Every finding on record at Applewood Nursing Center, Inc

Based on interview and record review the facility failed to honor R907's documented advance directive and failed to ensure the resident's right to refuse resuscitative efforts. R907 signed a code status form on [DATE] selecting a do not resuscitate (DNR) choice. According to progress notes dated [DATE] at 5:26 AM, the resident was found unresponsive and without a pulse. The resident was subjected to unwanted CPR (chest compressions, intravenous fluids, epinephrine three times) from 5:26 am to 6:00 am until emergency medical services (EMS) stopped the code, despite previously expressing a desire to forgo resuscitative measures. The facility's failure to honor R907's documented DNR choice resulted in the resident receiving unwanted resuscitative treatment and created a likelihood of serious physical and psychological harm, constituting immediate jeopardy.Findings include:The Immediate Jeopardy began on [DATE] when the facility failed to honor R907's documented advance directive and failed to ensure the resident's right to refuse resuscitative efforts. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were issued notification of the immediate jeopardy on [DATE] at 4:56 PM.Record review of R907's electronic medical record (EMR) revealed an original admission into the facility on [DATE] and readmission on [DATE] with a pertinent diagnosis of chronic respiratory failure with hypoxia (body tissues do not receive enough oxygen).Record review of R907's Brief Interview for Mental Status (BIMS) dated [DATE] at 9:12 AM, R907 scored 15 out of 15 indicating intact cognition.Record review of R907's Determination of Ability or Inability to Participate in Medical Treatment decisions form revealed the attending physician determined R907 was able to participate in medical treatment decisions. The form was signed by the attending physician on [DATE].Review of R907's Code Status Form revealed R907 selected the option indicating a choice to not be resuscitated. The form documented, in part: that if in event my heart and /or breathing should stop; no person shall attempt to resuscitate me. The document was signed by the attending physician on [DATE] and signed by R907 on [DATE].Review of R907's physician orders revealed an existing order for Code Status: Full Code (provide treatment to sustain life) dated [DATE], with no end date. An additional full code order was entered on [DATE]. Further review revealed no corresponding DNR order had been entered into R907's electronic medical record following the completion of the Code Status form.Review of R907's care plans revealed a full code care plan was initiated on [DATE] and resolved on [DATE]. A DNR care plan was subsequently initiated on [DATE].Record review of R907's progress notes documented on [DATE] at 6:33 AM, . At 5:25 am writer walked into Pt's room, Pt unresponsive, no pulse, code called, CPR immediately started, EMS arrived at 5:31am, IV (intravenous) inserted 5:36 am, fluids started at 5:45 am, epi (epinephrine) 1 at 5:48 am, IV line at 5:50 am, epi 2 at 5:52 am, epi at 5:57 am. Code stopped at 6am.An interview was conducted on [DATE] at 1:31 PM, the DON confirmed R907 had signed documentation indicating a DNR choice; however, the resident's wishes were not honored on [DATE], and CPR was performed by facility staff and EMS. The DON further reported that the facility was unaware, until the survey investigation, that R907's DNR choice had not been honored. The DON acknowledged that a DNR physician order should have been entered when the resident's new code status was completed to ensure staff were aware of and could implement the resident's wishes.An interview was conducted on [DATE] at 11:30 AM with NHA and it was reported that R907's DNR status should have been followed, and CPR should not have been initiated.An interview was conducted on [DATE] at 2:01 PM, the Medical Director reported R907's DNR status should have been reflected in the physician orders to ensure staff were aware of the residents' wishes.Record review of facility's policy Residents Rights dated 4/26 documented, . Choose a physician and treatment and participate in decisions and care planning. Further review of facility's policy Advance Directive dated 8/25 documented, . A Do Not Resuscitate is a physician's order that communicates that CPR is not to be performed.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:All current residents' code status and physician orders were reviewed by the facility.Education was provided immediately to ensure that staff are aware that all code statuses need to be updated.Education was provided to staff immediately to ensure that any updated code statuses will need to have a matching order.Education was provided for all nurses. No staff member was allowed to work in the facility until they have completed the necessary education.A QA Tool was developed to ensure residents have orders that match the code status and ensure the EHR (electronic health record) reflects the updated code status. This tool will be used weekly for 4 weeks to ensure compliance, and as needed after 4 weeks, as directed by the QAPI committee.

This citation pertains to Intake 3034845. Based on observation, interview, and record review, the facility failed to provide a homelike environment by not ensuring an adequate supply of clean washcloths and towels were available for nine residents (R2, R4, R14, R15, R24, R30, R77, R91, and R57) reviewed for care, resulting in resident feelings of frustration and unmet care needs. This deficient practice has the potential to affect all 138 residents who resided in the facility during the time of survey.Findings include: A review of an anonymous complainant revealed the following: . Staff members have reported ongoing shortages of basic hygiene supplies, including washcloths, towels, and clean linens. Due to these shortages, staff have been forced to use pillowcases to clean residents who have soiled themselves. In some cases, bed baths are reportedly being given using hospital gowns, and residents are not receiving proper showers because there is not enough clean linen available. R91 On 6/09/26 at 7:40 AM, R91 was observed in bed writing in a notebook. R91 was receiving enteral nutrition via a Gastrostomy Tube (G-tube- into the Stomach). R91 was asked about their care at the facility. R91 said, They run out of towels and washcloths all the time.Sometimes I hold on to my towels and washcloths so I can use them again. A review of R91's electronic medical record (EMR) revealed an admission to the facility on 2/04/2026 with the diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Heart Failure, Cardiac Pacemaker, G-Tube, and Weakness. R91 has a Brief Interview for Mental Status score of 15/15 (cognitively intact with normal thinking, learning, and memory skills) dated 5/14/2026. A review of R91's care plan revealed the following: Self care deficit, require assist with ADL (activities of daily living) r/t (related to) limited mobility, debility, and impaired balance Date initiated 2/03/2026). I prefer a shower twice weekly, if I cannot tolerate a shower offer me a bed bath instead dated 3/05/2026. On 6/10/2026 at 9:12 AM, an observation of Station One's linen cart revealed three towels and two washcloths. On 6/10/2026 at 9:31AM, an observation of Station Two's linen cart revealed zero towels and zero washcloths. On 6/10/2026 at 9:48 AM, an observation of Station Three's linen cart revealed zero towels and zero washcloths. On 6/10/2026 at 11:15 AM, an interview was conducted with four Certified Nurse Assistants (CNA) who requested to remain anonymous secondary to fear of retaliation. The CNAs were asked if they have sufficient towels and washcloths to perform daily resident care. The CNAs said they do not regularly have enough linen. The CNAs said they usually have to go look for washcloths and towels or cut up towels, sheets, and pillowcases to perform resident care. On 6/10/2026 at 11:40 AM, Laundry Supervisor D was interviewed and asked to view their soiled linen bin, clean linen, and new linen. The soiled linen bins were empty; there was a load of towels and washcloths in the dryer. In the storage room, there was a total of 480 new washcloths and 240 new towels. The residents census on 6/10/2026 was 139. Laundry Supervisor D was asked who was responsible for ordering the facility's linen. Laundry Supervisor D said the previous NHA (Nursing Home Administrator) ordered the linen but no longer works at the facility. Laundry Supervisor D added that she did not have computer access to order linen. Laundry Supervisor D said they've been in the supervisor role for about six months. Laundry Supervisor D was asked how often they check linen inventory on each unit and if the facility had a ratio to determine the number of bath linens needed per resident. Laundry Supervisor D acknowledged to not conducting inventories of linens and being unaware of the exact number of linens needed for the current resident census. In nursing homes, the linen ratio refers to the target par levels needed to maintain operations. On 6/11/2026 at 8:38 AM, an observation of Station One's linen cart revealed five towels and four washcloths. On 6/11/2026 at 8:45 AM, an observation of Station Two's linen cart revealed five towels and six washcloths. On 6/11/2026 at 8:54 AM, an observation of Station Three's linen cart revealed zero towels and zero washcloth. On 6/11/2026 at 09:15 AM, Laundry Supervisor D was queried about the shortage of bath linens on the units. Laundry Supervisor D stated, I just opened my last two boxes of towels to place on the units. Now I have none and will have to order two boxes (240 total) of towels. On 6/11/2026 at 10:04 AM, a License Practical Nurse (LPN) was interviewed and asked if they have enough linen on the unit for care. The LPN (did not want to be identified) said that they usually don't have enough washcloths. R24 On 6/11/2026 at 11:10 AM, R24 was observed sitting on the side of the bed watching TV. R24 was interviewed and asked if they had enough linen for care. R24 stated, They never have enough washcloths. I sometimes have to use the same face towel for 2-3 days.The therapist gave me about five washcloths back in May to keep in my drawer for emergencies.I feel like they don't care.linens are simple stuff to have. A review of R24's EMR revealed an admission to the facility on 3/19/2026 with the diagnoses of Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Anemia. R24 has a Brief Interview for Mental Status score of 14/15 (cognitively intact) dated 3/23/2026. A review of R24's Care plan revealed the following: Self care deficit, require assist with ADLs r/t limited mobility dated 3/16/2026.I need limited assist with 1 person to help me. Dated 3/16/2026. R15 On 6/11/2026 at 11:15 AM, R15 was observed in bed looking at a magazine. R15 was interviewed and asked if they had enough linen for care. R15 stated, We don't have enough towels and washcloths .I sometimes hide washcloths so I can take my shower.I'm mad.we pay a lot of money to live here and it's not right. A review of R15's EMR revealed an admission to the facility on 8/29/2017 with the diagnoses of Functional Quadriplegia, Anxiety, and Multiple Sclerosis. R15 has a Brief Interview for Mental Status score of 15/15 (cognitively intact) dated 5/17/2026. A review of R15's Care plan revealed the following: Self-care deficit, require assist with ADLs r/t limited mobility dated 3/16/2026.I need extensive assist with 1 person to help me. Dated 2/27/2025. On 6/11/2026 at 11:40 AM, the NHA (Nursing Home Administrator) was interviewed and queried about the status of linen, including towels and washcloths for resident care and if there was a laundry procedure manual available. The NHA stated, I just started working here.(Laundry Supervisor D) did not know there was a budget for linens. The NHA was asked if there was a linen ratio per resident. The NHA was unaware of the number of linens needed for the current resident census. The NHA added that he had never heard of a linen ratio and would search the internet for answers. On 6/11/2026 at 12:47 PM, the Director of Nursing (DON) was interviewed and queried about the availability of towels and washcloths. The DON said, Staff are throwing washcloths in the trash and cutting-up linens. The previous administrator left in April (2026) .We ordered 240 washcloths in May (2026) and 480 towels in the month of May (2026).(Laundry Supervisor D) was new to the position, having been moved from the role of CNA to Laundry Supervisor . (Laundry Supervisor D) is doing their best. A review of the facility's policy Laundry Staff (undated) revealed the following: Duties: Maintain a monthly housekeeping/laundry purchase log and weekly reports.Develop and maintain a housekeeping and laundry procedure manual.quarterly linen inventory. A review of the facility's policy Linen, Reviewed: 3/22; 4/26, revealed the following: POLICY: Guests will have clean linen available.A clean washcloth and towel will be provided daily to each guest. A review of the Accreditation Standards for Processing Reusable Textiles for Use in Healthcare Facilities 2023 Edition, Implementation Date: January 1, 2023, revealed the following: 1.3. Provider Inventory Management 1.3.1. The provider.shall jointly determine the par level for the facility, whereupon the provider shall use an inventory management system that ensures an adequate supply of clean textiles to meet the customer's needs. 1.3.2. Methods to ensure that an adequate supply of textiles is available to the provider and customer shall include documentation of historical fill rates for rental operations and/or 1.3.3. The provider and customer shall document in writing the provision of inventory for situations where increased need (e.g., surge capacity in response to a disaster) is anticipated and what adjustments are acceptable. R57 On 6/10/2026 at 9:14 AM, R57 was interviewed about care at the facility and stated, They don't always have enough linens. I didn't have a facecloth last night to wash my face before bed. R57 was alert and oriented to person, place, and time at the time of the interview. Record review of R57's EMR revealed admission to the facility on [DATE] with diagnoses which included Muscle Weakness, and Paraplegia. Review of the MDS dated [DATE] for R57 revealed moderate cognitive impairment and max assist for transfers and wheelchair bound. R2 On 06/11/2026 at 2:34 PM, R2 was interviewed and reported the facility does not have enough linen. It was further reported witnessing staff cut sheets and pillowcases up to make wash clothes. Record reviews of electronic medical records revealed R2 was admitted into the facility on 3/28/23 with a pertinent diagnosis of diabetes. According to Brief Interview of Mental Status (BIMS) dated 3/23/26, R2 scored 15 out of 15 (intact cognition). R4 On 06/11/2026 at 12:08 PM, R4 reported that facility is constantly out of towels and linens. Record reviews of electronic medical records revealed R4 was admitted into the facility on [DATE] with a pertinent diagnosis of diabetes. According to Brief Interview of Mental Status (BIMS) dated 4/3/26, R4 scored 15 out of 15 (intact cognition). R14 On 06/11/2026 at 9:41 AM, R14 reported that the facility is constantly out of linens, towels, and washcloths. R14 added, it was brought up in resident council last month. Record review of R14's electronic medical record (EMR) revealed admission into facility on 10/11/24 with a pertinent diagnosis of Rheumatoid Arthritis of right and left hands. According to the Brief Interview for Mental Status (BIMS) dated 5/4/26, R14 scored a 14 out of 15 (intact cognition). R77 On 06/10/2026 at 12:27 PM, R77 was interviewed and said that he receives a shower twice a week. R77 stated, I didn't receive a shower two weeks ago because staff told me they didn't have any linen available. Record review revealed an admittance date of 10/28/2024 and a Brief Interview of Mental Status score of 15/15 signifying cognitively intact. Record review of Care Plan revealed: Personal hygiene: I need set up assistanceDate Initiated: 04/08/2025 R30 On 06/11/2026 at 12:10 PM, R30 was interviewed in his room. Queried R30 about activities of daily living skills, needs, services and concerns. R30 stated, They tell me they are out of linen all the time. R30 further stated, I don't see too good. I have cataracts, my eyes water and they get crust around them. I need clean wash cloths to wash my face and they never have them available, so I just stopped asking! Record review revealed R30 was admitted to this facility on 05/20/2026, has a Brief Interview of Mental Status score of 15/15 indicating intact cognition. Record review of Care Plan revealed: The resident has impaired visual function r/t CataractsDate Initiated: 05/22/2026 On 06/11/2026 at 12:20 PM, Nurse I was interviewed and stated, I used a pillowcase to wash up a resident when washcloths were unavailable. Nurse I said that the facility runs out of linen quite often and sometimes there's a 1-2 hour wait for clean wash cloths and towels especially during the night shift. Nurse I also stated, Some CNA's (Certified Nursing Assistants) have started buying wipes themselves to use a backup when linen isn't available. Queried about expectations of available linen. Nurse I stated, We need access to supplies in order to do our job. Review of the facility policy entitled, Linen revised on 3/22 and reviewed 4/26 read in part: Policy: Guests will have clean linen available . Procedure: 5. A clean washcloth and towel will be provided daily to each guest. According to the facility policy, one face cloth and one towel should have been available for 138 residents for each day. Moreover, the policy did not address dependent residents who are checked and changed every two hours by staff (who may require additional bath linens) nor did the facility policy address fresh towels or the preferred number of towels to use when washing per resident preference (which may also require additional bath linens).

Based on observation, and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 06/10/2026 at 10:23 AM observed three dirty linen carts in the laundry dirty linen sorting room. One cart was observed with torn siding exposing the underlying wire frame. Another cart was observed with an opening along the bottom side edge creating a hole through which the floor was visible.On 06/10/2026 at 10:26 AM observed a clean linen cart with creases running through the wood panel false top and cracked and splintered wood on the top sides of the board. In an interview at this time regarding cleaning frequency, Housekeeping and Laundry Supervisor (HLS) D indicated the cart is cleaned daily. HLS D indicated they are talking about getting a new one.On 06/10/2026 at 10:43 AM observed water spraying from the Atmospheric Vacuum Breaker (AVB) when water was turned on in the station two janitor closet. On 06/10/2026 at 10:49 AM observed no holder for the shower head faucet in a shower stall in the station three shower room.On 06/10/2026 at 10:50 AM an interview with HLS D was conducted regarding cleaning of shower rooms. HLS D indicated housekeepers clean twice a day and aids clean after themselves and shower equipment. On 06/10/2026 at 10:51 AM observed paint scratches on the seat of the shower room toilet and the toilet seat removed in the station three shower room. In an interview at this time, HLS D indicated the seats were removed to make room for the commode to fit over. Further observation found the commode padding worn with paint peeling on the top surface of the pad exposing the cushion padding beneath.On 06/10/2026 at 10:53 AM observed several foot pedals laying on the ground by the drain in the station three shower room. On 06/10/2026 at 11:15 AM observed no caulking around the hand sink faucet and the fixture loose to mount and able to be moved around in the station two shower room. On 06/10/2026 at 11:20 AM observed the holder for the shower head faucet broken and inoperable in a shower stall in the station two shower room. Further observation found paint scratches around the rim of the toilet exposing the metal surface on the toilet, and the toilet seat missing.On 06/10/2026 at 11:22 AM observed the cold water handle release a trickle of water when turned on in the station one shower room hand sink.On 06/10/2026 at 2:07 PM observed dirt and debris accumulated at the bottom of three of the dirty linen sorting carts in the soiled linen sorting room. A glove was observed in one cart and black debris accumulated along the edges.On 06/10/2026 at 2:13 PM observed several foot pedals on the floor in the station three shower room near the drain.

Based on observation, interview and record review, the facility failed to implement and maintain an effective infection prevention and control program by failing to maintain an active water management plan to reduce the risk of Legionella (bacteria) and other opportunistic pathogens of premise plumbing (OPPP), and failing to ensure enhanced barrier precautions (EBP) were utilized during medication administration for one resident (R7) out of six residents reviewed for medication administration. These deficient practices had the potential to promote the growth and transmission of infectious organisms within the facility's environment and during resident care, placing all residents at increased risk for infection and disease transmission.Findings include: On 06/10/2026 at 10:22 AM observed a plastic bag with trash inside covering the utility sink basin in the laundry dirty linen sorting room. In an interview at this time, when asked how often the sink is used, Housekeeping and Laundry Supervisor (HLS) D indicated they do not use the sink very often. On 06/10/2026 at 10:39 AM observed a wood structure built under the utility sink faucet in the station two janitor closet near resident room [ROOM NUMBER]. When the faucets were turned on, discolored brown water was observed coming from the hot and cold faucet and collected in a bin. No drain was visible. On 06/10/2026 at 11:18 AM observed a functional therapy tub connected to the water supply in the station two shower room. In an interview at this time, HLS D indicated the tub has not been used in years. On 06/10/2026 at 11:26 AM observed a functional water fixture with no hose or faucet attached, located on the adjacent wall to the clean linen cart in the station one shower room. A chair was observed in front of the fixture, blocking access. On 06/10/2026 at 1:22 PM an interview was conducted with Nursing Home Administrator (NHA) and Regional Director of Operations (RDO) E regarding water management. When asked about team members on the water management program, RDO E indicated the maintenance director and two maintenance techs are on the team. On 06/10/2026 at 2:40 PM an interview was conducted with Maintenance Director (MD) C regarding water management. When asked who is on the water management team, MD C indicated they are currently the only one on the team. When asked about control measures in place to reduce the growth of legionella, MD C indicated they flush water fixtures in rooms that have been unoccupied for a week. When asked if there are any other fixtures that are a part of flushing, MD C indicated they only flush empty rooms and eyewash stations and everything else tends to get used. MD C indicated they take chlorine tests weekly around the facility and measure total chlorine on cold water and free chlorine on hot water fixtures. When asked what the boiler is set to, MD C indicated they were not sure. When asked if there is a flow diagram of how water moves through the system, MD C indicated not from their knowledge. When asked about the therapy tub, MD C indicated it is not used because it has no drain and leaks onto the floor. On 06/10/2026 at 3:29 PM observed a functional water fixture with no hose or faucet attached, located on the adjacent wall to the clean linen cart in the station one shower room. MD C indicated they did not know why the fixture was like that. Record review of the facility provided policy titled Legionella & opportunistic pathogens dated 4/16/25, includes steps in procedure, A Water Management Team will be formed which will include; [NAME] President or designee, Infection Control Preventionist, DHS, Maintenance Director, General Manager, City Director of Water Management. Record review of the facility provided document titled Water Management Plan Symphony Applewood lists Maintenance Director as the sole member on the team. Listed under the creation of HACCP (Hazard Analysis Critical Control Point) program documents was, Process Flow Diagrams (potable and Utility). A flow diagram was not present within the binder, and the potable water process flow diagram page was blank. Hazard analysis lists the tankless hot water heaters and hot water tank heater as a processing step. Under risk basis states, There is potential for microbial growth at the heating step. This is reduced at temperatures > 124 degrees F. An observation on 6/10/26 at 12:04 PM revealed signage at entrance of R7's room to remind staff to wear enhanced barrier precautions was posted. An observation on 6/10/26 at 12:05 PM during medication administration for R7, Licensed Practical Nurse (LPN) F entered resident's room to administer medications through R7's gastric tube (G-tube, a device surgically inserted into the stomach to provide nutrition and medications). During the observation LPN F was seen handling the g-tube while administering the medication. LPN F did not apply a gown during this procedure. Record review of electronic medical records (EMR) revealed R7 was admitted into facility on 1/2/25 with a diagnosis of functional quadriplegia (paralysis of all four limbs) and gastrostomy placement (feeding tube). According to the Minimum Data Set (MDS) dated [DATE], R7 was dependent on all activities of daily living. An interview on 6/10/26 at 12:30 PM, LPN F, reported that enhanced barrier precautions should be utilized when administering medication to a resident with a gastric tube. Record review of physician orders documented, Maintain enhanced barrier precautions to prevent infections r/t (related to) peg tube, wounds. Dated 3/27/26. Record review of R7's care plans dated 3/27/26 revealed EBP should be worn for G-Tube and wound care. An interview conducted on 6/10/26 at 1:00 PM, the Director of Nursing reported that the nurse should wear EBP when administering medication to a resident with a g-tube. Record review of facility's policy Enhanced Barrier Precautions dated 2/2026 documented, .When a resident is placed in Enhanced Barrier Precautions gown and gloves will be used during high-contact resident care activities. (Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing).

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 06/10/2026 at 8:21 AM an interview was conducted with Dietary Manager (DM) A regarding labeling and date marking. DM A indicated food items are dated when they come in if a date is not on the packaging. Then, an open date, and a discard date are placed on food items. On 06/10/2026 at 8:33 AM observed a missing hot water handle on the sink next to the dishwasher. In an interview at this time, when asked how long it had been broken, DM A stated a little while. When asked if a work order had been submitted, DM A indicated they have not submitted a request. On 06/10/2026 at 8:40 AM observed the three compartment sink drain lines for the wash, rinse, and sanitize basin all drain to a common line and discharge into the floor with no air gap present. On 06/10/2026 at 8:41 AM observed the drain line from the prep sink lead into the floor with no air gap present. On 06/10/2026 at 8:42 AM an interview with DM A was conducted regarding the drain lines. DM A indicated they changed the system from what it used to be. When asked about the three compartment sink, DM A indicated the drain line from the three compartment sink leads to the prep sink drain line. On 06/10/2026 at 8:52 AM an interview was conducted with DM A regarding cleaning of the ice machine. DM A indicated maintenance is responsible for cleaning the ice machines once a week or every two weeks. On 06/10/2026 at 8:53 AM observed a puddle of water in front of the ice machine in the station one kitchenette. Further observation found the drain line from the ice machine lead into the floor drain and terminate below the flood rim creating an improper air gap. On 06/10/2026 at 8:56 AM observed dried food debris at the bottom of the utensil bin in the station one kitchenette. In an interview at this time, when asked about cleaning frequency of the bin, DM A indicated it is cleaned every couple of weeks. On 06/10/2026 at 9:03 AM observed a pool of sticky brown residue behind the microwave and coffee machine in the station one kitchenette. On 06/10/2026 at 9:04 AM observed a crack forming along the surface of the service table at the station one kitchenette. Within the crack was an area of elevated surface and a section of the finish and underlying wood missing. The wood surface was visible and splintered making it no longer smooth and easily cleanable. DM A indicated that was a new spot. On 06/10/2026 at 9:08 AM observed a puddle in front of the ice machine in the station two kitchenette. The ice bucket that holds the ice scoop was observed with black residue along the bottom of the bucket. In an interview with DM A at this time when asked how often the bucket is cleaned, DM A indicated every couple of weeks. On 06/10/2026 at 9:10 AM observed brown residue buildup along the white drip tray on the inside of the ice machine in the station two kitchenette. When wiped with a paper towel the residue left a brown mark on the paper towel. Further observation found red residue along the outside bottom edge of the ice machine where the door rests, and a slimy clear residue was observed on the outside edge next to the door of the ice machine. On 06/10/2026 at 9:13 AM observed an out of order frozen compartment of a two-door refrigerator in the station two kitchenette. Upon opening the frozen compartment, a takeout bag of food was observed on the shelf. DM A indicated it was a resident's food. DM A indicated they inform staff not to put food in this area. On 06/10/2026 at 9:15 AM observed splattered juice residue on the racks and back of the wall in the two-door refrigerator compartment in the station two kitchenette. On 06/10/2026 at 9:16 AM observed splatter and food debris in the microwave in the station two kitchenette. On 06/10/2026 at 9:20 AM observed debris accumulated behind the ice machine, including gloves, plates, a plastic bag and washcloth, hindering the view of the back of the ice machine in the station two kitchenette. In an interview at this time, DM A indicated they clean behind the ice machines every couple of months. When asked if there is an air gap on the ice machine, DM A stated there is not an air gap. On 06/10/2026 at 9:23 AM observed a black residue along the bottom edge of the drip tray of the ice machine in the station three kitchenette. When wiped with a paper towel, the residue left a black mark on the paper towel. Further observation found black residue accumulated on the outside surface where the door rests. On 06/10/2026 at 9:25 AM observed the two-door refrigerator out of order in the station three kitchenette. In an interview at this time, DM A indicated a temporary refrigerator was brought in. Observation of the temporary refrigerator found food and dried juice residue coating the bottom surface of the refrigerator. DM A acknowledged the residue. On 06/10/2026 at 9:26 AM observed the waste receptacle sitting directly in front of the hand sink in the station three kitchenette. The counter and refrigeration unit were on either side requiring the waste receptacle to be moved in order to access the hand sink. DM A indicated this was a temporary solution to the refrigerator being down. On 06/10/2026 at 9:27 AM observed the microwave stained and with areas of corrosion in the back bottom corners in the station three kitchenette microwave. DM A indicated it was an old unit. On 06/10/2026 at 9:30 AM an interview with DM A was conducted regarding the two-door refrigerator out of order in the station three kitchenette. DM A indicated it has been out of order for a couple months and needs to be replaced. On 06/10/2026 at 9:31 AM observed white residue spots on the wall directly behind the steam table in the station three kitchenette. Further observation found debris behind the steam table and ice machine including, foil, a bowl, a plate, a cup, and a towel. When asked if there is an air gap at the ice machine, DM A indicated no. On 06/10/2026 at 9:33 AM observed a dishwasher in the activities kitchenette. In an interview with DM A at this time, DM A indicated it is broken. When asked how long it has been broken DM A stated, since covid. On 06/10/2026 at 9:34 AM observed a brown stain and food residue in the microwave in the activities kitchenette. DM A indicated activities cleans the microwave. On 06/10/2026 at 9:36 AM observed the resident refrigerator used to store resident food. In an interview at this time regarding cleaning of the refrigerator, DM A indicated kitchen staff clean it out every couple of weeks, and nursing staff also go through it. The following items were observed in the refrigerator: A protein drink with a manufacturers expiration date of February 25 2026. A large bag with brown residue coating the bottom of the bag and a foul odor upon opening. Within the bag included tomatoes in a plastic bag with a white coating around and black spots, a container of chicken salad with no date, and a container of olives with no date. Further observation of the refrigerator found cream cheese with a manufacturers expiration date of April 21, 2026. Cheese and cracker package with a manufacturers expiration date of may 20, 2026. A plastic bag containing beans and corn with no date. [NAME] pudding with a manufacturers date of 4/3/26, an opened bag of hotdogs with no open date. A half-gallon of whole milk with a manufactures expiration date of June 9, 2029, a container of cottage cheese with a manufacturers expiration date of April 27, and a bag of cherries and grapes with black and green spots covering the fruit. On 06/10/2026 at 9:53 AM an interview with DM A was conducted regarding the resident refrigerator. When asked who is responsible for cleaning it out, DM A indicated no particular person cleans out the refrigerator. On 06/10/2026 at 9:55 AM observed three outdoor waste receptacles with one of the lids in the open position on all three receptacles. In an interview at this time when asked if the lids are left open all the time, DM A stated yes. On 06/10/2026 at 12:13 PM observed water on the floor in front of the ice machine in the station one kitchenette. On 06/10/2026 at 12:27 PM observed a dietary aid carrying a stack of plates pressed against their body from the dishwasher to the steam table in the station two kitchenette during lunch service. On 06/10/2026 at 12:33 PM observed the waste receptacle in front of the hand sink in the station three kitchenette. On 06/10/2026 at 12:41 PM observed Dietary Aid (DA) B on the serving line touch and type on a tablet while wearing gloves, then continue plating trays without changing gloves or washing hands. DA B indicated the tablet is used to communicate when needed. On 06/10/2026 at 1:14 PM an interview was conducted with DM A regarding hand hygiene. When asked about expectations for hand washing, DM A indicated hands should be washed between glove changes and changing of tasks. When asked when gloves should be changed, DM A indicated gloves should be changed after changing tasks. On 06/10/2026 at 2:30 PM observed one of the lids in the open position on one of the outdoor waste containers. On 06/10/2026 at 3:19 PM in an interview with Maintenance Director (MD) C regarding the out of order refrigerators, MD C indicated they are in the process of getting approval to replace refrigerators. On 06/10/2026 at 3:20 PM DM A informed there were no test strips available to test the sanitizer in the sanitizer basin of the three compartment sink. On 06/10/2026 at 3:21 PM an interview with MD C was conducted regarding cleaning of the ice machine. When asked frequency of cleaning, MD C indicated they clean the ice machines once a month and wipe down and take apart the interior. On 06/10/2026 at 3:23 PM observed the drain line from the ice machine extend into the floor drain and terminate below the floor level rim creating an improper air gap in the station two kitchenette. An interview with MD C was conducted at this time regarding the water pooled in front of the ice machines. MD C indicated the door hits the machine and makes water drip onto the floor. On 06/10/2026 at 3:27 PM observed the drain line from the ice machine extend into the floor drain and terminate below the floor level rim creating an improper air gap in station three kitchenette. Record review of the facility provided document containing the quote for the kitchen grease trap was dated 4/1/2024. The scope of the project states We will remove the grease trap by the 3 compartment sink and install piping to connect the upstream and downstream piping eliminating the grease trap all together. Record review of the facility provided document titled Family Refrigerator was last dated 7/25. Under procedure states, Resident/families will be requested to label the food or drink item with the date it was put into the refrigerator as well as the resident's name . Food & Nutrition staff will assess the refrigerator and discard any food or drink items that do not have the residents' name or items that are outdated/undated . The refrigerator will be cleaned by the housekeeping staff as needed.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention, (A) Except as specified in ¶¶ (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. According to the 2022 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. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. According to the 2022 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. According to the 2022 FDA Food Code section 4-202.11 Food-Contact Surfaces, (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; Pf (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; Pf (3) Free of sharp internal angles, corners, and crevices; Pf (4) Finished to have smooth welds and joints. According to the 2022 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-TOEAT, 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. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink, (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. According to the 2022 FDA Food Code section 6-501.114 Maintaining Premises, Unnecessary Items and Litter, The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter. According to the 2022 FDA Food Code section 5-501.15 Outside Receptacles, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. According to the 2022 FDA Food Code section 4-904.12 Soiled and Clean Tableware, Soiled TABLEWARE shall be removed from CONSUMER eating and drinking areas and handled so that clean TABLEWARE is not contaminated. According to the 2022 FDA Food Code section 3-304.15 Gloves, Use Limitation, (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. According to the 2022 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices, A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided. On 6/9/26 at 6:20 AM, observation of the kitchen revealed Refrigerator #5 contained 12 packages of pork chops and seven bags of egg mixture that were thawing on a shelf. The food items were not labeled and dated, indicating when the thawing process had begun. On 6/9/26 at 7:30 AM, an interview was conducted with Dietary Manager (DM) A, it was reported that when food items should be dated when removed from freezer and placed into a refrigerator to thaw.

Based on observation, interview, and record review the facility failed to implement an effective smoking policy affecting all residents who resided in the facility. Findings include: On 6/9/2026 at 9:23 AM, R49 was observed with a pack of cigarettes in his shirt pocket. When R49 was asked about smoking R49 said that he signed out to smoke.On 6/10/2026 at 9:22 AM, R49 was observed with a pack of cigarettes in his shirt pocket.On 6/10/2026 at 1:07 PM, a pack of cigarettes and a lighter were observed on R49's bedside table. R49 was not observed in the room. On 6/10/2026 at 3:20 PM, R49's room was observed with Licensed Practical Nurse (LPN)/Unit Manager G. R49's door was open and no one was observed in the room. A pack of cigarettes and a lighter were observed on R49's bedside table. When LPN G was asked about the lighter and cigarettes LPN G said residents should not have smoking paraphernalia since it was a smoke free facility. LPN G further said there was a fire risk if another resident came into the room and took the smoking paraphernalia. LPN G acknowledged the unit did have residents who wandered into other residents' rooms.Review of R49's care plan revealed, Focus I am a current cigarette smoker. I am aware of the major risk that can be caused by cigarette smoking and still choose/wish to continue smoking. I smoke cigarettes less than hourly. I smoke cigarettes daily. Date initiated 5/12/2026. Goal I will not use tobacco products while residing in the facility. Date initiated 5/12/2026. R49's care plan did not address safe storage of smoking paraphrenia.Review of R49's Smoking Risk assessment dated [DATE] revealed R49 was a safe smoker. On 6/11/2026 at 9:36 AM, R57 was interviewed about smoking at the facility and stated, I keep my cigarettes and lighter in my nightstand or in my pocket. When asked if there was a place to lock up personal items R57 replied, There is a lockbox in my closet, but I can't reach it, so I don't use it. R57 said his nightstand did not have a lock.Review of R57's care plan revealed, Focus I smoke cigarettes at times. Date initiated 10/14/2025. I will stop smoking and stop using tobacco products. Date revised 10/22/2025. Target Date 7/7/2026. R57's care plan did not address safe storage of smoking paraphernalia. Review of R57's EMR did not reveal a Smoking Assessment.On 6/11/2026 at 8:31 AM, LPN G was interviewed regarding the facility smoking policy and said staff and residents were not following the policy. LPN G further said residents should not have any smoking paraphernalia with them. LPN G said the facility did not have a process in place for residents and staff to safeguard smoking paraphernalia.On 6/12/2026 at 8:52 AM, R49 and R57's care plans were reviewed with LPN G. LPN G said neither resident's care plans addressed safe storage of smoking materials and they should. LPN G further said the facility policy states that the facility is smoke free. The policy does not address how to safeguard smoking materials. LPN G stated, We are not following the current smoking policy.On 6/12/2026 at 12:05 PM, the Director of Nursing (DON) was interviewed and said smoking materials needed to be safeguarded, the facility policy did not address that issue. The DON said there was a risk of injury since the facility did have residents who wandered and could possibly gain access to unsecured smoking materials.Review of the facility policy titled, Resident and Visitors Smoking date Revised 2/2026 revealed in part . Policy: This campus is a tobacco/smoke/vape free campus. The facility may have residents with cognitive impairment, use oxygen, or have diagnoses/medications that may result in adverse events in the presence of tobacco/smokeless tobacco/vapor devices. Access to lighters, smoking devices, tobacco, marijuana, vapes, etc. has increased risk of injury, fire, and death. The policy seeks to reduce those risks. Goal. No smoking, vaping, or tobacco use is permitted anywhere inside the facility or on facility property unless a designated outdoor smoking/vaping area is established. Procedure. 1. Residents and visitors who choose to smoke or use smokeless tobacco/electronic smoking devices must do so off campus; however, no staff will be obligated to assist with this. The resident must be able to leave the campus independently or with family assistance. 2. Tobacco products and paraphernalia, including cigarettes, lighters, pipes, chew, electronic cigarettes, or vaporizers, are not to be stored in resident rooms. 3. These items should be collected and sent home with family. If that is not an option, they should be given to the Administrator or designee to be stored until resident discharge from the facility. 4. If the facility becomes aware that a resident has dangerous items such as those listed above, the facility reserves the right to perform a search of the resident room/premises and remove items until they can be sent home with family or stored safely until discharge from the facility. 5. If a resident or family member refuses to follow the facility policy, assistance with discharge/transfer may be offered. 6. If the resident and/or family continues to show disregard for others' safety, an involuntary transfer may be initiated.

Based on observation, interview and record review the facility failed to ensure necessary adaptive dining equipment was provided during meal service for one resident (R14) out of three residents reviewed for dining observations. This deficient practice had the potential to impair R14's ability to eat independently.Findings include:On 06/10/2026 8:21 AM R14 was observed and interviewed during breakfast meal. R14 reported that she was supposed to receive built up silverware and beverages should be served in a mug with lid. It was further reported that because of tremors it makes it more manageable for her to eat and the lids prevent liquids from spilling on her. R14's meal tray was observed to have regular silverware and no lids applied to mugs. Record review of R14's meal ticket documented: built up silverware and lids on mugs.Record review of Skilled Therapy/ADL (Activities of Daily Living) care plan it was documented on 5/19/26, , . Eating: I am independent, set up my tray. I will require the use of built-up handled utensils.Record review of Kardex (care instructions) documented R14 will require build up handled utensils and hot beverages must have mug with lid.Record review of R14's electronic medical record (EMR) revealed admission into facility on 10/11/24 with a pertinent diagnosis of Rheumatoid Arthritis of right and left hands. According to the Brief Interview for Mental Status (BIMS) dated 5/4/26, R14 scored a 14 (intact cognition).On 06/11/2026 12:15 PM, during an observation of R14's lunch meal, the tray was served with regular silverware and no lids on the mugs. During follow-up interview with R14, stated, Hit or Miss here with getting the right silverware and lids on your drinks.On 06/11/2026 12:20 PM, an interview was conducted with Unit Manager (UM) G after observing the R14's tray. UM G reported that the resident should be provided with the correct utensils and lids at each meal. On 06/11/2026 9:33 AM, an interview with Dietary Manager (DM) A was conducted. DM A reported that is the responsibility of the dietary staff to read the meal tickets and provide the requested utensils and others documented requests. Record review of facility's policy Self-Help Devices (Adaptive Equipment) (undated) documented, Self-help feeding devices will be provided on the tray to clients who require them.

Based on observation, interview, and record review the facility failed to provide proper safekeeping of resident smoking paraphernalia for two residents (R49 and R57) out of three residents reviewed for smoking.Findings include:R49On 6/9/2026 at 9:23 AM, R49 was observed with a pack of cigarettes in his shirt pocket. When R49 was asked about smoking R49 said that he signed out to smoke.On 6/10/2026 at 9:22 AM, R49 was observed with a pack of cigarettes in his shirt pocket.On 6/10/2026 at 1:07 PM, a pack of cigarettes and a lighter were observed on R49's bedside table. R49 was not observed in the room. On 6/10/2026 at 3:20 PM, R49's room was observed with Licensed Practical Nurse (LPN)/Unit Manager G. R49's door was open and no one was observed in the room. A pack of cigarettes and a lighter were observed on R49's bedside table. When LPN G was asked about the lighter and cigarettes LPN G said residents should not have smoking paraphernalia since it was a smoke free facility. LPN G further said there was a fire risk if another resident came into the room and took the smoking paraphernalia. LPN G acknowledged the unit did have residents who wandered into other residents' rooms.Record review of R49's Electronic Medical Record (EMR) revealed admission to the facility on 4/11/2024 with diagnoses which included Muscle Wasting and Atrophy, Acute and Chronic Respiratory Failure, and Dependence on Renal Dialysis.Review of the Minimum Data Set (MDS) dated [DATE] for R49 revealed intact cognition and independent for wheelchair mobility.Review of R49's care plan revealed, Focus I am a current cigarette smoker. I am aware of the major risk that can be caused by cigarette smoking and still choose/wish to continue smoking. I smoke cigarettes less than hourly. I smoke cigarettes daily. Date initiated 5/12/2026. Goal I will not use tobacco products while residing in the facility. Date initiated 5/12/2026. R49's care plan did not address safe storage of smoking paraphernalia. Review of R49's Smoking Risk assessment dated [DATE] revealed R49 was a safe smoker. R57On 6/11/2026 at 9:36 AM, R57 was interviewed about smoking at the facility and stated, I keep my cigarettes and lighter in my nightstand or in my pocket. When asked if there was a place to lock up personal items R57 replied, There is a lockbox in my closet, but I can't reach it, so I don't use it. R57 said his nightstand did not have a lock.Record review of R57's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses which included Muscle Weakness, and Paraplegia.Review of the Minimum Data Set (MDS) dated [DATE] for R57 revealed moderate cognitive impairment and max assist for transfers and wheelchair bound.Review of R57's care plan revealed, Focus I smoke cigarettes at times. Date initiated 10/14/2026. I will stop smoking and stop using tobacco products. Date revised 10/22/2026. Target Date 7/7/2026. R57's care plan did not address safe storage of smoking paraphernalia. Review of R57's EMR did not reveal a Smoking Assessment.On 6/11/2026 at 8:31 AM, LPN G was interviewed regarding the facility smoking policy and said staff and residents were not following the policy. LPN G further said residents should not have any smoking paraphernalia with them. LPN G said the facility did not have a process in place for residents and staff to safeguard smoking paraphernalia.On 6/12/2026 at 8:52 AM, R49 and R57's care plans were reviewed with LPN G. LPN G said neither resident's care plans addressed safe storage of smoking materials and they should. LPN G further said the facility policy states that the facility is smoke free. The policy does not address how to safeguard smoking materials. LPN G stated, We are not following the current smoking policy.On 6/12/2026 at 12:05 PM, the Director of Nursing (DON) was interviewed and said smoking materials and lighters needed to be safeguarded, facility policy did not address that issue. The DON said there was a risk of injury since the facility did have residents who wandered and could possibly gain access to unsecured smoking materials.Review of the facility policy titled, Resident and Visitors Smoking date Revised 2/2026 revealed in part . Policy This campus is a tobacco/smoke/vape free campus. The facility may have residents with cognitive impairment, use oxygen, or have diagnoses/medications that may result in adverse events in the presence of tobacco/smokeless tobacco/vapor devices. Access to lighters, smoking devices, tobacco, marijuana, vapes, etc. has increased risk of injury, fire, and death. The policy seeks to reduce those risks. Goal. No smoking, vaping, or tobacco use is permitted anywhere inside the facility or on facility property unless a designated outdoor smoking/vaping area is established.Procedure. 1. Residents and visitors who choose to smoke or use smokeless tobacco/electronic smoking devices must do so off campus; however, no staff will be obligated to assist with this. The resident must be able to leave the campus independently or with family assistance.2. Tobacco products and paraphernalia, including cigarettes, lighters, pipes, chew, electronic cigarettes, or vaporizers, are not to be stored in resident rooms. 3. These items should be collected and sent home with family. If that is not an option, they should be given to the Administrator or designee to be stored until resident discharge from the facility. 4. If the facility becomes aware that a resident has dangerous items such as those listed above, the facility reserves the right to perform a search of the resident room/premises and remove items until they can be sent home with family or stored safely until discharge from the facility. 5. If a resident or family member refuses to follow the facility policy, assistance with discharge/transfer may be offered. 6. If the resident and/or family continues to show disregard for others' safety, an involuntary transfer may be initiated.

Based on observation, interview and record review, the facility failed to respond to call lights in a timely manner for one resident (R111) of six residents reviewed resulting in unmet care needs. Findings include: On 06/10/2026, a short high pitched electronic sound of a call light in the hallway of Unit 200/Station 2 with no response from staff was observed for over two hours. On 06/10/2026 at 12:35 PM, R111 was interviewed in the resident's room. R111's call light was on upon arrival. R111 sat in a wheelchair during the visit. Three urinals observed on the nightstand; one full and two empty. Queried about the call light, R111 stated, My call light has been on for 1/2 hour, and no one has come to empty my urinal. R111 stated, This always happens until I go to the nurse's station to complain. R111's room observed with an odor of urine. R111 stated, They gave me three urinals, so they don't have to rush to empty them. Three staff observed talking in the hallway upon departure. Short high pitched electronic sound of the call light was heard in the hallway, call light observed illuminating over the door of R111's room. On 06/10/2026 at 2:52 PM, re-visited R111's room. High pitched electronic sound of a call light observed coming from a call light device located in the hallway of Unit 200/Station 2. Six staff persons observed in the hallway: Certified Nursing Assistants (CNA's) CNA J, CNA M, CNA N, CNA O. CNA P and CNA Q. Upon entering the room, R111's roommate stated, Yes, our call light is still on! Queried R111 if there was any response to the call light by staff since the initial request for assistance. R111 stated, My call light has been on since noon, all I want is for someone to empty my urinal. R111 stated, I'm tired of complaining and asking for help. R111 said the (CNA's) often tell him that they will return or will get to him in a minute but there are frequent delays for assistance. Queried as to how the delayed responses makes him feel. R111 stated, Their disregard makes me feel like shit. R111 said when he is tired of waiting for a call light response, he goes to the nurse's station to complain. He stated, They always stand there talking and laughing all day instead of helping us. R111 stated, I'm on Lasix (water pill) and my urinal needs emptying more frequently. R111 stated, I don't want more urinals, I just want the urinals emptied when needed. Observed the strong smell of urine within the room. On 06/10/2026 at 2:59 PM, upon departure from R111's room, seven staff persons observed in the hallway within hearing and seeing distance of the call light which was illuminating on the wall and ringing loudly. CNA J was approached and queried about the loud beeping sound coming from the call light device. CNA J stated, That's probably a call light on. CNA J pointed to the call light device on the wall which lights up with room numbers when call lights are activated. Queried CNA J as to which room triggered the call light sound. CNA J looked left and right and stated, Oh. that's down there. CNA J headed towards R111''s room after the inquiry. On 06/10/2026 at 3:11 PM visited the 200 unit/Station 2 with the Director of Nursing (DON). Queried about response times to call lights. Inquired if there is a call light timer which denotes the length of time a call light has been activated. The DON stated, There's no archive timer for the call lights. Theres no way to tell how long they go unanswered. Queried about expectations of call light responses. The DON stated, Call light responses are expected within 2-3 minutes. Discussed the length of time the call light bell was observed ringing on this unit. On 06/11/2026 at 12:30 PM interviewed CNA J to discuss the long wait times for the call light for R111. CNA J stated, Sometimes we're busy, we get to them as soon as we can. Queried as to the length of time the call light was on for R111 and if this is standard protocol. CNA J stated, I wasn't R111's CNA, I told another CNA to check on him. On 06/11/2026 at 2:06 PM, Unit Manager K was interviewed about delayed call light responses and the observation of long wait times for call light Reviewed the facilities policy entitled, Call Light Answering date reviewed August 2025, revealed in part: Procedure. Answer the patient or resident's call as soon as possible.Identify yourself and call the resident by his/her name.Listen to the patient/resident's request.Do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the patient/resident's request, ask for assistance.If assistance is needed when you enter the room, summon help to the room.After meeting the patient/resident's needs, turn off the call light.

Based on interview and record review the facility failed to develop a comprehensive care plan for two residents (R49 and R57) out of three residents reviewed for smoking care plans.Findings include:R49On 6/9/2026 at 9:23 AM, R49 was observed with a pack of cigarettes in his shirt pocket. When R49 was asked about smoking R49 said that he signed out to smoke.On 6/10/2026 at 9:22 AM, R49 was observed with a pack of cigarettes in his shirt pocket.On 6/10/2026 at 1:07 PM, a pack of cigarettes and a lighter were observed on R49's bedside table. R49 was not observed in the room. On 6/10/2026 at 3:20 PM, R49's room was observed with Licensed Practical Nurse (LPN)/Unit Manager G. R49's door was open and no one was observed in the room. A pack of cigarettes and a lighter were observed on R49's bedside table. When LPN G was asked about the lighter and cigarettes LPN G said residents should not have smoking paraphernalia since it was a smoke free facility. LPN G further said there was a fire risk if another resident came into the room and took the smoking paraphernalia. LPN G acknowledged the unit did have residents who wandered into other residents' rooms.Record review of R49's Electronic Medical Record (EMR) revealed admission to the facility on 4/11/2024 with diagnoses which included Muscle Wasting and Atrophy, Acute and Chronic Respiratory Failure, and Dependence on Renal Dialysis.Review of the Minimum Data Set (MDS) dated [DATE] for R49 revealed intact cognition and independent for wheelchair mobility.Review of R49's care plan revealed, Focus I am a current cigarette smoker. I am aware of the major risk that can be caused by cigarette smoking and still choose/wish to continue smoking. I smoke cigarettes less than hourly. I smoke cigarettes daily. Date initiated 5/12/2026. Goal I will not use tobacco products while residing in the facility. Date initiated 5/12/2026. R49's care plan did not address safe storage of smoking paraphernalia.Review of R49's Smoking Risk assessment dated [DATE] revealed R49 was a safe smoker. R57On 6/11/2026 at 9:36 AM, R57 was interviewed about smoking at the facility and stated, I keep my cigarettes and lighter in my nightstand or in my pocket. When asked if there was a place to lock up personal items R57 replied, There is a lockbox in my closet, but I can't reach it, so I don't use it. R57's said his nightstand did not have a lock.Record review of R57's EMR revealed admission to the facility on [DATE] with diagnoses which included Muscle Weakness and Paraplegia.Review of the MDS dated [DATE] for R57 revealed moderate cognitive impairment and max assist for transfers and wheelchair bound.Review of R57's care plan revealed, Focus I smoke cigarettes at times. Date initiated 10/14/2026. I will stop smoking and stop using tobacco products. Date revised 10/22/2026. Target Date 7/7/2026. R57's care plan did not address safe storage of smoking paraphernalia. Review of R57's EMR did not reveal a Smoking Assessment.On 6/12/2026 at 8:52 AM, R49 and R57's care plans were reviewed with LPN G. LPN G said neither resident's care plans addressed safe storage of smoking materials and they should. On 6/12/2026 at 12:05 PM, the Director of Nursing (DON) was interviewed and said R49 and R57's care plans did not address safeguarding smoking materials and should. The DON further said that smoking paraphernalia needed to be safeguarded in order to ensure the safety of all residents.Review of the facility policy titled, Plan of Care date revised 8/2025 revealed in part .The organization's policy is to develop a baseline care plan within 48 hours of admission and maintain a person-centered comprehensive care plan that represents the resident's personal preferences and goals. The plan of care is evident throughout the medical record. Procedure.1. A preliminary care plan is developed for each resident within 48 hours of admission to the facility. This care plan includes the admission assessments and orders by the physician that address the resident's immediate needs. 2. The resident or responsible party will receive a written copy of the baseline care plan at their first IDT conference. 3. A comprehensive person-centered plan of care is developed within 7 days of the resident's arrival at the facility a.The care plans are developed by the members of the interdisciplinary team based on their observations and interaction with the resident and/or resident's significant others. 4. The care plan consists of the following: a. Problems as identified by reviewing the medical record and discussion with the resident and/or significant others. b. Goals are set in conjunction with the family and resident. Goals are realistic, measurable, behaviorally stated and may be long or short term. Goals should prevent decline or maintain resident function if realistic and appropriate based on the diagnosis. c. Interventions are actions taken to achieve the goal. These interventions should build on the resident's strengths, be realistic, and identify those responsible for the interventions. 5. The care plans are reviewed at least quarterly or with a significant change in condition and updated as their condition warrants, by the appropriate department. 6. If a resident is readmitted to the facility, their care plans are reviewed and updated as needed. 7. The facility uses an electronic medical record that has a specific section of the record referred to as care plan. However, the organization believes the development of a true comprehensive care plan is more holistic. Therefore, it is the policy of the organization that elements of the care plan can be located throughout the electronic medical record. 8. The care planning process is never completed until the resident is discharged . The care plan needs to change as resident status changes.

Based on interview and record review, the facility failed to timely complete a Level I (PASARR) Pre-admission Screening and Resident Review and failed to obtain a Level II PASARR for one resident (R8) of three residents reviewed for mental health screenings. This resulted in the potential for care needs being unmet due to the lack of a comprehensive evaluation by the state designated authority. Record review of the Electronic Health Record (EHR) revealed no documentation of an updated Level I PASARR or a Level II PASARR screening by the state designated authority. Record review also revealed R8 was admitted to the facility on [DATE] and has a diagnosis of Vascular Dementia, Alzheimer's Disease, Mood Disorder, Major Depressive Disorder, Psychotic Disorder with Delusion Due to unknown Physiological conditions and Schizophrenia. R8 is prescribed: risperiDONE (Risperidone) Oral Tablet 1 MG at bedtime and 0.25 MG in the morning and Aricept 10mg once daily.Record review further revealed an order dated 03/21/2026 to monitor for anti-psychotic medication side effects: Anti-Psychotic Medication Use: Observe closely for significant side effects, sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention.Psych evaluation ordered for Schizophrenia/bipolar disorder. On 06/10/2026 at 1 PM, the Director of Nursing (DON) was interviewed and documentation requested for a current Level I and Level II PASARR for R8. The DON stated, I'm not familiar with the location of these documents, the Nursing Home Administrator (NHA) is new to this facility, and the Social Worker is resigning. I'll have to check. On 06/11/2026 at 12:55 PM Social Worker (SW) H was interviewed and queried regarding current Level I and Level II PASARRs for R8. SW H provided documentation of a PASARR Level I completed on 04/02/2025. SW H stated, This one slipped by me, but I did complete the Level I PASARR today. Requested documentation of a PASARR II from last year. SW H stated, I didn't follow up with the state authority regarding one from last year and the doctor delayed signing the Level I until December, 2025.Record review of the care plan revised 03/29/26 revealed: -I have impaired cognitive function r/t Dementia, delusional disorder, psychotic disorder w/delusions, mood disorder and major depressive disorder .-the resident uses antipsychotic medication r/t schizophrenia. On 06/12/2026 at 11 AM, the DON was interviewed regarding the lack of updated Level I PASARR screenings which necessitates an in-depth evaluation by the state designated authority, known as PASARR Level II. The Level II PASARR determination and the evaluation report specify services to be provided by the facility and/or specialized services defined by the state. The DON said the facility is interviewing for the Social Work position and will audit this process. Review of the Level I screening criteria provided- Section II dated 4/02/2025 identified 3 of 6 areas that meet the requirement for mental Illness with instruction to contact the local community mental health services program (CMHSP) for Level II screening.1.The person has a current diagnosis of mental illness- yes2. The person has received treatment for mental illness- yes3. The person has taken or been prescribed psychotropic medications within the last 14 days- Yes

Based on observation, interview, and record review, the facility failed to ensure a resident (R88) at high-nutritional risk (tube feeding/multiple wounds) was appropriately assessed and failed to implement interventions resulting in unidentified severe weight loss (10.6% in one month) for one out of three residents reviewed for high nutritional risk. The Immediate Jeopardy (IJ) started on 3/17/25 when R88, a resident at high nutritional risk due to a tube feeding and multiple wounds, was admitted into the facility, and the facility neglected to ensure R88 was appropriately assessed by a qualified nutritional professional and provided adequate nutrition to prevent a severe weight loss of 10.6% in one month. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/16/25 at 2:42 PM. The IJ was removed on 4/17/25, but noncompliance remains at a Level 2 due to sustained compliance that has not been verified by the State Agency. Findings include: On 4/14/25 at 7:56 AM, R88 was observed alert and lying in bed. R88 said he received pain medication but was still in a little pain. R88 was observed receiving a tube feeding of Promote 1.0 infusing at 55 cc/hour. On 4/15/25 at 9:55 AM, R88 was observed receiving a tube feeding of Promote 1.0 infusing at 55 cc/hour. During an interview on 4/15/25 at 1:05 PM, Licensed Practical Nurse (LPN) O said R88's family provided the nutrition formula, Promote 1.0. At 1:30 PM, R88 refused to be weighed and said it would cause him pain. LPN O said she would administer an as needed pain medication and check back with R88 in an hour to see if he would consent to be weighed. During an interview on 4/15/25 at 1:35 PM, Station 3 Unit Manager, LPN N reported that she put the order in for monthly weights on 4/8/25. During the previous four-week period, weekly weights were supposed to be obtained. LPN N identified two facility attempts to weigh R88. LPN N said R88 refused to be weighed once and once a clean sling (used with a mechanical lift to weigh a resident) was not available. A review of the clinical record did not reveal an effort to resolve R88's refusal to be weighed or an attempt to weigh R88 when a clean sling was available. A review of R88's April 2025 MAR (Medication Administration Record) revealed the administration of one tablet of hydrocodone-acetaminophen 5-325 (pain) at 12:52 PM on 4/15/25. On 4/15/25 at 2:42 PM, R88 allowed facility staff to obtain a weight. R88 weighed 177 lbs. R88 sustained a 10.6% weight loss from the admission weight of 198 lbs. obtained on 3/18/25. During an interview on 4/15/25 at 4:07 PM, CDM K said the facility has recently had a couple of different registered dietitians (RD). The newest RD, (RD J), started on 4/1/25. CDM K added that RD J works remotely on a part-time basis. CDM K said he had not had any direct contact with RD J about facility residents' clinical concerns. CDM K said residents receiving a tube feeding were at high nutritional risk and should be seen by the RD within the first week of their admission. CDM K acknowledged that he completed the Dietary Profile for R88 on 4/5/25. On the Dietary Profile, CDM K calculated R88's daily estimated caloric and protein needs as 2708 calories and 90 grams respectively. When the calories provided from R88's current tube feeding order was calculated at 1200 calories, CDM K stated, He's getting less than half of his caloric needs. CDM K stated if R88 had pressure ulcers, obviously he would need more grams of protein. CDM K acknowledged he did not factor pressure ulcers into the equation when determining R88's estimated daily protein requirement. CDM K said R88 should have been evaluated by an RD. Review of R88's clinical record revealed no progress notes or nutrition assessment had been completed by a RD. CDM K acknowledged that the Dietary Profile indicated that a dietitian referral was not appropriate and that the correct response should have been yes. CDM K said an affirmative answer would have triggered an RD referral. The registered dietitian is qualified to complete a nutrition assessment on such an individual. A review of the Transfer/Discharge Report for R88 revealed an admitted [DATE] and diagnoses that included dysphagia, hemiplegia, and hemiparesis following cerebral infarction, sacral region pressure ulcer - stage 4, right buttock pressure ulcer - stage 3, left buttock pressure ulcer - stage 3, pressure-induced deep tissue damage of right and left ankles, and gastrostomy status (R88 had a tube inserted into the stomach to provide a means of feeding). A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and the presence of one stage-4 pressure ulcer and two unstageable pressure ulcers. An additional review of R88's clinical record documented in part the following: 1. Hospital discharge paperwork documented a body weight of 198 lbs. 10.2 ounces. 2. Facility admission body weight of 198.6 lbs. obtained on 3/18/25. 3. Physician orders: A. Order for nutrition consult dated 3/18/25. B. Enteral Feed Order. One time a day Enteral feeding: enteral feeding formula: Promote 1.0, amount: continuous, rate 20 mL/hr. Change tubing with each bottle change. Mechanism of administration: Pump. Auto Flush water: 250 ml every 4 hours. Mechanism of administration: Pump. Start date 3/18/25. End date: 3/21/25. C. Enteral Feed Order. One time a day Enteral feeding: enteral feeding formula: Promote 1.0, amount: continuous, rate 50 mL/hour. Change tubing with each bottle change. Mechanism of administration: Pump. Auto Flush water: 250 ml every 4 hours. Mechanism of administration: Pump. Start date 3/21/25. D. Juven Packet (nutrition supplement) one time a day for nutrition 2 packs. Start date: 3/19/25. End date 3/21/25. E. Juven Packet. Give 1 packet via PEG (Percutaneous Endoscopic Gastrostomy - a tube inserted into the stomach to provide a means of feeding) tube two times a day for Nutritional Supplement Dissolve in 8 oz of warm water. Start Date 3/21/25. F. Weigh weekly and record times 4 weeks one time a day every Tuesday for weight monitoring for 4 Weeks. Start Date 3/18/25. G. Weigh monthly every night shift starting on the 8th and ending on the 8th every month for weight monitoring. Start Date 4/8/25. 4. Dietary Profile, dated 4/5/25, completed by CDM K documented in part the following: Reason for the assessment: Admission Most recent weight: 198.6 lbs. Current diet order: NPO (nothing by mouth) Current nutrition supplement: Enteral feed Estimated calorie needs: 2708 calories Estimated protein needs: 90 grams Estimated fluid needs 2708 ml Pressure related skin condition: Yes. Additional risk factors: Pressure sore and tube feeding Based on this review, a dietitian referral is appropriate: No 5. eMAR (electronic Medication Administration Record) note of 4/8/25: No sling available waiting for laundry. 6. Care plan. Focus: On current diet order - at risk for aspiration. NPO (nothing by mouth). TF (tube feeding) Promote 1.0 formula, cam (sic) at 20 cc/hour to increase q (every) 4 hours until goal rate of 50 cc/hour continuous (around the clock). Initiated and revised on 3/18/25. Interventions: Provide diet as ordered. Registered Dietitian evaluation to make recommendation as needed. An interview was conducted on 4/16/25 at 10:24 AM with Physician L. When Physician L was queried about R88's current tube feeding order, he stated, We have a dietitian on board that makes the recommendations for a resident on a tube feeding. Physician L said that usually the tube feeding is managed by the facility dietitian. Physician L identified the RD as the nutrition expert regarding tube feeding formulas and would go with their recommendation. During an interview on 4/16/25 at 10:46 AM, RD J said she received a message on 4/15/25 indicating that R88 had experienced a weight loss and requested that she complete a nutrition assessment on the resident. RD J said upon admission R88 would be considered at high nutrition risk because he had wounds and was on a tube feeding J said she was unaware of the 3/18/25 order for a nutrition consult because she was not the RD at that time. RD J stated, It would have been good to be notified about R88's pending consult when she started on 4/1/25. RD J said the CDM should have referred the high-risk resident to the RD. RD J said upon admission the standard was to obtain weekly weights for four weeks and if stable, obtain monthly weights thereafter. For residents on a tube feeding weekly weights would help determine if the tube feeding was the right amount. Once the nutrition assessment was completed by the RD, RD J recommended a change in R88's tube feeding order because the current order (of insufficient caloric and protein needs that R88 was on for 28 days) was not meeting his estimated needs. RD J said the facility has contracted her to work (remotely) 40 hours a month. A Dietary Progress Note, completed by RD J dated 4/15/25 at 11:27 PM, revealed in part the following: Weight 177 lbs.; Diet: NPO; Feeding: Osmolite 1.5 70 ml/hour. Supplement: Liquid Protein 30 ml BID (twice a day), Juven 1 packet BID. Skin: Stage 3 pressure injury to right and left outer ankles, stage 4 pressure injury to sacrum (according to) 4-10-25 wound assessment. Nutrition Problem: At risk for malnutrition, increased protein needs and swallowing problem. admitted [DATE]. Current weight shows 21 lb. decrease from admission weight. Estimated kcal needs - 2011 - 2414 kcal. (25 - 30 kcal/kg). Estimated protein needs - 97 - 116 g protein (1.2 - 1.5 g/kg). Recommended feeding change to Osmolite 1.5 as resident had been on a 1.5 calorie formula in the hospital. 70 ml/hour to provide about 2310 kcal., 96.6 g protein. (Based on 22 hour feeding which allows for time off feeding for ADL's [activities of daily living]). Recommended liquid protein 30 ml BID to provide additional 180 kcal. and 36 g protein to enhance wound healing. Requested weekly weights x 4 weeks. On 4/16/25 at approximately 12:00 PM, the NHA indicated that RD M (the RD at the time of R88's admission) was employed by the facility March 1, 2025, to March 31, 2025. During an interview on 4/17/25 at 12:48 PM, the DON said the facility was unable to provide Pivot 1.5 (the tube feeding formula R88 received while hospitalized ). The hospital registered dietitian (RD S) said it was okay to put R88 on Promote 1.0. The DON provided a communication between the hospital RD and the hospital case manager dated 3/17/25 that documented in part the following: - Contacted by CM, (Case Manager P), regarding discharge TF (tube feeding) order for patient as accepting facility unable to provide Pivot 1.5. Changing TF order to Promote 1.0 at goal rate 75 mL/hour + 2 packets Juven BID which accepting facility will be able to provide. - Orders placed this encounter: Enteral feed/tube feeding: Promote 1.0; Route: PEG; Administration: Continuous; Goal rate: 75 mL/hour around the clock + 2 packs Juven. The DON added that the facility's RD was expected to assess residents on a tube feeding upon admission and that was not done. The DON indicated the facility was aware that R88 could receive Promote 1.0 but was unaware that the infusion rate had changed. On 4/17/25 at 1:18 PM, the NHA and DON were asked if they had anything else to provide or add regarding this concern, and they said they did not. A review of a document titled, Certified Dietary Manager, undated but provided by the facility during the survey, revealed in part the following job description: - Coordinates all clinical/dietetic service under the limited direction of the Registered Dietician. - Performs and charts the initial resident assessment and quarterly summary. - Responsible for coordination and participation in the Nutrition at Risk or Wound Weight meeting. A review of a document titled, Consultant Dietitian Responsibilities, undated but provided by the facility during the survey revealed in part the following: - Assess the nutrition needs of clients who have been referred due to having a medical condition which puts them at nutritional risk. - Complete in-depth nutrition assessments for those residents at high risk including significant weight loss, tube feed residents, hemodialysis and pressure injuries. - Based on analysis of the data and input from the healthcare team, the dietitian will exercise clinical judgement to determine the best nutrition approach by recommending interventions appropriate to the individual. A review of a facility document titled, Nutrition Assessment, dated 2021, documented in part the following: - The consultant dietitian provides in-depth nutrition assessments for clients whose medical condition(s) may place them at nutrition risk. - The healthcare community and the dietitian work together in determining level of nutritional risk. Medical conditions which may place clients at nutrition risk includes: Enteral or parenteral tube feeding; Pressure injury; Dialysis; Significant weight loss. A review of the facility document that provides guidelines for weight monitoring, dated June 2021, revealed in part the following: All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. The Immediate Jeopardy that began on 3/17/25 was removed on 4/17/25 when the facility took the following actions to remove the immediacy. The IJ was removed on 4/17/25 based on the on-site verification of the facility's actions to remove the immediacy: 1. R88 was reviewed by the RD (Registered Dietitian) on 4/15/25 and new orders were initiated. Nutritional Assessment was performed on R88. Interventions were implemented including weekly weights and liquid protein. The facility implemented a process for notification of the RD when high nutritional risk residents (residents with tube feeding and multiple wounds) are admitted to the facility by the nurses and education began on 4/16/25. The facility assessment was updated. 2. Education was provided immediately to nursing staff regarding notification of high nutritional risk residents (residents with tube feeding and multiple wounds) upon admission. 3. Education was provided to CDM (Certified Dietary Manager) to make a referral to the RD for any high nutritional risk resident (residents with tube feeding and multiple wounds) upon admission.

Based on observation, interview, and record review, the facility failed to: 1. Consistently document that the dish machine, reach-in coolers, and reach-in freezers were operating properly; 2. Ensure the proper sanitizing solution was obtained for the three-compartment sink; 3. Ensure pans were allowed to air dry before stacking; 4. Properly date-label prepared food stored in the reach-in cooler; and 5. Consistently maintain the kitchen in a sanitary condition. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 4/14/25 beginning at 6:48 AM, the initial tour of the kitchen began with AM [NAME] H and Dietary Aide (DA) I present in the kitchen. Through observations, [NAME] H and DA I, confirmed a thermometer was not placed inside of reach-in refrigerator #5. Cook H presented a binder containing multiple logs used to document the temperatures and proper sanitizing solutions for multiple pieces of equipment located in the kitchen. A review of the logs documented the following: The last entry on the Dishwashing Machine Temperature Testing Tab Log was 4/11/25 during lunch service The last entry on the Pots & Pans Sanitation Log which documented that a proper sanitizing solution was achieved was 4/11/25 during lunch service The Final [NAME] and Food Serving temperatures were not available for 4/11/25 dinner, 4/12/25 breakfast, lunch and dinner, and 4/13/25 lunch and dinner The last documented temperature for reach-in refrigerators #2, #3, #4, and #6 and reach-in freezer #1 and #4 was 4/11/25. The last documented temperature for reach-in refrigerator #5 and reach-in freezer #3 was 4/10/25. Four full-size pans and one 1/2 size pans stacked in the clean pot/pan storage area were observed to have droplets of water. An unlabeled and undated 1/2 size pan of ambrosia and 1/2 size pan of cooked rice were observed in reach-in refrigerator #2. There was no liner bag placed in a 35-gallon garbage can observed in the kitchen. Loose trash was observed inside of the garbage can. On 4/17/25 at 12:58 PM, the Nursing Home Administrator said that temperatures should be taken and documented, pans should not be put away wet, and food should be properly dated in the refrigerator. On 4/17/25 at 1:33 PM, Food Service Director (FSD) K stated the ambrosia and rice should have been dated with the date made and expiration date. FSD K said temperatures and sanitizing solutions should be documented on the logs when they are taken. According to the 2013 FDA Food Code: Section 3-101.11 Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils shall be air-dried.

Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a visually unappealing property and the potential for harborage of pests. Findings include: On 4/14/25 at 6:07 AM, observations and pictures were taken of three eight-yard dumpsters located near the employee entrance on the east side of the facility. Three large garbage bags full of trash were observed on the ground next to the dumpster located closest to the building. At least three other large garbage bags, full of trash, were observed protruding from the top of the same dumpster which prevented closure of the top lid. The top lid of the middle dumpster was flipped open. On 4/17/25 at 12:51 PM, the Nursing Home Administrator (NHA) said in October 2024 the facility changed their commercial trash service company and was able to increase the number of dumpsters from two to three. The NHA stated, I got a third one because I did not want garbage on the ground. When the NHA viewed the photos taken on 4/14/25 at 6:07 AM she said it looked like staff just did not want to use the other dumpsters. The NHA added the bags on the ground was not a good look and the facility wants to keep rodents away.

Based on observation, interview and record review the facility failed to adequately store medications in three of three medications storage areas. Findings include: On 4/14/25 at 7:15 AM an observation of a medication refrigerator on Arlington Station revealed a jar of pickles sitting on a shelf. An interview was conducted on 4/14/25 at 7:16 AM with Licensed Practical Nurse (LPN) Q, it was reported that foods should not be stored in the medication refrigerator. On 4/14/25 at 7:20 AM an observation of a medication refrigerator on Bristol Station revealed a carryout container with a chicken dinner sitting on the shelf. An interview was conducted on 4/14/25 at 7:21 AM with LPN R, it was reported that foods should not be stored in the medication refrigerator. On 4/14/25 at 7:25 AM an observation of the Bristol Pixus System Room revealed door was ajar and not locked. Further observation revealed a large container with a lock that was not engaged and contained multiple intravenous solutions. An interview was conducted on 4/14/25 at 7:26 AM with LPN R, it was reported that the room should be locked and that the container with intravenous solutions should be locked too. An interview was conducted on 4/14/25 at 12:30 PM with the Director of Nursing, it was reported that foods should not be stored in medication refrigerators. Additionally, it was reported that the container with intravenous solutions should have had the lock engaged. Record review of facility's policy Medication Storage in the Facility dated November 2021, it was documented, .N. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, cads, and medication supplies are locked when not attended by persons with authorized access. Additionally, it was documented, . K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator.

Based on interview and record review the facility failed to report a significant weight loss to the physician and guardian for one resident (R1) out of three residents reviewed for a notification of a change in condition, resulting in the potential for missed opportunities to make medical decisions for the resident. Findings include: An observation of R1 on 4/14/25 at 9:10 AM resident lying in bed and did not respond to questions. Record review of R1's electronic medical record (EMR) revealed resident was admitted into the facility on [DATE] with pertinent diagnosis of Cerebral Palsy (disorder of movement, muscle tone, or posture), quadriplegia (partial or complete loss of function in all four limbs), and gastrostomy status (method of delivering nutrition into stomach through a tube). Review of Minimum Data Set (MDS) dated [DATE], R1 required total care with all Activities of Daily Living (ADLs). Further review of Brief Interview for Mental Status (BIMS), R1 scored 0 out of 15 (severe cognitive impairment). Review of Weights/Vitals revealed on 12/5/24, R1 was documented as 175 lbs (pounds). A subsequent weight record on 2/15/25 indicated a decrease to 158 lbs., reflecting a total weight loss of 17.8 lbs. (10.1 %) over this period. No weight was documented during January of 2025. Review of Physician Progress Notes dated 12/1/24 - 4/14/25 had no indications for reported weight loss. Review of Progress Notes dated 12/01/2024 - 4/14/25 revealed no documentation that the physician or guardian had been informed of the R1's weight loss. Review of Dietary Progress Notes dated 12/01/24 - 4/14/25 revealed no documentation the physician or guardian had been informed of R1's weight loss. Review of, Partners in Care Documentation, (care conference-held quarterly to discuss residents care needs) dated 3/11/25, had no documentation that indicated the guardian was made aware of the weight loss that had occurred. On 4/15/25 at 3:01 PM an interview with the Director of Nursing (DON), it was reported that residents that have a significant weight loss or any change of condition the Physician, family representative, and guardian should be informed. It was further reported that R1's physician and guardian were not informed of the resident's weight loss. Review of facility's policy Change in Resident's Condition dated 6/21, It was documented, . It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP (nurse practioner) and resident's responsible party of a change in condition. Further review revealed that 1. Nursing will notify the resident's physician or nurse practitioner when: . b. There is a significant change in the resident's physical, mental or emotional status.

Based on observation, interview, and record review the facility failed to properly secure protected health information for two residents (R66 and R131) out of two residents reviewed for privacy of medical information, resulting in the potential for unauthorized disclosure, access, and modification. Findings include: On 4/14/25 at 6:18 a.m. the laptop computer on Unit 200 medication cart, located in the back hallway, was observed with the electronic health record (EHR) visible for R66, and a Communication Report form of R131 faced up on the medication cart. The screen displayed personal identifiable information for the residents such as, their name, birthdate, and protected health information. There was no nurse observed near the Unit 200 medication cart however there were other staff in the hallway. On 4/14/2025 at 6:21a.m. Licensed Practical Nurse (LPN) B walked up verifying being the assigned nurse to the 200 Unit medication Cart. When queried about the visible EHR for R66 and R131, LPN B said the computer screen should not have been left open and the resident form should have been turned over. LPN B was asked why the residents' personal information shouldn't be left visible. LPN B stated, Because it a HIPAA (violation occurs when a covered entity, business associate, or individual fails to comply with the rules set by the Health Insurance Portability and Accountability Act. This can include unauthorized access, use, or disclosure of protected health information failure to implement security measures) violation and it's none of other's business. On 4/16/25 at 10:35 a.m., during an interview, the Director of Nursing (DON) stated, The residents personal information should not be open to any readers other than the nurses. The nurse should have locked or closed the computer not having the resident's information left open and turning over any personal information on the top of the medication cart. According to the facility policy, Privacy and Dignity revision date 5/2022, The facility ensures the privacy and dignity of its residents. On 4/17/2025 at approximately 3:00 p.m. upon exiting no additional information was provided related to the facility's privacy concerns and protection of resident's information.

Based on observation, interview, and record review, the facility failed to provide one resident (R128) with hair grooming out of seven residents reviewed for hair care resulting in uncombed, soiled, matted hair (hair tangled into a thick mass) with areas of tight coils of hair attached to the scalp and resident feelings of frustration and embarrassment. Findings include: On 4/14/2025 at approximately 6:18 a.m. a Certified Nursing Assistant (CNA), who wanted to remain anonymous, reported that R128's hair was not being washed, combed and was matted. The anonymous CNA said R128 is constantly asking for assistance to get her hair washed and for someone to assist in detangling R128's hair. The anonymous CNA identified R128's hair had been in that conditon for at least a week that they were aware of. The CNA reported the facility is telling the resident that the resident would have to pay for the services and stated, I am going to try to do something myself for the resident when I come back to work. On 4/14/2025 at 7:47 a.m., R128 was observed lying in bed wearing a black hair bonnet. During the interview R128 took off the hair bonnet to reveal her hair. R128 was observed with matted hair on both sides of the head and with knots of matted hair in the back of her head. There was a notable odor. R128 stated she would feel better if her hair would be washed and groomed. On 04/15/25 at 9:25 a.m., during an interview, R128 verbalized frustration and sadness when stated, I would like to have my hair washed, conditioned and braided because I used to wash my hair every two weeks before I came here (in the facility). My scalp is itching. R128 scratched her scalp and demonstrated what appeared to be dirty particles from the scalp underneath her fingernails with some dark particles falling onto the bed linen. R128 stated, My hair has grown, it's tangled and I know its dirty. When they (CNAs) wash me up in bed I'm not getting my hair washed. R128 confirmed no staff had been in the room to assist with grooming. On 04/15/25 at 2:47 p.m., R128's assigned CNA D confirmed the morning shift started at 7:00 a.m. and ADL care was provided. CNA D was asked what morning care was provided to R128. CNA D said the resident (R128) was given a bed bath, oral care, assisted with dressing, and assisted with getting up from bed in wheelchair. CNA D stated, I poof (fluff) the front of the resident's hair upward some because it was too tangled to comb. The resident's hair is matted in the back. I can only use my fingers because the resident's hair is too matted. I can't use a comb. CNA D explained that R128 had not refused any care during that shift. On 04/15/25 at 3:00 p.m., Unit Manager (UM) A was interviewed regarding R128's soiled and matted hair. UM A was asked if they were aware of R128's matted hair. UM A stated, Yes, I knew about the matted hair. No, I have not done anything to resolve the matted hair issue because they came in with some kind of braids in the facility on 2/6/2025. UM A was asked why there wasn't anything done with the resident's hair. UM A reviewed the resident's Medical Record and reported there was no evidence that R128 refused hair care. UM A agreed hair care should be provided, The beautician comes every Friday. I think the resident's daughter set up an appointment. UM A confirmed they were aware that R128's hair was matted and said, I saw it. However, there was no evidence the facility intervened to assist R128 with her hair concern. Review of the EHR documented R128 was initially admitted into the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic fatigue, muscle weakness and major depressive disorder. According to the admission Minimum Data Set assessment dated [DATE], R128 was cognitively intact (BIMS-15) and required extensive one-person assistance with grooming/hygiene. Review of the 2/6/2025 ADL care plan documented, ADL self-care deficit require assist with ADLS related to limited mobility, debility, and impaired balance. Interventions included: -Person hygiene: I need extensive assistance to help me. There was no documentation of R128's refusal of hair care. There were no care plans or intereventions that addressed R128's concerns with her hair care. On 04/16/25 at 10:20 a.m., the Director of Nursing (DON) said she became aware that R128's hair was matted yesterday (two months after R128's admission.) The DON was asked what should have been done to resolve the R128's hair care concerns. The DON stated, The expectation would have been that staff attempt to 'un-matt' the resident's hair. Wash it, get a hold of the beautician, talk to the family and determine how to prevent the hair from matting again. The DON confirmed that AM care consisted of hair care. The DON said the resident should not have been forced to feel like they have to go out in the dining room wearing a hair bonnet due to their hair not being groomed. On 04/17/25 at 9:04 a.m., during an interview with Social Services (SS) G, it was confirmed there was awareness of R128's matted hair about the end of February 2025. SS G said R128 was asked about the hair bonnet after the resident was admitted into the facility on [DATE] and confirmed that no one had followed up on the R128's matted hair. The facility (undated) Activity Daily Living (ADL) policy, did not address resident hair care.

Based on observation, interview, and record review the facility failed to provide appropriate grooming in the form of hair care for one resident (R128) of one resident reviewed for dignity, resulting in feelings of shame, embarrassment, and anger. Findings include: On 4/14/25 at 7:47 a.m. R128 was observed in bed awake and alert. R128 was also observed with thick , course hair that was matted. The resident said her hair has not been combed thoroughly since admission into the facility (about 2 months ago). R128 requested assistance with combing the hair, however staff had not offered or provided help. On 4/14/25 at 8:39 a.m. R128 was observed sitting in the dining room for breakfast, wearing a black hair bonnet. R128 was interviewed and stated angrily, If I had my hair done (combed), I wouldn't have to wear the bonnet. I don't want to wear it at the breakfast table, and I am feeling ashamed my hair is not done. They (staff) told me if I wanted my hair done, I would have to pay somebody to get it done. A nurse saw my hair and said that she would help me get my hair together. Before I had the stroke, my hair was always done. My hair on the back and the sides are matted, and I'm going to have to cut my hair off because it's too matted. I cut some of my hair in the back already with my scissors because it was too matted, and I couldn't comb it. I did not want to cut my hair, and I was mad about it. I know a lot about hair, and it is matted because no one had been combing it for me. Review of the clinical record documented R128 was initially admitted into the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic fatigue, muscle weakness and major depressive disorder, recurrent. According to the admission Minimum Data Set assessment dated [DATE], R128 was cognitively intact (BIMS-15) and required extensive one-person assistance with grooming/hygiene. On 4/15/25 at 9:25 a.m. R128 was interviewed and again verbalized frustration and sadness (tears in eyes). R128 stated, My hair is important to me and makes me feel good about myself especially when I look in the mirror with my lip stick on and hair done. I used to comb my own hair. R128 confirmed no one has been in the room to help with am care including hair care. On 4/15/25 at 2:47 p.m. CNA D was interviewed and confirmed being R128's nurse aide for the dayshift (7am-7pm). CNA D acknowledged R128's hair was matted in the back with balls of tangled hair, I couldn't do anything with the back. Probably if I had a pick and some good conditioner, I could have done a better job. CNA D did not notify anyone about the condition of R128's hair. On 4/15/25 at 3:00 p.m. Unit Manager (UM) A was interviewed and asked about the condition of R128's hair. UM A acknowledged R128's hair was matted and stated, I knew about the matted hair. I have not done anything to resolve the matted hair issue because the resident came in with some kind of braids, but hair care should have been given. UM A said there were no other interventions provided to address the resident's hair by staff. On 4/16/25 at 10:20 a.m. the Director of Nursing (DON) was interviewed. The DON was not aware of the condition of the resident's hair or how the resident felt about it. The DON stated the resident should not have been forced to go to the dining room wearing a hair bonnet due hair not being combed. Staff should have attempted to do something. On 4/17/25 at 9:04 a.m. the Social Service Director (SSD) G was interviewed and acknowledged R128's hair care needs at the end of February when the resident was queried about wearing the hair bonnet. SSD G said staff attempted to untangle the resident's hair but could not because it caused pain and discomfort. SSD G said the resident was frustrated and stated, I really need to get my hair done. There was no additional follow up provided. On 4/17/25 at 10:38 a.m. CNA F was interviewed via telephone. CNA F confirmed caring for R128 on a regular basis and had attempted several times to provide hair care. CNA F also said the resident expressed embarrassment about wearing a bonnet and did not want to (wear the bonnet) due to the poor hair care especially with the holiday (Easter) approaching. CNA F who said she has been a regular (aid) with R128 for about a week, explained the resident will be devastated over getting hair cut however does not want the hair to be matted. The resident wants to have hair. Review of the facility's policy titled Dignity, revision date 4/2024, documented in part the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Residents shall be treated with dignity and respect at all times . Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) .

This citation pertains to Intake MI00149373. Based on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available. Findings include: It was reported to the State Agency that the facility was using the emergency stock of food as their current, daily supply of food. On 2/18/25 at 11:00 AM, an observation and interview regarding the facility's emergency food supply was conducted with Food Service Director (FSD) B. FSD B said the food items listed on the emergency menu referred to canned and shelf-stable items that are not frozen or do not require refrigeration. The emergency food supply was stored in the dry food storage room. Based upon a review of the emergency menus, the following foods were not available: Day 1 menu: canned kidney beans for chili, canned green beans, canned tuna, and canned beets. Day 2 menu: canned chicken, canned carrots, canned ravioli, and canned waxed beans. Day 3 menu: canned tuna and canned beets. FSD B said the facility uses the emergency menus and guidelines from a company that provide services to the healthcare industry. A review of the facility document titled, Emergency Menu, dated 2019, documented in part the following: - In the event of an emergency or disaster, the facility shall have a plan in place to provide for the subsistence of all persons, including residents, staff, and visitors and/or volunteers. - When the regular menu can no longer be supported by the main food supply, the emergency menu and emergency stock shall be used. - The emergency menu is designed to utilize shelf-stable items needing only minimal preparation, and which do not require refrigeration or cooking. - Emergency Food Stock: -- Food for the emergency menu shall be stored in an area less likely to be affected by an emergency or stored per facility policy and/or state regulation in an area separate from the regular menu items. -- Inventory of the emergency stock shall be taken routinely, and/or per facility policy. The inventory shall include notation of both product quantities and product expiration dates. Any item quantities below par level shall be replenished with the next order. Any items approaching their expiration date or maximum storage time shall be replaced with the next order. - Emergency stock rotation: --Items within the emergency stock (food and water) will need to be replaced periodically according to product expiration date, facility policy, and/or state regulations. To minimize expenditures food items from the emergency stock may be incorporated into and used for the regular menu, once they have been replaced in the emergency stock and prior to their expiration date. When queried about the minimum amount of inventory (par level) of the emergency stock of food, FSD B provided no answer. On 2/18/25 at 2:09 PM, the Nursing Home Administrator (NHA) stated, We should have had the emergency food supply that coordinates with the menu. On 2/18/25 at 2:22 PM, during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information pertaining to this deficient practice when asked.

Based on observation, interview, and record review the facility failed to implement interventions to address a chronic leaking indwelling urinary catheter (foley) for one resident (R412) of three residents reviewed for catheter care resulting in the worsening and infection of a sacral Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur). Findings include: On [DATE] at 11:20 AM R412 was observed in a perimeter air mattress bed with a foley catheter and stated, I have been having problems with my catheter leaking. I have been waiting for my insurance to go through so that I can see the urologist. My catheter keeps leaking and has reopened the wound on my bottom. According to R412's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis (MS), Neuromuscular dysfunction of bladder and Pressure Ulcer of Sacral Region. According to the Minimum Data Set (MDS) assessment dated [DATE], (R412) had intact cognition and required extensive assist of 2 persons for bed mobility. On [DATE] a skin/wound note documented, (R412) sacrum has changed shape and is slightly deeper. Wound has a pink base with a skin bridge. (R412) continues to have a problem with the foley catheter. (R412) has an appt tomorrow with urology. Right ischium wound continues to be closed. On [DATE] a health status note documented, Guest (R412) returned from scheduled urology appointment not seen due to guest not having current insurance. On [DATE] a health status note documented Cancel appointment due to insurance pending. Will reschedule when guest has insurance. Office put in guest chart why appointment was cancelled. On [DATE] the Wound Care Practitioner's note indicated The patient is seen for multiple wounds located on buttocks, hips, sacrum, pain is intermittent, there are no signs and symptoms of infection. (R412) had a Stage 4 pressure ulcer on the right sacral area that measured: 3.0cm (centimeter) x 0.6 cm x 0.3 cm depth with an area of 1.8 sq cm and a volume of .54 cubic cm. Wound bed has ,d+[DATE]% granulation. The wound is improving. Right ischial recurrent is a chronic stage 3 pressure injury that measured 1.2cm length x 2cm width x 0.1 cm depth, with an area of 2.4 sq cm and a volume of 0.24 cubic cm. Wound bed has ,d+[DATE]% slough, ,d+[DATE]% epithelization. The wound is improving. Left sacral is a stage 4 pressure injury pressure ulcer and has received and outcome of resolved. On [DATE] the Wound Care Practitioners note indicated The patient was seen for a follow up wound care visit for the left sacral (reopened) right sacral, right ischial. The sacral wound has yellow slough at the wound bed. The right sacral has deceased in size, however increased in depth. The right ischial has reopened. The patients foley catheter is leaking again which is a contributing factor to wounds stalling. The left sacral recurrent is a stage 4 pressure injury and has received a status of not healed. Measurements are 2.5cm length x 1.7 cm width with no measurable depth with an area of 4.25 sq cm. The wound margin is attached to wound base wound bed has ,d+[DATE] slough. The wound is stalled. On [DATE] the Wound Care Practitioners note indicated The patient was seen for a follow up wound care visit for the bilateral sacral wound, right ischial wound. The sacral wounds have conjoined and now one wound. New rigid bone exposure found in sacral wound. Antibiotic therapy initiated; X-ray ordered to rule out osteomyelitis. Bilateral sacral deep tissue injury is a stage 4 injury pressure ulcer with measurements 9cm length x 4.2 cm width x 0.6 cm depth with an area of 37.8 sq cm and a volume of 22.68 cubic cm. Wound bed has ,d+[DATE]% granulation ,d+[DATE]% slough. The wound is stalled. Record review of physician's orders for R412 dated [DATE] revealed Bactrim DS Oral Tablet ,d+[DATE] MG (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth two times a day for wound infection, possible osteomyelitis for 7 Days [DATE] to [DATE]. Review of the care plan revealed, Focus: Potential/at risk for alteration in skin integrity due to risk factors associated with contractures of legs, immobility, incontinence (bowel and bladder), pain MS date initiated [DATE]. Goal: Resident will have no complications thru next review date. Initiated [DATE] revised on [DATE] Interventions included, .Provide peri care after each incontinent episode and apply barrier cream initiated [DATE] and .Keep linens dry and wrinkle free initiated [DATE]. Review of the care plans revealed, Alteration in skin integrity-Resident has pressure injury. Site hx of sacrum, coccyx, bilateral ischial tuberosity left I, healed left lateral foot, healed right ischial open, hx right lateral foot all pressure areas on admission. Factors that may inhibit wound healing immobility, incontinence, MS, contracted initiated [DATE] revised [DATE]. Goal: resident will be free from complications thru next review date initiated [DATE] revision on [DATE]. One of the interventions included, Peri care after each incontinent episode and apply barrier cream [DATE]. The Alteration in skin integrity care plan though initiated prior to R412's wound reopening, did not address the leaking foley catheter. Review of R412's care plan revealed Focus: I am on antibiotic related to sacral wound infection; date initiated [DATE]. Focus: I have an indwelling catheter related to stage 4 pressure ulcer to sacrum and multiple sclerosis, neurogenic bladder. Date initiated [DATE]. On [DATE] at 2:10 PM Registered Nurse (RN) A was interviewed and said (R412) has been on the same size Foley catheter for months and it has been leaking since May/[DATE]. We sent R412 to a urologist to be evaluated in June but the urologist would not see them due to lack of insurance. We are waiting for (R412's) insurance to get approved to send them back to the urologist. RN A stated I notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) and Business Office Manager (BOM) in [DATE] that R412 was refused a urology visit due to lack of insurance and notified the NHA and DON that the foley catheter was leaking. RN A agreed R412's chronic leaking catheter contributed to the wounds not healing and getting infected. On [DATE] at 3:10 PM Business Office Manager (BOM) B was interviewed and said she made the NHA aware of R412's lapsed insurance in [DATE] and was working with R412 to reapply. On [DATE] at 9:45 AM Licensed Practical Nurse (LPN) C was interviewed and said R412 has had a leaking catheter all summer and agreed urine could be affecting the wounds' ability to heal and contributed to an infection. LPN C also said she is in frequent contact with RN A regarding R412's care and was aware of R412 not being seen by urology due to a lack of insurance and said that R412's leaking catheter concern was brought up to the interdisciplinary meeting in [DATE]. On [DATE] at 12:45 PM LPN D was interviewed and said she became aware of the antibiotic ordered for R412 on [DATE] in morning meeting due to R412's sacral wound getting worse and infected. LPN D also said that there was no wound culture performed and did not offer an explanation. A urology appointment was not scheduled for R412 until [DATE]. Record review of a health status note dated [DATE] documented (R412) has been scheduled for urology appointment on [DATE] urology office to be bill facility for visit. On [DATE] at 2:30 PM the DON was interviewed and declined to answer if the facility should have paid for and rescheduled R412's urology appointment. On [DATE] at 3:10 PM the NHA was interviewed and agreed it was the facilities' responsibility to schedule and pay for R412's urology appointment. Review of the facility policy titled Indwelling Catheter care and maintenance reviewed ,d+[DATE] revealed in part .A current diagnosis and physician's order will be required to retain the indwelling catheter. Possible diagnosis to retain an indwelling catheter may include the following: To assist with healing of Stage 3 or 4 sacral injuries. Indwelling catheters, drainage bags and tubing will be changed upon clinical indication of infection, obstruction or when the closed system is compromised.

Based on observation, interview, and record review the facility failed to provide comprehensive foley catheter care for one resident (R412) of three residents reviewed for catheter care resulting in a chronic leaking foley catheter and resident concerns with reopening a sacral wound. Findings include: On 9/18/2024 at 11:20 AM R412 was observed in a perimeter air mattress bed with a foley catheter and stated, I have been having problems with my catheter leaking. I have been waiting for my insurance to go through so that I can see the urologist. My catheter keeps leaking and has reopened the wound on my bottom. According to R412's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Neuromuscular dysfunction of bladder and Pressure Ulcer of Sacral Region. According to the Minimum Data Set (MDS) assessment dated [DATE], R412 had intact cognition and required extensive assist of 2 persons for bed mobility. On 6/10/24 a skin/wound note documented (R412) sacrum has changed shape and is slightly deeper. Wound has a pink base with a skin bridge. R412 continues to have a problem with the foley catheter. R412 has an appt tomorrow with urology. Right ischium wound continues to be closed. On 6/11/24 a health status note documented Guest (R412) returned from scheduled urology appointment not seen due to guest not having current insurance. On 6/14/24 a health status note documented Cancel appointment due to insurance pending. Will reschedule when guest has insurance. Office put in guest chart why appointment was cancelled. On 9/2/24 the Wound Care Practitioners note indicated The patient was seen for a follow up wound care visit for the left sacral (reopened) right sacral, right ischial . The patients foley catheter is leaking again which is a contributing factor to wounds stalling. The left sacral recurrent is a stage 4 pressure injury and has received a status of not healed . The wound is stalled. On 9/9/24 the Wound Care Practitioners note indicated, The wound is stalled. Review of R412's care plan revealed Focus: I am on antibiotic related to sacral wound infection; date initiated 9/10/24. Focus: I have an indwelling catheter related to stage 4 pressure ulcer to sacrum and multiple sclerosis, neurogenic bladder. Date initiated 6/20/23. On 9/18/24 at 2:10 PM Registered Nurse (RN) A was interviewed and said R412 has been on the same size Foley catheter for months and it has been leaking since May/June 2024. We sent R412 to a urologist to be evaluated in June but the urologist would not see them due to lack of insurance. We are waiting for R412's insurance to get approved to send them back to the urologist. RN A stated I notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) and Business Office Manager (BOM) in June 2024 that R412 was refused a urology visit due to lack of insurance and notified the NHA and DON that the foley catheter was leaking. RN A agreed R412's chronic leaking catheter contributed to the wounds not healing and getting infected. On 9/18/24 at 3:10 PM BOM B was interviewed and said she made the NHA aware of R412's lapsed insurance in June 2024 and was working with R412 to reapply. On 9/19/24 at 9:45 AM Licensed Practical Nurse (LPN) C was interviewed and said R412 has had a leaking catheter all summer and agreed urine could be affecting the wounds' ability to heal and contributed to an infection. LPN C also said she is in frequent contact with RN A regarding R412's care and was aware of R412 not being seen by urology due to a lack of insurance and said that R412's leaking catheter concern was brought up to the interdisciplinary meeting in June 2024. On 9/12/24 at 12:45 PM LPN D was interviewed and said she became aware of the antibiotic ordered for R412 on 9/11/24 in morning meeting due to R412's sacral wound getting worse and infected. A urology appointment was not scheduled for R412 until 9/19/24. Record review of a health status note dated 9/19/24 documented (R412) has been scheduled for urology appointment on 9/20/24 urology office to be bill facility for visit. On 9/18/24 at 2:30 PM the DON was interviewed and declined to answer if the facility should have paid for and rescheduled R412's urology appointment. On 9/18/24 at 3:10 PM the NHA was interviewed and agreed it was the facilities' responsibility to schedule and pay for R412's urology appointment. Review of the facility policy titled Indwelling Catheter care and maintenance reviewed 10/2021 revealed in part: . Possible diagnosis to retain an indwelling catheter may include the following: To assist with healing of Stage 3 or 4 sacral injuries. Indwelling catheters, drainage bags and tubing will be changed upon clinical indication of infection, obstruction or when the closed system is compromised.

This citation pertains to intake MI00139087. Based on interview and record review the facility failed to ensure adequate assistance during incontinence care (brief change) for one resident (R104) out of four residents reviewed for falls, resulting in a fracture of the right femur (thigh bone) and hospitalization . Findings include: Review of an Admission Record revealed, R104 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Fracture of Femur, Fracture of Pubis (bones of pelvis), and adjustment disorder with anxiety. Review of a Minimum Data Set (MDS) assessment, with a reference date of 8/23/23 revealed R104 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. R104 required extensive assistance of two staff with bed mobility. Review of an incident report with a date of 8/10/23 revealed, Writer called to room by CNA (Certified Nursing Assistant) to assess guest after rolling out of bed during brief change . Guest stated that she was trying to roll in bed to help CNA. Guest c/o (complained of) pain to right knee, right hip, BL (both) shoulders and neck . Xrays ordered. Responsible party notified, Physician notified. Review of a care plan with focus I need help with my ADL's because I get tired easily, Limited Mobility . Interventions included bed mobility: I need extensive assistance of two persons to help me created on 6/3/22. Review of a progress note with a date of 8/10/23 at 9:27 a.m. revealed, . Pt fell out of bed and suffered a femur fracture of the right LE (lower extremity). Pt was sent out to the EC. Review of a progress note with a date of 8/10/23 at 11:59 a.m. revealed, Incident Note: Objective Description : Writer called into room by CNA to assess guest after rolling out of bed during brief change. Guest observed laying on [NAME] (sic) next to bed . Review of a progress note with a date of 8/10/23 at 1:34 p.m., XR (xray) results show distal right femur fracture. NP (Nurse Practitioner), guardian, and DON (Director of Nursing) made aware. NP ordered guest to be transferred to (Hospital Name). Guardian and guest aware. PRN Norco administered for pain prior to transfer. Review of a Xray with an exam date of 8/10/23 revealed, R104 had a displaced fracture of the right distal femur. In an observation and interview on 9/19/23 at 11:23 a.m. R104 laid in bed in high position. R104 did not recall how many staff assisted on the day of the fall. R104 recalled the date of the incident and stated August 10th. R104 reported rolling out of bed while being changed. R104 stated I just fell out of bed and broke my femur. In an interview on 9/19/23 at12:37 p.m. CNA B reported gathering supplies to begin the brief change when R104 fell out of bed. CNA B reported R104 starting rolling over and fell out of bed. CNA B reported there was no other staff present in R104's room. CNA B reported R104 required two staff assistance with care. In an interview on 9/19/23 at 1:14 p.m., Assistant Director of Nursing (ADON) A reported R104 required two person assistance with ADL care. In an interview on 9/19/23 at 1:30 p.m., the DON reported R104 required two person assist with brief changes. The DON then reported CNA B was on one side of the bed and R104 started rolling over. Review of a Fall Prevention Guideline policy with a revised date of 8/1/23 revealed, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries .

This citation pertains to intake MI00135751 Based on observation, interview, and record review, the facility failed to implement interventions to ensure exit door alarms were properly functioning resulting in an immediate jeopardy when one cognitively impaired resident (R101) eloped from the facility unbeknownst to staff and without the exit door alarm sounding on 4/2/23 at approximately 10:40 AM. A visitor alerted facility staff that a resident had exited the facility. Staff observed R101 in his wheelchair on the sidewalk between the facility and the parking lot and returned R101 to the facility without incident. This deficient practice resulted in the likelihood of serious injury or death when R101 eloped from the facility's exit door without a coat that faced toward a two-lane, 45 mph road and the temperature was 42 F (Fahrenheit) degrees. The Immediate Jeopardy started on 3/23/23 when the facility became aware the exit door alarm system was not functioning properly and failed to implement interventions to provide a safe functional environment for the 33 additional residents that were identified as being at risk for elopement. Findings include: The State Agency received a Facility Reported Incident (FRI) dated 4/2/23 that R101 had self-propelled himself through the exit door of the facility and was returned to the facility without injury by staff. The Facility's Investigation Report (IR) dated 4/10/23 indicated R101 was assessed to have severe cognitive impairment and be 'at risk' for elopement. The IR included a progress note dated 4/2/23 at 11:19 AM by Registered Nurse A that indicated R101 went outside through the exit door next to his room, on Station 1 South (S1S) Door and the door alarm system did not go off. Staff brought guest (R101) back into the facility, writer checked alarm, key alarm on. On 4/19/23 at approximately 10:00 AM, during an interview, RN A described what occurred when R101 eloped from the facility, On 4/2/23 at approximately 10:30 AM, a visitor told CNA (certified nurse assistant) B that she felt a rush of cold air and thought that Station 1 South (S1S) exit door had been opened and no alarm went off. CNA B went outside the S1S exit door and found R101 in his wheelchair down the sidewalk about 25 feet from the facility. When I looked at the key alarm it was in the 'off' position, so I turned it back to the 'on' position. RN A could not say when or who had turned the key alarm system off and stated, We do not regularly check to see if the alarm system is on. On 4/19/23 at approximately 10:20 AM observation of the S1S door revealed two different alarm systems in place; 1) a 'badge-reader' alarm system that required a card to be swiped down the reader (like swiping a credit card) to disengage the alarm system which was located on the door jam and 2) a 'key' alarm system that required a notched key to be manually turned to either the 'on' or 'off' position at a switch plate which was located on the wall next to the door. RN A said, the badge-reader alarm system doesn't work. It hasn't been reliable for a while. It works on some of the doors and sometimes it doesn't, but it hasn't worked on the Station 1 doors for a long time. We use the key alarm for this door. When R101 eloped, I noticed the notch on the key alarm was in the 'off' position and not engaged. RN A could not say when the key alarm was shut off. We don't periodically check to see if the door alarm is on. It is hard to tell where the notch should be to turn the key alarm 'on' because it's so small (the notch). Observation of key alarm system revealed it was in the 'on' position. RN A demonstrated that the badge reader alarm did not work. A card was swiped down the badge reader and the green light did not change. RN A opened the S1S door, and a buzzer alarm sounded. RN A explained the buzzer sound was the 'key' alarm sounding off and not the 'badge reader' alarm. The 'badge reader' alarm is a beeping sound. The 'key' alarm is a buzzer sound. RN A said the maintenance director was aware of the door alarm system not working correctly. On 4/19/23 at approximately 10:45 AM the Director of Nursing (DON) confirmed that the alarm did not sound when R101 eloped through the S1S exit door. When asked what interventions the facility used to provide a safe environment for residents at risk for elopement the DON said the facility did not use a wander guard system (a bracelet worn by residents that triggers the door alarm to alert facility staff when a resident is near an exit door) and that facility staff relied solely on the facility's exit door alarm systems to alert staff if an unauthorized person or resident has opened an exit door. The DON confirmed that the facility had an issue with the doors alarm system during the State survey in March 2023. The back door on Station 2 (S2N) had not been working properly at that time but when the security company arrived to repair it, the door was working fine (3/23/23). The DON said after R101 eloped on 4/2/23 all the residents in the facility were assessed for the risk of elopement utilizing the facility's elopement risk assessment tool. Thirty-three residents had been identified to be at risk for elopement with 16 residents at 'high risk' for elopement. The DON confirmed that these residents were located throughout the facility and had the potential to access the facility exit doors. When asked if any additional interventions were implemented to ensure the facility provided a safe environment for residents who were at risk for elopement while the exit door alarm system was not fully functioning the DON said, The exit doors alarms were functioning properly. On 4/19/23 at approximately 11:00 AM during an interview with Maintenance Director (MD) G he said that during the State survey inspection the facility became aware the alarm system at the back entrance door (S2N) was not locking correctly and another door (S3N) was not alarming correctly. MD G said, I had the security system company come out to repair it. When the security company arrived, the back exit door (S2N) was locking properly but the S3N door wasn't alarming properly. Since then (3/23/23) I have been manually checking the exit doors to ensure they are fully closed and locked, and the key alarm is in the 'on' position. I do not actually open the door to check if the alarms work. I don't want to set off the alarm because the badge reader alarm system is still messed up. Sometimes the badge reader will continuously alarm until I reset it at the control panel. The security company said repeatedly resetting the badge reader alarm system at the control panel may be causing the issue. MD G referred to the work order from the security company. According to the security company's work order dated 3/23/23; MD G, called and said a couple of his back doors, one being an emergency door, are not locking even though they are supposed to be badge access only to unlock. There is no alarm going off either The first door he showed me that was non-functional was working properly on my arrival. The second door (S3N) was not sounding the piezo (electric alarm) in the ceiling when opening the door . The staff have been resetting the door alarms by using the reset button on the control panel not by using the card reader. It is suspected that using the reset button may be causing issues with the cards in the panel, and we would need to access the systems software The current system in place is out dated and no longer offers tech support. We wouldn't be able to access the software The customer was presented with a quote to replace the system, but since then the lead of maintenance has changed I recommend getting in touch with our office regarding the quote and to discuss further actions to solve the issue. During interview MD G said he had not received any further instruction or information regarding the facility's plan to repair the exit door alarm system. MD G presented an excel spread sheet labeled Daily Alarm Check initiated on 3/23/23 and said, Since 3/23/23 I have used this sheet to document that I checked all the exit doors. MD G said he put his initials to indicate the date the door checks had been completed. Review of the Daily Alarm Check sheet revealed it was initiated on 3/23/23 and identified seven facility exit doors: Station 1 South (S1S), Station 1 [NAME] (S1W), Station 2 [NAME] (S2W), Station 2 North (S2N), Station 3 North (S3N), Station 3 East (S3E), Golf door (GD). The spread sheet did not identify what the alarm check entailed, only dates and initials. MD G's initials were missing on 3/25/23, 3/26/23, and 4/1/23 (the day prior to R101's elopement). MD G confirmed that he did not check the doors on 3/25/23, 3/26/23, or 4/1/23. On 4/19/23 at approximately 11:15 AM with MD G the Station 2 exit door had an alarm sounding. Staff were attempting to swipe the badge reader alarm with their badge and the alarm would not shut off. The Station 2-unit manager, RN D said, A visitor opened the exit door and the badge reader isn't working again. I tried a couple different badges, and it won't shut off. Can you reset it? At this time MD G went to a utility closet on Station 2 and used the reset button on the control panel to shut the badge reader alarm off. RN D said, This is the main entrance and exit door for staff and visitors. The badge reader alarm system does not work right sometimes, so we have to reset it. RN D said there were no residents at risk for elopement on her station. On 4/19/23 at approximately 11:25 AM during observation of Station 3 exit doors with MD G and Unit Manager Licensed Practical Nurse (LPN) E the Station 3 East (S3E) door alarm did not function properly. The S3E door was opened. The badge reader alarm did not sound. The key alarm sounded but shut off when the door closed. LPN E said, the alarm is not supposed to automatically shut off when the door closes. The door alarm should continue to sound until a staff member inspects and secures the area, then manually turns the key to reset it. LPN E said that R102 was at high risk for elopement. R102's room was at the end of the Station 3 East Hall with her door next to the S3E exit door. R103 was also identified to be at high risk for elopement and resided near the S3E exit door. According to the facility's Elopement policy revised on 8/2022 the purpose of the policy is to provide guidance on elopement management. Guidelines: 5. Access doors on some units are alarmed so that staff can secure the environment rather than the resident and can intercede when a resident wants to leave the unit or safe area. 6. All facility staff are responsible for responding to a door/elevator alarm immediately. On 4/19/23 at 3:40 PM, the Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) that began on 3/23/23 when the facility failed to implement interventions to prevent elopement when they became aware the facility's exit door alarms were not functioning properly. Although the Immediate Jeopardy was removed on 4/19/23, the facility remained out of compliance at a scope of isolated with severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency. A written plan of removal for the immediate jeopardy was received and verified on 4/20/23. The facility removal plan documented the following: 1. Education will be provided immediately to the licensed nurses to ensure that they are aware of the door alarms being able to be turned off and that they should be turned on in order for the alarm to sound when opened. If they find a nonfunctioning alarm- they need to notify their supervisor- and will assign staff to monitor door to ensure resident safety and no resident exits facility from that door. 2. No licensed nurses will be allowed to work in the facility until completing the necessary education. 3. Maintenance educated on door alarm checks 4. Staff to monitor door exit by room [ROOM NUMBER]- to ensure resident safety and ensure no residents exits the facility from that door until replacement alarm is installed-expected to be installed on 4/21/23 1. A QA Tool was developed to ensure door alarms are alarming when door is opened and remains alarming until disarmed by staff. 2. Daily QA will continue until the door alarm is replaced to the exit door by room [ROOM NUMBER] 3. Once door alarm is replaced to the exit door by room [ROOM NUMBER], The QA tool will be completed 4x/weekly for the next 30 days to ensure compliance, this will continue to be completed until QAPI has identified facility remains in continued compliance X 4 weeks. 4. The QA Tool will be presented to QAPI and will be continued to be reviewed for on-going compliance and for any further recommendations and or resolutions.

Based on observation, interview, and record review the facility failed to prevent abuse for one (R502) of six residents reviewed for abuse resulting in R#502, a known wanderer, from sustaining a laceration to the back of the head that required six sutures after being punched by another resident and subsequently falling. Findings include: According to the facility's 'Administrative Statement Investigation Analysis'; on 4/17/22 at approximately 11:00 AM, staff overheard R501 yelling at R502 to get out of his room. When staff entered the room, R502 was observed sitting on the floor in front of the closet with a laceration to the back of his head. R502 was unable to state what happened. R501 stated that R502 walked into his room and tried to get into his (R501's) bed. When R501 told R502 to leave, R502 got very close to him and shoved him. R501 stated that he then pushed him (R502) and he (R502) fell backwards. R501 then changed his story and said he punched him (R502). During an observation and interview on 6/15/22 at 10:08 AM, R501 was observed resting in his bed looking at his cell phone. R501 was asked if he recalled an altercation with another resident in April. R501 said, Yes, that guy tried to get in my bed. He tried to shove me off the bed. I sat up but I couldn't really stand up because he was blocking my way, so I punched him, and he fell backward and hit his head on something. According to R501's Electronic Medical Record (EMR), R501 has resided at the facility since 2017. The Minimum Data Set (MDS) dated [DATE] indicated the R501 had moderately impaired cognition with a BIMS (brief interview for mental status) score of 10/15. R501 had no history of verbal or physical behaviors. During a second interview with R501 at 11:45 AM, he (R501) said, That guy (R502) got in my face and yes, I punched him. He had been going in and out of everybody's room and bothering people. Since they moved him, there has been no problems. According to the EMR, R502 resided at the facility from 4/15/22 through 4/25/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R502 was identified to exhibit wandering behaviors 1-3 days, within two days of his admission. Section E 1000 A; 'impact of wandering' was left blank and not answered. A care plan for elopement risk/wanderer was initiated on 4/18/22 that had the following interventions; I will remain safe within facility unless accompanied by staff other authorized persons, I will not leave facility unattended. The CNA/NURSE assigned to me will perform routine monitoring of my whereabouts, Direct to visual It is time to be in bed when going to bed and redirect, If I am wandering in potentially unsafe area or situation, re-direct to safer area, leave safe and reassess regularly. A progress note dated 4/16/22 at 4:13 PM written by Licensed Practical Nurse (LPN) C reads as follows; Resident witnessed by staff members wandering into multiple resident's rooms. Resident attempting to take resident's possessions and lay in their beds. Writer attempted to redirect resident to his own room. Writer was unsuccessful and resident started to become aggressive with writer. Resident attempted to push, punch, and kick writer and other staff members in the process of redirecting resident back to his room. Writer and 2 CNAs (certified nursing assistants) were able to calm resident down and get him in his recliner in his room. Resident is currently in his room in his recliner with eyes closed. On 6/15/22 at 12:40 PM LPN C said R502 was anxious and had behaviors upon admission. LPN C said that R502 was a bigger man that was hard to redirect and easily got aggressive. LPN C said they staff tried to keep an eye on him but was unable. LPN C was asked if any other interventions were put in place to prevent R502 from entering other resident's rooms. LPN C said the family was asked to come in and assist with watching him (R502) and even stayed late at night. LPN C confirmed that he was the nurse assigned to R502 during the incident with R501 but was on his lunch break and did not witness the incident. On 6/15/22 at 12:10 PM CNA G said that R502 continually wandered into other resident's room and invaded their privacy. CNA G said that he (R502) took food and drinks from other resident's meal trays or bedside tables and consumed them. CNA G said R502 was difficult to redirect because he would become aggressive. CNA G said the resident's family members came it and assisted with supervising him (R502). A progress note dated 4/17/22 at 1:51 AM documented; Guest noted anxious and wandering from room to room. Guest attempted to go into different guest rooms and was redirected and guest noted anxious and aggressive with staff members. When guest was asked what was going on he said he needed to go. Guest was provided a cool beverage and snack with minimal relief. Guest noted attempting to exit seek near side door on unit and two nurses and staff attempting redirection and helped guest away from door. A progress note, dated 4/17/22 at 3:30 AM included the following: Guest noted with aggressive behavior towards staff and nurse. Guest continues to leave bed and self-transfer and is becoming combative with staff. Nurses and staff members provided redirection and was ineffective. Nurse even brought guest to a low stimulus area with TV on low volume. Guest was also provided a coloring book and nurse attempted to color with him and was ineffective. On 6/15/22 at 1:00 PM LPN D said that on 4/17/22 at approximately 11:00 AM she was in the medication room when she became aware that there was an altercation between R501 and R502. LPN D said she found R502 on the floor in R501's room. R502 had a laceration to the back of his head that was about 2.5 inches long. LPN D said that R501 said he punched him (R502) because he tried to push me out of my bed. LPN D said she got report that R502 had been wandering into other resident's room since he was admitted to the facility (two days earlier). LPN D said the only interventions was for staff to do frequent checks on him (R502) but we were unsuccessful on that day. On 6/15/22 at 2:05 PM the Director of Nursing (DON) B said that R502 was transported to the emergency room and had 6 sutures placed for the laceration on the back of his (R502) head. DON B confirmed that a care plan for 'elopement/wandering' was not initiated until 4/18/22, after the resident-to-resident incident on 4/17/22. DON B said that R502 was moved to a different unit and did not have any other resident-to-resident altercations after 4/17/22. DON B confirmed that R502's family did come into the facility to assist with supervising the resident until he was transported to another facility on 4/25/22. According to the facility's policy #3156 last revised 7/2017; POLICY: Guests will be protected from abuse, neglect, mistreatment, exploitation, or misappropriation of property no matter whom is at harm. GOAL: 1. To maintain a safe environment for guests.

This citation pertains to intake: MI 071 Based on Interview and record review the facility failed to provide adequate supervision to ensure the correct food item for a pureed diet was served for one (R601) of four residents reviewed for correct diet consistency. This resulted in an Immediate Jeopardy (IJ) causing death by asphyxia (choking) due to obstruction of the airway by an aspirated hot dog. Findings include: On [DATE] at 1:30 P.M., review of the Admission Record revealed R601 was admitted to the facility on [DATE], with diagnoses which included: Dysphagia Oropharyngeal Phase (impaired swallowing), Cognitive communication, Down's Syndrome, non-psychotic mental disorder, [CONDITION(S)] disorder, difficulty in walking, muscle weakness, and intraventricular laceration without a foreign body of the scalp. According to the Minimum Data Set (MDS) dated [DATE], R601 was cognitively impaired in decision making, required extensive assistance with Activities of Daily Living (ADLs) and required supervision, and set up help for eating. The complainant was interviewed on [DATE] at 9:35 A.M and reported R601 had been sent to the facility for short term rehab (,d+[DATE] days) and had died in the facility after the resident choked on a hot dog. The complainant stated, (R601) had been on a pureed diet for the last two and half years and there was no reason he should have received a hot dog. On [DATE], at approximately 5:58 P.M., the complainant was informed R601 was found unresponsive in his room. The complainant indicated that R601's family thought he was doing fine and had planned for the resident to go to a different Group Home once he was discharged . The complainant stated the family arrived at the facility shortly after the call around 6:20 P.M. and were allowed to be with R601 until around 10:00 P.M. when the mortician picked up the body and the remains were transported to Funeral Home AA. On [DATE] at 11:00 P.M., the complainant received an anonymous tip that the facility had given R601 food that was not allowed on his pureed diet. This prompted the complainant to seek an autopsy. On [DATE] at 1:30 P.M., review of the Admission Notes dated [DATE], indicated R601 was admitted from a local hospital with three staples to the forehead after a fall at the resident's Group Home. R601 was transitioned to the facility with Physician Orders for a pureed diet with thin Liquids. Review of the Health Status Progress Notes dated [DATE] through [DATE] documented Physical Therapy was started [DATE] and ended [DATE], Nutrition Review documented on [DATE] and a Speech Language Consult initiated on [DATE]. Record review of the Health Status Notes timed 6:43 P.M., revealed on the morning on [DATE] (upon start of the shift) R601 was described as spitting up thick phlegm, mucous. The resident vomited twice and was noted to have some congestion. R601 stayed up in his wheelchair until after lunch. Vitals were stable, when asked if he could lay down, R601 was seated in recliner instead of laying (sic) in bed in case he vomited. R601 reportedly was checked on frequently as the nurse's cart was outside of his door. The Doctor was alerted of the resident's status and his congestion. Timed entered at (11:55) A STAT Chest X-ray was ordered. Solumedrol (steroid) and [MEDICATION(S)] (antibiotic) were ordered. Review of the Health Status Notes dated [DATE], revealed R601 was found unresponsive by Nurse J at 5:34 P.M. upon entering room to give antibiotics. Unable to obtain Blood pressure, Pulse-119, SPo2 74%, no respiration rate. At that time R601 was sitting up in his recliner with his feet slumped to left side with wet emesis on his shirt and cheek. Code Blue 911 was called immediately, CPR started. R601 was witnessed by writer (Nurse J) watching television 2 hours prior when given IM medication. He stated at that time that he was feeling better. Vitals were stable. 1 hour later removed 3 staples from R601's right side forehead. Resident tolerated well and stated, it didn't even hurt. On [DATE] at approximately 3:30 P.M., review of the Forensic Pathology and Toxicology Report (Physician name redacted), dated [DATE], documented the following findings for R601: Report of Autopsy: Autopsy on the body of (Resident name and DOB redacted) was performed on the 2nd day of August, in the year 2021, at 11:40 A.M. at Funeral Home AA. *The Lungs are congested and moderately emphysematous. * Large pieces of Hot dog obstruct the upper airway. * Microscopic Examination: * Lung: Hemorrhage, focal foreign body fragments (HOT DOG), in lung alveoli and [MEDICATION(S)] branches, over distended and torn alveoli. OPINION: This [AGE] year-old (ethnicity redacted) gentleman, R601, died of asphyxia due to obstruction of the airway by aspirated hot dog. On ,d+[DATE] 2022 at 1:30 P.M. and [DATE] at 3:50 P.M. Chef D was asked for a copy of the menus served for [DATE] through [DATE]. Chef D stated, The menus were not saved that far back, and he did not have access to those menus. The Chef explained the menu cycle had changed out two times in the year and possibly the Corporate Office could provide a copy of the menu served. The ALA Carte menu and menus for the current cycle was provided. Both menus showing hot dog as a choice for residents. Chef D stated, All pureed food came from the main kitchen because that was the only place the facility had an Industrial Blender (heavy duty). The chef explained all pureed food was prepared in the kitchen and residents who had an order for pureed consistency diet usually received the same food items (in a pureed consistency) as a Regular diet. When queried if residents/staff requests were documented when items were requested from the kitchen, Chef D responded NO. At the time we had a different system in place, but that system was discontinued. Chef D suggested sometimes families brought food in for their loved ones without staff knowledge but denied any knowledge of the resident being served a hot dog in the facility. In a later interview with the complainant on [DATE] at 7:30 P.M., the complainant acknowledged the three siblings visited R601, almost daily but never during mealtimes and they never assisted feeding the resident while he was in the facility. The hours and frequency of visitations by the complainant and siblings were verified by the screening kiosk by the Administrator. On [DATE] at 2:30 P.M., an attempt was made to interview Registered Dietitian I. Dietitian I reported at that time she wasn't the Dietitian employed by the facility. The Dietitian that was employed during R601s stay no longer worked at the facility. In an interview with the Director of Nursing (DON) at 2:40 P.M., the DON reported she vaguely remembered the resident but thought he passed. The DON thought if she reviewed her Soft File that would jog her memory. The DON was queried why was there a soft file for R601? The DON stated, when the facility had an (unanticipated event) she usually initiated an investigation. At this time copies of three witness statements; Speech Language Pathologist G, LPN J and Dietary Aide K) were provided. Each statement documented R601 receiving the correct diet consistency of food on the day of [DATE]. The DON denied knowledge of R601 receiving a hot dog. In a subsequent interview at 2:55 P.M. with the Assistant director of Nursing (ADON), she indicated during the time frame R601 was in the facility she was off work . The ADON denied any knowledge or any reports of R601's death. On [DATE] at 4:05 P.M. and 5:00 P.M. the Administrator denied knowledge of the resident receiving a hot dog while in the facility. The Administrator reiterated the soft file had been reviewed and the witness statements reviewed did not document R601 received the wrong consistency of food item in the facility. On [DATE] staff that were present on [DATE] and [DATE] that may have had knowledge of how Resident 601 obtained a hot dog were attempted to be contacted. Staff included Nurse Aide (NA) U, R, and LPN W, S, Y, and T. Messages were left with a request for a return call. No calls or responses were returned from staff during the time of investigation. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 4:00 P.M. The Immediate Jeopardy began on [DATE] when the facility was informed of the autopsy findings. An abatement plan for this Immediate Jeopardy was requested and verified on [DATE]. I. Corrective action taken for identified resident - Res discharged to funeral home from facility on [DATE]. II. How facility identified resident(s) affected and resident(s) with the potential to be affected by the same deficient practice: No other residents were affected by this immediate jeopardy. However, all residents will be reviewed in this removal plan. III. The subsequent process outlined below under Action will be reviewed and implemented: IV. Education will be provided immediately to ensure that staff are aware when passing food trays to resident that the food consistency matches the resident's current diet orders. Initiated [DATE]. V. Education will be provided to staff immediately to ensure that staff know where to obtain a resident's diet order in the electronic health record and from their dietary slips. Initiated [DATE]. VI. Education will be provided to all receptionists and nurses. The receptionist will need to notify resident's nurse when food is brought into facility. So that the nurse will ensure that the food brought in matches the resident's current diet orders. Initiated [DATE]. VII. No staff member will be allowed to work in the facility until completing the necessary education. Initiated [DATE]. VIII. A QA Tool was developed to ensure residents are receiving the correct food consistency based on their current diet order. The QA tool will be completed 4x/weekly for the next 30 days to ensure compliance, this will continue to be completed until QAPI has identified facility remains in continued compliance, no less than 90 days. Immediate and ongoing. IX. The QA Tool has been presented to QAPI and continues to be reviewed for on-going compliance and for any further recommendations and or resolutions. Immediate and ongoing. Although the Immediate Jeopardy was removed on [DATE], the facility's deficient practice remained isolated with the potential for harm that is not immediate jeopardy. On [DATE] at 2:00 P.M., during the Exit Interview, the Administrator stated she had checked with outside sources (Funeral Home AA, etc.) and each had denied or was aware of the Forensic Pathology Report. During the Exit Interview the Administrator, DON and Regional Consultant were advised any additional information the facility wanted to provide related to R601 would be accepted at that time. No additional information was provided upon exiting the facility at approximately 2:30 P.M.

Based on observation, interview, and record review, the facility failed to ensure a resident's post-surgery hip pain was addressed, for one sampled resident (#181), resulting in voiced feelings of isolation, frustration, and unalleviated pain. Findings include: On 9/30/20 at 12:14 PM when entering the room of resident (181) during the initial tour, the surveyor observed the resident trying to shift his weight in the bed; every time he tried to move, the resident grimaced. The resident was asked if he was in pain. Resident (181) stated, I am in pain in my leg, but I have not gotten anything since I have been admitted . The resident was asked if he pressed his call light. Resident stated, I don't have no call light. Surveyor observed the call light of resident (181) dangling on the floor under his bed. Resident (181) was admitted to the facility during the early evening of 9/29/20. Per a record review of the resident's admission note dated 9/29/20. The resident was admitted to the facility via stretcher with 2 ambulance assistants. The resident was alert and orientated, and able to verbalize his needs to staff. The [DIAGNOSES REDACTED]. His medications were confirmed with the physician (O) and faxed to pharmacy. Resident (181) required extensive assistance 2-person assistance with activities of daily living and toileting. The prescription for pain management received from the hospital included a pain medication called [MEDICATION NAME]. Further record review indicated a late entry via the nurse practitioner dated 9/30 at 9:45 AM, the entry stated the resident was being seen for follow up for left hip surgery and pain. According to the Nurse Practitioner note, the resident has pain when he moves; otherwise he has no pain. Orders for pain management instructed the staff to continue current pain management regime with [MEDICATION NAME] Tablet 7.5-325MG 1 tablet as needed for moderate pain. A record review on 10/1/20 indicated, a possible drug allergy specific to the order for [MEDICATION NAME] Tablet 7.5-325MG. On 10/01/20 at 1:25 PM, the surveyor observed resident (181) in bed with a frown on his face. The resident was asked what his concern was. The resident stated, they will not give me anything for pain. They keep telling me they will bring me something for pain, but no one does. On 10/1/20 at 1:40PM an interview was conducted with nurse (K) during a medication pass. Nurse (K) was quired as to her intentions on providing resident (181) with pain medication. Nurse (K) stated, I will give the resident something for pain. The therapist was just in his room but resident (181) made the therapist leave his room, he refused his therapy. The surveyor replied, what pain medication will you give the resident. Nurse (K) looked at the resident's MAR (medication administration record) and responded, I will give the resident some [MEDICATION NAME]. Nurse (K) asked, Nurse (Q) to come over and look at the MAR (Medication administration record) for resident (181) On 10/1/20 at 2:30 PM resident (181) was asked if a nurse brought him some pain medication and the resident responded no. An interview was conducted with physician (O) on 10/2/20 at 2:45PM regarding the [MEDICATION NAME] order for resident (181). The surveyor inquired about the notice in the resident's record related to an allergy to [MEDICATION NAME]. (O) stated, the resident remains on this medication because he does not have a true allergy to this medication. There have been no changes in my orders related to the resident's pain medication. On 10/06/20 at 10:00 AM resident (181) was observed sitting up in a wheelchair at his bedside. When asked about his pain, the resident stated, my pain is half and half it hurts on my left leg because I got my fracture on my left hip. I will get therapy in my room in a little while, because I want to go home to my dog. When asked if he received any pain medication before therapy he stated no. The resident was asked why he does not ask for pain medication before therapy. The resident stated, I told you the other day, when I ask for pain medication, I do not receive it, that makes me feel upset and then I do not want to be bothered with my therapy, I need my therapy so I can go home. On 10/6/20 at 11:00 AM, Nurse (A) was asked what the resident received for pain, and when was the last time he received it. Nurse (A) and the surveyor reviewed the resident's MAR (medication administration record). Nurse (A) stated, the resident has not had any pain medication since 10/2/20 at 8:34pm according to his Medication Administration Record [REDACTED]. When asked if resident (181) has received any Tylenol, nurse (A) stated, he has not had any Tylenol signed out. Nurse (A) findings were confirmed by the surveyor. On 10/6/20 per record review of the admission care plan for resident (181), the focus of pain management specific to pain in the left hip and knee pain was identified. Interventions included: providing [MEDICATION NAME] 30 minutes before therapy. On 10/6/20 a pain management policy was requested from the DON. The surveyor informed the DON there was a concern regarding pain management for resident (181). The DON provided the surveyor with a pain management policy and procedure with a revision date of 11/2018. The goal of the policy indicated pain regimen will be built around a guest's personal pain goal, with a focus on anticipating and managing their pain at a level acceptable to them. Number 3 of the procedure stated, when there is an anticipation of a potentially painful event, such as therapy or outside appointment, this will be reviewed with the guest/decision maker and addressed on the interdisciplinary care plan. Number 13 of the procedure stated, any guest receiving pain medication will be asked at least daily if their pain is being managed. If their pain is not being managed the nurse will notify the physician of the need to review and adjust the guest's pain regimen.

This citation pertains to MI 1 Based upon observation, interview, and record review the facility failed provide adequate supervision and transfer assistance to prevent accidents with injury (laceration, skin tears, bruising and subdermal hematomas), for two (R17, 92) residents and hospitalization of one (#92) resident reviewed for accidents/hazards resulting in the likelihood for more falls, injuries, and physical declines. Findings include: Resident #92 On 5/21/19 at 3:13 P.M., during the initial tour, Resident #92 (R#92) was observed sitting in the dining room in a Geri chair able to make needs known. Resident denies any pain and appears not to be in any discomfort. On 5/23/19 at 9:16 A.M., Resident #92 was observed sitting in the dining room finishing breakfast with a wound dressing to the Right leg. When R#92 was queried while sitting at the breakfast table, she was unable to recall any incident happened on 1/9/19 that cause a laceration to her right leg and was transferred to the emergency room for sutures. On 5/23/19 at 11:30 A.M., review of the facility's investigation report dated 1/9/19 revealed, on 1/9/19 at approx. 10:15 P.M., R#92 was transferred into the bed from the wheelchair by CNA U and sustained a laceration to the right lower extremity (leg). Upon assessment by Nurse V, it was determined R#92 needed Medical attention for the right leg laceration and was transferred to the emergency roiagnom on [DATE] and returned on 1/10/19. The facility concluded the Guest received a laceration to the right lower leg following a transfer. On 5/23/19 at 11:33 A.M., review of the Hospital Problem List dated 1/10/10 documented, Contusion of right lower extremity (leg), Tetanus VIS. The Hospital Problem list did not include the numbers of sutures provided to repair the Right leg laceration. On 5/23/19 at 11:40 A.M., Review of the facility's investigation report revealed CNA U statement documented, I wheeled the resident into the bathroom and got her on the toilet, she was slipping off, so I got help to pull her back. Then I transferred her into the wheelchair, and I went in her room and transferred her by myself onto the bed. I saw the blood on My hands. I realized the blood was coming from a wound on her leg and went to get the nurse. During the interview the administrator stated to CNA U, this is a very extensive puncture wound, it's difficult to see how this could have happened if it wasn't during the transfer. On 5/23/19 at 11:45 A.M., the facility's investigation report documented, an interview was held with CNA U on 1/10/19 by the administrator. When CNA U was asked, if the nurse had told her earlier that the resident was a two-person extensive assistance with transfer, CNA U nodded in agreement. CNA U stated, I tried to wait as long as I could, but it was just a moment of carelessness, not that I don't care, I just didn't think twice about it. CNA U was asked, what's her normal practice was as far as removing the foot pedals prior to transferring. CNA U stated, that she normally would have removed the foot pedals, but she thought that the way the chair was angled toward the bed that the foot pedal was far enough under the bed. CNA U stated to the Administrator; she didn't know why she was getting suspended because she told the truth about transferring the resident by herself. The investigation report revealed; CNA U was suspended because she failed to follow the plan of care by not using the correct amount of staff (two-person) when transferring the resident. On 5/23/19 at 12:30 P.M., further review of the Facility's investigation report revealed, a sign document by CNA U titled, Employee Coaching Form dated 1/9/19, Topic: The following employee is in violation of the following rule, Transferred the resident by herself, resident ended up obtaining a laceration to the right upper extremity, sent to the hospital for sutures. Also, a signed document by CNA U titled Safety of Guests (residents) policy dated 5/8/18, Topic: Practices which may be considered unsafe include, but are not limited to the following: (F) Not using the proper number of staff and/or the proper equipment when transferring, toileting or showering a guest. The facility's investigation report revealed CNA U file was reviewed and the CNA had adequate training on transfers and the CNA was unable to articulate a reason that R#92 was transferred with one person assist when the injury occurred. On 5/23/19 at 1:45 P.M., the Director O Nursing (DON) was interviewed about R#92's 1/9/19 incident. When the DON was queried is CNA U still an employee at the facility. The DON stated, No, because of this incident. The DON was also queried about proper transfer status according to the care plan and Kardex (direct staff charting system). The DON stated, Because the employee did not follow the Resident Transfer Kardex, this was the reason for her disciplinary action. On 5/23/19 at 9:30 a.m., according to the medical record, R#92 was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the Resident was cognitively severely impaired and required extensive assistance with two-person assistance with transfers, bed mobility and toileting and required extensive assistance with one -person assistance for all activity daily living (ADLs). On 5/23/19 at 9:40 a.m., review of the resident 's Fall care plan dated 2/1/17 documented, I am an extensive assistance of two-person with all transfers. Review of the CNA's Visual/Bedside Kardex report (The Residents Care Guide that is provided for the CNA's) dated 1/31/17 documented, All transfers with extensive assistance of two-person. On 5/23/19 at 2:15 p.m., the facility policy titled, Proper Body Mechanics . date revised 8/2012 documented, . Ensure correct number of employees for a safe transfer. Check the guest (resident) transfer status which is in P.O.C. (Plan of Care), click on the guest's Kardex and their transfer status is in the transferring section . Remove the foot pedals when transferring a guest. Resident #17- On 5/22/19 at 8:37 AM, Resident #17 (R17), a double [MEDICAL CONDITION], was observed in his room sitting in his wheelchair. When R17 was queried about the care he received at the facility, he said, I get poor service. I slid out of the shower chair during breakfast and got pretty messed up. I'm lucky that I didn't hit my eye when I fell . I went to the hospital because of the fall. When queried why he was sitting in the shower chair during breakfast, R17 said, They got me up late. It was too late for me to take my shower before breakfast. So, I was sitting in the shower chair during breakfast. According to the medical record, R17 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. A MDS dated [DATE] documented intact cognition, no impairment in his upper extremities, and supervision with only setup help for eating. Review of R17's progress note, Incident/Accident report, and hospital documents revealed the following: 1. Progress note written by Nurse, Staff E, dated 4/22/19: Guest had fall that resulted in bumping his head, abrasions to forehead, nose, left temple. (Physician) paged, notified of vitals WNL (within normal limits), alert and oriented x3 (times three), skin tears to right hand and left anterior stump, no c/o (complaint of) pain at this time.send guest through ER for CT scan of head due to (anticoagulant) use. 2. Incident/Accident report dated 4/22/19: Nurses called to room during breakfast and observed guest lying on right side/face down with head against nightstand. Guest was lying on bottom of tray table also. Blood observed seeping through bandage on left stump and from small abrasion to left temple and left side of nose. [NAME] denies any pain at this time. Injuries Noted: Skin tear back of right hand, left anterior stump. Abrasion left temple, forehead, left side of nose. 3. History and Physical on 4/22/19 at (hospital): Review of Systems: Integument: bruise of abdominal wall from hoyer lift; abrasion on face. Musculoskeletal: skin tear right 4th finger Face: + abrasion/ecchymosis (discoloration of the skin resulting from bleeding underneath) forehead. 4. 4/23/19 (hospital) discharge summary: Multiple abrasions. CT all normal. Review of R17's care plans revealed: Focus: My fall risk assessment scored me at moderate risk for falls related to gait/balance problems. Initiated 4/17/19 Intervention: I should not be transferred to the shower chair until I am ready to go directly to the shower room. Initiated 5/15/19. Focus initiated 4/11/19: I need help with my ADL's (activities of daily living) because I have a left BKA ([MEDICAL CONDITION]) and right AKA (above the knee amputation). Interventions: I must be up in my wheelchair for all meals. Initiated on 4/11/19. On shower days, if the aides don't shower me before breakfast I prefer that they put me in the shower chair and let me eat breakfast in the chair that way they can take me right after breakfast into the shower. Initiated on 4/24/19 On 5/22/19 at 4:45 PM, when Nurse E was interviewed regarding R17's 4/22/19 fall, she said, I found out that morning (4/22/19) that he sits in the shower chair and eats breakfast on his shower days. He prefers not to get dressed and then undressed for breakfast. His shower is after breakfast. It's not advisable for him to sit in the shower chair because he is a double [MEDICAL CONDITION]. Nurse E added, He fell asleep in his (shower) chair. I don't know why he can't sit in his regular wheelchair for breakfast. On 5/23/19 at 1:52 PM, the Director of Nursing (DON) was interviewed about R17's 4/22/19 fall. When the DON was queried if an investigation was completed regarding R17's 4/22/19 fall, she stated There is not an investigation on it. When queried Do you know what chair he was sitting in when he fell ? The DON said, I thought he was in the bed. The DON reviewed the progress notes regarding the fall and said, He was in a chair and fell forward. On 5/23/18 at 2:09 PM, Certified Nurse Aide (CNA), Staff G, was interviewed about R17's 4/22/19 fall in the presence of the DON. When queried if she provided care for R17 on the morning of 4/22/19, she said, Yes. He was placed in a shower chair around 7:50 that morning. He likes to get out of bed to eat his breakfast. He doesn't want to eat in bed. After breakfast he goes to shower. When queried how he fell out of the shower chair, Staff G said, He said he fell asleep during breakfast. When queried if R17 had finished eating his breakfast before he fell out of the shower chair, Staff G stated she was unsure but added, It had been served. On 5/23/19 at 2:15 PM, when the DON was queried if she had any concerns with R17's 4/22/19 fall, she said, I do, because he was sitting in a shower chair. It's a concern for me because I just want him to be safe. I want to make sure the nurses have evaluated it to make sure it's safe (for him to sit in the shower chair for breakfast). R17's care plan was reviewed with the DON, and it was noted that he likes to sit in the shower chair for breakfast. This intervention was added by Unit Manager Staff I after R17's 4/22/19 fall. When the DON was queried if an evaluation was performed that indicated it was safe for him to use the shower chair during breakfast, the DON said, The nurse and OT (Occupational Therapist) should look at that. On 5/23/19 at 2:25 PM, Unit Manager, Staff I was interviewed in the presence of the DON. When Staff I was queried if an evaluation was completed to determine that it would be safe for R17 to sit in the shower chair during breakfast, she said, No. When Staff I was queried if the Therapy Department completed such an evaluation, she said, No. On 5/23/19 at 2:26 PM, when the DON was queried about him sitting in the shower chair during breakfast, she said, It is a concern for me; no evaluation was done. He is a double [MEDICAL CONDITION]; he has more difficulty stabilizing himself.

This citation pertains to intake #MI 766. Based on interview and record review, the facility failed to properly transfer a Resident that required a two person assist for one (#701) of three sampled Residents reviewed for Activities of Daily Living (ADLs) in a total sample of three, resulting in the Resident sustaining a laceration on the lower left extremity which required transfer to the hospital for sutures. Findings include: On 2/29/16 at 8:30 a.m., an interview was conducted with the Administrator and Assistant Director of Nursing (ADON). At that time, review of the facility's investigation for the reported incident which alleged a Resident was physically abused by staff revealed that although there was no substantiated willful abuse, Resident #701 had sustained a laceration which required transfer to the hospital for sutures following an improper transfer from the bed to the wheelchair with Certified Nursing Assistant/CNA A. This documentation included, On 2/10/16 aide (CNA A) was getting guest up when guest obtained skin tear on left lower leg. As part of the investigation it was identified that the guest was transferred with one person assist without the use of the gait belt or transfer disc. The plan of care stated the guest required two person assist for transfers and recommended the use of a transfer disc. The CNA (CNA A) verbalized that she was planning on taking the guest for a shower and admitted ly failed to review the kardex before participating in the transfer . On 2/29/16 at 9:45 a.m., CNA A was interviewed by phone and when asked about the incident on 2/10/16, stated I went in there to let him (Resident #701) know I was going to give him a shower. We (CNA A and Resident #701) did a pivot transfer and when I stood up he (Resident #701) immediately let me know his leg hurt. He reached down and said 'Honey honey my leg hurt'. I saw he was bleeding and went to get the nurse right away. When asked what Resident #701's transfer status was, CNA A stated I thought he was a one person assist. When asked whether a gait belt or a transfer disc was utilized, CNA A stated No, I'm not sure what a transfer disc is. When asked about what Resident #701 may have cut his leg on, CNA A stated I think it was the part that sticks out but it wasn't sharp (area on the wheelchair that the leg rest fits into). Review of Resident #701's care plans included a care plan for Risk for skin tears, bruises which was initiated 4/10/14 and revised 2/10/16, included interventions to Always transfer with gait belt or lift if guest requires assist. Review of Resident #701's Kardex documented, Transferring - Guest is a two person assist with the use of disk in room for transfer into wheelchair. Transfer guest with the use of gait belt 2 assists with use of transfer disk and follow the transfer status recommended by therapy . Further review of the clinical record revealed Resident #701 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] and the most recent Significant Change MDS assessment dated [DATE] both documented Resident #701 required extensive assistance of two persons for bed mobility and transfers. According to the facility's undated Kardex policy which has a section for staff to sign that they are in agreement to adhere to this policy, documented .will have a kardex for each guest in electronic charting .Under no circumstances may you transfer a guest and not follow what the kardex says . On 2/29/16 at 9:30 a.m., an interview and record review was completed with the Director of Nursing (DON). When asked about the reported incident, the DON reported that the day CNA A was due to report back to work, CNA A gave her notice and no longer worked at the facility. The facility was determined to be noncompliant with regulatory requirement F323 as a result of Resident #701's injury (laceration which required sutures) during an improper transfer with a nursing assistant. However, the facility identified a past noncompliance in regard to the reported incident with documentation, and a plan of correction date of 2/26/16. Therefore, although cited, no further action is necessary. On 2/29/16, during the onsite visit, the Surveyor verified that the following plan of correction had been implemented. The facility's Past Non-Compliance dated 2/12/16 with a correction date of 2/26/16 included: Description of the Deficient Practice (why and how did it happen): On 2/10/16 aide was getting guest up when guest obtained skin tear on left lower leg. As part of the investigation it was identified that the guest was transferred with one person assist without the use of the gait belt or transfer disc. The plan of care stated the guest required two person assist for transfers and recommended the use of a transfer disc. The CNA verbalized that she was planning on taking the guest for a shower and admitted ly failed to review the kardex before participating in the transfer. Maintenance checked the guests bed and w/c on 2/10/16 and did not find any sharp edges. It was discovered that the area of the wheel chair that the foot rest attaches to did come to a point (even though it was not sharp) on the inner aspect which might have caused Resident #701's skin to tear more easily given his fragility. The environment was surveyed by the nursing staff and observed to be free of clutter or any hazards which may contribute to an injury. Guest has fragile skin and is on Prednisone and Spiriva which thins the skin out making guest more prone to skin tears/lacerations/bruises. The facility ruled out abuse, and neglect. Further investigation revealed the CNA providing care to the guest had no intention of causing injury and had no intention of blatantly disregarding the plan of care. Her focus was simply to get the guest to the shower. How facility identified guest affected and the potential to be affected by the same deficient practice: Between 2/10/16 and 2/11/16 all guests kardex's were checked by the unit managers to ensure transfer status was listed. Measures or systematic changes made to ensure that deficient practice will not occur and affect others: Between 2/12/16 and 2/26/16 nurse aides were in-serviced on checking the kardex in the electronic record for transfer status. How facility monitors its corrective action to ensure deficient practice was corrected and will not recur: The QAPI committee will discuss the skin tear/laceration and why it happened. A QA was started and will be completed weekly x 4 then monthly by the ADHS or designee. The results of these audits will be presented to the quality assurance committee for further follow up and review. Review of the documentation also included education with CNA A which addressed reviewing of resident kardex's to ensure knowledge about the specific care needs in regards to transfers. As well as an in-service with nurses and nursing assistants conducted 2/17/16 - 2/26/16 about the facility's Kardex policy which included pre and post tests of the material presented, and a signature affirming that they have been made aware of the facility's policy regarding the Kardex, and their agreement to adhere to this policy. ( )

This citation has two deficient practices: Deficient Practice Statement #1: Based on observation, interview and record review, the facility failed to ensure that one (#506) of 17 residents reviewed for falls from a total sample of 24, received care planned supervision to prevent falls, was monitored for insomnia, and had properly functioning roll guard bolsters (soft removable bed side rails), resulting in multiple falls, including a fall with fracture. Findings include: On 3/4/14 at 12:30 P.M., and at 3:30 P.M., Resident #506 was observed asleep in a wheelchair in the lounge/dining room area. The Resident opened her eyes for less than one minute when addressed, and responded to questioning with nonsense syllables. On 3/5/14 at 9:00 A.M., Resident #506 was observed self propelling up and down the hallway in a wheelchair. The resident was alert, confused and responded to questions with nonsense syllables. On 3/7/14 at 9:25 A.M., Resident #506's current and previous clinical records, and facility Incident and Accident Reports (I&A) and falls investigations were reviewed with the Unit Manager, Nurse "E" and revealed the following the resident had fallen in the facility 10 times between July 3013 and March of 2014, and had sustained a fracture of the nasal bones (broken nose) during a fall on 12:21/13 at 11:15 P.M. On 3/7/14 at 9:25 A.M., Review of Resident #506's clinical record revealed a face sheet which documented the resident's most recent readmission to the facility was on 3/31/11. [DIAGNOSES REDACTED]. Minimum Data Set Assessments ((MDS) dated [DATE] and 7/19/13 documented that Resident #506 had severely impaired cognition, needed extensive staff assistance to transfer to the wheelchair, did not walk, and had impaired balance. The A falls Risk assessment dated [DATE] scored Resident #506 at moderate risk for falls. When queried, UM "E" reported that Resident #506 was already on the facility fall prevention program at that time, as she had a history of [REDACTED]. A fall risk assessment dated [DATE] documented that Resident #506 was at high risk for falls. A Physician's "History and Physical" dated 7/24/13, (prior to first Incident and Accident report provided), documented "falls- 4 recent." On 3/7/14 at 9:25 A.M., Review of Resident #506's Nursing care plans revealed a care plan entitled "fall" dated 2/8/13 with the following intervention "encourage resident to be in common area while up in wheelchair for safety", and an updated intervention, dated 9/25/13, "keep resident up in common areas until resident appears sleepy before placing in bed." There was no Care Plan for insomnia, and no care planned interventions for insomnia. An Activity Care Plan dated 2/6/13 contained no documentation of insomnia or nighttime wakefullness, but contained the following interventions, "provide in room activities when needed (books, music puzzles, games, cards), and "allow guest to chose her own bedtime." On 3/7/14 at 9:25 A.M., review of falls incident reports for Resident #506 with UM "E", dated 8/20/13 at 7:15 A.M., 9/25/13 at 9:30 A.M., 10/15/13 at 4:25 A.M., 10/20/13 at 10:20 P.M., 11/14/13 at 2:19 P.M., 12/6/13 at 5:36 A.M., 12/12/13 at 3:00 P.M., 12/20/13 at 11:15 P.M., 12/28/13 at 7:30 A.M., and 1/8/14 at 11:10 P.M., revealed that eight out of Resident #506's ten falls had occurred either late in the evening or early in the morning. When queried about this, UM "E" stated, "We did find out when we analysed her falls, that a lot of them were at night or early in the morning. She has insomnia. She's awake a lot at night. Her (Resident #506's) daughter said she was more of a night owl for most of her life. She (the daughter) said she used to stay up until 4:00 A.M., and then sleep until 10:00 A.M." When queried about Resident #506's waking and sleeping schedule, UM "E" stated, "We've changed her bedtime (HS) and get up time a couple of times to see if we could decrease her falls, and I think her whole sleep pattern got messed up. Before, she would go to bed at 7:00 to 8:00 P.M. at night and midnight shift would get her up at 5:00 A.M. She was awake a lot at night, and then she would be sleepy during the day. Her daughter wanted her gotten up later so we scheduled her for a later wake up time on day shift." I&A Dated 8/20/13 at 7:15 A.M., "during rounds, was observed sitting on buttocks next to bed. Stated she slid out after waking up." "Treatment Provided" was documented as "winged (perimeter) mattress to bed."When queried, UM "E" stated that Resident #506 was scheduled to be gotten up at 5:00 A.M, so was probably put in bed by 7:00 or 8:00 P.M. When asked, UM "E" stated that Resident #506 had fallen out of bed on this occasion. When asked why she was still in bed at 7:15 A.M. if she was scheduled to be gotten up at 5:00 A.M., UM "E" stated, "She might have been up all night and been tired in the morning. She often did that." Dated 9/25/13 at 9:30 P.M., "observed on the floor by the foot of the bed." When queried about this, UM "E" stated that Resident #506 was still scheduled for a 7:00 P.M. to 8:00 P.M. bedtime. UM "E" noted that the Nursing Care Plan for falls was updated after this fall, with the intervention, dated 9/25/13, "keep resident up in common areas until resident appears sleepy before placing in bed. Dated 10/15/13 at 4:25:A.M., "observed laying on right side on mat along side of bed." When queried, UM "E" stated that Resident #506 was scheduled to be gotten up at 5:00 A.M, so was probably put in bed by 7:00 or 8:00 P.M. When asked if Resident #506 was monitored for unassisted transfers when awake in bed, as insonmia at night was a diagnosed problem, UM "E" stated, "The aides (CNA - Certified Nursing Assistants) do rounds and check on every resident every two hours." When asked if Resident #506 had a television or other activity for entertainment when in bed and unable to sleep, UM "E" stated, "No, she doesn't have a TV or radio in her room." When queried, UM "E" was unable to provide documentation to indicate that Resident #506 was monitored for insomnia, or provided activities or supervision during periods of insomnia. Dated 10/20/13 at 10:20 P.M., documented "on floor on the blue mat." When queried, UM "E" stated that Resident #506 was scheduled to be gotten up at 5:00 A.M, so was probably put in bed by 7:00 or 8:00 P.M. When queried, UM "E" was unable to provide documentation to indicate that Resident #506 was monitored for insomnia, or provided any activity to prevent boredom and agitation after HS (bedtime), or of interventions to prevent self transfer (getting out of bed without assistance) prior to 12/20/13.The UM was unable to provide documentation to explain why the fall occurred if the intervention dated 9/25/13, "keep resident up in common areas until resident appears sleepy before placing in bed" had been followed. A Psychiatric Services progress note, dated 12/10/13 documented the following for Resident #506, ""This patient is being seen as an urgent consult for poor sleep. Staff has had some falls at night due to being restless and trying to get out of bed without assistance. Staff state patient was awake all night last night. Will start Melatonin to help patient sleep at night." Review of medication orders for March 2013 for Resident #506 revealed "Melatonin (a hormone to promote sleepiness) 3 milligrams (mg) by mouth (PO) at HS" was ordered on [DATE]. When queried, UM "E" was unable to provide any documentation to indicate Resident #506's response to the medication was monitored. When queried, UM "E" stated, "We told the physician that the melatonin wasn't working, but she said to give it more time." When queried, UM "E" was unable to provide documentation of monitoring for insomnia, or of implementation of supervision and interventions to prevent falls from unassisted tranfers due to restlessness during periods of insomnia. An I&A for a fall for Resident #505 at 12/20/13 at 11:15 P.M., and a nursing note dated 12/21/13 at 2:45 a.m., documented, "Guest was observed on the floor. Doctor called and said to send guest out to the ER for evaluation." "Injury type" was documented as, "bruise forhead, left eye, right eye." A transfer document (ambulance form) dated 12/20/13 for Resident #506 documented, "guest found by CNA (Certified Nursing Assistant) laying on side on floor. Nose bleeding and crooked with lump on forhead." A hospital Computerized Tomography (CT scan) report dated 12/21/13 at 4:22 A.M. noted the following result for Resident #506, "transverse fracture of the nasal bridge extending into the bilateral nasal bones with angulation to the left (broken nose)". A CNA statement dated 12/21/13 documented, "I was assigned to (Resident #506). I last checked her around 10:30. She was up in her chair in her room." When queried, UM "E" was unable to explain why Resident #506 was not supervised per the Nursing care planned intervention, dated 9/25/13, "keep resident up in common areas until resident appears sleepy before placing in bed", and could provide no documentation of interventions or activities to prevent self transfers when not supervised. Review of an updated nursing care plan for falls for Resident #506, dated 12/23/13, contained the intervention "roll bolsters" (soft removable bed side rails). A Physician's order dated 12/21/13 noted, "roll bolsters to bilateral sides of bed(both sides)". An I &A for Resident #506, dated 1/28/14 at 11:10 P.M., documented, "CNA walked by resident's room and observed resident on the floor on her left side holding the roll bolster." When queried about this, UM "E" stated, "I 'm not sure if the bolster wasn't properly applied or not, but I think that it might have been damaged. We ordered a new one." When queried, UM "E" was unable to provide documentation to indicate the roll bolsters were periodically to ensure they were functional, and was unable to provide evidence to indicate the CNA involved was questioned to determine if it was properly applied and functional when the resident was put to bed. The Don was unavailable for comment. The acting DON was unable to provide any additional information ( ) An updated electronic nursing care plan for falls for Resident #506, dated 11/14/13 did not contain the intervention added to the provious falls care plan on 9/25/13, "keep resident up in common areas until resident appears sleepy before placing in bed." When asked about this, UM "E" stated, "We've had some problems with the transition to computerized electronic records. That intervention was handwritten on the old care plan, and so probably wasn't already entered in the system and so got missed when we made the transition." On 3/7/14 at 9:40 A.M., review of Resident #506's current and previous nursing care plans with UM "E" revealed no care plan for insomnia (or late night wakefullness), interventions or activities to reduce restlessness and agitation due to boredom at night. Deficient Practice statement #2: Based on observation, interview and record review, the facility failed to ensure that non hospital grade power strips (multi plug electrical connection devices) were not used to connect care equipment to the electrical outlet for one (#501) of 21 sampled residents reviewed for environment, out of a total sample of 24, resulting in the potential for loss of power to care equipment. Findings include: On 3/4/14 at 9:10 A.M., during the initial tour of the facility, with Unit Manager (UM) "E", Resident #501's oxygen concentrator (a machine used to provide oxygen concentrated from room air) was observed to be connected to the electrical outlet via a non-hospital grade power strip. When asked, UM "E" stated, "I'm not sure if that is one of ours. Resident care equipment is supposed to be either connected directly into a wall outlet, or else with a hospital power strip." Resident #501 was in the room and stated, "No, that's mine. I had my daughter bring that in." When queried, UM"E" stated that Resident #501 had "end stage Congestive Heart Failure" (CHF) and, "used the oxygen as necessary (PRN), and at night." UM "E" then disconnected the oxygen concentrator from the power strip and connected it directly into the wall electrical outlet. On 3/4/14 at 12:15 P.M., Maintenance Supervisor "M" and Maintenance Assistant "N" were observed in Resident #501's room. Resident #501's oxygen concentrator was observed to be plugged connected to the electrical source via a non hospital grade power strip. When asked, Maintenance Supervisor "M" stated, "The oxygen concentrator shouldn't be plugged into a power strip unless it's hospital grade, and that one isn't hospital grade. When queried, the Maintenance Supervisor reported that the maintenance department checked resident rooms regularly for problems, including the use of power strips, but was unable to provide documentation of this when requested. On 3/6/14 at 3:50 P.M., the facility Interm Administrator was queried, and stated, "I can't believe that someone plugged that oxygen concentrator back into that power strip again after all the inservicing (staff education) we've done on that subject." On 3/4/14 at 10:00 P.M., review of Resident #501's clinical record revealed the following: A face sheet documented that Resident #501 was last readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #501 had intact cognition and needed extensive staff assistance for transfers to the wheelchair, toileting and hygiene. Review of current (March 2013) Physician's orders, revealed orders for PRN ( as needed) Oxygen (O2) when short of breath (SOB), and "titrate O2 to maintain blood O2 saturation (O2 sats) greater than 92% (percent)." On 2/7/14 at 9:00 A.M., review of the facility policy entitled, "Power cords, Extension Cords, revised 2/2013, revealed the following statements, "Goal: to ensure that guests safety is maintained. Maintenance will inspect and monitor the facility to ensure that power strips with surge protection are used appropriately.", "No medical equipment can be plugged into a power strip. (If a medical grade power strip is used, medical equipment may be plugged into it.)" ( )

REFER TO INTAKE NUMBERS MI 859, MI 837, AND MI 629. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY THE FACILITY FAILED TO IMPLEMENT SAFETY INTERVENTIONS AS ASSESSED TO PREVENT FALL FOR 3 ( #101, #102 AND #103) OF 3 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 3, RESULTING IN INJURY: RIGHT HIP FRACTURE (#101), CERVICAL (C-2) FRACTURE (#102) AND LEFT HIP FRACTURE (#103). FINDINGS INCLUDE: RESIDENT #102: INCIDENT REPORT DATED 5/19/13, AT 1:30 AM, NOTED: "RESIDENT (#102) WAS HEARD CALLING FOR HELP. CNA (CERTIFIED NURSING ASSISTANT) ENTERED THE ROOM AND FOUND RESIDENT (#102) ON THE FLOOR ON THE LEFT SIDE OF THE BED BETWEEN THE BED AND THE WALL. RESIDENT (#102) WAS PARTIALLY IN HIS RIGHT SIDE AND FACE DOWN. RESIDENT (#102) STATED HE WAS REACHING FOR HIS CALL LIGHT." ACCORDING TO HOSPITAL RECORDS DATED 5/19/13, THE COMPUTED TOMOGRAPHY (CT) SCAN IMAGES SHOWED: COMMINUTED C-2 FRACTURE. RESIDENT #102 WAS admitted to the facility on [DATE], WITH HISTORY OF SPINAL FUSION status [REDACTED]. RESIDENT #102 WAS HIS OWN RESPONSIBLE PARTY. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #102 NEEDED EXTENSIVE ASSISTANCE REQUIRING 2-PERSON ASSISTANCE DURING BED MOBILITY, TRANSFERS, TOILET USE AND HYGIENE. RESIDENT #102 RELIED ON AND USED THE CALL LIGHT TO CALL FOR "HELP." DURING THE ABBREVIATED SURVEY ON 7/9/13 AT 1:10 PM, RESIDENT #102 WAS OBSERVED LYING IN BED, WEARING A CERVICAL COLLAR. RESIDENT #102 STATED THAT HE WOKE UP IN THE MIDDLE OF THE NIGHT AND FOUND OUT THAT HIS CALL LIGHT WAS NOT WITHIN HIS REACH. RESIDENT #102 STATED THAT HE LOOKED AROUND AND FOUND THAT HIS CALL LIGHT WAS ON THE FLOOR. HE ATTEMPTED TO PICK IT UP FROM THE FLOOR. RESIDENT #102 DESCRIBED THAT WHILE HE TRIED TO REACH FOR THE CALL LIGHT, HE fell OFF THE BED AND FRACTURED HIS NECK. RESIDENT #102 RECALLED THAT HIS CALL LIGHT WAS NOT SECURELY CLIPPED ON HIS BED TO STAY WITHIN REACH. HE STATED THAT HE DEPENDED ON HIS CALL LIGHT TO ASK FOR ASSISTANCE. HE FURTHER STATED THAT THE CNA DID NOT CLIP IT TO THE BED THE LAST TIME SHE (THE CNA) PROVIDED CARE. HE DID NOT KNOW WHY SHE DID NOT. RESIDENT #102 ALSO STATED THAT THE BED WAS NOT AT THE LOWEST POSITION WHEN HE fell AND THERE WERE NO CUSHIONED PADS ON THE FLOOR. HE REMEMBERED THAT HE fell on THE FLOOR, LANDING ON HIS FACE. ACCORDING TO MIDNIGHT REGISTERED NURSE (RN) #3 ON 7/9/13 AT 11:09 AM, SHE WAS ON DUTY WHEN THE FALL OCCURRED. RN #3 RECALLED THAT RESIDENT #102 WAS HEARD YELLING FOR HELP AND WAS FOUND ON THE FLOOR. HE WAS NON-AMBULATORY AND REQUIRED EXTENSIVE ASSISTANCE DURING BED MOBILITY AND TRANSFER, USING A PIVOT DISK AND WITH 2 PERSON ASSISTANCE. AFTER THE FALL INCIDENT ON 5/19/13, RN #3 OBSERVED THAT RESIDENT #102'S BED WAS AT IN THE HIGH POSITION AT THE TIME OF FALL. RN #3 SAID THAT RESIDENT #102 EXPLAINED TO HER THAT HE WAS REACHING FOR HIS CALL LIGHT WHEN HE fell . RN #3 DESCRIBED THAT RESIDENT #102 HAD A HEMATOMA ON HIS LEFT FOREHEAD WITH AN ABRASION. ALSO, HE HAD A SKIN TEAR ON THE RIGHT ARM AND RIGHT HIP. ACCORDING TO RN #3, ICE WAS APPLIED ON THE FOREHEAD AND DOCTOR ORDERED TO TRANSFER HIM OUT TO THE HOSPITAL. RN #3 DID NOT SAY WHY THE CALL LIGHT HAD NOT BEEN SECURELY FASTENED TO THE BED. A WRITTEN STATEMENT FROM CNA #4 NOTED THAT SHE CHECKED RESIDENT #102 AT 12:15 AM AND MADE SURE THE CALL LIGHT AND THE BED REMOTE WAS IN HIS HAND BUT DID NOT SECURELY CLIP THE CALL LIGHT SO IT WOULD NOT FALL. CNA #4 NOTED THAT THE BED WAS ON A HIGH POSITION WHEN SHE LEFT THE ROOM. CNA #4 DID NOT CHECK ON RESIDENT #102 FROM 12:15 AM UNTIL THE TIME HE WAS FOUND ON THE FLOOR AT 1:30 AM. RECORD REVIEW SHOWED RESIDENT #102 HAD A FALL CARE PLAN AND HAD HISTORY OF FALLS PRIOR TO ADMISSION. RESIDENT #102 REQUIRED EXTENSIVE ASSIST DURING TRANSFERS USING A PIVOT DISK. THE FALL CARE PLAN DID NOT MENTION THAT RESIDENT #102 WAS ALLOWED TO CONTROL HEIGHT OF BED USING THE REMOTE. RESIDENT #103 THE FACILITY INCIDENT/ACCIDENT FORM DATED 5/6/13 AT 5:00 AM, NOTED THAT "NURSE AIDE (#5) REPORTED TO NURSE (#3) THAT RESIDENT (#103) WAS MISSING. CNA (#5) WENT TO CHECK ON RESIDENT (#103) TO TOILET HER BUT SHE WAS NOT IN HER BED. CHECKED ROOMS AND BATHROOMS. RESIDENT (#103) WAS OBSERVED IN THE SHOWER ROOM IN THE SHOWER STALL, SITTING ON BUTTOCKS AND SUPPORTING UPPER BODY WITH HANDS BEHIND HER." FURTHER REVIEW OF THE INCIDENT/ACCIDENT FORM REVEALED THAT RESIDENT #103 SUSTAINED A SKIN TEAR TO HER LEFT FOREARM. RESIDENT #103 WAS ASSISTED BACK TO BED AND ALARM WAS PLACED IN A CLOTH BAG TO KEEP OUT OF REACH FROM RESIDENT #103. RESIDENT #103 WAS admitted to the facility on [DATE]. ACCORDING TO THE history and physical examination [REDACTED]. RESIDENT #103 WAS NOT HER OWN RESPONSIBLE PARTY. ACCORDING TO THE MDS dated [DATE], RESIDENT #103 REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, DRESSING, TOILET USE AND HYGIENE WITH 1-PERSON ASSISTANCE. ACCORDING TO THE FALL RISK assessment dated [DATE], RESIDENT #103 WAS AT MODERATE RISK FOR FALL. A SENSOR ALARM WAS APPLIED TO HER BED AND WHEELCHAIR WITH STAFF TO CHECK PLACEMENT AND FUNCTIONING EVERY SHIFT. ACCORDING TO MIDNIGHT RN #3, SHE WAS THE NURSE ON-DUTY THE NIGHT WHEN RESIDENT #103 WAS FOUND IN THE SHOWER STALL. RN #3 STATED THAT THE INCIDENT WAS AN UNWITNESS FALL AND RESIDENT #103'S BED SENSOR ALARM DID NOT GO OFF. RN #3 RECALLED THT SHE WAS IN THE HALL STARTING HER MEDICATION PASS AT AROUND 5:00 AM. SHE DID NOT HEAR ANY BED ALARM SOUNDING. CNA #5 CAME TO HER AND SAID THAT RESIDENT #103.WAS MISSING AND THAT SHE (#5) HAD SEARCHED FOR HER EVERYWHERE. RESIDENT #103 WAS NOT IN HER BED, NOT IN THE BATHROOM AND NOT IN OTHER RESIDENT'S ROOM. RN #3 STATED THAT IT TOOK ABOUT 10 MINUTES LOOKING BEFORE RESIDENT #103 WAS FOUND SITTING IN THE SHOWER STALL. RESIDENT #103 WAS ASSESSED IMMEDIATELY AND VITALS WERE NORMAL. RESIDENT #103 DID NOT COMPLAIN OF HIP PAIN UNTIL LATER. RN 33 WENT ON TO SAY THAT RESIDENT #103 WAS CONFUSED AND NEEDED 1 PERSON ASSISTANCE WITH ADLS AND AMBULATION. SHE HAD A SENSOR ALARM IN BED BUT DID NOT SOUND. THE XRAY SHOWED THAT RESIDENT #103 HAD SUSTAINED A HIP FRACTURE. RN #3 STATED, "SOMEONE MUST HAVE PULLED THE ALARM OUT OR DID NOT PUT IT BACK AFTER CARE BECAUSE THE ALARM WAS NOT SOUNDING WHEN SHE (#103) AMBULATED OUT IN THE HALL TO THE SHOWER ROOM AND fell IN THE SHOWER STALL." ACCORDING TO RN #3, RESIDENT #103 HAD INCREASED CONFUSION AND EARLIER IN THE SHIFT AND HAD SEVERAL ATTEMPTS TO GET UP FROM BED THROUGHOUT THE SHIFT. RBN #3 ADDED, "SHE (#103) DID NOT HAVE THE BED ALARM ON BECAUSE THE ALARM WAS NOT SOUNDING WHEN WE FOUND HER. IN FACT IT TOOK US A FEW MINUTES TO FIND HER." THE XRAY FINAL REPORT DATED 5/6/2013 SHOWED: ACUTE INTERTROCHANTERIC FRACTURE INVOLVING THE LEFT PROXIMAL FEMUR. SEVERAL ATTEMPTS TO CONTACT CNA #5 BY PHONE WERE MADE DURING THE TIME OF SURVEY BUT THE PHONE NUMBER PROVIDED BY THE FACILITY WAS NOT IN SERVICE. . CNA #5 NO LONGER WORKED AT THE FACILITY. ON 7/9/13 AT 12:00 PM, THE DIRECTOR OF NURSING (DON) STATED THAT NURSE AIDE #5 WAS TERMINATED AND THEY DID NOT HAVE AN UPDATED TELEPHONE NUMBER. RESIDENT #101 ACCORDING TO THE FACILITY INCIDENT REPORT DATED 5/15/13 AT APPROXIMATELY 4:30 PM, RESIDENT #101 WAS OBSERVED IN ANOTHER RESIDENT'S ROOM, ON THE FLOOR, ON HER BUTTOCKS, NEXT TO THE BED. RESIDENT #101 STATED SHE WANTED TO GO TO BED. THE FALL WAS UNWITNESSED AND THE CHAIR ALARM DID NOT GO OFF. RESIDENT #101 IMMEDIATELY COMPLAINED OF RIGHT HIP PAIN. THE RIGHT HIP XRAY RESULT DATED 5/15/13 SHOWED: "NO OBVIOUS FRACTURE. RADIODENSE LINE IN SUBCAPITAL REGION RIGHT FEMORAL NECK. IF SYMPTOMS PERSIST, SHORT TERM PROGRESS STUDY WOULD BE HELPFUL. CROSS SECTIONAL IMAGING MAY ALSO BE HELPFUL." RESIDENT #101 CONTINUED TO COMPLAIN OF INCREASING HIP PAIN, AS EVIDENCED BY AS NEEDED (PRN) PAIN MEDICATION ADMINISTERED 5/15/13 THROUGH 5/21/13, ACCORDING TO THE MEDICATION ADMINISTRATION RECORD. A REPEAT XRAY WAS DONE ON 5/21/13 (6 DAYS LATER) SHOWING: RIGHT HIP FRACTURE. RESIDENT#101 HAD BEEN ASSESSED FOR THE NEED OF CHAIR AND BED ALARM AND THESE INTERVENTIONS HAD BEEN PLACED ON RESIDENT #101'S CARE PLAN. HOWEVER, NO ALARM WAS SOUNDING WHEN RESIDENT #101 WAS FOUND ON THE FLOOR. IT WAS OBSERVED BY NURSE #6 THAT THE SENSOR ALARM CORD WAS NOT ATTACHED TO THE ALARM BOX THUS THE CHAIR ALARM DID NOT SOUND DURING THE FALL. RESIDENT #101'S MEDICATION ADMINISTRATION RECORD (MAR) DATED 5/15/13 TO 5/21/13 SHOWED RESIDENT #101 RECEIVED NARCO (NARCOTIC) 5/325 TABLETS AS NEEDED FOR PAIN. RESIDENT #101 WAS admitted to the facility on [DATE]. ACCORDING TO HISTORY AND PHYSICAL 1/26/12, RESIDENT #101 HAD ALZEIHMER'S DISEASE, DIABETES MELLITUS AND DEMENTIA IN ADDITION TO OTHER DIAGNOSES. ACCORDING TO THE MDS dated [DATE], RESIDENT #101 REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY, TRANSFERS, TOILET USE AND PERSONAL HYGIENE REQUIRING 1 PERSON ASSISTANCE. RESIDENT #101 WAS NON AMBULATORY AND USED THE WHEELCHAIR FOR LOCOMOTION. THE BIMS DATED 11/26/12, SHOWED A SCORE OF 3 INDICATING IMPAIRED COGNITION. THE FALL RISK assessment dated [DATE], SHOWED A SCORE OF 32 INDICATING MODERATE RISK FOR FALLS. RESIDENT #101 HAD WHEELCHAIR AND BED ALARM FOR SAFETY. ACCORDING TO NURSE #6 DURING AN INTERVIEW ON 7/9/13 AT 11:48 AM, RESIDENT #101 WAS FOUND IN ANOTHER RESIDENT'S ROOM ON THE FLOOR. NURSE #6 WAS PASSING MEDICATION AT 4:30 PM WHEN SHE HEARD "HELP." NURSE #6 RESPONDED AND LOOKED FOR WHERE THE SOUND WAS COMING FROM AND FOUND RESIDENT #101 ON THE FLOOR. THE FALL WAS UNWITNESSED AND THE RESIDENT'S ALARM WAS NOT SOUNDING. RESIDENT #101 WAS ALERT AND ORIENTED TO SELF ONLY AND WAS NOT INDEPENDENT WITH AMBULATION. SHE REQUIRED 1 PERSON ASSISTANCE DURING TRANSFERS. RESIDENT #101 STATED: "SHE WANTED TO GO TO BED." NURSE #6 VERIFIED THE ALARM FUNCTION AND FOUND THAT THE CORD WAS NOT ATTACHED TO THE ALARM BOX (UNIT). THE SWITCH WAS IN AN "ON" POSITION BUT THE WIRE WAS NOT CONNECTED TO THE BOX. RESIDENT #101 COMPLAINED OF RIGHT LEG PAIN INSTANTLY BUT XRAY WAS NOT POSITIVE FOR FRACTURE. RESIDENT #101 CONTINUED TO EXPERIENCE INCREASED PAIN AND THE DOCTOR ORDERED FOR A REPEAT XRAY ON 5/21/13 AND RESULTS CAME BACK POSITIVE RIGHT HIP FRACTURE. CNA #7 DID NOT RETURN THE SURVEYORS CALL AFTER 2 ATTEMPTS FOR TELEPHONE INTERVIEW ON 7/9/13 AT 1:55 PM AND ON 7/17/13 AT 12:20 PM. THERE WAS NO RESPONSE BY THE ABBREVIATED SURVEY EXIT DATE. THE DON STATED ON 7/9/13 AT 12:00 PM THAT AFTER INVESTIGATION OF RESIDENT #101'S FALL, IT WAS UNCLEAR WHO DETACHED RESIDENT #101'S WHEELCHAIR ALARM. CNA #7 STATED THAT SHE HEARD THE ALARM BEEP WHEN SHE TURNED THE ALARM TO ON SWITCH BUT THERE WERE OTHER CNAS THAT ASSISTED RESIDENT #101 TO THE TOILET IN BEFORE THE FALL. THE ENTIRE STAFF WAS INSERVICED IN ENSURING THE FUNCTION OF THE ALARM. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 656. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE AND FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT A FALL FOR 1 (#501) OF 3 SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL OF THREE SAMPLED RESIDENTS, RESULTING IN A FALL WITH MULTIPLE INJURIES. FINDINGS INCLUDE: A FACILITY REPORTED INCIDENT ON FILE REVEALED THAT RESIDENT #501 SUSTAINED A FALL WITH INJURY. ON [DATE] AT 5:00 P.M., DURING A DISCUSSION WITH THE FACILITY'S ADMINISTRATOR #1, IT WAS REVEALED THAT RESIDENT #501 HAD expired on [DATE]. ACCORDING TO THE FACILITY'S ADMISSION SHEET, RESIDENT #501 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF THE ADMITTING physician's orders [REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON PHYSICAL ASSIST WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, AMBULATION ON AND OFF UNIT, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. RESIDENT #501'S "FALL RISK ASSESSMENT FORM" DATED [DATE] REVEALED A FALLS RISK SCORE OF 18. (,[DATE] POINTS INDICATED A LOW TO MODERATE RISK FOR FALLS). NO OTHER ASSESSMENT HAD BEEN PERFORMED UNTIL [DATE] WHICH WAS THE DAY RESIDENT #501 fell AND SUSTAINED INJURIES. A REVIEW OF THE FACILITY'S "ACCIDENT/INCIDENT REPORT" DATED [DATE] REVEALED THAT ON [DATE] AT 6:45 A.M., "...RESIDENT (#501) REPORTS SHE WAS AMBULATING FROM BED TO BATHROOM AND "BACKED IN" TO BATHROOM SLID AND HIT HER HEAD ON THE TUB AND WIRE BASKET ON WALKER HIT HER SHINS..., SMALL "BUMP" TO BACK OF HEAD, SKIN TEARS TO BILATERAL SHINS, OFFERED ICE TO HEAD, RESIDENT REFUSED, INTERVENTIONS: PAD ALARM TO BED WHEELCHAIR, GERI LEGS (PADDED) TO BILATERAL LOWER EXTREMITIES, STAT (NOW) LABS, PT (PHYSICAL THERAPY) EVAL (EVALUATION)..." A REVIEW OF THE FACILITY'S "ADDITIONAL ASSESSMENT FOR FALLS" DOCUMENT DATED [DATE] REVEALED "...RES (RESIDENT) (#501) MISJUDGED TOILET LOCATION D/T (DUE TO) EARLY HOUR AND INCREASED WEAKNESS..." A REVIEW OF THE FACILITY'S "ADDITIONAL ASSESSMENT FOR FALLS THERAPY" DOCUMENT DATED [DATE] REVEALED, "...LOCATION OF FALL, GUEST (#501) ROOM. WHAT WAS THE GUEST DOING AT THE TIME OF THE INCIDENT? GOING TO THE BATHROOM. RESIDENT STATES SHE WAS BACKING INTO THE BATHROOM AND MISJUDGED THE DISTANCE TO THE BATHTUB BEHIND HER. WILL INITIATE PT (PHYSICAL THERAPY) EVALUATION FOR BALANCE AND SAFETY AS WELL AS ADD TOILETING AND MOBILITY GOALS FOR OT (OCCUPATIONAL THERAPY). PAD ALARM TO BED AND WHEELCHAIR - ENCOURAGE RESIDENT TO USE CALL BUTTON FOR ALL NEEDS..." A REVIEW OF THE "FACILITY INCIDENT REPORT 24-HOURS" DATED [DATE] REVEALED "...AN X-RAY RESULT WAS REPORTED ON THE AFTERNOON OF [DATE] AT 2:40 P.M. INDICATING AN AGE INDETERMINATE COMPRESSION FRACTURE OF THE T9 (THORACIC) VERTEBRAL BODY..." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED [DATE] REVEALED "...THERE IS AGE-INDETERMINATE COMPRESSION FRACTURE OF T9 VERTEBRAL BODY (10% LOSS OF HEIGHT). THE BONY MINERALIZATION IS SEVERELY DECREASED. THERE IS SEVER NARROWING OF THE INTERVERTEBRAL DISC SPACES WITH SPURRING..." A physician's orders [REDACTED]. "...D/C (DISCONTINUE) THE FOLLOWING ...ASSIST X 2 WITH TRANSFERS, RESIDENT INDEPENDENT WITH ROLLING WALKER IN ROOM ONLY, ASSIST TIMES ONE WITH AMBULATION IN HALLWAY..." A REVIEW OF RESIDENT #501'S "INTERDISCIPLINARY PROGRESS NOTES" REVEALED THE FOLLOWING: [DATE] "...DR IN , SAW RES (RESIDENT#501) FOR SICK CALL D/T (DUE TO) DIZZINESS AND C/O (COMPLAINTS) OF EARS RINGING AND TO EVALUATE BILATERAL LOWER EXTREMITY EDEMA AND WEIGHT GAIN..." [DATE] "...RES C/O NON SPECIFIC HEALTH COMPLAINTS DIZZINESS, NAUSEA..." [DATE] "...THERAPY SCREEN WRITTEN FOR FAMILY WHO REQUESTED D/T DECREASED RANGE OF MOTION BILATERAL SHOULDERS..." [DATE] "...RIGHT SHOULDER PAINFUL, OBVIOUS RIGHT SHOULDER ROTATOR CUFF TEAR AND IMPINGEMENT SYNDROME..." [DATE] "...CALLED TO ROOM BY CNA #1 (CERTIFIED NURSING ASSISTANT) AT 6:45 A.M.. RESIDENT HAD WALKED TO BATHROOM WITH WALKER AND SLIPPED HITTING HER HEAD ON THE TUB IN BATHROOM AND HER WALKER BASKET HIT HER LEGS RESULTING IN SKIN TEARS TO BILATERAL SHINS. RESIDENT #501 DENIES PAIN TO HEAD..., SKIN TEARS CLEANSED AND COVERED WITH 9 STERI-STRIPS (PAPER SUTURES) TO RIGHT LEG..., LEFT LEG WITH 2 SEPARATE LARGE AREAS BOTH COVERED WITH STERI-STRIPS..., SMALL BUMP TO BACK OF HEAD WITH TINY CUT CLEANSED AND LEFT OTA (OPEN TO AIR)..., RESIDENT NOTED WITH BRUISE TO RIGHT BUTTOCK..." A REVIEW OF RESIDENT #501'S "INTERNAL MEDICINE (IM) PROGRESS NOTES" FOR THE MONTH OF NOVEMBER NOTED THE FOLLOWING ASSESSMENTS: [DATE] "...RIGHT SHOULDER ROTATOR CUFF TEAR..." [DATE] "...WAS SEEN TODAY FOR VERTIGO (LIGHTHEADEDNESS AND DIZZINESS), NAUSEA AND EDEMA. ASSESSMENT: VERTIGO, NAUSEA AND EDEMA, SHE HAS CHRONIC VERTIGO. WILL ADD ANTIVERT (MECLIZINE) (USED TO TREAT OR PREVENT NAUSEA, VOMITING, DIZZINESS CAUSED BY MOTION SICKNESS. ALSO USED TO TREAT SYMPTOMS OF VERTIGO. COMMON SIDE EFFECTS MAY INCLUDE DRY MOUTH, BLURRED VISION AND DROWSINESS)..." [DATE] "...CHIEF COMPLAINT: MALAISE (GENERAL ILL FEELING) AND VERTIGO..." A "PSYCHIATRIC SERVICES" NOTE DATED [DATE] REVEALED "...PATIENT'S CONFUSION APPEARS TO HAVE PROGRESSED SOME..." A physician's orders [REDACTED]. A REVIEW OF RESIDENT #501'S IM PROGESS NOTE FOR [DATE] REVEALED: "...WAS SEEN TODAY FOR CONFUSION, ANXIETY. ASSESSMENT: INCREASED CONFUSION AND ANXIETY..." A physician's orders [REDACTED]. INDICATION: MENTAL STATUS CHANGE AND INCREASED WEAKNESS..." A physician's orders [REDACTED]. START ONE PERSON ASSIST WITH AMBULATION AND TRANSFER..." UPON FURTHER RECORD REVIEW, IN LIGHT OF RESIDENT #501'S ASSESSMENTS, DIAGNOSES, AND MEDICATION REGIME, THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT ASSISTANCE WAS TO BE PROVIDED BY STAFF WITH AMBULATION AND OR TRANSFERS, IN ORDER TO PREVENT FALLS PRIOR TO [DATE]. ON [DATE] AT 9:05 A.M., DURING AN INTERVIEW, CERTIFIED NURSING ASSISTANT (CNA) #1 REPORTED, "...EVERY MORNING SHE (#501) USUALLY GETS UP BECAUSE SHE NEEDS TO BE TOILETED. WE (RESIDENT #501 AND CNA #1) WERE GOING TO THE BATHROOM. SHE USED HER WALKER TO WALK TOWARDS THE BATHROOM AND WHEN SHE GOT CLOSE TO THE BATHROOM SHE WAS GOING BACKWARDS. SHE WASN'T WALKING FORWARD. SHE WAS WALKING BACKWARDS INTO THE BATHROOM. SHE GOT INTO THE BATHROOM BUT SHE WENT BACK TOO FAR. THE BATHROOM IS REAL SMALL SO SHE PASSED THE TOILET. THE BACK OF HER LEGS HIT THE BATHTUB AND SHE fell BACKWARDS INTO THE BATHTUB...." CNA #1 FURTHER REPORTED, "...SHE (#501) LET GO OF HER WALKER WHEN SHE fell AND HER LEGS FLEW UP IN THE AIR AND THE FRONT OF HER LEGS SCRAPED THE BASKET ON THE BOTTOM OF HER WALKER. THE TUB IS VERY LOW. SHE HAD SKIN TEARS ON BOTH OF HER LEGS. ONE WAS MUCH WORSE THAN THE OTHER AND BLOOD WAS COMING ROM BOTH HER LEGS...." WHEN ASKED WHAT SHE WAS DOING AT THE TIME RESIDENT #501 AMBULATED BACKWARDS INTO THE BATHROOM, CNA #1 SAID, "..I JUST WATCHED HER..." WHEN ASKED OF HER (CNA #1) ACTIONS WHEN RESIDENT #501 fell , CNA #1 SAID, "...I SAW HER FALLING BUT THE WALKER WAS IN THE WAY AND I COULDN'T GET TO HER..." ADDITIONALLY, CNA #1 REPORTED, "...I GOT HER OUT OF THE BATHTUB AND SAT HER ON THE TOILET. I JUST WENT OFF REACTION. ANOTHER CNA HEARD ME SAY "GET A NURSE" AND LPN #1 CAME IN AND PUT SOME GUAZE AND STERI-STRIPS ON HER LEG. THE SKIN WAS PEELED BACK SO LPN #1 USED A Q-TIP TO ROLL THE SKIN BACK OVER THE WOUND OPENING. SHE (#501) SAID "OUCH" WHEN LPN #1 TOUCHED HER LEGS. THERE WAS A KNOT ON THE BACK OF HER HEAD BUT I DIDN'T SEE ANY BLEEDING AT THE TIME. SHE DID HAVE A BUMP AND SHE DID FALL AND HIT BACK PRETTY HARD..." WHEN ASKED WHY SHE (CNA #1) ALLOWED RESIDENT #501 TO WALK BACKWARDS INTO THE BATHROOM WHEN SHE WOULDN'T BE ABLE TO SEE WHERE SHE WAS GOING INSTEAD OF PROVIDING ASSISTANCE INTO THE BATHROOM, CNA #1 SAID, "...THAT BATHROOM IS REALLY SMALL. WE BOTH COULDN'T FIT IN THE BATHROOM WITH THE WALKER TOO..." WHEN ASKED WHY THE WALKER WASN'T PUT TO THE SIDE IN ORDER TO ASSIST #501 WITH TOILETING IN ORDER TO PREVENT FALLS, CNA #1 SAID, "...YOU'RE RIGHT. I COULD'VE DONE IT A DIFFERENT WAY BUT I WAS GOING BY WHAT SHE (#501) USUALLY DOES. SHE (#501) ALWAYS WALKS BACKWARDS INTO THE BATHROOM. I SHOULD'VE ASSISTED HER MYSELF AND I SHOULD HAVE TOLD HER TO WALK FORWARD INSTEAD OF BACKWARDS..." CNA #1 COULD NOT EXPLAIN WHY SHE FAILED TO OFFER ASSISTANCE AS RESIDENT #501 MANEUVERED HER WALKER BACKWARDS INTO THE BATHROOM RESULTING IN A FALL WITH INJURIES TO RESIDENT #501'S HEAD AND BILATERAL LOWER LEGS. ON [DATE] AT 10:10 A.M., THE PHYSICAL THERAPIST (PT #1) WAS QUERIED ON THE PROPER WAY TO AMBULATE WITH USE OF A WALKER AND REPORTED, "...THEY (THE RESIDENTS) ARE SUPPOSE TO AND SHOULD ALWAYS GO FORWARD AND NOT BACKWARDS BECAUSE OF LOSS OF BALANCE AND FALL ON [DATE] AT 10:32 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) #1 WAS QUERIED ON RESIDENT #501'S FALL WITH INJURIES. WHEN ASKED WHY RESIDENT #501 HAD AN INDEPENDENT AMBULATION STATUS, DON #1 SAID, "...IF PHYSICAL THERAPY DIDN'T THINK IT WAS SAFE THEY WOULDN'T GIVEN HER THAT STATUS..." WHEN ASKED ABOUT NURSING JUDGEMENT TO HAVE STAND BY ASSIST IN ORDER TO PREVENT A FALL, DON #1 SAID, "...PHYSICAL THERAPY COMMUNICATES WITH NURSING. HER (#501) SAFETY AWARENESS IS A BIG THING. SHOULD COULD USE HER CALL LIGHT..." WHEN REMINDED OF RESIDENT #501'S COMORBIDITY AND PRESENTING [DIAGNOSES REDACTED]. WHEN ASKED WHY CNA #1 FAILED TO PROVIDE TOILETING ASSIST AND FAILED TO INSTRUCT RESIDENT #501 ON THE PROPER USE OF HER WALKER IN ORDER TO PREVENT HER FALL WITH INJURIES, DON #1 REPORTED, "...I HAVE NO RESPONSE. I DIDN'T EVEN KNOW THE CNA WITNESSED THE FALL. IT'S NOT THE PROCESS TO HAVE THE RESIDENTS WALK BACKWARDS WITH THEIR WALKERS..." ON [DATE] AT 2:27 P.M., ALONG WITH DON #1 , OBSERVATIONS WERE MADE OF THE ROOM THAT RESIDENT #501 OCCUPIED DURING HER STAY AT THE FACILITY. THERE WAS AN ELEVATED "THRESHOLD/LIP" SEPARATING THE ROOM FROM THE BATHROOM. THE PURPOSE OF THE "LIP" IS TO PREVENT WATER FROM SEEPING INTO THE ROOM IN THE EVENT OF A FLOOD IN THE BATHROOM. THIS ELEVATION ON THE FLOOR SERVED AS A TRIP HAZARD FOR RESIDENT #501 AS SHE AMBULATED BACKWARDS INTO THE BATHROOM. DURING THE OBSERVATION, DON #1 OFFERED NO RESPONSE. FURTHER OBSERVATIONS WOULD REVEAL A GRAB BAR AND AN ATTACHED SOAP DISH NEAR WHERE RESIDENT #501'S HEAD HIT WHEN SHE fell . A REVIEW OF THE FACILITY'S "USE OF A WALKER" POLICY DATED "PRIOR TO ,[DATE]" REVEALED THE FOLLOWING: "...WALKERS WILL BE USED BY GUESTS WHO NEED THEM..." "...HELP THE GUEST TO STAND WITHIN THE WALKER AND INSTRUCT HIM TO HOLD THE HANDGRIP FIRMLY AND EQUALLY..." "...FOR ONE-SIDED WEAKNESS, ADVANCE THE WALKER ,[DATE] INCHES, STEP FORWARD..." "...IF THE GUEST CAN NOT USE ONE LEG, ADVANCE THE WALKER 6 INCHES AND SLOWLY SWING ONTO IT..." "...IF THE GUEST STARTS TO FALL, SUPPORT THE HIPS AND SHOULDERS..."

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CORRECTLY APPLY A WALKING BOOT FOR ONE (#601) OF 5 SAMPLED RESIDENTS REVIEWED FOR PRESSURE ULCER OUT OF A TOTAL SAMPLE OF 24, RESULTING IN THE DEVELOPMENT OF PRESSURE ULCERS. FINDINGS INCLUDE: ON 4/26/11 AT 09:41 A.M., RESIDENT # 601 WAS OBSERVED IN A WHEELCHAIR WITH A WALKING BOOT TO THE LEFT FOOT. THE RESIDENT STATED, "I fell . I WAS COMING BACK TO MY ROOM IN MY WHEELCHAIR AND I WENT TO TURN AROUND AND SLIPPED OUT OF THE CHAIR. MY FOOT GOT CAUGHT AND I FRACTURED MY ANKLE." UNIT MANAGER "F" REPORTED THE WALKING BOOT HAD CAUSED PRESSURE ULCERS IN TWO AREAS ON THE RESIDENT'S LEFT FOOT. ON 4/26/11 AT 12:15 P.M., RESIDENT #601'S ACTIVE CLINICAL RECORD WAS REVIEWED. ACCORDING TO THE ADMISSION FACE SHEET, RESIDENT #601 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE], INDICATED THE RESIDENT HAD NO COGNITIVE IMPAIRMENTS AND WAS DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. ON 4/26/11 AT 2:40 P.M., RESIDENT #601 PRESSURE ULCERS WAS OBSERVED WITH TREATMENT NURSE "P". THE RESIDENT HAD A STAGE TWO ( II) PRESSURE ULCER (PARTIAL THICKNESS SKIN LOSS THAT PRESENTS AS A BLISTER) ON THE LATERAL ASPECT OF THE LEFT FOOT MEASURING 0.8 CM X 1.1 CM CENTIMETERS (CM) AND A STAGE II ULCER ON THE LEFT HEEL MEASURING 1.8 CM X 1.3 CM. BOTH AREAS WERE DARK IN COLOR (INDICATING INJURY BENEATH THE TISSUE SURFACE) WITH INTACT SKIN. NURSE "P" STATED, "THE RESIDENT fell AT THE BEGINNING OF MARCH 2011 AND WAS FIRST GIVEN A SOFT CAST TO WEAR-- LATER A WALKING BOOT WAS ORDERED BY THE ORTHOPEDIC SPECIALIST". ON 4/27/11 AT 09:40 A.M., RESIDENT #601 STATED, "I TOLD THE THERAPIST WHEN SHE PUT THE BOOT OVER THE SOFT CAST THAT IT WAS BURNING. ONE DAY I TOLD TREATMENT NURSE "P" THAT IT "FELT LIKE A BLISTER". THE RESIDENT'S SON, WHO WAS PRESENT, CONFIRMED THE RESIDENT'S STATEMENT AND REPORTED TREATMENT NURSE "P" "FINALLY LISTENED TO (THE RESIDENT) AND CAME IN AND TOOK THEM BOTH OFF (SOFT CAST AND WALKING BOOT). THAT'S WHEN THE NURSE "P" SAW THOSE BLISTERS." ON 4/27/11 AT 10:10 A.M., THE FOLLOWING DOCUMENTS WERE REVIEWED: FACILITY DOCUMENT ENTITLED, "EVALUATION OF PRESSURE WOUND AVOIDABILITY", DATED 3/21/11, WHICH INDICATED: "AREAS DEVELOPED RELATED TO HALF CAST PLUS WALKING BOOT CAUSING PRESSURE TO LEFT HEEL AND LATERAL ASPECT OF FOOT." WOUND CARE ASSESSMENT, DATED 4/11/2011, DOCUMENTED, 1. "WOUND ON LEFT HEEL AREA. THE NATURE IS BLOOD BLISTER AND DEEP TISSUE INJURY, STAGE II FULL THICKNESS. WOUND MEASURES 1.5 CM X 1.4 CM." 2. "WOUND ON LEFT FOOT. THE NATURE IS BLOOD BLISTER, STAGE II FULL THICKNESS. WOUND MEASURES 1.1 CM X 0.7 CM. " THE NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE WEBSITE, INDICATED THAT "BLOOD BLISTERS ARE USUALLY CAUSED BY INJURY TO THE SKIN. IF THE SKIN IS RUBBED FOR LONG ENOUGH A BLISTER WILL FORM. FRICTION ON THE SKIN CAN CREATE A TEAR BETWEEN THE UPPER LAYER OF THE SKIN AND THE LAYERS BENEATH. WHEN THIS HAPPENS, THE SURFACE OF THE SKIN REMAINS INTACT BUT IS PUSHED OUTWARDS AS BLOOD COLLECTS IN THE NEWLY CREATED SPACE BETWEEN THE LAYERS." REVIEW OF THERAPY PROGRESS NOTES, DATED 3/14/11, DOCUMENTED, "PATIENT'S BOOT ARRIVED ON 3/11/11. WILL CHECK WITH THE DOCTOR ABOUT THE WEARING SCHEDULE ON MONDAY (3/14/11) AND ALSO THE FITTING. 3/14/11 ... BOOT FITS PATIENT ... WILL CALL THE ORTHOPEDIC DOCTOR TO CHECK THE WEARING SCHEDULE". FROM 3/14/11 TO 3/16/11, SEVERAL VOICEMAIL MESSAGES WERE LEFT BY THE THERAPIST FOR THE ORTHOPEDIC DOCTOR TO CONTACT THE FACILITY FOR THE WEARING SCHEDULE FOR THE BOOT. THE PROGRESS NOTE DID NOT INDICATE A WEARING SCHEDULE WAS OBTAINED FROM THE DOCTOR. ON 4/27/11 AT 2:50 P.M., THERAPY MANAGER "L" WAS QUERIED CONCERNING THE APPLICATION OF THE WALKING BOOT FOR RESIDENT #601. MANAGER "L" STATED, "I PUT THE WALKING BOOT ON OVER THE SOFT CAST. THE SON WAS INSISTING THAT SHE HAVE THE BOOT ON. I WAS HESITANT TO PUT THE BOOT ON". WHEN ASKED IF SHE HAD RECEIVED INSTRUCTIONS FROM THE ORTHOPEDIC DOCTOR ON THE APPLICATION OF THE BOOT, MANAGER "L"STATED " NO." THERAPY MANAGER "L" WAS UNABLE TO EXPLAIN WHY SHE PLACED THE BOOT ON THE RESIDENT WITHOUT INSTRUCTIONS FROM THE PHYSICIAN. ON 4/27/11 AT 3:00 P.M., UNIT MANAGER "F" WAS QUERIED CONCERNING THE APPLICATION OF THE WALKING BOOT FOR RESIDENT #601. UNIT MANAGER "F" STATED, "I REMEMBER THE SON WAS REALLY UPSET BECAUSE HIS MOTHER DIDN'T HAVE THE BOOT ON... BUT WHEN THE SON INSISTED AND HE WOULDN'T LISTEN TO US, THERAPY JUST PUT THE BOOT ON". A POLICY ON THE APPLICATION OF A WALKING BOOT WAS REQUESTED; HOWEVER, NOT PROVIDED. ( )