expected to be completed weekly during Friday wound rounds. LPN #3 further indicated any licensed nurse performing a dressing change could and should complete wound measurements if they are not completed during wound rounds. LPN #3 further indicated staff received training in completing wound measurements.Review of facility policy, Prevention & Management of Pressure Injuries, directed that pressure injuries are assessed and documented at least weekly and with any significant change until resolved. The policy directed documentation of wound measurements in centimeters (length, width, depth, undermining, and tunneling) and required a weekly RN assessment for all wounds in accordance with policy.The facility failed to ensure that Resident #103 received weekly wound assessments and measurements in accordance with facility practice and policy.

Based on observation of the environment and staff interviews, the facility failed to ensure an electric wheelchair was not obstructing an exit and failed to ensure staff used the appropriate location for charging the electric wheelchair battery per facility practice. The findings include: On 2/05/2026 at 10:35 AM observation identified the facility fire alarm sounding and an electric wheelchair noted parked at the open lounge area at the end of the resident unit hall next to a coffee table. The wheelchair was noted obstructing the facility emergency exit. The electric wheelchair was also noted to be plugged into the wall outlet in the common lounge area, recharging. Further observations identified no attempts by staff to remove the chair were made during the fire alarm. Once the fire alarm ended and it was safe to resume usual duties. An interview with LPN #2 at 10:40 AM indicated the chair belonged to a resident on the unit and must have been placed there by the prior shift. The Maintenance Director arrived at the common lounge area on the unit at 10:42 AM and after surveyor inquiry indicated the electric wheelchair was not allowing egress (a path for exit out of the building). The Maintenance Director further indicated the location and policy procedure for charging electric wheelchairs would have to be taken up by the nursing department, but s/he would have the wheelchair moved immediately. An interview with the Director of Nursing Services (DNS) on 2/10/2026 at 10:10 AM indicated a fire safety policy regarding the exit doors existed but even though a separate room exist for charging electric wheelchairs there was no policy 02/05/2026 10:35 AM fire drill electric w/c obstructing exit and plugged into a common area no residents at this time. pictures taken

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review observation, review of policy and interviews for 1 of 3 residents (Resident# 6) reviewed for pressure, the facility failed to ensure staff completed hand hygiene between donning and doffing gloves and failed to ensure staff utilized a cleansing solution (normal saline) that had not expired. The findings include: Resident #6 diagnosis included pressure ulcers and dementia. The care plan dated [DATE] indicated Resident #6 was at risk for alteration in skin integrity due to decreased mobility and had a history of pressure ulcers. Interventions included providing treatments as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was severely cognitive impairment and at risk for pressure ulcer noted with one unstageable pressure ulcer. On [DATE] from 11:50 AM through 12:20 PM an observation of a dressing change to Resident #6's right outer foot and interview with LPN #1 identified LPN #1collecting the items required to complete the dressing change prior to start of the observation. The bedside table was cleansed with an antibacterial wipe, clean paper towels were placed on the table with a small bottle of clear liquid, clean 4x4 dressings and a kerlix wrap. LPN #1 had a black marker and was noted writing on a small paper/tape and removed the top of the small bottle of clear liquid. LPN #1 applied a pair of non-sterile gloves. A nurse aide was in attendance to assist with turning and positioning Resident #6, once positioned, LPN #6 removed the dressing from Resident #6's right foot and placed it in the trash then removed the pair of gloves and donned a clean pair without the benefit of hand hygiene while reaching for a 4x4 dressing. Surveyor intervened and reminded LPN #1 of hand hygiene needed to be performed after removing (doffing) gloves. LPN #1 removed the gloves washed his/her hands and applied a clean pair of gloves and a 4x4 dressing and placed it on top of the solution bottle with one hand and with the other turned the bottle over slightly to pour liquid onto the dressing, cleansed the closed scabbed area of the outer right foot with the solution on the 4x4 then applied a kerlix wrap dressing. Resident #6 was repositioned by the nurse aide at the conclusion of the dressing change. LPN #1 then removed all the dressing items and paper towels and placed them in the trash except the small bottle of clear liquid which appeared at a distance to be over 3/4 full. LPN #1 removed the gloves and conducted hand hygiene the small bottle was brought to the cart outside the room. When asked to see the bottle it was noted to be a bottle of normal saline and to have a handwritten date in black marker on the cap indicating [DATE] (opened 13 days ago) and a manufactures' date of expiration stamped on the cap. LPN #1 indicated the marker date was when the bottle was opened and indicated the open bottle would be good to use until the manufacturers expiration date (2027). LPN#1 further indicated she/he was not sure if there was a facility policy related to how long an open bottle of normal saline could be used. On [DATE] at 12:50 PM an interview with the Infection Preventionist/wound nurse LPN #3 indicated hand hygiene should be completed before and after applying and removing gloves. LPN #3 indicated the saline bottles were good for 24 hours, but she/he would look to see if the manufacturer had a recommendation. LPN #3 indicated about a month ago the facility was no longer able to purchase normal saline in a spray bottle which had a longer shelf life and the small bottles of normal saline were purchased for use. LPN #3 was unaware of any training of staff regarding the transition from one form of saline to use of the new saline product. An interview and observation with Director of Nursing Services on [DATE] from 1:10 PM- 1:24 PM indicated the bottle of normal saline used during the earlier dressing change was discarded and the right foot dressing change was completed again under observation for proper hand hygiene and dressing change practice. The DNS indicated a new bottle of saline was used then discarded and pointed out on the bottle label in small writing with a notation for 1 time use. The DNS indicated no training had been provided regarding the use of a new product for wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, observation, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the shower room door alarm was functioning to prevent a fall with injury. The findings include:
Resident #1 had diagnoses that included dementia with behavioral disturbance, history of falls, vascular dementia, diabetes mellitus type 2, and hypertension.
The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was always incontinent of bowel and bladder, required moderate assistance with transfers, non-ambulatory, and independent with mobility using a manual wheelchair.
The care plan dated [DATE] identified Resident #1 was at risk for falls because of the following: history of falls, weakness, impaired mobility, and impaired safety awareness with interventions that directed to encourage not to get up alone, encourage to wear nonskid footwear or nonskid socks, explain the routine to me, offer me education to use the call bell when I need assistance, place commonly used items within easy reach, and staff to ensure the overhead light is off after PM care.
A physician's order dated [DATE] directed to transfer with the assist of one (1) and a rolling walker and ambulate on the unit with assist of one (1) and a rolling walker.
A fall risk assessment dated [DATE] identified Resident #1 as a high risk for falls.
A nurse's note dated [DATE] at 12:21 P.M. written by Registered Nurse (RN) #1 (7:00 AM- 3:00 PM supervisor), identified she was called to the unit and observed Resident #1 lying on h/her back on the floor in the shower room. RN #1 identified Resident #1 was bleeding from the occipital region on h/her head and noted to have a 2.0 centimeter laceration on the back of head. RN #1 identified APRN #2 was notified, and Resident #1 was transferred to the hospital.
A nurse's note dated [DATE] at 12:50 P.M. written by RN #3 identified she was informed by the Licensed Practical Nurse (LPN) #1 that Resident #1 had fallen. RN #3 identified she observed Resident #1 laying on the floor in the shower room with a complaint about a head strike. RN #3 identified Resident #1 had an open area on the occipital area of h/her head with a small amount of blood coming from the area. RN #3 identified Resident #1 was sent to the emergency room for further evaluation.
Review of the facility's accident and incident report dated [DATE] identified that on [DATE] at 11:10 A.M. Resident #1 was observed on the floor in the bathroom across from the recreation room. RN #1 assessed Resident #1 noting a 2.0-centimeter open area to the occipital area of h/her head orders were obtained to transfer Resident #1 to the emergency room. It was discovered that Resident #1 self-propelled out of the recreation room into the communal shower/bathroom. While in the emergency room a CT-scan of the chest revealed Resident #1 had acute fractures of the left 3rd, 4th, and 6th posterior ribs associated with a moderate size left hemo-pneumothorax.
Resident #1 was admitted to the hospital upon return from the hospital Resident #1 will be evaluated by PT/OT for transfers, self-mobility, and wheelchair safety.
Interview with Housekeeper #1 on [DATE] at 12:15 P.M. identified on [DATE] he observed Resident #1 lying on the floor in the shower room with h/her wheelchair pushed to the side. Housekeeper #1 identified the door to the shower room was open and the door alarm was not sounding. Housekeeper #1 identified he notified LPN #1 that Resident #1 was on the floor.
Interview with LPN #1 on [DATE] at 3:00 P.M. identified on [DATE] Housekeeper #1 reported that Resident #1 was on the floor in the communal bath/shower room. LPN #1 identified on [DATE] when Resident #1 was found in the shower room lying on the floor, the door alarm on the shower room door was not alarming. LPN #1 identified the door alarm is on the shower door to prevent residents from going in the shower room unsupervised. LPN #1 identified the door alarm on the shower door doesn't always work because when the staff are done using the shower room a code needs to be entered to activate the door alarm and staff forget to turn it back on.
Interview with RN #1 on [DATE] at 1:45 P.M. identified on [DATE] she was notified by LPN #1 that Resident #1 was found lying on the floor in the shower room. RN #1 identified upon arrival to the unit the door to the shower door was opened and door alarm was not alarming. RN #1 identified she observed Resident #1 on the floor in the shower room lying on h/her back and noted some bleeding coming from a small laceration on back of h/her head. RN #1 identified Advanced Practice Registered Nurse #2 was notified, an order was obtained to transfer Resident #1 to the emergency room. RN #1 identified when the shower room door alarm is activated it is very loud and can be heard throughout the unit.
Interview with the DNS on [DATE] at 2:15 P.M. identified on [DATE] at approximately 10:30 A.M. Resident #1 was found by Housekeeper #1 lying on the floor in the shower room. The DNS identified he immediately went down to the unit, observed Resident #1 lying on the floor in the shower room with h/her wheelchair pushed to the side, and the shower room door alarm was not alarming. The DNS identified Resident #1 was transferred to the hospital and did not return. The DNS indicated the door alarm on the shower room door should have been alarming, however on on [DATE] the door alarm on the shower room door was not functioning because the battery had died and the DNS was unable to provide documentation to reflect the door alarm on the shower room door was monitored and maintained to ensure it proper functioning.
Although requested, a facility shower room door alarm policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for activities of daily living, the facility failed to ensure the clinical record was complete and accurate to include documentation of personal care provided. The findings include:
Resident #1 had diagnoses that included depressive disorder and Chronic obstructive pulmonary disease.
Review of Resident #1's profile dated 8/1/24 directed the shower day as Tuesday on 3 P.M.-11 P.M. with special instructions to follow the master shower schedule.
The care plan dated 8/2/24 identified Resident #1 needs help performing ADLs with interventions that directed to sign off care needs in POC (electronic charting system) and chartable tasks in POC are unchecked included on profile are checked.
The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was occasionally incontinent of bowel, always continent of bladder, was independent with bed mobility, required set up with transfers, required maximal assistance with showers, and moderate assistance with toileting, and toileting hygiene.
Review of Resident #1's clinical record on 9/30/24 failed to identify any documentation to reflect any personal care provided from 8/1/24 to 8/15/24.
Interview and clinical record review with the DNS on 9/30/24 at 12:30 P.M. was unable to provide documentation to reflect that personal care was provided to Resident #1. The DNS identified his expectations are that the nurse aide documents what personal care was provided on every shift into the resident's ADL flowsheets in the POC. The DNS identified Resident #1's ADL flowsheets should have been completed from 8/1/24 to 8/15/24. The DNS could not explain why the ADL flowsheets were not completed.
Although requested, a facility documentation policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents (Resident #2) who required a wheelchair for mobility within the facility, the facility failed to ensure when being assisted by staff the leg rests were present on the wheelchair to prevent the resident from falling out of the wheelchair. The findings include:
Resident #2's diagnoses included cerebrovascular accident, unspecified dementia, hemiplegia on the right dominant side and muscle weakness.
A physician's order dated 6/17/24 directed pop-over transfers with the assist of two (2) staff members, and the resident was non-ambulatory.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life, was dependent with getting in and out of the bed and chair, had range of motion impairment of both upper extremities, was non-ambulatory and utilized a wheelchair for mobility.
The Resident Care Plan dated 8/1/24 identified Resident #2 was a fall risk. Interventions directed to encourage the resident not to get up alone, encourage non-skid footwear and non-skid socks, educate on use of the call bell for assistance, and place commonly used items within reach.
The nurse's note dated 8/7/24 at 3:37 PM identified at 2:30 PM Resident #2 was being pushed in the wheelchair during the recreation program, when Resident #2 fell forward out of the wheelchair and was noted with an open area to the right lateral scalp, actively bleeding. The note identified Resident #2 had intact neurological assessment, no changes in range of motion, no complaints of pain and no shortening/lengthening of extremities. The note indicated staff could not get the bleeding under control, the physician's assistant was notified, and a new order was obtained to send Resident #2 to the emergency department.
The nurse's note dated 8/9/24 at 9:41 PM identified Resident #2 was readmitted to the facility at approximately 8:30 PM, sutures to the right temporal laceration were intake, and there were no changes in cognition and neuros were at baseline.
Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 8/28/24 at 12:11 PM identified on 8/7/24 it was reported to her Resident #2 had fallen out of the wheelchair. RN #1 identified Resident #2 was in the wheelchair without the benefit of having the leg rests on and Resident #2 put his/her foot down to the ground which caused Resident #2 to fall forward out of the wheelchair. RN #1 indicated Resident #2 should have had the leg rests on the wheelchair.
Interview with the Director of Nursing (DON) on 8/28/24 at 12:17 PM identified Resident #2 sustained a fall forward from the wheelchair during transport. The DON identified the 7AM-3PM nurse aide, (Nurse Aide) #3, did not have the leg rests on the wheelchair at the time of the fall and the facility policy directs to always have the leg rests on the wheelchair.
Interview with NA #3 on 8/28/24 at 12:29 PM identified she was pushing Resident #2 in the wheelchair without the benefit of leg rests on the wheelchair, and when she stopped the wheelchair, Resident #2 put his/her foot down on the floor and fell out of the wheelchair. NA #3 identified there should have been leg rests on the wheelchair while transporting Resident #2 but she forgot to put them on.
Review of the facility policy titled Wheelchair, directed, in part, when wheelchair transporting any resident the leg rest must be used, and leg rests must always be used when transported by others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled residents for accidents (Resident #1), the facility failed to ensure supervision to prevent the resident from exiting the facility without staff knowledge, and failed to notify local law enforcement timely when a resident was identified missing, and failed to complete a quarterly elopement risk assessment timely in accordance with facility policy. The findings include:
Resident #1 was admitted to the facility with diagnoses that included dementia with agitation, anxiety, and difficulty in walking. A quarterly MDS assessment 4/25/2024 identified Resident #1 had severe cognitive impairment, and independent to transfer and walk. A resident care plan (RCP) dated 6/9/2024 identified Resident #1 had a cognitive impairment due to dementia and history of involuntary weeping, wandering, refusing to participate in care and exit seeking behaviors with a wander guard placed. Interventions directed to offer snacks or coffee if demonstrating exit seeking behavior, redirect, observe for changes in mental status that are different from baseline and to refer to a psych provider as appropriate and for new exit seeking behavior have resident reviewed by psych. Record review identified Resident #1 resided on the secure dementia unit.
A nursing note dated 6/15/2024 at 2:08 PM identified that Resident #1 was noted with increased behaviors; Resident #1 was observed standing in front of the unit attempting to hit a staff member. Staff attempted to redirect Resident #1 without success and a scheduled medication was administered. A call was placed to a family member who talked to Resident #1 with some success and Resident #1 was redirected to his/her room and offered coffee. At 12:35 PM, the unit nurse observed Resident #1 was standing on a chair in front of a partial opened secured window. Resident was placed on one to one (1:1) supervision and transferred to the hospital for evaluation.
A nursing note dated 6/15/2024 at 10:38 PM identified that Resident #1 returned from the hospital at 5:20 PM and received scheduled medications. Resident #1 was observed wandering on unit but was easily redirected.
A review of facility documentation dated 6/16/2024 identified Resident #1 was reported to have opened the window in room [ROOM NUMBER]. All windows on the secured dementia unit were evaluated by maintenance and determined to open approximately six (6) to eight (8) inches with a screw securely in place to prevent window from being opened further. All screens were noted to be intact.
A psychiatric evaluation dated 6/17/2024 identified that Resident #1 attempted to remove the screen from window over the weekend and had no recall of the event. Resident #1 was noted at baseline but due to given continued behaviors as well as some intermittent refusal of medications, Risperidone (medication that treats behavior) was increased.
A psychiatric evaluation dated 6/17/2024 identified that Resident #1 attempted to remove the screen from window over the weekend. Resident #1 had no recall of the event. Resident #1 was noted at baseline but due to given continued behaviors as well as some intermittent refusal of medications, Risperidone increased.
A psychiatric evaluation dated 6/19/2024 identified Resident #1 continued with confusion, but less agitation, and had no behaviors since last consult. The plan described to continue with redirection, may need to consider a higher level of care if continues with severe behaviors, and to continue to monitor symptoms.
A facility accident and investigation report dated 7/7/2024 at 2:30 PM identified an elopement event (missing resident). Resident #1 was not visualized on the unit during last rounds, a unit search was performed and the window in room [ROOM NUMBER] (not Resident #1's room) was open and the screen was removed. Dr. Hunt was initiated, and Resident #1 was found and returned to the unit without injury. Resident #1 was observed on the grass on an adjacent property (approximately 0.2 miles from the exit of window. The route took Resident #1 along a busy road with no sidewalks for 150 to 200 yards). Resident #1 was placed on 1:1 monitoring.
A nursing progress note dated 7/7/2024 at 5:45 PM identified that per the charge nurse, Resident #1 was not observed for 15 minutes prior to her being informed, and the DON, Administrator and family were notified. Assessment upon return to the facility was: vital signs Temperature 98.4, Heart Rate 81, Blood pressure 100/50, Respiratory Rate 18 with oxygen saturation at 93 percent.
A nursing note dated 7/8/2024 at 3:36 PM identified that the plan was to have Resident #1 remain on every 15-minute checks times 24 hours, then 30-minute checks times 24 hours then every 4-hour checks times 24 hours and then every shift checks times 48 hours.
A facility summary report dated 7/10/2024 identified that Resident #1's baseline behavior was that he/she walked freely throughout the unit with redirection if he/she wanders away from the common area.
A facility summary report dated 7/10/2024 identified that Resident #1's baseline behavior was that he/she walked freely throughout the unit with redirection if he/she wanders away from the common area. At 1:50 PM, staff confirmed they observed Resident #1 walking in the hallway on the unit. At approximately 2:00 PM, staff were not able to visualize Resident #1's whereabouts, a unit search was initiated, and it was noted that in another resident's room (409), there was a window open past the secure stopper and the screen was not in place. The window was 38 inches from the ground. At 2:07 PM (7 minutes after identified missing), Resident was observed on the property adjacent to the facility. An RN assessment was completed, no injury was identified, and Resident #1 denied any pain. After clearance from psych, Resident #1 was placed on every 15-minute check. All windows on the unit were check and all other windows had the safety stop in place and intact. Additional reinforcement was completed with 2 screws and an additional stopper device was placed to prevent the bending of any screws as this was what was determined to have happened for Resident #1 to force the window open.
Interview with NA #1 on 7/24/2024 at 11:15 AM identified that she was assigned to care for Resident #1 on 7/7/2024. During her last rounds, at approximately 2:00 PM she noticed that Resident #1 was no longer by the nurse's station or observed walking in the hallway. She immediately went to his/her room as a staff member told her they had redirected the Resident to his/her room. She looked in the room and Resident #1 was not there, so she began to check the other rooms. In room [ROOM NUMBER], she observed that the window was open, no screen and that a wheelchair had been placed by the window. She immediately told the charge nurse, and Dr. Hunt was called. NA #1 ran outside with another NA and proceeded to the left of the building and began to walk along the road. As she approached the building on the corner of the road, she could see Resident #1 lying on the ground on the other side of the building on a hill at the back of the side parking lot of the building. Resident #1 had taken all his/her clothes off except for pants and when she got to Resident #1, he/she stated he/she was hot. Another NA had driven her car over and they placed Resident #1 into the car and drove him back to the facility.
Interview and observations of Resident #1's route to the building adjacent to the facility with the DON on 7/24/2024 at 11:30 AM identified Resident #1 removed the screen from the window of room [ROOM NUMBER]. From there, a sidewalk runs along the side of the building that ends on the road in front of the facility. The road in front of the facility was a three-lane road, and included a three-way stop light intersection. A wooded area was located between the facility and the adjacent building next door with no visible paths through the wooded area and the adjacent building. The DON identified when he completed the investigation, he could see the adjacent building through the trees, and stated the ground was uneven with no path noted. Resident #1 had no scratches, cuts or bruises or any debris on his/her clothing when assessed on 7/7/2024 and was unable to identify if Resident #1 walked along the road or through the woods. The DON stated the last time Resident #1 was reported seen on the unit was at 1:45 PM, was discovered missing at 2: 00 PM and was then found at 2:07 PM, approximately 22 minutes after Resident #1 was last seen on the unit.
A review of weather temperatures recorded on July 7, 2024 identified that the outside temperature was recorded at 93 degrees Fahrenheit with a dew point of 70 percent (a dew point of 70 is considered oppressive and very uncomfortable).
The facility Elopement Policy directed in part, that the facility strived to promote safety for all residents at risk for elopement. Elopement is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and who may enter into harm's way.
a.
Interview with the DON on 7/25/2024 at 11 AM identified that he was notified by the nursing supervisor (RN #1) at approximately 2:00 PM that Resident #1 was not located on the unit, and he directed RN #1 to initiate a Dr. Hunt and start the search. The DON stated he was notified at 2:07 PM that Resident #1 was located off property grounds behind an adjacent building.
The facility policy Elopement directed in part, that the police should be notified as soon as the resident is not located with the facility or on immediate grounds.
b.
A quarterly elopement assessment dated [DATE] identified Resident #1 was at risk for elopement.
An elopement assessment dated [DATE] identified Resident #1 was completed when Resident #1 forced open a window on the secured dementia unit and left property unattended.
Resident #1's medical record lacked a completed quarterly elopement assessment due April 2024.
Interview with the DON 7/25/2024 at 11 AM identified that an assessment for elopement should be completed quarterly. The DON stated an assessment should have been completed three (3) months after the 1/23/2024 assessment and he did not know why one was not completed when due.
The facility policy Elopement directed in part, that a licensed nurse will conduct an Elopement risk screen on admission, annually, quarterly and upon a change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of three sampled residents for accidents (Resident #1), the facility failed to ensure the physician was notified timely of a significant change in behavior. The findings include:
Resident #1 was admitted to the facility with diagnoses that included dementia with agitation, anxiety, and difficulty in walking. A quarterly MDS assessment 4/25/2024 identified Resident #1 had severe cognitive impairment, and independent to transfer and walk. A resident care plan (RCP) dated 6/9/2024 identified Resident #1 had a cognitive impairment due to dementia and history of involuntary weeping, wandering, refusing to participate in care and exit seeking behaviors with a wander guard placed. Interventions directed to offer snacks or coffee if demonstrating exit seeking behavior, redirect, observe for changes in mental status that are different from baseline and to refer to a psych provider as appropriate and for new exit seeking behavior have resident reviewed by psych.
A psychiatric evaluation and consultation dated 6/6/2014 identified Trazadone (medication that treats depression) 50 mg TID was increased on 6/6/2024 due to increased agitation and an attempt to kick an NA.
A psychiatric evaluation and consultation dated 6/14/2024 identified that Resident #1 was evaluated after a medication change. Resident #1 continued crying, though slightly improved. The plan was to continue to monitor Resident closely. No other concerns from nursing staff were reported and to continue the current treatment plan.
A nursing note dated 6/15/2024 at 2:08 PM identified that Resident #1 was noted with increased behaviors; Resident #1 was observed standing in front of the unit attempting to hit a staff member. Staff attempted to redirect Resident #1 without success and a scheduled medication was administered. A call was placed to a family member who talked to Resident #1 with some success and Resident #1 was redirected to his/her room and offered coffee. At 12:35 PM, the unit nurse observed Resident #1 was standing on a chair in front of a partial opened secured window. Resident was placed on one to one (1:1) supervision and transferred to the hospital for evaluation.
A nursing note dated 6/15/2024 at 10:38 PM identified that Resident #1 returned from the hospital at 5:20 PM and received scheduled medications. Resident #1 was observed wandering on unit but was easily redirected.
A psychiatric evaluation dated 6/17/2024 identified that Resident #1 attempted to remove the screen from window over the weekend and had no recall of the event. Resident #1 was noted at baseline but due to given continued behaviors as well as some intermittent refusal of medications, Risperidone (medication that treats behavior) was increased.
A psychiatric evaluation dated 6/19/2024 identified Resident #1 continued with confusion, but less agitation, and had no behaviors since last consult. The plan described to continue with redirection, may need to consider a higher level of care if continues with severe behaviors, and to continue to monitor symptoms.
A psychiatric evaluation dated 6/28/2024 identified Resident #1 appeared more engaged and was noted to be stable by nursing staff with less behaviors and to continue treatment plan.
A facility accident and investigation report dated 7/7/2024 at 2:30 PM identified an elopement event (missing resident). Resident #1 was not visualized on the unit during last rounds, a unit search was performed and the window in room [ROOM NUMBER] (not Resident #1's room) was open and the screen was removed. Dr. Hunt was initiated, and Resident #1 was found and returned to the unit without injury. Resident #1 was observed on the grass on an adjacent property (approximately 0.2 miles from the exit of window. The route took Resident #1 along a busy road with no sidewalks for 150 to 200 yards). Resident #1 was placed on 1:1 monitoring.
A facility summary report dated 7/10/2024 identified that Resident #1's baseline behavior was that he/she walked freely throughout the unit with redirection if he/she wanders away from the common area.
A nursing note dated 7/12/2024 at 5:19 AM identified Resident #1 was exit seeking and crying that she/he wanted to go home and went to the back door of the unit. A NA tried to stop Resident #1 and Resident #1 was kicking and punching the NA. The nurse tried to calm Resident #1 by offering a snack and drink. The note indicated it took a while for Resident #1 to calm down and eventually go to bed, and was noted sleeping.
Record review failed to identify the physician/provider was notified of Resident #1's aggressive behaviors toward staff on 7/12/2024.
Interview with APRN #1 (psychiatry) on 7/24/2024 at 11:50 AM identified her treatment plan was adjusted when Resident #1 became physically aggressive, as the baseline for Resident #1 was crying, wandering with elopement behaviors but was easily redirectable. She was unaware that Resident #1 had physical aggression when redirected on 7/12/2024. APRN #1 stated staff would either call her or leave a note in her follow up book on the unit if there was a change in condition, and she identified that she was not notified. APRN #1 stated she should have been notified and that she would have evaluated Resident #1 if she been informed to determine if there was a need to change the treatment plan at that time. APRN #1 further stated that on 7/20/2024 Resident #1 had become more agitated, combative with exit seeking behaviors and when the provider was notified, Resident #1 was transferred to the hospital for evaluation.
Interview with Physician's Assistant (PA) #1 on 7/25/2024 at 9: 30AM identified that he was unaware that Resident #1 had demonstrated physical aggression on 7/12/2024 when being redirected for exit seeking behaviors. PA #1 stated if he was notified he would have then contacted APRN #1 to discuss any need to change the treatment plan at that time.
Interview and review of facility documentation with LPN 2 on 7/25/2014 at 10:00 AM identified she was Resident #1's nurse on the 11 PM to 7 AM shift on 7/12/2024, and recalled Resident #1 became aggressive as the NA attempted to redirect him/her away from the back door of the unit. Resident #1 began to kick and punch the NA and it was very difficult to redirect the Resident. The usual coffee and snack eventually worked but it took some time. She could not recall if she notified the nursing supervisor or the physician/APRN.
Interview with the DON on 7/25/2024 at 11:53 identified that if a Resident demonstrated increased behaviors with agitation staff should notify the supervisor who would notify the provider. He identified that Resident #1 had a history of physical aggression and that the staff were able to eventually calm Resident #1. The DON was unable to explain why the provider/APRN was not notified.
Attempts to contact RN #2, 11 -7 supervisor, during survey were unsuccessful.
The facility policy Condition, Significant change directed in part, that facility professional staff would communicate with the physician changes in condition to provide timely communication of resident status change that is essential to quality car management. The physician will be notified by the nurse in the event of a change in condition.

**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 resident (Resident #2) reviewed for abuse, the facility failed to ensure care was provided in accordance with physician orders. The findings include:
Resident #2 was admitted with diagnoses that included dementia and right sided hemiplegia (loss of movement on one side of the body). A quarterly MDS assessment dated [DATE] identified Resident #2 had severe cognitive impairment and was dependent for bed mobility. A resident care plan (RCP) dated 6/6/2024 identified Resident #2 required assistance with ALDs. Interventions directed to assist as indicated for positioning.
A physician's order dated 6/25/2024 directed ADLs with assistance from two (2) staff. Transfer assistance of 2 staff via Hoyer lift.
A facility reportable event form dated 7/11/2024 at 10:00 AM identified a hospice aide was providing care and noted multiple discolorations on Resident #2's body.
A facility summary dated 7/11/2024 identified that Resident #2 was observed to have bruising on the right forehead, left hip, left arm, left hand, left elbow, left knee, left shoulder and right wrist and shearing was identified on the left hip. Resident #2 identified that he/she had fallen overnight and got back in bed. The summary identified NA #1 provided care during the 3 to 11 PM shift on 7/10/2024 (evening before the bruises were noted) with no bruising was noted. NA #2 (worked 11 PM to 7 AM ending on 7/11/2024) reported she observed Resident #2 on his/her left side in the bed with his/her legs hanging off the side of the bed, she was not aware of any falls during the shift, and no bruising was noted. NA #2 then attempted to re-center Resident #2 to the middle of the bed using a drawsheet. As she pulled the drawsheet, Resident #2's body turned more to the left and indicated although Resident #2's head was near the bedrail but Resident #2 did not hit his/her head. NA #2 then attempted to move Resident #2 towards the center of the bed, by holding his right wrist and moving him/her to the center of the bed. She completed this care by herself as she felt she did not require assistance at that time. Repeat demonstration of NA #2 providing care and discussion of care aligns with the areas of bruising.
A nursing note dated 7/11/2024 at 10:26 AM identified she assessed Resident #2 due to multiple abrasions and ecchymosis (bruising) of the skin. On assessment an abraded area to left hand, shoulder and hip as well as small ecchymosis to right side of head. Resident #2 had complaints of pain in hip and shoulder and x-rays were ordered of left hip, shoulder, elbow and hand. A nursing progress note dated 7/11/2024 at 9:16 PM identified x rays were negative and no new orders.
Interview with NA #2 on 7/25/2024 at 1:11 PM identified around 12:30 AM she observed Resident #2 with his/her legs hanging off the lower part of the bed. She raised the bed and put Resident #2's legs back on the bed when Resident #2 again kicked them off the bed. NA #2 again placed Resident #2's legs back onto the bed. NA #2 stated she then used the drawsheet to pull Resident #2 into the center of the bed and using the draw sheet she again pulled Resident #2 towards her. NA #2 stated she may have grabbed Resident #2's right arm to as she adjusted his/her position. Resident #2 did not resist care or report any discomfort at the time. NA #2 stated she did not check the care card prior to providing care and was not aware at the time that Resident #2 needed 2 staff to provide care, and stated after 7/11/2024, she was re-educated to always check the care card prior to providing care.
Interview and review of the 7/11/2024 investigation documents with the DON on 7/25/2024 at 12:40 PM identified NA #2 repositioned Resident #2 alone. The DON stated NA #2 re-demonstrated the way she repositioned Resident #2 and the injuries were consistent with the care NA #2 had provided. The DON stated NA #2 should have reviewed the level of care Resident #2 required, and should not have provided the care without help.
Although requested, the facility was unable to provide a policy on turning and positioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #1 and #3) reviewed for pressure ulcers, the facility failed to create and implement a care plan for newly identified wounds. The findings include:
1. Resident #1 was admitted to the facility with diagnoses that included type II diabetes and dementia.
The care plan dated 1/5/24 identified Resident #1 was at risk for skin breakdown with interventions that included assisting Resident #1 with position changes approximately every 2 hours and as indicated, pressure reducing relieving devices, and to offer to offload Resident #1's heels when in bed.
The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers.
A nursing note dated 2/24/24 at 6:50 PM identified Resident #1 was noted with an opening to the coccyx measuring 1 centimeter (cm) x 1 cm. The site was superficial, clean and pink with no signs of infection. The APRN was updated with new orders in place for triad mixed with Aquaphor for 14 days.
Review of Resident #1's medical record failed to identify Resident #1's care plan was updated to include Resident #1's coccyx wound and appropriate interventions.
A nursing note dated 3/16/24 at 4:20 PM identified the on call APRN was notified of Resident #1's change in coccyx area. The plan was to monitor and place in wound care book for re-evaluation on 3/18/24. Resident #1's family member was notified and wanted Resident #1 to be sent to the hospital. The APRN was updated and Resident #1's family member went to the hospital with Resident #1.
A nurse practitioner note dated 3/19/24 at 10:02 AM identified review of Resident #1's hospitalization was for Resident #1's coccyx wound. Resident #1's coccyx wound was not infected and no interventions were done beyond basic wound care. Resident #1 was seen by the wound care nurse who recommended to cleanse the wound with soap and water, apply skin barrier cream to wound and cover cream with a full sheet of xeroform twice a day and as needed.
Review of Resident #1's medical record failed to identify Resident #1's care plan was updated to include Resident #1's progressing coccyx wound with interventions.
2. Resident #3 was admitted to the facility on with diagnoses that included neuromyelitis Optica (autoimmune nerve disease), neurofibromatosis (tumors grow in the nervous system) and an intellectual disability.
The care plan dated 2/28/24 identified Resident #3 was at risk for skin breakdown with interventions that included assisting Resident #3 with position changes approximately every 2 hours and as indicated, offer to take Resident #3 to the bathroom every 2 hours and as needed, when incontinent provide care per protocol, pressure reducing relieving devices, and to offer to offload Resident #3's heels when in bed.
The admission MDS dated [DATE] identified Resident #3 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at risk for developing pressure ulcers.
A nursing note dated 3/18/24 at 7:00 AM identified she was informed by the unit nurse that Resident #3 was noted with a red area to the mid coccyx and buttocks. A linear 3 cm area of denuded skin at the right buttocks was assessed. The area was cleansed with normal saline and triad was applied.
A nursing note dated 3/18/24 at 12:05 PM identified Resident #3 was seen by the wound team secondary to bilateral buttock diffused moisture associated skin damage (MASD) with no drainage noted. The site was cleansed with normal saline followed by triad cream.
Review of Resident #3's medical record failed to identify Resident #1's care plan was updated to include Resident #3's progressing coccyx wound and interventions.
Subsequent to surveyor inquiry, Resident #3's care plan was updated on 5/7/24 to include the problem that Resident #3 had a stage four pressure ulcer on his/her coccyx with interventions that included to notify the supervisor/physician of any changes in the wound, supplements as ordered, encourage completing of all foods and fluids, treatments as ordered by the wound physician and weekly wound measurements.
Interview with the ICN on 5/7/24 at 2:57 PM identified she gives a list of wounds to the MDS coordinator weekly and the MDS coordinator would create or change the resident's care plan. She further identified for a resident with a pressure ulcer/injury, they should have a care plan in place.
Interview with the MDS coordinator on 5/7/24 at 3:15 PM identified she was the MDS coordinator for Resident #1 and Resident #3. She identified she gets a wound list weekly and adds them to the resident's care plans. She identified she must have missed imputing Resident #1's wound to the care plan. She further identified she thought she added Resident #3's wound interventions to the care plan but checked Resident #3's care plan and they were not there.
Review of the comprehensive care plan policy identified care plans are oriented toward preventing avoidable decline in clinical and functional levels, maintain a specific level of functioning and reflect resident preferences and rights. It identified the interdisciplinary team develops a comprehensive care plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified in the RAI and IDT. It further identified the care plan is evaluated and revised as needed, but at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, facility documentation, and interviews for one of three residents (Resident #9) reviewed for falls, the facility failed to follow a care plan. The findings included:
Resident #9 diagnoses included Alzheimer's disease, muscle weakness, and difficulty walking.
Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 as severely cognitively impaired, required maximal assistance with toileting, dressing, and personal hygiene, and utilized both a walker and wheelchair for mobility.
Review of the Resident Care Plan dated 2/18/24 identified a risk for falls due to a history of falls, weakness, impaired mobility, and impaired safety awareness with interventions that directed to encourage non-skid footwear or non-skid socks.
Review of a Reportable Event form dated 3/11/24 identified Resident #9 was observed on the floor next to the nurse's station which resulted in a hematoma and laceration to the back of his/her head.
Review of the fall observation dated 3/11/24 identified Resident #9 was wearing regular socks (not non-skid) and that Resident #9 was forgetful and would ambulate independently.
Interview with the Infection Control Nurse on 5/6/24 at 3:05 PM identified Resident #9 should have been wearing non-skid socks as he/she was care planned to wear non-skid socks. The Infection Control Nurse further identified it was the certified nurse's aide's and nurse's responsibility to ensure the correct footwear was applied.
Interview with NA #5 on 5/7/24 at 11:20 AM (who was assigned to Resident #9's care on 5/7/24) identified it was the her responsibility to follow the care plan directive and apply non-skid socks to the resident.
Review of the Comprehensive Care Plan policy indicated the Interdisciplinary Team develops a Comprehensive Care Plan for each resident that includes measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews, The facility failed to ensure that (1) of three (3) residents reviewed for abuse, (Resident #11), was free from sexual abuse, and for one (1) of three (3) residents reviewed for incontinent care and turning and repositioning, (Resident # 4), the facility failed to ensure that the resident was free from neglect.
The findings included:
1. Resident #10 had a diagnosis of dementia. An annual Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severely impaired cognition, had no behaviors or changes in mood, required substantial assistance with Activities of Daily Living (ADL's), and was independent with ambulation.
A care plan dated 4/7/24 identified that the resident had cognitive loss related to a diagnosis of dementia with interventions that included psychiatric evaluations as indicated, administer medications as ordered, and to provide re-direction.
A nurse's note dated 5/6/24 at 4:04 PM identified that the resident was in the roommates bed undressed from the waist down touching Resident #11's genital area and h/her own genital area at the same time. The residents were immediately separated and Resident #10 was placed on 1:1 supervision.
2. Resident #11 had a diagnosis of dementia. A significant change MDS dated [DATE] identified that the resident has severely impaired cognition, and was dependent on staff for ADL's.
A care plan dated 4/7/24 identified that the resident had cognitive loss due to dementia with interventions that directed to administer medications as ordered and refer to psychiatric services as needed.
A nursing note dated 5/6/24 at 2:35 PM identified that the resident's roommate was noted to be in h/er bed touching Resident #11's genital area, the resident had no recollection of the event, an exam was performed and no abnormalities were assessed. The resident was seen by social services and had a room change.
a) A Reportable Event dated 5/6/24 at 9:00 AM identified that Resident #10 was found in Resident #11's bed ( the 2 residents are roommates). Resident #10 had h/her hands on Resident #11's genital area.
Interview with Licensed Practical Nurse (LPN) #5 on 5/6/24 at 10:50 AM identified that she had entered Resident #10 and Resident #11's room to do wound care on Resident #11, the door was open, and the curtain was drawn between the two beds. Resident #10 was lying behind Resident #11 in bed undressed from the waist down, and Resident #11 still had an adult brief on, however, it was undone and Resident #10 had h/her hands on Resident #11's genital area, while h/her hand was on h/her own genitals. The resident's were immediately separated and Resident #10 was placed on 1:1 supervision, and Resident was given a room change.
Interview with RN #1 on 5/6/24 at 2:01 PM identified that by the time she was called to the room the residents were already separated, she completed a physical assessment on both resident and no injury or abnormalities were identified. The physician and families were updated and Resident #10 remained on 1:1 until a psychiatric evaluation could be completed.
Interview with the Psychiatric Advanced Practical Registered Nurse (APRN) on 5/6/24 at 2:30 PM identified that Resident #10 did not have any history of sexually inappropriate behaviors and it was her thought that it was due to a progression in dementia. The APRN identified that she had adjusted Resident #10's trazdone the week prior, so she did not do any medication adjustments on Resident #10. Resident #10 was assessed not to be a danger to self or others, so one to one supervision was discontinued and every 15 minute checks were started. Additionally, neither Resident #10 or Resident #11 had any recollection of the event upon assessment.
Review of the abuse policy identified that each resident has the right to be free from abuse.
3. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's, was always incontinent of bowel and bladder, and was at risk for developing pressure ulcers.
A care plan dated 4/7/24 identified that the resident was at risk for skin breakdown related an inability to respond to pressure related discomfort, impaired mobility and bowel and bladder incontinence with interventions that included assistance with position changes every 2 hours, and incontinent care per facility protocol.
Constant observation on 5/6/24 from 9:45 AM to 1:45 PM identified the following:
a. From 9:45 AM until 10:00 AM the resident was seated across from the nurses station in a wheelchair with h/her body position leaning to the left side.
b. At 10:00 AM the resident was taken into the recreation room for an activity.
c. At 11:02 AM the resident was taken from the lounge by a visitor to the lounge at the end of the hallway, and brought back to the lounge by the nurse's station at 11:10 AM.
d. from 11:10 AM until 11:45 AM the resident was seated in the lounge with h/her body positioned leaning to the left side.
e. At 11:45 AM the resident was taken from the lounge and brought down to the lounge at the end of the hallway for lunch, she was seated to the left of the main table in her wheelchair.
f. At 12:30 PM the resident was fed lunch, after lunch the resident remained in the lounge for an activity until 1:45, the residents body position was still leaning to the left.
At 1:45 PM the surveyor informed LPN #1 that the resident had not received any incontinent care or repositioning from 9:45 AM until 1:45 PM (a total of 4 hours).
Subsequent to surveyor inquiry the resident was taken back to h/her room for care. Surveyor entered the room at 2:00PM while care was already in progress, the resident had already been hoyered into bed and NA#1 stated that she had not yet performed any incontinent care. Observation identified that the resident had not been incontinent and the brief that the resident was wearing was dry. A skin check of the resident identified a 5 centimeter (cm) by 1 cm blanchable area of redness on the residents left hip.
Observation on 5/7/24 at 10:00 AM with LPN #1 identified that the balanceable area of redness to the left hip had resolved.
Interview with Nurse Aide #1 on 5/6/24 at 2:00 PM identified that she was the NA assigned to Resident # 4, and Resident #4's hospice NA had done morning care on the resident, however, she wasn't sure what time care was given. NA#1 identified that she had not checked the resident for incontinence or repositioned the resident until after surveyor inquiry at 1:45 PM because she had 13 residents on her assignment, and she had been busy all morning with care for the other residents.
Interview with LPN #1 on 5/7/24 at 2:10 PM identified that she was Resident #4's nurse and she had a total of 26 residents on her floor with 2 NA. She further identified that NA #1 did not notify her that she could not provide care for Resident #4, if she had been notified she would have called the supervisor.
Interview with the nursing supervisor for the 7:00 AM to 3:00 PM shift (RN)# on 5/6/24 at 2:45 PM identified that she was not aware that NA #1 was having difficulty with h/her assignment, if she was aware she would have made adjustments to the assignments.
Interview with the Director of Nurses on 5/6/24 at 2:50 PM identified that Resident #4 should have been checked for incontinence, and changed if soiled and repositioned every 2 hours in accordance with facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents, (Resident #5), who was dependent for incontinent care and repositioning, the facility failed to ensure that the resident was given care in a timely manner.
The findings included:
Resident #5 had a diagnosis of dementia. A care plan dated 4/5/24 identified that the resident was at risk for pressure ulcers related to inability to respond to pressure related discomfort, impaired mobility, and bowel and bladder incontinence with interventions that included position changes every two (2) hours and incontinent care per facility protocol.
An admission Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, required total care with activities of daily living (including bed mobility), was always incontinent of bowel and bladder, had moisture associated dermatitis (skin inflammation caused by prolonged exposure to moisture), and was at risk for pressure ulcers.
Observation on 5/6/24 at 11:45 AM identified that a family member had approached the nurse's station with concerns about Resident #5 on whether or not the resident had received morning care as the resident was still in bed in a johnny.
Interview with Nurse Aide (NA) #6 on 5/6/24 at 11:50 AM identified that he/she had Resident #5 on her assignment and had provided incontinent care and repositioning at approximately 8:30 AM that morning. NA #6 further identified that she had a very busy morning with an assignment of 15 residents and only one other NA on the floor. The reason Resident #5 was still in bed at 11:45 AM and had not received incontinent care and positioning since 8:30 (3 hours and 15 minutes) was that the resident required assistance of 2 people and she had not had an opportunity to get back to the resident with a second NA #6 also had 15 residents on her assignment.
Interview with LPN # 6 identified that she was Resident #5's nurse for the 7:00 AM to 3:00 PM shift and the census on the unit was 30, and had 2 NA. She was unaware that the NA's were having difficulties completing their assignments.
Interview with the nursing supervisor on 5/6/24 at 1:00 PM identified that if she had been notified that the NA's were having difficulty completing the assignment, she would have made adjustments to the staffing.
Interview with the Director of Nurses on 5/6/24 at 2:00 PM identified that if the NA were having difficulty with their assignment they should have let the charge nurse/supervisor know. Additionally the resident should have been turned and repositioned and given incontinent care every 2 hours.
x

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents reviewed for nutrition, (Resident #6), the facility failed to ensure that a resident who had a diagnosis of dysphagia was properly positioned during mealtime. The findings included:
Resident #6 had a diagnosis of dysphagia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition, and was dependent on staff for activities of daily living including eating.
A care plan dated 4/6/24 identified that the resident was at risk for choking/aspiration with swallowing due to a diagnosis of dysphagia with interventions that directed to provide the diet as ordered and elevate the head of the bed 90 degrees during mealtime and to observe for signs and symptoms of aspiration.
A physician's order dated 4/1/124 directed the resident to receive a puree diet with thin liquids.
Observation on 5/6/24 at 9:10 AM identified Nurse Aide (NA) # 2 feeding Resident #6 in bed, the resident has a neck pillow on, however, the bed was flat, and the head of the bed was not elevated.
Interview with NA #2 at the time of the observation identified that she had fed the resident the pureed eggs and some of the oatmeal, however, she didn't think to elevate the head of the bed.
Interview and observation with LPN #7 of Resident #6's positioning during mealtime on 5/6/24 at 9:12 AM identified that Resident #6 was on aspiration precautions and the head of the bed was not elevated as it should have been during mealtime to 90 degrees.
Interview with the speech therapist on 5/6/24 at 12:21 PM identified that Resident #6 has dysphagia and is on aspiration precautions and refuses to get out of bed for meals. Resident #6 has cervical spine issues and if the head of h/her bed is elevated too much it causes pain, however, the head of the bed should never be flat and for Resident #6 the head of the bed should have been at least 75 to 80 degrees elevated to prevent the potential for aspiration.
Review of the aspiration precaution policy identified that the aspiration precaution policy will be utilized to prevent the aspiration of food into a resident's lungs and aspiration precautions will be individualized for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1) reviewed for pressure ulcers, the facility failed to assess and document changes in the resident's skin. The findings include:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included type II diabetes and dementia.
The nursing admissions assessment dated [DATE] at 4:00 PM identified Resident #1 had no pressure ulcers and was at risk for developing pressure ulcers/injuries.
The physician's orders dated 1/4/24 directed an assist of two staff for activities of daily living (ADL's), an assist of two staff with a Hoyer lift for transfers and triad topical for rash.
The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers.
The care plan dated 1/5/24 identified Resident #1 was at risk for skin breakdown with interventions that included assisting Resident #1 with position changes approximately every 2 hours and as indicated, pressure reducing relieving devices, and to offer to offload Resident #1's heels when in bed.
A physician's order dated 1/11/24 directed Aquaphor to peri-area every shift with incontinence care per family.
a. A nurse's note dated 2/18/24 at 7:40 PM identified Resident #1's family member had complaints of Resident #1's buttocks, stating Resident #1's wound had returned because staff was not applying Aquaphor (a skin protectant). LPN #6 assessed Resident #1's buttocks, applied Aquaphor, and notified the supervisor.
A nursing note dated 2/24/24 at 6:50 PM identified Resident #1 was noted with an opening to the coccyx measuring 1 centimeter (cm) x 1 cm. The site was superficial, clean and pink with no signs of infection. The APRN was updated with new orders in place for triad mixed with Aquaphor for 14 days. The wound notification form was completed.
Wound care documentation dated 2/28/24 at 9:55 PM identified Resident #1 was seen by the wound care team secondary to Moisture Associated Dermatitis (MASD)on Resident #1's coccyx measuring 0.5 cm x 0.5 cm x 0.1 cm, 100% granulation tissue and scant amount of drainage noted, a New order for triad cream every shift was obtained.
Wound care documentation dated 3/4/24 at 11:22 AM identified Resident #1's coccyx wound was stable, measuring 0.5 cm x 0.5 cm, 100% non-granulation tissue, no drainage and to continue the current treatment. Wound care documentation dated 3/12/24 at 9:36 PM identified Resident #1's coccyx wound was improving, measuring 0.3 cm x 0.3 cm x 0.1 cm, no drainage noted and to continue the current treatment.
A RN nursing note dated 3/16/24 at 4:20 PM identified the on call APRN was notified of Resident #1's change in coccyx area. The plan was to monitor and place in wound care book for re-evaluation on 3/18/24. Resident #1's family member was notified and wanted Resident #1 to be sent to the hospital. The APRN was updated and Resident #1's family member went to the hospital with Resident #1.
A nurse practioner note dated 3/19/24 at 10:02 AM identified review of Resident #1's hospitalization was for Resident #1's coccyx wound. Resident #1's coccyx wound was not infected and no interventions were done beyond basic wound care. Resident #1 was seen by the wound care nurse who recommended to cleanse the wound with soap and water, apply skin barrier cream to wound and cover cream with a full sheet of xeroform twice a day and as needed.
A nurse's note written by LPN #7 dated 3/24/24 at 2:15 PM identified Resident #1's treatment to the sacral area was done as ordered and a dressing applied, a foul odor was noted with no drainage.
A nurse practioner note dated 3/25/24 at 11:31 AM identified per wound care, Resident #1's sacral wound was worsening, however the wound was not assessed.
Wound care documentation dated 3/25/23 at 12:23 PM identified Resident #1's coccyx wound, now unstageable, was declining, measuring 4 cm x 3 cm, unknown depth a new order to clean with normal saline followed by santyl followed by calcium alginate followed by boarded foam.
A nursing note dated 3/25/24 at 12:23 PM identified Resident #1 was seen today by the wound care team secondary to MASD on Resident #1's coccyx which was now an unstageable ulcer measuring 4 cm x 3 cm with the depth unknown. a small amount of drainage noted with 75% slough and 25% epi tissue. A new order to clean the area with normal saline, followed by santyl and calcium alginate followed by bordered foam.
Interview with RN #2 on 5/7/24 at 2:13 PM identified she was not notified of the odor from Resident #1's wound by LPN #7 on 3/24/24. She identified if she were notified, she would have assessed the wound, including measuring it and checking for drainage and then would notify the physician.
Although multiple attempts were made, an interview with LPN #7 was not obtained.
b. A nurse's note dated 4/3/24 at 3:09 PM identified during Resident #1's dressing change and repositioning, LPN #3 observed an open area to the left of Resident #1's coccyx ulcer measuring 1.2 cm x 1.2 cm and the Physician's assistant was updated with the new order to apply triad cream every shift.
Interview with LPN #3 on 5/7/24 at 10:30 AM identified she notified RN #1 (supervisor on 4/3/24) of the newly identified open area to the left of Resident #1's coccyx wound.
Interview with RN #1 on 5/7/24 at 11:33 AM identified she had assessed Resident #1's newly identified wound notified by LPN #3, however, she failed to document a progress note and probably forgot. She further identified a nursing note should be documented for any changes in residents' skin.
c. A nurse's note written by LPN #1 dated 4/6/24 at 10:22 PM identified triad cream was applied to the left coccyx ulcer and Aquaphor to his/her peri area as ordered. Resident #1's dressing was soiled and changed, and a smelly odor was noted prior to the dressing change and the supervisor was made aware.
A physician's assistant note dated 4/9/24 at 12:12 PM identified he attempted to discuss Resident #1's poor oral intake and wound healing with his/her conservator. It identified there were no reports of wound infection by the wound care team and that Resident #1's conservator persisted on having Resident #1 evaluated in the hospital despite it not changing the management of Resident #1's wound.
A physician's order dated 4/9/24 directed to transfer Resident #1 to the emergency department for an evaluation of Resident #1's non-healing coccyx wound per Resident #1's emergency contact.
Although multiple attempts were made, an interview with LPN #1 was not obtained.
Interview with RN #2 on 5/7/24 at 2:13 PM identified she was not notified of the odor from Resident #1's wound by LPN #1 on 4/6/24. She identified if she were notified, she would have assessed the wound, including measuring it and checking for drainage and then would notify the physician.
Interview with the ICN nurse on 5/6/24 at 1:30 PM identified herself and wound nurse are both LPN's and report to the DNS of any changes in the resident's wounds status.
Interview with the DNS on 5/7/24 at 3:00 PM identified for any changes in condition such as changes in a resident's wound status, the LPN should alert the RN and the RN should complete and document an assessment and interventions, if any.
Interview with the facility Nurse Practitioner on 5/8/24 at 11:58 AM identified the facility practitioners/physicians should be notified of a change in a resident's wound, such as a new odor.
Review of the significant change policy identified that the physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition and that the notification should be documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews for two (2) of fifteen (15) residents reviewed for activities of daily living, (Resident #4 and Resident #5), the facility failed to ensure adequate staffing to meet the needs of the residents.
The findings include:
Review of the nursing schedule from 7:00 AM to 9:00 PM for 5/6/24 identified that the facility met the requirements of the state agency for staffing , however, for the Evergreen unit and the [NAME] unit, staffing was not sufficient to meet the needs of the residents. The Evergreen unit had a census of 26 residents and had 2 Nurse Aides (13 residents each) and the [NAME] unit had 30 residents and 2 NA (15 residents each)
1. Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's, was always incontinent of bowel and bladder, and was at risk for developing pressure ulcers.
A care plan dated 4/7/24 identified that the resident was at risk for skin breakdown related an inability to respond to pressure related discomfort, impaired mobility and bowel and bladder incontinence with interventions that included assistance with position changes every 2 hours, and incontinent care per facility protocol.
Constant observation on 5/6/24 from 9:45 AM to 1:45 PM identified the following:
a. From 9:45 AM until 10:00 AM the resident was seated across from the nurses station in a wheelchair with h/her body position leaning to the left side.
b. At 10:00 AM the resident was taken into the recreation room for an activity.
c. At 11:02 AM the resident was taken from the lounge by a visitor to the lounge at the end of the hallway, and brought back to the lounge at 11:10 AM.
d. from 11:10 AM until 11:45 AM the resident was seated in the lounge with h/her body position leaning to the left side.
e. At 11:45 AM the resident was taken from the lounge and brought down to the lounge at the end of the hallway for lunch, she was seated to the left of the main table in her wheelchair.
f. At 12:30 PM the resident was fed lunch, after lunch the resident remained in the lounge for an activity until 1:45, the residents body position was still leaning to the left.
At 1:45 PM the surveyor informed LPN #1 that the resident had not received any incontinent care or repositioning from 9:45 AM until 1:45 PM (a total of 4 hours).
Subsequent to surveyor inquiry the resident was taken back to h/her room for care. Surveyor entered the room while care was already in progress, the resident had already been hoyered into bed and NA#1 stated that she had not yet performed any incontinent care. Observation identified that the resident had not been incontinent and the brief that the resident was wearing was dry. A skin check of the resident identified a 5 centimeter (cm) by 1 cm blanchable area of redness on the residents left hip.
Observation on 5/7/24 at 10:00 AM with LPN #1 identified that the blanchable area of redness had resolved.
Interview with Nurse Aide #1 on 5/6/24 at 2:00 PM identified that she was the NA assigned to Resident # 4, and Resident #4's hospice NA had done morning care on the resident, however, she was not sure what time care was given. NA#1 identified that she had not checked the resident for incontinence or repositioned the resident until after surveyor inquiry because she had 13 residents on her assignment, and she had been busy all morning with care for the other residents.
Interview with LPN #1 on 5/7/24 at 2:10 PM identified that she was Resident #4's nurse and she had a total of 26 residents on her floor with 2 NA. She further identified that NA #1 did not notify her that she could not provide care for Resident #4, if she had been notified she would have called the supervisor.
2. Resident #5 had a diagnosis of dementia. A care plan dated 4/5/24 identified that the resident was at risk for pressure ulcers related to inability to respond to pressure related discomfort, impaired mobility, and bowel and bladder incontinence with interventions that included position changes every two (2) hours and incontinent care per facility protocol.
An admission Minimum Data Set (MDS) dated [DATE] identified that the resident had severely impaired cognition, required total care with activities of daily living (including bed mobility), was always incontinent of bowel and bladder, had moisture associated dermatitis(skin inflammation caused by prolonged exposure to moisture), and was at risk for pressure ulcers.
Observation on 5/6/24 at 11:45 AM identified that a family member had approached the nurse's station with concerns about Resident #5 on whether or not the resident had received morning care as the resident was still in bed in a johnny.
Interview with Nurse Aide (NA) #6 on 5/6/24 at 11:50 AM identified that he/she had Resident #5 on her assignment and had provided incontinent care and repositioning at approximately 8:30 AM that morning. NA #6 further identified that she had a very busy morning with an assignment of 15 residents and only one other NA on the floor. The reason Resident #5 was still in bed at 11:45 AM and had not received incontinent care and positioning since 8:30 (3 hours and 15 minutes) was that the resident required assistance of 2 people and she had not had an opportunity to get back to the resident with a second NA #6 also had 15 residents on her assignment.
Interview with LPN # 6 identified that she was Resident #5's nurse for the 7:00 AM to 3:00 PM shift and the census on the unit was 30, and had 2 NA. She was unaware that the NA's were having difficulties completing their assignments.
Interview with the nursing supervisor on 5/6/24 at 1:00 PM identified that if she had been notified that the NA's were having difficulty completing the assignment, she would have made adjustments to the staffing.
Interview with the Director of Nurses on 5/6/24 at 2:00 PM identified that if the NA were having difficulty with their assignment they should have let the charge nurse/supervisor know. Additionally the resident should have been turned and repositioned and given incontinent care every 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews, for one (1) of three (3) residents reviewed for dining, (Resident #4), the facility failed to ensure that a dietary restriction was followed.
The finding includes.
Resident # 4 had a diagnosis of dementia. A quarterly MDS dated [DATE] identified that the resident had significant cognitive impairment, was dependent on staff for all ADL's.
A care plan dated 4/7/24 identified that that the resident had an alteration in nutrition related to fluctuating intake with interventions that included to provide the diet as ordered and to assist with meal intake.
Review of physician's orders identified an allergy to lactose (a sugar found in milk)
A physician's order dated 5/1/24 directed to provide a puree diet with thin liquids (may have soft foods such as pasta).
Review of a meal ticket on 5/6/24 identified that the resident was on a lactose free diet, puree with thin liquids.
Observation on 5/6/24 at 12:30 PM identified NA #4 feeding Resident #4 seafood alfredo and thrive ice cream.
Interview with NA #4 on 5/7/24 at 1:59 PM identified that she knew that the resident had was not supposed to have lactose and did not think the alfredo or thrive had lactose.
Interview with the cook on 5/7/24 at 1:56 PM identified that the alfredo sauce is made with lactaid milk (lactose free), parmesan cheese, and butter. The cook further identified that parmesan cheese and butter have small amounts of lactose.
Interview with dietary aide #1 on 5/7/24 at 2:00 PM identified that he had read the meal ticket to the cook on 5/6/24 for Resident #4, however, he was unaware that the alfredo sauce had lactose. Further, he served the resident the thrive ice cream because he thought it was lactose free, however, observation identified that the first two ingredients were milk and cream.
Interview with the Head [NAME] on 5/7/24 at 3:00 PM identified that the resident should not have been served the seafood alfredo or the thrive ice cream.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for activities of daily living, the facility failed to ensure the clinical record was complete and accurate to include complete documentation of meals and personal care provided. The findings include:
Resident #1 had diagnoses that included type II diabetes and dementia.
Review of Resident #1's nurses aid (NA) care card dated 1/4/24 directed to record bowel movement every shift.
The physician's orders dated 1/4/24 directed an assist of two staff for ADL's, an assist of two staff with a Hoyer lift for transfers and triad topical for rash.
The care plan dated 1/5/24 identified Resident #1 needed help to perform his/her ADL's with interventions that included that Resident #1 was unable to participate in his/her ADL's and to provide all of his/her care, incontinent care per protocol, assist Resident #1 out of bed to eat breakfast and return to bed after eating lunch and assist of two for all ADL's.
The admission MDS dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and bladder, did not have any pressure ulcers or injuries and was at high risk for developing pressure ulcers.
Review of Resident #1's NA care card dated 1/27/24 directed to follow the master schedule for shower day. The care card was updated on 3/20/24 to direct the shower day on Sunday 3:00 PM - 11:00 PM shift.
Review of Resident #1's ADL Report identified the following:
1. Review of toilet use and eating documentation identified:
a. For the month of February 2024 out of 87 opportunities (29 days in the month for three shifts), the facility documented 10 of 87 opportunities; the facility had no documentation for 77 opportunities.
b. For the month of March 2024 out of 93 opportunities (31 days in the month for three shifts), the facility documented 12 of 93 opportunities, the facility had no documentation for 81 opportunities.
c. For the month of April 2024 out of 27 opportunities (9 days of the month for three shifts due to being transferred to the hospital on 4/9/24), the facility documented 5 of 27 opportunities; the facility had no documentation for 22
opportunities.
2. Review of bathing documentation identified:
a. For the month of February 2024 Resident #1 had 8 documented occurrences of bathing, and 8 of 8 occurrences were bed baths; the facility failed to document if a shower was provided and/or documented.
b. For the month of March 2024 Resident #1 had 12 documented occurrences of bathing, and 1 of the 12 occurrences was a shower; the facility failed to document if any other showers were provided and/or documented.
Although requested, the facility did not provide a policy related to ensuring accuracy of nursing documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for pressure ulcers, the facility failed to ensure multi-patient use wound care supplies were maintained in a clean, sanitary manner. The findings include:
Resident #2 was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, and dementia.
The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was always incontinent of bowel and bladder, and had three stage three pressure ulcers/injuries.
The care plan dated 3/5/24 identified Resident #2 was at risk for skin breakdown related to a left heel deep tissue injury (DTI) with interventions to measure the wound weekly and perform treatments as ordered, and for left lateral ankle DTI to measure wound weekly and treatments as ordered, remove Hoyer pad when in the wheelchair, encourage to change position frequently, offer to assist with position changes approximately every 2 hours and offer to off load heels when in bed.
A physician's order dated 4/22/24 directed for the left heel stage three pressure ulcer to clean the area with normal saline followed by betadine-soaked gauze followed by abdominal (ABD) pad followed by gauze wrap and change daily on the 7:00 AM - 3:00 PM shift.
A physician's order dated 4/22/24 directed for left lateral ankle stage three pressure ulcer to clean with normal saline followed by betadine-soaked gauze followed by ABD pad followed gauze wrap and change daily on the 7:00 AM - 3:00 PM shift.
Observations were conducted on 5/7/24 at 10:55 AM of Resident #2's dressing change performed by LPN #10 identified LPN #10 performed hand hygiene, donned clean gloves, removed Resident #2's left boot and dressing. removed her gloves, performed hand hygiene and donned clean gloves. LPN #10 lifted Resident #2's left foot to observe the skin and then took gauze pads from the multi-use package with the same gloves LPN #10 used to lift Resident #2's foot. LPN #10 continued with Resident #2's dressing care and once completed, returned the multi-use gauze package to the treatment cart.
Interview with the ICN on 5/7/24 at 3:00 PM identified the expectation when performing dressing changes is to take a few pieces of gauze from the package to bring into a resident's room. She identified the entire multi-use gauze package should be thrown away due to cross contamination.
Review of the clean dressing technique directed licensed staff will use clean dressing technique for all dressing changes unless otherwise specified by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility documentation, review of facility policy and interviews for one of four sampled residents (Resident #111) reviewed for pressure ulcer/injury, the facility failed to accurately document the location of a pressure wound. The findings include:
Resident #111 's diagnoses included unspecified dementia, dysphagia, and abnormal weight loss.
The significant change Minimum Data Set assessment dated [DATE] identified Resident #111 was severely cognitively impaired, required extensive assistance of one for eating, and bed mobility, and required the assist of two for transfers and toileting.
The care plan dated 1/4/23 identified Resident #111 had an unstageable left hip pressure ulcer with interventions that included: perform wound care as ordered, weekly wound measurements, frequent position changes approximately every 2 hours and utilize pressure reducing/relieving devices in bed and while sitting.
A physician's order dated 2/6/24 directed to clean the unstageable left hip wound with wound cleanser, apply Dakins 0.25% soaked gauze to wound bed and cover with a foam dressing. Change twice daily and as needed.
Observation of wound care on 2/7/24 at 1:17 PM with LPN #2 identified she was assisted by NA #8 with turning and positioning Resident #111 on his/her right side. The resident's brief and the old dressing were removed, and the location of the wound was noted to be on the left ischial tuberosity area of the left buttock. No wound was observed on the left hip. The wound bed was noted to be covered with 80 to 100% yellow slough and was oval in shape with a crater like appearance. LPN #2 cleansed and applied the ordered dressing to the affected area.
Interview on 2/14/24 at 1:06 PM with LPN #2, and the Infection Control Nurse (ICN) (LPN #4) identified that the wound doctor comes in weekly and noted that the wound doctor measures the wounds weekly. LPN #4 identified that she also measures the wounds on a weekly basis. LPN #4 noted that Resident #111's wound was located on the right side of the right buttock. She further noted that she thinks the documentation of the left hip ulcer is due to staff confusion concerning an old, healed pressure ulcer that used to be on Resident #111's left hip. LPN #4 conveyed that the unstageable wound is on the right side not the left, and on the ischial tuberosity of the buttock not the left hip.
Interview on 2/14/24 at 2:39 PM with the DNS identified that he I do surveillance reviews the wound list weekly with LPN #4, he noted that he collaborates by reading the notes and through discussions with LPN #4 but note that he does not sign off on anything and that he does not perform wound rounds. In addition, the DNS could not explain the discrepancy in the wound documentation and the inaccurate description of the location of the wound.
Interview on 2/15/24 at 11:49 AM with the Wound Specialist (MD #1) identified that when he saw the resident it looked like the wound was on the left hip because of the way he/she was positioned. I can see how it's lower and could be seen as on the buttock or on the ischial tuberosity. It's over a bony prominence and is from pressure. MD #1 further identified that he would be coming to the facility later and would reassess the wound location.
Review of the Prevention & Management of Pressure Injuries policy identified that wound assessments should include location, measurements in centimeters, length, width, depth, undermining and any tunneling, odor and appearance of the wound bed, edges and peri-wound area. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident # 75) reviewed for accidents, the facility failed to develop and implement a comprehensive care plan following an incident of suspicion of ingesting non-food items. The findings include:
Resident #75 was admitted to the facility on [DATE] with diagnoses that included pneumonia, dementia, anxiety, malnutrition, type 2 diabetes mellitus and hypertension.
Review of the resident care card dated 1/10/24 identified Resident #75 required assistance with activities of daily living (ADL) and with all meals.
The admission MDS assessment dated [DATE] identified Resident #75 had a severe cognitive impairment and required extensive assistance for hygiene, toileting, transfers, was non-ambulatory and utilized a wheelchair for mobility.
The Resident Care Plan (RCP) dated 1/25/24 identified Resident #75 had mental illness that may cause behaviors and mood disturbances. Care plan interventions included: monitor the resident's mood and behaviors, monitor response to treatment, refer to psychiatrist support as indicated, and provide emotional support and reassurance when needed.
The nurse's note dated 1/14/24 at 1:41 PM written by RN #1 identified Resident # 75 was noted with feces on his/her hands and in his/her mouth. Resident #75's hands and mouth were cleaned and no signs and/or symptoms of gastrointestinal upset noted. The APRN and responsible party were updated, the resident's responsible party indicated Resident #75 had a history of the same behavior in the community.
The nurse's note dated 2/1/24 at 9:14 PM written by RN #1 identified Resident #75 had vomited a moderate amount of yellowish colored liquid and noted that there was a presence of liquid soap on his/her clothing and mouth, abdomen was soft, non-distended, and non-tender. Resident #75 had no indication of pain and/or discomfort. APRN and responsible party were updated.
Review of nurses' notes from 2/1/24 to 2/4/24 identified Resident #75 was being monitored for status post ingestion of liquid soap.
The nurse's note dated 2/5/24 at 7:20 PM written by RN #2 identified Resident #75's family was visiting and noted the resident expelled a small amount of clear emesis while lying in bed. The family also noted a bottle of house lotion was lying next to the resident. The note further noted RN #2 observed a half bottle of lotion on the floor with a small amount spill on the floor and some lotion on the bedside table. The family expressed a concern that Resident #75 had possibly ingested lotion. The APRN was updated and advised to call poison control for further instructions. Poison control was called and advised to monitor the resident for coughing, nausea, loose stool and to give resident fluids to demonstrate normal swallowing. The note further identified Resident #75 drank fluids without difficulties.
The revised RCP dated 2/5/24 identified Resident #75 had a problem with ingesting non-food items related to dementia. Care plan interventions included: keep all personal care items away from resident's room and provide personal care items with supervision.
Interview with RN #1 (nursing supervisor for 3-11 shift when the first incident occurred) in the presence of the DNS on 2/7/24 at 11:20 AM identified Resident #75 was in the dining room with the family member on 2/1/24 when he/she vomited a small amount of yellowish liquid. Resident #75 was brought to his/her room for evaluation and was noted to have the presence of liquid soap on his/her hands and around his/her mouth. RN #1 further identified that during her investigation, she was not able to determine where the resident obtained the liquid soap. There was no liquid soap in the resident's room or the dining room and when she updated the responsible party, she was informed that there was no history of Resident #75 ingesting liquid soap; however, Resident #75 had a behavior of touching his/her feces and putting it in his/her mouth. She further identified that she had not updated the RCP after the incident on 1/14/24 when she found the resident with feces on his/her hands and in his/her mouth and/or after the resident was found with the soap in his/her mouth.
Interview with the DNS on 2/7/24 at 11:30 AM identified that he was unaware of the incidents involving Resident #75 and noted that he/she should have been monitored closely to prevent the ingestion of non-food items. He further identified that the resident's care plan should had been updated to address the resident's behavior of ingesting non-food items.
Interview with NA #1 (nursing aide for 7-3 shift) on 2/7/24 at 12:25 PM identified Resident #75 is able to self-propel himself/herself in the wheelchair, is very confused and has activated the fire alarm multiple times. NA #1 further identified that all personal care products were stored inside the bedside table. He further identified that he was not aware of the first incident of Resident #75 ingesting the liquid soap.
The Comprehensive Care Plan policy identified that the facility was committed to providing residents with all necessary care and services to achieve the highest quality of life. Care plans were oriented toward preventing avoidable decline in clinical and function level and care plan would be evaluated and revised as needed.

**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 four sampled residents (Resident #31) reviewed for falls, the facility failed to ensure the fall risk assessment was completed in accordance with the facility policy. The findings include:
Resident #31's diagnoses included spinal stenosis without neurogenic claudication, glaucoma, gout, anxiety, and hypertension.
Review of the clinical record identified a fall risk assessment dated [DATE] that identified Resident #31 had a score of 22 indicative of high risk for falls (a score of 10 or higher represents high risk). The clinical record did not contain any other documented fall risk assessments.
The monthly physician's orders for January/2024 directed Resident #31 was independent for transfers and ambulation with a rolling walker in room and the hallway, this order had been in effect since 6/22/23.
The quarterly MDS assessment dated [DATE] identified Resident #31 had intact cognition, was independent with hygiene, toileting, transfers, and ambulation, and utilized a rolling walker. In addition, the MDS also identified Resident #31 had multiple falls in the last three months.
The Resident Care Plan (RCP) dated 12/28/23 identified Resident #31 was at risk for falls related to history of falls, impaired mobility, and impaired safety awareness. Care plan interventions included: educate resident to ensure non-skid socks in place, rolling walker within reach, educate to utilize chair arms prior to sitting in a chair for stability, offer resident assistance to toilet on the last rounds for 7-3 shift and encourage to use call bell for assistance when needed.
Reportable event reports dated 11/15/23, 1/12/24, and 1/28/24 identified Resident #31 sustained falls without injuries.
The Fall Management policy identified a fall risk evaluation would be conducted on admission, each MDS cycle (quarter), with a significant change in status, annually, and following a fall.
Interview with RN #1 (7-3 shift nursing supervisor) on 2/7/24 at 2:00 PM identified that the fall risk assessment is completed on admission and the charge nurse on the unit is responsible for completing the fall risk assessment. She further identified she was unaware that a fall risk assessment needed to be completed quarterly and/or after each fall.
Interview with the DNS on 2/7/24 at 2:10 PM identified that the fall risk assessment was completed on admission and he also identified that the facility needed to complete the fall risk assessment on admission, quarterly, annually and when there's a significant change in status; however, the DNS identified that he was unaware that the facility's policy directed that a fall risk assessment be completed after each fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one sampled resident (Resident #107) reviewed for Activities of Daily Living (ADL) and who was dependent for care, the facility failed to ensure the resident was provided a shower on scheduled shower days. The findings include:
Resident #107 's diagnoses included osteoarthritis, obesity, and atrial fibrillation.
The quarterly MDS assessment dated [DATE] identified Resident #107 had moderate cognitive impairment and required extensive assistance for bathing, personal hygiene, and toileting.
The Resident Care Plan (RCP) dated 11/28/23 identified Resident #107 required assistance with mobility and self-care related to weakness, unsteady gait, and medical illness. Care plan interventions directed: encourage resident to make their own choices, provide set-up with oral care, and report any changes and/or concerns with ADL care to the nurse.
Interview with Resident #107 on 2/5/24 at 11:00 AM identified he/she was not consistently getting a weekly shower. He/she identified that he/she is scheduled for a shower every Sunday on the 7-3 shift and that he/she has never refused to be showered.
Review of the master shower schedule identified Resident #107 was scheduled to have a shower every Sunday on the 7-3 shift.
Review of the Nurse Aide (NA) shower flow sheets from 12/1/23 through 2/14/24 identified documentation that indicated Resident #107 had received a shower on 2/11/24, the other scheduled shower dates contained no documentation (1 shower out of 11 opportunities).
Review of nurses' notes from 12/1/23 through 2/14/24 identified Resident #107 had a shower on 12/13/23, 12/17/23, and 1/19/24 (3 showers out of 11 opportunities).
Interview with NA #2 on 2/14/24 at 11:10 AM identified that the facility had a master shower schedule that lists all residents' shower schedules. She identified that Resident #107's shower schedule was every Sunday on the 7-3 shift. She also identified that the shower is documented in the NA task documentation when it is provided and/or when a resident refuses. She further identified that Resident #107 did not have a history of refusing care.
Interview with the DNS on 2/14/24 at 11:45 AM identified that the nurses' aides are responsible for providing and documenting showers. He identified that the nurses' aides should document whether a shower was provided and/or if a resident refuses. He further identified that he would not be able to verify whether Resident #107 was provided a shower due to the lack of NA documentation.
The Shower policy identified that the residents receive a shower given by the nursing staff as desired and the showers are documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interviews for one of three residents (Resident # 1) reviewed for wounds, the facility failed to notify the physician of a change in condition timely. The findings include:
Resident #1 was admitted with diagnoses that included dementia, stroke, and contractures of both knees, both elbows and the left hand. A quarterly minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, did not walk, was dependent with the assistance of two (2) staff members for bed mobility, transfers, toileting and personal hygiene, and was fed via a gastrostomy tube (feeding tube directly in the stomach).
The Resident Care Plan (RCP) dated 5/25/2023 identified Resident #1 was at risk for skin breakdown due to immobility, inability to respond to pressure related discomfort, bladder/bowel incontinence with instances of wounds. The RCP directed treatments as ordered, pressure reduction cushion in wheelchair, offload heels, and to reposition approximately every 2 hours.
The nursing note dated 7/7/2023 (Friday) at 9:42 PM identified Resident #1 had a new possible skin breakdown on his/her right heel. The note further indicated Resident #1 had a scheduled skin prep order already in place. The supervisor (RN #1) was notified of the new area on the right heel and a request form was completed for the wound care team to evaluate the area.
Review of the clinical record identified although Resident #1 had a standing physician order that directed to apply skin prep to all scabbed areas on the right and left ankles, the bottom of the left big toe and the ball of the foot, and the bottom of the right foot near a bunion daily, review failed to identify a treatment order was in place for the right heel.
A wound care team progress note dated 7/10/2023 (Monday) at 12:56 PM identified Resident #1 was seen by the wound team to assess the new area on the right heel. The note identified the area was a stage 3 pressure ulcer (full thickness tissue loss) with a large amount of serous drainage (clear fluid that leaks out of wounds) noted. New orders for bilateral lower extremity ultrasound and an antibiotic were obtained.
Clinical record review failed to identify the physician was notified and a treatment order was obtained when the new area on Resident #1's heel was identified on 7/7/2023, until Resident #1 was seen by the wound care team physician on 7/10/2023 (three days later).
Interview and clinical record review with the Infection Control/wound nurse (LPN #1) on 10/4/2023 at 11:32 AM identified Resident #1's right heel change in skin condition was identified on 7/7/2023 at 9:42 PM. She further identified that she and the wound physician evaluated the Resident on 7/10/2023 noted that this was the first time she was aware that Resident #1 had a new heel wound. LPN #1 further indicated if a nurse identifies a change in skin condition, they would be expected to notify the supervisor who would assess the change and determine if the medical doctor needed to be notified as well as the family. LPN #1 indicated the RN supervisor should have completed a wound assessment and notified the physician to obtain new treatment orders.
Interview with LPN #2 on 10/4/2023 at 12:22 PM identified that she was the charge nurse on 7/7/2023 and she identified the new area on Resident #1s right heel, and indicated the area was very dark in color and different from what she had observed prior. LPN #2 indicated the area was non-blanchable, had no drainage and the skin was intact. LPN #2 notified RN #1 who was the supervisor. LPN #2 applied skin prep to the area, documented the area, and the supervisor was responsible to assess the area and make necessary notifications.
Although attempted, an interview with RN #1 was unsuccessful during the survey.
Interview and clinical record review with the DON on 10/4/2023 at 3:00 PM identified although LPN #2 identified a change in the condition of Resident #1's right heel, she was unable to provide documentation that the physician was notified. The DON indicated the physician should have been notified and new orders obtained.
Interview with MD #2 identified that he could not recall being notified of the change in Resident #1's heel condition.
Review of the facility policy, Condition, Significant Change, dated 7/17, directed in part, that the physician and/or responsible party will be notified by the nurse in the event of a change in condition and the notification shell be documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interviews for one of three residents (Resident # 1) reviewed for wounds, the facility failed to ensure an RN assessment was completed timely when a change in condition was identified. The findings include:
Resident #1 was admitted with diagnoses that included dementia, stroke, and contractures of both knees, both elbows and the left hand. A quarterly minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, did not walk, was dependent with the assistance of two (2) staff members for bed mobility, transfers, toileting and personal hygiene, and was fed via a gastrostomy tube (feeding tube directly in the stomach).
The Resident Care Plan (RCP) dated 5/25/2023 identified Resident #1 was at risk for skin breakdown due to immobility, inability to respond to pressure related discomfort, bladder/bowel incontinence with instances of wounds. The RCP directed treatments as ordered, pressure reduction cushion in wheelchair, offload heels, and to reposition approximately every 2 hours.
The nursing note (written by LPN #2) dated 7/7/2023 (Friday) at 9:42 PM identified Resident #1 had a new possible skin breakdown on his/her right heel. The note further indicated Resident #1 had a scheduled skin prep order already in place. The supervisor (RN #1) was notified of the new area on the right heel and a request form was completed for the wound care team to evaluate the area.
Review of the clinical record failed to identify an RN assessment was completed after LPN #2 identified the change in skin condition.
Interview and clinical record review with the Infection Control/wound nurse (LPN #1) on 10/4/2023 at 11:32 AM identified Resident #1's right heel change in skin condition was identified on 7/7/2023 at 9:42 PM. She further identified that she and the wound physician evaluated the Resident on 7/10/2023 noted that this was the first time she was aware that Resident #1 had a new heel wound. LPN #1 further indicated the RN supervisor should have completed a wound assessment and notified the physician to obtain new treatment orders.
Interview with LPN #2 on 10/4/2023 at 12:22 PM identified that she was the charge nurse on 7/7/2023 and after she identified the new area on Resident #1s right heel, she notified RN #1 who was the supervisor.
Although attempted, an interview with RN #1 was unsuccessful during the survey.
Interview and clinical record review with the DON on 10/4/2023 at 3:00 PM identified although LPN #2 notified the nursing supervisor/RN #1 of the change in condition, the DON was unable to provide documentation that an RN assessment was completed. Further, the DON indicated new physician orders should have been obtained for a treatment to the area.
The facility policy, Prevention and Management of Pressure ulcers, dated 7/17, directed in part, that an RN assessment is required upon identification of any new wounds.
The facility policy, Prevention and Management of Pressure ulcers, dated 7/17, directed in part that wound treatments are done per MD order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of policy and procedures and interviews for one of two residents at risk for weight loss, the facility failed to ensure the resident received assistance with meals in accordance with the plan of care. The findings included:
Resident #11's diagnoses included abnormal weight loss, glaucoma, adjustment disorder with anxiety, amnesia, dementia, cognitive communication disorder, restlessness and agitation.
A quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, without behaviors, requiring limited assistance from staff for eating.
The RCP updated on 7/12 21 identified a risk for weight loss as the problem. Interventions included: to provide supervision for meals, assist when needed and to provide encouragement with eating.
The physician's monthly orders for September 2021 directed supervision with meals when needed.
Observation of Resident #11 during lunch on 9/16/21 at 1:15 P.M. identified the resident was eating his/her lunch with supervision and cueing from Licensed Practical Nurse (LPN#1), the resident was cooperative with LPN#1 and was eating spaghetti and meatballs with a sandwich.
During intermittent constant observations of Resident #11 for lunch on 9/20 21 from 12:53 P.M. through 1:22 P.M. identified that the resident was not receiving supervision and cueing, or assistance from staff with his/her meal.
An observation of Resident #11 and a review of his/her lunch tray on 9/20/21 at 12:53 P.M. identified the resident had consumed half of a tuna fish sandwich, his/her eating utensil remained partially wrapped in a napkin and the rest of the resident's meal which had not been consumed consisted of pasta Florentine with Italian sausage, green beans, a fruit cup of watermelon and three 4-ounce glasses of cranberry juice. In addition, the seasoning packets for the meal had not been opened.
The resident was observed on 9/20/21 at 12:53 P.M., 12:58 P.M., 1:04 P.M., 1:10 P.M., 1:15 P.M. 1:18 P.M. sitting in his/her room alone talking to his/herself without the benefit of staff providing supervision as needed with meal.
On 9/20/21 at 1:22 P.M. Nurse Aide (NA#1) was observed removing the resident's tray from his/her room, upon interview and review of Resident # 11 tray with NA#1 identified the resident had consumed only 1/2 of a tuna fish sandwich and had taken sips of juice with the tuna fish. The resident did not consume the pasta Florentine with Italian sausage or the watermelon and Resident#11's eating utensils still remain partially wrapped in the napkin, and the seasoning packets for the meal had not been opened.
On 9/20/21 at 1:42 P.M. during a second interview with NA#1 indicate he/she informed LPN#1 that the Resident #11 had not consumed all his/her meal and the resident was provided with a supplement drink. NA#1 further indicated that although she was assigned to provide care for the resident, he/she had helped unwrapped the resident's sandwich. NA#1 then left the room to continue to pass dietary trays and indicated she/he didn't return to the room until it was time to pick up the resident's tray.
On 9/21/21 at 6:00 P.M. observation of Resident #11 during the dinner meal identified that although staff had completed distributing trays to all residents residing on the unit (Evergreen), Resident #11 had not receive a dietary tray for dinner. Subsequent to inquiry, the Administrator was observed checking to see if Resident #11 had a dietary tray for dinner, when the resident was identified with no tray. The Administrator was observed bringing a dinner tray into Resident #11's room for the resident to eat.
On 9/21/21 at 2:10 P.M. an interview with Medical Doctor (MD#1) regarding the physician's order for supervision with meals when needed s/he indicated that although s/he would not expect the staff to be in the room with the resident the entire time Resident #11 consumed his/her meal, supervision from staff would ensure that Resident #11 is at least taking in some of his/her food and drink.

Based on observations, review of facility policy and interviews for one of two emergency medication boxes reviewed, the facility failed to ensure medications were not within the appropriate expiration date and stored securely. The findings include:
1 a. Observation of the emergency medication storage boxes on 9/21/21 at 11:00 A.M. identified the following medications expired:
1. Nitrostat 0.4 MG SL expire 3/11/20
2. Transdermal patch expire 6/21
3. Coumadin 3 MG expire 7/29/20
4 Zofran 4 MG expire 2/26/21
5. Blue Cap expire 7/21/12
6 Coumadin 1 MG expire 6/22/21
Additionally, several other medications were noted expired in the emergency storage boxes.
Interview and observation on 9/21/21 at 11:00 A.M. with RN #2, RN #3 and RN #4 identified the expired medications were removed from the red box and placed in the orange box on the 3-11 P.M. shift by the RN supervisor. They also indicated the night shift licensed staff was responsible for monitoring the emergency medication box for expired medications. RN #4 stated the red box will no longer be utilized as the facility will use the Pyxis machine from the pharmacy.
Interview with the DNS on 9/21/21 at 11:15 A.M. identified the red box is no good and no longer in use.
Interview with the Administrator on 9/21/2 at 11:30 A.M. identified the licensed nursing staff will be utilizing the Pyxis medication system once passwords/ accounts are set up by the pharmacy. This process will provide a complete stock of approved medications (current supply is minimal with a limited medication at present). The Pyxis system will provide a medication list to the facility.
b. Observation on 9/21/21 at 12:41 P.M. identified the medication boxes unattended, in the supervisor's office with the door open.
Interview with who the Administrator on 9/21/21 at 1:15 P. M. identified medication should be secured.
Review of the facility policy medication storage directed in part medications are stored in a locked compartment area with access of only authorized personnel. The policy also notes that the facility should destroy or return outdated/expired medications.

Based on observations of the kitchen and interviews, the facility failed to ensure that kitchen appliance and resident equipment were maintain in good repair. The findings included:
Observation on 9/16/21 at 9:54 A.M. to 10:20 A.M. of the kitchen area with the [NAME] and the Infection Preventionist Nurse (IPN/RN#4) identified the following concerns:
1.The gasket at the top right side of the walk-in freezer door was detached causing a disruption with closing of the freezer's door to create a seal.
2. The exterior of a large industrial size mixer was identified as being rusted and corroded with large missing areas of paint.
On 9/16/21 at 2:12 P.M. an interview with the Food Service Director (FSD) identified he/she would arrange to have the gasket to the walk-in freezer door repaired and the ice removed.
On 9/19/21 at 1:20 P.M. an additional interview was conducted with FSD identified the mixer is only used by the kitchen staff when preparing to bake a cake. Subsequent to surveyor's inquiry, the mixer was removed from the kitchen.
3. Interview and review of the facility scale for resident weights with the Administrator on 9/22/21 at 2:10 P.M. indicated that after conversing with the Physical Plant Manager (PPM) and a review of the product service sticker, he/she identified the facility scales utilized to obtain the residents' weights have not been calibrated for accuracy since March of 2019 and that ordinarily the scales are calibrated on a yearly basis.

Based on observations of the kitchen and interviews, the facility failed to ensure that foods items were stored or prepared under sanitary conditions or that kitchen equipment were maintained in a clean or sanitary manner and kitchen floors and other areas of the kitchen were maintained in a clean, sanitary manner or in good repair. The findings included:
Observation on 9/16/21 at 9:54 A.M. to 10:20 A.M. of the kitchen area with the [NAME] and the Infection Preventionist Nurse (IPN/RN#4) identified the following concerns:
1. Walk in Freezer
a. The floor of the walk-in freezer was soiled with an unidentifiable substance causing the surveyors shoes to adhere to the floor. In addition, the floor was also soiled in opened spaces. The area beneath the food storage racks was noted with rust stains, black-colored dirt, grime, debris, and noted with a small pieces of old freezer-burned food items.
b. The ceiling area of the walk-in freezer was covered with heavy buildup of ice.
c.
Two boxes of food items (i.e., pasta and twice baked potatoes) stored on the shelf of a food rack in the walk-in freezer were soiled and damaged with a heavy buildup of ice.
d. The cooling fan of the walking freezer was identified as having a large icicle which had formed above boxes of food items stored on a shelf of a food rack.
e.
Food items were stored in the walk-in freezer without the benefit of being labeled with a date to reflect the foods age or shelf-life. The undated food items consisted of the following items:
A large opened plastic bag of 18 freezer burned biscuits
One- cardboard tray of 24 frozen pre-cooked biscuits
One-package of a pureed green colored vegetable food item
One-package of frozen broccoli
Two plastic bags of frozen chicken breast.
One-package of frozen spinach
2. The walk-in Refrigerator was noted with the following
a.
The floor was noted as being soiled with blackened dirt, and debris.
b
Four trays on a serving rack in the refrigerator was identified as having 24 cups of assorted juices to each tray (i.e., orange, apple and cranberry juice were being stored without the benefit of being labeled with a date of the beverage or shelf-life. In addition, the following food items were also identified as being stored in the refrigerator without a label with a date to reflect the age or the shelf-life for each of the food items:
1.Six-trays of assorted cups of fruit and sandwiches
2.One- carafe of iced tea was left uncovered and exposed to the elements of the refrigerator
3.One- box of cranberry juice was left uncovered or without a top, exposing the juice to the elements of the refrigerator
4.1/2p- package of sandwich wraps were found to be opened and wrapped in loosely fitting plastic wrap.
5.Four-sealed packages of pork tenderloins
Further observation of the kitchen on 9/16.21 identified food items in the refrigerator identified the kitchen staff the staff was attempting to label the unlabeled and dated food items at the time of the observation.
3. Additional areas of concern in the kitchen included the following:
a.
The tiled floors in the kitchen were noted to be soiled with food matter, dirt, and debris. The peripheral areas of the kitchen floor and areas beneath or around the 3-bay sink were identified as having missing tiles exposing the concrete and to be soiled with blackened dirt and debris.
b.
The ceiling tiles of the prep tables in the kitchen were soiled with old food splatter and one tile was noted to have a hole in the corner area.
c. A Styrofoam container with seafood salad was labeled with the name of a dietary staff member as his/her own personal food stored in the walk-in refrigerator with resident food.
On 9/16/21 at 2:12 P.M. an interview with the Food Service Director (FSD) regarding the unclean, disrepair of the kitchen and the safe storage of food items identified he/she would expect all food items stored in the kitchen be labeled with a date. He further indicated, dietary staff are not allowed to store their own personal food items in the facility's walk-in refrigerator or freezer. The Food Service Director also indicated the facility have a cleaning schedules for the kitchen and appliances, he would have expected the staff to continuously clean as they work and to follow the cleaning schedule assignment. The FSD further indicated he/she would arrange to have the gasket to the walk-in freezer door repaired and the ice removed.
Based on observations of dining and interviews, the facility failed to ensure food was served or distributed in accordance with infection control standards. The findings included:
1.
On 9/16/21 12:50 PM during an observation of steam table service with Cook#1 identified that after Cook#1 served a plate of spaghetti, meatballs, and string beans, cook #1 was observed pausing between plating of the meals to pull up his pants with his gloved hands. [NAME] #1 then was noted resting his gloved hands on his waist as he waited for the next meal slip to be placed on the steam table by the dietary aide. After the next meal ticket was placed on the steam table to inform Cook#1 a resident's food preference, Cook#1 was identified as attempting to serve another plate without the benefit of washing or sanitizing his hands and changing his gloves. Subsequent to surveyor's inquiry, Cook#1 performed hand hygiene prior to serving or plating any addition meals.
On 9/21/21 03:40 P.M. an interview with the IPN/R#4 indicated he/she would have expected Cook#1 to wash hands, use proper hand hygiene, and change his gloves prior to serving any additional meals.
2. On 9/16/21 at 9:54 AM to 10:20 A.M., observations of the kitchen area of the facility with the [NAME] #1and the Infection Preventionist Nurse (IPN/RN#4) identified the following concerns:
a.
The floor of the walk-in freezer was noted as being soiled with an unidentifiable
substance causing the surveyor's shoes to adhere to the floor. In addition, the floor was also
soiled in opened spaces and beneath the food storage racks with rust stains, black-colored dirt,
grime, debris, and small pieces of old freezer-burned food items
b. The tiled floors in the kitchen were noted to have been soiled with food matter,
dirt, and debris.
c.
The ceiling tiles of the prep tables in the kitchen was soiled with old food splatter
The Food Service Director on9/16/21 at 2:12 P.M. during an interview identified the facility have a cleaning schedules for the kitchen and appliances, he would have expected the staff to continuously clean as they work and to follow the cleaning schedule assignment.

Based on observation during the initial tour, interviews and facility policy review for one of four nursing units, the facility failed to report an incident of equipment malfunction (call bell system) to the State Agency. The findings include:
Observation on 9/16/21 during initial tour on the Meadowbrook unit, all resident's rooms were observed with manual ring bells in place instead of call bells. Interview with the Administrator identified the manual ring bells were provided to all residents' secondary to the call bell system had not been continuously functioning. The Administrator indicated s/he was made aware of the call bell system malfunction upon initial employment three weeks ago. The Administrator on 9/16/21 identified at the time s/he was informed of the malfunction of the call bell system (s/he) was informed the system was scheduled for repair.
Interview with the Regional Administrator with the Administrator present on 9/17/21 at 10:15 A.M. identified the call bell system had intermittent problems since the last week of August 2021. The Regional Administrator indicated initially, it was not a full failure of the system, one call bell would be repaired and then another would malfunction and need repair, the system then became a full failure. The Regional Administrator stated an outside company was contacted for service by the previous administrator and scheduled to be at the facility on 9/20/21. The Regional Administrator, the Administrator and RN#1 were unsure if the state agency had been notified of the call bell system malfunctions leading to full failure.
Subsequent to inquiry and during a follow up interview with the facility Administrator on 9/21/21 at 3:45 P.M. h/she indicated an Incident Report would be filed with the state agency.
Review of the facility Accident/Incident Report policy directed in part, an incident defined as any occurrence not consistent with the routine operation of the facility, i.e.: malfunctioning equipment or observation of a situation that poses a threat to safety or security should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for one of three sampled residents reviewed for hospitalization (Resident #76), the facility failed to ensure the physician was notified in a timely manner when a change of condition was noted. The findings included:
Resident#76's diagnoses included dementia without behavioral disturbance, diabetes mellitus, GERD (gastro-esophageal reflux disease) without esophagitis, dysphagia, atherosclerotic heart disease and a history of repeated falls.
A quarterly MDS assessment dated [DATE] identified the resident at moderately impaired for decision-making skills, requiring extensive assistance from staff for most activities of daily living and noted no problematic conditions for vomiting or any recent surgeries.
The RCP dated 8/31/21 identified nutritional status as a problem. Approaches included to notify the physician/ Advanced Practice Registered Nurse (APRN) of any changes,
The nurse's progress notes dated 9/2/21 at 9:14 P.M. identified the charge nurse was in to see Resident#76 because the resident complained of abdominal pain. Upon assessment, the resident was noted with positive bowel sounds in all four quadrants, abdomen slightly hard, resident noted with small bowel movements since yesterday (9/1/21). Medical Doctor (MD#1) was updated and a new order for CBC (complete Blood Count), CMP (Comprehensive Metabolic Panel) and directed an abdominal x-ray to be done in the morning as ordered. The resident's Power of Attorney (POA) was updated.
The nurse's progress notes dated 9/3/21 at 2:35 A.M. identified in part, that during this shift (11:00 P.M. to 7:00 A.M.), Resident #76 was restless in bed with legs hanging off bed. The resident was observed with shortness of breath while lying down in bed. The head of the bed was elevated, the resident's O2 saturation at 96% on room air. No cough/congestion noted. Resident # 76 also had coffee ground emesis around 1:30 A.M., supervisor notified, no signs/symptoms of cardiac distress, pain medication given for general discomfort, call bell within reach and safety maintained.
On 9/21/21 at 3:05 P.M. an interview and review of the clinical record with the Director of Nursing Services (DNS) identified that the clinical record failed to reflect that MD#1 was notified of the resident's coffee ground emesis on 9/3/21 during the 11:00 P.M. to 7:00 A.M. The DNS indicated that although she was unable to determine that the physician had been notified by RN#5, she would have expected MD#1 to be called.
On 9/21/21 at 3:10 P.M. during the interview and record review with the DNS identified the DNS placing a call to RN#5 in the presence of the surveyor.
On 9/21/21 at 3:20 P.M. an interview and review of the clinical record with RN#5 identified she did not notify the physician on 9/3/21 of the resident's coffee ground emesis. RN # 5 identified although she did not notify the physician on 9/3/21, she changed the resident's morning laboratory blood work from routine to stat (immediate) and decided to wait for the Advanced Practice Registered Nurse (APRN) to arrive in the morning before 8:30 A.M.
On 9/22/21 at 10::20 A.M. an interview and review of the clinical record with the APRN#1 regarding the resident's change in condition on 9/3/21 at 1:30 A.M. related to coffee ground emesis indicated, she would have expected the facility to reach out to MD#1 because her business hours are from 8:00 A.M. to 4:30 P.M. and indicated she would not have been available at 1:30 A.M. on 9/3/21.
On 9/22/21 at 2:27 P.M. an interview and review of the clinical record with MD#1 indicated he would have expected immediate notification on 9/3/21 at 1:30 A.M. when the resident was experiencing coffee ground emesis.
Upon further review of the clinical record noted in part on 9/3/21 at 1:56 P.M., Resident #76 vomited coffee colored emesis again. The resident's heme occult (stool test) times 1 was positive for blood. The APRN was updated, and Resident #76 was sent to an acute care facility for an evaluation.
A review of the acute care record noted in part, Resident#76's was diagnosed with hydropneumothorax (as the principal diagnosis), constipation/obstipation and received a manual dis-impaction and multiple rounds of enemas with good effect.
According to the facility policy and procedures for notifying the physician, noted in part, the physician oversees plan of care and must be involved to ensure plan is appropriate to that resident, make changes as necessary for optimum resident response. The physician must be notified of all changes in condition and regarding any incident with or without injury, temperature, vomiting, changes in level of consciousness, change in mental statis congestion, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility documentation and interviews for two of four units toured during the survey, the facility failed to ensure the facility was maintained in a clean, sanitary, homelike manner or that furniture, privacy curtains and wall surfaces were clean and in good repair The findings included:
1. Observation on 9/16/21 12:01 PM AM through 12:40 PM of the environment on the Evergreen unit identified the following:
a. In room [ROOM NUMBER] bed 1, the wall behind the headboard of Resident #6's bed in room was marred and scarred with blackish/gray marks and with areas of paint missing from the wall.
b. The privacy curtain in room [ROOM NUMBER] between bed 1 and bed 2 and the privacy curtain in room [ROOM NUMBER] between bed 1 and 2 both were noted to have a brown colored stain located in the mid center and in the lower areas of the curtains.
c .In room [ROOM NUMBER] the lower wall area, on the right, outside of the bathroom door was noted as having a horizontal marred area, black and brown in color.
d. In room [ROOM NUMBER] the nightstand cabinet door was noted as broken, partially detached and hanging on by one of the hinges. Review of the maintenance log for the unit on 9/16/21 lack documentation to reflect item was listed as in need of repair.
e. In room [ROOM NUMBER], it was noted that the wall behind the room's door was cracked and dented because of the door handle.
f. Two ceiling vents on the Evergreen unit was noted as being soiled with thick matter of gray dust throughout the grille.
A review of the maintenance log on the Evergreen unit, lacked documentation to reflect that the environmental concerns regarding the disrepair of the walls, furniture and unclean vents were documented in the maintenance log.
On 9/21/21 at 3:28 P.M. during rounds of the Evergreen unit with the Physical Plant Manger PPM identified he had completed repairs in other areas of the facility and indicated he would follow up on the needed repairs on the Evergreen unit. He also noted that the air vents are cleaned once a year and are due to be cleaned at this time.
2. 9/16/21 at 11:00 AM. Observations on the Meadow [NAME] unit the following:
a. In room [ROOM NUMBER] identified a dent in the wall behind door to entrance of room.
b. In room [ROOM NUMBER] identified holes in the wall in the bathroom, radiators, and floors dirty looking.
c. In room [ROOM NUMBER] identified the wall behind Resident #63's bed was shredded behind the bed.
d. In room [ROOM NUMBER] identified the baseboards as discolored rust in color.
e. In room [ROOM NUMBER] identified the wall and the bottom portion of radiator laying on the floor.
f. In room [ROOM NUMBER] identified handle hanging off second drawer in dresser, wall torn slightly.
g. In room [ROOM NUMBER] identified wall coming into room by door with the wallpaper peeling.
h. In room [ROOM NUMBER] identified the vent by sink in bathroom dirty and discolored, vent in ceiling dusty.
Review of maintenance log on 9/16/21 lacked documentation to indicate the radiator needed to be repaired.
Interview with Infection Control Nurse on 9/21/21at 9:39 A.M. identified Environmental Rounds were being done monthly until August 2021, when the facility implemented quarterly Environmental Rounds to be done with the Maintenance Director, House- keeping staff, Infection Control Nurse and Administrator present.
Interview and observation with Maintenance Director on 9/22/21 11:05 A.M. identified he had started the repairs to the rooms but started with the empty rooms first. The Maintenance Director also indicated now he attends Environmental Rounds. Prior to attending rounds, he would get a list from Infection Control Nurse and complete day to day repairs and would schedule the larger repairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, review of facility policy and interviews for one sampled resident (Resident # 103) reviewed for death, the facility failed to obtain a physician's order for RN may pronounce in accordance with facility policy. The findings include:
Resident # 103 was admitted to the facility on [DATE]. The resident's diagnoses included depression, hypertension, osteoarthritis, depression, and anxiety.
The physician's order dated 8/26/21 directed compassionate care. The physician's order dated 6/23/21 identified the resident was a Do Not Resuscitation (DNR).
The Nurse Pronouncement Physician Order Sheet dated 6/23/21 identified Resident # 103 was a DNR, lacked documentation of Resident's prognosis is and indicated the order for DNR was signed by an APRN.
The admission MDS dated [DATE] identified was severely cognitively impaired, required extensive two-person physical assistance for bed mobility and toileting. The resident also required extensive one-person physical assistance for personal hygiene.
The RCP dated 9/1/21 identified I have chosen comfort care. Interventions included: to provide hospice care, to administer pain medication as needed and to offer the resident break through pain medication, to assist with finding a comfortable position for me and observe for signs and symptoms of constipation.
The nursing progress note dated 9/5/21 at 10:58 A.M. identified this writer was called to the resident's room to declare expiration. Family was noted at bedside. Resident did not respond to sternal rub, pupils were fixed and dilated, noted with absence of carotid pulse and heart sound, absence of audible breath sounds for one minute. Additionally, the progress note identified death was verified at 10: 15 A.M.
Interview with the DNS on 9/22/21 at 2:08 P.M. identified she could not provide evidence that the physician signed and reviewed the resident's RN Pronouncement Physician Order Sheet dated 6/23/21.
The facility policy for RN Pronouncement notes in part the attending physician must give written authorization for all Registered Nurses employed by the facility to pronounce death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for one resident (Resident # 37) reviewed for vision and hearing, the facility failed to ensure the resident had access to a hearing device in accordance with the plan of care. The findings include:
Resident #37 was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure with Hypoxia, Dysphagia and Dementia with behavioral disturbance.
The quarterly MDS assessment dated [DATE] identified Resident #37 was severely cognitively impaired, required extensive assistance with personal hygiene and utilized a hearing appliance.
The care plan dated 7/20/21 identified alteration in ADL requiring extensive assist secondary to dementia. An intervention includes the application of left hearing aid.
Observations on 9/16/21 at 11:01 A.M. and 9/17/21 at 1:13 P.M. identified Resident#37 in the wheelchair without his/her left hearing aid.
Interview with LPN#2 on 9/17/21 at 1:14 P.M. identified Resident#37 doesn't wear his/her hearing-aid but uses an amplifier. However, when LPN#2 demonstrated the use of the amplifier, the battery was dead.
Interview and review of the clinical record with DNS on 9/21/21 at 3:30 PM failed to provide evidence to reflect that Resident#37 had been using the left hearing aid in accordance with the care plan.