Every finding on record at Adrian Bay Rehabilitation and Nursing Center

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 91 residents, resulting in the increased potential for cross-contamination, bacterial harborage, and decreased air quality.Findings include: On 08/12/2026 at 11:15 AM, an environmental tour of sampled resident rooms was conducted with Director of Maintenance (DM) L and Director of Environmental Services (DES) M. The following items were noted:B-3: The bed 1 and bed 2 overbed lower 48-inch-long fluorescent light bulbs were observed non-functional.B-6: The bed 2 overbed upper 48-inch-long fluorescent light bulb was observed non-functional.C-1: The drywall surface was observed (etched, scored, particulate), adjacent to the restroom entrance door. The damaged drywall surface measured approximately 6-inches-wide by 36-inches-long.C-7: The bed 1 overbed upper 48-inch-long fluorescent light bulb was observed non-functional. The restroom commode support was also observed loose-to-mount. The commode support could be moved from side to side approximately 3-4 inches.C-9: The bed 2 overbed upper and lower 48-inch-long fluorescent light bulbs were observed non-functional.C-12: The restroom entrance interior door surfaces were observed (etched, scored, particulate). The damaged interior door surfaces measured approximately 36-inches-wide by 36-inches-long.D-5: The restroom return-air-exhaust ventilation grill was observed to be soiled with dust/dirt deposits. The bed 1 tower fan was also observed to be soiled with accumulated and encrusted dust/dirt deposits. The bed 2 desk fan was further observed to be soiled with dust/dirt deposits.D-7: The restroom return-air-exhaust ventilation grill was observed to be soiled with dust/dirt deposits.D-9: The restroom return-air-exhaust ventilation grill was observed to be soiled with dust/dirt deposits.D-10: The bed 2 oscillating floor fan was observed to be soiled with accumulated and encrusted dust/dirt deposits.D-16: The restroom return-air-exhaust ventilation grill was observed to be soiled with accumulated dust/dirt deposits.On 08/12/2026 at 1:19 PM, 6 of 6 upholstered gray fabric chairs were observed soiled and stained, within the Nurses Station. The gray upholstered fabric chairs (6) were also observed stained with symmetrical cylindrical moisture impressions.On 08/12/2026 at 01:23 PM, an interview was conducted with Director of Environmental Services (DES) M regarding an upholstery cleaning/extractor machine. (DES) M stated: We do not have a fabric shampooer or extractor for cleaning. (DES) M also stated: We usually try to purchase vinyl chairs that are easily cleanable.On 08/13/2026 at 09:30 AM, record review of the Policy/Procedure entitled: Physical Environment dated 07/11/2018 revealed under Policy: Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible.On 08/13/2026 at 09:45 AM, record review of the Policy/Procedure entitled: Physical Environment dated 03/08/2021 revealed under Policy: To provide guidelines to maintain a safe and sanitary environment for residents, facility staff, and visitors.On 08/13/2026 at 10:00 AM, record review of the Policy/Procedure entitled: Preventative Maintenance dated 04/12/2021 revealed under Policy: Each facility will have a preventative maintenance program in place that scheduled preventative maintenance on equipment and the physical plant.On 08/13/2026 at 10:15 AM, record review of the digital work orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview, and record review the facility failed to treat one resident with dignity (Resident 87) out of 1 reviewed for dignity. Finidngs include:Review of the medical record reflected R87 was admitted to the facility on [DATE], with diagnoses that included major depression and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/24/26, reflected R87 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an interview on 8/11/2026 at 12:20 PM, R87 reported that the night shift nurse left his medications in a cup at his bedside. When R87 woke up and observed the cup of medications, he took the cup of medication with him on his way to the dining room for lunch. On his way to his meal, he inquired with his day shift nurse, Licensed Practical Nurse (LPN) O about what pills were in the cup. R87 explained that recently, his blood pressure medication had not been administered to him due to not being available from pharmacy, so R87 stated that he really wanted to know if his blood pressure medication was one of the pills in the cup. R87 said that he went and sat by the nurse station to try and talk to his nurse, LPN O however, LPN O wouldn't even look at me. R87 finally got the attention and stated that LPN O was very rude about the question regarding what medications were in the cup and R87 felt belittled. R87 said LPN O took the medication from him instead of answering his questions and R87 felt blamed for not taking his medications timely. R87 then proceeded back to his room and made a sign that said, no water, no medications, no food, and attached the sign to his bedroom door. R87 stated that after some time, no one acknowledged his concern and felt that staff ignored his sign, so he started to make a fuss and began to scream and strike himself in the head. When staff responded, R87 felt that no one took the time to address his concern of not knowing which medications were left at his bedside, and the concern that he was going another day without his blood pressure medication. R87 said he felt very disrespected by LPN O for ignoring him and dismissing his concerns. R87 said he packed his belongings and attempted to leave the facility. R87 said the staff intervened and convinced him to stay. R87 said that this interaction was very upsetting to him, and he did not appreciate being treated in such a manner when he was simply just inquiring about the medications in the cup. Review of a Social Services note dated 6/24/26 at 5:37 PM stated Writer F/U (followed up) with the resident (R87) after he voiced some frustrations the other day. Resident stated he feels like some individuals don't take the time to listen to him and he knows that communication is hard. 08/13/2026 10:17 AM. LPN O stated that she remembered the day R87 approached her with a medication cup containing pills. LPN O told R87 he could not take the medication due to the delay in administering. Review of a Psych note dated 5/14/2026 revealed Psych services discussed his concern about leaving as he has no place to go. He doesn't understand the fluid restrictions he's on. He stated that his behavioral problems are an attempt to see if someone cares. we discussed more effective ways of meeting this need. In an interview on 8/13/2026 at 12:17 PM, Social Worker P stated that she followed up with R87 regarding the behavior. SW P stated that R87 felt like somebody wasn't listening to him and his concerns and it was related to medications.

Based on observation, interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for two (R25, R92) of 20 reviewed.Findings include:Resident #25 (R25) Review of the medical record reflected R25 admitted to the facility on [DATE], with diagnoses that included Alzheimer's with late onset and dementia with psychotic disturbance. The admission MDS, with an Assessment Reference Date (ARD) of 2/2/26, reflected R25 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received antipsychotic medication on a routine basis only. On 08/12/2026 at 1:49 PM, R25 was observed lying in bed, awake. The admission MDS, with an ARD of 2/2/26, reflected question, N0450. Antipsychotic Medication Review .Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? was coded for antipsychotics being received on a routine basis only. The 1/2026 Medication Administration Record (MAR) reflected R25 received antipsychotic medication routinely and on an as needed basis. In an interview on 08/13/2026 at 1:50 PM, MDS Coordinator E reported R25's MDS was coded inaccurately. MDS Coordinator E reported the MDS should have been coded as receiving antipsychotic medication on a routine and as needed basis. Resident #92 (R92) Review of the medical record reflected R92 admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia, major depressive disorder and anxiety. The admission MDS, with an ARD of 5/8/26, reflected R92 scored 14 out of 15 (cognitively intact) on the BIMS.An OBRA Level II evaluation, dated 4/30/26, reflected R92 had a diagnosis of schizoaffective disorder. The admission MDS, with an ARD of 5/8/26, was coded No for question, A1500. Preadmission Screening and Resident Review (PASRR) .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?.In an interview on 08/12/2026 at 1:58 PM, MDS Coordinator E reported during an audit of R92 during the survey (8/12/26), she confirmed that R92's admission MDS had been coded inaccurately.

Based on interview and record review the facility failed to confirm that the Pre-admission Screening and Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for 1 resident (Resident #2) of one reviewed. Findings include: Review of the clinical record revealed Resident #2 (R2) was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included anxiety, major depression and unspecified dementia. The Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 6/05/26 revealed R2 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review of R2's clinical record reflected no PASARR but a Change of Condition 3877 form dated 6/27/25 which was signed by the previous Director of Nursing (DON). The 3877 change of condition form revealed R2 had a diagnosis of mental illness and unspecified dementia. There was no 3878 form to reflect a dementia or 30-day exemption, nor was there an original PASARR, or the required Annual Resident Review (due June 2026) or any acknowledgment letter from OBRA. DON B was queried on 8/12/26 at 3:00 pm and reported she was unsure of what occurred and would need to follow up. During an interview with DON B on 8/13/2026 11:35 AM, DON B reported OBRA was never made aware of R2's admission or diagnoses because the previous DON did not submit the information to OBRA. When queried why the 3877 was marked as a change in condition opposed to PASARR, DON B could not offer any explanation. When queried if there had been a 3878, DON B was not certain. On 08/13/2026 at 12:02 PM, during a telephone interview with OBRA coordinator K, she reported they have a tracking system in place and verified R2's 6/27/25 3877 was labeled incorrectly and never submitted.

Based on observation, interview, and record review the facility failed to notify the Physician after not administering a scheduled medication in one (Resident #87) out of 1 reviewed for missed medications. Findings include:Review of the medical record reflected R87 was admitted to the facility on [DATE], with diagnoses that included major depression and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/24/26, reflected R87 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an interview on 8/11/2026 at 12:20 PM, R87 reported that he takes a medication for his blood pressure, however, the night shift nurse had not administered his blood pressure medication and he was unsure why it was being missed. Review of the Physician Orders revealed an active order for Zestoretic Oral Tablet 10-12.5 MG (milligram) (Lisinopril & Hydrochlorothiazide). Give two tablets by mouth one time a day for Hypertension. On 6/22/26, the Zestoretic Oral Tablet 10-12.5 MG was marked as not available in the Medication Administration record. Review of the medical record revealed no indication that the Physician was made aware of the medication not being administered. In an interview on 8/14/2026 at 10:54 AM, Director of Nursing B stated that the expectation would be to notify the Physician if a medication was not being administered as ordered.

This citation pertains to intake 3157012. Based on observation, interview and record review, the facility failed to ensure supervision to prevent elopement from the facility for one (R68) of four reviewed. Findings include:Review of the medical record reflected R68 admitted to the facility on [DATE], with diagnoses that included mild cognitive impairment of uncertain or unknown etiology. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/31/26, reflected R68 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and walked independently, with an assistive device. On 08/13/2026 at 3:39 PM, R68 was observed walking in their room, without an assistive device. A Staff Member (SM) was in the room, for one-to-one supervision of R68. A wander management device was not observed to be in place for R68. On 08/13/2026 at 3:42 PM, SM G reported a wander management device was previously in place for R68 but had been removed since one-to-one supervision was in place. A late entry Progress Note for 8/6/26 at 9:31 PM reflected the Social Worker met with R68 regarding increased anxiety and wanting to leave the facility, to go home. According to the note, R68 did not have a plan to leave the facility. The note reflected that R68 was agreeable to placement of a wander management device. According to the medical record, R68 was assessed as a high risk for wandering on 8/6/26, with a wander risk score of 13. A facility investigation reflected that on 8/8/26, at approximately 6:30 PM, R68 had been observed by staff, near the nursing station, walking back to their room. At 6:34 PM, a Certified Nurse Aide (CNA) alerted the Registered Nurse (RN) that R68 was no longer located in the facility. During that time period, staff at the nursing station had released the automatic front doors, to allow visitors to exit the building. A Code Yellow procedure was initiated at 6:34 PM, and staff began an interior/exterior perimeter search for R68. At 6:37 PM, staff located R68 in front of a house. The house was located on a different road than the facility was located on. The facility's investigation included a statement from R68, which reflected, I left the building like I said I would, through the front door. I took my bracelet off . In an interview on 08/13/2026 at 2:09 PM, SM H reported locating R68 outside of the facility. SM H described when approaching a nearby road, they observed an individual (R68) sitting in a chair, in the front lawn of a house. At that time, R68 had a cane, a purse, and a doll, which was wrapped in a blanket. SM H stated R68 had to cross the road to get to that particular house. SM H reported that day, R68 had been calling their family, stating they were going to leave the facility and cut their bracelet (wander management device) off, if family did not come to pick them up. SM H reported R68 told family if they did not pick them up, R68 would walk to their family's house. According to SM H, within one to one and a half hours, R68 called their family approximately five to six times, from the nursing station phone, beginning at approximately 3:30 PM to 4:00 PM. In an interview on 08/13/2026 at 2:29 PM, SM G reported a Code Yellow was called at 6:35 PM (on 8/8/26), when R68 was not located in the facility. SM G described that R68 was located outdoors, in front of a house, at 6:37 PM. SM G reported being unaware of how R68 was able to go outdoors without knowledge of staff. SM G reported R68 previously had a wander management device in place, which they had observed that day. SM G stated the device was no longer in place when R68 was brought back inside the facility. SM G reported that on 8/8/26, R68 had increased anxiety, was pacing, exit seeking and vocalizing that they wanted to leave the facility, to be with family. SM G reported an antianxiety medication was administered to R68. According to SM G, R68 seemed to settle down and went to the dining room for dinner. SM G reported interventions that were attempted for R68 on 8/8/26 included antianxiety medication administration, redirection and conversation. According to SM G, R68 would be agreeable to going back to their room, briefly, before resuming pacing. SM G reported they had last visualized R68 in the dining room, seated in a chair, at mealtime (dinner). The August 2026 Medication Administration Record (MAR) reflected an antianxiety medication was administered to R68 at 3:10 PM, on 8/8/26. A Progress Note for 8/8/26 at 8:23 PM reflected that at 6:35 PM, R68 was identified as not being located in the facility. At 6:37 PM, they were found outdoors, by facility staff. According to the note, pharmacological and non-pharmacological interventions were attempted for R68 throughout the day. In an interview on 08/14/2026 at 8:56 AM, Nursing Home Administrator (NHA) A reported that on 8/8/26, staff made attempts to redirect R68 throughout the day. A wander management device had been placed, but R68 removed it. NHA A denied being aware that R68 verbalized desire to remove the wander management device and leave the facility on 8/8/26. NHA A reported the root cause of R68 eloping from the facility was determined to be that R68 was looking for family. NHA A stated the wander management device had been placed due to R68 asking to see family repeatedly.

Based on observation, interview and record review, the facility failed to act upon Pharmacy recommendations timely for one (R67) of five reviewed. Findings include: Review of the medical record reflected R67 admitted to the facility on [DATE], with diagnoses that included type 2 diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/12/26, reflected R67 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 08/12/2026 at 1:45 PM, R67 was observed in bed, using a tablet device. A Pharmacy review for 8/11/25 included a recommendation to consider a Hemoglobin A1c (test that measures the average amount of sugar in the blood over the past three months) at least every six months. The recommendation was signed by the Provider, acknowledging they agreed with the recommendation. A Physician Order, dated 8/22/25, with a start date of 8/25/25, reflected a Hemoglobin A1c was ordered to be drawn every six months. A Pharmacy review for 9/11/25 reflected the Hemoglobin A1c lab result(s) could not be located in the electronic chart since ordered. A recommendation was to ensure lab(s) were drawn as ordered, and results filed in the chart. Review of documentation reflected a Hemoglobin A1c test was collected on 2/25/26. In an interview on 08/12/2026 at 3:33 PM, Director of Nursing (DON) B reported after the Pharmacist completed medication regimen reviews, they were emailed to the DON for review. DON B reported they then distributed them to Providers for review. Either the Provider or the DON would enter Physician Orders. DON B reported the test for 2/25/26 was the only Hemoglobin A1c result she was able to locate since 8/1/25. DON B reported the lab orders should have populated to be drawn every six months.

Based on observation, interview, and record review the facility failed to offer Pneumococcal immunizations in one (Resident 18) out of five reviewed for Pneumococcal immunizations. Findings include:Resident 18 (R18) Review of the medical record reflected R18 was admitted to the facility on [DATE], with diagnoses that included aphasia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/26, reflected R18 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R18 and Immunization record in the medical system showed no consent for the Pneumococcal immunization had been administered, despite being eligible for the immunization.In an interview on 8/14/2026 at 11:34 AM, Infection Preventionist stated that R18 was eligible to receive the Pneumococcal immunization and had offered and completed a consent form for the immunizations during the survey on 8/14/26.

Based on observation, interview, and record review the facility failed to offer COVID-19 immunizations in two (Resident 18, 87) in five reviewed for immunizations Resident 18 (R18) Review of the medical record reflected R18 was admitted to the facility on [DATE], with diagnoses that included aphasia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/26, reflected R18 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Resident 87 (R87) Review of the medical record reflected R87 was admitted to the facility on [DATE], with diagnoses that included major depression and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/24/26, reflected R87 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R18 and R87's Immunization record in the medical system showed no consent for the COVID-19 immunization and no evidence that the COVID-19 vaccination had been administered, despite being eligible for the COVID-19 immunization. In an interview on 8/14/2026 at 11:34 AM, Infection Preventionist stated that R18 and R87 were both eligible to receive the immunization and had offered and completed consent forms for the immunizations earlier that day during the survey on 8/14/26.

This citation pertains to intake #3030201.Based on observation, interview and record review, the facility failed to ensure their transfer status was accurately following resident's plan of care to prevent fall to occur for one resident (R#2) of 3 sampled residents sustaining a fall resulting in a hospital transfer and admitted for Right Rib Fractures 5-10, Right Forehead Hematoma, Right non-displaced Humeral Fracture, and Right Superior Pubic Rami Fracture and pain.Findings include: The facility incident report was reviewed on 6/22/26 at 1:30 PM. It revealed that Resident#2 (R#2) had a Fall on 5/26/26, while being assisted by CNA A to the bathroom. The Certified Nursing Assistant (CNA A) assisted R#2 to ambulate from the wheelchair to the bathroom using a walker without a gait belt. R#2 was at High Risk for falling, and the plan for R#2's transfer status is to use a lift. Meanwhile, during this transfer, CNA A stepped away from R#2 to put her gloves on for care, and CNA A heard R#2 saying I am falling and suddenly fell. CNA A immediately called for help, and the nurse went to assess R#2.R2 was transferred to the Acute care hospital on 5/26/26 and was admitted . Upon return from the hospital on 6/2/26, hospital records noted the following added diagnoses resulting from a fall that occurred on 5/26/26: Fall resulting in a hospital transfer for Right Rib Fractures 5-10, Right Forehead Hematoma, Right non-displaced Humeral Fracture, and Right Superior Pubic Rami Fracture and pain.The facility terminated CNA A, on 5/29/26 who was the only witness during R#2's fall, and admitted ambulating R#2 using a walker and did not follow R#2's Kardex and Care Plan instructions.Resident #2 (R#2)According to the resident's face sheet and facility record, R#2 was originally admitted to the facility 10/30/2024, with diagnoses of Nutritional Deficiency, Allergic Rhinitis, Muscle Wasting and Atrophy, Dysphagia and Gastroesophageal Reflux Disease (or GERD), Dementia, Adjustment Disorder, Depression, Neurofibromatosis, and Retention of Urine in addition to other diagnoses. R#2's Face Sheet noted no diagnosis of Osteoarthritis or Osteoporosis found in her Face Sheet dated 6/10/1026. However, according to the facility, R #2's Brief Interview of Mental Status (BIMS) Score assessed on 5/1/2026 was 12/15. A BIMS Score of 12 indicates a moderate cognitive impairment.Fall risk assessment scored a High Risk for falling, and the current plan for R#2's transfer status is to use a Sara Steady lift and ambulate with one assist/Gait Belt and Rolling Walker.An interview with CNA A by telephone was conducted on 6/22/26 at 1:05 PM. CNA A revealed she worked at the facility for 3 years and often worked at the hall with R#2. She stated: They don't update residents' kardexes. They changed her Care Plan and Kardex without letting us know. I am assigned to R#2. I was not aware that she needed a sit-to-stand lift for transfers. No update on the Kardex, and no transfer (gait) belts were available at the facility. It takes a long time to find one, and residents need to go when they press the light. That is why R#2 did not have one on her. CNA A continued to explain that R#2 was assisted to the bathroom, ambulating with a walker, and her foot got caught, and she fell down. No changes on her transfer status were communicated. Nothing was changed in the Kardex, not at the point of care. That's where we look. She has always been a transfer using a walker.An attempt was made to call Nurse B on 6/22/26 at 1:15 PM, but Nurse B did not pick up the phone. A message was left on voicemail requesting a callback, but no reply was received.A review of Nurse B Witness Statement dated 5/26/26 revealed Resident (R#2) was lying down positioned between the 2 rooms in the bathroom but into the neighboring room. (Shoulder up was in room [ROOM NUMBER]). R#2 was asked whether she had hit her head and was observed to have a bump on her right eyebrow . The Unit Manager came into the room to assist, and the NP said to send her to the hospital. Nurse B took R #2's vitals, and her BP was high. R#2 complained of pain in her right arm. Staff got her on the toilet, and R#2 used the restroom, then we cleaned her up. R#2 then started to complain of pain in her right leg and was grabbing with her left arm. Staff used steady and got her onto the stretcher .The Facility AVHS.NSG-Resident Lift Assessment-Vs for R#2, Effective Date 4/26/2026 revealed:A. Resident can reliably stand and pivot with only contact guard or stand by assistance from staff with minimal risk of falling/ Answer: No.B. Resident is able to pull self into standing position AND weighs less than 265 pounds AND has reliable trunk stability? Answer: Yes, Use Sit to Stand Lift C. Resident can reliably bear weight on at least one leg AND reliably able to follow simple instructions AND reliably able to grip with at least one hand AND has reliable trunk stability? Answer: Yes, Use Sit to Stand Lift.A review of R#2 Care plan was conducted on 6/22/26 at 2:00 PM. It indicated:Care Plan 1. R#2 has ADL self-care performance deficit r/t/ T12 burst fracture, Neurofibromatosis, dementia. Date initiated: 10/24/24. Intervention: Toilet use: R#2 requires extensive assistance with toileting needs. R#2 utilizes the (Manufacturer's name mentioned) Lift (a sit-to-stand lift) for toilet needs and may require assistance with brief changes at times. (Date created/initiated: 02/11/2025).Care Plan 2. R#2 has limited physical Mobility r/t/ T12 Fracture, Neurofibromatosis, OA. Intervention: TRANSFER: Sara Steady. Date created and initiated 10/24/24.Care Plan 3. R#2 at risk for falls r/t Alzheimer's, history of falls at home, OA, glaucoma, visual impairment, urinary retention, IFG, and T12 burst fracture. GOAL: Will remain FREE from fall-related injury through the review date. Interventions: Provide Assistance as needed for mobility tasks and ensure the use of appropriate devices. Refer to ADL/Mobility plans of care. Report any changes. (Date created/initiated: 10/24/24.)R#2 Kardex (A quick reference nursing system that provides a concise, at-a-glance overview of a patient's current care needs.) dated as of 5/26/25, indicated in Transferring: Transfer status: Sara Steady (is a manual, non-powered sit-to-stand patient transfer aid).Resident Nurse's Notes dated 5/26/26 at 11:36 AM noted, Per CNA interview, resident was ambulating with 2WW to the restroom with CNA supervision. Once in the bathroom, the resident's foot appeared to twist, or to come partially out of the shoe, causing the resident to fall to the floor. Resident landed partially through the adjoining door to next room . Resident complained of pain to head, large hematoma developing. Neuro assessment at baseline; vitals WNL (within normal limits); ROM reveals pain in the right arm/shoulder. NP in facility and immediately responded to fall; new order to send to emergency department for evaluation .Transported via EMS on stretcher. First Emergency contact (Name mentioned) called, and VM left to call facility. Signed by the nurse on 4/26/26.CNA A employee file was reviewed, and on 5/29/26, CNA was terminated under Category 3 #58: Employees may not disregard the resident's care plan related to repositioning, transfers, and/or lifting. It was further described what happened: CNA (A) did not follow the resident's care plan regarding the resident's transfer status, which required the use of a mechanical lift. CNA performed an inappropriate transfer and also did not use a gait belt. Resident fell during this transfer and as a result sustained significant injuries. Corrective action needed: Termination.On 6/22/26 at 3:15 PM, a tour observation was conducted with the In-service Director/Infection Control Nurse C. Both the surveyor and the in-service director C observed that the entire B Hall lacked gait belts, contrary to the in-service director's expectation that they would be in place after the education and purchasing the belts. None of the random rooms the surveyor and in-service director visited had a gait belt for access. The in-service director was surprised because she had placed them herself for staff to use a week ago for fall-prevention intervention. She did not find them in the rooms we randomly checked in Hall A and Hall C. Only one staff member was carrying her gait belt with her and was wearing it as her belt, but the in-service director stated that that is the belt that is made of cloth and is not appropriate for cleaning and disinfecting. The In-service Nurse C has been getting 36 pieces every week to replace the cloth gait belts. The Inservice director said that staff received training that 2 belts (if 2 residents per room) are made accessible in each room for staff to use on residents. But none were found behind the door with the hooks.An interview with the Administrator on 6/22/26 at 3:30 PM was conducted, and she stated that they have kept the belts in the corridor closet. The administrator went to a closet in Hall B and showed the surveyor where the CNAs can find the gait belts where it was stored. There was a small box containing 4 gait belts. When asked if the in-service director knows where they are kept? The administrator had no response. Fall Policy dated 7/11/2018 indicated, It is the policy of this facility to evaluate the extent of injury after a fall, prevent complications, and to provide emergency care.

This citation pertains to Intake 2807029.Based on interview and record review, the facility failed to administer medications as ordered by the physician for one (R1) of three reviewed.Findings include: Review of the complaint received by the State Agency revealed Family was not notified that he [R1] had not received Paxlovid for COVID after it was prescribed until after inquiring about it. Family was not informed that the medication was not covered by insurance, nor were they given the option to obtain it privately. No additional treatment was initiated until he developed worsening shortness of breath requiring oxygen therapy. At that point, he was prescribed prednisone and nebulizer treatments. Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included sepsis, urinary tract infection, and cerebral infarction (a type of stroke). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 revealed R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R1 had a legal guardian. R1 transferred to another facility on 1/15/26. Review of the General Progress Note dated 12/30/25 revealed COVID-19 test obtained .result returned positive. Resident currently symptomatic, presenting with congestion. Resident notified of test results. Family notified via telephone. Provider notified; new orders received for Paxlovid [antiviral medication] 300 mg [milligrams]/100 mg BID [twice per day] for 5 days. Droplet precautions initiated. Review of the Physician's Order dated 12/30/25 and given as a verbal order from Physician N (R1's primary physician) revealed an order for Paxlovid (300/100) give one tablet two times a day for COVID for 5 days. The order was scheduled to begin on 12/31/25. Review of the Medication Administration Record (MAR) revealed R1's Paxlovid was not given the morning of 12/31/25 and marked as 9=Other/See Nurse Note. Review of the Progress Notes revealed awaiting arrival from pharmacy. Medication order updated to reflect. The previous order for Paxlovid was discontinued and a new Physician's Order dated 12/31/25 revealed a verbal order from Physician N (R1's primary physician) for Paxlovid 300/100 give one tablet by mouth two times a day for COVID for 4 days and give one tablet by mouth two times a day for COVID for 1 day. This order was discontinued the same day (12/31/25). A third Physician's Order was given verbally by Physician N (R1's primary physician) on 12/31/25 for Paxlovid (300/100) one tablet two times a day for COVID for 5 days. The order was scheduled to begin on 1/1/26. Review of the MAR revealed R9's Paxlovid was marked as 9=Other/See Nurse Note on 1/1/26 morning, 1/2/26 evening, 1/3/26 evening, and 1/4/26 morning. R1's MAR did not have any documentation for the dose scheduled in the morning on 1/3/26. R1's Paxlovid was documented as administered on 1/1/26 evening and 1/2/26 morning. Review of the Progress Notes revealed on 1/1/26 at 4:31 AM, Paxlovid was not given because it was on order. The Progress Note dated 1/3/26 at 12:20 AM revealed Paxlovid was not given because it was on order. The Progress Note dated 1/3/26 at 9:59 PM revealed R1's Paxlovid was not given because medication on order. The Progress Note dated 1/4/26 at 9:26 AM revealed the Paxlovid was not given because Medication unavailable. Pharmacy notified and stated they received a high cost form back from facility stated to cancel the order. Review of R1's Physician's Orders revealed the Paxlovid order cancelled per [Nurse Practitioner] dt [due to] high-cost medication. In an interview on 4/22/26 at 11:03 AM, Director of Nursing (DON) B reported she recalled that an on call physician ordered Paxlovid for residents during their COVID outbreak in January, but then the primary physician determined Paxlovid was only necessary for residents with severe symptoms. DON B reported if a medication flagged as a high-cost medication, the facility had three options which included to bill the facility, change the order, or cancel the order. On 4/22/26 at 12:30 PM, DON B reported she contacted the pharmacy and discovered that R1 never received Paxlovid at the facility; therefore, the two doses that were documented as administered was inaccurate. In a telephone interview on 4/22/26 at 12:20 PM, Pharmacy Representative (PR) M reported they did not have full access to R1's notes because the facility had changed pharmacy branches since then. PR M reported R1's Paxlovid was assigned for delivery to the facility on 1/2/26, but then the order was cancelled before it left the pharmacy; therefore, R1's Paxlovid was never delivered to the facility. Review of R1's General Progress Note dated 1/4/26 revealed Vitals obtained and resident [oxygen saturation] 88% [room air] and experiencing difficulty to [breathe]. Lung sounds clear. Resident [placed] on 2L [liters] NC [nasal cannula] O2 [oxygen] and O2 increased to 93%. Physician notified. Orders received to begin prednisone 20 mg 2 tabs at bedtime for 5 days. Ipratropium-albuterol treatment q6 [every 6] hours. STAT 2 view chest xray.

This citation pertains to Intake 2807029.Based on interview and record review, the facility failed to ensure the accuracy of medical records for one (R1) of three reviewed. Findings include:Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included sepsis, urinary tract infection, and cerebral infarction (a type of stroke). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 revealed R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R1 had a legal guardian. R1 transferred to another facility on 1/15/26. Review of the General Progress Note dated 12/30/25 revealed COVID-19 test obtained .result returned positive. Resident currently symptomatic, presenting with congestion. Resident notified of test results. Family notified via telephone. Provider notified; new orders received for Paxlovid [antiviral medication] 300 mg [milligrams]/100 mg BID [twice per day] for 5 days. Droplet precautions initiated. Review of the Physician's Order dated 12/30/25 and given as a verbal order from R1's primary physician revealed an order for Paxlovid (300/100) give one tablet two times a day for COVID for 5 days. The order was scheduled to begin on 12/31/25. Review of the Medication Administration Record (MAR) revealed R1's Paxlovid was not given the morning of 12/31/25 and marked as 9=Other/See Nurse Note. Review of the Progress Notes revealed awaiting arrival from pharmacy. Medication order updated to reflect. The previous order for Paxlovid was discontinued and a new Physician's Order dated 12/31/25 revealed an order for Paxlovid 300/100 give one tablet by mouth two times a day for COVID for 4 days and give one tablet by mouth two times a day for COVID for 1 day. This order was discontinued the same day (12/31/25). A third Physician's Order was given verbally by R1's primary physician on 12/31/25 for Paxlovid (300/100) one tablet two times a day for COVID for 5 days. The order was scheduled to begin on 1/1/26. Review of the MAR revealed R9's Paxlovid was marked as 9=Other/See Nurse Note on 1/1/26 morning, 1/2/26 evening, 1/3/26 evening, and 1/4/26 morning. R1's MAR did not have any documentation for the dose scheduled in the morning on 1/3/26. R1's Paxlovid was documented as administered on 1/1/26 evening and 1/2/26 morning by Registered Nurse (RN) E. Review of the Progress Notes revealed on 1/1/26 at 4:31 AM, Paxlovid was not given because it was on order. The Progress Note dated 1/3/26 at 12:20 AM revealed Paxlovid was not given because it was on order. The Progress Note dated 1/3/26 at 9:59 PM revealed R1's Paxlovid was not given because medication on order. The Progress Note dated 1/4/26 at 9:26 AM revealed the Paxlovid was not given because Medication unavailable. Pharmacy notified and stated they received a high cost form back from facility stated to cancel the order. Review of R1's Physician's Orders revealed the Paxlovid order cancelled per [Nurse Practitioner] dt [due to] high-cost medication. An attempt to contact RN E via telephone was made on 4/22/26 at 9:38 AM. RN E did not return the phone call. In an interview on 4/22/26 at 12:30 PM, Director of Nursing (DON) B reported she contacted the pharmacy and discovered that R1 never received Paxlovid at the facility; therefore, the two doses that were documented as administered was inaccurate. DON B reported RN E no longer worked at the facility. In a telephone interview on 4/22/26 at 12:20 PM, Pharmacy Representative (PR) M reported R1's Paxlovid was assigned for delivery to the facility on 1/2/26, but then the order was cancelled before it left the pharmacy; therefore, R1's Paxlovid was never delivered to the facility. Review of RN E's personnel file revealed a previous Disciplinary Action Report dated 11/18/25 for documenting a medication was given when the medication was not administered. There were no disciplinary actions related to the inaccurate documentation for R1's Paxlovid.

This citation pertains to intakes 2677539 and 2677568.Based on observation, interview, and record review, the facility failed to maintain accurate controlled substance and medication administration records for five residents (R1, R3, R4, R5, R6) of six reviewed and two medication carts of two reviewed. Findings include:During an observation and interview with Licensed Practical Nurse (LPN) M, on 12/8/25 at 10:37 AM, it was noted that the controlled substance book indicated 45 controlled medications were in the medication cart. Upon count of the total number of medications, it was observed that 44 controlled medications were in the medication cart. LPN M counted the total amount of medications a second time and was initially unable to explain the discrepancy. LPN M then reported one medication had been removed from the medication cart, after the last dose was administered that morning. LPN M obtained the Controlled Drug Record from the facility's mail room, which noted the last dose of the controlled medication was signed out on 12/8/25 at 7:15 AM. During count of the individual controlled medications in the medication cart, with LPN M, it was observed that R1's Controlled Drug Record for Morphine Concentrate 100 milligrams (mg) per five milliliters (mL) noted 17 mL remained in the bottle. Observation revealed that more than 20 mL remained in the bottle. When asked how much was in the bottle, LPN M reported the amount to be approximately 23 mL. It was noted that the last entry on the Controlled Drug Record was 11/30/25. LPN M reported the process for counting controlled medications was for the off-going nurse to read the count from the controlled substance book, while the on-coming nurse verified the count of each medication. LPN M reported the total amount of controlled medications was verified first, followed by count of the individual controlled medications. When removing controlled medications from the medication cart, LPN M reported they noted medication on the Controlled Drug Record but did not record the time until they knew the resident was taking it. In an interview on 12/8/25 at 12:08 PM, LPN E reported controlled medications were to be signed out after they were administered, in case the resident refused. According to LPN E, the process was to pull the medication (from the package), flag the Controlled Drug Record, then sign the medication out on the Medication Administration Record (MAR) and Controlled Drug Record (after the medication was administered). In an interview on 12/8/25 at 1:43 PM, Director of Nursing (DON) B reported she was to be contacted if there was a discrepancy with controlled medication count. DON B reported counting controlled medications that day, and R1's Morphine count was over. The Controlled Drug Record reflected 17 mL was in the bottle, however, there was approximately 23 mL remaining, according to DON B. Resident #1 (R1) Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, chronic pain, muscle spasm and malignant neoplasm (cancerous tumor) of overlapping sites of the lip, oral cavity and pharynx. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/26/25, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R1 was observed in the hallway on 12/8/25 at 11:57 AM and declined to be interviewed. R1's November 2025 and December 2025 Medication Administration Records (MARs) reflected a Physician's Order for Percocet (oxycodone-acetaminophen) 10/325 mg by mouth, every four hours, as needed, for pain. Review of the MARs and the Controlled Drug Records reflected the following discrepancies: On 11/1/25 at 9:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/2/25, at an illegible time, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1 for that date. On 11/4/25, at 4:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/6/25, at 12:30 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/6/25, at 5:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/6/25, at 9:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed on the MAR as administered to R1 at 8:06 PM. On 11/7/25, at 5:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed on the MAR as administered to R1 at 5:53 AM. On 11/14/25, at 12:30 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/17/25, at 9:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/18/25, at 5:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/20/25, at 9:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 11/22/25, at 2:43 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1. On 12/1/25, at an illegible time, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1 for that date. On 12/6/25, at 1:10 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1 for that date. Resident #3 (R3) Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, osteoarthritis, low back pain and spinal stenosis. The Quarterly MDS, with an ARD of 11/2/25, reflected R3 scored 15 out of 15 (cognitively intact) on the BIMS. On 12/8/25 at 9:40 AM, R3 was observed in bed and reported taking Norco (opioid/controlled pain medication) as needed. R3 reported there had been a nurse that documented administering Norco to her two times in one day/shift, but she did not receive the medication either time. R3 reported requesting pain medication after wound care and being told by the nurse that it was too soon to have a dose, due to documentation which reflected she received it at 4:00 AM. R3 reported not receiving Norco on another occasion and could not recall the date. R3's November 2025 and December 2025 MARs reflected a Physician's Order for Hydrocodone-Acetaminophen 5/325 mg by mouth, every four hours, as needed, for pain. Review of the MARs and the Controlled Drug Records reflected the following discrepancies: On 11/4/25 at 3:30 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed out on the MAR as administered to R3 at 4:48 AM. On 11/4/25, at an illegible time (possibly 8:00 PM or 9:00 PM), hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/6/25 at 1:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed out on the MAR as administered to R3 at 2:45 PM. On 11/6/25 at 5:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/7/25 at 1:38 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/7/25 at 9:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/11/25 at 9:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/14/25 at 8:00 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date. On 11/14/25 at 1:30 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date. On 11/16/25 at 9:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date. On 11/17/25 at 1:10 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/18/25 at 4:30 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/21/25 at 8:00 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3. On 11/27/25 at 2:42 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date. Resident #5 (R5): Review of the medical record reflected R5 admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and type 2 diabetes mellitus with diabetic neuropathy. The admission MDS, with an ARD of 10/13/25, reflected R5 scored 15 out of 15 (cognitively intact) on the BIMS. On 12/8/25 at 11:29 AM, R5 was observed sitting on the edge of their bed. R5 acknowledged taking pain medication, stating they had requested some that morning. R5's November 2025 and December 2025 MAR reflected a Physician's Order for oxycodone hydrochloride (HCl) five mg by mouth, every six hours, as needed, for moderate to severe pain. Review of the MARs and the Controlled Drug Records reflected the following discrepancies: On 11/5/25 at 9:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/7/25 at 7:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/8/25, at an illegible time, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/8/25 at 10:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/9/25 at 4:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/9/25 at 1:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/9/25, at an illegible time, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/12/25 at 5:30 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 11/12/25 at 12:30 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 11/13/25 at 4:45 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/14/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/15/25 at 5:15 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 11/15/25 at 8:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 11/19/25, at an illegible time (possibly 8:00 PM or 9:00 PM), oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/20/25, at an illegible time (possibly 8:00 PM or 9:00 PM), oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 11/21/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 11/23/25 at 4:30 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 11/24/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. On 12/2/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date. On 12/4/25 at 8:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5. In a phone interview on 12/8/25 at 10:17 AM, LPN C reported suspicion of their signature being forged to sign out controlled medications, which Nursing Home Administrator (NHA) A had been made aware of on 11/18/25. LPN C reported controlled medications were being signed out on the Controlled Drug Record but not the MAR. In an interview on 12/8/25 at 12:08 PM, LPN E reported being aware that LPN C had concerns pertaining to controlled medications being signed out but not being received by residents in the prior two to three weeks. LPN C reported the DON was aware, and an investigation had been started. LPN E stated LPN D also reported a concern for a signature (on a Controlled Drug Record) which they did not believe was theirs. LPN E stated LPN C had also made a previous complaint, in April or May of 2025, pertaining to not believing a signature (on a Controlled Drug Record) was theirs. LPN E stated that was reported to the DON, and they were unsure what happened with that concern. In an interview on 12/8/25 at 1:43 PM, when asked if there had been any controlled medication discrepancies prior to 12/8/25, DON B reported the facility had a thick investigation file because R3 reported not receiving two controlled medications. NHA A was made aware, as she was the facility's abuse coordinator. According to DON B, LPN C stated someone was signing out their name (on the Controlled Drug Record) when they were not in the facility. DON B reported they cross-referenced from May to current on C hall and for the entire month of November. DON B reported they did a full investigation, and LPN C had been working the days the medications were signed out. In a phone interview on 12/9/25 at 12:25 PM, LPN D reported belief that their signature had been forged to sign out Percocet for R1 on 11/20/25. LPN D reported checking the Controlled Drug Record the next time she worked and noticed her signature. LPN D stated R1 had been sleeping, and she knew for a fact she did not give R1 and as needed medication on 11/20/25. R4 Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that include polyneuropathy (disease affecting nerves) and low back pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/25 revealed R4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/8/25 at 11:02 AM, R4 was observed sitting in her wheelchair in the dining room. R4 reported she takes Norco (hydrocodone-acetaminophen 5-325 milligrams (mg)/controlled opioid pain medication) every six hours as needed for pain. Review of the Physician's Order dated 10/13/25 revealed an order for hydrocodone-acetaminophen 5-325 mg give one tablet every six hours as needed for pain management. Review of the Medication Administration Records (MARs) and the Controlled Drug Records revealed the following discrepancies: On 10/25/25 at 11:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/26/25 at 4:45 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/26/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/26/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/29/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/29/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/30/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/30/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/31/25 at 3:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 10/31/25 at 8:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/5/25 at 3:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/8/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/8/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was signed out on the MAR as administered to R4 at 2:16 PM. On 11/9/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/10/25 at an illegible time (possibly 12:00 AM or 5:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4 on 3:19 AM. On 11/11/25 at 8:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/12/25 at 7:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/12/25 at 2:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/12/25 at 9:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/13/25 at 6:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/13/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/15/25 at an illegible time (possibly 12:00 AM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/15/25 at 9:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/19/25 at 9:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/21/25 at 5:15 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/22/25 at an illegible time (possibly 8:00 PM or 10:00 PM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/22/25 at an illegible time (possibly 8:00 PM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/23/25 hydrocodone-acetaminophen was signed out as administered on the MAR at 12:25 AM but not signed out on the Controlled Drug Record until 4:30 AM. On 11/26/25 at 6:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/27/25 at 8:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/28/25 at an illegible time (possibly 8:00 PM or 10:00 PM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. On 11/29/25 at 5:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record but was not documented on the MAR as administered to R4 until 7:03 AM. On 12/4/25 at 5:30 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4. R6 Review of the medical record revealed R6 was admitted to the facility on [DATE] with a diagnosis of right humerus fracture. Review of the BIMS dated 12/8/25 revealed R6 scored 12 out of 15 (moderate cognitive impairment). Review of the Physician's Order dated 12/4/25 revealed an order for hydrocodone-acetaminophen 5-325 mg every six hours as needed for pain. Review of the MAR revealed on 12/7/25 at 10:10 PM, hydrocodone-acetaminophen was documented as administered to R6 however, the medication was not signed out on the Controlled Drug Record as being removed from the medication cart at that time. Review of the Controlled Drug Record revealed on 12/8/25 at 300 [possibly 3:00 AM], hydrocodone-acetaminophen was signed out as removed from the medication cart. Review of the MAR revealed the medication was not signed out as administered to R6. On 12/8/25 at 11:28 AM, R6 was observed sitting on the edge of her bed with her right arm in a sling. R6 reported she experienced pain when she moved and that the staff gave her Tylenol for her pain. (It should be noted R6 also had an order for Tylenol as needed). R6 reported there was one night a few nights ago when a male nurse gave her Norco. R6 reported she did not like how the Norco made her feel and preferred to take Tylenol. R6 reported she did not take any Norco for the last two nights. An observation on 12/8/25 at 11:07 AM with Registered Nurse (RN) K revealed the controlled substance book indicated 34 controlled medications were in the medication cart. Upon count of the medications, 35 controlled medications were observed in the medication cart. RN K was unable to explain the discrepancy and reported it could have been a counting error when medications were removed and new medications added. In an interview on 12/8/25 at 1:43 PM, Director of Nursing (DON) B reported RN K notified her of the discrepancy noted that day. DON B reported the count should have been 35, but the book revealed 34 total medications. Nursing Home Administrator (NHA) A joined the interview. NHA A and DON B agreed there were discrepancies in R4 and R6's Controlled Drug Records and MARs.

This citation pertains to intakes 2677539 and 2677568.Based on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for two (R3 and R7) of seven reviewed.Findings Include: Resident #3 (R3) Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, osteoarthritis, low back pain and spinal stenosis. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/2/25, reflected R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 12/8/25 at 9:40 AM, R3 was observed in bed and reported taking Norco (opioid/controlled pain medication) as needed. R3 reported there had been a nurse that documented administering Norco to her two times in one day/shift, but she did not receive the medication either time. R3 reported requesting pain medication after wound care and being told by the nurse that it was too soon to have a dose, due to documentation which reflected she received it at 4:00 AM. R3 reported not receiving Norco on another occasion and could not recall the date. Resident #7 (R7) Review of the medical record reflected R7 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle wasting and atrophy, malignant neoplasm (cancerous tumor) of unspecified part of bronchus or lung and fracture of the sacrum. The Quarterly MDS, with an ARD of 6/5/25, reflected R7 scored 11 out of 15 on the BIMS. R7 discharged from the facility on 6/28/25.A Witness Statement for R3, dated 11/18/25 at 2:45 PM, reflected R3 reported a nurse marked down that she took Norco (opioid/controlled pain medication), but she did not get it. R3 reported asking Licensed Practical Nurse (LPN) C if her Norco was marked down (as administered) and was told that it was. R3 stated she knew she did not receive it. R3 reported her pain was not usually too bad, but she had a treatment on her buttocks that day and had level ten out of ten pain on her right side. A Witness Statement for LPN C, dated 11/18/25 at 3:02 PM, reflected R3 asked LPN C to see if her Norco was signed out the night prior. LPN C informed R3 it was signed and the time it was signed out for. According to the Witness Statement, LPN C reported in May (2025) that a nurse was (allegedly) not giving narcotic (controlled medication) that was signed out and was (allegedly) forging signatures. The Witness Statement reflected LPN C reported it to their direct supervisors. A Witness Statement for Registered Nurse (RN) G, dated 11/18/25 at 3:47 PM, reflected R3 requested pain medication the night prior, around 10:00 PM. RN G could not recall if R3 received pain medication that morning. When asked if she gave R3 one or two doses of pain medication on her shift (11/17/25 to 11/18/25), RN G stated just one but could not remember. R3's Controlled Drug Record reflected doses of one tablet of hydrocodone-acetaminophen (Norco) 5/325 milligrams were signed out of the medication cart on 11/17/25 at 9:00 PM and on 11/18/25 at 4:30 AM, with RN G's signature. The November 2025 MAR reflected a dose was documented as administered by RN G on 11/17/25 at 8:52 PM. The dose signed out of the Controlled Drug Record on 11/18/25 at 4:30 AM was not documented on the MAR as being administered to R3. A Witness Statement from LPN C for 11/26/25 reflected she alleged forged signatures ongoing since May (2025), which she first noticed on 5/20/25, pertaining to R7's oxycodone (opioid/controlled pain medication). According to the statement, LPN C alleged since then, there had been several other instances, which had been reported to Director of Nursing (DON) B. The statement reflected LPN C reported discrepancies with her signature for 3/30/25, 5/5/25 and 11/17/25. An investigation binder, provided by the facility, reflected daily timecard punches for LPN C for 5/1/25 to 6/1/25, as well as Controlled Drug Records for residents, which had LPN C's signatures highlighted. LPN C's signatures for May 2025 had notation of work and eMAR (Electronic Medication Administration Record) beside them. In a phone interview on 12/8/25 at 10:17 AM, LPN C reported suspicion of their signature being forged to sign out controlled medications, which Nursing Home Administrator (NHA) A had been made aware of on 11/18/25. LPN C reported controlled medications were being signed out on the Controlled Drug Record but not the MAR and reported suspicion that her signature had been forged for oxycodone on 3/30/25, 5/5/25 and 5/21/25 and for Norco on 11/17/25. In an interview on 12/8/25 at 12:08 PM, LPN E reported being aware that LPN C had concerns pertaining to controlled medications being signed out but not being received by residents in the prior two to three weeks. LPN E reported the DON was aware, and an investigation had been started. LPN E stated LPN C had also made a previous complaint, in April or May of 2025, pertaining to not believing a signature (on a Controlled Drug Record) was hers. LPN E stated that was reported to the DON but was unsure what happened with that concern. LPN E stated LPN D had also reported a concern for a signature (on a Controlled Drug Record) which she did not believe was hers.In a phone interview on 12/9/25 at 12:25 PM, LPN D reported belief that her signature had been forged to sign out Percocet for R1 on 11/20/25. LPN D reported checking the Controlled Drug Record the next date she worked and noticed her signature. She stated she notified the on-call manager. LPN D stated R1 had been sleeping, and she did not give R1 any as needed medication on 11/20/25.In an interview on 12/8/25 at 1:43 PM, when asked if there had been any controlled medication discrepancies prior to 12/8/25, DON B reported the facility had a thick investigation file because R3 reported not receiving two controlled medications. DON B stated that NHA A was made aware, as she was the facility's abuse coordinator. According to DON B, LPN C stated someone was signing out their name (on the Controlled Drug Record) when they were not in the facility. DON B reported they cross-referenced from May to current on C hall and for the entire month of November. DON B reported they did a full investigation, and LPN C had been working the days the medications were signed out. NHA A joined the above interview with DON B on 12/8/25 at 1:54 PM and reported being notified on 11/18/25 that R3 alleged she did not receive her pain medication the prior night. NHA A reported starting a concern form and interviewing R3, who said the nurse documented that she received Norco, but she did not receive it. NHA A reviewed RN G's witness statement and reported that RN G gave R3 as needed pain medication around 10:00 PM the night prior (11/17/25) but could not recall if she gave R3 a dose that morning (11/18/25). During the interview, it was stated that LPN C reported a concern in May (2025) (pertaining to the use of her signature), which the facility audited but did not note any discrepancies. There was no evidence that the facility reported allegations of forged signatures on Controlled Drug Records to the State Agency or Law Enforcement. Additionally, there was no evidence that the facility reported R3's allegation of not receiving controlled pain medication that had been signed out on the Controlled Drug Record. According to the facility's policy pertaining Abuse and Neglect, updated on 6/28/25, .If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety .6. Notify law enforcement authorities and press charges, if indicated. 7. Report the investigation findings to the appropriate State Agencies, as required by law .Reporting/Response: .All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received. A final investigation report will be submitted to the appropriate State Agencies within 5 working days. If the event that results in allegation of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency .1150 B Posting Any owner, operator, employee, contractor, or manager of the LTC [Long-Term Care] facility has the obligation to report to the State Agency and at least one local law enforcement agency, any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility .In the event that the cause of reasonable suspicion of a crime - a) results in serious bodily injury, the individual shall report the suspicion immediately but not later than 2 hours after forming the suspicion; and b) does not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion, unless it involves abuse .REPORTING .if the event that caused the allegation involved abuse or resulted in serious bodily injury, the allegation of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury .The abuse coordinator must submit a final investigation report to the appropriate State Agencies within five (5) working days of the allegation.

This citation pertains to intakes 2677539 and 2677568.Based on observation, interview, and record review, the facility failed to administer medications according to the physician's order for two (R4 and R5) of five reviewed.Findings include:Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that include polyneuropathy (disease affecting nerves) and low back pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/25 revealed R4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/8/25 at 11:02 AM, R4 was observed sitting in her wheelchair in the dining room. R4 reported she takes Norco (hydrocodone-acetaminophen 5-325 milligrams (mg)/controlled opioid pain medication) every six hours as needed for pain. Review of the Physician's Order dated 10/13/25 revealed an order for hydrocodone-acetaminophen 5-325 mg give one tablet every six hours as needed for pain management. Review of the Controlled Drug Record revealed doses were signed out at a frequency greater than every 6 hours on 10/26/25 at 6:00 PM and 7:40 PM, 10/30/25 at 6:00 PM and 8:00 PM, 11/8/25 at 12:00 PM and 1:00 PM, 11/9/25 at 6:00 PM and 8:30 PM, and 11/13/25 at 6:00 PM and 11:00 PM. Of these doses, the Medication Administration Record (MAR) did not reflect documentation on 10/26/25 at 6:00 PM, 10/30/25 at 6:00 PM, 11/8/25 at 12:00 PM and 1:00 PM, 11/9/25 6:00 PM, and 11/13/25 at 6:00 PM. Resident #5 (R5): Review of the medical record reflected R5 admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and type 2 diabetes mellitus with diabetic neuropathy. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/25, reflected R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/8/25 at 11:29 AM, R5 was observed sitting on the edge of their bed. R5 acknowledged taking pain medication, stating they had requested some that morning. R5's November 2025 Medication Administration Record (MAR) reflected a Physician's Order for oxycodone hydrochloride (HCl) (opioid/controlled pain medication) five milligrams (mg) by mouth, every six hours, as needed, for moderate to severe pain. According to the MAR, the medication was signed out as administered on 11/9/25 at 7:17 AM and 8:37 PM. There were no further doses signed out as administered on the MAR for 11/9/25. According to R5's oxycodone HCl five mg Controlled Drug Record, five total doses of the medication were signed out on 11/9/25. The documented times, in order, reflected 4:00 AM, an illegible time, 1:00 PM, 8:40 PM and an additional illegible time. According to R5's November MAR and the oxycodone HCl five mg Controlled Drug Record, R5's doses were signed out at a frequency of less than every six hours on 11/9/25. The November 2025 MAR reflected oxycodone HCl five mg by mouth, every six hours, as needed, for moderate to severe pain was signed out as administered on 11/13/25 at 8:45 PM. There were no further doses signed out as administered on the MAR for 11/13/25. According to R5's oxycodone HCl five mg Controlled Drug Record, two doses of the medication were signed out on 11/13/25. One dose was signed out at 4:45 PM and one dose at 9:00 PM, which was less than six hours apart. R5's December 2025 MAR reflected oxycodone HCl five mg by mouth, every six hours, as needed, for moderate to severe pain was signed out as administered on 12/4/25 at 6:06 PM. There were no further doses signed out as administered on the MAR for 12/4/25. According to R5's oxycodone HCl five mg Controlled Drug Record, doses of the medication were signed out less than two hours apart on 12/4/25. One dose was signed out at 6:06 PM and an additional at 8:00 PM. In a phone interview on 12/8/25 at 3:31 PM, when asked if they knew why there could be discrepancies between documentation on MARs and Proof of Use sheets (Controlled Drug Records), Registered Nurse (RN) G indicated there was so much to do and so much going on that they were forgetting (to document in both places). Regarding timing of as needed medication administration, RN G reported the MAR would indicate if the medication was able to be given and would not allow a nurse to sign a medication out before a resident could have the next dose. In an interview on 12/9/25 at 9:45 AM, Director of Nursing (DON) B reported the expectation for signing out controlled medications was to look at the log, as the Proof of Use sheet was the most accurate form of documentation. DON B reported nurses should have been signing out controlled medications on the Proof of Use sheet and the MAR. DON B agreed that R4 and R5 had doses of controlled medications that had been administered too close together based on the time parameters in the Physician's Orders.

Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and resident accidental falls and/or injury. Findings include: On 06/11/25 at 08:15 A.M., A common area environmental tour of the facility was conducted with Director of Maintenance (DM) E and Director of Environmental Services (DES) D. The following items were noted: Nursing Station: Five sections of Formica laminate surface were observed (etched, scored, particulate, missing), within the interior lower-level desk surface edge. The five damaged sections of Formica laminate measured approximately 2-inches-wide by 1-inch-long, 3-inches-long, 4-inches-long, 8-inches-long, and 18-inches-long respectively. A-Unit Beauty Shop: 2 of 3 upholstered chairs were observed severely stained and discolored. (DES) D stated; We have discussed purchasing a fabric upholstery extractor. B-Unit Occupational Therapy/Physical Therapy: 2 of 4 rubber end caps were observed missing from the Parallel Bars. (DM) E stated: I not sure if I have rubber caps that large, if not, I will order some new ones. On 06/11/25 at 09:30 A.M., An environmental tour of sampled resident rooms was conducted with (DM) E. The following items were noted: A-17: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 2-4 inches. The commode seat was also observed (etched, scored, particulate). (DM) E stated: I will replace the entire assembly. The Bed 2 black clip fan was further observed soiled with accumulated and encrusted dust/dirt deposits. B-2: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 2-3 inches. C-2: The drywall surface was observed with three deep holes, adjacent to Bed 1. C-4: The Bed 1 overbed light assembly lower 36-inch-long fluorescent bulb was observed non-functional. The pull string extension was also observed missing. The Bed 2 overbed light assembly was additionally observed non-functional. The pull string extension was further observed missing. C-8: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 4-6 inches. (DM) E stated: I will have staff tighten the commode support as soon as possible. The drywall surface was observed (etched, scored, particulate), adjacent to Bed 2. The damaged drywall surface measured approximately 24-inches-wide by 24-inches-long. C-10: The drywall surface was observed (etched, scored, particulate), adjacent to Bed 2. The damaged drywall surface measured approximately 24-inches-wide by 36-inches-long. On 06/11/25 at 10:50 A.M., An interview was conducted with (DM) E regarding the facility maintenance work order system. (DM) E stated: We have the TELS program. On 06/11/25 at 11:40 A.M., An environmental tour of sampled resident rooms was continued with (DM) E. The following items were noted: D-6: The Bed 2 overbed light assembly actuation switch was observed broken. (DM) E indicated he would have staff replace the faulty switch as soon as possible. D-12: The drywall surface was observed (etched, scored, particulate), adjacent to the closet and bathroom entrance door. The damaged drywall surface measured approximately 30-inches-wide by 30-inches-long. On 06/12/25 at 08:00 A.M., Record review of the Policy/Procedure entitled: Physical Environment Preventative Maintenance dated 04/12/2021 revealed under Policy: Each facility will have a preventative maintenance program in place that scheduled preventative maintenance on equipment and the physical plant. On 06/12/25 at 08:15 A.M., Record review of the Policy/Procedure entitled: Quality of Life Homelike Environment dated 07/11/2018 revealed under Policy: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. On 06/12/25 at 08:30 A.M., Record review of the Policy/Procedure entitled: Physical Environment Bathrooms dated 07/11/2018 revealed under Policy: Bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Record review of the Policy/Procedure entitled: Physical Environment Bathrooms dated 07/11/2018 further revealed under Procedures: (1) Bathrooms, including showers, whirlpools, century baths, commodes, etc., will be cleaned daily in accordance with our established procedures. On 06/12/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Housekeeping Guidelines dated 03/08/2021 revealed under Policy: To provide guidelines to maintain a safe and sanitary environment for residents, facility staff, and visitors. On 06/12/25 at 09:00 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on interview and record review the facility failed to preserve the dignity for 5 of 5 members of the Resident Council. Findings include: Review of the Resident Council minutes dated 3/19, 4/23 and 5/20/25 revealed residents had complaints about staff being on their phones. On 06/11/25 at 01:02 PM, during the confidential group meeting, 5 of the 5 resident participants reported staff were routinely on their cell phones including in their rooms while providing care. When queried how they felt when this occurred, one resident reported like I am left out and not important. another group participant reported it made them upset because their nurses aid gets distracted while on the phone then forgets a request made by the resident, leaving an unmet need. On 06/12/25 08:32 AM, during an interview with Nursing Home Administrator (NHA) Ashe reported she was aware of issues brought forth by Resident Council members and was trying to correct the issue.

This citation pertains to intake MI00149511. Based on interview and record review, the facility failed to honor code status wishes for one (R333) of two reviewed. Findings include: Review of the medical record reflected R333 admitted to the facility on [DATE], with diagnoses that included heart failure, atrial fibrillation, rheumatic mitral stenosis, nonrheumatic aortic valve stenosis, presence of prosthetic heart valve and atherosclerotic heart disease. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R333 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was dependent for transfers. R333's medical record reflected they had a Do-Not-Resuscitate (DNR/no Cardiopulmonary Resuscitation/CPR) order in place, dated [DATE]. A Progress Note for [DATE] at 11:36 AM reflected R333 became unresponsive during a transfer and was lowered to the floor. The nurse responded immediately and assessed for carotid pulse and respirations. According to the note, life saving measures were initiated while staff checked for R333's code status, which was confirmed to be DNR. In an interview on [DATE] at 11:56 AM, Licensed Practical Nurse (LPN) Z reported responding to unresponsiveness being paged overhead and promptly assessed R333. LPN Z reported CPR was initiated right away, as she did not know R333's code status. CPR continued until Emergency Medical Services (EMS) arrived, according to LPN Z. In an interview on [DATE] at 1:37 PM, LPN Z stated the nursing report sheets included resident code status information, and nurses could also look in the Electronic Medical Record (EMR). In an interview on [DATE] at 1:51 PM, Registered Nurse (RN) T stated the quickest way to verify code status was to look at their report sheet, but they could also look in the EMR. RN T reported it only took seconds to verify a resident's code status. If her report sheet was not on her, it would be located on her medication cart, or it would only take a few seconds to log into the computer (EMR). RN T stated CPR should not be initiated without knowing the code status of a resident.

Based on interview and record review, the facility failed to assess and monitor a change in condition timely for one (R38) of one reviewed. Findings include: Review of the medical record reflected R38 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included muscle wasting and atrophy, type 2 diabetes and obstructive and reflux uropathy. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/27/25, reflected R38 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had an indwelling urinary catheter. R38 was transferred to the hospital on 6/5/25 and was not in the facility at the time of the survey. A Progress Note for 6/4/25 at 7:19 PM reflected R38 was refusing all meals and stated she was vomiting each time she ate. The note reflected the Certified Nurse Aide (CNA) reported R38 had been having green foul smelling discharge. According to the note, the physician was notified. A Progress Note for 6/5/25 at 10:48 AM reflected R38 was unresponsive to verbal and tactile stimulation. The note reflected documentation of R38's vital signs and noted that she was pale and diaphoretic, and her upper and lower extremities were cool to touch. The on-call Nurse Practitioner was notified, and orders were given to send R38 to the emergency room (ER). A Progress Note for 6/5/25 at 1:50 PM reflected the ER reported R38 was receiving intravenous (IV) fluids and IV antibiotics and was expected to return to the facility that day. A Progress Note for 6/6/25 at 8:23 AM reflected R38 was admitted to the hospital. In an interview on 06/11/25 at 3:02 PM, CNA W reported the last time they worked with R38, she had green drainage from her vagina, which the nurses were aware of. CNA W stated R38 had green vaginal discharge for approximately one week or so. Some days the discharge was heavy and noted to be in R38's wheelchair. CNA W stated R38's catheter was cloudy, and there may have been some discharge in their catheter tubing as well. They reported staff were performing catheter care twice per shift, using antibacterial soap, because they knew R38 had an infection. In a phone interview on 06/12/25 at 1:14 PM, CNA X reported R38 had been having mucous-looking vaginal discharge with a foul odor for a couple of weeks, which had been reported and the nurses were aware of. CNA X reported they were performing perineal care more frequently on R38, but she often refused. R38's Care Plan reflected an intervention dated 1/22/25 for, Monitor/record/report to MD [Medical Doctor] for s/sx [signs/symptoms] UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview on 06/12/25 at 3:01 PM, Director of Nursing (DON) B reported any time there was vaginal discharge or blood, the expectation was to get a set of vital signs and contact the physician. DON B was unaware of staff reports of vaginal discharge presenting for weeks.

Based on observation, interview and record review, the facility failed to ensure the safe storage of smoking materials for one (R58) of one reviewed for smoking. Findings include: Review of the medical record reflected R58 admitted to the facility on [DATE], with diagnoses that included saddle embolus of the pulmonary artery and tobacco use. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/25, reflected R58 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/10/25 at 10:51 AM, R58 was observed seated on the edge of their bed, eating a banana. They were observed to grab a pack of cigarettes from their overbed table and place them behind their body, on their bed. R58 reported there were designated smoking times at the facility, and they smoked out back, in the corner, independently. R58 reported they stored their cigarettes and lighter in a drawer, in their room. A Smoking Safety Screen, dated 3/17/25, reflected R58 needed the facility to store their lighter and cigarettes. In an interview on 06/12/25 at 11:25 AM, Certified Nurse Aide (CNA) H reported there was a safety box at the nurse's station where cigarettes and lighters were stored, which nurses had access to. CNA H reported residents were not permitted to store cigarettes and lighters on them or in their rooms. In an interview on 06/12/25 at 11:56 AM, Licensed Practical Nurse (LPN) Z reported cigarettes and lighters were stored in a lock box, at the nurse's station. LPN Z reported R58 had short-term memory loss and was non-compliant with giving their cigarettes and lighter to staff. LPN Z stated R58 kept cigarettes and lighters in their top drawer at times, and staff had also observed them on the bathroom counter. LPN Z stated if nurses were handing out cigarettes, they should be getting them back.

This citation pertains to intake MI00138570. Based on observation, interview, and record review, the facility failed to provide care planned interventions to maintain functional strength to prevent falls, in one of three reviewed for falls (Resident #1), resulting in multiple falls and injuries including a fracture. Findings include: Resident #1 (R1) R1 was observed sitting in her wheelchair on 9/06/23 at 10:55 AM. R1's Minimum Data Set (MDS) dated [DATE] indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener, score of 04 (00-07 Severe Impairment). The same MDS indicated R1 required extensive assistance of one person for transfers. Incident Report dated 3/08/23 at 7:01 AM indicated R1 lowered herself to the floor from her wheelchair. Witness statements dated 3/07/23 indicated R1 fell on [DATE] at 11:00 PM when attempting to transfer self. Progress note dated 3/08/23 at 8:51 PM revealed R1's family stated R1 thought she could do things on her own and would not ask for assistance. The same note indicated R1's physician was reviewing R1's medications. Incident Report dated 4/18/23 at 4:03 PM indicated R1 was observed sitting on a pillow and scooting out to the hallway; and prior to incident had been observed resting in bed. The same report indicated the plan was to keep R1's wheelchair within reach and have physical therapy evaluate. R1's Physical Therapy Discharge Summary dated 4/27/23, revealed she had received physical therapy services following a fall at the facility. R1 had a history of Alzheimer's Dementia, Depression, Peripheral Neuropathy (nerve damage), and orthostatic hypotension (blood pressure changes when moving from lying to sitting or sitting to standing position). The same discharge summary indicated R1's gait was not functional and should be completed with 2 assist if done by nursing with high top tennis shoes and would benefit from attending exercise based activity programming and recumbent cross trainer bike with staff assist to get on and off the machine. The same note recommended R1 use a recumbent cross trainer three times a week as tolerated. R1's activities of daily living (ADL) care plan dated 6/04/21, indicated the nurse assistant/nurse were to assist R1 in use of recumbent cross trainer for 10 minutes. In review of R1's care plans, walking with 2 assist with high top tennis shoes or any walking program was not on any of R1's care plan's in order to maintain functional status gained from physical therapy. Incident Report dated 5/19/23 at 3:50 PM indicated R1 had been observed on the floor in her room. Incident Report dated 5/27/23 at 4:47 PM revealed R1 was observed crawling on the floor in her room and wanted to get into her wheelchair. Nurses Note dated 5/28/23 at 2:47 PM revealed R1 had a fall on 5/28/23 at 6:13 PM and was seen by the nurse assistant crawling on the floor in her room next to her bed. The same note revealed R1's care plan was reviewed. The same note revealed a nurse assistant that worked on second and third shift, reported R 1 was restless in the evening time, typical to behavior; and she had a pattern of falling around those times. The same note indicated the intervention to prevent future falls was to refer to Primary Physician or Nurse Practitioner (NP) for a medical review and possible need for any pharmacological interventions. Incident Report dated 7/02/23 at 7:20 AM revealed R1 was found sitting on the floor next to her bed with a laceration above her left eyebrow. The same report indicated R1 had fell when getting up from her bed. R1 was unable to answer questions including her name, where she was or what year it was. R1 was transferred to the emergency department and a computed tomography (CT) scan was obtained. CT scan dated 7/02/23 at 7:50 AM revealed a supraorbital (above eye) scalp hematoma (blood collects under skin forming a lump) and a new mildly displaced fracture of the right nasal bone as well as an old healed right clavicle (collarbone) fracture. Incident Report dated 7/23/23 at 11:08 PM revealed R1 was observed on the floor at the side of her bed sitting on top of pillows. Incident Report dated 8/02/23 at 6:00 PM revealed R1 fell at nurses station from her wheelchair. A medication review was included on the same report to prevent further occurrences. Incident report dated 8/17/23 at 10:24 PM revealed R1 was observed on the floor in the hallway lying partially on her side; R1 reported she had hit her head. A hematoma was noted on R1's forehead. Physician Progress Note date 8/22/23 at 12:07 PM indicated since R1's fall on 8/17/23, she had not attempted to get out of bed and was not able to feed herself. R1 was noted with lethargy and followed minimal commands. 8/23/23 at 3:57 PM indicated R1 was transferred to the emergency department due to facial rash and nonspecific skin eruption; it was unclear if the rash was due to the bruise on her forehead versus the rash around her nose and mouth. The same notes indicated a repeat CT scan was obtained and lubricating lotion was recommended for her rash. Director of Nursing (DON) B was interviewed on 9/07/23 at 2:39 PM and stated the facility did not have a restorative nursing program and the nurse assistants were responsible in providing restorative care. DON B stated in the same interview that only therapy staff assist residents with using the recumbent cross trainer machine. DON B stated in the same interview the interdisciplinary team did not consider a beveled edge walkable floor mat next to R1's bed as a intervention to prevent injury from falls because they did not have those kinds of fall mats at the facility. Physical Therapist (PT) C was interviewed on 9/07/23 at 3:32 PM and stated therapy did not assist residents with the recumbent cross trainer machine after discharged from therapy. PT C stated in the same interview that nursing was responsible for assisting R1 with the recumbent cross trainer machine recommended by therapy following her discharge from physical therapy.

This citation pertains to intake MI00131462. Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions and treatments for two (Resident #28 and Resident #29) of three reviewed, resulting in the worsening of a pressure ulcer for Resident #29 and the potential of a worsening pressure ulcer for Resident #28. Findings include: Review of the medical record revealed R29 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the left heel, diabetes, and chronic kidney disease stage 3. Review of the MDS with an Assessment Reference Date (ARD) of 3/13/23 revealed R29 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of two people for bed mobility, and was not on a turning/repositioning program. Review of the Braden Scale for Predicting Pressure Sore Risk dated 3/6/23, revealed R29 scored 16 (15-18 is at risk). Review of the Admission/Re-Admission Evaluation dated 3/6/23 revealed Stage 1 pressure ulcer-staged by RN [Registered Nurse] to R29's left heel. Review of the Skin & Wound Evaluation dated 3/7/23 (day after admission) revealed R29 had a stage one pressure ulcer that measured 0.9 centimeters (cm) x 0.5 cm. Review of R29's Physician's Orders and Treatment Administration Records (TARs) revealed on 3/6/23, border form was ordered for R29's left heel but was never applied or implemented. The order was discontinued on 3/7/23. No treatments were documented as completed on 3/6/23 or 3/7/23. Starting on 3/8/23, skin prep was ordered to apply to bilateral heels every day for protection. Skin prep was discontinued on 3/15/23. Review of R29's At Risk for Alteration in Skin Integrity care plan initiated on 3/7/23 revealed elevate heels as able was implemented on 3/7/23, pressure redistributing device on bed/chair was implemented 3/7/23, use pillows/positioning devices as needed was implemented 3/7/23, and EHOB boots to bilateral feet were implemented on 3/12/23. The Skin & Wound Evaluation dated 3/11/23 revealed R29's pressure ulcer was a deep tissue injury (persistent non-blanchable deep red, maroon, or purple discoloration) that measured 0.8 cm x 1.2 cm. The wound bed was documented as 100% eschar (dead tissue/unstageable). Review of R29's Pressure Ulcer to Left Heel care plan initiated 3/13/23 revealed EHOB boots were implemented 3/13/23, pressure redistributing support surface was implemented 3/13/23, and repositioning during Activities of Daily Living (ADLs) was implemented on 3/13/23. According to the TAR on 3/15/23, a Hydrofera Blue dressing was applied to R29's left heel. The order was to change the dressing every three days. The dressing was changed four days later, on 3/19/23. The Hydrofera Blue dressing was discontinued on 3/23/23. The Skin & Wound Evaluation dated 3/19/23 revealed a 1.7 cm x 2.3 cm deep tissue injury with light serious drainage and macerated surrounding tissue. According to the Order Summary and TAR, on 3/23/23 the treatment order was changed to cleanse with normal saline, apply skin prep, and apply optifoam every two days. The treatment was not documented as completed and the order was discontinued on 3/24/23. On 3/24/23 the order was changed to normal saline, medi honey, and a dry dressing daily. The Skin & Wound Evaluation dated 3/24/23 revealed a1.2 cm x 0.8 cm unstageable (obscured full-thickness skin and tissue loss) pressure ulcer due to slough and/or eschar; however, the wound bed was documented as 20% granulation tissue without any documentation of the amount of slough and/or eschar. Review of the MP Wound Progress Note dated 3/24/23 revealed I am going to change the plan .3. pressure reducing seat cushion, 4. pressure reducing heel boot, 5. pressure reducing air mattress, 6. turn and reposition per facility . The Skin & Wound Evaluation dated 3/31/23 revealed a 2.4 cm x 1.6 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 70% granulation tissue and 30% slough. Review of a General Progress Note dated 4/6/23 revealed .consider referral to wound clinic .Elevate left heel off bed at all times . The Skin & Wound Evaluation dated 4/7/23 revealed a 1.7 cm x 2.1 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar. Review of the Wound Care Initial Consultation, History and Physical dated 4/7/23 revealed R29's pressure ulcer was 100% stable black eschar and measured 1.73 cm x 2.06 cm. The consultation revealed If patient sits in bed, appropriate offloading mattress .Frequent turning and positioning every two hours to the best of her ability to offload the area. Review of the care plans revealed turning and repositioning every two hours was not implemented. The Skin & Wound Evaluation dated 4/14/23 revealed a 3.1 cm x 1.6 cm unstageable pressure ulcer due to slough and/or eschar. The assessment did not reflect any additional wound characteristics (i.e. wound bed, drainage). The Skin & Wound Evaluation dated 4/21/23 revealed a 2.5 cm x 1.8 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar. Review of the Radiology Report dated 4/21/23 revealed R29's left heel soft tissues appear swollen with ulceration .findings suspicious for calcaneal osteomyelitis [inflammation of bone due to infection], recommend MRI. The Skin & Wound Evaluation dated 4/28/23 revealed a 1.3 cm x 2.2 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar. Review of the MRI dated 5/4/23 revealed R29 had osteomyelitis of the left heel. R29 was on IV antibiotics for osteomyelitis. The Skin & Wound Evaluation dated 5/5/23 revealed a 2.6 cm x 1.8 cm unstageable pressure ulcer due to slough and/or eschar; however the wound bed was documented as 60% granulation without any documentation of the amount of slough and/or eschar. On 05/3/23 at 09:41 AM, R29 was observed sitting in a wheelchair in her room. Both feet were wrapped with kerlix and boots were in place. R29 reported she developed a pressure ulcer on her left heel due to her heel rubbing on the bed. R29 reported she was on IV antibiotics for an infection in her left heel. R29 did not recall elevating her feet off the bed prior to the development of the pressure ulcer. R29's bed was observed with a bariatric mattress that was not an alternating pressure mattress. On 5/8/23 at 10:05 AM, R29 was observed in bed while staff were providing care. R29 did not have an alternating pressure mattress on her bed. In an interview on 05/8/23 at 11:08 AM, Director of Nursing (DON) B reported it was her understanding that R29 was admitted to the facility with the left heel deep tissue injury. DON B reviewed R29's wound assessments and agreed that on 3/6/23 and 3/7/23, the wound was documented as a stage 1 pressure ulcer to the left heel. DON B reported R29 now had osteomyelitis to the left heel. DON B reported the facility's standard mattresses were foam mattresses and that R29 should have had an alternating pressure mattress in place since 3/13/23. DON B reported the skin prep was started on 3/8/23 and agreed there was no documented preventative treatment completed on 3/6/23 or 3/7/23. DON B entered R29's room and reported the mattress on the bed was a standard foam mattress and not an alternating pressure mattress. On 05/9/23 at 09:41 AM, Licensed Practical Nurse (LPN) K was observed performing a skin check on R29. LPN K reported R29 was also due for dressing changes. LPN K began by removing R29's boots and dressings dated 5/8/23 from both feet. LPN K then placed both of R29's heels directly on a bath blanket. R29 had a pillow under her legs, but the pillow did not prevent her heels from resting on the bed. R29's left heel was observed with a a pressure ulcer. LPN K completed the remainder of the skin check and then left the room to obtain wound care supplies. When asked about the left heel pressure ulcer, R29 stated I just didn't get moved enough. R29 went on to further explain that she thought staff put something under her legs to elevate her heels when she first came in, but her heels still touched the mattress. LPN K returned at 10:00 AM to perform wound care. R29's heels were still resting on the mattress at that time. LPN K cleansed R29's left heel with normal saline, patted dry, applied betadine to the wound, applied calcium alginate to the wound, placed an ABD pad over, and then wrapped with kerlix. Review of the Physician's Order dated 5/7/23 revealed left heel cleanse with NS [Normal Saline] apply collagen to heel and wrap with kerlix every day and PRN [as needed]. The treatment was scheduled for Mondays, Wednesdays, and Fridays. In an interview on 05/9/23 at 10:26 AM, LPN K was asked about the treatment orders for R29's left heel. LPN K showed the order for betadine to left heel, soak 4x4 gauze with betadine, and wrap with kerlix. There was not an active treatment for 5/9/23 which reflected the order that was placed on 5/7/23 for normal saline, collagen, and kerlix. In an interview on 05/9/23 at 11:34 AM, DON B reported R29's betadine order was supposed to be discontinued and the order for collagen was to be completed on Mondays, Wednesdays, and Fridays. DON B reported she did not recall that calcium alginate was ever an order for R29's pressure ulcer. DON B reported R29 now had an alternating pressure mattress in place. In an interview on 05/10/23 at 09:34 AM, Maintenance Director (MD) E reported work orders were usually not filled out for mattresses. MD E reported Housekeeping Director (HD) F kept track of when specialty mattresses were put into place. In an interview on 05/10/23 at 09:38 AM, HD F reported as of 1/1/23, she did not keep track of mattresses; however, the requests were still done through email. HD F reported she looked back and found that the only conversation related to R29's bed was for a bariatric mattress and a trapeze. HD F reported R29 first received an alternating pressure mattress on 5/8/23. 38383 Resident #28 (R28): Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room, locomotion on and off the unit. R28 was not coded as having any wounds. On 05/03/23 at approximately 10:40 AM, R28 was observed seated in a wheelchair in her room. R28 stated she had some sores but was unsure if they were present before she admitted to the facility. On 05/04/23 at 9:15 AM, R28 was observed lying on her left side in bed, watching TV. She reported she had absolutely no concerns with her care. Everyone has been really super. She reported she was able to turn and reposition herself in bed and sit up independently. She stated they told her she had fallen since she had been here. She reported sliding out of the bed. Upon interview, she acknowledged there are things she does not remember. A Skin and Wound Evaluation for 4/16/23 reflected an in-house acquired open lesion to the sacrum, measuring 1.1 centimeters (cm) in length by (x) 0.8 cm in width. There was no description of the wound bed, and there were no additional assessments of the area after 4/16/23. Progress of the wound was marked as New. During an interview on 05/08/23 at 11:04 AM, Director of Nursing (DON) B reported R28 had a spot on her sacrum that measured 1.1 cm x 0.8 cm and healed on 4/16/23. DON B reported the picture showed a pink area with a bit of a scab on it. She reported the staff nurse was supposed to document that the area was healed, and Nursing Home Administrator (NHA) A closed (healed) the wound assessment on 4/25/23 at 11:47 AM. DON B reported R28 had a history of a pressure ulcer to that area. DON B was notified of the request to observe R28's skin, including her sacrum/coccyx and left foot during scheduled treatments on 5/9/23. On 05/08/23 at 1:00 PM, R28 was observed seated in her wheelchair, in her room, watching TV. She was wearing gripper socks on both feet, with her feet resting on the floor. Review of wound notes by Wound Doctor Q reflected R28 was seen on 4/14/23 for an open sacral lesion that measured 1.1 x 0.8. The note reflected treatment was going to include MediHoney, collagen and foam dressing, to be changed three times a week and as necessary. Review of the April 2023 TAR reflected those orders were not implemented and continued to reflect Coccyx: cleanse with NS [normal saline], pat dry and place optifoam over wound every day shift for wound care. During an interview on 05/09/23 at 12:15 PM, DON B was notified that R28's treatments had already been documented as completed for the day, and the Survey Team had not been made aware for the previously requested observation. DON B was asked if she knew why the treatment was not updated to reflect Wound Doctor Q's treatment recommendation for the coccyx, as referenced in his Progress Note for 4/14/23. DON B believed Wound Doctor Q healed that area and that there was no need for the recommended treatment.

Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for four (Resident #11, #13, #20, and #464) of five reviewed for accidents, resulting in reoccurring falls (Resident #13), falls with the potential for major injury (Resident #464) and falls with major injury (Resident #11 and #20). Findings Include: Resident #13 Review of an Admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/6/23, reflected R13 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R13 did not walk and required extensive of two or more people for transferring and toileting. In an observation on 05/03/23 at 09:58 AM, R13 was observed resting in bed with her eyes closed. R13 had a Broda chair (wheelchair that provides tilt-in-space positioning, recline and leg rest adjustments) in her room. R13 did not have a non-skid mat on the seat of the Broda chair. R13's television was off. In an observation on 05/04/23 at 01:01 PM, R13 was seated in her Broda with a blanket covering her, slightly reclined back. R13 had a tablet on a stand in front of her but was not watching the content playing on the device. R13 had a blanket but did not have any other materials with her at the time of observation. In an observation on 05/04/23 at 01:50 PM, R13 was observed seated on her bottom on the floor in front of R13's Broda chair. Staff members were assessing and assisting to R13. In an observation on 05/04/23 at 01:53 PM, R13 was assisted back into the Broda chair and wheeled to the vicinity of the nurse's station. R13 had a blanket on her but had no other materials with her at the time of observation. An observation was made of the seat of the Broda chair, and it did not appear that R13 had a non-skid mat underneath her bottom on the seat of the chair. In an observation on 5/04/23 at 1:56 PM, the staff member at the nurse's station left the area. R13 was left unsupervised by facility staff members for approximately five minutes. In an observation 05/04/23 at 02:37 PM, R13 was seated in her Broda chair and slightly reclined back in the vicinity of the nurse's station. R13 appeared to have slid down significantly from her previous position with her buttocks towards the edge of the seat. R13 was attempting to lean up out of chair. A staff member approached R13 and wheeled R13 away from the nurse's station and down the hall. R13 was not repositioned in the Broda chair. In an interview on 05/04/23 at 02:05 PM, Licensed Practical Nurse (LPN) CC reported that she did not witness the fall that R13 sustained. LPN CC reported that the iPad in front of her prior to falling was for entertainment purposes, to watch tv and stuff. Review of the Care Plan revealed R13 had an At Risk for Falls Care Plan initiated on 12/1/2020. Some listed interventions included assist patient near nurses' station if she is becoming restless in her chair, ensure patient has her baby doll when sitting in her chair, leave TV [television] on at bedtime with low volume, non-skid surface to wheelchair, reposition in Broda chair when noted restless or agitated, and watching iPad while in Broda chair of favorite show and music. Review of the Care Plan revealed R13 had an increased risk of fracture related to Osteoporosis Care Plan initiated on 01/16/2022. Interventions included to monitor for risk of falls and educate resident, family/caregivers on safety measures that needed to be taken in order to reduce risk of falls. Review of the same Care plan revealed R13 had bilateral hearing loss and an Activities of Daily Living deficit Care Plan which revealed R13 wore glasses. Review of the Assessment tab located in the Electronic Medical Record revealed R13 had 18 Fall Assessments from falls sustained from 1/1/23 until 5/8/23. In an observation on 05/08/23 at 09:58 AM, R13's Broda chair was in R13's room. R13 was using the restroom at the time. There was no non-skid mat observed on R13's Broda chair. In an interview on 05/08/23 at 12:53 PM, Certified Nursing Assistant (CNA) EE reported that R13's fall interventions included ensuring R13's toileting needs were tended to, ensuring the bed is in the lowest position, not leaving R13 unattended in her room, and leaving her up by the nurse's station for increased supervision purposes. CNA EE stated that R13 does not respond much to the iPad. When queried about the non-skid pad that is Care Planned as a fall intervention, CAN EE reported that she [R13] used to have one but the facility got rid of them. CAN EE also reported that R13 had hearing loss but did not have hearing aids and has glasses, but they were in her drawer and not used. In an observation on 05/08/23 at 10:08 AM, R13 was wheeled out of her room by a staff member and parked in the vicinity of the nurse's station. The staff member walked away from R13. At 10:32 AM, a staff member approached R13 and removed her from the nurse station and into her room. R13 had no direct supervision for the 24 minutes that R13 was left in the vicinity of the nurse's station. In an observation on 05/08/23 at 10:46 AM, R13 was resting in bed with her eyes closed. R13's television was turned off and the Broda chair did not have a non-skid mat on the seat. In an observation on 05/09/23 at 10:15 AM, R13 was observed in the hall seated in her Broda chair, slightly reclined back, with a blanket. R13 did not have a baby doll with her at the time of observation. In an interview on 05/08/23 at 02:29 PM, LPN CC stated that fall interventions for R13 included keeping her at the nurse's station, toileting before and after meals, ensuring she had her blanket and baby doll and providing fluids after meals. When quired about the non-skid mat, LPN CC reported that the facility got rid of them and was no aware of any alternative for the non-skid mat. LPN CC reported that R13 did not having hearing aids or require the use of glasses. In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that she was aware of R13's frequent falls and was going to start implementing risk management meetings with the facilities Interdisciplinary Team in the near future to monitor, track and trend resident falls. DON B confirmed that one of R13's fall interventions was to park her near the nurse's station to provide increased supervision. DON B reported that the facility does have and utilize the use of non-skid mats but was not certain why R13 did not have one on her Broda chair. Resident #20 Review of an Admission Record revealed Resident #20 (R20) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included traumatic subdermal hemorrhage with loss of consciousness, adult failure to thrive, dementia, Alzheimer's disease, repeated falls, glaucoma, and visual disturbance. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, reflected R20 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R20 required extensive of one person for transferring and toileting. In an observation on 05/04/23 at 01:01 PM, R20 was seated in a wheelchair in her room with a blanket on her lap. R20's call light was clipped to her right side but was hanging out of reach. R20 yelled out can I go back to bed now? There was no response from staff. In an observation on 05/04/23 at 01:14 PM, R20 yelled out Can I go back to bed? There was no response from staff even though there were two staff members approximately 6 feet outside of R20's room. In an observation on 05/04/23 at 01:22 PM, R20 called out I need to go to the bathroom, and I need to go back to bed. A staff member passed by as R20 was calling out but did not respond to the request. In an observation on 05/04/23 at 01:37 PM, a Certified Nursing Assistant (CNA) approached this surveyor for an interview when R20 called out I need to go to the bathroom. The CNA then tended to R20. In an observation on 05/08/23 at 12:44 PM, R20 was seated in her wheelchair and parked in the middle portion of her room. R20 did not have a call light within reach. Review of a Progress Note dated 3/7/2023 at 5:39 PM revealed .on 3/4/23 @ [at] 930am, staff observed resident [R20] resting on the floor on her eft [sic] side near the bed of her roommate, her walker upright in front of her. She was unsure if her head made contact with anything. She stated she was trying to go back to bed after using the restroom following breakfast . She was incontinent at time of incident Immediate intervention: assist w/ [with] toileting following breakfast. CP (care plan) updated. Review of an Incident report dated 3/4/23 at 9:35 AM revealed resident observed lying on the floor on her left side near roommates' bed .fall interventions already in place: have commonly used articles within reach, provide assistance to transfer and ambulate as needed. New intervention toilet before and after meals . Review of a Progress Note dated 4/10/2023 at 07:38 AM revealed R20 observed lying on the floor face/body down next to bed. Resident stated, I was trying to get back into bed. Resident states hitting head and having 7/10 pain in head .Resident assisted off floor by EMS [Emergency Medical Service] and transported to ER [Emergency Department] for further evaluation. An Incident Report dated 4/10/23 revealed that the fall occurred at 4/10/23 at 7:15 AM. The Incident report provided by a Certified Nursing Assistant on 4-10-23 revealed resident toileted on midnight shifting [sic] observed resting in bed approx. 0700 [AM]. fell 0710 [AM]. A Patient Safety Note dated 4/11/2023 at 10:47 AM revealed R20 states she was getting up to go to bathroom .New intervention to update plan of care includes bed against wall. Interventions in place at time of fall include commonly used articles within reach, assist to use restroom after breakfast, encourage to change positions slowly . Review of the Hospital Paperwork dated 4/11/23 revealed R20 sustained a subdermal hematoma (A condition due to bleeding under the membrane covering the brain called, the dura) and was admitted to the Critical Care Unit. Review of the Care Plan revealed R20 had an At Risk for Falls Care Plan initiated on 4/6/2020. Interventions included administer medications per physician's order, encourage to transfer and change positions slowly, evaluate medications if patient demonstrates changes in mental status, provide assistance to transfer and ambulate as needed, refer to the therapy plan of treatment in the medical record for more detail, and therapy evaluation and treatment per orders. In an interview on 05/08/23 at 02:37 PM, Licensed Practical Nurse CC reported that R20 is hard of hearing and seldomly uses her call light. R20's preferred method of asking for assistant was to call out. Review of the Kardex (portion of the Electronic Medical Record commonly used by Certified Nursing Assistants to communicate residents needs) revealed R20 required assistance to the restroom after breakfast and before staff leave room, place call light in patient hand for ease to access . In an interview on 05/10/23 at 10:03 AM, Certified Nursing Assistant (CNA) FF reported that R20 makes her needs known by calling out for help but at times, R20 will use the call light appropriately. CNA FF reported that staff will pin the call light to R20 to help with locating the call light when needed. In an observation in 05/11/23 at 09:17 AM, R20 was in bed with her eyes closed. R20's bedside table was located at foot of bed. R20's water was located on the bedside table, which was out of reach from R20. R20's call light was observed on the floor, out of reach from the resident. In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that R20 did sustain a fall in April when R20 rolled out of bed and was transferred out to the hospital. DON B reported that R20's current fall interventions included assisting R20 to the restroom after breakfast, have R20's bed against wall, transfer change position slowly, evaluate medications, and keep commonly used articles within reach. When asked to define commonly used articles, DON B stated drinks, bedside table, call light, and whatever the resident preference might be. Resident #464 Review of an Admission Record revealed Resident #464 (R464) admitted to the facility on [DATE] with pertinent diagnoses which included heart failure, dementia, difficulty in walking, cognitive communication deficit, weakness, anxiety, major depressive disorder, and expressive language disorder. A Social Services Note dated 4/24/23 revealed that R464 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R464's Kardax (computer program that communicates resident's care needs to staff) reflected R464 requires one person guidance and physical assistance for transfer. In an observation on 05/03/23 at 12:02 PM, R464 was seated in the dining room at a table and speaking with a Hospice staff member. R464 was in his wheelchair and wearing standard socks. A Progress Note dated 4/23/2023 at 2:45 PM revealed R464 was observed crawling on the floor in his room. When asked what happened, patient states, This is the only way I can get around. An Incident Report dated 4/23/23 revealed R464 was discovered on the floor by his bed, sitting on his bottom. R464 did not sustain any injuries but was unsure how he fell out of his bed. A Progress Note dated 4/24/2023 at 10:15 PM revealed R464 was discovered crawling on the floor in his room at 9:30 PM. When asked why he was on the floor, R464 replied I was trying to get up. An Incident Report dated 4/24/23 revealed R464 was attempting to stand throughout the shift and was eventually discovered on the floor in his room during a routine check. The same Incident Report revealed that R464 was in need of incontinent care at the time of the fall. R464 was educated to use his call light if he needed anything. A Progress Note dated 4/25/2023 at 02:01 AM revealed R464 was observed sitting on his bottom on the floor in his room. R464 was wearing one shoe on his foot and incontinent at the time of his fall. An Incident Report dated 4/25/23 confirmed R464 was incontinent upon discovery. R464 was placed in his wheelchair and moved out into the hallway. A Progress Note dated 4/30/2023 at 7:34 AM revealed R464 was observed on the floor in the dining room. R464 was unable to describe how the fall occurred. An Incident Report dated 4/30/23 revealed R464 self-transferred out of his bed and into his wheelchair. R464 propelled himself down to the dining room where the fall took place. Review of the Care Plan revealed R464 had an At Risk for Falls Care Plan initiated on 4/21/23. Interventions included reenforce the need to call for assistance, provide assistance to transfer and ambulate as needed, and have commonly used articles within easy reach. On 4/26/23 additional interventions were added to include refer to the therapy plan of treatment located in the medical record and preference to crawl on the floor. Review of the same At Risk for Falls Care plan revealed addition interventions were added on 5/8/23 to include decrease activity and stimulation at times of increased anxiety and stress. In an interview on 05/08/23 at 12:58 PM, Certified Nursing Assistant (CNA) EE reported that R464 will occasionally crawl on the floor. CAN EE reported that R464 is a one assist for transfers but occasionally self-transfers. In an interview on 05/09/23 at 11:58 AM, Director of Nursing (DON) B reported that Incident Reports are completed by staff after a fall and any interventions implemented after a fall should go into the care plan. The staff should also be implementing an immediate fall intervention after a resident sustains a fall. If staff requires assistance formulating an intervention, the fall can be referred to the Interdisciplinary Team to help come up with additional or appropriate interventions. Regarding R464's fall on 4/23/23, the intervention was to care plan R464's preference to crawl on the floor. After the fall on 4/24/23 the intervention was staff to assist with call light within reach and educated on call light use. When queried if R464 was likely to benefit from reeducation with a low BIMS, DON B responded that he would not. After R464's fall on 4/25/23, DON B reported that the intervention was to refer to Physical and Occupational therapy for an evaluation. After the fall that R464 sustained on 4/30/23, DON B reported that the fall intervention implemented was to decrease activity stimulation at all times to decrease anxiety and review the care plan. When asked if DON B would consider a more appropriate intervention such as a toileting schedule considering R464 was incontinent for two of his four falls, she replied that she felt that would be an appropriate intervention. An email was sent on 5/9/23 to Nursing Home Administrator (NHA) A requesting documentation of R464's Physical and Occupational therapy evaluation. NHA A responded via email at 3:39 PM reporting None- he came in hospice. 38383 Resident #11 (R11): Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction, flaccid hemiplegia affecting left non-dominant side and unspecified intellectual disabilities. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/23, reflected R11 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 did not walk and required extensive assistance of one to two or more people for most activities of daily living. R11 was coded for fall with major injury. On 05/03/23 at 1:51 PM, R11 was observed in bed, with the head of the bed elevated and the bed height in a low position. Upon entering the room, R11 was asking for help. He was lying with his head towards the wall at the right bedside while trying to maneuver his body towards the left side of the bed. R11 was saying help me. A pillow was observed on the floor at the left bedside. With his requests for help, R11 was asked how he alerted staff of his needs. R11 indicated he wanted up. Review of R11's Incident Reports since 1/1/23 reflected four falls. An Incident Report for a fall on 1/21/23 at 10:31 AM reflected the Certified Nurse Aide (CNA) yelled down the hall to nurse at 9:55 AM and stated R11 was lying on the floor. Upon entering the room, R11 was observed lying on the floor, turned to his side, in front of his wheelchair. R11 laughed and stated he was fine. The documented cause reflected R11 slid out of wheelchair onto floor and when asked if he wanted to lay down, he said yes. The corrective action reflected R11 was assessed and an intervention for R11 to lie down between meals if he is wanting to lie down. R11's Care Plan reflected an intervention that was initiated and created on 1/21/23 and revised on 1/24/23 to offer/assist R11 to return to bed for rest after breakfast. An Incident Report for a fall on 1/30/23 at 12:59 PM reflected the CNA informed nurse that R11 had fallen out of his wheelchair. Upon entering R11's room, he was observed lying on the floor in front of his wheelchair. He was assessed for injuries, placed in his wheelchair via hoyer lift (mechanical lift), vital signs were obtained, and the call light was placed in reach. The cause of the fall was documented that R11 slid out of his wheelchair, onto the floor. The corrective action reflected R11 was assessed for injuries, placed in his wheelchair and vital signs were obtained. The Investigation Report for the same fall reflected R11 had a history of sliding out of his wheelchair, and a non-slip grip would be placed in the wheelchair. R11's Care Plan reflected an intervention that was initiated on 1/30/23 and created on 2/2/23 to encourage use of non-slip pad in wheelchair and encourage/assist R11 to be out in common area of nursing station when out of bed, for enhanced safety. An Incident Report for a fall on 1/30/23 at 1:32 PM reflected the CNA informed the nurse that R11 was on the floor in the hallway. The nurse observed R11 in the hallway, lying in front of his wheelchair. He was assessed for physical injury, vital signs were obtained, hoyered into bed, positioned for comfort, bed placed in lowest position and call light placed in reach. The cause was documented as R11 sliding himself to the floor. The corrective action was to remove his wheelchair. The Investigation Report for the same same fall reflected when R11 was out of bed, offer and assist him to sit in the hallway, close to the nurse's station, for closer supervision, as R11 allowed. R11's Care Plan reflected an intervention that was initiated and created on 1/31/23 for offering and assisting R11 to sit in the hallway, close to the nurses station, for closer supervision when out of bed, as R11 allowed. An Incident Report for a fall on 2/18/23 at 9:20 AM reflected R11 was found on the floor by the nurse around 8:50 AM. There was a significant amount of blood on the floor. Once R11 was cleaned up, he was noted to have a gash on the bridge of his nose, some swelling and a bruise on the side of his forehead. R11 was assessed for visible injuries and pressure was held related to bleeding. Emergency Medical Services (EMS) was called, and R11 sent to the emergency room (ER) for evaluation due to hitting his head. The documented cause of the fall reflected R11 fell out of his wheelchair while in his room. The corrective action reflected staff was re-educated about encouraging R11 to sit at the nurse's station or out in hallway while up in his wheelchair. Hospital Records reflected R11 had a laceration to the bridge of his nose, requiring three sutures (stitches). Additionally, there were comminuted left and right nasal bone fractures and probable remote type I odontoid process (part of the neck) fracture without displacement. R11's Care Plan reflected an intervention for routine safety checks when R11 preferred to stay in his room, dated 2/19/23. During an interview on 05/08/23 at 9:57 AM, CNA P reported she was not sure if R11 would be classified as a fall risk. She reported R11 had fallen a few times when she had been on duty and had trips to the ER. On 05/09/23 at 2:51 PM, R11 was observed lying in bed, with the bed height in low position. R11 had a standard size bed, not a bariatric bed, as indicated on the Care Plan. On 05/11/23 at 9:12 AM, R11 was observed seated in a specialty wheelchair, watching TV in his room. Rear anti-tip bars were observed on the wheelchair. No call light was observed in R11's reach. A perimeter mattress without linens was observed on the bed. The mattress was observed to be a standard size, not bariatric as care planned. An overbed table was near R11's right side. A bottle of pop with a straw was observed on the dresser, under R11's TV. When asked if staff had offered to take him out of his room this morning, R11 denied. On 05/11/23 at 9:19 AM, CNA Z stated R11 had been up since about 6:00 AM and had been in his room since after breakfast. On 05/11/23 at 9:23 AM, R11 continued to be observed seated in his room, in a specialty wheelchair. He was observed using his feet to slightly and intermittently move the wheelchair back and forth. At 9:24 AM, he was observed moving the wheelchair towards the dresser and was attempting to move his torso forward. Upon entering the room and speaking with R11, he asked for his pop (which was on the dresser). R11's roommate overheard the request and stated he turned the call light on for R11. R11's roommate reported R11 had a call that he used, but it was probably on his bed. At 9:30 AM, Licensed Practical Nurse (LPN) GG entered R11's room, in response to the call light. R11's roommate notified LPN GG that he had the call light on for R11. LPN GG was overheard asking R11 if he wanted his pop and stated to R11 that he was on thickened liquids, so he had to thicken the pop before giving it to him. The cap was placed on the pop, which was left on R11's dresser. The nurse exited the room at 9:32 AM, after telling R11 he would get him pop that was thickened. An order dated 12/2/22 reflected R11 was on a regular diet with pureed texture, .2 Mildly Thick consistency [liquids]. During an interview on 05/11/23 at 10:25 AM, CNA Z reported when R11 was up in his chair, she kept an eye on him all the time. She reported R11 went to the dining room that morning and returned to his room around 9:00 AM. CNA Z reported R11 could not be in the bathroom alone but thought he could be in his room, in his wheelchair, alone.

This citation pertains to Intake MI 582 Based on observation, interview, and record review the facility failed to prevent a fall for one (Resident #60) of three reviewed, resulting in R60 falling out of bed and sustaining a fracture. Findings include: Review of the medical record revealed Resident #60 (R60) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included left femur fracture on 12/1/21, [CONDITION(S)], diabetes, anxiety, and right above the knee amputation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/21 revealed R60 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance of two people for bed mobility. Review of the Activities of Daily Living (ADL) care plan dated 8/30/21 revealed R60 required extensive assistance of two people for bed mobility and positioning. Review of the Kardex (care guide) revealed the same information. On 04/05/22 at 10:35 AM, R60 was observed lying in bed with the head of the bed elevated. There were bilateral grab bars in place. R60 reported on 12/1/21, an aide came into her room to provide incontinence care. R60 stated, She told me to roll right [away from the aide]. I did. My right leg is already amputated. I fell on the floor. As soon as I fell on the floor, I knew I broke my titanium knee. I heard it snap .I was crying. She was on my bed acting like she was King Kong on the Empire State Building saying she didn't know what to do. R60 reported she was sent to the hospital and had a hard cast in place until 3/5/22 and had surgery on 3/7/22. R60 reported staff always had two people to assist with rolling her in bed and stated, one on each side. Review of the Incident Description and Investigation dated revealed on 12/1/21 at 6:25 PM, Staff was conducting a bed check. Once found that resident needed attention staff then proceeded to toileted [sic] the resident. While turning the resident the resident fell on the floor. Review of the Xray dated 12/1/21 revealed R60 sustained an acute, displaced, comminuted fracture of the distal femoral diaphysis. On 04/06/22 at 4:16 PM, an attempt was made to interview Certified Nursing Assistant (CNA) H, who was an agency CNA and no longer employed at the facility. CNA H did not answer and did not return the phone call. Review of CNA H's Witness Statement dated 12/1/21 revealed I was changing her [R60] and the bed was wet. I had to do a complete bed change. When I turned her over I saw the bed was wet. I moved the fitted sheet and ran to the bathroom to get paper towel to wipe the bed off and next thing I know she was on the floor. I immediately left the room to get my nurse. In a telephone interview on 04/06/22 at 4:50 PM, Registered Nurse (RN) J reported at the time R60's fall occurred, she was passing meds. RN J reported CNA H came out of R60's room and reported a fall. RN J stated R60 was on the floor, in excruciating pain. RN J reported the other CNA who was working on the hallway at that time, was off the hall at that moment. RN J reported CNA H did not ask her for assistance with bed mobility for R60. Review of the One-On-One Inservice Record dated 12/1/21 revealed CNA H was educated that During incontinence care, bed linen change, never roll a resident away from you without a CNA/nurse present on the other side of the bed. Do not provide care for 2 assist resident by self. Review of the facility's Bed Positioning Policy dated 10/2011 and updated 2/2019 revealed Move the person to the edge of the bed on the side farthest from you so that when they are turned they are in the middle of the bed .Gently roll the patient towards you . In an interview on 04/06/22 at 4:59 PM, Director of Nursing (DON) B reported CNA H was an agency CNA who began working at the facility around 11/1/21 and had a skills check at that time. DON B reported R60 was care planned for two-person assistance with bed mobility and that CNA H had access to R60's Kardex.

This citation pertains to intake MI 327. Based on interview and record review, the facility failed to prevent a fall for one (Resident #7) of two reviewed for falls, resulting in R7 being rolled away from the Certified Nursing Assistant (CNA) during care, falling from their bed onto the floor and sustaining a contusion, laceration and transfer to the hospital. Findings include: Review of the medical record reflected that Resident #7 (R7) was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/2020, reflected that R7 had short-term and long-term memory problems, was non-ambulatory (did not walk) and required total assistance of one to two or more people for Activities of Daily Living (ADL's). R7 was discharged from the facility on 8/4/2020. According to a facility investigation, on 6/28/2020 at 4:50 AM, R7 slid out of bed while receiving incontinence care from CNA M. A Concern Form, dated 6/28/2020, reflected that R7's mother was worried about R7 due to her falling out of bed. According to the Concern Form, R7's mother stated they felt it was neglectful. A Progress Note for 6/28/2020 at 6:08 PM reflected that at 4:40 AM, CNA M notified the nurse that R7 slid out of the bed while she was attempting to roll her onto her side to change her brief. R7 had minimal bleeding on her lip from where her tooth had hit when she fell . The note further reflected that R7 appeared frightened but was showing no visible or audible signs of pain. A Progress Note for 6/28/2020 at 8:40 AM reflected that during 7:30 AM neurological checks, it was discovered that R7 was developing a hematoma to the right side of her forehead, measuring five centimeters by three centimeters. The areas was maroon in color and slightly raised. The on-call provider was notified, and R7 was sent to the emergency room . Hospital documentation reflected that R7 had ecchymosis and evidence of a contusion to the right forehead as well as a superficial laceration to upper lip and mucosa, with scab formation. R7's medical record reflected that they returned to the facility on [DATE]. According to the facility investigation file, CNA M's statement on 6/28/2020 at 10:15 AM, reflected that CNA M was changing R7's brief, and she was still wet. CNA M was wiping R7 off with a towel. CNA M tucked the brief under R7, and R7 was facing away from CNA M. CNA M had just tucked the brief under R7 and was holding onto R7 with her left hand, while tucking the brief with her right hand. R7 moved her left leg over her right leg. CNA M's glove was wet, and R7's hip was wet. R7 slipped out from underneath CNA M's hand. She turned right over on her stomach and slid off the bed. I've always turned (R7's First Name) away from me to change her. She doesn't normally move. I have turned other patients away from me as well, (sic) but will never do it again. The statement reflected that CNA M was educated that it was not safe to turn patients away from her when changing them, as it was a safety risk where they could roll out of bed. CNA M was notified to always have another staff member present on the other side of the bed when turning patients away from her. According to the statement, CNA M agreed she should have waited for help. CNA M was contacted via phone on 9/2/2020 at 3:15 PM. The surveyor provided their first name, title and purpose of call being for a survey at (Facility Name). When asked if they were still employed by the facility, CNA M stated they were not. When asked how long it had been since their employment with the facility had ended, CNA M stated she could not do this right now. She requested to be called the next day, as she was busy. CNA M hung up the phone before the surveyor could respond. CNA M was contacted via phone on 9/3/2020 at 9:47 AM. The surveyor provided their first name and title. CNA M reported that she did not have time and was getting ready to go to work. CNA M hung up the phone before the surveyor could respond. During a phone interview on 9/3/2020 at 1:22 PM, Director of Nursing (DON) B reported that R7 was totally dependent for care and required two people to assist with care, such as incontinence care. DON B reported that CNA M turned R7 away from her during perineal care, which was against facility guidelines, according to DON B. DON B reported that R7's hip was wet and slid out from under her, resulting in R7 falling off the other side of the bed. DON B reported that CNA M received education regarding not rolling residents away from her in the bed. CNA M was suspended pending investigation but did not return to work, according to DON B. CNA M had given her (resignation) notice and no longer worked for the facility, according to DON B. A ONE-ON-ONE INSERVICE RECORD, dated for 7/1/2020, reflected that CNA M was educated on a topic of patient care, patient protection practice guide forms of abuse. The description of the education reflected, Ensure that you do not roll residents away from you without another staff member present x2 if the bed isn't against the wall.

This deficient practice has two deficient practice statements DPS1 and DPS2. DPS 1) Based on observation, interview and record review the facility failed to: 1.) ensure the safety of residents in dining room, and 2.) implement care-planned and non-care-planned interventions in 1 of 3 sampled residents (Resident #2) reviewed for falls, resulting in R2's unwitnessed fall in the main Dining Room with cervical neck fracture on 12/17/19. Findings include: Resident #2 (R2) According to the facility, Post Fall Evaluation, dated (MONTH) 2011, reflected, Falls are common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs throughout a patient's stay. In the event that a patient does experience a fall, a comprehensive clinical evaluation by the nurse supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas to focus for a post-fall evaluation may include: Vital signs .Mental Status .Sensory a) pain .response to touch .Pupillary response-equality, reactivity to light .visual changes .Numbness .Motor function a) Muscle strength or weakness .Skin integrity .Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient has hit their head; following an un-witnessed fall when a head injury may be suspected and following non-fall event which result in known or suspected head injury .In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but not move the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R2 was a [AGE] year old male admitted to the facility on [DATE] and readmission from the hospital on [DATE] after cervical spine fracture after an unwitnessed fall at the facility on 12/17/19, with [DIAGNOSES REDACTED]. The MDS reflected R2 had a BIM (assessment tool) score of 9 which indicated his ability to make daily decisions was moderately impaired, and he required one person physical assist with locomotion on unit and two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, and bathing . During an observation on 1/08/20 at 9:12 a.m., R2 was in his shared room alone sitting in a high back recliner chair that was facing the television with a neck brace on and both feet elevated. R2 appeared R2 had difficulties communicating and was not able to answer simple questions. Review of the facility Progress Notes on 1/8/20 at 9:21 a.m., dated 12/17/19 through 12/18/19 reflected R2 had an two unwitnessed falls on 12/17/19 from the wheelchair. One in his room and another within four hours in the Dining Room and hit his head on table or floor and was sent to the emergency room . Review of the facility Patient Safety Progress Noted, dated 12/18/19 at 1:37 p.m., reflected, IDT(Interdisapinary team) team reviewed fall from 12/17/19 1730(5:30 p.m.). Therapist observed resident around 4:15pm heading in the dining room for dinner . Therapist assisted in placing patient at dining table per his seating preference and adjusting him to the table in his chair for comfort. Therapist did leave to go tend to another resident who was scheduled for therapy at time. Therapist did then hear a loud banging sound from the prior dining room area where patient was last visualized. Resident was observed lying on the floor on his stomach. He had moved from where he was placed on the opposite side of the table to the new location appearing to have wanted to be in between the other two residents seated at the table at time. He does have one sided weakness and does move/ambulate in his wc with his left leg as he moves his heel pulling himself in his wheelchair around .He did obtain a cut to his head .send to hospital for med review and also xrays . During an interview on 1/8/20 at 2:01 p.m., this surveyor requested Director of Nursing (DON) B to provided 6 months of R2's incident accident reports including complete investigations for review. During an interview on 1/8/20 at 3:29 p.m., this surveyor had not received requested incident accident reports for R2. DON B reported she was working on getting them. Review of the facility, Daily Staffing Sheet, dated 12/17/19, reflected three Certified Nurse Assistance (CNA) and one nurse assigned to R2's hall D. During an interview on 1/8/19 at 4:30 p.m., Licensed Practical Nurse Unit Manager (LPNUM) M provided R2 fall incident accident report for 12/17/19 at 1:30 p.m. LPNUM M reported R2 only had one fall on 12/17/19. Review of the provided facility, Post Fall Investigation Process packet, dated 12/17/19 at 1:30 p.m., reflected R2 had an unwitnessed fall from a wheelchair in his room. The report included the facility, Post Fall Investigation Process, fall pathway, Care Path Fall, Fall Prevention Strategies & Interventions, Neurological : Neurological Evaluation. The packet included nurse and CNA witnesses statements that reflected R2 had an unwitnessed fall in room after staff assisted R2 back to room in wheelchair after lunch that included drawings. LPN V completed witness statement that reflected R2 was alert and oriented. The packet included a blank, Witness Statement (Resident). The packet included Progress Notes, dated 12/17/19 at 5:30 p.m. that reflected, Patient was in the dining getting ready to eat dinner and fell out of his wheel chair. The fall was not witnessed and patient hit his head either on the table or on the floor .sent to (named hospital) ER per doctors orders. The Progress Note was signed by LPN V. The packet included R2 Fall Care Plan, dated 7/7/19, reflected R2 was as risk for falls due to history of falls, right side weakness and dementia. The Care Plan(printed on 12/18/19) interventions were, Administer medications per physician orders, bed against wall, dycem to wheelchair, evaluate medications if patient demonstrates changes in mental status, ADL function, appetite, neurological status, etc., have commonly used articles within easy reach, low bed, non skid strips to bedside, rear anti-tipper on wheelchair, reinforce need to cal for assistance, and reinforce wheelchair safety as needed, right foot pedal to wheelchair all initiated 7/1/19. During an interview on 1/8/19 at 5:10 p.m., LPNUM M reported after review of R2 Progress Note, dated 12/17/19 at 5:30 p.m., R2 appears to have had two falls on 12/17/19 at 1:30 p.m. and 5:30 p.m. LPNUM M verified with DON B R2 did not have a fall investigation for the 5:30 p.m. fall in the dining room that required transfer to the hospital. During an interview on 1/8/20 at 6:00 p.m. UM F reported she was responsible for maintaining Incident Accident reports and the team was responsible for overall investigations. UM F reported R2 should have an fall investigation for both falls on 12/17/19 and reported was unsure where R2's 12/17/19 5:30 p.m. fall report was. UM F reported after R2 first fall on 12/17/19 the nurse implemented new intervention to place R2 in bed after meals. During an interview on 1/8/19 at 6:18 p.m., UM F provided this surveyor with R2's fall investigation including witness statements for the 12/17/19 fall at 5:30 p.m. UM F reported DON B had it on her desk because R2 had a fracture. UM F reported she was unsure why DON B did not provided investigation when both this surveyor and UM M had asked previously. During an interview on 1/8/20 at 6:20 p.m., Rehab Director U reported Physical Therapist (PT) W saw R2 prior to fall in the dining room on 12/17/19 and completed a witness statement. Review of the provided facility, Post Fall Investigation Process packet, dated 12/17/19 at 5:30 p.m., reflected R2 had an witnessed fall by other residents from a wheelchair in the dining room that resulted in transfer to the hospital with positive cervical spine fracture. The fall packet had no mention of evidence of neuro checks prior to moving resident from the floor to the wheelchair or evidence that care planned interventions were in place such as dycem in wheelchair. The fall investigation did not address the time discrepancy between the witness statements and the fall investigation did not include any resident witnesses statements. During an interview on 1/8/20 at 6:28 p.m., PT W reported she had observed R2 on 12/17/19 at 4:15 p.m. in the dining room. PT W reported she assisted R2 position his wheelchair at the square table in the dining room with three other residents. PT W reported she then went to assist another resident with with therapy and was walking other resident from dining room area toward B hall(with back turned to dining room). PT W reported she heard loud bang from dining room, turned around and observed R2 on the opposite site of the table where she had position him on the floor face sown on his belly. PT W reported she immediately sat other resident down and went to the dining room and observed R2 flat on the ground trying to lift up. PT W reported R2 was laying on right side with right forehead on floor and reported R2 had history of stroke with right side weakness. PT W reported R2's right side of forehead was bleeding with palm size puddle of blood on floor. PT W reported she sat on the floor with R2, staff came to door, asked for them to get nurse. PT W reported one of the three other residents at the table was alert and oriented was resident witness X. PT W reported she was unsure who all was in dining room at time but reported was before dinner so residents were all heading toward dining room. PT W verified witness statement and reported completed on the day of the fall 12/17/19. PT W reported again the fall took place between 4:15p.m. and 4:30 p.m. and was able to recall that because therapy visits need are required to be monitored by times and documenting was reviewed to verify times. PT W reported R2 was in a regular wheelchair at the time of the fall with one foot pedal on the right side and able to self propel with the use of the left foot. PT W reported after R2 returned from the hospital R2 was provided with different chair and changes related restrictions related to collar for cervical fracture. During an interview on 1/8/20 at 6:47 p.m., Registered Nurse (RN) Y reported had worked at the facility for eight months. RN Y reported was working on A hall on 12/17/19 when R2 fell in the dining room. RN Y reported she heard someone yell there was an emergency in the dining room, immediately entered the dining room and observed R2 laying on the floor with right side of head down in puddle of blood on the floor. RN Y reported she assessed R2 without moving, assessed leg length, neuro checks, and held pressure to bleeding right forehead and reported R2 denied pain. RN Y reported two other nurses came and assisted to roll R2 on his back. RN Y reported R2's vitals were obtained then aids came with the hoyer and assisted R2 up off floor into the wheelchair. RN Y reported R2 denied pain and laughed. RN Y reported was not R2 that evening but helped by calling R2's Durable Power of Attorney (DPOA) who stated he did not need to go to emergency if he did not want to because at RN Y reported R2 did not want to go to the hospital but later agreed. RN Y reported R2 was in regular wheelchair at the time of the fall. RN Y verified witness statement and reported completed at the time of the fall and reported assessment should be documented in the progress notes. RN Y reported other staff that were present after the fall were two Certified Nurse Assistance Z and Aa, and two Licensed Practical Nurses (LPN) V and Bb. During an interview on 1/8/20 at 7:02 p.m., LPN V reported working at the facility as a nurse for five months. LPN V reported she was R2's nurse on 12/17/19 from 7:00 a.m. to 7:00 p.m.(during both falls). LPN V reported she was informed by an aid R2 was on the floor in his room at 1:10 p.m., after entering the room R2 was observed on the floor. LPN V reported Doctor Cc entered the room with her as well. LPN V reported R2 was on his right side on the floor and reported R2 was laughing and stated he was tired. LPN V reported Doctor Cc assessed R2, R2 denied injury or pain and used a hoyer to move resident from the floor back into the wheelchair. LPN V reported the fall was not witnessed and the immediate interventions were to place resident back in bed after meals. LPN V reported R2 had a regular wheelchair with one foot rest on the right and self propelled with left foot and brace on right leg. LPN V reported R2 remained in room and performed neurological checks on R2 every 15 minutes for one hour, then every 30 minutes for one hour according to direction on Neuro assessment form. LPN V verified witness statement and reported completed at the time of the fall. LPN V was unable to recall what was in the wheelchair at the time of the fall. LPN V reported was asked by management to complete an additional Progress note with more details after the event. LPN V reported on 12/17/19 between 5:15 p.m. and 5:30 p.m. R2 had a second fall in dining room. LPN V reported she saw RN Y run from other hall and alerted her there was a fall. LPN V reported she observed R2 on the floor with blood everywhere, retrieved vital machine, informed LPN Bb need for assistance. LPN V reported R2's face was laying on right side with right hand under him moving pooled blood back and forth laughing, and denied pain, neuro checks, vitals where obtained in that position, RN Y held a towel on R2's forehead and supported R2 neck when R2 turned on back. LPN V reported R2 was lifted off the floor with the hoyer and four staff to the wheelchair and CNA Z transferred R2 out of the dining room to the area by the nurse station and staff held a towel on R2 head the had two laceration until Emergency Medical Services (EMS) arrived. LPN V reported R2 was transferred from the wheelchair to the EMS gurney with the use of the sit to stand. LPN V reported she called EMS and R2 DPOA and RN Y called the doctor. LPN V reported R2 denied pain and did not want to go to hospital it first but later agreed. LPN V reported prior to the fall R2 had been sitting at a table in the dining room with several other residents at the time of the unwitnessed fall. LPN V verified witness statement and reported completed at the time of the event. LPN V reported she documented fall on progress note after management request for additional fall details. LPN V was unsure what intervention were in place at the time of the dining room fall after review of the witness statement related to incomplete form and was unsure what was in R2 wheelchair prior to the either fall on 12/17/19. LPN V verified no neuro check was documented for R2 after the second fall and was unsure why and reported she should have documented nuero check. During an interview on 1/8/20 at 8:03 p.m., CNA Aa reported had worked at the facility for seven months and worked second shift on 12/17/19 at the time of R2's fall in the dining room. CNA Aa reported she was told in report R2 had fall in room that day. CNA Aa reported she did not provide direct care to R2 per family request prior to that day unless emergency. CNA Aa reported she gathered towels and gloves as requested by nurse and observed R2 on the floor in the dining room with a pool of blood under his head. CNA Aa reported she did not provided direct care for R2 after the fall except to sit with R2 and CNA Z prior to EMS arrival. CNA Aa reported she completed a witness statement the day of the event and verified. During an observation and interview on 1/9/20 10:53 a.m. Resident witness X reported R2 was sitting at round table with him and moved behind him and had had a [MEDICAL CONDITION] because body jerked out of wheelchair to floor and hit the floor hard. Resident witness X reported R2 fell out of chair before dinner in the dining room. During an interview on 1/9/20 at 11:01 a.m., Nutrition Service Manager (NSM) C reported not present for dinner on 12/17/19 but provided schedules and reported dinner was at 5:00 p.m. on 12/17/19. During an interview on 1/9/20 at 11:03 a.m., PT W verified R2 fall in the dining room was at 4:15 p.m. on 12/17/19 as evidenced by timed therapy records. During an interview on 1/9/20 at 11:28 a.m., Physician Cc reported he did not recall seeing R2 after first fall on 12/17/19 but may have and reported he did not document visit. Physician Cc reported R2 was not cognitively reliable related to dementia. Physician Cc reported R2 often has inappropriate responses included laughing inappropriate times. Physician Cc stated, not able to clear c spine with resident like (named R2) related to dementia. Physician Cc reported what happened was resident hit floor forward on chin and fractured cervical spine area. Physician Cc reported common injury with face forward fall and had occurred with two residents recently at that facility and R2's cervical neck fracture was not detected on x-ray but seen with cat scan. Review of the Hospital Discharge records, dated 12/19/19, reflected R2 had a witnessed fall on 12/17/19 at the facility that resulted in an acute C2 fracture with use of cervical collar. The discharge document reflected R2 would require dysphasia diet with thickened liquids and need full supervision and assistance with all PO(oral intake). The records reflected R2 had cat scan on 12/17/19 that reflected, There is a mildly displaced acute type II odontoid fracture with the 2mm superior and posterior angulation of the odontoid process . The hospital records reflected R2 arrived at the emergency room at 5:36 p.m. During an interview on 1/9/20 at 12:14 p.m., R2's DPOA Dd reported was not present at the time of the fall 12/17/17 in dining room and was not aware of more that one fall on 12/17/19 and reported visits R2 daily. R2's DPOA Dd reported she was informed R2 had an unwitnessed fall at dinner time. R2's DPOA Dd reported she found it hard to believe it was unwitnessed because she knew at least other residents witnessed the event. R2's DPOA Dd reported R2 was in regular wheelchair with foot rest on the right and self propelled with left leg. R2's DPOA Dd reported facility called to inform of R2's fall in the dining room and two hours later she received call from hospital that R2's had a fractured neck and needed to send R2 to Toledo. R2's DPOA Dd reported R2 does not try to get up on own related to stroke with right side weakness. R2's DPOA Dd reported R2 had recent episode of thrashing in bed and concerned R2 may fall out of bed reported to staff. During an interview on 1/9/20 p.m. 1:28 p.m., Dietary staff Ee reported working in the dining room on 12/17/19 but did not witness R2's fall but saw nurses with R2 on floor about 4:45 p.m. while putting food out on steam tables. Dietary staff Ee reported Ancillary staff Ff was in the dining room. During a telephone interview on 1/09/20 at 1:50 p.m., Ancillary staff Ff reported was working in the dining room on 12/17/19 when R2 fell and completed a witness statement at the time of the event. Ancillary staff Ff reported R2 was observed sitting in the dining room moving more than usual in his wheelchair and seemed restless, leaned forward then observed R2 fall forward face down on floor and staff came in to assist R2. Ancillary staff Ff reported fall took place before dinner was served and nursing staff or CNA staff were not in the dining room at the time. During an interview on 1/09/20 at 1:57 p.m., Director of Nursing (DON) B reported working at the facility for three months. DON B reported would expect nurse staff to assess the resident, call the physician and family and document after a fall. DON B reported staff are trained and are aware of facility fall policy(Fall Practice Guide Flowsheet) including required assessments. DON B reported the nurse does the investigation then the IDT team will continue investigation as a team. DON B reported if information does not match they reinterview staff. DON B reported they did not notice time discrepancy with R2's second fall on 12/17/19 between 4:15 p.m. and 5:30 p.m. DON B reported the resident is the concern during a fall not the time. DON B reported she did not believe R2 was able to self transfer. DON B reported the IDT team note include the fall investigation. DON B reported staff are expected to follow care plans. When this surveyor ask about assessments including pain, DON B provided this surveyor with pain assessments prior to R2's dining room fall on 12/17/19 and reported nurses document pain on the, Pain/Pain Assessment in Advanced Dementia (PAINAD) Evaluation - V2 form. DON B and ADM A were unable to provided this surveyor documentation that facility fall policy and procedure had been reviewed by the medical director within the past 12 months. Deficient Practice Statement #2 Based on observation, interview, and record review, the facility failed to: (1) effectively maintain 4 (A8, A16, B2, B11) of 18 sampled restroom commode supports, and (2) maintain acoustical ceiling tile within the B-5 resident restroom effecting 16 residents, resulting in the increased likelihood for resident accidental falls and/or personal injury. Findings include: On 01/08/20 at 12:30 P.M., An environmental tour of sampled resident rooms was conducted by this surveyor. The following items were noted: Resident restroom A-8: The commode support was observed loose to mount. The commode support could be moved from side to side approximately 3-6 inches, creating an accidental resident fall risk. Resident restroom A-16: The commode support was observed loose to mount. The commode support could be moved from side to side approximately 3-6 inches, creating an accidental resident fall risk. Resident restroom B-2: The commode support was observed loose to mount. The commode support could be moved from side to side approximately 3-6 inches, creating an accidental resident fall risk. Resident restroom B-5: One acoustical ceiling tile was observed severely bowed and loose to mount, adjacent to the hand sink vanity. Resident restroom D-11: The commode support was observed loose to mount. The commode support could be moved from side to side approximately 3-6 inches, creating an accidental resident fall risk. On 01/08/20 at 02:35 P.M., An interview was conducted with Director of Maintenance D regarding a specific Policy/Procedure for identifying and/or correcting maintenance concerns. Director of Maintenance D stated: We use a single copy manual work order sheet for documenting maintenance requests. Director of Maintenance D also indicated the facility will be changing to the Direct Supply TELS software system in the near future. On 01/09/20 at 08:30 [NAME]M., Record review of the Facility Name Work Order Maintenance Request documents from 10/01/19 to present revealed no specific entries related to the aforementioned maintenance concerns.

This citation pertains to intake: MI 115 Based on observation, interview and record review the facility failed to accurately assess, treat and prevent the development of a pressure ulcer in 4 of 4 residents (R201, R202, R203 and R204) reviewed for pressure ulcers, resulting in R201 developing a facility acquired stage 4 pressure ulcer. Finding include: According to the Pressure Ulcer Treatment, Quick Reference Guide, 2009, under Common Definition of Pressure Ulcers, defined a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure with combination of shear. According to the National Pressure Ulcer Advisory Panel (NPUAP) defines a Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) in the wound bed. The nurse is obligated to follow the physician's orders unless they believe the order is in error or would be detrimental to the resident. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, Perry, P., Potter, [NAME], 1985). According to the facility, Dressing Change: Non sterile (clean) policy and procedure, dated 01/19, reflected, Dressing changes are performed according to physician's orders. Non-sterile (clean) dressing changes area appropriate for select wounds such as chronic and acute wounds to clean and protect the wound. NOTE: In the event of multiple wounds each wound is considered a separate treatment .Procedure: 1. Verify physician's order .9. Remove soiled dressing .RN measures wounds (weekly at a minimum and prn). 10. Remove soiled gloves .11. Prepare dressing supplies. If physician order indicated irrigation of wound pour saline or prescribed solution over 4x4 sterile gauze pad . According to the facility, Negative Pressure Wound Therapy policy and procedure, dated 01/19, reflected, Change negative pressure wound therapy as per physician order .Follow manufacturer's recommendations .Procedure .Position tubing and connector away from bony prominence's . Resident #201 (R201) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R201 was a [AGE] year of female admitted to the facility on [DATE], with recent re-admission 8/28/19 related to facility acquired stage 4 pressure ulcer complications, with [DIAGNOSES REDACTED]. The MDS reflected R201 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was intact, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person physical assist with locomotion on unit, and eating. The MDS reflected R201 did not have any behaviors including no history of refusal of care. Review of the facility acquired pressure ulcer list, provided by the facility on survey entrance on 9/24/19, reflected R201 had a facility acquired pressure ulcer. During an observation on 9/24/19 at 4:41 p.m., R201 was laying in bed on back on an air mattress and appeared thin, calm and pleasant and alert and oriented to person, place and time. R201 reported receiving artificial nutrition by tube feeding during the night, noted hanging at the bed side, unlabeled and undated. R201 reported she had an open would and currently had a wound vac in place. During an observation and interview on 9/25/19 at 8:15 a.m., Wound Care Nurse (WCN) C reported had been facility wound care nurse for about one year and reported plans to provided R201 with wound care. WCN C gathered supplies including wound vac supply kit, collegen, normal saline, skin prep, and clear wound measurement tool from treatment cart located in Hall [NAME] WCN C entered R201 room and placed supplies on towel on top of R201 bedside table. At 8:38 a.m. R201 reported 6/10 pain and WCN C reported plan to contact Physician for additional pain control informed R201 plan to wait on would care. During an observation on 9/25/19 at 10:05 a.m., WCN C entered R201 room for second attempt for wound care with assistance of Certified Nurse Aid (CNA) D. WCN C had supplies on R201 bedside table on top of towel. R201 reported to WCN C pain was currently 4/10. WCN C reported wound vac setting was currently set at 125. R201 was noted to have wound vac dressing in place over right ischium(buttock) with removable layer still in place and trac pad of wound vac placed directly over pressure wound(directly over bony prominence). R201 appeared very thin. WCN C reported R201 dressing was changed every Monday, Wednesday and Friday and staff nurse changed last on Monday. WCN C removed soiled dressing and R201 had a open wound that appeared to have 20-30% white slough in base with beefy red tissue. WCN C removed soiled gloves, washed hands and donned clean gloves and used Normal Saline to irrigate wound. WCN C then used the clear wound measurement tool (handled from the medication cart, moving in and around resident room) and place the tool directly against R201 previously cleaned wound. WCN C reported the wound size was 5.6cm x 3cm x 1.2 cm. WCN C continued with wound care and applied moistened collagen to wound base, followed by black wound vac foam and transparent wound vac drape. WCN C bridged (placed wound vac trac pad to right hip with foam bridge) and additional drape was placed and wound vac suction resumed. CNA D assisted R201 position on right hip per R201 request. WCN C informed R201 she could position on right hip for short time only related to would and would vac placement. During an interview directly following R201 dressing change on 9/25/19 at 10:50 a.m., WCN C reported R201's wound to the right ischium was a stage 4 facility acquired pressure ulcer and reported was unsure when wound was first identified without looking. WCN C reported she did not have any special wound care training or certifications. WCN C reported she was unsure why the nurse on Monday had not removed the the second layer of removable film from wound vac drape dressing and was unsure why the trac pad was positioned directly over R201's wound or if the would had declined since last assessment the week prior. Review of the facility Braden Scale assessment, dated 5/14/19, reflected R201 was at moderate risk for developing a pressure ulcer. Review of the facility, Skin Alteration Record, dated 7/9/19 through 8/13/19, reflected on 7/9/19 R201 had a wound to the right ischium area that was dark pink/red tissue with scant serosanguineous drainage and pain that measured 1.2cm by 1cm by 0.01cm. The Skin Alteration Record, dated 7/17/19, reflected WCN C documented R201's same wound measured 0.3cm by 0.2cm by 0.1cm. According to the Skin Alteration Record, dated 7/18/19(one day after previous skin assessment), reflected R201 had a wound to the right ischium area that was that was moist yellow or gray necrotic tissue and pain that measured 4cm by 3cm by 0.4cm. The wound was assessed on 7/23/19 and 7/30/19 with little changes except on 7/30/19 peri wound was documented as reddened. The same wound was assessed on 8/7/19 and reflected scant serosanguineous drainage and reddened, blue, purple, yellow peri wound and and pain that measured 4cm by 4.5cm by 0.3cm and no changes documented on 8/13/19 skin assessment. Review of the facility, Nursing Progress Notes, dated 7/6/2019 at 1:40 p.m., for R201 reflected, Resident has a sore on right upper leg/lower buttock. Triad was put on it. Was unable to find skin assessment to enter it. 0.5 x 1 0 x less than 0.1 in depth. Review of the facility, Progress Note, dated 7/9/2019, for R201 reflected, Right gluteal fold open area measuring 1.2 x 1.0 x 0.01. Area washed with water/soap, patted dry, Triad cream applied for comfort. Wound nurse consulted. Reported to on-coming shift for evaluation. written by Registered Nurse (RN). Review of the facility, Progress note, dated 8/7/2019 at 11:53 a.m., for R201 reflected, Skin Note Text: Patient has a wound on the inner gluteal fold. Wound is measuring 4cm*4.5cm with 0.3dept. Drainage is scant with serosanguineous color. Skin around wound has discoloration. Patient tolerated it well, patient complained of mild pain. Review of the facility, Progress Note, dated 8/16/2019 at 11:26 a.m., for R201, reflected , General Progress Note Note Text: Pressure wound to right gluteal fold Cleanse with normal saline pack loosely with 2x2 moist with Dakins 1/4 strength solution. Cover with dry dressing change twice daily and PRN. two times a day for Pressure ulcer AND as needed for Pressure ulcer Start Date: 8/16/2019. This nurse was notified of wound increasing in size, (named Nurse Practioner) and this nurse assessed wound. New treatment ordered received. Resident started on [MEDICATION NAME], odor, red, warm, scant serosanginous drainage. Stage III pressure ulcer to right gluteal fold. Wound started from shearing of brief .Refereed to BMC wound care on 8-26-2019. Review of the facility, Progress Note, dated 8/20/2019 at 12:53 a.m., for R201 reflected, Skilled Nursing Note Text: Resident started on ABX Doxyxycline 100mg for wound infection for 10 days. Wound care orders updated. Resident denies NVD. No further needs at this time. Review of the facility, Progress Note, dated 8/21/2019 at 12:11 p.m., for R201 reflected, Skin Note Text: Resident noted to have a pressure ulcer on right gluteal fold. History of coccyx pressure ulcer with surgical flap repair, pressure ulcer right ankle and poor nutrition refusing tube feeding at times. Braden Scale Score: 12 Wound Location: Right gluteal fold PUSH: 13 Stage III Measurement: 3.8cm x 2.7cm x 0.4 Wound bed: Red/Yellow Periwound: Intact Drainage: Serousanginous Treatment: Pressure wound to right gluteal fold Cleanse with normal saline pack loosely with 2x2 moist with Dakins 1/4 strength solution. Cover with dry dressing change twice daily and PRN. Intervention in place LAL mattress. Resident has an apt scheduled at BMC wound clinic on 8-26-2019. Review of the facility, Progress Note, dated 8/21/2019 at 3:30 p.m., for R201 reflected Infection Control Note Text: Resident continues on Antibiotic [MEDICATION NAME] 100mg for wound infection. wound appears red warm and pus at wound site . Review of the facility, Progress Note, dated 8/27/2019 at 7:35 a.m., for R201 reflected, General Progress Note Text: Spoke with (named hospital). Per nurse, resident admitted to (named hospital and room) d/t wound after wound clinic appt. on 8/26/19. She stated physician was in assessing resident this AM. Review of the facility, Progress Note, dated 8/29/2019 at 12:40 a.m., for R201 reflected, Skilled Nursing Note Text: Resident readmit after being discharged from acute hospital setting for Stage IV right ischial wound infection . Review of the facility, Progress Note, dated 8/29/2019 at 8:57 a.m., for R201 reflected, Nutrition/Weight Note Text: Readmission Nutrition Note: Resident readmitted to facility from hospitalization for wound. Weight on readmission 89.0#, no significant weight changes however weight is down 8.2# over last 6 months . During an observation on 9/25/19 at 2:34 p.m., R201 was noted in same position on right side as noted after dressing change at 10:50 a.m. R201 reported she had tried to move off of right side where she was positioned after dressing change but was unable(on same side as trac pad and wound). R201 reported CNA's had not repositioned her since wound care and added staff do not assist with repositioning every 2 hours. During an observation and interview on 9/25/19 at 3:35 p.m., Restorative Therapy (RT) [NAME] was exiting R201's room. R201 was positioned on right side (same position post dressing change). RT [NAME] reported R201 was positioned on right side prior to performing range of motion with R201 and reported RT [NAME] did not move R201 off of right side. RT [NAME] reported facility is short staffed related to being required to perform restorative therapy for 11 residents plus other duties that included assist resident with feeding, weights, door checks, which left 3 hours to perform restorative therapy for 11 residents that should take 30 minutes each and not enough time to provide each resident with required therapy. During an interview on 9/25/19 at 2:40 p.m., CNA G reported she had worked day shift that day on Hall A and had not performed care including repositioning for R201 that day. During an interview on 9/25/19 at 3:42 p.m., outside R201 room, CNA F reported she had worked at the facility for eight years. CNA F reported she was currently working with two other aids on hall A and had not provided R201 with any care that day. During an observation and interview on 9/25/19 at 3:44 p.m., R201 was positioned on right side. R201 reported recently had restorative therapy but was not moved off of right side. R201 reported she had been on right side since dressing change around 11:00 a.m. and staff have not been in to reposition her and reported increased discomfort from laying on dressing and wound. During an interview on 9/25/19 at 3:45 p.m., CNA H reported working at the facility for 6 years, and being mandated that day. CNA H reported she gets mandated at least one time weekly and works part time. CNA H reported facility has a lot of open positions including at least five on days and nine on afternoons. CNA H reported was one of three CNA staff on that day for Hall A and they often all work together instead of assignments. CNA H reported she did not assist R201 with position changes that day. During an interview on 9/25/19 at 4:15 p.m., Director of Nursing (DON) B reported would expect staff to follow wound care Policy and Procedure including measurement of wound prior to cleaning of wound, proper use of multiple use items including treatment supplies, proper wound vac dressing changes per policy and would expect staff to assist R201 to be positioned every two hours. DON B reported R201 is alert and oriented and had history of not asking for help. During an interview on 9/26/19 at 11:00 a.m., DON B reported she was unsure when R201's pressure wound was identified but knew it was facility acquired pressure ulcer. During an interview on 9/26/19 at 11:28 a.m., DON B reported R201's pressure ulcer was identified on 7/6/19. During an interview and record review on 9/26/19 at 12:05 p.m., DON B provided wound clinic appointment notes, dated 8/26/19, who reported they had not been part of the medical record but obtained from hospital Electronic Medical Record. The wound clinic visit notes indicated R201 was sent to hospital from the wound clinic for a stage 4 pressure ulcer wound debridement and biopsy and increase pain. The wound clinic notes including orders to avoid direct pressure to wounds at all times and reposition at least every 2 hours and bedrest only on low air loss mattress with frequent turning. Review of the facility, Skin Care Plans, dated 6/30/19 to 9/26/19, reflected R201 did not have a Skin Care Plan or pressure ulcer preventions in place until 8/15/19. Review of the facility Treatment Administration Record, dated 7/1/19 through 9/26/19, reflected R201 had skin treatment for [REDACTED]. No documentation of right ischial or gluteal wound treatments noted prior to 7/23/19. Review of the facility Physician orders, dated 7/1/19 through 7/31/19, reflected no physician orders for wound care for R201 During an interview on 9/26/19 at 12:56 p.m. RN I verified Progress Noted, dated 7/9/19, RN I reported had observed R201's wound, consulted wound nurse who advised her how to treat. RN I reported she was unable to locate order and reported most likely obtained order from Doctor after consult with wound nurse. RN I reported she was unsure why she was unable to locate order or treatment on TAR. RN I reported she did not recall when R201's pressure wound was identified. During an interview on 9/26/19 at 1:15 p.m., WCN C reported she was aware of shear injury but not sure when. Reviewed skin sheets and reported after review appeared 7/18/19 WCN C documented on wound. WCN C reported she had been on vacation for two weeks and was informed by nurse on 8/16/19 of worsening wound and notes reflected stage 3 Pressure ulcer. WCN C reported she provided complicated wounds care and provides pressure wound treatments at facility. WCN C reported no one informed her R201's wound was worse on 7/18/19 or 7/23/19(verified not on vacation on those days). WCN C reported had been on vacation from 7/27/19 through 8/12/19 and 8/16/19 through 8/26/19. WCN C reported had thought R201 had an order for [REDACTED]. During an interview on 9/26/19 at 1:50 p.m., RN I reported she was unable to locate skin treatment order for R201 starting 7/6/19 but reported should have had physician order for [REDACTED].>Resident #202 (R202) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R202 was a [AGE] year of female admitted to the facility on [DATE], with recent re-admission 9/13/19, with [DIAGNOSES REDACTED]. The MDS reflected R202 had a BIM (assessment tool) score which indicated her ability to make daily decisions was moderately impaired, and she required two person physical assist with bed mobility, transfers, dressing, toileting, hygiene, bathing and one person physical assist with locomotion on unit, and eating. The MDS reflected R202 did not have any behaviors including no history of refusal of care. During an observation on 9/25/19 at 8:55 a.m., WCN C obtained dressing supplies from the Hall A treatment cart that included normal saline, dakin solution(multiple use bottle), dry dressing, clear wound measuring tool and tape. WCN C entered R202 with supplies and place wound care supplies on towel on soiled bedside table including clear wound measuring tool, Dakin solution and hand sanitizer(multiple use items) that had been directly on top treatment cart. WCN C removed R202 dressing from right inner heel. WCN C provided wound care and by first irrigating wound with normal saline followed by clear wound measurement tool touched on wound(had come directly out of treatment cart. WCN C completed wound care, removed multiple use items including Dakin solution, and hand sanitizer from R202 room and placed directly on Hall A treatment cart then placed in treatment cart. WCN C reported R202 wound developed at the hospital. Resident #203 (R203) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R203 was a [AGE] year of male admitted to the facility on [DATE], with recent re-admission 7/19/19, with [DIAGNOSES REDACTED]. The MDS reflected R203 had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired, and he required two person physical assist with bed mobility, transfers, dressing, toileting, bathing and one person physical assist with locomotion on unit, hygiene and eating. The MDS reflected R203 did not have any behaviors including no history of refusal of care. During an observation and interview on 9/25/19 at 11:27 a.m., WCN C obtained wound care supplies from the Hall A treatment cart including multiple use items including Dakin solution. WCN C entered R203's room with wound care supplies, placed towel on bedside table along with gauze and normal saline. WCN C placed Dakin solution 0.125% directly on R203 bed side table along with hand sanitizer. WCN C reported R203 was admitted to the facility with the pressure wound. R203 had coccyx wound, old dressing removed, normal saline use to irrigate wound, wound bed appears beefy red deep with tunnel noted toward left buttock distal end, WCN C measured wound with gauze package directly on wound and q-tip, wound packed with Dakin soaked gauze, dry dressing and tape. WCN C removed hand sanitizer and Dakin solution placed directly on treatment cart than inside cart without cleaning. Resident #204 (R204) Review of the Minimum Data Set ((MDS) dated [DATE], reflected R204 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS reflected R203 did not have any behaviors including no history of refusal of care. During an observation on 9/25/19 at 12:24 p.m., WCN C entered R204's room with supplies from the Hall A treatment cart including foam dressing, normal saline, triad(directly on R204 bedside table), and gauze and placed in towel on R204's bedside table. WCN C removed soiled dressing from left buttock, irrigated with normal saline, pressure held related to moderate amount bleeding at site. gauze with moderate bleeding. R204 flinch with pain. WCN C cleaned wound with normal saline soaked gauze, placed clear wound measuring tool against clean wound, applied triad ointment to wound, covered with foam dressing. WCN C began to clean up in R204 room and placed Triad ointment and hand sanitizer directly on R204's bedside able then directly on top of treatment cart then placed in the cart.

This citation pertains to MI 408. Based on observation, interview and record review, the facility failed to use the proper amount of staff to perform a mechanical lift transfer for one (Resident #1) of three reviewed for accidents and supervision, resulting in Resident #1 being transferred in an unsafe manner and sustaining a fracture of her right leg. Findings include: Review of the Admission Record, dated 5/28/19 at 2:55 PM, reflected that Resident #1 (R1) was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) for 2/13/19 reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). She was non-ambulatory (did not walk) and required total assistance of two or more people for transfers. On 5/28/19 at 9:27 AM, R1 was observed in bed with her eyes closed and a hoyer sling beneath her. Her bed height was observed to be approximately three feet from the floor with the left side of the bed against the wall. R1's legs were elevated, and her right leg was observed to have a splint in place. R1's Care Plans reflected that she had an Activities of Daily Living (ADL) self-care performance deficit related to impaired mobility, decreased functional ability, generalized weakness, medication side effects, lack of coordination and balance, [MEDICAL CONDITION], hypertension, stroke and femur fracture. The ADL Care Plan was initiated on 5/11/19 and was revised on 5/28/19. An intervention for hoyer lift (mechanical lift) for transfers with two person assistance was initiated on 9/22/16 and was revised on 8/23/18. R1's Kardex (care guide) reflected that she required two people to assist with transfers using a hoyer lift. R1's Behavior Care Plan with an initiated date of 5/23/17 and a revision date of 5/17/19 reflected that R1 requested that staff used the hoyer lift with one person assistance because she did not want to wait for a second staff member. Review of a facility investigation reflected that R1 indicated that she had been put to bed (on 5/8/19) by a Certified Nurse Aide (CNA). In the process, she felt some discomfort in her right knee area. Later in the night, it had been reported to nursing that R1 had experienced pain, and she received pain medication. The following day (5/9/19), R1 was noted to have some redness to her knee area. An x-ray of R1's right knee was ordered and reflected that she had a mildly displaced fracture involving the lateral femoral condyle. Review of a typed statement from CNA C reflected that R1 requested to be put to bed around 7:30 PM on 5/8/19. CNA C was the only person on the hall at the time. When CNA D returned to the floor around 7:50 PM, R1 was insistent on going to bed. CNA C told R1 that she could not put her to bed by herself. CNA C asked CNA D to assist with putting R1 to bed. R1 became upset and did not want CNA D in her room. R1 agreed to have CNA D outside the curtain but not to help get her in bed with the hoyer lift. The statement reflected that CNA C took extra care not to bump R1's feet during the transfer. CNA C stayed in the room after the transfer to clean R1's closet and organize her bedside table. R1 did not report any pain or discomfort while staff were in the room. CNA C had been back in the room prior to the end of her shift to care for R1's roommate. R1 did not report pain or discomfort at that time. During a phone interview on 5/28/19 at 11:11 AM, CNA C reported that they used two CNA's at all times for hoyer lift transfers. CNA C reported assisting R1 to bed the night of 5/8/19, between 7:45 PM to 8:00 PM. R1 had been insisting on being put to bed. CNA C told R1 that CNA K was at lunch and that CNA D would have had to assist with the transfer. R1 did not want CNA D to assist, so CNA C told R1 to wait for CNA K to return. CNA C then had CNA D come in the room, and the privacy curtain was pulled so that R1 could not see CNA D. After CNA C transferred R1 into bed, CNA D left the room with the mechanical lift. CNA C reported being in R1's room for 30 minutes to 45 minutes after the transfer, to change R1 and straighten up her room. According to CNA C, CNA D was in the room helping with the transfer. She stated that she had CNA D stand behind the privacy curtain so that R1 could not see CNA D or deal with her. CNA C reported that she raised R1 in the lift and did not need assistance to turn the lift. When she got R1 over the bed, she lowered her and unhooked the transfer sling from the lift. CNA C had CNA D walk out of the room with the mechanical lift afterwards. When asked what the purpose of the second person was for a mechanical lift transfer, CNA C stated that it was in case something happened. She reported that a second person was not needed to press the lift buttons. According to CNA C, they were supposed to have two people in the room at all times for a lift transfer. CNA C stated that R1 was not very heavy so she was able to turn R1 by herself in the lift. CNA C stated that facility staff received education regarding mechanical lift transfers that consisted of making sure they were using two aides at all times. Basically, that second aide has to stand in the room, not just behind the curtain, according to CNA C. When asked if any other CNA's cared for R1 during her shift on 5/8/19, CNA C stated that herself, CNA D and CNA K were the only ones on second shift that day. CNA D and CNA K stayed for third shift, while CNA C left at 11:00 PM. A typed statement from CNA D reflected that R1 would not allow her to assist CNA C with the mechanical lift transfer. CNA K was on lunch at the time. CNA D waited outside of the privacy curtain while CNA C put R1 to bed. CNA D did not hear R1 complain of any pain or discomfort during the transfer. Around 11:45 PM, R1 put her call light on, and CNA K answered it. CNA D witnessed CNA K and the nurse go to R1's room for approximately ten minutes. CNA K had reported that they were trying to make R1 more comfortable because her foot hurt. During a phone interview on 5/28/19 at 11:42 AM, CNA D reported that she was able to be in the room when a mechanical lift transfer was being done for R1, but she could not do care on her or touch her. CNA D reported that R1 did not like her. To assist with R1's mechanical lift transfer, CNA D reported that she only hooked the transfer sling to the lift, then stood beside the privacy curtain while CNA C completed the transfer. R1 did not have any complaints during the transfer. CNA D then assisted to unhook the transfer sling from the lift and remove the lift from the room. CNA D reported that it was taking CNA C too long in the room, so she went back in. CNA C and R1 were talking, and CNA C was doing other things for R1. CNA D reported that CNA C was in the room a couple more times prior to the end of her shift. CNA D reported that after the transfer to bed on 5/8/19, R1 did not complain about anything until around 12:00 AM to 12:30 AM, when she asked for the nurse due to foot pain. CNA D reported that R1 had never complained of leg, knee or foot pain to her prior to that. CNA D reported that she received education regarding having two people for mechanical lift transfers. She stated, we all know that is just the rule. When asked if anything was being done differently after the education, CNA D stated, no, they were still using two people to assist. During a phone interview on 5/28/19 at 11:55 AM, Licensed Practical Nurse (LPN) [NAME] reported that her shift began at 6:30 PM on 5/8/19. R1 had been complaining of leg pain while LPN [NAME] was in with R1's roommate. When asked what happened, R1 did not know. Around 12:00 AM, R1 had CNA K tell LPN [NAME] that she wanted to talk to her (the nurse). R1 told LPN [NAME] that she could not get comfortable and that her leg hurt. R1 thought it was from when she got put to bed and thought maybe the girl that put her to bed pulled on the mechanical lift sling. According to LPN E, R1 had complained of pain before she laid down. When asked who put her to bed, R1 denied that it was CNA C or CNA D. LPN [NAME] stated that CNA C was the staff member that put R1 to bed on 5/8/19. LPN [NAME] assessed R1's right leg and did not see signs of injury. According to LPN E, R1 was kind of all over the place. She did not know where to pinpoint the pain. During an interview on 5/28/19 at 12:10 PM, LPN H reported that she received report (on 5/9/19) from LPN [NAME] that R1 was very uncomfortable and had pain in her leg. When LPN H assessed R1, her right knee was swollen on the medial side (inner aspect, closer to the midline of the body) and was sore to touch underneath (posterior side). She reported giving R1 Tylenol and getting an order for [REDACTED]. R1 could not recall who it was and did not state how they were rough with her. LPN H stated that she reported to the Director of Nursing (DON) right away. According to LPN H, R1 was not one to complain of pain and did not commonly report pain to her right leg prior to the injury. Review of ER documentation reflected that R1 complained of right knee pain and stated, the staff put me to bed rough last night. According to the significant change in status MDS assessment, with a reference date of 5/16/19, R1 was cognitively intact with a BIMS score of 14. During an interview and observation on 5/28/19 at 12:20 PM, R1 was lying awake in bed. In regards to the fracture to her right leg, R1 reported that one day when getting ready for bed, she yanked on my leg. I yelled. R1 stated that she went to the hospital for three hours, and her leg was wrapped. When asked if she knew who yanked on her leg, R1 reported that it was CNA C, but she didn't do it on purpose. R1 stated, she moved it with a little bit of force. According to R1, it occurred while being transferred to bed. Twice during the conversation, R1 stated that she was not using the mechanical lift at the time. R1 reported that she believed she was standing and reported that her leg hurt right away and forever after. R1 stated that there was not anyone else in the room at the time and reported, whatever she did made me yell. During an interview on 5/28/19 at 12:30 PM, Social Worker (SW) I reported interviewing R1 on 5/10/19. R1 reported CNA C answered her call light, and she wanted to go to bed. R1 reported that it was only CNA C that put her to bed. While she was in the air in the mechanical lift sling, CNA C yanked her leg to turn her, which caused R1 pain. SW I reported that R1 was alert and oriented and even recalled who the other CNA's were on the hall that night (5/8/19). According to SW I, her and LPN J went in to follow-up with R1 at a later time, but R1 was really out of it. During an interview on 5/28/19 at 1:50 PM, DON B reported that one of their CNA's was helping R1 into bed. Later that evening, around midnight, R1 started to report some pain. According to DON B, CNA C did not report anything unusual with the transfer. DON B reported that they did some education on lifts just because we are assuming it happened during the lift transfer. DON B stated that in regards to lift transfers, one person was running the lift, and one person was the stand-by to help guide. Review of R1's Medication Administration Record [REDACTED]. R1 did not utilize the PRN Tylenol during the month of (MONTH) 2019. R1's daily pain level evaluations for (MONTH) 2019 were documented as level one out of ten on 4/7/19, 4/10/19, 4/11/19 and 4/14/19. R1's daily pain evaluation level was documented as zero (no pain) out of ten (worst possible pain) on the remaining days of (MONTH) 2019. R1's (MONTH) 2019 MAR indicated [REDACTED]. On 5/10/19, R1 had a new order for [MEDICATION NAME] 5/325 mg (narcotic pain medication), one tablet by mouth every six hours as needed for pain. R1 received PRN [MEDICATION NAME] 16 times between 5/10/19 and 5/25/19, for pain levels that ranged from two out of ten to ten out of ten. Review of a facility in-service training document, dated for 5/10/19, reflected staff were educated on the following items: total lifts required two people at all times; when turning/moving a resident in a lift, use the handles on the lift, not resident extremities; failure to have two people for transfers increased risk for injury to patient's and staff; not following proper procedures would result in discipline up to termination, upon investigation. A progress note authored by LPN J on 5/17/19 at 11:32 AM, reflected that a care conference was held with R1, her son and facility staff. According to the note, .(R1's first name) at times will request staff utilize the Hoyer lift x1 assist as she does not want to wait for staff to obtain 2nd staff member, including just this morning . During an interview on 5/28/19 at 2:12 PM, LPN J reported that she and SW I followed-up with R1 a few days before her care conference (held on 5/17/19). R1 felt a staff member had pulled on her leg while she was in the mechanical lift. LPN J confirmed that R1 was in fact transferred by one person in the mechanical lift on 5/17/19. LPN J reported that staff member was educated on the spot. An investigation and review of R1's medical record revealed that R1 was transferred via mechanical lift with assistance of only one person on 5/8/19 and 5/17/19. During a phone interview on 5/29/19 at 12:52 PM, CNA K reported that he worked second and third shift on 5/8/19. He reported that R1 did not say anything to him until around third shift. R1 put her call light on and stated that her leg was bothering her. CNA K reported that he tried readjusting R1, and the nurse applied some cream. R1 put her call light on two to three more times before CNA K went home at 3:00 AM. During those times, R1 reported that her leg was aching and bothering her. According to CNA K, there were not any visible signs of injury when he saw R1's right leg. CNA K reported that he was at lunch when R1 was put to bed the evening of 5/8/19. He believed that CNA C and CNA D put R1 to bed that night. According to CNA K, R1 was usually pretty content after she went to bed. CNA K stated that R1 usually had complaints about her back and neck hurting. He could not recall any complaints that R1 usually had about pain or discomfort to her right leg. CNA K reported that two people were needed to perform hoyer lift transfers. He stated that one person would operate the lift, while the other person maneuvered the residents while in the transfer sling. According to the facility policy titled, Lift Equipment with an approval/revision date of 12/7/10, .Employees whose duties include (or may include) lifting, transferring, repositioning or otherwise assisting a resident will be educated on the lift equipment .Staff will be observed for competency in using mechanical lifts annually for adherence to policies and procedures regarding use of equipment and safe lifting techniques .The resident's Care Plan and Care Guides will reflect assistive device requirements . A MaxiMove (mechanical lift) skills checklist, dated for 5/23/19 for CNA C, was provided by the facility. The checklist included nine true and false questions as well as six items in a section for performance evaluation. The performance evaluation items were not marked as Met or Not Met.

Based on observation, interview and record review, the facility failed to ensure adequate positioning in a specialty chair for one (Resident #46) and failed to implement appropriate interventions to prevent further skin damage from a hot liquid burn for one (Resident #12) of two reviewed for quality of care, resulting in improper positioning (R#46) and second [MEDICAL CONDITION](R#12) and the potential for discomfort and further thermal burns. Findings include: Resident #12: Review of the Admission Record, dated for 11/15/18 at 12:37 PM, reflected that Resident #12 (R12) was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated for 8/27/18, reflected that R12 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS) (a cognitive screening tool), which indicated that she had severe cognitive impairments. She was non-ambulatory and required set-up and supervision for meals and assistance of one to two or more people for hygiene, bathing, toilet use, dressing, transfers and bed mobility. A Skin/Wound Progress Note for 11/7/2018 at 8:44 AM reflected, .Resident was in DR (dining room) when (Staff Name) (Certified Nursing Assistant (CNA) P) handed resident hot coffee. The coffee slipped and fell on to residents left forearm and left leg. This nurse immediately assessed and found resident to have deep reddened areas to left forearm measuring 5.5cm (centimeters) x (by) 7cm and left upper hip area measuring 6cm x 15 cm. Cold compresses applied along with [MEDICATION NAME]. (Physician Name) notified and ordered [MEDICATION NAME] cream. Family also notified. Staff to be reeducated on the handling when giving residents coffee. A Skin/Wound Progress Note for 11/9/2018 at 1:54 PM reflected, .Skin/Wound Meeting: (R12) is being monitored for a 11/7/18 L (left) forearm and L Hip burn blisters. Provided staff education when giving hot liquids to resident. Treatment is in place and care plans updated. Will continue to monitor. A Skin/Wound Progress Note for 11/14/2018 at 2:44 PM reflected, .Wound care nurse completed residents treatment to left thigh . Wound Location: Left forearm-closed Wound Location: Left thigh Type: Burn Stage: II (second-degree burn) (a burn that extends beyond the top layer of the skin and into the second layer) Measurement 3.8cm x 4cm < (less than) 0.1 Wound bed: Pink Periwound (area around wound): Intact Drainage: Tan slough Treatment: Clean with normal saline (sic) apply [MEDICATION NAME] cream (sic) cover with [MEDICATION NAME]. Staff education provided in regards to hot liquids . On 11/15/18 at 1:15 PM, hot liquid screens for the past 12 months and all incident reports, including investigation material, for the prior 6 months was requested from Director of Nursing (DON) B. Incident reports for 8/15/18 and 11/7/18 were provided by the facility. The incident report for 11/7/18 did not contain any additional facility documents. A Restorative Dining assessment dated for 8/3/17 was provided. The document reflected .13. Resident is assessed for the ability to handle and consume containers of hot food and beverage (Yes for capable .) . The item was marked Yes. In an interview on 11/16/18 at 1:04 PM, Occupational Therapy Rehab Manager (OTRM) E reported that restorative did hot liquid screens on admission. Speech Therapy or Occupational Therapy got involved if there was a concern from restorative. According to OTRM E, hot liquid screens were a restorative function. She believed that maybe they were done annually. A facility Incident Report for 11/7/18 at 7:10 AM, reflected an event type that was listed as Burn. The nature of the injury was listed as Burn - Thermal to the left hip and left arm. The severity level reflected, Serious Safety Event Level 5 - Moderate Temporary Harm. The report reflected that R12 was in the dining room, and CNA P handed R12 hot coffee. The coffee slipped and fell on to R12's left forearm and left leg. The nurse immediately assessed and found deep reddened areas to the left forearm, measuring 5.5 cm x 7 cm, and to the left hip, measuring 6 cm x 15 cm. Cold compresses were applied along with [MEDICATION NAME]. The report reflected that staff was re-educated on the handling when giving residents coffee. The Investigation and Resolution section of the Incident Report reflected that CNA P immediately applied ice to the areas. It also reflected that the nurse educated the CNA on proper handling of hot liquids. The Activities of Daily Living (ADL) care plan with a revision date of 9/26/18, reflected that R12 had impaired mobility, decreased functional ability, generalized weakness, lack of coordination and balance and lack of safety awareness. The skin impairment care plan with an initiated and revision date of 11/9/18, reflected that R12 had actual skin impairment as evidenced by left hip and left [MEDICAL CONDITION] to spilled coffee. The risk for falls care plan with an initiated date of 8/17/18, reflected that R12 had vision and hearing problems. The care plan interventions were not reflective of measures to prevent [MEDICAL CONDITION] hot liquids. During an interview on 11/15/18 at 3:20 PM, Licensed Practical Nurse (LPN) N reported that R12 did not require lids on her hot liquids. R12 was in the dining room when coffee spilled on her. The staff reported that they went to hand the coffee to R12, and that is when it spilled, when transferring the cup to the resident. LPN N reported that she immediately assessed R12 after staff brought her right back to the hallway after the coffee spill. LPN N reported that there were red areas to the left arm and left leg. She reported that she put washcloths on the areas after removing R12's clothing. According to LPN N, CNA P reported that she poured some cold water on R12 because that is what CNA P was trained to do. LPN N reported that the burn to the left leg blistered later that evening (11/7/18), and the blister remained intact for a couple of days before rupturing. According to LPN N, the initial treatment was to apply Santyl (an ointment that removed dead tissue from wounds) to both areas. LPN N stated that an ABD (absorbent dressing material) was placed on the leg to protect the burn from rubbing on R12's pants. When asked if the facility had a protocol for hot liquid spills, LPN N reported that they usually added lids to cups as an intervention. They did not add that for R12 because it was not due to her (staff was at fault). When asked if the facility had a protocol for treating a burn, LPN N reported that she would have to question that. She stated, I have always been taught to remove the clothing, assess the area and do cold compresses and call the doctor for [MEDICATION NAME] (cream). LPN N stated that she re-educated staff to make sure they put the coffee on the table instead of handing it to R12. When asked how the education was presented to staff, LPN N stated, I verbally told the staff, my staff that was on the floor and second shift when they came on. When asked if that change was added to the care plan, LPN N stated, I'm not sure. When asked how all staff would know to follow those precautions (education on providing R12 with hot liquids), LPN N reported, the staff verbally telling them (other staff members in report). When asked if she could guarantee that all staff members would pass the education along in report, LPN N stated, probably not. R12 was observed eating breakfast in the dining room on 11/16/18 at 8:05 AM. She had water and a cup of coffee without a hot liquid lid. She was feeding herself and was observed reaching to the middle of the table, beyond her cup of coffee, for sugar to add to her cereal. During an interview on 11/16/18 at 9:15 AM, CNA P reported that R12 required a lot of assistance for ADL's but was pretty independent for meals and only required set-up assist. Regarding the coffee spill, CNA P reported that she was passing coffee, and R12 wanted some. I went to hand it to her, she had it, but it slipped out of her hand. It got on her left forearm, a little spot, and her left hip. CNA P reported that when she handed the coffee to R12, it was half on the table and half off the table. She described, in transition, when we both connected, the cup tipped over. CNA P reported that she had a tray that had water and coffee on it. I immediately poured ice water on her, both places According to CNA P, pouring the water on R12 was the first thing that she did. CNA P reported that she checked the areas, and both were a little red. CNA P stated that LPN N spoke to her and basically told me to put it (coffee) on the table first and come in from the right side, make sure the cup is stable. CNA P reported that she had to write a statement of what occurred that same day. She also reported that she signed a paper that day. CNA P stated that everyone was educated, and management followed up with written education. On 11/16/18 at 9:34 AM, the State Agency made another request for any investigation materials for the 11/7/18 incident report, including any witness statements, educations or disciplines. An undated witness statement that did not include a resident name was provided to the State Agency. The statement was signed by CNA P. A typed Re-education with a handwritten date of 11/7/18 was attached to the witness statement. The education was signed by LPN N and CNA P. Staff in-service documents regarding hot liquids were also attached to the witness statement and re-education. A page containing staff signatures was dated for 11/15/18. During an interview on 11/16/18 at 10:06 AM, DON B reported that the witness statement that was provided was written by CNA P on the day of the occurrence (11/7/18). She also reported that the typed re-education was typed by LPN N that same day or the next day (11/7/18 or 11/8/18). According to DON B, LPN N initially gave verbal education, then a typed education the same day (that was inconsistent with LPN N's report of education method). DON B reported that the facility's process was for the nurse to give verbal education, then a typed education that the staff member signed. DON B reported that the facility realized they were deficient in that, and they typed education yesterday (11/15/18). When queried as to why the additional documents were not initially provided to the State Agency, DON B reported that the witness statement and written education were in the fall stuff. During a follow-up interview by phone on 11/16/18 at 12:36 PM, LPN N reported that she did verbal education with all staff, then before CNA P left (for the day), she did a written education for her. She offered that CNA P also had a written statement. When asked why she did not report that information to the State Agency in her interview the day prior, LPN N reported it was because she forgot. She did not recall the contents of CNA P's written statement but reported that it should have contained a resident name and a date. During an observation and interview on 11/16/18 at 1:15 PM, R12 stated that her leg was not really painful but did bother her sometimes. She stated that she could not recall what happened. Her left arm was not observed to have any apparent injury upon on observation. Registered Nurse (RN) EE provided wound care to the burn on R12's left hip/thigh region. A red area was observed to the left hip, with what appeared to have ruptured blisters. RN EE reported that the wound bed was previously blistered, but the blisters had ruptured. RN EE had removed the old dressing prior to the state agency's observation and reported that drainage from the burn was serosanguinous (thin, blood-tinged drainage). Review of facility temperature logs reflected that a coffee temperature was not obtained on 11/7/18. Coffee temperatures that were recorded for 11/5/18 and 11/8/18 were documented as 177 degrees Fahrenheit. According to the State Agency Department of Community Health: Scalding Injuries Caused By Excessive Hot Water, Food and Hot Beverage Temperatures (Revised (MONTH) 5, 2008), it can take less than 1 second for a second degree burn to develop in water that is 150 degrees Fahrenheit. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin [MEDICAL CONDITION] depth more quickly. According to the Burn Institute, first aid [MEDICAL CONDITION] the following steps, stop the burning process, remove the source of heat .remove all burned clothing .pour cool water over burned area, keep pouring the cool water for at least 3-5 minutes, never put ice or cold water on a burn as it lowers the body temperature and can make the burn worse .do not apply ointments, creams, or salves to wound .cover burn with a soft, clean, dry dressing, bandage or sheet. Seek medical attention as soon as possible. (www.burninstitue.org/fbp/factsheets/firstaid.html) Review of Textbook for Basic Nursing, 2008, by Caroline Bunker Rosdahl, [NAME] T. Kowalski, indicates emergency first aid for the treatment of [REDACTED].flood the area with cool water. Resident #46 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #46 (R#46) was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed R46 scored 2 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further record review revealed R46 started receiving hospice care in (MONTH) of (YEAR). On 11/14/18 at approximately 9:30 AM, during the initial tour Resident #46 (R#46) was observed in his room sitting in a specialized wheelchair leaning to the left side, there were no pillows or positioning devices used to assist R#46 to sit upright. R#46 was observed the same day in the main dining room during the lunch meal to be sitting in the same chair leaning on his left side with no pillows or devices to assist with his positioning. On 11/15/18 at 9:15 AM R#46 was observed sitting in his specialized wheelchair leaning to the left side without any pillows or positioning devices. On 11/15/2018 at approximately 10:00 am, during an interview with the Director of Nursing (DON) B she reported that R#46 was able to sit straight in his specialized wheelchair with the use of pillows to assist with his positioning. DON B further reported that hospice ordered the wheelchair. When queried if R#46 had been evaluated by the therapy department for positioning, DON B reported No, he is hospice. When queried why R#46 had not had the pillows in place to assist with his positioning on 11/14/18 and 11/15/18, DON B offered no explanation.

Based on observation, interview and record review, that facility failed to prevent hot [MEDICAL CONDITION] implement appropriate interventions to prevent further hot [MEDICAL CONDITION] one (Resident #12) of three reviewed for accidents, resulting in second [MEDICAL CONDITION] the potential for further thermal burns. Findings include: Review of the Admission Record, dated for 11/15/18 at 12:37 PM, reflected that Resident #12 (R12) was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated for 8/27/18, reflected that R12 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS) (a cognitive screening tool), which indicated that she had severe cognitive impairments. She was non-ambulatory and required set-up and supervision for meals and assistance of one to two or more people for hygiene, bathing, toilet use, dressing, transfers and bed mobility. A Skin/Wound Progress Note for 11/7/2018 at 8:44 AM reflected, .Resident was in DR (dining room) when (Staff Name) (Certified Nursing Assistant (CNA) P) handed resident hot coffee. The coffee slipped and fell on to residents left forearm and left leg. This nurse immediately assessed and found resident to have deep reddened areas to left forearm measuring 5.5cm (centimeters) x (by) 7cm and left upper hip area measuring 6cm x 15 cm. Cold compresses applied along with [MEDICATION NAME]. (Physician Name) notified and ordered [MEDICATION NAME] cream. Family also notified. Staff to be reeducated on the handling when giving residents coffee. A Skin/Wound Progress Note for 11/9/2018 at 1:54 PM reflected, .Skin/Wound Meeting: (R12) is being monitored for a 11/7/18 L (left) forearm and L Hip burn blisters. Provided staff education when giving hot liquids to resident. Treatment is in place and care plans updated. Will continue to monitor. A Skin/Wound Progress Note for 11/14/2018 at 2:44 PM reflected, .Wound care nurse completed residents treatment to left thigh . Wound Location: Left forearm-closed Wound Location: Left thigh Type: Burn Stage: II (second-degree burn) (a burn that extends beyond the top layer of the skin and into the second layer) Measurement 3.8cm x 4cm < (less than) 0.1 Wound bed: Pink Periwound (area around wound): Intact Drainage: Tan slough Treatment: Clean with normal saline (sic) apply [MEDICATION NAME] cream (sic) cover with [MEDICATION NAME]. Staff education provided in regards to hot liquids . On 11/15/18 at 1:15 PM, hot liquid screens for the past 12 months and all incident reports, including investigation material, for the prior 6 months was requested from Director of Nursing (DON) B. Incident reports for 8/15/18 and 11/7/18 were provided by the facility. The incident report for 11/7/18 did not contain any additional facility documents. A Restorative Dining assessment dated for 8/3/17 was provided. The document reflected .13. Resident is assessed for the ability to handle and consume containers of hot food and beverage (Yes for capable .) . The item was marked Yes. In an interview on 11/16/18 at 1:04 PM, Occupational Therapy Rehab Manager (OTRM) E reported that restorative did hot liquid screens on admission. Speech Therapy or Occupational Therapy got involved if there was a concern from restorative. According to OTRM E, hot liquid screens were a restorative function. She believed that maybe they were done annually. A facility Incident Report for 11/7/18 at 7:10 AM, reflected an event type that was listed as Burn. The nature of the injury was listed as Burn - Thermal to the left hip and left arm. The severity level reflected, Serious Safety Event Level 5 - Moderate Temporary Harm. The report reflected that R12 was in the dining room, and CNA P handed R12 hot coffee. The coffee slipped and fell on to R12's left forearm and left leg. The nurse immediately assessed and found deep reddened areas to the left forearm, measuring 5.5 cm x 7 cm, and to the left hip, measuring 6 cm x 15 cm. Cold compresses were applied along with [MEDICATION NAME]. The report reflected that staff was re-educated on the handling when giving residents coffee. The Investigation and Resolution section of the Incident Report reflected that CNA P immediately applied ice to the areas. It also reflected that the nurse educated the CNA on proper handling of hot liquids. The Activities of Daily Living (ADL) care plan with a revision date of 9/26/18, reflected that R12 had impaired mobility, decreased functional ability, generalized weakness, lack of coordination and balance and lack of safety awareness. The skin impairment care plan with an initiated and revision date of 11/9/18, reflected that R12 had actual skin impairment as evidenced by left hip and left [MEDICAL CONDITION] to spilled coffee. The risk for falls care plan with an initiated date of 8/17/18, reflected that R12 had vision and hearing problems. The care plan interventions were not reflective of measures to prevent [MEDICAL CONDITION] hot liquids. During an interview on 11/15/18 at 3:20 PM, Licensed Practical Nurse (LPN) N reported that R12 did not require lids on her hot liquids. R12 was in the dining room when coffee spilled on her. The staff reported that they went to hand the coffee to R12, and that is when it spilled, when transferring the cup to the resident. LPN N reported that she immediately assessed R12 after staff brought her right back to the hallway after the coffee spill. LPN N reported that there were red areas to the left arm and left leg. She reported that she put washcloths on the areas after removing R12's clothing. According to LPN N, CNA P reported that she poured some cold water on R12 because that is what CNA P was trained to do. LPN N reported that the burn to the left leg blistered later that evening (11/7/18), and the blister remained intact for a couple of days before rupturing. According to LPN N, the initial treatment was to apply Santyl (an ointment that removed dead tissue from wounds) to both areas. LPN N stated that an ABD (absorbent dressing material) was placed on the leg to protect the burn from rubbing on R12's pants. When asked if the facility had a protocol for hot liquid spills, LPN N reported that they usually added lids to cups as an intervention. They did not add that for R12 because it was not due to her (staff was at fault). When asked if the facility had a protocol for treating a burn, LPN N reported that she would have to question that. She stated, I have always been taught to remove the clothing, assess the area and do cold compresses and call the doctor for [MEDICATION NAME] (cream). LPN N stated that she re-educated staff to make sure they put the coffee on the table instead of handing it to R12. When asked how the education was presented to staff, LPN N stated, I verbally told the staff, my staff that was on the floor and second shift when they came on. When asked if that change was added to the care plan, LPN N stated, I'm not sure. When asked how all staff would know to follow those precautions (education on providing R12 with hot liquids), LPN N reported, the staff verbally telling them (other staff members in report). When asked if she could guarantee that all staff members would pass the education along in report, LPN N stated, probably not. R12 was observed eating breakfast in the dining room on 11/16/18 at 8:05 AM. She had water and a cup of coffee without a hot liquid lid. She was feeding herself and was observed reaching to the middle of the table, beyond her cup of coffee, for sugar to add to her cereal. During an interview on 11/16/18 at 9:15 AM, CNA P reported that R12 required a lot of assistance for ADL's but was pretty independent for meals and only required set-up assist. Regarding the coffee spill, CNA P reported that she was passing coffee, and R12 wanted some. I went to hand it to her, she had it, but it slipped out of her hand. It got on her left forearm, a little spot, and her left hip. CNA P reported that when she handed the coffee to R12, it was half on the table and half off the table. She described, in transition, when we both connected, the cup tipped over. CNA P reported that she had a tray that had water and coffee on it. I immediately poured ice water on her, both places According to CNA P, pouring the water on R12 was the first thing that she did. CNA P reported that she checked the areas, and both were a little red. CNA P stated that LPN N spoke to her and basically told me to put it (coffee) on the table first and come in from the right side, make sure the cup is stable. CNA P reported that she had to write a statement of what occurred that same day. She also reported that she signed a paper that day. CNA P stated that everyone was educated, and management followed up with written education. On 11/16/18 at 9:34 AM, the State Agency made another request for any investigation materials for the 11/7/18 incident report, including any witness statements, educations or disciplines. An undated witness statement that did not include a resident name was provided to the State Agency. The statement was signed by CNA P. A typed Re-education with a handwritten date of 11/7/18 was attached to the witness statement. The education was signed by LPN N and CNA P. Staff in-service documents regarding hot liquids were also attached to the witness statement and re-education. A page containing staff signatures was dated for 11/15/18. During an interview on 11/16/18 at 10:06 AM, DON B reported that the witness statement that was provided was written by CNA P on the day of the occurrence (11/7/18). She also reported that the typed re-education was typed by LPN N that same day or the next day (11/7/18 or 11/8/18). According to DON B, LPN N initially gave verbal education, then a typed education the same day (that was inconsistent with LPN N's report of education method). DON B reported that the facility's process was for the nurse to give verbal education, then a typed education that the staff member signed. DON B reported that the facility realized they were deficient in that, and they typed education yesterday (11/15/18). When queried as to why the additional documents were not initially provided to the State Agency, DON B reported that the witness statement and written education were in the fall stuff. During a follow-up interview by phone on 11/16/18 at 12:36 PM, LPN N reported that she did verbal education with all staff, then before CNA P left (for the day), she did a written education for her. She offered that CNA P also had a written statement. When asked why she did not report that information to the State Agency in her interview the day prior, LPN N reported it was because she forgot. She did not recall the contents of CNA P's written statement but reported that it should have contained a resident name and a date. During an observation and interview on 11/16/18 at 1:15 PM, R12 stated that her leg was not really painful but did bother her sometimes. She stated that she could not recall what happened. Her left arm was not observed to have any apparent injury upon on observation. Registered Nurse (RN) EE provided wound care to the burn on R12's left hip/thigh region. A red area was observed to the left hip, with what appeared to have ruptured blisters. RN EE reported that the wound bed was previously blistered, but the blisters had ruptured. RN EE had removed the old dressing prior to the state agency's observation and reported that drainage from the burn was serosanguinous (thin, blood-tinged drainage). Review of facility temperature logs reflected that a coffee temperature was not obtained on 11/7/18. Coffee temperatures that were recorded for 11/5/18 and 11/8/18 were documented as 177 degrees Fahrenheit. According to the State Agency Department of Community Health: Scalding Injuries Caused By Excessive Hot Water, Food and Hot Beverage Temperatures (Revised (MONTH) 5, 2008), it can take less than 1 second for a second degree burn to develop in water that is 150 degrees Fahrenheit. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin [MEDICAL CONDITION] depth more quickly. According to the Burn Institute, first aid [MEDICAL CONDITION] the following steps, stop the burning process, remove the source of heat .remove all burned clothing .pour cool water over burned area, keep pouring the cool water for at least 3-5 minutes, never put ice or cold water on a burn as it lowers the body temperature and can make the burn worse .do not apply ointments, creams, or salves to wound .cover burn with a soft, clean, dry dressing, bandage or sheet. Seek medical attention as soon as possible. (www.burninstitue.org/fbp/factsheets/firstaid.html) Review of Textbook for Basic Nursing, 2008, by(NAME)Bunker Rosdahl,(NAME)T. Kowalski, indicates emergency first aid for the treatment of [REDACTED].flood the area with cool water.

Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, 3.) ensure that those interventions were functional and in place; and 4.) provide timely treatment for 2 of 9 sampled residents (Resident #6 and #96) reviewed for falls and accidents from a total sample of 23 residents, resulting in Resident #6's fall with left hip fracture on 5/25/16 and delay in instituting interventions to prevent future burns to resident #96. Findings include: According to the facility Fall Policy, dated July 19, 2010, reflected under Policy: To provide preventative measures and guidelines relative to the safety of all residents at (named facility) and to maintain a safe environment in accordance with state and federal regulations the following policy has been adopted. Process: 1. Upon admission a Morse fall risk assessment is completed for all resident to establish a level of risk for future falls. Based upon the risk score, the higher the number the greater the risk, preventative interventions are put in place to assist in keeping the resident safe .Fall interventions may include but are not limited to: Bed bolsters, fall mats, hourly checks, 30 minute checks, 15 minute checks, non-skid strips, seat belts, lap buddies, belt restraints, w/c anti-tippers, anti-rollback devices, extremity pads, low beds, and extended brake handles. 2. MDS Nurses complete a fall risk assessment on a quarterly and as needed basis if a resident shows a decline. A fall risk re-assessment is completed if a resident has an actual fall. Interventions are again updated based on the residents fall risk score .6. Residents experiencing a fall, injury, or other patient event have an incident report completed .If the incident is a fall the report includes a post fall nursing assessment, a post-fall problem analysis, a fall risk re-assessment, and a 72 hour follow up form to document the resident's condition over the first 72 hours immediately following the fall .10. The Fall Management Professional maintains a fall tracking form for each individual resident to monitor for trends in time, location, staff, or environmental factors .12. Interventions will be reviewed within six days of being instituted to ensure effectiveness. According to the facility Physician Notification policy and procedure, dated 5/28/14, reflected under Background: All residents of (named facility) will be provided with appropriate, timely, and concise treatment for [REDACTED].Policy: 1. Any change in status or condition, signs and symptoms of infection, change in behavior, refusal of care, non-compliance with care or other resident issues will be directed to the nurse in charge. All employees of (named facility) are expected to comply with this and report to the nurse, including non-nursing departments. 2. The nurse in charge of the resident will initiate a notification to the physician in person, by fax, or by phone within 1-2 hours of being notified of the residents change .4. The muse should document in the nurses notes and on the report sheet the time the physician was notified, what the residents issue was, and the requested interventions . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #6 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #6's had a BIM (assessment tool) score of 0 which indicated his ability to make daily decisions was severely impaired, easily distracted, out of touch or difficulty following what was said types of behavior continuously present. Resident #6 required one person physical assist with extensive assistance for locomotion on unit, bathing, transfers, toileting, hygiene and dressing. In an observation, during the initial facility tour on 6/7/16 at 3:20 p.m. LPN (Licensed Practical Nurse) AA reported Resident #6 had a fall at the facility that resulted in a left hip fracture that required surgical intervention. Resident #6 was observed in a wheelchair with a lift sling under resident #6 in his room located at the foot of the bed with no call light in reach. Resident #6's bed was located with the head of the bed against the wall with no staff in the room at that time. LPN AA reported prior to the fall Resident #6 started to decline physically and was ambulating and fell in the hall. LPN AA reported Resident #6 currently required total assistance with care including mechanical lift for transfers. In an interview on 6/8/16 at 4:00 p.m. the DON (Director of Nursing) B reported she did not reported Resident #6's fall on 6/25/16 that resulted in a left hip fracture because it was a fall and they did an investigation. DON B reported Resident #6 was not able to say what happened after the fall and it was unwitnessed. This surveyor asked for the complete investigation at that time. According to the Nursing Progress Note, dated 5/25/16 at 7:06 p.m., reflected Resident ambulated from chair and fell on C hall. Neuro checks were WNL. Resident (#6) complained of left leg pain and groin pain. Left leg was externally rotated. No apparent bumps or skin tears. (Named doctor) notified. Received orders for x-ray of left hip and pelvis. X ray ordered. Left message with resident POA and talked with Residents guardian. Pain medicine given to resident. New order for 15 min. checks. Signed by RN (Registered Nurse) FF. According to the next Nursing Progress Notes, dated 5/26/16 at 3:31 a.m., reflected Received x-ray results showing no definite evidence of fracture or dislocation in either hip. Results will be faxed to (named doctor) in the morning. The note was signed by RN FF. No additional Nursing Progress Notes were noted between the time of the fall until an entry at 9:28 a.m. that reflected, This nurse went in to give resident his medication around 8a and do neuro checks as ordered. Resident's (#6) pupils were unequal but reactive. Left pupil 2 mm and right was a 3 mm. On ROM of left leg, resident refused to move leg. I went to have another nurse to also evaluate (named LPN C). Resident had facial grimacing and would state ouch. T-98.5 BP-103/58 P-107 R-21. (Named doctor) office called in new findings and ordered to have him sent to (named hospital) for evaluation. Son David called to update. Resident did have an X-ray of pelvic region and bilateral hips with no definite evidence of fracture or dislocation. The note was signed by LPN E. According to the facility Fracture Risk Assessment Form for Nursing Facility Residents, dated 1/22/16, reflected Resident #6 had a score of 5 which indicated Resident #6 was at risk for fracture. According to the facility Morse Fall Assessment, prior to 5/26/16 fall, reflected Resident #6 had a score of 80 which indicated he had a high risk of falling. Review of the facility Safety Event & Risk Management Reporting, dated for 12/29/15 trough 5/25/16, reflected Resident #6 had 6 falls prior to the 5/25/16 fall that included 3 falls in the hallway with at least one incident that required hospitalization related to a head injury. According to the facility Fall Care Plan, dated 5/3/16, reflected Resident #6 was at high risk for falls related to a history of falls, impaired mobility, generalized weakness, decreased functional ability, impaired safety awareness, lack of coordination and balance, medication side effects, generalized pain and altered mental status. The Fall Care Plan reflected, Resident will not sustain serious injury through the review date. Date Initiated: 5/3/16. The Fall Care Plan reflected interventions that included; bed against the wall, call light within reach, and fall risk resident not to be left alone in their rooms or bathrooms. Review of the facility Safety Event & Risk Management Reporting, dated 5/25/16 @ 7:00 p.m. reflected Resident #6 had an unwitnessed fall after ambulating from a wheelchair in C hall. The report reflected under Brief Factual Description - Resident ambulated from chair and fell on C hall. Neuro checks were WNL. Resident complained of left leg pain and groin pain. Left leg was externally rotated . The report reflected Resident #6 was at risk for falls with a Morse Score of 80 prior to the fall on 5/25/16. In an interview on 6/8/16 at 6:23 p.m. LPN C reported she had completed the investigation on Resident #6 for the 5/25/16 fall that resulted in the left hip fracture. LPN C reported she contacted RN FF via the telephone that day (6/8/16) and questioned RN FF about the incident. LPN C reported that RN FF informed LPN C over the phone that RN FF had seen Resident #6 out of the corner of her eye fall to the ground. LPN C reported the report or investigation did not reflect that. In an interview on 6/8/16 at 7:19 p.m. RN FF reported she was Resident #6's nurse on 5/25/16 when Resident #6 fell at 7:00 p.m. RN FF reported she was sitting at the nurse station when out of the corner of her eye she saw Resident #6 on the C hall. RN FF reported it was a shadow type view, out of the corner of her eye, of resident #6 that she had and did not consider it a witnessed fall. RN FF reported Resident #6's fall on 5/25/16 was an unwitnessed fall. RN FF reported there was no one else in the area at the time of the fall. RN FF reported she approached Resident #6 and he was positioned more on his right side and back and complaining of left hip and groin pain. RN FF reported Resident #6 was holding left groin and Resident #6's left leg was turned in. RN FF reported she did a neurological assessment because the fall was not witnessed that included bilateral hand grasps, pupil response, vitals, ROM (range of motion). RN FF reported Resident #6 did not want to bend left leg at all at any joints including the hip and Resident #6 was moaning and grimacing and said his left leg hurt. RN FF reported Resident #6 was transferred from the floor to the wheelchair with the use of a mechanical lift with assistance of 2 other staff members. RN FF reported Resident #6 continued to complain of pain during the transfer and was than taken to his room in B Hall and transferred to the bed with the use of the mechanical lift. RN FF reported she contacted the physician while the CNA's transferred Resident #6 into his bed from the wheelchair and received an order for [REDACTED].#6 was still in bed. RN FF reported Resident #6 was complaining of pain in left hip area with laying position and decision was made to transfer resident #6 from bed to the wheelchair with use of the mechanical lift. RN FF reported Resident #6 appeared more comfortable in a sitting position. RN FF reported she administered Resident #6 his scheduled pain medications(1000 mg of Tylenol and 50 mg of Tramadol) at about 8:00 p.m. RN FF reported Resident #6 remained in the wheelchair by the nurses station most of the night. RN FF reported she did frequent neurological checks every 15 minutes times 4 then every 30 minutes and as documented on neurological flowsheet. RN FF reported she completed a ROM assessment with each neuro check as well and reported Resident #6 would not allow her to move the left leg at all related to increased pain. RN FF reported X-ray arrived at about 11:00 p.m. and Resident #6 transferred from the wheelchair to the bed for the X-ray with the lift and back to the wheelchair after because Resident #6 complained of pain while in bed. RN FF reported she did not call physician again after the first call at about 7:30 p.m. initially because Resident #6 only complained of pain with ROM. RN FF reported she did not give Resident #6 any additional pain medication during her shift or did not document any pain assessments. RN FF denied offering any other comfort measures for Resident #6. RN FF reported she completed the Incident and Accident report and that is why she did not complete a witness statement and reported that 15 minute checks were immediately initiated as an intervention after the fall. RN FF reported Resident #6 had been on 15 minute checks prior to fall related to history of falls. RN FF reported she received the negative X-ray results at about 3:30 a.m. on 5/26/16. RN FF reported she continued to perform neurological checks, vitals and ROM at the same time as the documented neurological checks. RN FF reported Resident #6 would not allow her to perform ROM on the left lower extremity at all related to increased pain and did not report to the physician because she thought Resident #6 was just sore from fall because X-ray report came back negative for fractures. RN FF reviewed the Nurse Progress Notes, Medication Administration and Treatment Administration records for 5/25/1 through 5/26/16 and verified she did not document Resident #6's assessments including pain assessments after the fall note at 7:06 p.m. on 5/25/16. RN FF reported she gave report to LPN E on morning shift. According to to facility 15 minute check documentation, dated 5/1/16 through 5/31/16, reflected Resident #6 had documented 15 minute checks 5/1/16 through 5/26/16 at 1:45 p.m. The 15 minute check documentation reflected a check at 2:15 p.m. on 5/25/16 and the next documented 15 minute check occurred at 6:48 p.m followed 9:53 p.m. and 2:57 a.m. on 5/26/16. The 15 minute checks documentation had several missing 15 checks noted both prior to the 5/25/16 fall. According to the Radiology Report, dated stamped as faxed the the facility on 5/25/16 at 10:20 p.m., reflected there was no definite evidence of fracture or dislocation in either hip. Review of the facility Neurological Flowsheet, dated 5/25/16 at 7:00 p.m. through 5/26/16, reflected RN FF performed neurological assessments that included moving all extremities with no noted documentation of weakness or pain with ROM. Review of the facility Post Fall Nursing Assessment, dated 5/25/16, reflected Resident #6 was noted to have left leg outward rotation after the fall and before moving the resident. The assessment indicated that joint pain with palpation and ROM with assessed and reflected, left leg painful .unable to bear wt. r/t pain in left leg. Review of the MAR (Medication Administration Record), dated 5/25/16 through 5/26/16 reflected Resident #6 received scheduled pain medications before bed and upon rising. No additional as needed pain medications were administered. In an interview on 6/9/16 at 10:00 a.m. LPN C reported she contacted the Radiology department and verified the Xray results for Resident #6 from 5/25/16 were faxed to the facility at 10:20 p.m. LPN C reported she would have expected the nurse to call the physician at that time if Resident #6 was still having pain with ROM. In an interview on 6/9/16 at 10:40 a.m. LPN E reported she received morning reported from RN FF at about 6:30 a.m. on 5/26/16. LPN E reported she was told Resident #6 had a fall on C hall after Resident #6 stood up from the wheelchair and fell to the floor. LPN E reported she was informed the xray report was negative and that Resident #6 slept though the night un-agitated. LPN E reported when she first assessed Resident #6 at about 8:00 a.m. he was in bed moaning and not normal and pupils unequal. LPN E reported Resident #6 would not allow a ROM assessment to the left leg at all including the knee. LPN E informed the unit manager LPN C. LPN E reported she administered Resident #6 his morning scheduled pain medication and called the physician and received an order to send Resident #6 to the hospital for evaluation. LPN E reported Resident #6 was transported to the hospital by ambulance at 9:28 a.m. on 5/26/16. Review of the Radiology Report, dated 5/26/16 at 10:05 a.m. reflected Resident #6 had a positive left intertrochanteric fracture Review of the hospital Operative Report, dated 6/27/16, reflected Resident #6 has a Smith and Nephew lift hip compression screw pinning on 5/27/16 related to a left intertrochanteric hip fracture. In an interview on 6/9/16 at 2:05 p.m. the DON B reported it would be her expectation that the nursing staff would reported a change in condition to the physician timely. DON B reported that after the nurse received the negative X-ray back for Resident #6 on 2/25/16 and Resident #6 continued to complain of pain with ROM that the DON B would expect to see documentation of the assessments completed and would expect a call to be placed to the physician related to the continued pain. In an interview on 6/9/16 at 4:10 p.m. CNA (Certified Nurse Aid) S reported he worked the night shift on 5/25/16 through 5/26/16 when Resident #6 fell . CNA S reported he did not witness the fall because he was caring for another resident but he cared for Resident #6 that evening. CNA S reported Resident #6 was not tolerating being in that evening. CNA S reported he repeatedly kept hanging his left leg over the edge of the bed and moaning like he was in pain. CNA S reported he know something was wrong with Resident #6 because he had never seen Resident #6 act like that. CNA S reported Resident #6's behaviors to RN FF and assisted Resident #6 with transfers that night with mechanical lift. CNA S was unsure of the times related to the transfers. ( ) Based on the Minimum Data Set (MDS) Assessment, dated 5/28/16, Resident #96 was an [AGE] year old severely cognitively impaired female whose [DIAGNOSES REDACTED]. The above MDS reflected Resident #96 required staff assistance for transfers, ambulation, dressing and toileting and staff supervision/cueing for eating. The Brief Interview for Mental Status (BIMS) on the above MDS was 5 out a possible 15 indicating severe cognitive impairment. Based on the Ophthalmology (eye physician) consultation, dated 11/2/15, Resident #96 had end-stage macular degeneration in both eyes and had hand motion vision (only able to see hand motions, no clear vision). The Optometrist's assessment, dated 4/22/16, reflected severe wet macular degeneration in both eyes. The exam was unable to determine if Resident #96 was able to see in adequate light. Based on the Safety Event & Management Reporting, dated 6/3/16 by Licensed Practical Nurse (LPN) F, Resident #96 was in the dining room for the evening meal at 6:15 PM on 6/2/16 and grabbed a pot of coffee from the table and attempted to pour some into a drinking glass she was holding in her hand. Resident #96 missed the glass and poured the coffee onto her leg. Resident #96 yelled out and LPN F took her to her room to assess the leg. The left inner thigh was found to have redness and a cold compress was applied. No interventions to prevent future burn injuries were listed on the report. There was no detailed description of the wound on the report or in the nursing notes. On 6/10/16 at 12:18 PM LPN F was interviewed by telephone. LPN F stated she had witnessed Resident #96 grab a pot of coffee off the table in the dining room and attempt to pour it into a drinking glass the Resident was holding. LPN F stated she was unable to get to Resident #96 before the Resident poured the coffee onto her leg, missing the glass in her hand. LPN F stated Resident #96 was immediately taken to her room and assessed for injury. LPN F stated Resident #96's left thigh was a little red and a cold cloth and cold pack was applied. LPN F stated Resident #96 was assessed later in the shift and the left leg was still red without blisters. LPN F stated the physician was not notified as there were no blisters. LPN F stated she worked the next day on a different unit and asked the nurse caring for Resident #96 (LPN E) how the Resident's thigh was and was told blisters had developed. LPN F stated she observed the wound and there were eight small fluid filled blisters in a 2 inch by 2 inch area (second degree burn) and the whole reddened area (first degree burn) of the burn was approximately 6 inches by 6 inches. LPN F stated she then notified the physician and received orders for the Silvadene cream treatment. LPN F stated she did not document the condition or size of the wound on 6/2/16 or 6/3/16. LPN F stated she did not institute or recommend any interventions to prevent future burn injuries for Resident #96. No assessment of the Resident's ability to handle hot liquids was done. On 6/5/16 at 6:48 PM the Nurse's Notes written by LPN E reflected Resident was in DR (dining room) and was drinking hot chocolate when she spilled some in her lap. No new redness. Will ask (Certified Dietary Manager J's name) in dietary to place resident on a cup with lid for precautions. LPN E was interviewed on 6/10/16 at 11:00 AM and stated the hot chocolate Resident #96 had spilled on 6/5/16 was lukewarm as the CNAs had added ice to the hot drink before giving it to the Resident. LPN E stated the hot chocolate spill was near the top of the left thigh above the burn from 6/2/16. LPN E stated she talked to Certified Dietary Manager (CDM) J the next day to get cups with lids for Resident #96. LPN E stated she did not fill out a Safety Event & Management Report as there was no hot liquid spill on Resident #96's thigh. No assessment of the Resident's ability to handle hot liquids was done. The intervention of the cup with a lid was not started until 6/6/16. On 6/10/16 at 12:00 PM Unit Manager (UM) LPN C stated the treatment of [REDACTED]. UM LPN C confirmed there were no interventions added or hot liquid assessments done after the 6/2/16 burn injury. Review of orders in the electronic medical record reflected the order Resident to have cups with lids at all meals to prevent burns was not added until 6/10/16 at 10:11 AM by Director of Nursing B. Review of Resident #96's care plan for potential nutritional problems, dated 9/8/15 and revised 6/1/16, reflected the intervention Provide sippy cups (a two handled cup with a lid and drinking spout) for all beverages was initiated on 6/10/16. On 6/10/16 at 11:25 AM CDM J was interviewed and stated LPN E had called her on the telephone on 6/6/16 with the request for lids on Resident #96's cups. CDM J stated she entered the instructions on the Resident's meal tray card as she was speaking to LPN E. Observation of the order in the electronic order system and the printed copy reflected the order was entered at 1:23 PM on 6/6/16, two meals after the second hot liquid spill. CDM J stated she was not responsible for hot liquid safety assessments for the residents. CDM J stated insulated coffee pots and water pitchers were put on the tables in the dining room by the Ancillary Aides and if no one drank coffee at the table the aides don't put a carafe on the table. CDM J stated there was no relationship between the tables that had coffee pots on them and the cognitive status of the residents seated at the tables. On 6/10/16 at 9:50 AM Restorative Manager (IRM) Registered Nurse (RN) I was interviewed and stated each resident's ability to handle hot liquids was assessed on admission by the Restorative staff. IRM RN I stated additional assessments were done if staff requested them or the residents could be assessed by the Therapy Department. IRM RN I stated she was aware of Resident #96's burn from discussions in the morning meeting but was not asked to complete an assessment for hot liquid handling for Resident #96. IRM RN I stated Resident #96 was not in the restorative dining program. On the same date at 11:58 AM Restorative CNAs M and N stated hot liquid handling assessments were completed for residents on admission and when requested. Both CNAs stated they had not been asked to perform an assessment for Resident #96. On 6/10/16 at 11:20 AM the dining room was observed prior to the lunch meal. Twelve tables were set up with an insulated pitcher of coffee and a pitcher of water in the center. The three tables along the window area in the assisted dining area did not have coffee pots. The table where Resident #96 sat did not have either coffee or water on the table. At 11:42 AM on the same day Ancillary Aide (AA) K stated the table Resident #96 sat at had had coffee and water pitchers and the Resident was able to reach the pitchers. AA K stated the pitchers had been removed recently as Resident #96 was supposed to have thickened liquids and the pitchers contained regular consistency coffee and water. AA K stated she was not aware Resident #96 had sustained a burn injury in the dining room. On 6/10/16 at 3:10 PM CNA O stated she had seen Resident #96 grab the coffee container on the dining room table and pour from it. CNA O stated she's not very good at it that's why we try to stop her. During the same interview CNA DD stated that's a problem with carafes and pitchers on the tables. At 3:44 PM on the same day CNA P stated Resident #96 did reach out and grab things on the table whether they were hers or not. On 6/8/16 at approximately 1:00 PM during temperature testing of a resident meal tray the coffee in a covered insulated cup was 147 degrees Farenheit (F). Based on the U. S. Consumer Product Safety Commission Tap Water Safety Alert, undated, a second degree burn occurs with 3 seconds of contact of a hot liquid at 140 degrees F and less than 1 second at 150 degrees F. On 6/10/16 at 11:52 AM Resident #96 was observed seated at her table in the dining room. There was a coffee cup without a lid at her place and CNA EE handed a glass of thickened water without a lid to Resident #96 who drank from it independently. The intervention of lids on drinking cups was not followed. ( ) On 6/9/16 at 9:30 a.m., the burn on Resident #96's inner left thigh was observed while she was in her bed in her room, assisted by Licensed Practical Nurse (LPN) N. The area was approximately 3 inches below the groin, and the nearly rectangular-shaped area was pink and intact. An approximately 1-centimeter oval area extended from a bottom corner of the rectangular-shaped pink area and was partially open with dried tissue and a scant amount of eschar. There was no drainage or dressing. When asked if the inside of her leg hurt, Resident #96 did not answer, but did not appear uncomfortable as the area was examined. When asked if the burned area was kept open to air, LPN N said that it was. ( )

This citation pertains to intake number MI 083. Based on observation, interview, and record review the facility failed to prevent the physical and verbal abuse in 2 of 3 sampled residents (Resident #500 and #501), out of a total sample of 3, when Certified Nurse Aid (CNA #2) placed her hands on Resident #500's shoulders and shook her, and when CNA #2 verbally stuck out at Resident #501 when Resident #501 requested assistance, resulting in Resident #500 having fear and being afraid of CNA #2 and Resident #501 feeling "awful, stupid, and having hurt feelings. Findings include: Resident #500: Per the facility face sheet Resident #500 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a "Minimum Data Set" ((MDS) dated [DATE] revealed Resident #500 had the ability to make herself understood, had clear speech, and had the ability to understand others. The MDS revealed Resident #500 had a recall score of 3 out of a total of 6. The MDS revealed Resident #500 could recall correctly when cued. The MDS revealed Resident #500 was assessed to not have [MEDICAL CONDITION]. The MDS revealed Resident #500 did not reject care, required extensive assistance with ambulation and toilet use. Record review of a "Facility Investigative Report" dated 3/26/2012 revealed that on 3/25/2012, Resident #500 reported to CNA #1 that she had been shaken by the shoulders on the night of 3/24/2012 by another CNA (CNA #2). The investigation revealed that Resident #500 was alert and oriented with "mild" forgetfulness. The investigation revealed Resident #500 was cooperative with care. The investigation revealed that Resident #500 was interviewed by three staff members (Licensed Practical Nurse-LPN #3, Director of Nursing-DON #4, and Registered Nurse-RN #5) on the dates of 3/25, 3/26, and 3/38/2012 and indicated Resident #500 statement remained the consistent regarding the incident. Review of a written statement by DON #4 of an interview conducted with CNA #1 dated 3/26/2012 revealed that CNA #1 had gone into Resident #500's room (did not provide the date) to provide care and that Resident #500 stated to CNA #1, "I don't want that girl in here." The statement revealed that CNA #1 asked Resident #500, "what girl" and Resident #500 stated that she did not know the "girl's" name but stated that the "girl" had put her hands on her shoulders and shook her. The statement revealed that Resident #500 was "very upset" while telling the story and looked afraid. The statement revealed that CNA #1 immediately reported the allegation to LPN #3. CNA #1 was interviewed on 4/13/2012 at 12:17 PM. CNA #1 stated that CNA #2 only cared for Resident #500 "periodically". CNA #1 said CNA #2 did go into Resident #500's room to assist Resident #500 and stated that she also went into Resident #500's room. CNA #1 said that when she went into Resident #500's room, Resident #500 said to her (CNA #1) that only she (CNA #1) could go into her (Resident #500) room and not the other (CNA #2). CNA #1 said Resident #500 did not know CNA #2's name but stated that CNA #2 had just been in her room. CNA #1 said she asked Resident #500 why she felt that way but stated that Resident #500 would not tell her why and only kept saying, "I only want you (CNA #1) in here." CNA #1 said Resident #500 stated that she did not want "that lady" in here (Resident #500's room). CNA #1 said she told Resident #500 okay and stated that Resident #500 was visibly upset and fearful. CNA #1 said that she told CNA #2 that Resident #500 did not want her to care for her anymore. CNA #1 said CNA #2 did not ask why, but only stated that she (CNA #2) cared for all residents the same. CNA #1 said CNA #2 had told her she had assisted Resident #500 to the bathroom. CNA #1 said the next night (shift of 11:00 PM - 7:00 AM on 3/25/2012) when she went into Resident #500's room, Resident #500 asked her if "that lady" was there. CNA #1 said she told Resident #500 that CNA #2 was not working and Resident #500 said "oh, good". CNA #1 said she saw Resident #500 relax after Resident #500 was told that CNA #2 was not working. CNA #1 said it was at that time that Resident #500 stated that CNA #2 had put her hands on her and shook her. CNA #1 said Resident #500 stated that the incident occurred while she was in the bathroom. CNA #1 said she reported the incident immediately to LPN #3. CNA #1 said Resident #500 would not give any further details. CNA #1 was interviewed again on 4/16/2012 at 1:00 PM. CNA #1 stated that on 3/24 into 3/25/2012 on the third shift, CNA #2 did not tell her that she had any problems with Resident #500. CNA #1 said at one time she did go with CNA #2 in Resident #500's room. CNA #1 said it was at that time, while in Resident #500's room with CNA #2, that Resident #500 said she did not want CNA #2 in her room. CNA #1 said CNA #2 then left Resident #500's room. Review of a written statement by LPN #3, not dated, revealed that on 3/25/2012 on the third shift and regarding the date of 3/24/2012, Resident #500 made a comment that a CNA (CNA #2), whose name Resident #500 could not recall but was able to describe CNA #2, had shook her. The statement revealed Resident #500 did not know why CNA #2 had shaken her but revealed Resident #500 stated she was scared. The statement revealed that LPN #3 assured Resident #500 that CNA #2 would not care for her again and Resident #500 felt better. LPN #3's statement revealed that Resident #500 had not made "this type" of an accusation before. LPN #3 was interviewed on 4/16/2012 at 11:27 AM. LPN #3 said he was approached by CNA #1, during the third shift dates of 3/25 into 3/26/2012, and was told that Resident #500 was "acting scared". LPN #3 said he spoke with Resident #500 who stated that the CNA from the night before had shaken her. LPN #3 said the only two CNA's in the hall the night before were CNA's #1 and #2. LPN #3 said he reported the allegation to the Unit Manager (RN #5). LPN #3 said CNA #2 was not working at the time that he learned of the incident. LPN #3 said Resident #500 was "afraid" of, "that CNA" (CNA #2). LPN #3 said Resident #500 appeared to feel better when he told her that CNA #2 was not working. LPN #3 said he had not known Resident #500 to make an accusation of this type before. LPN #3 said Resident #500 was able to describe CNA #2. Review of a written statement by RN #5, dated 3/26/2012, revealed that RN #5 questioned Resident #500 in regards to the incident. RN #5's documented that she asked Resident #500 what happened the "other night" and that Resident #500 responded stating, "are you asking about the CNA who shook me the other night?" The statement revealed RN #5 asked Resident #500 to state what happened and Resident #500 told RN #5 that CNA #2 grabbed her shirt with both hands and pulled and stated that, "she (CNA #2) shook me." The statement revealed Resident #500 had told CNA #2 that she needed to get out of here (Resident #500's room) and CNA #2 replied by saying that she was not going anywhere as she would be caring for her (Resident #500) all night. The statement revealed that RN #5 asked Resident #500 if she was hurt and Resident #500 stated that she was not hurt but did not understand why CNA #2 did that and did not want CNA #2 back in her room ever again. RN #5 was interviewed on 4/16/2012 at 10:03 AM. RN #5 said Resident #500 stated that CNA #2 grabbed her shirt at her shoulders and shook her. RN #5 said Resident #500 did not want CNA #2 to care for her again. RN #5 said she reported the incident to DON #4. Review of a written statement by DON #4, dated 3/27/2012, revealed DON #4 asked Resident #500 about the incident and Resident #500 stated that she had already talked to several people about the incident. The statement revealed Resident #500 did not know why she (CNA #2) shook her and stated that she (Resident #500) was shocked and just could not figure it out. DON #4 was interviewed on 4/13/2012 at 11:47 AM. DON #4 stated that CNA #2 had told her that she knew Resident #500 well and would sing songs with Resident #500. DON #4 said Resident #500 stated that she had never seen/met CNA #2 before. DON #4 said CNA #2 reported that on the night of 3/24 into 3/25/2012 she went to assist Resident #500 up to the bathroom and that Resident #500 would not remove her heel protectors, but insisted that she (Resident #500) was going to get up anyway, as such, CNA #2 blocked Resident #500 from getting up out of her bed by standing in front of Resident #500 while Resident #500 sat on the side of her bed. DON #4 stated on 4/16/2012 at 10:36 AM that CNA #2 was not on the schedule as of the date of the incident and was suspended on 3/27/2012. Record review of an "Employee Corrective Behavior Report" dated 3/29/2012 revealed CNA #2 was discharged from her employment at the facility as of 3/29/2012. Review of a statement written by Social Worker (SW) #6, dated 3/27/2012, revealed that when SW #6 asked Resident #500 what occurred, Resident #500 stated that the "aid" (CNA #2) approached her, while she was in the bathroom, grabbed her shoulders and shook her. The statement revealed that the incident made Resident #500 "mad". The statement revealed Resident #500 did not want "that aid" (CNA #2) in her room and that she felt safe at the facility but did not want "that one girl" in her room. The statement revealed Resident #500 stated that she was not hurt, but did not like what was done to her. SW #6 was interviewed on 4/13/2012 at 12:07 PM. SW #6 said she was told about the incident on either 3/26 or 3/27/2012. SW #6 said Resident #500 told her that she (Resident #500) was in the bathroom then stated "that girl" had gone into her room, put her hands on her shoulders and shook her. SW #6 said Resident #500 told her that the incident made her mad and said Resident #500 did not know why CNA #2 had shaken her. LPN #8, who was familiar with Resident #500 and cared for Resident #500, was interviewed on 4/16/2012 at 1:30 PM. LPN #8 said Resident #500 did not have a history of making accusations against staff. Resident #500 was interviewed on 4/13/2012 at 10:10 AM. Resident #500 said she did not know CNA #2's name but stated that CNA #2 had brown hair that was pulled back. Resident #500 stated that her birthday was 8/23/1924 (correct). Resident #500 said she could not remember if she was standing or where she was at the time of the incident but stated that she was going to use the bathroom. Resident #500 stated that "she" (CNA #2) had put her hands on her shoulders and shook her. Resident #500 stated that she had not ever seen CNA #2 before. Resident #500 said she did not know why CNA #2 had shaken her and said she told CNA #2 to leave (Resident #500's room). Resident #500 said CNA #2 then told her that she would be there all night and would stay as long as she wanted. Resident #500 was again interviewed on 4/16/2012 at 11:00 AM. Resident #500 was asked if she remembered speaking to this surveyor on 4/13/12 and Resident #500 stated, "Yes, we talked about that lady that shook me." Resident #500 then stated that she was not going to talk about it anymore, and per observation Resident #500 pinched her lips together, turned her head, and would not speak of the incident anymore. CNA #2 was interviewed on 4/16/2012 at 12:09 PM. CNA #2 stated that on the third shift of 3/23 into 3/24/2012 she was assigned with CNA #1 to Resident #500's hall. CNA #2 said CNA #1 was on break when Resident #500 put her call light on. CNA #2 said Resident #500 wanted to use the bathroom. CNA #2 said she grabbed Resident #500's slippers and went to remove Resident #500's heel protectors when Resident #500 asked her what she was doing. CNA #2 said she put both her hands up in the air and stated to Resident #500 that she needed to remove her heel protectors for safety. CNA #2 said Resident #500 became angry and swung her legs over the side of the bed. CNA #2 said she stood in front of Resident #500 with her legs spread so Resident #500's feet would slip between hers and prevent her ability to stand up. CNA #2 said Resident #500 finally agreed to take of her heel protectors and she (CNA #2) then assisted her to the bathroom. CNA #2 said the next time that she went into Resident #500's room to assist her, CNA #1 was in the doorway, Resident #500 yelled at her (CNA #2) to get out. CNA #2 stated that she did not put her hands on Resident #500. Resident #501: Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of an MDS dated [DATE] revealed Resident #501 had no cognitive impairment, was understood by others, and had the ability to understand others. Resident #501 was interviewed on 4/16/2012 at 11:00 AM. Resident #501 said CNA #2 was "terrible". Resident #501 stated (CNA #2 by name) had one time, about one month prior, answered her call light. Resident #501 said CNA #2 approached her bed and looked at her with a mean look and said, "What do you want." Resident #501 said she did not reply to CNA #2 and stated that CNA #2 then said, "you know we have 31 other residents in this hall?" Resident #501 said she stated to CNA #2 that "yes" she knew that and that she (Resident #501) had been at the facility longer than CNA #2. Resident #501 said she felt "stupid", "awful", and like a "dunce". Resident #501 said that she did not have "Alzheimer's" and said she did not want to be treated like this. Resident #501 said she immediately told CNA #2 to "get out" of her room and stated that she did not want CNA #2 near her again. Resident #501 stated that her feelings were hurt. ( )