Every finding on record at Allegan County Medical Care Facility

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) timely for 1 (Resident #21) of 1 resident reviewed for resident assessments, resulting in the potential for an inaccurate reflection of the resident's status.Findings include:Resident #21Review of an admission Record revealed Resident #21 was a female, originally admitted to the facility on [DATE].A review of Resident #21's electronic medical record (EMR) MDS screen revealed that Resident #21's 12/9/25 Quarterly MDS was completed. It was not marked as accepted to indicate that it had been transmitted to CMS.In an interview on 2/19/26 at 12:47 PM, MDS Coordinator (MDSC) Y reported that Director of Nursing (DON) B had previously been the MDS Coordinator and was still the one who exported (referring to transmitting) the completed MDS assessments to CMS.In an interview on 2/19/26 at 12:51 PM, DON B reviewed Resident #21's 12/9/25 Quarterly MDS with this surveyor and confirmed that it had not been transmitted to CMS. DON B reported the Quarterly MDS on 12/9/25 was not closed correctly and she had not caught that error and missed transmitting the MDS to CMS. DON B reported if an MDS was not submitted timely, CMS may not have an accurate reflection of the resident's status.In an interview on 2/19/26 at 3:46 PM, MDSC Y was queried as to how she tracked the MDSs in the system (to ensure all MDSs were transmitted timely). MDSC Y reported that was a question for DON B.In an interview on 2/19/26 at 3:55 PM, DON B was queried as to how she tracked the MDSs in the system (to ensure all MDSs were transmitted timely). DON B reported that was a question for MDSC Y.

Based on interview and record review, the facility failed to ensure that 1.) a complete physician order was in place for BiPAP (bilevel positive airway pressure - a noninvasive breathing device that helps people with breathing difficulties breathe more easily) therapy and 2.) BiPAP therapy administration was documented for 1 (Resident #18) of 1 resident reviewed for respiratory care, resulting in an incomplete reflection of the resident's care.Findings include:Resident #18Review of an admission Record revealed Resident #18 was a female, with pertinent diagnoses which included: obstructive sleep apnea (breathing repeatedly stops and starts during sleep due to the muscles in the back of the throat relaxing and causing airway blockage).Review of a current Care Plan for Resident #18 revealed, (Resident #18) has obstructive sleep apnea and uses a BiPap with oxygen while asleep with a date initiated of 7/24/23.Review of a current Physician's Order revealed, BiPap setting: Min (minimum) 4.0 (cmH2O - centimeters water)-Max (maximum) 8.0 (cmH2O), Auto 5 (cmH2O), pressure 13.3 (cmH2O), min 9.3 (cmH2O), PS (pressure support) 4.0 (cmH2O) verbal active 4/17/2023Review of a current Physician's Order revealed, BiPap clean daily and store per protocol, in the morning related to OBSTRUCTIVE SLEEP APENA.verbal active 4/12/23On 2/19/26 at approximately 9:45 AM, Resident #18's Order Summary was reviewed and revealed no physician's order for the time or frequency of administration of BiPAP therapy for Resident #18.Review of Resident #18's January, 2026 MAR TAR (medication administration record treatment administration record) revealed no documentation of Resident #18's BiPAP therapy administration.Review of Resident #18's February, 2026 MAR TAR from 2/1/26 - 2/18/26 revealed no documentation of Resident #18's BiPAP therapy administration.In an interview on 2/19/26 at 11:09 AM, Director of Nursing (DON) B reviewed Resident #18's Physician Orders with this surveyor and reported there was no order in place for Resident #18 regarding the time or frequency of administration of BiPAP therapy. DON B reported without the complete order, nursing staff wouldn't know what to do for Resident #18. DON B reported the importance of a complete order was to have all the information on how to care for the resident and so the therapy was completed. DON B reported Resident #18 had respiratory failure and if the BiPAP therapy didn't get done, Resident #18 would have trouble breathing at night.In an interview on 2/19/25 at 11:15 AM, Registered Nurse (RN) P reported Resident #18 would normally put her BiPAP on when she got ready for bed. RN P reported without a physician's order, nursing staff would not know specifically when Resident #18 needed the BiPAP therapy. RN P reported there should be a section in the medical record to check off when the BiPAP therapy was administered.

Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care (to include nail care) to a dependent resident for 1 (Resident #3) of 1 resident reviewed for ADL care resulting in dirty nails and the potential for feelings of embarrassment.Findings include:Resident #3Review of an admission Record revealed Resident #3 was a female, with pertinent diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side; vascular dementia, moderate with psychotic disturbance (abnormal thinking and loss of contact with reality); and major depressive disorder, recurrent, moderate. Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 2/3/26 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #3 was moderately cognitively impaired. Further review of said MDS revealed Resident #3 had a functional limitation in range of motion impairment on one side of upper extremity and impairment on both sides of lower extremity.Review of a current Care Plan for Resident #3 revealed a focus of, (Resident #3) had an ADL self-care performance deficit r/t (related to) Confusion, Dementia, Fatigue, Hemiplegia d/t (due to) dx (diagnosis) of hx (history) of TIA (transient ischemic attack - stroke), cerebral infarction (blood flow to part of the brain is blocked), hemiplegia affecting left side, dysphagia (swallowing difficulty), COPD (chronic obstructive pulmonary disease) with a date initiated of 11/11/2022 and a revision date of 3/1/23 and care planned interventions which included, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse with a date initiated of 11/11/22.In an observation and interview on 2/18/26 at 12:08 PM, Resident #3 reported she liked having her nails done. It was noted that Resident #3's nails, specifically the thumbnail and pointer finger on the right hand were caked with black debris underneath the nails.In an observation on 2/19/26 at 9:29 AM, Resident #3's nails were observed. Resident #3's nails, specifically the thumbnail and pointer finger on the right hand, were caked with black debris underneath the nails.In an interview on 2/19/26 at 9:50 AM, Certified Nurse Aide (CNA) AA reported Resident #3 did not refuse nail care and that she liked getting nail care.In an observation and interview on 2/19/26 at 1:54 PM, CNA L observed Resident #3's nails with this surveyor and reported that Resident #3's nails needed to be cleaned. CNA L reported nail care was typically provided when it was noticed that they were dirty.In an interview on 2/19/26 at 2:24 PM, Director of Nursing (DON) B reported residents' nails should be cleaned on the resident's shower day at least weekly and should be cleaned whenever they are dirty. DON B reported if nails were visibly dirty, they should absolutely be cleaned.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During a tour of the kitchen, at 11:00 AM on [DATE], an interview with Certified Dietary Manager (CDM) K, found that the stand up mixer does not get used very often. Upon taking the plastic cover off the mixer, it was observed to have white and yellow dried crusted debris on the inside of the shield / grate of the unit. When asked if she could see the accumulation, CDM K nodded. According to the 2022 FDA Food Code section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . During an interview with CDM K, at 11:18 AM on [DATE], it was found that staff cool food and keep a log of their process. A review of the Rapid Cooling Monitoring Chart, dated [DATE] to [DATE], found that logged cooling for stuffed pepper soup, minestrone soup, and turkey, were all logged that they did not reach 70F within two hours of cooling. The bottom of the log states Cool foods from 135F to 70F within 2 hours, and then from 70F to 41F in 4 hours, for a total cooling time of 6 hours maximum. A review of the logged cooling for stuffed pepper soup, not dated, was found to have been 140F at 1:00 PM, 133F at 2:00 PM, and 72F at 4:00 PM. A review of the logged cooling for minestrone soup, not dated, was found to have been 150F at 5:30 PM, 100F at 7:00 PM, 81F at 8:00 PM, and 30F the next morning at 6:30 AM. A review of the logged cooling for turkey, dated on the log for [DATE], was found to have been 135F at 2:00 PM, 90F at 4:00 PM, and 39F at 7:00 PM. When asked if this item was served to residents, CDM K stated it was. According to the 2022 FDA Food Code section ,d+[DATE].14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . During a tour of the [NAME] kitchen, at 11:50 AM on [DATE], it was observed that pre cooked bacon was found open and exposed in the freezer. CDM K stated that it should be covered or wrapped. According to the 2022 FDA Food Code section ,d+[DATE].11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: . (4) Except as specified under Subparagraph ,d+[DATE].15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings . During a tour of the [NAME] kitchen, at 11:52 AM on [DATE], it was observed that three buckets of solution were found on the kitchen counter. A green bucket for soapy water, red bucket for sanitizer, and white bucket labeled with disinfectant. When asked what the disinfectant is used for, CDM K stated that staff only use it for tables and surfaces in the dining room, and that usually the disinfectant is not stored on the counter in the kitchen. At this time, the disinfectant was tested with the facilities QT-40 Hydrion quaternary ammonium test kit, and found to be well over the 500 parts per million maximum on the strip. According to the 2022 FDA Food Code section ,d+[DATE].11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. During a tour of the Hillside kitchen, at 12:01 PM on [DATE], it was observed that an expired blueberry yogurt was found in the refrigeration unit with a best by date of Feb52025. During a tour of the [NAME] kitchen, at 12:10 PM on [DATE], it was found that six yogurts were found passed their best by dates. Two blueberry yogurts dated best by Feb52025 and four strawberry yogurts dates best by Feb42025. According to the 2022 FDA Food Code section ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, to include anticoagulant (blood thinner) use, for 1 (Resident #3) of 5 residents reviewed for unnecessary medications, resulting in an incomplete reflection of the resident's medication status and the potential for unmet care needs. Findings include: Resident #3 Review of an Admission Record revealed Resident #3 was a female, with pertinent diagnoses which included: unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of a physician's order for Resident #3 revealed, Eliquis Tablet 5 MG (milligrams) (Apixaban) Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION (I48.91) Pharmacy Active 12/7/2022 A review of Resident #3's current Care Plan on 2/11/25 at 10:49 AM, revealed no care planned focus, goals, or interventions related to her Eliquis (an anticoagulant) use. In an interview on 2/11/25 at 2:09 PM, Director of Nursing (DON) B reported she had just recently taken over the position of DON and had previously been the MDS (Minimum Data Set) Coordinator. DON B reported a care plan should be developed and implemented for high-risk medications and gave the example of anticoagulants, antibiotics, and diuretics. DON B reported the MDS Coordinator was responsible for developing the care plan for some of the high-risk medications including Eliquis, because it was an anticoagulant. DON B reviewed Resident #3's care plan with this surveyor and reported there was no care plan in place for her anticoagulant use but that there should have been. DON B reported it was important to care plan anticoagulant use because of the high risk of bleeding while on this type of medication.

Based on observation, interview, and record review, the facility failed to: 1.) maintain safe infection control practices in regards to hand hygiene (glove use) during direct care for 1 resident (Resident #4) and 2.) ensure that all staff consistently don proper PPE (personal protective equipment) prior to conducting high contact activities with a resident where Enhanced Barrier Precautions (EBP) were in place for 1 resident (Resident #12) of 11 residents reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of bacteria. Findings include: Resident #4 Review of Resident #4's Care Plan revealed, .(Resident #4) is on Enhanced Barrier Precautions r/t (related to) history of extended-spectrum-beta-lactamase (this is a type of enzyme or chemical produced by some bacteria, that can make some antibiotics ineffective in treating bacterial infections) in urine, J-tube (indwelling medical device used to deliver nutrition directly into the small intestine), and foley catheter (indwelling medical device used to drain urine from the bladder). Date initiated: 1/13/25. Interventions: Alcohol based handrub or wash with soap and water if visibly soiled before entering and after leaving the room. Staff must wear gown and gloves for all high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with catheter, assisting with J-tube, and wound care. Date initiated: 1/13/25 . During an observation on 02/11/25 at 10:53 AM in Resident #4's room, Certified Nursing Assistant (CNA) F and CNA P were preparing to provide a bed bath and incontinence care for the resident. Resident #4's room was posted with signage indicating that EBP were in place. Resident #4 was observed lying in bed, with tube feeding running via J tube, and a foley catheter. The CNA's donned gowns and gloves and began preparing the wash basin and repositioning Resident #4 in her bed. CNA P was delegated to perform the washing and CNA F was assisting. CNA P used a wash cloth to clean Resident #4's face and lips, and then provided the resident a drink of water. Then with the same gloves on, CNA P obtained wash clothes and water basins out of the residents dresser. At 10:59 AM Licensed Practical Nurse (LPN) R was in the room to turn off the resident's tube feeding. CNA P then began washing Resident #4's upper body, then applied deodorant to the resident's armpits. CNA P removed the positioning wedge that was under the resident's legs and feet. The CNA's positioned the resident onto her side to wash her back. The resident was unable to tolerate and needed to be repositioned and rest for a minute. CNA F then left the room and CNA I came in to help with care. With the same gloves on, CNA P continued with Resident #4's care. CNA P used a wash cloth and cleaned Resident #4's anal area, where there was feces observed on the wash cloth, and a bandage covering her coccyx (tailbone area). CNA P handled Resident #4's tube feeding J tube and reported that it appeared to be leaking. CNA P finished cares, repositioned Resident #4, handled the bedding, moved the table, used the bed controls to raise the head of bed. CNA P did not change her gloves, or perform hand hygiene when moving from dirty to clean, or at any point during Resident #4's care. CNA P exited the room and used hand sanitizer that was in the hallway. In an interview on 02/11/25 at 01:14 PM, Infection Preventionist (IP) M reported that an audit of hand hygiene had been performed recently and they had discovered the need for further education. IP M reported that therapy staff should be donning PPE when performing therapy services in a resident's room when EBP orders were in place. 41982 Resident #12 Review of an Admission Record revealed Resident #12 was a female, with pertinent diagnoses which included: neuromuscular dysfunction of bladder, unspecified. In an observation on 2/10/25 at 11:26 AM, it was noted that there was a sign on Resident #12's door indicating she was on Enhanced Barrier Precautions. There was a cart with PPE (personal protective equipment) outside of Resident #12's room in the hallway. Review of Resident #12's physician's order revealed, Straight cath (catheterize) via suprapubic using 14 fr (French - size of catheter) catheter every 6 hours and PRN (as needed). Flush at end of cath with 100mL (milliliters) or (sic) normal saline or sterile water four times a day AND as needed Other Active 1/11/2024 Review of Resident #12's current Care Plan revealed, (Resident #12) requires enhanced barrier precautions r/t (related to) intermittent catheterization, hx (history) of recurrent UTIs (urinary tract infections) and urosepsis Date Initiated: 04/23/2024 In an observation/interview on 2/10/25 beginning at 1:29 PM, Resident #12 was seated in her room in her wheelchair. There was a staff member (Occupational Therapy Assistant (OTA) S) present in the room with Resident #12. It was noted that OTA S was not wearing any PPE and was assisting the resident, hands-on, with what appeared to be arm exercises. As OTA S exited Resident #12's room, this surveyor queried OTA S what she had been assisting Resident #12 with while she had been in her room. OTA S reported she had been adjusting Resident #12's splint and was working on upper extremity (arm) range of motion exercises to decrease pain. When queried as to whether PPE should have been worn while working with Resident #12, OTA S reported it was not necessary for staff to wear PPE while working with Resident #12 unless they were touching her catheter in any way. OTA S reported she did not need to wear PPE, including gloves, when touching the resident to do range of motion exercises. According to the the Centers for Disease Control Frequently Asked Questions (FAQ's) about Enhanced Barrier Precautions in Nursing Homes (June 28, 2024) revealed, . 26. Is Physical or Occupational Therapy considered a high-contact resident care activity? Yes. Therapists should use gowns and gloves when working with residents on Enhanced Barrier Precautions in the therapy gym or in the resident ' s room if they anticipate close physical contact while assisting with transfers, mobility, or any high contact activity. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html

Based on observation, interview, and record review, the facility failed to post the required daily nurse staffing information on 2/10, 2/11 and 2/12/2025, for all 33 residents in the facility, resulting in a lack of available staffing information for residents and visitors. Findings include: In an observation and review on 2/10/25 at 2:21pm, the Resident Care Labor Hours document, posted in the common area near the nurses station, was dated 2/7/25. The document identified the number of Certified Nursing Assistants (CNA's) and nurses working on each unit, during each shift, for 1 day. In an observation and review on 2/11/25 at 10:32am, the Resident Care Labor Hours document posted in the common area near the nurses station, was dated 2/7/25. In an observation and review on 2/12/25 at 11:05am, the Resident Care Labor Hours documented posted in the common area near the nurses station, was dated 2/7/25. In an interview on 2/11/25 at 2:18pm, Director of Nursing (DON) B reported the Staffing Scheduler was responsible for posting the required daily Resident Care Labor Hours document. DON B reported the daily posting of the nurse staffing information was displayed in the common area outside the nurse's station. When further queried, DON B reported the Staffing Scheduler was on vacation and DON B did not know who was responsible for posting the daily nurse staffing information. In an interview on 2/12/25 at 12:47pm, Nursing Home Administrator (NHA) A she was responsible for posting the daily nurse staffing information when the Staffing Scheduler was absent. NHA A reported she forgot to post the document on 2/10, 2/11 and 2/12/25.

Based on interview, and record review, the facility failed to develop policies and procedures to include current standards of practice in regard to pneumococcal immunizations, resulting in the potential for eligible residents to not be offered either the PCV15 (15-Valent Pneumococcal Conjugate Vaccine), PCV20 (20-Valent Pneumococcal Conjugate Vaccine) or PCV21 (21-Valent Pneumococcal Conjugate Vaccine) therefore increasing the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Review of the facility policy/procedure Pneumococcal Vaccination, last revised 6/2018 and last reviewed 9/2023 revealed, .5. The type of pneumococcal vaccine (PCV13 (13-Valent Pneumococcal Conjugate Vaccine), PPSV23/PPSV (23-Valent Pneumococcal Conjugate Vaccine) offered will depend upon the recipient's age and susceptibility to pneumonia .7. A series of vaccinations will be offered to immunocompetent adults (greater than or equal to) 65, depending on current vaccination status and practitioner recommendation: a. No previous vaccination (or vaccination status is unknown): PCV13 first, then PPSV23 one year later. b. Previously received PPSV23 at age (greater than or equal to) 65: PCV13 at least 1 year after receipt of PPSV23. c. Previously received PPSV23 before age 65 who are now aged (equal or greater than) 65: PCV13 at least 1 year after receipt of PPSV23, then PPSV23 after 5 years of previous vaccination (no earlier than one year of PCV13) . In an interview on 02/11/25 at 03:34 PM, Infection Preventionist (IP) M reported that the 2018 policy is the facility's current pneumococcal policy. Review of the Centers for Disease Control and Prevention (CDC) report Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged =[AGE] years: Recommendations of the Advisory Committee on Immunization Practices, dated January 9, 2025 revealed, Before October 2024, the Advisory Committee on Immunization Practices (ACIP) recommended use of a pneumococcal conjugate vaccine (PCV) for all adults aged =[AGE] years .who have not received a PCV or whose vaccination history is unknown. Options included either 20-valent PCV or 21-valent PCV alone or 15-valent PCV in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23 .). There are additional recommendations for use of PCV20 or PCV21 for adults who started their pneumococcal vaccination series with 13-valent PCV (PCV13 .). The ACIP Pneumococcal Vaccines Work Group employed the Evidence to Recommendations framework to guide its deliberations on expanding the age-based PCV recommendation to include adults aged 50-[AGE] years. On October 23, 2024, ACIP recommended a single dose of PCV for all PCV-naive adults aged =[AGE] years. Recommendations for PCVs among adults aged 19-[AGE] years with risk conditions and PCV13-vaccinated adults have not changed from previous recommendations .

Based on observation and interview the facility failed to properly store clean and sanitary items, maintain laundry equipment, and clean resident shared equipment. These conditions resulted in the increased risk of clean and sanitary items and equipment to become contaminated before use, increasing the risk of negative outcomes for the resident population. Findings include: During a tour of the facility, with Maintenance Director FF, starting at 9:27 AM on 4/17/24, the following observations were made: The Hillcrest North linen closet found an accumulation of dust and debris located underneath the bottom open wire racks, leaving clean linens open and exposed to possible contamination from cleaning. The clean utility room in [NAME] was found with a cardboard covering on shelves containing clean and sanitary personal hygiene products. An observation of the private bathroom in room [ROOM NUMBER] found a cloth chair stored between the shower and the commode. The Hillcrest South spa was found with cleaning products and personal hygiene products stored commingled in the floor cabinet. The Hillcrest South linen closet was found with an accumulation of dust and debris under the bottom rack and no bottom barrier to protect clean linens from contamination due to cleaning. The Oxygen supply room was found with a dozen packs of oxygen tubing stored underneath the wastewater line of the sink. An observation of the beauty shop found hygiene products and hair care items stored underneath the wastewater line of the sink. Observation of the laundry room found three linen carts used to process and store linens, When asked if these carts would be used for clean linen, Laundry Aide GG, stated yes. The carts were found to be ripped, tattered, and torn with numerous openings in each cart. One of the carts false bottom had been replaced with a piece of plywood that is not smooth and easily cleanable. 46999 Review of facility policy, Routine and Transmission Based Cleaning and Disinfecting, with a reference date of 3/2023, revealed a statement This facility will ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .to prevent the development of and transmission of infections .consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas. During an observation on 04/18/24 at 10:18 am, Resident #26 sat with Activity Assistant (AA) DD at a dining table in the memory care unit common area and colored a picture using colored pencils. Approximately 50 colored pencils were available in a plastic storage container. AA DD reported the pencils were for community use. AA DD reported during the pandemic, resident's had their own coloring supplies in effort to avoid cross contamination. During an observation on 4/18/24 at 10:19am, Resident #26 dropped a maroon-colored pencil on the floor. The floor under the table was soiled with food particles from breakfast. AA DD retrieved the pencil from the floor and handed it back to Resident #26 without cleaning it. Resident #26 continuing coloring, then selected a new colored pencil a few minutes later and the maroon pencil was returned to the shared box of supplies. In an interview on 04/18/24 at 10:22 AM, (AA) DD reported there was no set schedule for cleaning activity supplies, and items were just cleaned as needed. AA DD added unless someone is sick, we clean on demand. In an interview on 4/18/24 at 9:41am, Infection Preventionist/Director of Nursing (DON) B reported the Activity Director (AD) C had a schedule for cleaning of shared activity supplies, including the sensory supplies that were available for all residents in the day room and other common areas. In an interview 04/18/24 01:40 PM, AD C reported the activity supplies in the common areas should be cleaned by the responsible staff after each use. AD C reported the supplies were easily accessible by all residents and could be touched by several residents. When told the activity supplies in the day room appeared soiled, AD C stated I'm not surprised. I should work on a cleaning schedule to make sure items are cleaned. AD C reported he developed policies for cleaning of bingo supplies, the supplies used for balloon toss, and for personal fidget items, but had not developed a schedule for cleaning activity supplies that were available to all residents in the common areas of the facility. AD C reported the facility also did not have a cleaning procedure for a companion robot cat and he planned to determine the best method for cleaning it. AD C reported the device had been in use for several weeks, had not been cleaned, and was kept in the common area where multiple residents could access it. During an observation on 4/18/24 at 10:17am, a companion robotic cat (an interactive sensory stimulation tool designed to encourage residents to touch and hold it as they would a cat) sat on the dining table in the common area of the memory care unit. The robotic cat was covered with faux fur. During an observation on 04/18/24 at 12:13 PM, sensory stimulation items including a tackle box with simulated fishing supplies, and a toggle switch board were stored on an open shelf in the day room. The shelf was easily accessible and stood approximately 3' high. The sensory toggle switch board was soiled with 3 spots of dried brown liquid on the top of the device, adjacent to the toggle switches. The outside of the tackle box was soiled with a 3 area of dried brown liquid. The inside of the lid was soiled with more than 30 white flakes that appeared to be dried skin. A dried white substance was also present on the lid. The upper tray of the box was soiled with dried brown liquid, and sticky residue was present on the handle of a plastic clamp in the bottom of the box. In an interview on 04/18/24 at 12:39 PM Housekeeper BB reported she cleaned the resident day room, including the activity supplies in the room (wiped them down) on this date, and the expectation was that any staff member that distributed the activity supplies would clean them after use. During an observation on 4/18/24 at 1:31pm a handheld toggle switch board that sat on the open shelf in the day room, was noted to be soiled with 3 spots of dried brown liquid. The spots were near the toggle switches and along the edge where a user would place their hand to hold the device. During an observation on 04/18/24 at 01:33 PM the soiled tackle box was opened and sat on the table in the day room, the dried brown liquid remained on end of box, dusty debris remained on the inside of the lid, along with the white dried liquid also on the inside of the box. In an interview on 4/18/24 at 1:54pm, DON B confirmed the toggle switch board and tackle box were soiled and should have been cleaned after each use in order to maintain sanitary conditions and reduce the potential for cross-contamination.

Based on observation, interview, and record review the facility failed to develop a baseline care plan for 1 of 12 residents (Resident #232) reviewed for baseline care plans, resulting in the potential for unmet care needs. Findings include: Review of an Admission Record revealed Resident #232 had pertinent diagnoses which included: hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominate side and weakness. During an observation on 4/16/24 at 12:29 PM., Resident #232 was seated in his wheelchair, leaning to his left side, at a table in the dining room with his food on the table in front of him and made no attempt to initiate eating. During an observation on 4/16/24 at 12:35 PM., Certified Nurse Assistant (CNA) EE was sitting at the table in the dining room with Resident #232. CNA EE was assisting Resident #232 to eat his lunch. In an interview on 4/16/24 at 12:45 PM., CNA EE reported that Resident #232 was new to the facility, and she was not sure what assistance he required. Review of Resident #232's electronic medical record revealed no noted baseline care plan. In an interview on 4/17/24 at 12:54 PM., Registered Nurse/Nurse Educator (RN/NE) O reported that baseline care plans should be started at admission. RN/NE O reported that a baseline care plan was a resident's basic needs for care and should include things like ADLs (activities of daily living) and transfer status. In an interview on 4/17/24 at 1:04 PM., Director on Nursing (DON) B reported that a paper copy of a baseline care plan was placed into the resident's closet. DON B reported that if an admission occurred on a weekend, the baseline care plan was completed on the following Monday. During an observation on 4/17/24 at 1:10 PM., observed taped to the inside the closet door in Resident #232's room was a paper titled . Care Guide. This paper was observed to have two different types of transfer status information for Resident #232 which included CGA (contact guard assist) x 1 (one person) with a 2 wheeled walker plus a gait belt and a mechanical lift. During an observation on 4/17/24 at 1:29 PM., CNA F transferred Resident #232 from wheelchair into bed with a gait belt and a front wheeled walker. In an interview on 4/17/24 at 1:50 PM., CNA F confirmed that the Care Guide on the inside of Resident #232's closet door did indicate two different types of transfers. When asked how CNA F knew the transfer status of Resident #232, CNA F reported the blue card pined to the cork board next to the resident's bed that revealed a number 1 was her indication that Resident #232 was a one-person transfer. In an interview on 4/18/24 at 10:29 AM., Minimum Data Set/Registered Nurse MDS/RN R reported that the admission nurse should start a baseline care plan. MDS/RN R reported she was responsible for baseline care plans. MDS/RN R reported she was absent from work for two days following Resident #232's admission and did not complete his baseline care plan within 24-48 hours of admission. MDS/RN R reported that the paper care guide taped to the inside of Resident #232's closet door was not his baseline care plan. In an interview on 4/18/24 at 10:56 AM., DON B was asked who was responsible for baseline care plans when MDS/RN R was absent from work and DON B responded RN/NE O was able to complete care plans and so can I . In an interview on 4/18/24 at 11:17 AM., RN/NE O reported that Resident #232's baseline care plan was not completed because MDS/RN R was absent from work. RN/NE O reported that the paper care guide in Resident #232's closet was not a baseline care plan. RN/NE O reported that care plans were now a part of her responsibilities. RN/NE O stated .I didn't know it was up to me to complete baseline care plans. Review of facility policy Baseline Care Plan with an implementation date of 9/2023 reviewed by DON B and Nursing Home Administrator (NHA) A revealed .the baseline care plan will be developed within 48 hours of a resident's admission .a supervising nurse shall verify within 48 hours that a baseline care plan has been developed .

Based on observation, interview, and record review, the facility failed to develop and implement person centered comprehensive care plans for 2 of 12 residents (R9 and R11) reviewed for care planning, resulting in the potential of a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: R9 According to the Minimum Data Set (MDS) dated [DATE], R9 scored 14/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), had no impairments in his arms but did have impairment in his legs, and was independent in rolling left and right. Section M: Skin Conditions indicated R9 was at risk for pressure ulcers, had 1 or more unhealed pressure ulcers with 1 unstageable suspected deep tissue injury in evolution. During an observation and interview on 4/16/24 at 10:42 AM, R9 reported he was able to reposition the top portion of his body from his waist and hips side to side. Resident demonstrated moving side to side without lifting his bottom off the mattress. Certified Nursing Assistant (CNA) I stated, He (referring to R9) is red on his bottom. R9 reported he thought he had a sore on his bottom. During an observation of R9 and interview on 4/16/24 at 10:55 AM, Registered Nurse (RN) S measured a wound on right buttock at 5.5 cm x 2 cm while describing it as shearing. The skin was clear of any barrier cream. The RN stated, (R9) does not use a pad underneath his bottom because of the shearing. He scoots his bottom around. Staff monitor it and put barrier cream on it. I will chart the shearing in a skin assessment, tell the DON (Director of Nursing), and put a note in the doctor book so the PA (Physician's Assistant) will see it tomorrow. Observed the RN applying barrier cream to the shearing. The resident was not wearing underwear under a hospital gown and was lying on wrinkled sheets. During an observation on 4/17/24 at 10:34 AM, R9 was sitting in bed at 45 degrees with his knees bent while wearing a hospital gown and no underwear. His sheets were wrinkled under his bottom. He was on an air mattress set at a comfort level of 4 and alternating pressure. Review of R9's Braden (Scale for Predicting Pressure Sore Risk) dated 4/11/24 at 2:21 PM, indicated the resident was AT RISK with a score of 16.0 with slightly limited sensory perception, skin occasionally moist, chairfast, makes frequent though slight changes in body or extremity position independently, FRICTION & SHEAR as a potential problem during a move the skin probably slides to some extent against sheets .AT RISK 15-18. Review of R9's Order Summary, dated 2/6/24, revealed, Apply Desitin (barrier cream) to bilateral buttocks each shift. Every shift for skin protectant. Review of R9's Order Summary dated 4/16/24 at 11:05 AM indicated staff were to monitor sheering to left buttock and apply Desitin as needed every shift. Review of R9's Care Plan on 4/17/24 and 4/18/24 01:38 PM revealed there was no person-centered treatment plan for shearing to the resident's right buttock. It was noted there was a Care Plan for the resident with foci for malnutrition related to left hell pressure sore (4/9/24), chronic pain related to pressure injuries to buttock (11/3/23), deep tissue injury to bilateral buttocks .stage 2 pressure injury to his coccyx which occurred during stay at facility .deep tissue injury to left heel which occurred at facility . (11/3/23). Review of R9's Kardex (care guide to direct Certified Nursing Assistant (CNA) person-centered care) did not indicate a treatment guide under Wound Dressing or Monitoring for the shearing on buttock area. Review of R9's Progress Note, dated 4/16/2024 at 11:00 AM, revealed, Health Status Note, Note Text: Shearing noted to left buttock. 5.5 cm (centimeter) x 2 cm. (Director of Nursing (DON) B) notified .order placed in TAR to monitor area. Skin assessment completed. Review of R9's Progress Note, dated 4/17/2024 at 2:27 PM, revealed, Health Status Note, Note Text: Special visit with (name of Medical Doctor) . Skin to buttocks examined. Very small areas of shearing to right buttock. Continue with Desitin application. Resident remains on air mattress. Skin to feet and heels also assessed. Skin intact, heels boggy to touch slowly bleachable . During an interview and record review on 4/18/24 at 11:50 AM, DON B stated, Care Plans are done by (MDS R) who does most of them, probably 95%. She attends the daily Huddles where skin integrity concerns would be discussed and then she puts the concerns in a Care Plan. She is to go to HUDDLE, take the information from them and do care plans. (MDS R) would be responsible for doing the care plan for (R9's) skin shearing. I do not know if she attended the HUDDLE when (R9's) skin was talked about. The facility does not have staff nurses get into or do care plans because they get wonky with them. They do not know the program. I guess I could train the nurses on how to do care plans in the system. If a nurse finds an issue with skin integrity, they write a progress note and tell me. The doctor and I looked at (R9's) shearing yesterday (4/17/24). It was shearing and did not look too exciting to me. During an interview and record review on 4/18/24 at 12:40 PM, RN/MDS Coordinator R stated, I attend HUDDLE up to twice a day, depending if a new nurse comes on at the afternoon shift. I was not at the facility on Monday (4/15/24) or Tuesday (4/16/24). I did not do a care plan for (R9's) skin shearing when I came back to work on Wednesday (4/17/24). I saw the wound today and did change the order from his left buttock to his right buttock. The area has just a little bit of shearing. (R9) has a history of pressure wounds. He came to the facility with one on his buttock (3/30/23) and developed another wound on his heel that has healed. Is the facility supposed to do a care plan for every little bruise and bump? Nurses do not develop Care Plans. That is left to me. If I am gone for an extended time the two other leadership nurses, (DON B and Nurse Educator) I guess could do Care Plans. 47955 Resident #11 Review of an Admission Record revealed Resident #11 had pertinent diagnoses which included: Schizoaffective disorder bipolar type (mental health disorder that can include hallucinations and delusions along with mood swings), restlessness and agitation and post-traumatic stress disorder (PTSD), chronic (a mental health disorder that is triggered by an event and symptoms can include flashbacks, nightmares, anxiety, and/or uncontrollable thoughts about the event). Review of a Minimum Data Set (MDS) assessment for Resident # 11, with a reference date of 3/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #11 was cognitively intact. Review of Resident #11's medical record revealed a diagnosis of post traumatic stress disorder. In an interview on 4/16/24 at 12:57 PM., Resident #11 reported she had symptoms of PTSD. Resident #11 stated there is a lady who lives here that is a trigger for me, and staff is aware . Review of Care Plan for Resident #11 revealed no noted care plan for PTSD or any triggers. Review of Social Work Note for Resident #11 dated 4/12/24 revealed .continues to acknowledge becoming triggered by another resident's personality that she perceives as negative . In an interview on 4/16/24 at 1:04 PM., Certified Nurse Assistant (CNA) F reported that Resident #11 and another resident had to be kept separated due to not getting along. In an interview on 4/17/24 at 2:30 PM., Social Worker (SW) V reported that she was responsible for care plans related to mood and behaviors. SW V reported that a resident with a diagnosis of PTSD, that does have triggers should have a care plan with the triggers listed. In an interview on 4/18/24 at 9:10 AM., Registered Nurse (RN) T reported that Resident #11 did have another resident that was a direct trigger for her. In an interview on 4/18/24 at 11:24 AM., Registered Nurse/Nurse Educator (RN/NE) O reported that Resident #11 was fixated on another resident and has had verbal altercations with this same resident. RN/NE O reported that this same resident was a trigger for Resident #11. In an interview on 4/18/24 at 11:28 AM., SW V reported that Resident #11 and another resident that she disliked have argued but this was not considered a trigger for Resident #11 and was not listed on Resident #11's care plan. SW V reported that Resident #11 did not have a specific care plan in place related to a PTSD diagnosis and any triggers. In an interview on 4/18/24 at 11:53 PM., Nursing Home Administrator (NHA) A reported that Resident #11 had become obsessed with a peer, did have a fixation on the same peer, and Resident #11 does have many different triggers. NHA A reported that there was no care plan for PTSD and triggers for Resident #11.

Based on observation and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents who reside in the South and East 100 Halls. Findings Include: During a tour of the facility, at 3:27 PM on 2/21/23, observation of empty resident room [ROOM NUMBER], found that the bathroom sink temperature reached 124 F while using a rapid read thermometer. At this time, the surveyor went to empty rooms 158 (across the hall) and 163 (down the hall) and ran the hot water for 5 minutes without reaching the 120 F. At 3:38 PM on 2/21/23, the temperature of the 100 hall spa sink was found to be 125.3 F At 3:39 PM on 2/21/23, the temperature of resident room [ROOM NUMBER]'s bathroom sink was found to be 126.5 F At 3:41 PM on 2/21/23, the temperature of resident room [ROOM NUMBER]'s bathroom sink was found to be 122.5 F At 3:47 PM on 2/21/23, the surveyor went to the end of the 100 East hall, room [ROOM NUMBER]. The bathroom sink to empty resident room [ROOM NUMBER] was found to be 122.5 F. At 3:51 PM on 2/21/23, the surveyor informed NHA A that there were concerns regarding excessive hot water at some domestic resident fixtures. NHA A stated that there had been a vendor working on the system and they may still be onsite. At 3:54 PM on 2/21/23, the surveyor and NHA A went to the boiler room. Upon reaching the boiler room it was found the vendor had left the building and NHA A left to report the issue. At this time, the surveyor observed the storage tank labeled Domestic 112 F-118 F and found the outgoing thermometer showed domestic hot water leaving the boiler room at 125 F. At 4:12 PM on 2/21/23, an interview with NHA A found that the vendor had been contacted and was working on the issue remotely, but has concerns about the water temperatures dropping too low during peak demand. The NHA stated that when temperatures were taken this afternoon, it was during low demand when the system heats up the most. At 4:18 PM on 2/21/23, a temperature of the 100 hall spa sink was found to be 121 F. At 4:20 PM on 2/21/23, a temperature of resident room [ROOM NUMBER] was found to be 122 F.

Based on observation, interview, and record review, the facility failed to maintain proper storage temperatures in 2 of 2 medication refrigerators in the main medication room, resulting in the potential for decreased potency and efficacy of medications and the exacerbation of resident medical conditions. Findings include: In an observation on 2/22/2023 at 9:45 AM, the Med room [ROOM NUMBER] Refrigerator/Freezer Temperature Check Sheet documented the temperature in the resident medication refrigerator to be 35 degrees Fahrenheit on 2/3/2023, 35 on 2/4/2023, 35 on 2/5/2023, 34 on 2/6/2023, 33 on 2/15/2023, 34 on 2/17/2023, 34 on 2/18/2023, 34 on 2/19/2023, 34 on 2/20/2023, and 33 on 2/21/2023. The Med room [ROOM NUMBER] Refrigerator/Freezer Temperature Check Sheet documented the temperature in the resident vaccine refrigerator to be 34 degrees Fahrenheit on 2/4/2023, 34 on 2/5/2023, 34 on 2/6/2023, 34 on 2/7/2023, 34 on 2/8/2023, 35 on 2/9/2023, 33 on 2/10/2023, 33 on 2/10/2023, 35 on 2/13/2023, 35 on 2/14/2023, 33 on 2/16/2023, 35 on 2/17/2023, and 32 on 2/21/2023. In an interview on 2/22/2023 at 9:45 AM, LPN (Licensed Practical Nurse) J reported that she was not certain what temperature range the medication and vaccine refrigerators are required to be kept at. LPN J reported that she believed the required temperature range was between 36 and 42 degrees Fahrenheit. In an interview on 2/22/2023 at 9:45 AM, DON (Director of Nursing) B reported that nursing staff are required to adjust the refrigerators if the temperature is out the required range. DON B reported that these adjustments are not documented. In an email correspondence received on 2/22/2023 at 3:23 PM, NHA (Nursing Home Administrator) A reported that the facility follows their pharmacy's guidelines regarding the storage of pharmaceuticals. In an email correspondence received on 2/22/2023 at 3:34 PM, NHA (Nursing Home Administrator) A reported that adjustments made to refrigerator temperatures are not documented. Review of facility policy/procedure Medication Cart/Medication Room, revised 11/2021, revealed .Medications that require refrigeration or freezing are kept in the refrigerator or freezer in the locked medication room. Daily checks of temperatures are recorded to ensure proper temperatures . Review of the facility pharmacy's Medication Storage Guidance, dated 2022, revealed that refrigerated medications and vaccines were required to be stored between 36 and 46 degrees Fahrenheit.

Based on observations, interviews, and record review the facility failed to provide a dignified dining experience for 3 of 3 residents (Residents #3, #8, #14) reviewed for eating assistance, from a total sample of 12, resulting in a potential for feelings of frustration and decreased sense of self worth. Findings include: Resident #3 A review of a Face Sheet dated 9/29/21 revealed Resident #3 was admitted to the facility with pertinent diagnoses that included vascular dementia, psychotic disorder with delusions, major depressive disorder with psychotic symptoms and weakness. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 required extensive assistance for eating. Resident #8 A review of a Face Sheet dated 6/16/20 revealed Resident #8 was admitted to the facility with pertinent diagnoses that included frontotemporal dementia, chronic pain syndrome, and psychotic disorder with delusions. A review of a Minimum Data Set(MDS) assessment dated [DATE] revealed Resident #8 required total assistance with eating. Resident #14 A review of a Face Sheet dated 6/2/21 revealed Resident #14 was admitted to the facility with pertinent diagnoses that included dementia, cognitive communication deficit, muscle weakness. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 required extensive assistance with eating. During an observation on 2/21/23 at 12:23pm, Resident Assistant (RA) N was observed standing next to Resident #14 in the dining room, loading a spoon with food from the Resident's plate and then bringing the food to the Resident's mouth. RA N then sanitized her hands, walked to Resident #3's side, stood next to the Resident, loaded a spoon with food from that Resident's plate and brought the food to Resident #3's mouth. 4 Residents who needed assistance with eating were present at this time. RA N was the only staff member assisting the residents with eating. During an observation on 2/22/23 at 9:09 am, Resident Assistant (RA) N was observed standing next to Resident #8, loading the Resident's spoon with food and bringing the spoon to Resident #8's mouth. 5 residents who needed assistance were present at this time. RA N was the only staff member assisting the residents with eating. In an interview on 2/22/23 at 9:11am, Resident Assistant (RA) N reported she learned in feeding assistant training that the proper technique for assisting residents with eating was to sit next to them rather than stand. RA N indicated she was the only staff member assisting the residents with eating which made it difficult to follow the proper technique. Residents were observed waiting, at times staring at their plates, unable to attempt to feed themselves as RA N assisted other residents.

Based on observation, interview, and record review the facility failed to: 1. Properly date and discard potentially hazardous foods; 2. Keep food and non-food contact surfaces clean to sight and touch; 3. Maintain equipment in good repair. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 40 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, at 10:08 AM on 10/26/21, an interview with Dietary Manager (DM) Y found that potentially hazardous items are held for four days. At this time, observation in the walk-in cooler found a container of sliced tomatoes dated 10/22/ to 10/25 and an open gallon of white milk with no date. A review of the Garden View serving site, at 11:10 AM on 10/26/21, found a slice of venison salami dated 10/19/21 to 10/22/21, DM Y stated it needs to be gone. It was also observed that an open gallon container of white milk and an open half gallon container of chocolate milk were found with no open or discard dates noted. During the initial tour of the [NAME] serving area, at 11:15 AM on 10/26/21, it was observed that an open half gallon of chocolate milk was in the refrigerator with no open or discard date on the item. According to the 2013 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . According to the 2013 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A) . 2. During the initial tour of the kitchen, at 10:20 AM on 10/26/21, it was observed that the stand-up mixer was found with dried spots of yellow and white food splatter on the under arm and shield of the unit. When asked how often the mixer gets used, DM Y stated, it gets used weekly. When asked what the plastic bag covering the mixer means, DM Y stated it helps keep the mixer clean between uses. A review of the main kitchen microwave, at 10:24 AM on 10/26/21, found that the top inside of the unit was coated with stuck on food debris. During the initial tour of the kitchen, at 10:35 AM on 10/26/21, observation of the ice machine found black accumulation of debris on the inside plastic lip of the unit. When asked who cleans the ice machine, DM Y stated they have a company that comes in and cleans the unit. When asked when they were in last for cleaning, DM Y was unsure. During a tour of the Hillcrest serving area, at 10:48 AM on 10/26/21, it was observed that the inside top of the microwave showed accumulations of stuck on food debris. Further review of the area found a top cupboard stored with pancake mix and can goods, that had pancake debris spilled over the area. A review of the pantry room, at 11:04 AM on 10/26/21, found that the ice scoop holder didn't allow for water to drain and was found with stagnant water inside the holder along with an accumulation of white debris at the bottom of the holder. At this time, the ice scoop was sitting in the holder in contact with the stagnant water. Once pointed out to DM Y, the ice scoop and holder were taken to be washed and have holes drilled for proper draining. During the initial tour of the Garden View serving area, at 11:10 AM on 10/26/21, it was observed that the lazy [NAME], in the corner of the kitchen, showed an accumulation of yellow splatter marks and food debris on the carousel and inside as well of the cabinet area. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3. During the initial tour of the kitchen, at 10:23 AM on 10/26/21, it was observed that the microwave in the main kitchen showed pitting and peeling of the ceramic surface on the edges and inside top of the microwave. When pointed our to DM Y she was unaware of the chipping and peeling on the inside of the unit. A review of the [NAME] serving area, at 11:15 AM on 10/26/21, observed that the microwave for this area was found pitted and chipped on the inside of the unit. DM Y stated that she would be looking into to purchasing some new microwaves. According to the 2013 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 .

Based on observation, interview and record review the facility failed to maintain medication refrigerator temperature logs for 1 of 2 medication rooms resulting in the potential for decreased medication efficacy due to improper storage. Findings include: Review of the Policy Medication Cart and Medication Room dated 2/2019 revealed, The facility ensures licensed nurses secure all medications at all times for the safety of elders, staff, and visitors. The policy further revealed, Daily checks of temperatures are recorded to ensure proper temperatures. During an observation on 10/26/21 at 04:29 PM, the Garden View medication room was noted with Licensed Practical Nurse (LPN) GG. Observed in the medication room was a medication refrigerator and medication Refrigerator/Freezer Temperature Check Sheet. Review of the Medication Refrigerator/Freezer Temperature Check Sheet dated 10/2021 revealed no documented medication refrigerator/ medication freezer temperatures from 10/1/21 to 10/21/21 and from 10/24/21 through 10/26/21. During an interview 10/28/21 at 10:22 AM, Nursing Home Administrator (NHA) A, stated staff were to be checking refrigerator temps (temperatures) daily until Garden View forgot to check their temperatures for the medication refrigerator. During an interview on 10/28/21 at 10:52 AM, Director of Nursing (DON) B stated staff were to make sure the temperature is safe for storing medications by performing daily temperature checks and documenting the temperatures in the medication refrigerator log.

Based on observation, interview and record review the facility failed to maintain a medication error rate less then 5% for 1 of 5 residents (Resident #37) reviewed for medication administration resulting in a medication error rate of 8%. Findings include: Review of the Policy Medication Administration Schedule dated 8/2019 revealed, The facility's licensed nurses schedule medication administration in a manner that accommodates the elder's preferences and complies with recommended standards. The policy further revealed, A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Face Sheet revealed Resident #37 was an [AGE] year old female admitted to the facility in 5/2020 and diagnosed with diabetes and [CONDITION(S)]. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 10/26/21 at 10:18 AM, Registered Nurse (RN) R was noted with Resident #37. RN R was observed to have given Resident #37 a [MEDICATION(S)] .500 mg and [MEDICATION(S)] .75 mg at 10:18 AM (indicated medications given more than 2 hours after scheduled time). During an interview on 10/28/21 at 08:39 AM, RN X stated if the medications are for a set time then the nursing staff had 1 hour before and 1 hour after the time to administer the medications. During an interview on 10/28/21 at 10:45 AM, Director of Nursing (DON) B stated some medications were to be given within certain time. DON B stated for medications scheduled for a certain time then we (facility) have an hour before and an hour after the scheduled administration time. DON B stated if the medication was to be given outside of the 1 hour prior or after the scheduled administration time then staff were to hold off and call the provider for guidance.

Based on observation, interview and record review the facility failed to provide a comfortable environment free from accumulated dust for 2 of 15 sampled resident (Resident #11 and Resident #31) reviewed for homelike environment, resulting in an unsanitary buildup of dust particle on the fan frames with a possible increase in the amount of particulate matter in the air, and an increased risk of poor air quality throughout the room. Findings include: Resident #11 Review of the Admission Record revealed Resident #11 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 9/24/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #11's cognitive skills for daily decision making were intact. During an observation on 12/09/19 at 9:04 AM, Resident #11 was laying in bed the fan was at the base of the bed to the left osculating, fan was notice to have notable built up fine dust particles on front and back wire framing. During an observation and interview on 12/10/19 at 3:00 PM, Resident #11 reported that the housekeeping supervisor came in and they cleaned the fan today, I told them you were looking at it and they took it apart and cleaned it. Resident #31 Review of the Admission Record revealed Resident #31 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 10/16/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #31's cognitive skills for daily decision making were intact. During an observation on 12/10/19 at 9:09 AM, Resident #31 was sitting on the side of her bed dressed for the day the fan was pointed at the bed, but not on the fan was covered on all surfaces of the frame with light brown particles. Resident #31 reported that she had brought the standing fan from home in (MONTH) when she came to the facility since she gets very warm. During an interview on 12/11/19 12:02 PM, Housekeeping Supervisor (HS) Q reported that the fans should have been cleaned and she would be adding checking fans to the daily check list for her staff. Review of the Housekeeping Cleaning Checklist - Daily revealed fan cleaning was not listed as a daily cleaning task.

Based on observation, interview and record review the facility failed to maintain oxygen equipment for 3 of 4 residents (Resident #10, Resident #40 and Resident #11) reviewed for specialty care resulting in the potential for increased respiratory distress and difficulty breathing. Findings include: Review of the Policy Oxygen Therapy: Administration/Titration/Safety dated 10/2019 revealed the facility ensures the safe delivery of oxygen therapy by establishing guidelines for use and oxygen concentrator Filters are cleaned .weekly. Resident #10: Review of the Face Sheet revealed Resident #10 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 had a brief interview for mental status (BIMS) score of 10 out of 15 which indicated she had moderately impaired cognition. The MDS further revealed Resident #10 had received Oxygen therapy while a resident in the facility. Review of the physician's orders [REDACTED]. In an observation on 12/10/19 at 08:10 AM, Resident # 10 was noted to be in bed on oxygen via a nasal cannula (device to deliver oxygen) from her oxygen concentrator. Resident #10's oxygen concentrator filter was noted to be covered in a gray dust like substance. In an observation on 12/10/19 at 03:57 PM, Resident #10 was noted to be in bed on oxygen via nasal cannula. Resident #10's oxygen concentrator filter was noted to be covered in a gray dust like substance. In an interview on 12/11/19 at 10:07 AM, Registered Nurse (RN) M stated the oxygen concentrator filters were to be cleaned weekly and as needed. RN M observed Resident #10's oxygen concentrator filter and stated, that (filter) looks a little dusty needs to be cleaned. Resident #40: Review of the Face Sheet revealed Resident #40 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS dated [DATE] revealed Resident #40 had a BIMS score of 13 out of 15 which indicated she was cognitively intact. The MDS further revealed Resident #40 had received Oxygen Therapy while a resident in the facility. Review of physician's orders [REDACTED]. In an observation on 12/09/19 at 02:46 PM, Resident #40 was noted to be in bed on oxygen via nasal cannula. Resident #40's oxygen concentrator filter was noted to be covered in gray dust like substance. In an observation on 12/10/19 at 04:01 PM, Resident #40 was noted to be in bed on oxygen. Resident #40's oxygen concentrator filter was noted to be covered in gray dust like substance. In an observation on 12/11/19 at 10:11 AM, Resident #40's oxygen concentrator filters was noted to be covered in a gray dust like substance. In an interview on 12/11/19 at 10:11 AM, RN M stated, those (oxygen concentrator filters) are definitely dusty. In an interview on 12/11/19 at 01:34 PM, Director of Nursing (DON) B stated oxygen concentrator filters were to be cleaned weekly they have to be rinsed and if dusty then should be changed. Resident #11 Review of the Admission Record revealed Resident #11 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a MDS assessment for Resident #11, with a reference date of 9/24/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #11's cognitive skills for daily decision making were intact. During an observation on 12/09/19 at 9:04 AM, Resident #11 was laying in bed the fan was at the base of the bed to the left osculating, fan was notice to have notable built up fine dust particles on front and back wire framing. Review of the Anxiety Care Plan dated 10/4/19, (name of resident) has a [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to submit an accurate significant change in status Minimum Data Set (MDS) in 1 of 16 residents (Resident #57) reviewed for MDS discrepancies resulting in an inaccurate reflection of resident assessment. Findings include: Review of the Policy MDS Significant Change in Status Assessments dated 7/27/2010 revealed a significant change in status MDS should assess elder status on an ongoing basis and intervenes to assist elders to meet his/her highest .practicable well being. Review of the Face Sheet revealed Resident #57 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS dated [DATE] revealed Resident #57 had a brief interview for mental status (BIMS) score of 13 out of 15 which indicate she was cognitively intact. In an interview on 12/11/19 at 01:27 PM, Resident #57 stated, Yes I am on hospice. Review of the physician's orders [REDACTED]. Review of the Hospice Election Statement dated and signed on 6/6/19 revealed Resident #57 had chose to focus on .palliative or comfort care rather than curative treatment. Review of the MDS dated [DATE] revealed no documentation of Hospice care for Resident #57 under section O. Review of the MDS dated [DATE] revealed no documentation of Hospice care for Resident #57 under section O. Review of the MDS dated [DATE] revealed no documentation of Hospice care for Resident #57 under section O. In an interview on 12/11/19 at 1:16 AM, Registered Nurse (RN) M stated yes I did her (Resident #57's) MDS's and yes Resident #57 was on hospice. RN M reviewed Resident #57's medical record and stated on (MONTH) (6) 6th 2019 Resident #57 .was switched in the billing to hospice care. RN M stated the MDS should have indicated an election of hospice care for Resident #57. RN M reviewed Resident #57's MDS since 6/6/19 and stated, stated, .no the MDS did not reflect the hospice status of Resident #57. In an interview on 12/11/19 at 01:41 PM, Director of Nursing (DON) B stated, yes Resident #57 was on hospice a few months ago. DON B stated, yes she (Resident #57) should have had a significant change MDS to reflect her hospice status. DON B reviewed the MDS dated [DATE], 9/3/19 and 11/19/10 and stated all the MDS's should be yes for hospice care for Resident #57.

Based on observation, interview, and record review the facility failed to prevent the elopement and ensure the safety of 1 of 6 sampled residents (Resident #100) reviewed for elopement, from a total sample of 6 residents resulting in an Immediate Jeopardy when Resident #100 exited the facility at approximately 3:05 p.m. on 9/12/16. This deficient practice placed all 13 residents, identified as elopement risk, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #100 was a [AGE] year old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #100 was severely cognitively impaired for daily decision making skills. Review of the Elopement Incident dated 9/12/16, reflected On 9/12/16 at approximately 2:40 p.m., an announcement was made to disregard the fire alarm for the next five minutes, due to testing the fire alarm company was conducting .This type of announcement alerts staff of an upcoming alarm and also that facility exit doors that lock will be open and to monitor residents whereabouts and safety . Review of the Facility Fire Procedure Policy updated 2014, reflected that the policy indicated that one Perrigo Memory Care Center (PMCC) staff member was to monitor the common area and assist in keeping residents calm and supervised, while the other PMCC staff close resident room doors and report the head count to the command center. The policy was updated on 9/13/2016 to state that one PMCC staff member indicates that he/she takes responsibility for the doors and places themselves in front of the East glass exit door to monitor the PMCC corridor to ensure that no residents exit the household. During an interview on 10/12/16 at 11:55 p.m. and 3:15 p.m., Certified Nursing Assistant (CNA) C reported that the just before shift change they announced that there would be a fire drill or alarm testing, CNA C reported that she and CNA H were in the common area with the residents on the unit and that she could not see the east and west exit door from the common area. CNA C reported that in training she recalled that the exit doors unlocked during a fire drill and ask CNA H if the exit doors on this unit also unlocked during a fire drill. CNA C reported that Resident #100 was walking from the east exit door to the west exit door, which was his normal routine. CNA C reported that she heard the sound of a different door shut and alerted staff to look for Resident #100, staff checked the rooms and then CNA H went out the east exit door to the outside to look for Resident #100. CNA C reported that not much time passed, maybe a minute or 2 before they began looking for Resident #100. During an interview on 10/12/16 at 10:05 a.m., Rehab Director F reported that he was in his office when the fire alarm sounded, saw Resident #100 from his window but did not see his wife with him. Rehab Director F reported he went out of the building and walked with him until Household Coordinator E came and redirected Resident #100 into the building. Rehab Director F reported that Resident #100 was seen approximately 1-2 minutes after the fire alarm sounded. During an interview on 10/12/16 at 9:59 a.m., Household Coordinator E reported that while the fire alarms were sounding she was up in the main lobby and noted Resident #100 outside with Rehab Director F so she went out to help redirect Resident #100 into the building. During interviews on 10/12/16 at 1:08 p.m. and 3:05 p.m., CNA H reported that she was in the common area at the time of the fire drill keeping track of residents and did not remember that the fire doors were unlocked during a fire drill. CNA H reported that she was just keeping track of the residents in the common area, not watching the exit doors. CNA H reported that 2 other staff members were shutting doors and then someone said this was not a real fire drill so they stopped checking rooms and closing doors. CNA H reported that CNA C heard a door sound that was different and ask where Resident #100 was. CNA H went to look in his room and other resident rooms and then left by the east exit to the outside and turned left towards the gardens where Resident #100's wife usually walks him, did not find him. CNA H then went on the sidewalk towards the parking lot and ran into Rehab Director F who informed her that Resident #100 had been located and was back in the building. During an interview on 10/12/16 at 1:05 p.m., CNA D reported that when the fire alarm sounded she was shutting doors to resident rooms. CNA D reported that a staff member was always supposed to be in the common area with the residents. During an interview on 10/12/16 at 1:22 p.m., CNA M reported that she started check rooms and closing residents doors after the fire alarm sounded, but was told it was just a drill and left the unit to go to lunch. On 10/12/16 at 3:45 p.m., Administrator A was notified of the Immediate Jeopardy that began on 9/12/16 at approximately 3:05 p.m., when the facility failed to secure the fire doors and prevent the elopement of Resident #100. On 10/12/16, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 9/12/16 at approximately 3:05 p.m. Resident #100 was found and returned to his unit. 10 of 10 residents of the unit were identified to be at potential risk for elopement were accounted for. 2. On 9/12/16 the Facility Fire Emergency Procedures were reviewed and the procedures were updated on 9/13/16 to state that a staff member takes responsibility for the doors and places themselves in front of the East glass exit door to monitor the residents and ensure that no residents exit the facility. 3. On 9/13/16, 146 of 146 staff members were informed through messaging system of the elopement incident and the policy change in the emergency procedures for fire. The changes to the procedure were highlighted and placed on the memory unit for staff reference. 4. Between 9/14/16 -9/21/16, group mandatory staff meetings included the new Fire Emergency Procedure updated 9/13/16. 5. On 9/13/16 monitoring by Administration and Household Coordinator began. 6. On 9/21/16 a fire drill was conducted and the new procedure was followed correctly. 7. On 9/15/16 the Quality Assurance Committee reviewed the incident from 9/12/16, the policy change, and the education, and will continue to monitor. A Past Noncompliance was accepted to remove the Immediate Jeopardy as of 9/14/2016. At that time, the facility was deemed to be in substantial compliance with federal regulatory requirements.

Complaint Intake Number: MI 043 Based on observation, interview, and record review, the Facility failed to prevent staff-to-resident physical abuse in 1 of 4 sampled residents (Resident #101), from a total of 4 sampled residents, resulting in actual harm; a [MEDICAL CONDITION] and fractured arm. Findings include: Per the Incident Report dated 6/18/12 Resident #101 fell to the floor in the corridor on 6/18/12 and was sent to the hospital where she was diagnosed with [REDACTED]. Per the Investigation Summary (not dated) "Further investigation and review of surveillance video footage revealed that (Nurse Aide #30) pushed resident (#101) prior to closing the door of room [ROOM NUMBER], resulting the fall to the floor. On 7/11/12 an observation of the Surveillance Video dated 6/18/12 starting at 3:11:00 was conducted by this surveyor along with the Acting Administrator who identified the persons seen in the video. At 3:11:02.517, Nurse Aide #30 and Resident #104 entered the frame at the top of the screen, walking in the corridor from the residents' common area towards the camera which was located at the end of the corridor. At 3:11:08.913, Resident #104 and Nurse Aide #30 stopped and turned towards the couch (back of which was visible) at the edge of the resident common area. The video from a second surveillance camera showed Resident #101 who had been seated on the couch, got up and had a conversation over the back of the couch with Nurse Aide #30. As Nurse Aide #30 and Resident #104 turned and resumed walking down the corridor Resident #101 rounded the couch and followed them. At 3:11:32.531, Resident #104 entered her room while Nurse Aide #30 was still in the corridor behind her and Resident#101 continued walking towards them. At 3:11:34.029, Resident #104 was no longer visible, and Nurse Aide #30 turned towards Resident #101 who continued walking towards her. In the video, from 3:11:36.837 to 3:11:41.236, Resident #101 and Nurse Aide #30 were in physical contact with one another. Resident #101 reached out with her right hand to Nurse Aide #30 who put her left hand up (as if "stop"), Resident #101's right hand connected with Nurse Aide #30's left hand. Nurse Aide #30 pulled her left hand towards her chest then while Resident #101's right arm rested on Nurse Aide #30's left arm. Nurse Aide #30 lifted her left hand which caused Resident #101's right arm to rotate and lift at the shoulder. Nurse Aide #30's left hand moved onto Resident #101's right arm or hand and Resident #101's upper body began to turn to her right at the waist while her feet remained in place. At 3:11:41.330, Nurse Aide #30 leaned towards Resident #101 with her left arm raised. At 3:11:41.532, Resident #101 pulled her right arm back and away from Nurse Aide #30 and raised her hand in a fist. Nurse Aide #30 continued forward motion towards Resident #101 (her foot lifted from the floor). At 3:11:41.938, Nurse Aide #30's left foot moved toward Resident #101 as her left arm moved towards Resident #101's chest and Resident #101 turned and took a step away from Nurse Aide #30. At 3:11:42.032, Nurse Aide #30 shoved Resident #101. At 3:11:42.437, Resident #101 began to lose her balance. She stretched her right arm out to her right as she pivoted away from Nurse Aide #30 who reached forward and leaned towards Resident #101. Nurse Aide #30 rocked back on her feet and flung her left hand and arm to her left (as if 'shooing' a fly). By 3:11:42.531, Resident #101's body was falling with her upper body turned to her right. Her left foot was off the floor and her left leg was bent at the knee and hip and crossed over the right leg while her right leg remained in position. Nurse Aide #30's left hand continued the flinging motion and her head was turned to Resident #101 (if her eyes were open she had to see Resident #101 falling). At 3:11:43.030, Resident #101's right hand and knee were inches from contact with the floor and Nurse Aide #30's head began to turn to her right. At 3:11:43.436, Resident #101 was lying on the floor and Nurse Aide #30 had crossed the threshold to enter Resident #104's room. At 3:11:46.540, Resident #101 was alone, lying on the floor and the door to Resident #104's room was shut. At 3:11:48.537 Nurse Aide #11's feet are visible at the top of the screen as she ran towards Resident #101. At 3:11:49.535, as Nurse Aide #11 was almost at Resident #101's body, the door to Resident #104's room opened a crack. At 3:11:51.735, as Nurse Aide #11 walked around Resident #101's head, Nurse Aide #30 began to cross the threshold to exit Resident #104's room. At 3:12:51.077, Nurse Aide #30 and Resident #104 were almost out of the upper frame (their feet were still visible near the back of the couch in the common area at the top of the frame) and LPN #13 & LPN #14's feet are visible entering the frame walking towards Resident #101 and Nurse Aide #11. In an interview on 7/10/12 at 3:38 p.m., Nurse Aide #11 said on 6/18/12 while she was in room [ROOM NUMBER] she heard an audible fall alarm sound which alerted her Resident #104 had stood up somewhere within hearing distance and then heard Resident #101's fall alarm (via the pager) which alerted her Resident #101 had stood up. Nurse Aide #11 said she could not leave room [ROOM NUMBER] as she had just entered there in response to a fall alarm sounding. Nurse Aide #11 said she ensured the safety of the resident in room [ROOM NUMBER] and upon exiting the room saw Resident #101 lying crosswise alone on the corridor floor on her right side with her back towards Nurse Aide #11. Nurse Aide #11 said, "When I got to her she was groaning. I called out for help. (Nurse Aide #30) responded, she came out of (Resident #104)'s room with (Resident #104). She walked (Resident #104 past them) to the couch and then came back. I told her to get the nurse. (Resident #101) was groaning and saying, 'It hurts!' I asked her 'Where does it hurt?' and she said 'My arms hurt! My legs hurt!' She was groaning. (Licensed Practical Nurse/LPN #13) got there incredibly fast...2 other nurses came too...they assessed her...we 5-person carried her on a sling to her bed...the nurses called for an ambulance. (Nurse Aide #30) said (Resident #101) was 'trying to follow us' into (Resident #104)'s room." In an interview on 7/10/12 at 4:06 p.m., LPN #13 said on 6/18/12 Nurse Aide #30 came to the office door as she and LPN #14 met for change of shift report and "said there was a fall." LPN #13 said she and LPN #14 immediately were "up and out the door." LPN #13 said she saw Resident #101 lying crosswise on the corridor floor "facing away. (Nurse Aide #11) was crouched beside her-trying to reassure her. (Nurse Aide #30) didn't say anything. (Resident #101) complained of pain in the hip she was laying on and her pelvis and shoulder. Later she said her right wrist hurt. All on the same side she was laying on. She said she hurt all over...We log rolled her onto a mat and 4-manned her onto a bed...when (Resident #101) was gone to the hospital (LPN #14, Nurse #15) and maybe the Social Worker watched the (video surveillance) tape. We wanted to see if (Resident #101) bumped her head. We saw (Resident #101) coming after (Resident #104). She went the same way they went. We saw (Resident #101) putting her hands onto (Nurse Aide #30), trying to get at (Resident #104). (Nurse Aide #30) pushed (Resident #101) away and then stepped into (Resident #104)'s room and pulled the door shut." In an interview on 7/11/12 at 12:27 p.m., LPN #14 said on 6/18/12 Nurse Aide #30 "came and reported a fall" as she and LPN #13 were in the nurses' office conducting change of shift report. LPN #14 said Nurse Aide #30 "said, 'I didn't see her fall.' We went to (Resident #101)." LPN #14 said she and Nurse #15 assisted LPN #13 to assess and transfer Resident #101 to the hospital. Per the hospital x-ray's dated 6/18/12, Resident #101 sustained an acute fracture to her to the head of her right femur (top leg bone), a fracture to the end closest to her wrist of her right radius (lower arm bone) and a possible fracture to the right ulnar (other lower arm bone) close to the wrist. A CT scan of her head was inconclusive as "chronic small vessel ischemic changes seen could obscure a small underlying acute or subacute subcortical infarct (rupture of a blood vessel in the brain)." Per the hospital Physician's Progress Note dated 6/20/12, Resident #101 "underwent open reduction internal fixation of the right femoral neck fracture by Dr. (name) yesterday." Per the Physician's Progress Note dated 6/25/12, Resident #101 "complained of pain in her hip-right-secondary to recent fall...pain is severe with movement..." Per the Facility's Admitting History and Physical dated 6/27/12, Resident #101 was an [AGE] year old female with "fairly advanced dementia" who "fell on [DATE]th sustaining an impacted subcapital right femoral neck fracture and an angulated interarticular [MEDICAL CONDITION] right radius. The hip was treated surgically with ORIF and the hand/wrist was placed in a brace. Since back she has had some pain and we are trying to get the [MEDICATION NAME] dosing optimal. She has just started working with therapies and that certainly has increased her pain somewhat...Currently she is not bearing weight at all..." even though she was allowed weight bearing as tolerated. Review of Resident #101's Medication Administration Records (MAR) revealed prior to the fall on 6/18/12, she took Tylenol Extra Strength 500 mg 2 tablets routinely 3 times a day. No extra Tylenol doses or other pain medication was documented on the MAR from 6/01/12-6/18/12. Per the Nurses' Notes dated 6/22/12 Resident #101 was readmitted at 6:00 p.m. with a "brace on right arm" and "a 3.0 cm slit midline between coccyx healed with faint white area, bruise to left hand 4.0 cm x 2.0 cm purple in color, bruise to forearm 16 cm x 12 cm purple in color, and many other bruises." At 7:00 p.m. she "complained of pain, moaning and crying. Medicated with [MEDICATION NAME] and Tylenol for fever 100.2 (earlier) comfortable at this time in common area although infrequently tearful when alone." Per Resident #101's MAR initiated on readmission on 6/23/12, she received the pain medication [MEDICATION NAME] 50 mg and Tylenol 650 mg on 6/23/12 and 6/24/12. From 6/25/12 through 7/11/12 continued to receive Tylenol Extra Strength 500 mg 2 tabs 3 times a day and she received extra doses of Tylenol 650 mg on 6/27/12 and 6/30/12. On 6/25/12 the [MEDICATION NAME] 50 mg was changed from PRN (as needed) to routine twice a day. Extra doses of [MEDICATION NAME] were also given on 6/25/12, 6/26/12, 6/27/12 and twice on 6/29/12. On 6/27/12 the frequency of [MEDICATION NAME] administration was increased from 2 to 3 times a day. Per Resident #101's July 2012 MAR she continued to receive [MEDICATION NAME] 50 mg 3 times a day routinely and had extra doses on 7/2/12, 7/4/12 (twice), 7/5/12, 7/9/12 and 7/10/12 for "right hip pain." Per the Nurses' Notes dated 6/24/12 the incision on Resident #101's right hip was "clean, dressing dry and intact, sutures intact, some puffiness toward top of incision,...brace remains on to right wrist-fingers less puffy today..." Per the Nurses' Notes dated 7/02/12 the sutures were removed from Resident #101's right hip. In an observation on 7/10/12 at 3:25 p.m., Resident #101 was seated in the common area on the locked dementia unit looking at a story book with Nurse Aide #31 and talking about going fishing. Resident #101 wore a brace on her right arm/hand. When asked why she wore the brace Resident #101 said, "I broke my arm. I fell down." Resident #101 denied she was pushed to the floor and said her injury "has nothing to do with fishing". When asked if she had pain Resident #101 said, "Yes." Resident #101 said her pain was due to "arthritis" and said "yes" the pain medication helped relieve the pain. Resident #101 denied having had a [MEDICAL CONDITION] and denied having had hip surgery. Per the Minimum (MDS) data set [DATE] Resident #101's [DIAGNOSES REDACTED]. Per the Minimum (MDS) data set [DATE] Resident #101's cognitive status had declined (score of 3 out of a possible 15) and she was unable to ambulate. Review of Nurse Aide #30's employee file revealed she was hired 9/16/1996; she was rated as "commendable" or "outstanding" in all categories on her most recent performance appraisal dated 8/12/2011; and her employment was terminated on 6/19/2012. Per the Criminal Check Nurse Aide #30 was arrested on 7/03/12. In an interview on 7/10/12 at 3:00 p.m. the Acting Administrator said Nurse Aide #30 was charged with a second degree felony-elder abuse and because it was an open case the police department would not release a copy of their report. Due to the criminal charges no attempt was made to contact Nurse Aide #30 for an interview. ( )