Every finding on record at Azria Health Park Place

Based on clinical record review, hospitalization record review, facility policy review, resident and staff interviews, the facility failed to safely discharge 1 of 3 residents (Resident #1) reviewed for discharge planning, by discharging the resident to a location that did not meet his health and safety needs. On 4/21/26, Resident #1 with a history of a traumatic brain injury and cognitive impairment was assisted by nursing staff to sign an Against Medical Advice form after the resident became upset when reminded of the facility smoking policy and stated he would just leave. Resident #1 signed the AMA form, took his belongings and left the facility via a cab. Resident #1 went to a homeless shelter without his medication and was unable to tell the shelter staff where he came from or how he arrived at the shelter. Resident #1 was then taken to a local hospital and admitted on a court order. The State Agency (SA) informed the facility of the Immediate Jeopardy (IJ) situation on 04/28/2026 at 02:56 PM. The IJ began on 4/21/26 at 1:09 PM and the SA confirmed the immediate removed on 4/28/2026 by implementing the following actions: a. Assessing all residents in the facility to determine if there were residents at risk for improper AMA discharge.b. Educating the Interdisciplinary team and all Nurses on the process for AMA discharges to ensure there are safeguards in place to prevent cognitively disabled residents from unsafe discharges.c. Reviewing all discharges including AMA discharges to assess facility practices and the appropriateness of the transfer.The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education and procedures.The facility reported a census of 66.Findings include: The admission Minimum Data Set (MDS) for Resident #1, completed on 04/06/2026, documented the resident's Brief Interview for Mental Status (BIMS) score was 9 out of 15, which indicated a moderate cognitive impairment. The MDS list of diagnoses included: cirrhosis of the liver, renal insufficiency (kidney failure), seizure disorder or epilepsy, traumatic brain injury (TBI), anxiety disorder, depression, asthma or chronic obstructive pulmonary disorder (COPD), other lack of coordination, muscle weakness, unspecified mood (affective) disorder, other symptoms and signs with cognitive functions and awareness, restlessness and agitation. The MDS documented Resident #1 prescribed antidepressants, diuretics (water pills), opioids, antiplatelet, and anticonvulsant medications. The MDS revealed Resident #1 required prompting and supervision to complete oral care, showering or bathing, personal hygiene, toileting hygiene, dressing lower part of body, and putting on or taking off shoes. The MDS indicated Resident #1 admitted to the facility on [DATE], after a short hospital stay. Review of [Name of hospital redacted] hospitalization records sent to the facility on March 9, 2026 at 11:03 AM prior to Resident #1's admission to the facility revealed: Date of admission (to hospital): 2/24/26. History.admitted with a chief complaint of inability to care for himself. Active Hospital Problems Diagnosis: inability to return to living situation, traumatic brain injury with loss of consciousness, generalized anxiety disorder, tobacco abuse, alcohol abuse, stage 3a chronic kidney disease, gastroesophageal reflux disease, seizure disorder and cognitive deficits. Assessment and Plan, in part:a. Neurocognitive disorder with inability to care for himself. Patient has a history of traumatic brain injury. Family unable to care for himself as well. He needs safe placement. b. History of polysubstance abuse and alcoholismc. Agitation. Secondary to his neurocognitive disorder and mental instability and psych issues given his history of polysubstance abuse as well as traumatic brain injury. Atarax (antianxiety medication) p.r.n (as necessary).d. Thrombocytopenia (low platelets, affecting blood clotting) secondary to liver disease and alcohol use.e. History of smokingf. Seizure disorder on Keppra (antiseizure medication).g. Generalized anxiety disorderh. History of liver cirrhosis.Review of records obtained by the State Agency for the hospitalization from February 18, 2026 to March 30, 2026 revealed:a. admission date: 2/18/26. discharge date : [DATE]. Chief Complaint: Psychiatric Evaluation (Dual committal. Affidavit's reports frequent alcohol use and violence.). The Disposition section revealed, in part: 2/19/26 1824 (6:24 PM) .substance abuse court order has been dropped. Mental Health court order remains with search for placement.2/23/26 0715 (7:15 AM) .it was clarified with nursing staff that both the mental health and substance abuse court orders have been dropped. Given concerns about patient's cognitive baseline due to underlying prior traumatic brain injury, consideration of placement continued. However, patient is now requesting discharge home. Social worker has spoken with patient. Appropriate resources and referrals have been provided. Patient is currently deemed competent to make his medical decision and does not have a guardianship. As such per his request we have no indication to keep him here against his will and he will be discharged .b. (Re)-admission date: 2/24/26. Chief Complaint: Failure to Thrive (Recently here for mental health. Hx (history) of TBI's (traumatic brain injury) and confusion due to this. Visit Diagnosis, in part: Cognitive deficient (primary), Inability to return to living situation, and Traumatic brain injury with loss of consciousness. History of Present Illness section.Patient was discharged yesterday after social worker attempted to give appropriate resources and referrals for being at home independently. Patient was deemed competent to make medical decisions at that time and he has his own guardianship.Only a few hours later, he returned to the ER with his son who stated he could not care for the patient and that he was unable to be his guardian. Social work spoke with administration on-call and was advised that the patient be assessed for competence. [Name of Behavioral Health consultant service redacted] states the patient is not capable of making healthcare decisions in own best interest.Review of the facility electronic health record (EHR) admission Note entered on 3/30/26 at 4:26 PM Note text: [no text entered] Review of Resident #1 Care Plan revealed the following Focus areas:a. DISCHARGE PLANNING-LONG TERM: Requires the support/services of the LTC (long term care) setting. The stay is presently identified as Long-Term. Initiated: 4/9/26.b. The resident has impaired cognitive function or impaired thought processes r/t (related to) Long term memory loss, Neurological symptoms, Psychotropic drug use. Short term memory loss. Interventions included, in part: Cue, reorient and supervise as needed; and Present just one thought, idea, questions or command at a time. Initiated: 3/31/26.c. Resident is a Level 2 PASRR for Serious Mental Illness. Time approved through 9/7/26. Interventions included, in part: Resident will receive appropriate specialized services to attain or maintain his/her highest practicable psychological, physical, functional and psychosocial well-being; and As indicated, refer to following Care Plan focus Mood State, Psychiatric Disorders, At risk Substance Use, Discharge Planning Return to Community Referral. Initiated: 3/31/26.Review of the April 2026 Medication Administration Record (MAR) revealed Resident #1 prescribed the following medications, in part, prior to the 4/21/26 discharge: a. Furosemide (a diuretic, often called a water pill) Oral Tablet 20 MG (milligrams) - give 40 mg [2 tablets] by mouth in the morning related to CHRONIC KIDNEY DISEASE STAGE 3 A. D/C (discharged date): 4/21/26 at 1:55 PM. MAR documented the last dose administered during the scheduled 7:00 AM to 9:00 AM medication pass. b. Sertraline HCL Oral Tablet 50 MG - give 50 mg by mouth in the morning related to DEPRESSION. D/C date: 4/21/26 at 1:55 PM. MAR documented the last dose administered during the scheduled 7:00 AM to 9:00 AM medication pass.c. Levetiracetam Oral Tablet 500 MG - give 500 mg by mouth two times a day related to EPILEPSY. D/C date: 4/21/26 at 1:55 PM. MAR documented the last dose administered during the scheduled 7:00 AM to 9:00 AM medication pass. Resident #1 discharged prior to the 7:30 PM to 10:00 PM medication pass. d. Buspirone HCL tablet 5 MG - give 1 tablet by mouth three times a day related to GENERALIZED ANXIETY DISORDER. D/C date: 4/21/26 at 1:55 PM. MAR documented the last dose administered during the scheduled 7:00 AM to 9:00 AM, and the 12:00 PM to 1:00 PM medication passes. Resident #1 discharged prior to the 7:30 PM to 10:00 PM medication pass. e. Gabapentin Oral Tablet 600 MG - give 600 MG by mouth three times a day related to POLYNEUROPATHY, UNSPECIFIED. D/C date: 4/21/26 at 1:55 PM. MAR documented the last dose administered during the scheduled 7:00 AM to 9:00 AM, and the 12:00 PM to 1:00 PM medication passes. Resident #1 discharged prior to the 7:30 PM to 10:00 PM medication pass. Review of the EHR revealed a Nurses Note entered on 4/21/26 at 1:09 PM: Resident [Resident #1] was smoking in his room. ED was made aware and asked this resident to turn over his lighter in which this resident refused and made the comment he would just leave. AMA (Against medical Advice) was signed and the resident took his belongings and went to the front door. Review of a document titled Against Medical Advice (AMA form) revealed Resident #1 signed the form on 4/21/26. The form documented, in part: Have not been deemed Incompetent/Incapable by my physician or court of law, therefore, I am competent to make my own decisions. The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks. Review of the EHR revealed the following:a. Nurses Note entered on 3/30/26 at 3:50 PM: admitted with a lighter in his pocket, the admission coordinator attempted to place it with smoking materials. He refused. This writer also attempted to get him to give his lighter to staff for safety, he adamantly refused.b. Social Service Note entered on 3/30/26 at 3:58 PM: Called Placed to Son informing him of his dad's wish to leave AMA. Son indicated he is currently displaced.Son is listed as the primary contact but an unequivocal No as far as being his caregiver.c. Nurses Note entered on 4/3/26 at 2:11 PM: Around 1300 [1:00 PM] heard back door alarming sounding. [Name reacted, Resident #1] was outside in the smoke area smoking a cigarette. Requested he return inside and give the cigarettes and lighter to this writer. He stated F*** you, they are mine.he came back into the building. When informed that he could not keep the smoking items he stated, then I'm leaving. Attempted to talk him down and get him to stay by telling him that he would get his meals, have somewhere to sleep, get his medications and have medical care. He stated he wanted to leave. Discussed with him that he would need to sign the AMA paperwork and that would mean that he would have to leave and could not return.d. Nurses Notes entered on 4/16/26 at 1:09 PM: Resident stated he wanted to leave, offered resident AMA paperwork, resident stated he wanted to talk to his son first.Resident stated that on Monday he will talk to the lady with the money and get the rest of his money and then he will leave.e. Behavior Note entered on 4/18/26 at 5:23 PM: This resident walked out setting off the door alarm on North. Staff intervened and was able to persuade him to come back inside. This resident was upset d/t the fact that at smoke break only one cigarette is given. The rules and policy were discussed and he said that he was not having anyone tell him when and how may he could smoke. He was educated on signing AMA if he wanted to leave.f. Nurses Note entered on 4/19/26 at 3:39 PM: This resident made the comment that he was bored and was going to run out the back door of the North Nursing unit. This writer discussed the risks of doing such things and reminded this resident that if he did not want to be here anymore that he was free to sign the AMA form and that was explained to him as well. Resident calmed down. g. Social Service Note entered on 4/22/26 at 9:14 AM: Admin reached out to residents' son to notify him that [name redacted, Resident #1] was non-compliant with smoking. He previously signed the smoking policy and continued to want to smoke all hours of the day, and has stated he wants to leave so he can smoke. Residents' son stated he wanted him to go to a homeless shelter but couldn't take care of him at this time. Administrator notified APS (Adult Protective Services) of his location, and diagnosis and current living situation.Cab came to pick up resident. State Agency will be notified of AMA on transfer/discharge notice form for the month of April.Review of records from [name of homeless shelter redacted] revealed Resident #1 entered the shelter on 4/21/26. A review of the Coordinated Intake Shared Client Notes section revealed, in part:a. Note added on 4/21/26: This writer met with [Name redacted, Resident #1] for [name of shelter redacted] intake. [Name redacted, Resident #1] was very confused on the questions asked. [Name redacted, Resident #1] kept talking about his car and going back to [NAME], Tennessee. This writer asked [Name redacted, Resident #1] over and over where he came from that brought him to the shelter.b. Note added on 4/27/26: This writer met with [Name redacted, Resident #1] and [shelter name redacted] Advocate. Advocate stated that she had concerns about [Name redacted, Resident #1] as he was able to remember where he came from before checking into [shelter name redacted] the night before. The Shelter manager [name redacted] stated that [Name redacted, Resident #1] was dropped by a taxi on 7/20/26 [although this note stated 7/20/26, the note entered on 4/27/26] the evening before at about 5:30 PM. At that time, he did not know what his name was or where he just came from.This writer called and spoke to [name redacted] Administrator of [facility name redacted]. He stated that he asked [Name redacted, Resident #1] to leave because he smoked a cigarette. This writer asked how [Name redacted, Resident #1] chose to come to [shelter name redacted] and how he paid for the taxi. [Name redacted, facility Administrator] stated he signed himself out on his own. This writer called [initials of the state adult protective services] to make a report of a dependent adult as it was clear that [Name redacted, Resident #1] still could not say where he was, he did not know what day or year it was and he was not able to state his name.This writer and [name redacted, shelter advocate] went to the local court house and filed a Mental Health Committal. It was approved by the judge. The county sheriff department picked up [Name redacted, Resident #1] and he was taken to [name of psychiatric unit redacted]. On Monday 4/27 [2026] a mental health hearing took place. The inpatient psychiatrist that evaluated [Name redacted, Resident #1] did agree that [Name redacted, Resident #1] had a severe past head trauma and had dementia. It was her testimony that [Name redacted, Resident #1] need to stay in the hospital until appropriate placement was found for him. The judge agreed with this. [Name redacted, Resident #1] will stay in-patient until they find appropriate placement. Review of [name of psychiatric unit redacted] hospitalization notes, dated 4/24/26 revealed, in part: [Name redacted, Resident #1] admitted to behavioral health unit on 4/23/26. SOAP Narrative: [Name redacted, Resident #1] .with a history of traumatic brain injury and suspected dementia and seizure disorder, presenting on a mental health court order filed by [shelter name redacted] staff based on observations of disorientation and inability to care for himself following voluntary discharge from long term, memory care facility. Current presentation is notable of significant cognitive impairment, including disorientation to place and situation, markedly impaired short-term memory, limited insight, and poor executive functioning as evidenced by inability to articulate a safe or realistic plan for meeting basic needs (food, shelter, medications) .Diagnoses: Neurocognitive disorder.a Reevaluation #2 dated 4/23/26 at 01:48 [AM] documented, in part.Patient inappropriately discharged form nursing home. Patient has dementia secondary to TBI. Not competent to make decisions and patient signed out AMA. Patient sent to a homeless shelter. Homeless shelter ordered the patient here. No SI (suicidal ideation) or HI (homicidal ideation). Psychiatry aware.likely will need to involve legal department. During an interview on 04/23/2026 at 03:16 PM, the Administrator, explained the details of Resident #1's discharge was as follows: Resident #1 had threatened to leave multiple times because he wanted to smoke at will against facility policy. The facility had members of their team reapproach him and had calm him down on a number of occasions, and had previously been successful at preventing him from leaving the facility. On 04/21/2026 at 01:09 PM the Resident was caught smoking in his room, it was believed he pocketed his cigarettes and a lighter while outside smoking with staff supervision. He was asked to hand over his cigarettes and lighter and reminded he could not smoke in his room. The Resident became belligerent and refused to hand over the cigarettes and lighter, stating he wanted to smoke when he wanted. A family member of Resident #1 was contacted, and the Family member informed the facility he wanted nothing to do with Resident #1's care. The Administrator stated he was told to send him to a local homeless shelter by the family member. AMA paperwork was presented to the resident, the resident signed the AMA paperwork, was given his belongings, and left through the front door. The resident left the facility in a cab that he called and paid for on his own.During an interview on 04/28/2026 at 9:36 AM, Staff A, Licensed Practical Nurse (LPN), stated she had a good rapport with Resident #1. She stated he had made comments about leaving the facility since entering, but was redirectable and could be calmed down. She stated she did not believe Resident #1 had the capacity to make choices for himself, was forgetful and often confused. She stated staff were told to contact Social Services when Resident #1 became agitated and Social Services would redirect and calm him down. She stated she worried about the resident being discharged to a homeless shelter because she did not believe he could meet his needs there. She stated she does not believe Resident #1 should have been allowed to leave AMA without further assessment.During an interview on 04/28/2026 at 9:50 AM, Staff B, LPN, stated she was the nurse who assisted Resident #1 in checking out Against Medical Advice. She stated she did not believe Resident #1 was impaired, but did not know his diagnoses. She stated he had been non-compliant with their smoking policy on the day of 04/21/2026, and she made an initial effort to redirect the resident but he stated he wanted to leave the building and she believed he could.During an interview on 04/30/2026 at 01:34 PM, the Social Services Director (SSD) stated he was present in the building the day of Resident #1's discharge, but was not contacted until after the resident had already been signed out AMA. He stated he was not contacted that day to attempt to deescalate Resident #1. The SSD stated he believes he could have redirected and deescalated Resident #1, it would have just taken time. He stated Resident #1 needed support making decisions due to his poor short-term memory and minimal recall.During an interview on 5/05/2026 at 8:25 AM, Staff C, LPN stated in her scope as a nurse, when a cognitively disabled resident wanted to check out AMA she would first contact the family and doctor to attempt to prevent an unsafe discharge, then contact outside agencies like local hospitals if they could not prevent the resident from leaving. She stated this is how she has always done things as a nurse.During an interview on 4/28/2026 at 2:25 PM, the Administrator stated he provided Resident #1 with a telephone number for a cab service after Resident #1 signed out AMA. He stated Resident #1 was able to dial the cab number independently, and paid for the cab with his own money. The number to this cab service was provided at this time. He stated he did not contact the corporate nurse or physician prior to Resident #1's discharge, but did contact them after. He stated he did not contact the Homeless Shelter.During an interview on 04/30/2026 at 11:11 AM, the SA contacted the cab service number provided to Resident #1 and the SA by the Administrator. The number went to a personal cell number, and was answered by the former owner of a cab service. In the interview, he explained he used to operate a cab service, but had not operated a cab service in three years. He stated he had not provided transportation for anyone at all since then, and now owns and operates a business in a different sector.During an interview on 4/28/2026 at 11:45 AM, a family representative of Resident #1 stated Resident #1 only knows how to call him [family representative] on his cell phone. He disputed Resident #1's ability to place calls or dial numbers on a cell phone independently. He stated he doesn't have the memory recall to perform such tasks and hasn't for at least two years. He stated he did tell the facility to take Resident #1 to a homeless shelter, but stated that he suggested a hospital first. He was upset Resident #1 was allowed to leave AMA and did not understand how they could allow an incompetent resident to leave on their own. He denied paying for a cab for Resident #1.During an interview on 04/27/2026 at 01:03 PM, the Shelter Director stated Resident #1 arrived at the homeless shelter at an unknown time and was discovered near the doors of the building around 5:30 PM on 04/21/2026. She stated a coworker completed Resident #1's initial assessment, and she [Shelter Director] provided a follow-up assessment. She stated that when she arrived to perform the follow-up assessment Resident #1 was incapable of using his cell phone independently, did not know who he was or how he arrived at the shelter, and did not know where he had come from.During a phone interview on 04/28/2026 at 11:34 AM, Resident #1 stated he thought he was in prison and could not say how he ended up in the hospital. During an interview on 04/28/2026 at 02:03 PM, the Shelter Manager stated she completed the initial assessment for Resident #1. She stated Resident #1 had been found outside of the shelter around 05:30 PM on 04/21/2026. The Shelter Manager explained the shelter had been at capacity at this time, and they did not have room for Resident #1, but the resident did not seem to be alert. She performed the assessment and found the Resident could not reliably give his name, did not know who he was, where he had come from, or how he had arrived at the shelter. The Shelter Manager stated the assessment revealed the resident could not perform basic self-care, and due to his confused state, she made the decision to house him in the lounge with staff oversight. She stated that during the night the Resident did not sleep, and spent his time wandering. The Shelter Manager stated Resident #1 soiled himself twice and had no awareness that he had soiled himself or that he needed to be cleaned up. She reported he required assistance cleaning himself up. The Shelter Manager added when the resident was found outside of the shelter he was carrying a basket of belongings, but was only wearing one shoe and one sock. She stated he did not have any paperwork on him, and after her initial assessment she knew Resident #1's needs could not be met at the shelter.During an interview on 04/27/2026 at 03:14 PM, the Psychiatric provider for Resident #1 for his on-going, current hospitalization stated she completed the initial assessment of Resident #1 when he arrived from the shelter on 04/23/2026. She stated Resident #1 was able to identify who he was at the time of her assessment, but was unable to identify what state he was in, where he was from, how he had arrived at the hospital. The Provider stated Resident #1 had been consistently incontinent and required assistance for most tasks. She stated her assessment revealed even immediate recall failed for the resident and she was able to piece together the resident had severe dementia secondary to a TBI (traumatic brain injury) in the past. She stated the resident was not capable of using a cell phone independently, and was not competent to make decisions about his care. The Provider stated she had reviewed the records from Resident #1 hospitalization from February 2026 to March 2026 at a different local hospital, and noted the records indicated Resident #1 had been found to not be competent to make his own decisions. During an interview on 04/28/2026 at 12:27 PM, the current Hospital Medical provider stated in her dealings with the resident he does not know who he is or where he is most of the day and should not have been released to a homeless shelter.During an interview on 05/04/2026 at 03:34 PM, the facility Clinical Nurse Consultant stated she had not been present at the time Resident #1 discharged AMA. She stated the facilities AMA discharge policy speaks to ensuring proper notifications and calling additional agencies as indicated.Review of a facility policy provided document titled Discharging a Resident without Physician's Approval, revised March 2025 and March 2026 revealed a Policy Statement which declared A physician's or provider's order is obtained for discharges, unless a resident or representative requests the discharge against medical advice. The Policy Interpretation and Implementation section directed, in part:1. Should a resident, or the representative (sponsor), request a discharge earlier than outlined in the care plan and without the approval of the physician or provider ( against medical advice), the resident's attending physician or provider is notified.3. If a resident or representative requests to be discharged to a setting that does not appear to meet the resident's post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care and will:a. Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident or representative is choosing that location;b. Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge.

Based on observation, record review, staff interviews and policy review, the facility failed to ensure residents on a therapeutic diet to include pureed food (Residents #24, #38, #40 and #42) were served the correct amount and serving size. The facility reported a census of 51 residents. Findings include: During an observation 12/3/25 at 10:30 AM, Staff E, cook, prepared the pureed lunch food items following a specific recipe for each food item. The recipe was followed accurately and provided the serving scoop size for each food item. Staff E advised there were 3 residents on a full pureed diet (Residents #24, #40 and #42) and one resident on a pureed meat diet (Resident #38). The food items pureed were frosted chocolate cake, beef stew, steamed vegetables and biscuit. Review of the Electronic Health Record (EHR) for Resident #24 revealed a diet order with a start date of 2/4/25 for a general diet, pureed texture (smooth, creamy and lump-free) and thin consistency. Review of the EHR for Resident #40 revealed a diet order with a start date of 10/29/25 for a general diet, pureed texture, nectar consistency. Review of the EHR for Resident #42 revealed a diet order with a start date of 2/5/24 for a general diet, pureed texture, thin consistency. Review of the EHR for Resident #38 revealed a diet order with a start date of 9/21/20 and a revision date of 5/24/22 for a general diet, mechanical soft texture, thin consistency and pureed meats. During a continuous observation 12/3/25 beginning at 12:00 PM, Staff E, [NAME] began preparation for lunch service in the main dining room and placed serving scoops into the pureed food items on the steam table. Staff E used the red handled scoop, which is a #16 scoop size (2 ounces), for the pureed beef stew, the pureed vegetables, and the pureed biscuit. Staff E used the grey handled scoop for the pureed dessert of frosted chocolate cake, which is a #8 scoop size (4 ounces). Review of the Sysco Dining Manager recipe sheets for the pureed food prepared and served for lunch revealed the residents on the pureed diet for the dessert should have received a scoop size #10 (3.76 ounces), for the vegetables it should have been a scoop size #12 (2.67 to 3.3 ounces), for the beef stew it should have been 2 servings of the scoop size #8 (4 ounces in each scoop) and for the biscuit it should have been a #12 scoop size. The residents received a smaller serving of the vegetables, beef stew and biscuit than what they should have received and a larger serving of the dessert. During an interview 12/3/25 at 1:30 PM, the Certified Dietary Manager (CDM) stated that staff are expected to use the appropriate size serving scoop for residents to ensure each resident is served the appropriate amount of food. The CDM acknowledged the residents on a pureed diet did not receive the appropriate amount of food, and were served less than what they should have been served for each food item other than the dessert, which was a larger portion than what they should have been served. Review of the facility policy Food and Nutrition Services, with a revision date of October 2017, documented each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Meals and/or nutritional supplements will be provided per order or per resident request.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 3 surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of 1 areas of concern. The facility reported a census of 51 residents. Findings include:The facility had the following concern identified at the current recertification survey that had also been cited at the previous 2 recertification surveys and at a recent complaint survey at a harm level:a. Food Procurement,Store/Prepare/Serve-SanitaryThe facility policy Quality Assurance and Performance Improvement (QAPI) Program, dated 2001, documented this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to:provide a means to measure current and potential indicators for outcomes of care and quality of life.provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.reinforce and build upon effective systems and processes related to the delivery of quality care and services.establish systems through which to monitor and evaluate corrective actions. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include:tracking and measuring performance;establishing goals and thresholds for performance measurement;identifying and prioritizing quality deficiencies;systematically analyzing underlying causes of systemic quality deficiencies;developing and implementing corrective action or performance improvement activities; andmonitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. During an interview 12/04/2025 at 1:15 PM, the Administrator acknowledged F812 was cited on the current survey, the previous 2 surveys and a recent complaint survey.

Based on clinical record review, staff interview, guidance from the Centers for Disease Control (CDC) and facility policy review, the facility failed to offer the recommended pneumococcal and Influenza vaccines to eligible residents for 4 of 5 residents reviewed for vaccines (Resident #14, Resident #33, Resident #41 and Resident #50). The facility reported a census of 51 residents. Findings include:1.The admission Minimum Data Set (MDS) of Resident #14 dated 10/22/25 documented an admission date to the facility of 10/16/25 and a date of birth of [DATE]. The MDS documented that the resident had diagnoses including chronic respiratory disease, heart disease, peripheral vascular disease, and diabetes. The MDS indicated that the resident had oxygen therapy. It also indicated that he was not given the influenza vaccination as it was not offered.Observation 12/03/25 at 7:28AM revealed the residents room had an oxygen concentrator, and a Continuous Positive Airway Pressure (CPAP) machine in the room at the bedside.The Electronic Health Record (EHR) indicated that Resident #14 received the influenza vaccination on 12/3/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 7:15 PM on 12/3/25.2. The MDS of Resident #33 dated 11/5/25 documented an admission date to the facility of 12/12/24 and a date of birth of [DATE]. It also indicated that she was not up to date with her pneumococcal vaccination as it was not offered.The Electronic Health Record (EHR) indicated that Resident #33 received the pneumococcal vaccination on 12/4/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 7:15 AM on 12/4/25.3. The MDS of Resident #41 dated 10/8/25 documented an admission date to the facility of 6/16/20 and a date of birth of [DATE]. It also indicated that he was not given the Influenza vaccination and none of the above reasons was indicated as why not.The Electronic Health Record (EHR) indicated that Resident #41 received the influenza vaccination on 12/3/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 7:18 AM on 12/4/25.4. The MDS of Resident #50 dated 11/23/25 documented an admission date to the facility of 11/20/25 and a date of birth of [DATE]. It also indicated that she was not up to date with her pneumococcal vaccination as it was not offered.The Electronic Health Record (EHR) indicated that Resident #50 received the pneumococcal vaccination on 12/4/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 7:02 AM on 12/4/25.On 12/03/2025 a list of missing vaccinations for 4 residents was provided to Staff A, Infection Preventionist. Resident #14 missing Influenza and COVID-19, Resident #33 missing pneumovax, Resident #41 missing Influenza and COVID-19 and Resident #50 missing COVID1-19 and pneumovax. Requested documentation of offering and refusing or vaccination given. Stated she would look into it.In an interview on 12/4/25 at 10:15 AM Staff A, Infection Preventionist (IP) stated that her process for ensuring residents are offered vaccinations is to look on the Immunization Registry Information (IRIS) database (database which tracks vaccination records), ask residents on admission and offer yearly required vaccinations. She has an immunization tracker that she follows. When asked about how 4 out of 5 residents reviewed were missing vaccinations. She stated that she must have just missed them and she takes responsibility. She stated that since being aware of the missing vaccinations she has now received orders and has given them.In a policy titled Azria Influenza, Prevention and Control of Seasonal revised August of 2020, it indicated that the IP organizes and oversees an annual influenza vaccine campaign and all residents and staff are offered the vaccine prior to the onset of the influenza season.In a policy titled Azria Pneumococcal Vaccine updated September 2020, it indicated all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. It also indicated that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.The CDC document titled Adult Immunization Schedule Notes, dated 10/7/25 documented the following concerning pneumococcal and influenza vaccinations and can be found at https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html#note-pneumo:Pneumococcal Vaccine age [AGE] years or older who have:Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21.If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose (may use minimum interval of 8 weeks for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak).Previously received only PCV7: follow the recommendation above.Previously received only PCV13: 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PCV13 dose.Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose.If PCV15 is used, no additional PPSV23 doses are recommended.Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 or 1 dose PCV21 at least 5 years after the last pneumococcal vaccine dose.Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose.Influenza vaccine age [AGE] years or older: 1 dose any influenza vaccine appropriate for age and health status annually.Solid organ transplant recipients aged 19 through 64 years receiving immunosuppressive medications: HD-IIV3 and aIIV3 are acceptable options. No preference over other age-appropriate IIV3 or RIV3.Age 65 years or older: Any one of HD-IIV3, RIV3, or aIIV3 is preferred. If none of these three vaccines is available, then any other age-appropriate influenza vaccine should be used.

Based on observations, staff interview and policy review, the facility failed to ensure staff used proper food handling procedures, failed to ensure hair was covered by staff while in the kitchen area, failed to maintain a clean kitchen area where food was served to residents, failed to ensure all food was covered on room trays and failed to ensure staff used proper hand placement on glassware used to serve residents. The facility failed to prevent possible contamination of food. The facility reported a census of 51 residents. Findings include:During a continuous observation 12/1/25, beginning at 12:00 PM, Staff D, Dietary Aide, placed his hand directly on the rim of a coffee cup while serving residents drinks during lunch service for four separate residents. Staff D carried two separate room trays out of the dining room down hallways with the dessert (cake) not covered. The remainder of the room trays served to residents who ate their meal in their room were placed on carts and delivered to residents with the dessert partially covered by a plastic lid. During an observation 12/3/25 at 10:30 AM, Staff D, Dietary Aide, was observed performing meal preparation tasks in the main kitchen without a beard net, Staff D had a beard. During a continuous observation 12/3/25, beginning at 11:50 AM, Staff D, Dietary Aide, stacked the water/juice plastic cups and delivered residents cups from this stack of cups, with his hand on the rim of the cups. During an observation 12/3/25 at 12:00 PM, food was brought from the main kitchen in the basement to the kitchenette in the main dining room for lunch service. Observed the swinging door into the kitchenette to have splattered fluid and food on the inside of the door, pink and brown in color, with a pick substance pooled on the bottom of the rim of the door. Observed food/fluid splattered on the walls by the door and door frame area. The walls by the utility sink in the kitchenette had a brown substance splattered on the two walls. The insulated food cart used to bring up food from the kitchen in the basement to the kitchenette in the dining room had food/fluid splattered on the outside of the cart. During a continuous observation 12/3/25, beginning at 12:05 PM, Staff E, Cook, began preparations for lunch service from the kitchenette. Lunch served on this date was beef stew, a tossed green salad with shredded cheese and dressing, a biscuit and frosted chocolate cake. Staff E placed hot food in the steam table and placed a plastic container of shredded cheese and two separate plastic containers of shredded and torn salad greens on a cart next to the steam table. Staff E put a glove on her right hand, then placed plates out on the surface of the steam table with her right hand and began plating food, using her right hand to scoop hot food onto the plate and into bowls. Staff E put her right hand directly into the lettuce containers to place lettuce onto the plates and then put her right hand directly into the cheese container and put the cheese on top of the lettuce on the plates. Staff E continued this process of plating food for residents. In between placing the lettuce and cheese onto the plates, Staff E used this same gloved hand to touch plates, paper tickets, utensils and surfaces. Staff E used this same gloved hand to put the lettuce and the cheese onto several plates without changing the glove. Staff E did change the glove after touching fish sticks and then placed her gloved hand into the lettuce and then into the cheese for several more plates without changing gloves and touched surfaces, plates and utensils, and paper tickets in between. At the end of lunch service, with approximately 10 room trays left to plate, Staff E then used tongs to put the lettuce and the cheese onto the plates. The room trays had the dessert on a plate, the plate was covered with just a plastic lid, it did not cover the entire dessert, which was a piece of cake. During an interview 12/3/25 at 1:30 PM, the Certified Dietary Manager (CDM) stated an expectation staff do not place their hands on the rim of the cups or glasses to serve residents and do not stack the plastic cups while placing cups at each resident's table. The CDM stated an expectation all food is covered completely on room trays before they leave the dining room. The CDM stated an expectation staff change gloves each time before putting the gloved hand into a container of food and touching the food directly, the CDM stated an expectation staff use tongs or a utensil to touch food items and not their hands, and not use the same gloved hand after touching surfaces to stop the potential for cross contamination and for infection control purposes. The CDM stated an expectation the kitchenette area be clean and staff with beards wear a beard net while in the kitchen. The CDM acknowledged male staff in the kitchen, two staff, have a beard and have not worn beard nets, he stated the facility does not have beard nets available and they will need to be ordered. During an observation 12/3/25 at 1:50 PM, observed two male staff in the main kitchen, both cleaning the lunch service dishes, neither of them had a beard net and both had beards. Review of the facility policy Food Preparation and Service, with a revision date of April 2019, documented food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices and food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Review of the facility policy Sanitization, with a revision date of November 2022, documented the food service area is maintained in a clean and sanitary manner, all kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.

Based on clinical record review, staff interview and facility policy review, the facility failed to refer a resident (Res #3) for a Level II PASRR evaluation following a newly diagnosed mental disorder for one of four residents reviewed for PASRR (Pre admission Screening and Resident Review). The facility reported a census of 51 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment of Resident #3 dated 9/17/25 documented an admission date to the facility of 2/2/2023. The MDS documented diagnoses that included depression and psychotic disorder. The Care Plan of Resident #3 identified a (resolved) Focus Area of Antipsychotic Medications for behavior management with revision date of 10/01/25. The Encounter Note dated 12/17/24 from the facility physician documented the chief complaint for this visit was due to increased delusional behavior with hallucinations. The note additionally documented orders to add a new diagnosis of Delusional disorders, along with orders to begin an antipsychotic medication.Per review of the resident electronic health record performed on 12/4/25, nearly one year after the new diagnosis, the only PASRR located was dated 7/13/22 and did not include the diagnoses of depression, delusional disorder or the use of any psychotropic medications. On the afternoon of 12/2/25, the Chief Operating Officer of the long term care corporation stated the facility had self identified several PASRR being outdated or incomplete during an audit the day prior. She stated the facility Social Services Director had received education regarding this and a list of residents who needed PASRR updated. On 12/02/2025 at 3:55 pm, the Social Services Director confirmed he had received education and the list of residents. The Social Services Director shared the list of residents needing updated PASRR and confirmed Resident #3 was not included on the list, and was noted as her PASRR was accurate. The Social Services Director acknowledged no PASRR had been completed for Resident #3 since her admission to the facility. He explained the nursing staff is responsible to inform him when any new diagnoses or medications which could potentially affect the PASRR process are documented. He stated he did not recall ever being told about the diagnosis or medications for Resident #3. He added the facility had recently changed the process to include providing copies of visit notes and orders to him. The facility policy titled admission Criteria, revision date March 2019 documented the following:All new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid Pre-admission Screening and Resident Review process. The policy failed to reflect the need for updated screenings based on a resident change of condition.

Based on clinical record review, staff interview, and contracted Registered Dietitian interview, the facility failed to implement dietary interventions in a timely manner for a resident who was experiencing significant weight loss (Res # 44). The facility reported a census of 51 residents.Findings include: The Minimum Data Set (MDS) Assessment of Resident #44 dated 11/12/25 reflected a height of 72 inches and a weight of 122 pounds. The MDS documented the resident had experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months, and that the resident was not on a physician-prescribed weight-loss regimen. The Care Plan of Resident #44 identified a Care Area of Inability to Maintain Nutrition, dated 12/19/24. The Care Plan directed staff to provide and serve supplements are ordered. The Weights section of Resident #44 Electronic Health Record (EHR) documented a weight of 138.5 pounds on 5/5/25. The EHR documented a weight of 122 pounds on 11/6/25, a 11.91% loss. The Orders section of the EHR documented an order for a nutritional supplement was placed on 11/24/2023. The Weight Change Note, authored by the facility Registered Dietitian (RD), dated 10/9/25 noted a weight of 125 pounds, which triggered a significant weight loss in the prior 90 days. The note documented the current interventions in place and recommended increasing his house supplement to 240 milliliters at 10:00 am and maintaining the order for 120 milliliters in the afternoon/evening. The Episodic Dietary Note, authored by the RD, dated 11/25/25 noted a weight of 122 pounds. The note stated the resident was again triggering for a significant weight loss, with the weight being stable over the last month. The note documented the RD was still recommending increasing the house supplement to 240 milliliters at 10:00 am and maintaining the order for 120 milliliters in the afternoon/evening. On 12/3/25 at 12:40 pm, the RD stated Resident #44 had always been thin and it had been a battle for years. She stated the resident likes to hide things in his coat pockets and it was implemented to make sure and weigh him with his coat off for accurate weights. She included in nicer weather, the resident likes to be outside smoking during breakfast hours so she implemented bringing him a breakfast sandwich outside so he could still eat breakfast. She stated he had been on supplements for long term in addition to other interventions such as finger foods and offering substitute meals. On 12/3/25 at 2:38 pm, the Chief Operating Officer (COO) of the facility corporation stated the Director of Nursing (DON) is to follow through on the recommendations made by the RD. On 12/3/25 at 3:40 pm, the DON stated when the RD made the recommendations, it had been faxed to the provider. She stated the provider never replied so she had called the provider that day and updated the order. On 12/3/25 at 4:30 pm, the COO stated there are other forms of communication and if the provider did not respond to a fax, the facility staff should have either called the provider or spoke to the provider in person when they are in the building. She stated the Nurse Practitioner is in the building weekly.

Based on clinical record review, staff interview and facility policy review, the facility failed to perform pre and post dialysis assessments for one of one resident reviewed for dialysis (Res #6). The facility reported a census of 51. Findings include: The Minimum Data Set (MDS) Assessment of Resident #6 dated 11/12/25 documented diagnoses that included renal (kidney) failure. The MDS documented the resident received hemodialysis during the last 14 days of the look back period. The MDS documented that the resident scored a 14 out 15 for the brief interview for mental status, indicating intact cognitive skills. The Care Plan documented a Focus Area of Dialysis, dated 11/7/25. The Care Plan documented the resident attending dialysis on Monday, Wednesdays and Fridays, dated 11/7/25. The Care Plan failed to direct staff to perform pre and post dialysis assessments. The Evaluation section of the Electronic Health Record revealed pre and post dialysis assessment were logged for a total of 10 times between 11/7/25 and 12/3/25. The Treatment Administration Record (TAR) for November of 2025 reflected an order dated 11/6/25 to complete pre/post vital signs and weight, as well as completing a pre/post evaluation, twice a day, every Monday, Wednesday, and Friday. On 12/2/25 at 10:48 am, the Director of Nursing stated she would look into the resident's pre and post dialysis assessments. On 12/2/25 at 11:42 am, the DON stated she was unable to find any further information on the assessments and provided the facility policy. On 12/03/2025 at 9:38 am, Staff G, Registered Nurse (RN) stated he assesses what the resident ate for breakfast, vital signs, and assesses the dialysis site for pre-evaluation. He stated when the resident returns, he offers food, and assesses vital signs and the dialysis site again. He stated there is a form for pre and post dialysis that is to be filled out. The facility policy End-Stage Renal Disease, Care of a Resident with, revision date September 2010 documented the following: Point 2: Education and training of staff includes, specifically:a. the nature and clinical management of ESRD (including infection prevention and nutritional needs);b. the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis;c. signs and symptoms of worsening condition and/or complications of ESRD;

Based on clinical record review, staff interview and policy review, the facility failed to follow through and act on recommendations of Pharmacy drug regimen reviews to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 5 residents reviewed (Resident #21). The facility reported a census of 51 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #21 scored a 12 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The resident had diagnoses to include debility, cardiorespiratory conditions, renal insufficiency, diabetes mellitus, respiratory failure, anxiety disorder and depression. The MDS indicated the resident was taking high-risk drug classes to include an antipsychotic in the look back period. The Care Plan for Resident #21, with an initiation date of 9/4/25, included a focus area the resident is on a antipsychotic medication with a goal the resident will be/remain free of psychotropic drug related complications, including movement disorder. Review of the Electronic Health Record (EHR) revealed Resident #21 had an order and was receiving the medication Haloperidol (antipsychotic) oral tablet 5 MG, give 0.5 tablet by mouth two times a day related to Major Depressive Disorder, with a start date of 8/29/25, the date of admission to the facility. The EHR for Resident #21 included Pharmacy Medication Regimen Reviews (MRRs), dated 9/28/25, 10/14/25 and 11/13/25. The findings and recommendations for each review were the same, which documented the resident is taking the antipsychotic medication Haloperidol, monitoring for movement disorders with an Abnormal Involuntary Movement Scale (AIMS) is recommended upon initiation of the medication, during dosage changes and then at least every 6 months. Complete an AIMS assessment now. The 11/13/25 MRR included the statement initial AIMS not found in the EHR. The EHR lacked a response by the facility to the MRR recommendations. The EHR for Resident #21 included one AIMS evaluation, completed on 12/1/25. During an interview 12/04/2025 at 8:45 AM, the Director of Nursing (DON) acknowledged an AIMS assessment was not completed until the 1st of December and should have been completed upon admission given Resident #21 was on an antipsychotic. These should be done upon admission and quarterly, or as needed. Review of the facility policy Medication Regimen Reviews, with a revision date of May 2019, documented the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.

Based on clinical record review, staff interview, guidance from the Centers for Disease Control (CDC) and facility policy review, the facility failed to offer the recommended COVID-19 vaccine to eligible residents for 3 of 5 residents reviewed for vaccines (Resident #14, Resident #41 and Resident #50). The facility reported a census of 51 residents. Findings include:1.The Minimum Data Set (MDS) of Resident #14 dated 10/22/25 documented an admission date to the facility of 10/16/25 and a date of birth of [DATE]. It also indicated that he was not up to date with his COVID-19 vaccination.The Electronic Health Record (EHR) indicated that Resident #14 received the COVID-19 vaccination on 12/4/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 8:14 AM on 12/4/25.2.The MDS of Resident #41 dated 10/8/25 documented an admission date to the facility of 6/16/1920 and a date of birth of [DATE] It also indicated that he was not up to date with his COVID-19 vaccination.The EHR indicated that Resident #41 received the COVID-19 vaccination on 12/4/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 8:20 AM on 12/4/253.The MDS of Resident #50 dated 11/23/25 documented an admission date to the facility of 11/20/25 and a date of birth of [DATE]. It also indicated that she was not up to date with her COVID-19 vaccination.The EHR indicated that Resident #50 received consent and an order to give COVID-19 on 12/3/25 at 6:33 PM but lacked documentation of the vaccination being given prior to the surveyors exiting. The EHR also lacked documentation of offering, educating or declination of vaccination prior to this time and date.On 12/03/2025 a list of missing vaccinations for 4 residents was provided to Staff A, Infection Preventionist. Resident #14 missing Influenza and COVID-19, Resident #33 missing pneumovax, Resident #41 missing Influenza and COVID-19 and Resident #50 missing COVID1-19 and pneumovax. Requested documentation of offering and refusing or vaccination given. Stated she would look into it.In an interview on 12/4/25 at 10:15 AM Staff A, Infection Preventionist (IP) stated that her process for ensuring residents are offered vaccinations is to look in IRIS, ask residents on admission and offer yearly required vaccinations. She has an immunization tracker that she follows. When asked about how 4 out of 5 residents reviewed were missing vaccinations. She stated that she must have just missed them and she takes responsibility. She stated that since being aware of the missing vaccinations she has now received orders and has given them.In a policy titled Azria Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures revised October 2022, it indicated that the facility follows infection prevention and control practices recommended by the CDC to prevent the transmission of COVID-19 within the facility.The CDC document titled Staying Up to Date with COVID-19 Vaccines, dated 11/19/25 documented the following concerning COVID-19 vaccination and can be found at https://www.cdc.gov/covid/vaccines/stay-up-to-date.html:Importance of staying up to dateGetting the 2025-2026 COVID-19 vaccine is important because:Protection from the COVID-19 vaccine decreases with time.Immunity after COVID-19 infection decreases with time.COVID-19 vaccines are updated to give you the best protection from the currently circulating strains.Getting the 2025-2026 COVID-19 vaccine is especially important if you:Never received a COVID-19 vaccineAre ages 65 years and olderAre at high risk for severe COVID-19Are living in a long-term care facilityAre pregnant, breastfeeding, trying to get pregnant, or might become pregnant in the future.Want to lower your risk of getting Long COVID

Based on clinical record review, staff interview and policy review, the facility failed to fully submit a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation to the appropriate state-designated authority prior to admission or within 30 days for 1 of 4 residents reviewed (Resident #50). The facility reported a census of 51 residents. Findings include:The Annual Minimum Data Set (MDS) dated [DATE] documented Resident #50 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had diagnoses to include medically complex conditions, cerebral palsy, anxiety disorder and depression. The MDS documented the original admission date for Resident#50 as 3/3/25. Review of the Electronic Health Record (EHR) for Resident #50 lacked documentation of a Level I PASRR submitted prior to admission or within 30 days of admission. Resident #50 admitted to the facility on [DATE]. During an interview 12/2/25 at 11:30 AM, Staff F, Social Services Director (SSD), stated he just submitted a Level I PASRR last week for Resident #50 which had a determination of Level II, time limited approval. The determination date was 11/28/25. Staff F acknowledged the resident admitted to the facility in March of 2025. Clinical record review of the PASRR report for Resident #50, dated 11/28/25, had a determination of Level II approval, time limited, ending on 5/28/26. The PASRR report documented on 3/15/25 a Level I screen was submitted by the facility for consideration of nursing facility level of care, the screen was cancelled because the submitter did not submit requested documentation. On 11/8/25 a Level I screen was submitted by the facility for consideration of ongoing nursing facility level of care due to not having a PASRR approval prior to nursing facility admission. A full PASRR Level II assessment was completed and identified services and supports are identified. During an interview 12/2/25 at 12:40 PM, Staff F, SSD stated they were the one who submitted the PASRR in March for Resident #50 and did not realize it was cancelled due to not having the required documentation. Staff F acknowledged he did not go back in and check the resident's PASRR status and did not submit another PASRR until November which resulted in a Level II with identified specialized services for the resident. During an interview 12/2/25 at 1:39 PM, the Administrator stated an expectation a PASRR screening should have been fully completed in March when Resident #50 was admitted to the facility, and the requested documentation should have been submitted upon request in March of 2025 to completed the PASRR screening. The Administrator acknowledged the gap of time from March to November of 2025 with PASRR not completed for the resident. Review of facility policy admission Criteria, revision date of March 2019, documented all new admissions are screened for mental disorder, intellectual disabilities or related disorders per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria.

Based on clinical record review, staff interview and policy review, the facility failed to limit a as needed (PRN) psychotropic drug (drugs that affect a person's mental state) to 14 days for 1 of 5 residents reviewed (Resident #21). The facility reported a census of 51 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #21 scored a 12 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The resident had diagnoses to include debility, cardiorespiratory conditions, renal insufficiency, diabetes mellitus, anxiety disorder and depression. The MDS indicated the resident was not taking an antianxiety medication in the look back period. Review of the Electronic Health Record (EHR) for Resident #21 revealed an order for Lorazepam (medication to treat anxiety disorders) oral tablet 0.5 mg/ml, give 0.5 ml by mouth every 12 hours as needed for anxiety and SOB (shortness of breath), with an order date of 8/29/25 and a discontinue date of 12/3/25. Review of the Medication Administration Record (MAR) for Resident #21 for the months of August, September, October, November and December (up to the 3rd of December) revealed this medication was not administered. The EHR for Resident #21 included Pharmacist Medication Regimen Reviews (MRRs) dated 10/14/25 and 11/13/25. The recommendation on 10/14/25 documented CMS requires a 14 day stop on all PRN psychotropic medications unless the prescriber documents clinical rationale for continued use and provides a new duration for use on the continued order and further recommended to discontinue the PRN Lorazepam order due to non-use. The recommendation on 11/13/25 was the same as the recommendation on 10/14/25. The EHR lacked a response by the facility to both MRRs. During an interview 12/4/2025 at 12:00 PM, the Director of Nursing (DON) acknowledged the PRN order for Lorazepam exceeded the 14 days without a rationale or an end date for Resident #21 and acknowledged the facility did not respond to the pharmacy recommendations in October and November to discontinue the order. The DON stated an expectation PRN orders for psychotropic medications have a rationale to go past the 14 days and an end date. Review of the facility policy Psychotropic Medication Use, dated July 2022, documented psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

Based on direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to maintain the kitchen in a safe and hygienic manner that is free from pests and protects food safety and prevents food borne illness. It further failed to maintain regular kitchen and dietary cleaning logs to maintain and ensure cleanliness in the kitchen. The facility reported a census of 59. The Stage Agency informed the facility of the Immediate Jeopardy (IJ) on 09/03/2025 at 03:55 PM. The IJ began on at least 04/29/2025. Facility Staff removed the Immediate Jeopardy on 09/04/2025. The facility staff removed the IJ by implementing the following actions:1. Facility ceased operations of food service from the kitchen on 9/3/25 at 3:55pm. Facility will order outside meals, and ensure diet orders are followed.2. No residents will be impacted as kitchen operations ceased on 9/3/25.3. CDM was educated on kitchen sanitation policy on 9/3/25 at 4:00pm. Facility staff to clean/sanitize kitchen on 9/3/25. Dietary staff will be educated on 9/3/25 or prior to the start of their next shift worked.4. A contract service was brought in at 4:30 PM on 09/03/2025 to implement pest control plan. They confirmed mitigation efforts and confirmed that control measures had been effective. 5. Ceiling Repairs were completed on 09/03/2025. 6. A monitoring system was put into place with the following details; Administrator will monitor kitchen sanitation, pest control, and ceiling tiles weekly x/3 weeks, then monthly x 3/months. Kitchen sanitation audits will be completed and reviewed by administrator weekly x/3 weeks then monthly x/3 months.The scope lowered from a L to a F at the time of the survey after ensuring the facility implemented education and their policy and procedures.Findings include: The initial kitchen observation on 09/03/2025 at 12:30 PM revealed the following:1. The kitchen and basement area appeared to have significant water damage, revealing numerous missing ceiling tiles, collapsing ceiling tiles, and ceiling tiles that showed significant signs of water damage. One tile, near the food preparation area, was moist and drops of water were observed beading on the tile. 2. Several strong smells permeated the kitchen, one smelled of spoilage and the other smelled damp. 3. The entire floor of the kitchen appeared caked in sticky substances and food particles. The grout appeared black in color in areas of use and was a light grey color in areas that were inaccessible to staff. 4. Numerous sticky traps were found, with one of them showing what appeared to be rodent droppings, light grey fur, and numerous insects near the kitchen dry storage area. 5. Peaches with an expiration date of 08/24/2025 were found in one of the refrigerators, the Director of Food Services confirmed they had been served for breakfast the morning of 09/03/2025. 6. What appeared to be small, worm-like insects in the floor drain were found near the HVAC Unit. What appeared to be insect eggs were found on the floor near the drain. The drains had food debris inside of them.7. What appeared to be rodent droppings were also found under and in front of the oven. 8. What appeared to be a collection of coffee creamers and sponges behind a dish washing sink with what appeared to be a mold-like-substance with a strong smell growing on it. This mold-like substance was also found in all of the kitchen floor drains. 9. The equipment throughout the kitchen appeared to be covered in a layer of grime, the flattop cooking surface was visibly blackened and appeared to not have been cleaned in some time. 10. There were two unlabeled bags of food in one of the freezer units, one of which was open to the air of the freezer. A direct observation on 09/03/2025 at 04:44 PM revealed what appeared to have been fresh rodent droppings near the stove and in the dry storage area of the kitchen, as they were not present during the initial kitchen observation at these locations. Staff L, Cook, confirmed she had swept the floor already and was seen actively cleaning at the time. She confirmed at this time to the surveyor that she had seen a mouse in the kitchen just minutes before the observation. Review of pest control documents from the facility contracting service dated 02/28/2025, 04/14/2025, 05/23/2025, 06/17/2025, 08/21/2025, and 09/04/2025 revealed pest control measures had been in place since the first date, but also documented facility sanitation issues. They included; Excess water pooled in the downstairs hallway and kitchen with large standing pools of water were noted on 05/23/2025, easy access to garbage with unlocked and unclosed dumpster was found on 4 of 6 service dates. The service records do not document pest activity. This finding is discrepant from staff and resident interviews. Review of kitchen cleaning logs since January of 2025 documented the last kitchen cleaning log for cooks was filled out on 05/31/2025. The last documented dietary aide cleaning log was dated 04/29/2025. In an email from the Regional Director of Operations (RDO), sent on 09/08/2025 at 09:56 AM she stated the dietary manager and herself were unable to find additional cleaning log documentation. In an interview on 09/03/2025 at 12:39 PM with Staff M, Dietary Aide, he stated that he has seen mice or rodents in the kitchen every single day since he started, and revealed he believed he started around January 2025. He stated he had brought this up with management staff on a number of occasions, but nothing had been done. He stated it is extremely hard to clean the kitchen, and pointed out the years of what he described as “crusted gunk” covering the floor. He stated the kitchen floods, and last seriously flooded in August, though he did not know the exact date. He stated he has seen what he believes to be cockroaches in the kitchen for a long time as well, though he's been told by other staff they are crickets. He also sees a significant number of flies, and that has been an ongoing issue. In an interview on 09/03/2025 at 01:01 PM with Staff L, Cook, she stated she is seeing one to two mice a day in the kitchen. She stated this has been ongoing for months now, and that she has told at least two different managers about the pest issue. She says that management has done nothing about the issues in the kitchen. She further stated the kitchen has also had issues with ants, what she has been told are crickets, and flies. She stated she has been directed by the previous dietary manager to push food debris and mop water down the floor drains, and confirmed at this time the drains appeared to have fly larvae in them. She expressed frustration with the situation, and stated she is unsure what more she can do. She had been considering quitting her job because of the pest situation and the general state of the kitchen. She stated the kitchen is too much to deal with, as it is too dirty to properly clean. She also revealed the kitchen floods during periods of heavy rain. She stated it last flooded in early August, and at one point had standing water in the entire kitchen. She stated that issue has also been going on for years. She stated the ceiling had been leaking for some time as well, though the facility attempted to fix that recently. She was unable to state how or where the staff members document kitchen cleaning logs, but stated they used to use paper cleaning sheets. In an interview on 09/03/2025 at 02:23 PM with The Housekeeping Supervisor, she stated she has also seen mice frequently near the kitchen, though she noted she rarely goes into the kitchen, she said the entire basement smells of mildew. In an interview on 09/03/2025 at 12:43 PM with the Dietary Manager, he stated he had started recently, and felt the kitchen was in extremely poor shape. He stated the kitchen has known issues with flies, cockroaches, and rodents that he believes to be mice. He stated the mice infestation is so bad they are catching 1-2 mice a day on glue traps since he started. He stated he has no idea how the kitchen got that bad, and stated it was a mess. He confirmed that he believed the black tapered specks near the food preparation station were rodent droppings. He shared the week before surveyors entered the building he picked up a box of foodstuffs from the floor in the dry storage area and it contained a mouse nest chewed into the side of the box. He stated the entire downstairs smelled strongly of what he believed to be mold. In an initial interview with the Acting Administrator and Regional Director of Operations on 09/03/2025 at 03:53 PM, she stated she had only just been informed of rodent activity and her staff are reporting it has been ongoing for at least two weeks. She was aware of previous rodent activity in March of 2025, but had not heard about it since. She stated they had contacted pest control about rodents at that time. In an interview on 09/08/2025 at 10:40 AM with Staff O, dietary Aide, she stated the kitchen has been in bad shape since she started with the facility, which was in Spring of 2025. She stated the facility leadership knew how unclean the kitchen was and shut it down for a deep cleaning in the summer before they were allowed to use the kitchen again. She stated it helped for a while, but that they have fallen behind on cleaning again. In an interview on 09/08/2025 at 11:03 AM with Staff P, Dietary Aide, she stated she has seen mice in the kitchen, and has been told by other staff there are mice in the kitchen. She was unable to recall when the problem started. In an interview on 09/08/2025 at 08:41 AM with a pest services contractor who serviced the facility. He stated he did not see pests while he was serving the building as part of the IJ removal plan on 09/04/2025. He stated he was shown a picture of a glue board that did not show evidence of pest infestation, and did not see signs of pests at the time of his inspection. The surveyor shared pictures of the glue boards that were present in the kitchen on 09/03/2025 and he confirmed that the pictures showed what he called significant evidence of infestation. He said he could clearly see mouse droppings, what appeared to be mouse fur attached to a glue board. He further stated he could see what appeared to be a cockroach. He confirmed he was not shown this glue board by the facility, and if he had his report would have indicated signs of pest activity. He stated the facility has had past issues with mice, and he visits the facility once a month. He revealed he was last in the facility on 08/21/2025 for a targeted cockroach inspection. He does not believe he saw evidence of cockroaches at that time, but did not look for signs of rodent infestation. When he comes monthly for his inspection he looks for any products that have been chewed on, and droppings on the floor. He stated that droppings in high human traffic areas are a sign of significant infestation. He stated that typically when he visits the facility the kitchen has been recently cleaned, but even on his most recent visit was in poor condition. He stated when he arrived in the kitchen on 09/04/2025 it was the best shape he had ever seen the kitchen in. He stated the kitchen often smells of mildew, but on 09/04/2025 smelled like a bleaching agent had been used recently. In a subsequent interview on 09/08/2025 at 09:53 AM with the Dietary Manager, he confirmed his hire date as 08/07/2025 and stated his first date on the floor was either 08/18/2025 or 08/25/2025. He stated he has personally found at least 8+ mice on sticky traps within the facility with other mice seen free roaming the facility since he started. He stated he asks maintenance to dispose of the mice on the sticky traps, and asked maintenance to dispose of the mouse nest that he found. He acknowledged that his expectations on kitchen sanitation are not being followed, and he feels it is a result of “years of neglect”. In an interview on 09/08/2025 at 11:43 AM with the Registered Dietician, she stated that she rarely goes into the kitchen but it has been disorganized in the past few months. She stated she knew the kitchen was in need of significant cleaning. In an interview on 09/08/2025 at 02:46 PM with the Director of Maintenance, with the RDO present, he confirmed he has been disposing of mice on sticky traps, and he was aware that mice were a problem in the kitchen. He stated personally disposed of 4 baby mice and 3 adult mice in the week before surveyors entered the building, but that count might be off by one, give or take. In an interview on 09/08/2025 at 03:11 PM with Staff E, Certified Nurse Aide (CNA), they stated they have seen cockroaches and mice in the basement and kitchen for months now. They stated they had talked to the facility management several times in the past but management downplayed the issue and told them the cockroaches were just water bugs and the mice weren't a problem. They stated they had noticed an increase in emesis (vomiting) and loose stools (diarrhea) in the resident population they served in the last month. They had been reporting this to their charge nurse. They also noted numerous residents have complained about the quality of their meals in the last month. In an interview on 09/08/2025 at 12:00 PM with Resident #8, he stated that while he has not seen mice in his room he sees flies all the time. He stated the food is “gross” sometimes. In an interview on 09/09/2025 at 03:20 PM with Resident #11, she stated the food does not taste good. In a subsequent interview on 09/10/2025 at 03:40 PM with the Housekeeping Supervisor, she stated again she has seen mice for months downstairs and in the kitchen. She also stated she had seen mice droppings in the laundry room downstairs, and had seen mice personally while cleaning at least two resident rooms in their dressers in the recent past. In an interview on 09/10/2025 at 09:51 AM with Staff B, Licensed Practical Nurse (LPN), she stated she was asked to remove a mouse in a mouse trap on 09/07/2025 from the kitchen. She stated she has also heard staff and residents talking about mice. She also reported a bout of diarrhea and emesis that impacted multiple residents in the month of August, though she did not know the source. On 9/8/25 at 10:16AM the Infection Preventionist (IP) stated she tracks nausea/diarrhea if it's multiple days, if it's one day episode they don't typically track it. The IP reported not track any increase in gastrointestinal symptoms last month. A Mcgeer Criteria for Gastrointestinal Tract Infection Surveillance dated 6/3/25 documented Resident#22 had diarrhea and vomiting. A Mcgeer Criteria for Gastrointestinal Tract Infection Surveillance dated 6/4/25 documented Resident#23 had vomiting with nausea, and abdominal pain or tenderness. A Mcgeer Criteria for Gastrointestinal Tract Infection Surveillance dated 6/6/25 documented Resident#22 had abdominal pain or tenderness, and diarrhea and was admitted to the hospital with colitiis (can be caused by infections).Review of a facility provided document titled “Sanitation”, with a last revised date of November 2022, stated all kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. An article from the National Parks Service (NPS), last updated 05/10/2023, warns that rodents transmit a number of pathogens that can cause human disease in the United States. These diseases are noted to be hantavirus, leptospirosis, rat bite fever, and salmonellosis. It noted that humans can become infected through various routes, including contact with food contaminated with rodent feces, urine, or saliva. It further warned rodents also serve as hosts for ectoparasites such as ticks and fleas which can transmit further diseases. It instructs the public to properly store of food and properly dispose of trash. The website cdc.gov/health-pets/rodent-control/index.html included a topic titled Controlling Wild Rodent Infestations dated April 8, 2024 included the following key facts; Rodents can carry many diseases that can spread directly or indirectly to people. Rodent droppings, urine, and saliva can spread by breathing in air or eating food that is contaminated with rodent waste. Rodents can also carry ticks, mites, or fleas that can spread disease. Many disease do not cause any apparent illness in rodents. This means you cannot tell if a rodent is carrying a disease just by looking at it Rodents can spread both bacterial and viral diseases some of which can cause death. A tour of the main kitchen (located in the facility's basement) on 9/4/25 starting at 7:40 AM revealed the following: a. The shelves across from the food prep table had peeled and chipped paint and a scuffed appearance. b. The shelves by the food prep table and across from the food prep table had a blackened and scuffed appearance, as well as what appeared to be worn, rusty, exposed metal. c. The bottom drawer by the food prep counter had particles and crumbs of food debride and what appeared to be dead maggots and mouse droppings. d. Large bulk containers labeled “sugar” and “thickener” had contents inside and had black specks of what appeared to be mouse droppings on the top. e. The steam oven had a brown, sticky residue on the door and wall of the oven inside. f. The bottom and inside of the oven had a black charred appearance and a heavy build-up of liquid drippings/debride. g. The shelves in the dry storage area were empty. h. The dry storage area had two sticky rodent traps lying on a plastic crate. i. The Arctic Air freezer had an unlabeled bag of what appeared to be frozen eggs. The bag was open and not sealed. In an interview 9/3/25 at 5:10 PM, Staff B, LPN, reported there had been 1 to 2 weeks when residents at the facility had an illness. It was the week leading up to the Labor Day weekend. They ran out of briefs that weekend. In an interview 9/3/25 at 5:25 PM, Staff A, CNA, reported she could not eat the food at the facility. She had diarrhea all day when she ate the food at the facility. Staff A stated over the past weekend and Monday (8/30/25 to 9/1/25), there were several residents that had diarrhea and vomiting. On 9/4/25 at 7:50 AM, the DM reported they replaced the ceiling tile in the kitchen, pulled everything out and cleaned behind the refrigerators and freezers. He was at the facility until 9:30 PM on 9/3/25 with management cleaning the kitchen. The DM reported they had Service Master coming to clean the floors. In an interview on 9/4/25 at 8:05 AM, the RDO reported she had worked as the RDO since 3/2025, then became the acting Administrator on 4/11/25. When the surveyor asked when the last time she had been to the kitchen, the RDO stated she had not been to the kitchen in a while. The facility had hired a DM who had been at the facility for two weeks. The RDO reported there had been a lot of staff turnover. She had a Kitchen Cleaning Party on 7/17/25. Staff came in and helped clean the kitchen for 4 ½ hours, but she thought they needed to have another cleaning event to do the rest of the kitchen. The RDO reported she left the facility at 10:45 PM on 9/3/25 and came back to the facility at 3:30 AM on 9/4/25 to continue cleaning the kitchen. The RDO reported since 9/3/25 after the IJ, the ceiling tiles got replaced, everything was pulled out of the kitchen and they sanitized the kitchen. All of the dishes got washed, the freezers and shelves got pulled out and cleaned, everything was thrown out in dry storage area, and the floor had been swept and mopped several times. The Surveyor told the RDO the kitchen cleaning logs were requested 9/3/25 but no cleaning logs were received. The RDO said she would look for the cleaning logs and get them to the surveyor. In an interview on 9/4/25 at 10:05 AM, Resident #1 reported she had diarrhea all of the time. She didn't have diarrhea until she came to the facility. On 9/4/25 at 11:25 AM, the RDO asked if the surveyors needed anything. The surveyor advised the RDO we were still waiting on the kitchen cleaning logs, as these were requested twice on 9/3/25 and again on 9/4/25 AM. The RDO reported they were still working on it. At this time, the surveyor told the RDO to provide whatever cleaning logs they had found. On 9/3/25 at 11:35 AM, the RDO sent an email with the cleaning logs attached. The most recent [NAME] Cleaning Log was dated 5/31/25 and the Dietary Aide Cleaning Log was last completed on 4/29/25. In an interview 9/4/25 at 12:24 PM, Resident #6 reported he had projectile vomiting for three weeks. In an interview on 9/8/25 at 3:20 PM, Resident #14 reported the food at the facility was not that great. She could not eat the tomato soup at the facility because it made her have diarrhea. She ate tomato soup at home without having diarrhea but that was not the case at the facility.

Based on observations, resident and staff interviews, and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility also failed to maintain and ensure adequate supplies of the appropriate sized briefs to meet the needs of all residents who used briefs and pull-ups, and failed to ensure an adequate supply of resident care supplies and linens for two of two units. The facility identified a census of 59 residents.Findings include: Observations on the North Hall on 9/3/25 starting at 12:34 PM revealed the following: a. The window air conditioner (AC) vent in room [ROOM NUMBER] had a black substance that appeared to be mold and dirt inside the vents. The AC was on during this time. b. The window AC unit in room [ROOM NUMBER] had a black substance that appeared to be mold in the vents. The room smelled musty. c. room [ROOM NUMBER]- the bathroom floor in front of the toilet had a black non-skid strip missing and particles of old glue on the floor. The wall base was missing by the bathroom door entrance exposing the drywall. d. room [ROOM NUMBER] - the wall base was missing in the bathroom. e. room [ROOM NUMBER]- the bathroom ceiling had heavy patches of spackling.f. room [ROOM NUMBER]- the air mattress had stains and what appeared to be dried fluids on the surface. g. room [ROOM NUMBER] -the sheets on the bed (by the door) had a wet yellow and brown stain in the middle of the bed. The sheets along the side of the bed (by the window) had brownish stains. A urinal filled with urine hung on the trashcan of each resident assigned to this room. The North Hallway had a strong smell of ammonia resembling an odor of urine on 9/3/25 at 12:49 PM and 3:40 PM, and again on 9/4/25 at 12:20 PM and 9/8/25 at 10:00 AM. Observations on 9/4/25 at 7:35 AM revealed: a. The hallway in the basement had carts and equipment lined up along the wall. The air smelled musty. b. The ceiling tiles and the drop ceiling apparatus had fallen down in the activity supply room and housekeeping office. A dry, brown liquid streamed down the wall from the ceiling toward the floor. c. The laundry room had a pail of what appeared to be soiled rags or washcloth and black specks of what appeared to be mouse droppings on the soiled cloths. d. The laundry room had a black/brown liquid substance running down the wall near the clean clothes rack.e. The Exit door near the kitchen had open cracks on the side and under the door. Observations on the South Hall on 9/4/25 starting at 8:30 AM revealed heavily soiled and stained mattresses on beds in rooms 7, 8, 10, and 21The South Shower room had the following: a. The ceiling had peeling paint and two areas of the ceiling falling down. b. The shower stall area had a grayish and brown mud-like debride on the shower tiles and the floor. The wall tiles in the shower area were cracked. c. The shower chair strap appeared worn and had strands of hair on it.On 9/8/25 at 3:20 PM, the top of the headboard in room C2 was dusty. The stand-up fan had a heavy build-up of dust.On 9/11/25 at 8:35 AM, Staff E, certified nursing assistant (CNA), lifted up the mats on the floor in room [ROOM NUMBER]. Crumbs, dirt, and debride were observed under the mats lying on the floor. The mats surrounded a resident lying on a mattress on the floor in this room.Observations of the North Shower Room on 9/11/25 at 8:44 AM revealed:a. Cracked and missing floor tile just outside the shower area and by the toilet.b. The shower drain cover was partially off and the drain had an excessive amount of biofilm. c. Parts of non-skid strips in the shower were missing and areas of the nonskid strips had curled up edges.d. The cabinet under the sink had a black substance that appeared to be mold. e. The wall behind the entrance door to the shower room had a large open hole in the dry wall. Observations of supplies revealed the following: a. On 9/3/25 at 12:36 PM, the North Hall clean utility room had one XL (extra large) package of briefs and three packages of cleansing wipes. The clean utility room lacked other sizes of briefs or pull-ups or boxes of gloves. At 12:38 PM, a staff person pushed a cart to the North clean utility room.At 12:50 PM, the surveyor checked the North Hall clean utility room after the staff person had stocked the room. Observation revealed only 6 boxes of large (L) gloves, 2 boxes of medium (M) gloves, 3 packages of XL briefs, and 4 packages of cleansing wipes on the shelves. The matrix provided by the facility on 9/3/25 after the surveyor's entrance revealed 28 residents resided on the North Hall. The North Hall had no residents on hospice services. b. On 9/3/25 at 5:35 PM, the Central Supply room (by the therapy room) with Staff A, certified nursing assistant (CNA), revealed a pile of cardboard boxes broken down and lying on the floor. The shelf had 4-5 packages of briefs in various sizes (3XL 2XL, XL, L, M) and boxes of gloves with 10 boxes of gloves in each box in sizes XL, L and M. Two boxes of cleansing wipes were located on the lower shelf. c. On 9/4/25 at 8:20 AM, the North Clean Utility Supply room had the following: 6 boxes of L gloves2 boxes of M gloves1- package of XL and 1 package of L briefs 2 packages of wipes 21 washcloths8 towels9 sheets6 fitted sheets d. On 9/8/25 at 10:40 AM, the North Clean Utility Supply room had no packages of briefs or boxes of gloves on the shelves. In an interview on 9/3/25 at 4:05 PM, Resident #17 reported the facility did not give the person who did the showers enough linens. The resident reported he saw a lot of flies, but no mice or other insects. The resident thought the flies came in through the cracks by the window where the hose for the AC unit went out. The resident reported the bathroom ceiling in his room caved in and it flooded the entire room, then it flooded into the whole hallway this past summer. In an interview 9/3/25 at 4:10 PM, Staff H, CNA, reported the facility management thought staff were double briefing the residents. Staff H said she told them that briefs came with 20 in a bag, and when staff changed a resident at least three times a shift the briefs were going to be gone before long. Staff H reported the nurses didn't have enough wound supplies either. Staff J, Central Supply, ordered the supplies. Staff H reported Resident #5 and Resident #10 didn't have big enough briefs. One resident sat in a pool of urine because they did not have big enough briefs or pads for her. Staff H reported a couple of nights ago staff had to staple two briefs together to put on the resident so the brief would fit. Staff H reported she had to stash briefs so she would have some to use on the residents. In an interview 9/3/25 at 5:02 PM, Resident #19 reported housekeeping did not come into her room as often as she thinks they should. She had been at other facilities where the rooms were cleaned more often, but her room got cleaned once a week at this facility. The facility also had a lot of flies because the door to the outside was left open for residents to go out to smoke. Resident #19 reported the facility ran short on diapers (briefs) toward the end of the week. She stated she thought it all came down to the money and why the facility did not have adequate supplies.In an interview 9/3/25 at 5:10 PM, Staff B, Licensed Practical Nurse (LPN), reported there had been 1 to 2 weeks when residents at the facility had an illness. It was the week leading up to Labor Day weekend. They ran out of briefs that weekend but she called the on-call person and was told where to look for more. Staff B reported the facility used a lot of agency and supplies were not organized. She put together a list of treatment and dressing supplies needed for residents so supplies could get ordered. In an interview 9/3/25 at 5:25 PM, Staff A, CNA, reported the facility did not have enough supplies such as gloves, wipes, and briefs. If the facility ran out of supplies, she used whatever was available, such as a washcloth. If a resident used a 3 XL brief but the facility did not have those, then they had to use a 2XL brief or whatever they had available. She sometimes used a pull-up and tied up the sides of the pullup to make it work when they did not have briefs. Staff A stated the facility did not always have enough linens. They ran out of clean linens all of the time. She let the nurse know whenever supplies or linens ran low or out. The nurse could call whoever was on-call but staff did not always get what was needed right away, and the on-call person did not always come in. Running out of briefs and linens happened all of the time when she worked. She just did the best she could to make it work. In an interview 9/4/25 at 8:45 AM, Staff D, Housekeeper, reported she was the only housekeeper in the facility on that day. She was responsible to clean the central and North Halls. The cleaning entailed cleaning resident rooms, including the bathroom, and the hallway. Staff D reported she does not strip the linens off the bed or clean the mattresses. She was not sure who cleaned the mattresses on the beds. In an interview 9/4/25 at 10:05 AM, Resident #1 reported staff get her dressed in a wet bed, and she smelled like pee. Staff put a diaper on her at night but they don't clean her up. She had been lying in pee and she doesn't like feeling or smelling like pee. Staff don't clean the bed or her mattress. Resident #1 also stated she saw mice in her room last week. Resident #1 reported she did not think the facility was very clean. It smelled like pee all of the time in the facility. In an interview 9/4/25 at 12:45 PM, Resident #20 reported she could hear mice running above her ceiling. The facility was getting the ceiling fixed and putting on a roof. The resident stated the water dripped outside her door when it rained hard. There are so many places in facility where it dripped water. Resident #20 stated the supply of briefs got skimpy sometimes. She wore a large brief but the facility ran out of her size so staff were using XL pull-ups.In an interview 9/4/25 at 12:55 PM, Staff J, Central Supply, reported she ordered supplies based off of demand. She explained that once a month, she printed a list of residents that were in the facility at that time and she ordered supplies based off of the resident size and the type of brief the resident wore. She also asked staff about if a resident was a wetter and then incorporated this into what she ordered. She placed an order on Thursday and the shipment of supplies got delivered to the facility on Mondays. When the holiday fell on a Monday, the shipment of supplies got delivered on Tuesday. Staff J reported the facility had a total of three supply rooms, that entailed a small supply room on the North and South Halls, and one large central supply room by the Therapy room. The two smaller supply rooms are used for stocking items such as soaps, toothbrushes, linens, and gloves. The CNA's are supposed to stock the two smaller supply rooms but staff know supplies are in the main supply room get what they need from the main supply room a lot of the time. Staff J reported she kept some supplies for emergency stock so they don't run out. Staff J reported there had been issues with staff double and triple briefing residents. She talked to the DON (Director of Nursing) when she found out about the double and triple briefing and the DON put a stop to it. Staff J reported she is making sure there is enough briefs and supplies for the night and weekend shifts. She just got shipments to restock her emergency supply. Staff J reported there had been a lot of use of the briefs due to days when residents had a lot of BM's (bowel movements) and they went through a lot more briefs.In a follow-up interview 9/10/25 at 12:00 PM, Staff J reported she marked things off on the supply invoice as she went through the supplies that were delivered. She put a star on the invoice when everything had been received. She highlighted things on the invoice such as the packages of briefs so she can find it easier on the form. Staff J reported she sent an email to the supplier when supplies on the invoice were not delivered. The items got overnight shipped and she typically received those items the following day. In an interview 9/8/25 at 10:05 AM, Resident #10 reported staff almost ran out of briefs last week. She was sent the wrong size brief, it was a size smaller than what she wore. Staff had to lay one brief and then pieced another brief to it. The staff made it work, it held the urine.In an interview 9/8/25 at 3:20 PM, Resident #14 reported she thought her room needed to be dusted more often then it was being done. The facility always ran out of supplies, then the facility tells the staff they are using too much or wasting it. In an interview on 9/10/25 at 3:40 AM, the Infection Preventionist (IP) reported she would need to get back to the surveyor about who was responsible for cleaning the mattresses on the resident beds. She would also need to get back to the surveyor about who was responsible for cleaning resident equipment, such as fans. The IP reported Staff J ordered the supplies. Staff told Staff J what they needed. On 9/11/25 at 11:20 AM, the IP reported she checked on who cleaned the mattresses and equipment. Housekeeping routinely cleaned the mattresses and fans in the rooms. If a mattress is visually soiled then anyone could wipe down the mattresses. When asked what staff would clean mattresses with, she said she would have to get back to the surveyor on what cleaning product is used to clean the mattresses. In an interview 9/11/25 at 11:40 AM, the DON reported Staff J ordered supplies. The DON stated she felt the staff always had adequate supplies and linens. The DON acknowledged there had been a time when she got a call they were running low on some supplies but they never ran out. The DON stated she couldn't recall when this occurred, she did not want to speak on the wrong date. The DON reported linens were stocked by housekeeping, and staff were to obtain supplies from the bigger supply room to stock the hall supply rooms. In an interview 9/11/25 at 12:05 PM, the Regional Director of Operations (RDO) reported she was in the shower rooms within the past two weeks. She had maintenance adjust the doors so they latched. The RDO reported she didn't notice any concerns or issues when she was in the shower rooms. The RDO reported she did not know how long the ceiling in the housekeeper office / activity supply room had been falling down or how long the water stained walls in the laundry room or housekeeper office had been there. She doesn't spend time in the basement. The RDO reported she was aware of mice in the facility about two weeks ago, otherwise she was last aware of mice activity in 1/2025 or 2/2025. She believed the outside door (exit door by the kitchen) contributed to the mice coming into the kitchen. The RDO confirmed she had never seen a mouse at the facility, thank goodness. She does not do critters. A tour of the facility with the RDO on 9/11/25 at 12:50 PM to observe some environmental areas of concern with the AC units in resident rooms, missing wall base, and concerns in the shower rooms. The RDO confirmed the AC units in resident rooms needed to be cleaned.A Homelike Environment policy revised 2/2021 revealed residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment, clean bed and bath linens that are in good condition, and pleasant, neutral scents. The facility staff and management minimized, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting, including institutional odors. A Standard Precautions policy revised 9/2022 revealed standard precautions presume that all blood, body fluids and excretions may contain transmissible infectious agents. Resident Care Equipment soiled with blood, body fluids, secretions and excretions are handled in a manner to prevent cross-contamination and transfer of microorganisms to other residents and environments. Environmental surfaces and beds are appropriately cleaned.

Based on observations, record review, resident and staff interviews, call light reports, resident council meeting notes, and policy review the facility failed to provide sufficient staff to meet resident needs with toileting assistance and answering call lights (within 15 minutes) for 2 of 2 units. The facility reported a census of 59 residents. Findings include:1.The Quarterly MDS assessment dated [DATE] revealed Resident #15 had diagnoses of a hip fracture, cerebrovascular accident (CVA) (Stroke), muscle weakness and a history of falls. The MDS revealed the resident had a Brief Interview for Mental Status score of 12 out of 15 indicating moderately impaired cognition. The resident had dependence on staff for transfers. The Care Plan revised 8/21/25 revealed Resident #15 had an ADL impairment related to impaired mobility and a recent surgical repair of her hip fracture. The resident had a fall with major injury on 8/21/25. The Care Plan directed staff to be sure to respond promptly to all requests for assistance. During continuous observation on 9/9/25 at 11:38 AM, a resident was heard hollering as the surveyor walked down the hall. Resident #16 (Resident #15's roommate), yelled she needs help. Surveyor entered the room to find Resident #15 sitting on the toilet with her catheter bag hung above the level of the bladder. Resident #15 reported she needed help. She had been sitting on the toilet for 1/2 hour and she couldn't sit there any longer. The emergency call light was flashing (on), and the call light was lit in the room. Resident #16 reported she pushed the call light too because nobody was coming. No staff were observed in the area. At 11:42 AM, Resident #10 hollered out to the surveyor. Resident #10's room was next to Resident #15's room. Resident #10 pointed to the bathroom and told the surveyor somebody needed to help the little boy in there. The boy had been hollering to get out for over 20 minutes. At the time of the observation, the bathroom doors were partially open on both sides leading to each of these residents' room At 11:43 AM, Staff C, CNA, stood by the desk and looked at the monitor screen with activated call lights and stated she needed to figure out where to go next. Staff C reported she was floating between the halls and assisting. At 11:44 AM Staff C, CNA, entered Resident #15's room. Staff C asked Resident #15 who helped her to the bathroom. Resident #15 reported she couldn't wait any longer and got up to go to the bathroom. Staff C donned a pair of gloves and began looking for supplies. At 11:47 AM, Staff C placed a gaitbelt and assisted the resident to stand up. Staff C then provided pericare and transferred the resident to a wheelchair. A large indentation and redness was noted to the resident's outer buttocks from sitting on the toiletseat for an extended time.2.Observations revealed the following: On 9/8/25 on 11:15 AM, Resident #12 sat in a motorized wheelchair outside her room in the North hallway. At 11:20 AM, another resident walked down the hall and asked Resident #12 what she was doing. Resident #12 responded I am waiting to get changed. Resident #12 then said they (staff) are always doing something. She thought maybe the staff would help her if she sat in the hall. At 11:22 AM, Resident #12 drove her motorized wheelchair back into her room. At 11:26 AM, Resident #12 maneuvered herself in the motorized wheelchair back into the hall outside her room and parked the wheelchair along the railing. At 11:35 AM, Staff E, certified nursing assistant (CNA), and Staff F, agency CNA entered Resident #12's room. At 11:37 AM, the Regional Nurse entered Resident #12's room and reported she planned to observe staff. Staff F then left the room and talked with the Regional Nurse who now stood in the hallway. At 11:38 AM, Staff E reported he was waiting for Staff F. At 11:39 AM, Staff F stood at the end of the hall and was observed talking with the DON. At 11:43 AM, Staff F entered the room and washed her hands as Staff E connected the sling straps to the mechanical lift. Staff E then left the room to get a towel. At 11:44 AM, Staff E returned to the room. At 11:45 AM, Staff E began to raise the resident up with a mechanical lift and transferred the resident from the wheelchair to the bed. The resident and the air in the room reeked of urine. Staff E removed the resident's brief and provided pericare. Resident #12's brief was notably wet and soiled with liquid stool. 3. On 9/9/25 at 1:51 PM, Resident #1 reported she put her call light on but staff came in and shut it off and said it would be awhile. Review of the call light report revealed the resident's call light was activated on 9/9/25 at 1:16 PM and turned off within 49 seconds. On 9/9/25 at 2:01 PM, Resident #1 reached behind her and pushed the call light located in the recliner chair behind her. 4. During an interview on 9/4/25 at 10:05 AM, Resident #1 reported it took a long time for someone to come when she pushed her call light. Her roommate yells help, help but staff still do not come to help. During an interview on 9/4/25 at 12:24 PM, Resident #6 reported he had to have two staff to transfer and change him. It took up to two hours before staff came and helped him. He did not get changed right away and he got upset because he did not get sufficient cares from people to take care of him. The staff put two briefs on him during the day and sometimes at night so they do not have to change him as often. He would rather have the staff use one brief because it hurt when he had two briefs on. During an interview on 9/8/25 at 10:05 AM, Resident #10 reported it took a while for staff to respond. It's longer than she would like it to be. During an interview on 9/8/25 at 3:20 PM, Resident #14 reported it took forever to get staff assistance. On the average, it took 30 minutes or longer for staff to respond to her call light. Response times depended upon the shift and the staff who worked at the time. Call light response times were terrible on the 10 PM - 6 AM shift and on the weekends but it just depended on the staff who were working and the number of staff that were scheduled to work. During an interview on 9/9/25 at 1:45 PM, Staff E, CNA, reported they were supposed to have two CNA's on each hall and one float. The facility did not have enough stable employees. Agency and management staff were filling in to work. When there were call-ins or staff did not show up as scheduled it made it hard to fill the open shift. During an interview on 9/9/25 at 2:40 PM, Staff A, CNA, reported the facility did not have many staff that were employed at the facility on the day and evening shift. The facility used a lot of agency to help out. Staff A stated she got called to work extra hours all of the time. In an interview on 9/9/25 at 3:10 PM, the Unit Manager reported she is not involved with scheduling or staffing. The Unit Manager told the surveyor she would need to talk to the Staffing Coordinator about the number of staff scheduled each shift. In an interview on 9/9/25 at 3:27 PM, Staff I, CNA, reported most of the residents required the assistance of two staff and needed to use the hoyer (mechanical lift) which required two staff assistance. She sometimes got called to work extra hours, and picked up shifts a few days a week depending upon the needs. In an interview 9/10/25 at 3:40 AM, the Unit Manager reported everybody was responsible for answering the call lights. She expected call lights to be answered within 15 minutes as set by the Federal and State guidelines. In an interview 9/11/25 at 11:40 AM, the DON reported staffing entailed the following: 2 nurses on each shift (6 AM - 6 PM and 6 PM to 6 AM)1 CMA 6 AM-6 PM 2 CNA on the North Hall, 2 CNA's on the South Hall, and 1 CNA to float 2 shower aides Monday through Friday1 shower aid on Saturday/Sunday who also performed restorative functions1 Restorative CNA on Monday through FridayThe shower aide sometimes got pulled to work on the floor as a CNA until coverage was found. The Staffing Coordinator was good about getting the shifts covered, the Unit Manager also picked up numerous hours so the DON did not have to work the floor. Human Resources, maintenance, and the scheduler also worked as a CNA and picked up shifts. They also offered staff a triple bonus to work extra. The DON reported she had worked as a CNA once in the past month. In an interview 9/11/25 at 11:40 AM, the DON reported on the day the agency CNA went in to help Resident #12, the agency CNA was freaking out, she said she had never had State watch her before. The DON told her to relax, it was fine, she knew how to do the job. In an interview on 9/11/25 at 12:05 PM, the Regional Director of Operations (RDO) reported the Regional Staffing Coordinator determined the staffing levels at the facility and the facility also had a staffing coordinator on-site who was responsible for scheduling staff. The RDO reported she updated the facility assessment. The RDO reported she expected the resident's call lights answered within 15 minutes. All staff were responsible to answer the call light. If the staff person could not address what was needed then the staff person needed to let the appropriate staff know they needed to help the resident. Review of the Past Calls Report dated 8/27/25 to 9/9/25 revealed call light response times greater than 15 minutes for the following rooms: N14 bed 2 - 3 times. The longest response time was 23 minutes, 24 seconds.N16 bed 2 - 4 times. The longest response times was 23 minutes, 22 seconds.S5 bed 1 - 47 times. The longest response time was 1 hour and 51 minutes.S5 bed 2 - 3 times. The longest response time was 27 minutes. S6 - 44 times, with the longest response times of 1 hour and 23 minutes and 2 hours and 2 minutesS8 bed 1 - 17 times. The longest response time was 1 hour and 25 minutes. S8 bed 2 - 9 times. The longest response times was 1 hour and 27 minutes. C2 bed 2 - 23 times. The longest response time was 1 hour and 34 minutes and 2 hours and 8 minutes. Resident Council Notes revealed under New Business an issue of concern to continue with call light audit. The section directed that for each concern raised, ask for a show of hands and how many residents shared the same concern. The following was recorded as the concern and the number of residents who shared the concern for call light audit: 12/26/24: 8 of 8 1/23/25: 7 of 8 2/27/25: 11 of 11 3/26/25: 11 of 114/24/25: 11 of 115/22/25: 10 of 10 The Resident Grievance/Complaint Log dated 1/1/25 - 9/2/25 revealed call light concerns 1/21/25 and 5/27/25. The facility assessment updated 5/29/25 revealed a facility assessment utilized to determine theresources necessary to care for the resident population served during day to day operations. The facility assessment included the average daily census of 47-50 residents, the care required by the population in consideration of the types of diseases, conditions, physical and cognitive abilities, and overall acuity of the residents. The facility assessment also revealed staff competency necessary to provide the level and types of cares needed for the population. The Facility Assessment revealed the number of residents who required assistance with ADL's and needed the assistance of 1-2 staff: Dressing - 31Bathing- 46Transfers- 29Eating -6Toileting -31The Facility Assessment also revealed the number of residents who had dependence on staff for ADL's: Dressing - 9Bathing- 4Transfers-3Eating -1Toileting -9The Facility Assessment revealed staffing plans are based off resident volume. to evaluate the overall number of facility staff needed to ensure enough qualified staff are available to meet each resident's needs 7 days a week and 24 hours per day. The Facility Assessment listed the total number of staff needed in a 24-hour period, including 3-4 licensed nurses providing direct care, 13-16 CNA/CMA's, and 2-4 housekeeping/laundry/maintenance staff. The resident matrix provided by the facility on 9/3/25 at 12:04 PM revealed the following:28 residents on the North Hall25 residents on the South Hall6 residents on the Center Hall4 residents had pressure ulcers5 residents were on hospice care1 resident required enteral tube feedings4 residents had a catheterAn Answering the Call Light policy revised 9/2022 revealed ensure timely response to resident's requests and needs. Ensure the call light is accessible to the resident. Answer the call system timely. If you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

Based on observations, resident, and staff interviews, Centers for Disease Control (CDC) website data, and resident council meeting notes the leadership of the facility failed to provide adequate management of the facility. The Administrative team failed to provide adequate incontinent supplies, linen supplies and a comfortable homelike environment free of vermin. In addition, the facility failed to provide the residents with a clean kitchen. The facility identified a census of 59 residents. Findings include:Observations conducted on 9/3/25 at 12:34 PM revealed the following concerns during a walk through the North hallway; black like substances on vents of two air conditioners in two resident rooms, missing wall base in two resident rooms, minimal incontinent supplies in the North Clean Utility room (1 package XL briefs, 3 packages of wipes), room22 bathroom ceiling with spackling /heavy patches. Also, during the initial walk through the building resident mattresses were noted to been stained, a strong foul smell was noted in different areas of the building, stained linen on beds, and several beds were unmade. Observation of the south end supply room conducted on 9/3/25 at 5:35PM revealed the following; carboard boxes broken down on the floor, 4 to 5 packages of incontinent briefs in various sizes (3XL, 2XL, XL, L, and M) 10 boxes of gloves in sizes XL, L, and M, and a couple boxes of cleansing wipes. In an interview 9/3/25 at 5:25 PM, Staff A, CNA, reported the facility did not have enough supplies such as gloves, wipes, and briefs. If the facility ran out of supplies, she used whatever was available, such as a washcloth. If a resident used a 3 XL brief but the facility did not have those, then they had to use a 2XL brief or whatever they had available. She sometimes used a pull-up and tied up the sides of the pullup to make it work when they did not have briefs. Staff A stated the facility did not always have enough linens. They ran out of clean linens all of the time. She let the nurse know whenever supplies or linens ran low or out. The nurse could call whoever was on-call but staff did not always get what was needed right away, and the on-call person did not always come in. Running out of briefs and linens happened all of the time when she worked. She just did the best she could to make it work. On 9/8/25 at 3:11PM Staff E, C.N.A stated that there have definitely been times where once or twice a week they run out of supplies. On 9/9/25 at 3:20PM Resident#11 reported that staff told her that they were running out of clean linens. On 9/3/25 a 4:05PM Resident#17 reported the staff that does showers runs out of linen. On9/3/25 at 5:02PM Resident#19 reported that towards the end of the week incontinent supplies get short, and her room only gets cleaned once a week. On 9/3/25 at 4:10PM Staff H, C.N.A reported told management about the backup on the ice machine, mice, ants and water bugs. Staff H stated that there is a resident that does not have big enough incontinent briefs, the resident is a bigger person she sits in urine since the briefs are not big enough. Staff H reported she stapled 2 incontinent briefs together to put on the resident. In an interview on 09/03/2025 at 02:23 PM with The Housekeeping Supervisor (HS), stated she has also seen mice frequently near the kitchen, though she noted she rarely goes into the kitchen, she said the entire basement smells of mildew. The HS further reported that she knew of the issue with the linens in the building, Certified Nurses' Aides (CNA) have used folded up linens as incontinence pads for residents, because they report to her that they don't have enough supplies. The HS showed the surveyor a bin filled with soiled linens with deep brown stains and stated those couldn't be cleaned and have to be disposed of, that's a why they're short on linens. On 9/3/25 at 12:43PM the smell and general state of the kitchen was enough to nauseate the surveyor. In an interview on 09/03/2025 at 12:39 PM with Staff M, Dietary Aide, he stated that he has seen mice or rodents in the kitchen every single day since he started, and revealed he believed he started around January 2025. He stated he had brought this up with management staff on a number of occasions, but nothing had been done. He stated it is extremely hard to clean the kitchen, and pointed out the years of what he described as crusted gunk covering the floor. He stated the kitchen floods, and seriously flooded in August, though he did not know the exact date. He stated he has seen what he believes to be cockroaches in the kitchen for a long time as well, though he's been told by other staff they are crickets. He also sees a significant number of flies, and that has been an ongoing issue. In an interview on 09/03/2025 at 1:01 PM with Staff L, Cook, she stated she had seen one to two mice a day in the kitchen. She stated this has been ongoing for months now, and that she has told at least two different managers about the pest issue. She says that management has done nothing about the issues in the kitchen. She further stated the kitchen has also had issues with ants, and what she has been told are crickets. She stated she has been directed by the previous dietary manager to push food debris and mop water down the floor drains, and confirmed at this time the drains appeared to have fly larvae in them. She expressed frustration with the situation, and stated she is unsure what more she can do. She had been considering quitting her job because of the pest situation and the general state of the kitchen. She stated the kitchen is too much to deal with, as it is too dirty to properly clean. She also revealed the kitchen floods during periods of heavy rain. She stated it last flooded in early August, and at one point had standing water in the entire kitchen. She stated that issue has also been going on for years. She stated the ceiling had been leaking for some time as well, though the facility attempted to fix that recently. She was unable to state how or where the staff members document kitchen cleaning logs, but stated they used to use paper cleaning sheets. In an interview on 09/03/2025 at 12:43 PM with the Dietary Manager, he stated he had started recently, and felt the kitchen was in extremely poor shape. He stated the kitchen had known issues with flies, cockroaches, and rodents that he believes to be mice. He stated the mice infestation is so bad they are catching 1-2 mice a day on glue traps since he started (8/7/25). He stated he had no idea how the kitchen got that bad, and stated it was a mess. He confirmed that he believed the black tapered specks near the food preparation station were rodent droppings. He shared the week before surveyors entered the building he picked up a box of foodstuffs from the floor in the dry storage area and it contained a mouse nest chewed into the side of the box. He stated the entire downstairs smelled strongly of what he believed to be mold. On 9/8/25 at 11:15AM Staff S, Previous Dietary Manager reported he was employed at the facility from 1/29/25 to 7/17/25. Staff S stated saw 2 to 3 mice in the kitchen in January to when he was terminated in July. The kitchen was in extreme disrepair, as it had ongoing problems with years of mismanagement to get the kitchen into the state that it is in today. Staff S confirmed that during storms the sump pumps on at least on occasion shut down and began to flood the lower level of the basement, there was standing water in the kitchen and throughout the downstairs in general. The facility had to call a company to vacuum the water from the basement. Staff S confirmed there had been ceiling leaks in the past. Staff reported issues with pests as well mostly mice. In an interview on 09/08/2025 at 11:43 AM with the Registered Dietician, she stated that she rarely goes into the kitchen but it had been disorganized in the past few months. She stated she knew the kitchen needed significant cleaning. On 9/8/25 at 3:11PM Staff E, C.N.A reported for months now, the staff member saw mice in resident rooms, and roaches in the basement, also two and a half weeks ago ceilings were leaking. Staff E, had approached management about the roaches, and they down played it saying they were water bugs. Staff E reported that the toilets flood the rooms all the time, and walls are leaking from the roof. Staff E, stated that the housekeepers are not doing their jobs the beds are often soiled, disgusting, and the C.N. A's don't have time to do deep cleaning. Resident Council Minutes dated 1/23/25 at 2:00PM documented the following; talked about recent water leaks. In an interview 9/3/25 at 5:02 PM, Resident #19 reported housekeeping did not come into her room as often as she thinks they should. She had been at other facilities where the rooms were cleaned more often, but her room got cleaned once a week at this facility. The facility also had a lot of flies because the door to the outside was left open for residents to go out to smoke. Resident #19 reported the facility ran short on diapers (briefs) toward the end of the week. She stated she thought it all came down to the money and why the facility did not have adequate supplies. On 9/10/25 at 3:40PM the Housekeeping Supervisor (HS) reported her room had the broken and leaking ceiling for over a year, and she started reporting it before the last survey 11/2024, the leak has gotten worse since then. The HS stated the corporate had come out and viewed the leaks because she reported it to them, and they say it's terrible but nothing gets done. HS further reported the laundry room is the same it hasn't been repaired yet, it's leaking directly down to a drain. The HS confirmed seeing mice downstairs, and knows there had been mice droppings on laundry as well. The HS reported seeing mice in resident rooms as well a few months ago, and the residents were asked to put their snacks in plastic containers. The Housekeeping Supervisor, stated had seen mice personally while cleaning at least two resident rooms in their dressers in the recent past. In an initial interview with the Acting Administrator and Regional Director of Operations on 09/03/2025 at 3:53 PM, she stated she had only just been informed of rodent activity and her staff are reporting it has been ongoing for at least two weeks. She was aware of previous rodent activity in March of 2025, but had not heard about it since. She stated they had contacted pest control about rodents at that time. On 9/11/25 at 12:35PM the Regional Director of Operations (RD0) reported she was unaware that there was no kitchen sanitation documentation completed, until the survey team requested it. The RDO further stated she was told there had been an issue with mice in the kitchen dating back to the last survey, but staff had not been reporting things to her. She also reported not being aware of mice in resident rooms, the Maintenance Director should have reported that to her. In an interview 9/11/25 at 12:05 PM, the Regional Director of Operations (RDO) reported she did not know how long the ceiling in the housekeeper office/activity supply room had been falling down or how long the water stained walls in the laundry room or housekeeper office had been there. She doesn't spend time in the basement. The RDO reported she was aware of mice in the facility about two weeks ago, otherwise she was last aware of mice activity in 1/2025 or 2/2025. She believed the outside door (exit door by the kitchen) contributed to the mice coming into the kitchen. The RDO confirmed she had never seen a mouse at the facility. In an interview on 09/11/2025 at 1:12 PM the Regional Director of Operations (RDO), acknowledged the previous facility leadership had not followed through with the QAPI plan created due to the results of the last standard survey

Based on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. The facility reported a census of 59 residents.Findings Include:The CASPER Report for the facility identified the facility had previously received an Infection control deficiency in 2023 and 2024. A Safe, clean, and homelike environment deficiency in 2023 and 2024. At the conclusion of the complaints survey on 09/11/2025 the facility was cited again for Infection control and Homelike environment. The Facility's QAPI Plan, revised 2/05/2025, identified a monitoring process which included multiple sources of data. The QAPI Plan failed to identify a process to address previously identified quality deficiencies.Review of the QAPI minutes since 11/27/2024 identified repeat deficiencies and deficient practices from the last standard survey, but did not document follow through and showed numerous repeated issues addressed during QAPI meetings. In an interview on 09/11/2025 at 01:12 PM with the Director of Nursing (DON), the acting QAPI designee, she could not explain why there are repeated issues documented in the QAPI meetings, and could not explain where the follow through was documented. She stated her expectation is for the follow through to be documented and for issues to not be repeated. In that same interview, the Regional Director of Operations (RDO), she acknowledged the previous facility leadership had not followed through with the QAPI plan created due to the results of the last standard survey.

Based on direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to provide incontinence care and transfers in a manner that promotes hygiene and protects residents from the spread of disease when they failed to change contaminated gloves and used another residents mechanical lift sling without sanitizing it first for 3 of 4 residents reviewed. (Resident #1, #8, and #12). In addition, the facility failed to utilize Enhanced Barrier Precautions (EBP) when providing care to a resident with an indwelling catheter (Resident #8). The facility reported a census of 59.Findings include: 1. The significant change Minimum Data Set (MDS) for Resident #8, dated 10/15/2024, documented the residents Brief Interview for Mental Status (BIMS) Score as 14, indicating intact cognition. It documented the following relevant diagnosis of indwelling catheter. It also documented the residents dependency on staff for transfers and the use of a wheelchair for mobility. The care plan for Resident #8, last revised on 07/03/2025, documented the resident required two-person assistance with a mechanical lift for transfers. A direct observation on 09/08/2025 at 03:21 PM revealed Staff G, Certified Nurse Aide (CNA), and Staff E, CNA, transferring Resident #8 via a mechanical lift. Before Staff E arrived to assist, Staff G attempted to place Resident #8 on a mechanical lift sling. This was discovered to be the wrong size, and Staff G pulled a mechanical lift sling from the resident's neighbor's room. No sanitation of the sling was witnessed. During the transfer neither Staff G nor Staff E wore enhanced barrier precautions. In an interview on 09/08/2025 at 02:27 PM with Staff R, Registered Nurse (RN), she stated if she is transferring a resident with an indwelling medical device, such as a catheter, she is required to wear enhanced barrier precautions. In an interview on 09/10/2025 at 09:51 AM with Staff B, Licensed Practical Nurse (LPN), she stated staff are required to wear enhanced barrier precautions while transferring a qualifying resident. She stated qualifying residents include those with catheters, but also wounds of any kind. She acknowledged that a transfer is considered a high contact activity because of the direct contact staff members make during assisted transfers. In an interview on 09/10/2025 at 11:23 AM with the Infection Preventionist, she stated each resident should have their own clean mechanical lift sling. She stated her expectation is for staff to not grab a lift sling from another residents room. She acknowledged staff should have been wearing enhanced barrier precautions when they transferred Resident #8. In an interview on 09/10/2025 at 11:41 PM with the Director of Nursing (DON) she stated her expectation is for staff members to use clean slings from bulk storage, and not take slings from another resident's room. She stated slings must be sanitized before being used between residents. She confirmed staff should be wearing enhanced barrier precautions during transfers as it is considered a high contact activity. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had diagnoses of chronic obstructive pulmonary disease, left above the knee amputation, and moisture associated skin disorder (MASD). The MDS documented the resident had incontinence and had dependence on staff for toileting hygiene and dressing. The Care Plan revised 4/29/25 revealed the resident had bowel and bladder incontinence. The care plan directed staff to clean the peri-area with each incontinence episode. During observation on 9/8/25 at 11:45 AM, Staff E, certified nursing assistant (CNA), and Staff F, CNA, used a mechanical lift to move Resident #12 from a wheelchair to the bed. The resident and the air in the room reeked of urine. Staff rolled the resident onto the left side and removed her pants. Staff E changed gloves then removed the brief tabs and proceeded to spray peri-wash over the resident's periarea. Staff E took disposable wipes and cleansed the periarea. Staff rolled the resident onto her right side. Staff F, agency CNA, wiped the resident's left buttock in a downward manner from the upper buttock toward the leg. Staff F touched and opened the drawers on a bedside table, then opened a cabinet door and obtained a clean brief. Staff F then changed her gloves and sanitized her hands. Staff F rolled the resident onto her left side. Staff E removed the soiled brief and sling, then took disposable wipes and cleansed the resident's lower back and buttocks. A large amount of liquid stool was present. Staff E continued to cleanse the resident's buttocks with disposable wipes. Staff E placed the soiled linens into a plastic bag, then placed the bag of soiled linens on top of a trashcan. Staff rolled the resident onto her right side then onto her back and attached the tabs on the brief. Staff F removed gloves and sanitized his hands. At 12:08 PM Staff E bagged up the trash and wheeled the mechanical lift to the common area by the nurse's station. 3.The MDS assessment dated [DATE] revealed Resident #1 had diagnoses of dementia, a fractured right lower leg and morbid obesity. The MDS recorded the resident had incontinence. The Care Plan revised 8/21/25 revealed the resident had incontinence and required assistance of two staff for toileting. During observation on 9/8/25 at 2:18 PM, Staff E, CNA, removed Resident #1's brief and sprayed cleansing foam onto the resident's abdominal fold and periarea. Staff E provided pericare, then rolled the resident onto her left side. Staff E removed the sling and soiled brief under the resident. Staff E took the bottle of foam cleanser and sprayed the cleanser to the resident's buttocks area. Staff E took disposable wipes and cleansed the buttocks area. Staff G, CNA, rolled the resident, placed a clean brief on the resident then removed her gloves. Staff E did not change gloves or sanitize hands during cares. In an interview 9/10/25 at 10:45 AM, the Regional Nurse reported she expected staff to change gloves whenever the gloves were dirty. In an interview 9/10/25 at 3:40 PM, with the Infection Preventionist (IP), the Regional Nurse sat in the room as the surveyor interviewed the IP and stated she was present to observe. The IP reported gloves needed to be changed in-between contact with residents, whenever staff did a check and change, and during cares. The IP stated gloves needed changed especially if the gloves were soiled. She expected staff to sanitize their hands every time gloves were taken off and staff could use hand sanitizer up to 3-5 times then hands needed to be washed. The IP reported staff should disinfect equipment in-between each use. In an interview 9/11/25 at 11:40 AM, the Director of Nursing reported she expected gloves changed if soiled or in-between going from a dirty to clean area or task. The facility's Infection Control Policies and Practices revised 7/2014 revealed the infection control policies were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. A Standard Precautions policy revised 9/2022 revealed standard precautions presume that all blood, body fluids and excretions may contain transmissible infectious agents. Hand hygiene performed with alcohol-based hand rub or soap and water before and after contact with a resident, before moving from work on a soiled body site to a clean body site on the same resident, and after removing gloves. Gloves changed as necessary during the care of a resident to prevent cross-contamination from one body site to another such as when moving from a dirty site to a clean site. Resident care equipment are handled in a manner to prevent transfer of microorganisms to other residents and the environment.

Based on observation, resident and staff interviews, manufacturer instructions, and policy review the facility failed to lock brakes on a bed when staff repositioned and provided cares for 1 of 3 residents observed (Resident #12), and failed to operate a mechanical lift safely for 2 of 3 residents observed for transfers (Resident #12 and #1). The facility reported a census 59 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had diagnoses of left above the knee amputation, fracture, muscle weakness, morbid obesity, and anxiety disorder. The MDS recorded the resident had no falls since re-entry to the facility on 3/14/25. The MDS documented the resident had dependence on staff for transfers. The Care Plan revised 1/24/25 revealed the resident had a risk for injury related to falls. The Care Plan revealed staff directives to use a mechanical lift and two staff for transfers. The care plan documented the resident had a fall out of bed 12/30/24 and diagnosed with a left distal fracture. The resident verbalizes she thought she was too close to the edge of her mattress when she repositioned. On 9/8/25 at 11:42 AM, the Regional Nurse reported to surveyor she would be observing staff when the surveyor was in the room. During observation on 9/8/25 at 11:45 AM, Staff E, certified nursing assistant (CNA), used a mechanical lift to lift Resident #12 from a wheelchair. Staff E and Staff F, agency CNA, transferred the resident from the wheelchair and lowered the resident into bed. As Staff E and Staff F provided incontinence care for the resident, the bed kept moving. The surveyor observed the brakes on the bed were not locked. Resident #12 voiced concern she was going to fall. Staff F reassured the resident she had her and she would not let her fall. The resident's right leg and left stump were near the edge of the bed. The Regional Nurse, who was observing staff in the room at the time, walked over and stood in front of the resident lying in the bed. Staff E continued to cleanse the resident's buttocks with disposable wipes. At 12:01 PM, Staff E attempted to lock the bed. Staff E and Staff F continued to roll the resident back and forth on the bed to get her pants on. In an interview 9/10/25 at 10:45 AM, the Regional Nurse reported on the day she observed staff perform cares on Resident #12, she went and stood by the bedside in front of the resident because she was scared for her. The resident was so close to the edge of the bed and she did not want her to fall. The Regional Nurse confirmed the brakes were not on the bed and there were a number of things that didn't go well while she observed staff provide cares for Resident #12. She spoke with the management team afterward and told them they needed to do something different. They ended up getting Resident #12 a bari (bariatric) (large) bed and moved the resident to another room. The Regional Nurse reported she expected staff to lock the brakes on the bed whenever a resident in bed. In an interview on 9/10/25 at 11:55 AM, Resident #12 reported she got a bigger bed and staff moved her to a different room this week. The resident confirmed she sometimes felt like she was going to fall out of bed when staff performed cares on her but she felt safe since she got the new bed.2.The MDS assessment dated [DATE] revealed Resident #1 had diagnoses of dementia, a fractured right lower leg, and morbid obesity. The MDS indicated the resident had dependence on staff for transfers. The Care Plan revised on 8/21/25 revealed the resident had a self-care deficit in ADL's (activities of daily living) related to a fractured right lower leg (ankle). The Care Plan directed staff to use a mechanical lift and assistance of two staff for transfers. During observation on 9/8/25 at 2:18 PM, Staff E, CNA, and Staff G, CNA, attached a sling under Resident #1 to a mechanical lift as the resident sat in a wheelchair. Staff E took the remote for the lift and raised the resident up in the mechanical lift. The sling strap was looped around the armrest of the wheelchair. Staff E, CNA, stopped raising the resident in the lift, adjusted the strap, then continued to raise the resident up from the wheelchair. The mechanical lift leg bar remained together as the resident was raised up and transferred toward the bed. As Staff E pushed the mechanical lift under the bed, the lift hit the cords under the bed. Staff E instructed Staff F, CNA, to pull the cords back. Staff E pushed the lift under bed and lowered the resident into bed. In an interview on 9/10/25 at 10:45 AM, the Regional Nurse reported the spread bar needed to be out whenever a resident transferred in a mechanical lift from one surface to another. The Regional Nurse reported they were going to do survey preparation but had not done any kind of competency audits such as transfers with the staff. In an interview 9/11/25 at 11:40 AM, the Director of Nursing (DON) reported their policy did not have information on whether the bars on the mechanical lift should be in or out when a resident transferred in a mechanical lift. The DON reported she thought it depended on where the lift was used and where the resident was being transferred to. The resident rooms were small and the mechanical lift needed to fit in the space that the staff were going. The DON reported she expected staff to follow the manufacturer instructions for use of the mechanical lift. On 9/11/25 at 4:20 PM during exit conference, the [NAME] President of Operations reported the mechanical lifts they have at the facility did not require the legs to be out when transferred a resident, the spreader bar should be opened to get around furniture or a wheelchair. A Safe Lifting and Movement of Residents policy revised 7/2017 revealed staff responsible for direct resident care would be trained in the safe and proper use of mechanical lifting devices. An undated Resident Lift/Transfer Safety Observation Form revealed wheelchair/bed locked prior to transfer. The Form lacked the steps for using a mechanical liftThe Protekt(R) 600 Lift Operation Manual revealed the lift allowed a person to be lifted and transferred safely with minimum physical effort provided by the caregiver. During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. Do not roll casters over any object while the resident is in the sling.The Hoyer HPL500 revealed the lift used for safe lifting and transfer of an individual from one resting surface to another such as a bed to a wheelchair. The lift leg bar can be opened to enable access around armchairs, wheelchairs and other furniture. For transferring and negotiating narrow doorways and passages, the lift legs should be in the closed position.The Linak Medline-Careline Lift User Manual revealed do not open the closing device on the twindrive during operation. Assure free space for movement of the application in both directions to avoid a blockade.

Based on observations, staff interviews, and policy review, the facility failed to ensure a homelike environment and reduce clutter in the hallway for 2 or 2 units (North and South Halls). The facility reported a census of 49 residents. Findings include: Observations revealed the following: a. On 11/19/24 at 10:45 AM, the North hall had equipment parked in the hallway by the handrails including a mechanical lift, a shower chair, a stand mechanical lift, a plastic bin with drawers containing Personal Protective Equipment (PPE), carts for trash and soiled laundry, two medication carts, a treatment cart, and a wheelchair. At the same time, the North/Central hall had equipment parked along the hallway and handrails including a mechanical lift, a stand mechanical lift, and a large motorized wheelchair. At 10:55 AM, the staff on the North hall had to move to the side of the hallway in order to allow a male resident to propel his wheelchair down the hall to his room. At 12:45 PM, a wheelchair sat by the exit door in the North hall. The North hall had a stand mechanical lift, a plastic bin with drawers with PPE inside, trash cart and soiled laundry carts, two medication carts, and a treatment cart parked along the hallway and handrails. The North/Central hall had a wheeled cart with a cooler on it, a mechanical lift, a medication cart, a cart with food trays, a stand mechanical lift, and a large motorized wheelchair parked in the hallway by the handrail. At 12:55 PM, Resident #22 sat in a wheelchair and yelled I told you to quit following me. Resident #3 sat in a motorized wheelchair heading in the opposite direction of Resident #22 but unable to get through due to the equipment parked in the hallways. The Administrator approached the residents and requested Resident #22 to backup so Resident #3 could get his wheelchair through. At 4:30 PM, a large bariatric sized wheelchair and another wheelchair sat by the North hall exit door. Equipment continued to line the hallway including a mechanical lift, a stand mechanical lift, trash and soiled laundry carts, two medication carts, a treatment cart, and a plastic bin with PPE inside. b. On 11/20/24 at 7:46 AM, the North hall had a medication cart, a treatment cart, soiled laundry and trash carts, a stand mechanical lift, and a mechanical lift parked along the handrail. A large bariatric wheelchair and a wheelchair were parked by the North Hall exit door. The North/Central hall had a mechanical lift, a medication cart, and a wheelchair parked along the handrail. At 9:14 AM, Resident # 22 wheeled herself in a wheelchair down the North/Central hallway toward the nurse's station as Resident #7 propelled his wheelchair down the same hallway in the opposite direction toward Resident #22. Resident #7 and Resident #22 hollered at each other regarding the need to move out of the way. The residents were unable to get through the hallway due to the equipment parked along the hallway at the time. Staff M, Licensed Practical Nurse (LPN), approached the residents to break up the argument and provided directive to Resident #22 to move over so Resident #7 could get through. c. On 11/19/24 at 11:41 AM. the South Hall was cluttered with equipment including two mechanical lifts, a medication cart, and several wheelchairs. The surveyor had to wait for a resident to pass through the hallway before the surveyor could proceed to walk down the hallway. d. On 11/20/24 at 7:16 AM, the South hall was cluttered with equipment, including two mechanical lifts, a medication cart, and two wheelchairs. One of the mechanical lifts had the stability legs open. As the surveyor pushed a bedside table down the hall, the bedside table clipped the side of the lift causing the surveyor to trip over the open mechanical lift leg. e. Observation on 11/21/24 at 6:00 PM, Staff B, certified nursing assistant (CNA) quickly pushed Resident #22 in a wheelchair without foot pedals on from the dining room down the hallway 40 feet as the resident's feet quickly shuffled along the floor. During an interview on 11/26/24 at 10:15 AM, the Regional Corporate Nurse Consultant reported the facility didn't have a policy for transporting residents in a wheelchair. She expected staff to follow the standards of practice with using wheelchair pedals whenever staff pushed a resident in the wheelchair. During an interview on 11/26/24 at 12:45 PM, the Regional Director of Operations reported the facility did not have a policy for equipment storage. A Homelike Environment policy revised 2/2021 revealed residents are provided with a safe, clean, comfortable and homelike environment. The characteristics of a clean and orderly environment reflected a personalized, homelike setting.

Based on observations, resident and staff interviews, record review, facility policy and procedure, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing on residents with history of pressure ulcers for two of two residents reviewed (Resident #1 and #2). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. A Quarterly Minimum Data Set (MDS) completed for Resident #1 with an Assessment Reference Date (ARD) of 12/8/23, documented diagnosis for which included peripheral vascular disease, diabetes mellitus, non-Alzheimer dementia and depression. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated no impaired cognitive decisions and no impairments for hearing or the ability to be understood and understand others and does not resist cares. The resident required partial to substantial assistance from staff for dressing, toilet use and personal hygiene and dependent with transfers. The MDS also documented a wheelchair as prior mode of transportation. The MDS documented the resident with 1 stage 4 pressure ulcer and pressure reducing device for chair, bed and pressure ulcer/injury care and no turning or repositioning program. The Braden scale for predicting pressure sores, dated 2/13/24, failed to document a score. The mobility portion of the Braden scale documented that the resident is slightly limited, makes frequent though slight changes in body or extremity position. Friction and Shear, potential problem, moves feebly or requires minimum assistance. The Careplan with a focus area initiated 6/12/18, the resident has potential impairment to skin integrity related to immobility, incontinence, lymphedema, history of pressure ulcers and colostomy, wounds to bilateral feet and bilateral shins (9/22/23). Sees wound care consult, Stage 3 pressure wound to the left plantar foot (2/23/24). Interventions include: *Assist with repositioning throughout shift *(11/14/23) Currently has a stage 4 pressure wound to the right foot, plantar. Will be follow by wound care nurse weekly. Will follow treatment order as prescribe by provider. *(10/6/23) Deep pressure injury bilateral lower extremity lateral. Resident was ordered new foot rests for wheel chair d/t impaired skin integrity on his plantar. Revision on: 01/22/2024 *Occupational Therapy educated [NAME] on the importance of repositioning while sitting up in wheelchair. *Referral sent to wound physician. *(1/25/24) Unstageable Pressure Ulcer to Right Lateral foot *Off load heels *Wheel chair cushion *Follow facility procedures for treatment of injury. A Metro Geriatric Services dated and signed by the, Advanced Registered Nurse Practitioner (ARNP) 1/9/24, documented: A bed extender has been added to bed due to resident typically sliding down in bed. *Order and Requisitions: consult therapy to evaluate and treat as indicated for bed positioning; feet against foot board despite bed extender. A Metro Geriatric Services Encounter Note dated and signed by the ARNP on 1/26/24, A bed extender has been added to bed due to resident typically sliding down in bed. Therapy has been consulted to evaluate bed positioning, no update on consult yet. Discussed with nursing padding footboard edge. They will explore this idea. *Order and Requisitions: consult therapy to evaluate and treat as indicated for bed positioning; feet against footboard despite bed extender. A Metro Geriatric Services Encounter Note dated and signed by the ARNP on 2/2/24, A bed extender has been added due to resident typically sliding down in bed. Therapy has been consulted to evaluate bed positioning. A Metro Geriatric Services Encounter Note dated and signed by the ARNP on 2/9/24, A bed extender has been added to bed due to resident typically sliding down in bed. Therapy has been consulted to evaluate bed positioning, resident states that nobody has evaluated him yet. Nursing aware and will look into this. A Metro Geriatric Services Encounter Note dated and signed by the ARNP on 2/16/24, A bed extender has been added to bed due to resident typically sliding down in bed. Therapy ha been consulted to evaluate bed positioning, resident reports nobody has evaluated him. Nursing aware of recommendation to pad footboard edges due to resident sliding down in bed and resting feet on edges. The clinical record lacked documentation of the therapy consult being completed for bed positioning and feet against the footboard. The Progress notes dated 2/23/2024 at 1:10 p.m., documented: This nurse and wound care provider enter resident's room to follow up on wound care for resident current wounds. Resident advised this nurse and provider that they had new area to the left foot. Upon assessment of the left foot, wound care provider noted area to the left plantar. Area to be noted stage 3 pressure wound. Full skin assessment to the wound site, treatment put in place and TAR was updated. Weekly skin assessment completed. A Metro Geriatric Services Encounter Note dated and signed by the ARNP on 2/23/24, documented, resident reports he has new area to left foot that requires assessment today. There is gauze wrap to left foot. A bed extender has been added to bed due to resident typically sliding down in bed. Dressing to foot dated 2/21/24. Location: left foot plantar, etiology=pressure ulcer, Stage 3 Measurement= 4.2 centimeters (cm) by 2.7 cm by 0.1 cm Wound status= new tissue 50% deep tissue injury, 15 % red granulation. Observation on 2/27/24 at 9:00 a.m., resident lying in bed watching television, resident with foot board on his bed, no padding along the edges of the foot board. Resident with bilateral heels on the top of the footboard. Observation on 2/28/24 at 9:00 a.m., Staff J, Registered Nurse (RN), and facility interim director of nursing, and this surveyor walked into residents room to do treatment and dressing to resident open areas on plantar of feet. foot board off end of bed. resident with no heel protectors, dressing to the plantar portion of both feet. An open area was noted on residents left heel. Resident winced when dressing was placed on the left heel. Interview on 2/28/24 at 9:22 a.m., Staff J, confirmed and verified that the residents foot board was just removed from the end of the bed and that there was no dressing to the left heel open area. Interview on 2/28/24 at 9:42 a.m., resident stated that the treatment to the bottom of his right foot was not completed last week for 4 days and that the foot board was just removed today, and that the resident does slide down in bed and that the plantar (ball) of foot does hit the foot board when he slides down. The Progress note dated 2/28/2024 at 7:00 a.m., documented: This nurse went to residents room to put his sweatshirt in his closet. While in the room, it was noted that the foam border to top of footboard for pressure prevention had slipped up partially. This nurse asked resident if I could fix it for him while in his room. Resident stated, yeah, that's fine, I think they were removing that today anyway. This nurse asked resident if it was okay with him if it was removed now. Resident agreeable. Footboard removed and placed in N13 for storage. Fax sent to PCP to update. The Progress notes dated 2/28/2024 at 11:54 a.m., documented: Completed treatment to left heel, left plantar/right plantar foot, no drainage or door noted at this time, resident did have some pain when completing dressing to left heel. The Progress notes dated 2/28/2024 at 5:01 p.m., documented: This nurse was notified by the north charge nurse that resident has new area to the left heel. This nurse went into the resident room and asked resident if it is ok to do skin assessment. This nurse got verbalized ok for assessment. Full skin assessment with measurements lengthens 6.0 cm x width 7.2 cm x depth 0.1 cm to the wounds, no noted drainage, area around site blanchable, wound bed tissue noted red granulated tissues, call placed to Doctor and got verbalized orders for treatment to wound, Resident is aware of this new order. Resident will be followed by wound care weekly. A Metro Geriatric Services Encounter Note dated and signed by the ARNP on 3/1/24 documented, resident is currently on Bactrim, DS for infection to lower leg extremity foot wound, wound culture pending. An arterial study has been ordered, awaiting portable x-ray for testing. Location: left foot plantar, etiology=pressure ulcer, Stage 3 Measurement= 5.2 cm by 5.4 cm by 0.2 cm Wound status=20% slough, 10% red granulation, 30% epithelial, 40% serous blister. Location left heel, etiology; pressure ulcer, Stage 2 Measurements= 5.5 cm by 6.9 cm by 0.1 Wound status= 45% epithelial flap, 15% dark epitheal, 40% partial thickness A New Skin Alteration Evaluation dated 2/28/24 at 4:24 p.m., documented: Shearing on left heel, for which measures width 7.5 cm by 6.0 cm by 0.1 cm. 2. A Quarterly MDS completed for Resident #2 with an ARD of 1/30/24, documented diagnosis for which included non-Alzheimer dementia, Parkinson disease, multiple sclerosis, malnutrition and abnormal posture. The MDS documented the resident had a BIMS score of 9 which indicated moderately impaired cognitive decisions and minimum difficulty for hearing and usually is able to be understood and understand others and does not resist cares. The resident required dependence with all activities of daily living. The MDS also documented a wheelchair as prior mode of transportation. The MDS documented the resident with 1 stage 2 pressure ulcer, 2 Stage 3 pressure ulcers and pressure reducing device for chair, bed and pressure ulcer/injury care and no turning or repositioning program. The Braden scale for predicting pressure sores, dated 1/30/24, failed to document a score. The moisture portion of the Braden scale documented that the resident is very moist, skin is often but not always moist. Linen must be changed at least once a shift. The mobility portion of the Braden scale documented that the resident is very limited, makes occasional slight changes in body or extremity position but unable to make frequent or significant changes. Friction and Shear, problem, requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible The Plan of Care with an initiated dated 11/19/20, stated the resident has potential impairment to skin integrity. Interventions include: *02/09/24: Trauma to the lumbar spine: will be followed by the Wound care Doctor weekly, will follow all treatment orders as prescribed. *10/16/23 Stage 3 pressure wound to the Sacrum, Apply tx per physician orders *10/21/23: Unstageable pressure wound to the right heel. Area is dark purple and Non-blanchable, Apply tx per physician orders, pressure reliving boots. *RESOLVED: 12/29/23: Stage 2 pressure ulcer wound to the thoracic back, monitor weekly, followed Wound care, follow any treatment orders as prescribed. *2/23/2024: Unstageable pressure wound to right lateral foot. Wound care rounds with doctor weekly until healed *Assist in repositioning frequently as resident allows. *Check and change frequently, keep skin clean and dry as able. *Currently has stage 3 pressure wound to the sacrum, will be followed by wound care nurse weekly, will follow current treatment order by MD or ARNP. *Heel suspension/protection device applied while in bed as resident allows. *Moisture barrier to be applied as needed as resident allows *Pressure reducing mattress *Roho cushion to w/c *CANCELED: Utilize duoderm to mid spine for prophylaxis *Use a draw sheet or lifting device to move resident. The Progress notes dated 2/9/24 at 2:58 p.m., documented resident was seen by doctor, new area to the lumbar spine noted trauma, area is blanachable. Weekly skin assessment completed. The Metro Geriatric Services Encounter Note signed and dated on 2/9/24 by the ARNP, documented that the resident requires Hoyer for transfers, does require staff assistance with bed mobility. Location=lumbar spine, etiology: trauma Measurement= 0.8 cm by 0.5 cm by 0.1 cm. Wound tissue= new tissue, 100% red granulation. Observation on 2/28/24 at 12:10 p.m., resident was sitting up in a broda chair in the main dining room, no cushion behind the resident back, Hoyer lift sling under [NAME] the resident while in the broda chair. Observation on 2/29/24 at 12:45 p.m., resident sitting in broda chair in room feet on foot plate, Hoyer sling behind resident and no cushion behind resident back. Observation 3/5/24 at 12:35 p.m., resident sitting in the broda chair with a Hoyer sling behind her back, no pressure reduction cushion to the back of the broda chair. Interview on 3/12/24 at 9:00 a.m., the facility Interim Director of Nursing, came in and explained that the facility failed to look into another pressure cushion device for the broda chair, and that the broda chair came with the cushion and that the facility had no other interventions prior to the open area.

Based on facility record review, resident and staff interview, and review of facility fall protocol the facility failed to ensure residents call lights and needs were answered/met in a timely manner for 3 of 19 residents, (Resident #15, #32, and #41). The facility failed to answer a call light timely to prevent Resident #15 from assisting herself in her wheelchair and the wheelchair getting stuck resulting in the resident falling out of the wheelchair and fracturing her left distal (far end of) femur. The facility reported a census of 55. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #15 reported a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. The resident was able to make herself understood and understood others. The MDS coded she required total assistance with 2 staff for transfers, supervision of 1 staff for locomotion on the unit and supervision with set up help for eating. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's Care Plan revised 4/6/18 identified her at risk for limitations in ability to perform Activities of Daily Living (ADL's) and directed staff to allow time to complete tasks and to assist with reposition throughout shift. The Care Plan also identified resident at risk for falls and directed staff to anticipate and meet her needs, follow facility fall protocol and place the call light within reach and encourage the resident to use if tor assistance as needed. The facilities document titled Fall- Clinical Protocol revised 3/18 included the following; In addition, the nurse shall assess and document/report the following. a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for changes in normal range of motion, weight bearing, etc. d. Change in cognition of level of consciousness. e. Neurological status. f. Pain. g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how fall occurred. i. All current medication especially those associate with dizziness or lethargy and j. All active diagnoses. A facility document dated 1/9/21 tiled Un-witnessed for Resident #15 included a Nursing Description, called to Resident #15's room by Certified Nursing Aide (CNA). Upon arrival resident was lying on floor next to bed by window on her back with head laying against bed and feet laying toward bed by door. Resident complained of left knee pain. Resident verbalized tried to get food back close to her so she could eat after moving food to get to purse. Resident verbalized tried to move chair toward table and just fell out. Doctor notified at 1:46 PM. A Progress Note dated 1/9/21 at 1:46 PM documented by Assistant Director of Nursing (ADON) include the following; Called to Resident #15's room by CNA. Upon arrival resident lying on floor next to bed by window. Residents head lying against bed. Resident's feet lying toward bed by door. Lying on back. Wheelchair next to resident. Resident #15 had complaints of left knee pain 5 out of 10 and right knee noted with small sheared area 1 by 1 centimeter (cm). Resident verbalized tried to get food back close to her so she could eat after moving food to get to purse. Resident verbalized tried to move chair towards table and just fell out of wheelchair. Call placed to Dr. to notify of low blood pressure, fall and increased confusion. The Dr. verbalized wanted her monitored in facility and to call back if blood pressure doesn't self-correct or if the residents respiratory or cardiac status declines. No other complaints. Responsible party aware. Resident denies hitting head, but neurological status initiated for unwitnessed fall. Untitled document provided for call data on 1/9/21 for Resident #15's room included the following; 1/9/21 at 12:31 PM response 7:31 minutes. 1/9/21 at 12:56 PM response 5:03 minutes. 1/9/21 at 1:13 PM response 22:54 minutes. The Computed Radiography (CR) (a digital radiographic that records radiographic images on photostimulable phosphor plates instead of film image receptors) Report dated 1/9/21 at 6:31 PM reason for exam, injury. Clinical indication: left knee twisting injury. Impression: Lipohemarthosis and apparent cortical offset of the tibial plateau, concerning for intra-articular fracture. Further characterization with cross-sectional imagine may be indicated, given limitation of examination due to the degree of osteopenia and varus angulation of knee. The Computed Tomography (CT) (a radiographic technique that produces an image of detailed cross section of tissue) Report dated 1/9/21 at 7:11 PM included clinical indication suspected fracture on radiograph. Impression included comminuted (fracture with more than two pieces may have significant associated soft tissue trauma, direct crushing injury or force to tissues and bone), intra-articular fracture of distal femur. Resident #15's Census listed discharge on 1/9/21 and readmitted on [DATE]. During interview on 7/22/21 at 8:59 AM Resident #15 stated staff brought in her food and she could not reach it so she put on her call light and no one came so she tried to move and thinks her call light and or oxygen tubing got caught up in the wheel of her wheelchair. Resident could not move and fell and broke her knee. Resident #15 explained she yelled out and then someone came. During interview on 7/22/21 at 12:00 PM the ADON acknowledged Resident #15 was sitting in wheelchair and leaned forward to reach her tray table and could not reach it. The aide stated to her the table was in front of her when they left the room she had pushed it away to get something and then could not reach it and fell . The ADON stated she did not remember if the call light was on or not. During interview on 7/22/21 at 4:02 PM the Regional Nurse Consultant acknowledged they do not have a call light policy but do have a fall protocol and provided document titled Fall- Clinical Protocol revised 3/18. During interview on 7/22/21 at 4:04 PM the Administrator she explained she would expect regular call lights to be answered within 15 minutes and if a bathroom call light she would expect them to be answered in 5 min. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15. A score of 14 indicated no cognitive impairment. The MDS revealed the resident required one person assistance from staff for personal hygiene, transfer, and toilet use. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan initiated 6/10/19 encouraged the resident to use bell to call for assistance. In an interview on 7/19/21 at 1:20 p.m. Resident #32 stated call light is not answered promptly. Resident stated she turned on her call light at 6:10 a.m. and it was answered by staff at 6:50 a.m. Resident #32 stated she watched the clock in her room. In an interview on 7/21/21 at 10:00 a.m. Resident #32 stated that her call light took over 45 minutes to be answered on 7/20/21 in the morning. Record review on 7/21/21 at 12:30 p.m. a facility provided form titled Vision Link Call Data revealed on 7/19/21 at 6:04 a.m. for room North 6 (Res #32) call light response was 85 minutes and 15 seconds. Document revealed on 7/20/21 at 6:05 a.m. call response time was 50 minutes and 14 seconds. In an interview on 7/21/21 at 1:21 p.m. the Facility Administrator stated she expected call lights to be answered within 10 minutes. 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #41 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderate cognitive impairment. The MDS indicated Resident #14 needed extensive assistance for bathing, personal hygiene and transferring. The Care Plan initiated 3/02/20 encouraged the resident to use bell to call for assistance. During the group interview on 7/20/21 at 2:10 p.m. Resident #41 stated in the morning his call light takes 20-30 minutes to be answered. Resident #41 stated that he pushed his call light on at 6:30 a.m. this morning and received help from the staff at 7:05 a.m Resident #41 stated he had a clock on the wall and he watched the time. Record review on 7/22/at 11:30 a.m. of a facility provided form titled Vision Link Call Data revealed on 7/20/21 at 6:34 a.m. for room North 10 (Res #41) call light response was 36 minutes and 32 seconds. During an interview on 7/22/21 at 11:52 a.m. the Facility Administrator revealed the facility does not have a policy on call light response time.

Based on observation, record review, and staff interviews, the facility failed to ensure Resident #5 maintained acceptable parameters of nutritional status and failed to provide the nutritional supplements as recommended to the resident in order to prevent a significant weight loss. The sample consisted of 4 residents and the facility reported a census of 61 residents. Findings include: 1. The physician History & Physical document dated 3/18/17, identified Resident #5 had [DIAGNOSES REDACTED].#5. The Minimum Data Set (MDS) assessment with a reference date of 9/15/17 indicated the resident had a Brief Interview of Mental Status (BIMS) score of 6. A score of 6 identified the resident with a severe cognitive impairment. The MDS indicated the resident required set-up and supervision for eating and had no significant weight loss of 5% or more in 1 month or 10% for more in 6 months. The Care Plan identified a problem dated 9/12/17 that the resident at risk for weight loss related to the [DIAGNOSES REDACTED]. The Care Plan approach indicated the resident able to feed herself but may require assistance at times and preferred to eat meals in the Restorative Dining Room. The Care Plan goal plan identified the resident would consume 50-75% for 2 of 3 meals each day and maintain a healthy weight. The form titled Quarterly Nutritional Progress Note, signed by the consulting dietician dated 9/14/17, identified the resident with a significant weight loss of 5.4% in 30 days and 7.9% in 90 days. The note indicated the dietician questioned the accuracy of the admission weight. The dietician recommended the resident weighed weekly for monitoring purposes. The MDS dated [DATE] failed to contain this information. The documentation completed by the consulting dietician dated 10/12/17, indicated the resident refused breakfast and lunch on this day. The dietician recommended the resident receive 60 milliliters (ml) of 2 Cal supplement 3 times daily (TID) due to meal refusal and overall downward weight trend. Documentation completed by the consulting dietician on 11/9/17 documented the resident had a significant weight loss of 5.8% in 30 days and 12.2% in 90 days and 18.8% in 180 days. The note further documented the resident currently being seen by the speech therapist and the resident requires direct feeding assistance most of the time. The dietician recommended increasing the 2 Cal supplement to 60 ml four times a day (QID) and Ensure supplement offered when meals are refused. The ST (speech therapy)-Therapist Progress & Discharge Summary dated 11/29/17 indicated the resident treated by the therapist 11/1-11/29/17 for oral phase dysphagia (difficulty swallowing). The summary documented the resident requires assistance with feeding due to difficulty following commands and noted poor hand-motor coordination with decreased visual and depth perception and the resident would remain seated at the assisted dining table for meals. Continuous observation of the resident in the dining room beginning at 11:40 AM identified the following: At 11:40 AM-resident seated in wheelchair at table with 2 other residents. At 11:43 AM-dietary aide pours resident beverages into 2-handled cups in front of the resident. At 12:01 PM-resident food served. Staff did not unwrap (open) the resident's silverware or open the package that contained a dinner roll and prepare it for the resident. At 12:10 PM-resident has not initiated feeding self; remained seated in the wheelchair with eyes closed and leaning slightly to the right. Staff A, certified nursing assistant (CNA) sat at the resident's table to visit with another resident. Staff A observed Resident #5 but did not attempt to assist her. At 12:17 PM-Staff A sat on the resident's left side and handed the resident a spoon and then left the table. At 12:23 PM-observer requested Staff A taste the resident mashed potatoes/gravy and ground turkey with 2 separate disposable spoons. When asked if the food items were palatably hot, Staff A replied not at all. Staff A did not reheat the resident's food or ask the resident about an alternate meal selection. At 12:25 PM-Staff B, CNA, sat down on the resident's left side and offered the resident a bite of mashed potatoes and gravy. Staff B cued the resident to take a bite but the resident refused. At 12:31 PM-Staff B transported the resident out of the dining room. On 12/5/17 at 8:15 AM, Staff C, CNA/restorative aide, was interviewed and stated Resident #5 needs fed by staff as over the last couple of months the resident had a decline and sometimes pockets food in her mouth but often refuses meals and/or assistance. On 12/5/17 at 9:20 AM, Staff B, CNA, was interviewed and stated the resident needs to be fed by staff. Staff B stated the resident has really declined over the last 2 months. Staff B stated the resident often refuses meals and/or lets food run out the sides of her mouth. Review of the meal consumption record for Resident #5 dated 11/16/17 through breakfast 12/5/17, identified the resident refused 33 of 84 meals served. Review of the Medication Administration Record [REDACTED]. On 1/29/18 at 2:27 PM the resident's physician was interviewed and stated she was aware of the resident's significant weight loss and felt it is unavoidable due to the resident's [DIAGNOSES REDACTED]. The physician stated being aware the resident often refused meals and/or eating assistance but would expect staff to attempt to assist the resident with eating and would also expect staff provide the resident assistance with drinking a can of Ensure if refuses meals as ordered.

Based on observation, record review and staff interviews, the facility failed to prevent, identify and promote healing of pressure ulcers for 1 of 13 residents reviewed (Resident #8). The facility identified a census of 62 residents. Resident #8 was admitted into the facility without pressure ulcers, although at risk for pressure ulcers. The facility did not implement measures to prevent the development of pressure ulcers or adequately assess the skin to determine the development of pressure ulcers so wounds could be healed and prevent further skin deterioration. Findings include: 1. Resident #8 had a MDS (Minimum Data Set) assessment with a reference date of 2/11/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance by 2 plus staff for bed mobility, personal hygiene and toilet use. The resident did not transfer and depended on 2 plus staff for transferring. The resident had moderate cognitive impairment with a score of 12 and functional limitations with range of motion to both upper and lower extremities. The MDS identified the resident to be at risk for the development of pressure ulcers but did not have pressure reducing devices for the chair, bed or a turning/repositioning program. The Care Plan identified a problem area dated 2/21/16. The problem indicated the resident to be at risk for pressure ulcers related to immobility, diabetes, [MEDICAL CONDITION] (decreased nerve sensations in the extremities). The Care Plan directed staff to monitor skin daily with cares and with bathing and report any signs of skin breakdown. The Care Plan had an updated entry on 3/7/16. The update documented the resident had a Stage II pressure ulcer on the right buttock/gluteal area. The Care Plan lacked any other information related to the presence of pressure ulcers. The undated Initial Wound Evaluation for Resident #8 documented a DTI (deep tissue injury) on the left hip. The area measured 3 cm (centimeters) length by 2 cm width. The diagram picture of a body identified the area to be on the right buttock - a discrepancy from the words written on the lower half of the page. The Weekly Wound Progress Note dated 3/9/16 for Resident #8 documented a Stage II pressure area to the left buttock acquired in the facility. The area measured 3 cm length by 1.8 cm width by less than 0.1 cm depth. The weekly summary on the note documented the area noted to the left gluteal area as a fluid blister previously that opened. The clinical record lacked any other documentation of assessments for any new skin issues or updates to the above wound sheets. The facility failed to complete the monitoring of skin daily per the Care Plan. Observation on 3/23/16 at 8:25 a.m. identified Staff F, certified nurse aide (CNA), and Staff P, CNA, providing incontinence care for Resident #8 while she/he lay in bed. The CNA's rolled the resident to the right side and exposed 2 reddened pressure sore areas on the buttock. The left buttock near the top of the pelvis, towards the outer left hip, contained 1 area and the right buttock near the coccyx contained the other. Both pressure areas looked approximately the size of a 50 cent piece. The Director of Nursing was present during the observation and agreed on the size of the wound. On 3/23/16 at 9:00 a.m., the DON (Director of Nursing) stated she had audited the skin sheets the previous Friday. The DON reported she found the skin assessments were not always completed or signed with a date. On 3/24/16 at 10:15 a.m. with the Assistant Director of Nursing (ADON) and the DON, the ADON stated she was responsible for the weekly skin measurements. The ADON stated she was unaware Resident #8 had 2 pressure areas. The ADON commented the resident had only 1 skin sheet for the left hip that she was following. The ADON stated skin issues were assessed on skin sheets and no other documentation was available. The ADON could not recall the last time she had measured the pressure areas for Resident #8. The DON reported she expected weekly skin assessments and measurements to be completed. The DON commented she discovered the communication issue between the nurses and the ADON the previous Friday and instructed the ADON to begin auditing the skin issues.

Based on record review and family and staff interviews, the facility failed to provide adequate supervision to ensure against hazards when transferring a resident in a mechanical lift. The sling strap came loose and could not hold the resident in the sling. The resident hung from the sling and hit head on the floor. The ambulance transported the resident to the emergency room and determined [DIAGNOSES REDACTED].#9). The sample consisted of 4 residents and the facility reported a census of 62 residents. Findings include: 1. Resident #9 had a MDS (Minimum Data Set) assessment with a reference date of 1/21/16. The MDS indicated the resident had short and long term memory problems with severely impaired cognitive skills for daily decision making. The assessment identified the resident as dependent upon 2 staff persons for transfers. The Care Plan dated 12/5/13 indicated a problem area with needing assistance with activities of daily living due to the disease process of Alzheimer ' s and multiple co-morbidities. The approach directed the staff to transfer the resident with a Hoyer (mechanical) lift and 2 staff persons assisting with the transfer. The Incident Report Form dated 2/27/16 at 8:00 a.m. documented Resident #9 had a transfer related to a fall. The report noted the CNA's (certified nurse aides) transferring the resident via Hoyer lift stated the Hoyer came undone on the top of sling allowing the resident's head to fall to the floor, striking head. The report documented the buttocks and legs were in the air. The report documented the CNA's stated they assisted the resident's upper body up into the bed and called for help. The report documented an approximate half dollar sized goose egg, raised area, noted to the back of the head and a dark purple ecchymotic area (bruise) to the left dorsal (back of) hand. The report recorded the witnesses as Staff Q, CNA, and Staff R, CNA. The nurse contacted the physician and received an order to send the resident to the hospital emergency room by ambulance for an evaluation. The emergency document titled After Visit Summary identified the [DIAGNOSES REDACTED]. The summary indicated the resident had CT (computerized testing) scan of the cervical spine and head or brain, both without contrast. The nurses performed neurological checks. The neurological assessment flow sheet identified the resident voiced complaints of headache pain after the fall and at 3:00 p.m. on 2/27/2016. The resident continued to have headaches on 2/29/16 during the 2 p.m.-10:00 p.m. shift and on 3/1/16 during the night hours and at noon. In an interview on 3/23/16 at 7:10 p.m., Resident #9's family member reported s/he had been told about the fall from a Hoyer lift 5 or 6 weeks ago. The family member commented she/he spoke with the Administrator who assured him/her that someone should have been at the end to catch the resident. The family member stated the Administrator said it would not happen again. In an interview on 3/24/16 at 8:30 a.m., Staff D, registered nurse (RN), stated she had been on duty the day Resident #9 fell from the Hoyer lift. Staff D relayed she got called to Resident #9's room where she found Staff Q and Staff R. Staff D stated Staff Q and Staff R had the Hoyer sling completely disconnected, the resident positioned in the bed, and ice applied to his/her head. Staff D said Staff Q and Staff R reported to her the bottom of the sling had still been attached but 1 of the sides of the sling came undone. Staff D said she educated the CNA's they should never touch a resident before getting the nurse; although she understood the resident's bottom had been in the air. Staff D reported she did document in the nurse's notes and completed 72 hour follow up after the fall. Staff D stated she thought the nurse's notes that covered the time period of the fall were missing because the paper punch holes were ripped and the paper must have fallen out. In an interview on 3/24/16 at 9:08 a.m., Staff Q stated she worked the day Resident #9 fell from the Hoyer lift. Staff Q claimed she was called into the resident's room by Staff R to spot him with the Hoyer transfer. Staff Q reported she did not hook up or handle the machine. Staff Q said she stood behind the resident's wheelchair as Staff R lifted the resident up. Staff Q recalled the left strap came undone then the right. Staff Q stated she tried to get around from behind the wheelchair to grab the resident, but it was too late and the resident fell . Staff Q also reported she attempted to get the wheelchair out of the way by moving it to keep the resident from falling but then the 2nd strap came undone. Staff Q said the resident went backward as if in the motion of a backflip and the resident's head touched the floor briefly leaving a knot in the middle of the back of the head. Staff Q stated Staff R lowered the Hoyer down and put the resident on the bed, and then he went to get the nurse. Staff Q reported that she did not touch the resident to guide at any time during the transfer until the straps came undone. Staff Q stated the Hoyer sling was detached before the nurse came into the room. In an interview on 3/24/16 at 11:49 a.m., Staff R (certified nursing assistant) claimed he entered Resident #9's room per request of Staff Q to assist. Staff R reported the resident was hooked up to the Hoyer lift but remained in bed. Staff R recalled he positioned himself behind the wheelchair and Staff Q guided the controls. Staff R stated the top left strap popped out and the resident went backwards with the head brushing the ground. Staff R stated they stopped with the resident hanging about wheelchair height. Staff R reported he grabbed the resident's shoulders, lifted the resident, re-hooked the straps, put the resident back into the bed, then left to get the nurse. Staff R stated the resident's head did not hit hard but there was a knot where the head hit the floor. Staff R reported he thought the straps were connected to begin with but if not double checking the loop they do not go all the way down. The facility investigation determined the questionable conclusion was if the straps were securely under the black disc. The Administrator had the lift placed in the basement and maintenance determined the black disk tight and no problem. The report indicated the Administrator planned to educate the staff about proper Hoyer transfers and placement of the sling straps. On 3/23/16 at 7:05 p.m. the maintenance person was interviewed and stated the facility had 3 mechanical lifts and he checks the lifts 3 times a month. An out of service tag identified the lift used by Resident #9 to be out of service (2/27/16). On 2/29/16 the tag directed the maintenance department to check the button and indicated it not working. On 2/29/16 the button was checked and no problem. The facility returned the lift into service on 3/2/16.

Based on observation, clinical record review and staff and resident interviews, the facility failed to provide interventions in order to prevent pressure ulcer development and promote healing of pressure ulcers (Resident #1). The facility reported a census of 57. The sample consisted of 1 resident. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 11/2/13 which identified [DIAGNOSES REDACTED]. The MDS documented the resident scored a 15 on the Brief Interview for Mental Status (BIMS). A score of 15 reflected the resident had no cognitive problems. The MDS documented the resident required extensive assistance of two staff members for bed mobility. The Care Plan dated 11/14/12 identified a problem with the resident at risk for skin breakdown due to impaired mobility and a history of spinal stenosis (narrowing of the spine). The Care Plan directed the staff with the following approaches: a. Assess resident for presence of risk factors. b. Treat, reduce, eliminate risk factors to extent possible. c. Keep clean and dry as possible. d. Minimize skin exposure to moisture. e. Keep linen clean dry, and wrinkle free. f. Conduct a systematic skin inspection weekly by nurse, twice a week with showers, and daily as needed with personal cares. g. Pressure reducing mattress to bed and special cushion to wheel chair. h. Diabetic shoes on when up in wheel chair as resident tolerates and allows. i. Avoid shearing resident ' s skin during positioning, transferring and turning. j. Encourage physical activity, mobility and range of motion to maximal potential. k. Provide incontinence care after each incontinent episode. l. Report any signs of skin breakdown (sore, tender red or broken areas) A Weekly Wound Progress Note dated 1/8/14, reflected the resident had been to the Wound Healing center and the physician had evaluated areas and reinforced all education for the resident to change position frequently, only up to wheel chair for meals, no extra linens between resident and the mattress other than necessary to maintain proper positioning. A Weekly Wound Progress note dated 2/17/14, documented an area on the residents right buttock had been resolved at that time. The form documented an area on the resident ' s left upper buttock had been a stage 2and acquired at unity point health services. The wound measured 0.5 centimeters (cm) x 0.5 cm with no depth and had been dry. Observation on 2/25/14, revealed the following: a. At 8:45 a.m., the resident laid in bed on his/her back. b. At 9:15 a.m., the resident laid in bed on his/her back. d. At 9:43 a.m., the resident laid in bed on his/her back. e. At 10:20 a.m., the resident laid in bed on his/her back. f. At 11:45 a.m., the resident laid in bed on his/her back. At that time the resident told the surveyor no one had been in his/her room to reposition him/her since 6:30 a.m. that morning. The resident stated they had a sore on his/her bottom. h. At 12:30 p.m., the resident laid in bed on his/her back. i. At 1:15 p.m., the resident laid in bed on his/her back. j. At 2:10 p.m., the resident laid in bed on his/her back. An activity of living detailed report dated 2/25/14 at 1:50 p.m., documented Staff R (Certified Nurse Aide, CNA) assisted the resident with bed mobility, with one person physical assist. At 3:15 p.m., Staff J (Registered Nurse) completed a treatment to a pressure sore on the resident ' s bottom. Staff J measured the area on the resident ' s left inner buttock to be 4.5 centimeters (cm) by 1.0 cm. The resident also had a superficial area on the inner right buttock to be 3.2 cm by 0.8 cm. Staff J verified the area on the right buttock had been a superficial open area. Upon completion of the treatment, the resident requested to be tipped to his/her side with pillows. Staff Q (Registered Nurse) stated the resident had no pillows in the room to position the resident on their side, and went to get pillows. The resident laid on an alternating air mattress with a sheet, a large draw sheet and a soaker pad between the resident and the mattress. A weekly wound progress note for the above assessment included a note the resident had refused to change positions every two hours as needed and wanted to stay up in a chair, non-compliant with lying down. The staff educated the resident about the right buttock pink superficial area noted with a treatment. A Wound Clinic Note dated 2/26/14, documented two pressure ulcers as follows: a. The left buttock had a Stage II and measured 0.3 cm in length by 0.4 cm in width by 0.1 cm in depth. The wound had a small amount of serosangineous drainage. b. The right proximal buttock, Stage II. The wound measured 1.5 cm in length by1.8 cm in width by 0.1 cm in depth. The wound had a small amount of serosangineous drainage. A physician order [REDACTED]. The words position and sitting appeared to be written in larger letters. On 2/27/14 at 1:40 p.m., the Acting Director of Nursing was interviewed and stated the staff only documented on the care tracker at the end of the shift and did not document every time staff repositioned the resident. The Acting DON stated the resident had very specific requests about his/her cares, and refused things at time. At 3:10 p.m., the facility Acting Director of Nursing provided the surveyor with an edited resident profile dated 2/25/14, which documented the resident preferred to be checked and changed between 5:00-6:00 a.m., 11:00-12:00 p.m., 4:00-5:00 p.m. and 9:00-10:00 p.m. The form did not reflect that the resident did not wish to be repositioned.

Based on observation, record review, review of facility policy documents, review of training records and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment and failed to ensure and maintain equipment for personal care is in a safe working condition (Resident #5). The sample consisted of 1 resident. The facility reported a census of 57 residents. Findings include: A resident admission record documented Resident #15 had an admission date of [DATE], with a [DIAGNOSES REDACTED]. A resident profile (no date) documented the resident transferred with a Hoyer lift, assistance of two (staff members) and a red sling. A facility incident report dated 2/1/14 at 11:30 a.m., documented the resident had an admitting [DIAGNOSES REDACTED]. The report documented the resident had fallen from a Hoyer (mechanical) lift and sustained a head injury, struck head on floor. A Medicare daily skilled nurse ' s note dated 2/1/14 at 11:30 a.m., reflected the nurse had been called to the resident ' s room by a therapist and CNA (Certified Nursing Assistant) in hall (way) and informed on way that resident fell from a Hoyer lift sling to the floor. The resident was noted lying on back on floor with feet and legs between the Hoyer lift legs. Upon entering the room, the resident ' s head was toward the TV/window and the resident ' s feet toward the bathroom/door of room. The Hoyer lift with legs faced toward the TV/window. The resident had his/her eyes open, had struck head on floor, and had no verbal response initially. The resident ' s blood pressure registered 162/84, pulse 76 (normal 60-100), respirations 20 (normal 16-20), temperature 100.5 (normal 98.6), oxygen saturation (normal 96-100%), 91%, 89% and down to 88%. Staff initiated oxygen therapy at 2 liters per minute via nasal cannula and the oxygen saturation raised to 93%. The North nurse called 911 as requested and the physician on call paged (11:45 a.m.) and informed. An order was received to send the resident to the emergency room . A smear of blood was noted on the resident ' s neck line of hoodie and on hair. In keeping resident as immobile as able, staff applied a Snap ice pack to the resident ' s head with washcloth covering the pack. Resident became verbal after 3-5 minutes. The resident ' s pupils initially 6 millimeters (mm) and had no response to light with change. The resident answered the nurse yes verbally when asked if her/his neck and back. Resident #15 raised head slightly independently and staff lid an ice pack underneath head. Observation revealed no active bleeding noted. The staff member asked the resident to move extremities and did not comply. The resident coughed white phlegm and cleared airway. The staff performed oral care with a toothette (foam device) in order to ensure phlegm removed. At 11:45 a.m., the resident did not comply when asked to move tongue. The resident ' s blood pressure registered 160/82, pulse 72, respirations 20 and pupils measured 6 mm with no response to light. The resident answered questions verbally and answered yes when asked if she/he had a headache. An Ambulance arrived and performed a quick assessment, placed the resident on a split back board, applied a cervical collar to the resident ' s neck and transported the resident to the hospital. A patient information section of a transfer sheet dated 2/1/14, reflected 2 staff assisted the resident via a Hoyer lift, loop of lift pad came undone and the resident fell to the floor. A Medicare daily skilled nursing note at 3:00 p.m., documented the resident had been admitted to the hospital. A computerized tomography (CT) scan report dated 2/1/14, documented the impression included the following: a. a right subdural hematoma(collection of blood outside of the brain) b. a small right temporal subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain). c. bifrontal contusions (head injury). d. left posterior parietal extra cranial soft tissue swelling. The Acting Administrator was interviewed on 2/26/14 at 12:08 p.m., and stated since the incident, the facility had re-educated all staff about transfers. The staff had been trained after a previous incident as well. The Acting Administrator stated both staff present during the incident swore they had checked each other to make sure the sling had been secured properly. The lift had a spring loaded O-ring which sat where the sling hoop attached to the hook. They stated it had been worn and did not go back to the top as it should have. The manufacturer came to the facility and they re-enacted the incident and when weight had been in the sling the hook could not come undone. Even though the CNA stated the sling loop had been down on the hook, it may have come undone before the resident ' s weight held the loop in a down position. They did not think there had been any education check list for a Hoyer use for Staff E (Occupational Therapist) who had assisted with the lift transfer. They stated Staff E had been prn (as needed) and there had been a trained CNA with Staff E. They stated the serial number on the lift used did not match the maintenance check list, but the Maintenance Director went by the #2 when doing safety checks so they knew the lift had been inspected monthly as it should have. The Acting Administrator stated lift #2 had been used during the incident. At 12:50 p.m., the Acting Administrator showed the surveyor the lift which had been used when the resident fell . Observation revealed the serial number to be worn and illegible. The lift had a #2 on the top surface and the Administrator stated that had been the identifying number the facility used to do maintenance checks. The Acting Administrator showed the surveyor the O-ring and stated the lift had been initially removed from the floor until it could be repaired. The Acting Administrator demonstrated to the surveyor how one would need to place force on the properly functioning O-ring when placing a sling loop on the hook, and once the loop went far enough over the hook, then the O-ring popped back up and would not allow the sling loop to come off of the hook. During an interview with the facility Maintenance Director on 2/26/14 at 1:20 p.m., they stated they did routine maintenance checks on the Hoyer lifts using a check list, one time per month. They stated that before the CNA or nurse used the lift they were to do a visual check. The maintenance director stated there had been no specific check done with the O-rings on the monthly check list, but they did push down on the ring during checks to make sure it functioned. They stated the other maintenance person that worked at the facility prior to them had the wrong serial number on the check list form used and they just continued to use that form after starting at the facility. They stated they identified the lift by a number they placed on it (#2) and the form used for maintenance checks had been a corporate form. They stated they wrote a number on it to identify which lift had been which. They stated they could not verify the serial number on the lift used during the transfer because it had worn off, but knew it had been lift #2. During an interview with Staff E (Occupational Therapist) on 2/26/14 at 3:19 p.m., she stated on the day of the incident she had gone into the resident ' s room to do an OT (Occupational Therapy) evaluation and the resident had been lying in bed. They stated they got Staff D (Certified Nurse Aide) and they put the Hoyer sling under the resident. Staff E stated they repositioned the resident on the sling and brought the Hoyer in. Staff E stated she hooked the sling to one side and Staff D hooked the other side. They then checked each other ' s (hoops), and both hooked the orange loop. Staff E stated they did not notice anything unusual so they lowered the bed and Staff D assisted the resident to the side of the bed. The resident was then raised and Staff D held the resident as Staff E pulled the lift away. Staff D turned the resident and went to get the wheel chair, two steps away. Then the resident fell . The resident ' s left shoulder side (loop) seemed to come undone. Staff E stated they did not use the lift very often at this facility but had been unofficially trained by a CNA. Staff E stated they had used Hoyer lifts frequently at other facilities. Staff E stated they had not been aware of the O-ring function but they did not feel that any formal training would have prevented the incident from occurring. During an interview with Staff D (Certified Nursing Assistant)on 2/26/14 at 3:50 p.m., they stated they had come back from lunch and Staff E had asked for help. They arranged a Hoyer pad under the resident. Staff D stated they hooked one side of the sling and Staff E hooked the other side (shoulder and leg). Staff D stated they used a small/medium sling and therapy or a nurse decided this by a resident ' s weight and which sling to use. Staff D stated they had no guidelines as far as which sling to use for the resident before they began the Hoyer transfer. Staff D stated there had been a sling in the room. Staff D stated they assisted the resident up on one side of the bed and then went two steps and the resident went down. Staff D stated it happened very fast. Staff D stated they had been evaluated about lift use one time a year. Staff D stated they had double checked the loops when they hooked the resident up to the sling and made sure the right colored loop had been on the hook. Staff D sated it looked like the O-ring had been alright. Staff D stated the sling seemed to be the right size for the resident and fit the resident alright. During an observation on 12/26/14 at 4:07 p.m., Staff D and Staff E demonstrated how the sling had been hooked on the Hoyer during the incident. Staff E applied gentle force to make the O-ring go down far enough for the loop to slide onto the hook. At that time, Staff E stated they did not have to do that (apply force to make O-ring go down) when the incident occurred, it just slipped right on. The Acting Administrator verified the lift used for the demonstration had a functioning O-ring, unlike the non-functioning ring when the resident fell . On 2/27/14 at 7:30 a.m., the Acting Director of Nursing (DON) was interviewed and stated the first thing they saw after the incident had been the O-ring on the Hoyer had not been above the spring. The Acting Director of Nursing stated Staff F (CNA/Restorative Aide) had been the lift coordinator and gave the staff training. The Acting DON stated staff were trained by Staff F to check and make sure of the safety latch (O-ring). The Acting DON stated she knew Staff D and the nursing staff had been trained on the lift use prior to the incident but she could not speak as to if therapy staff had the training. On 2/27/14 at 8:30 a.m., Staff F stated she had been responsible to train new hires before they worked with Hoyer and EZ stands. Staff F stated the training was performed monthly but she had not been able to do it monthly due to chaos and being busy. Staff F stated the facility try to get training done monthly and don't. Staff F stated a part of the training she did with staff had been to make sure the staff triple check to make sure the hoops were on and the little spring had been connected. Staff F verified they always trained staff on the importance of checking the O-ring functioned prior to using the lifts. At 10:30 a.m., Staff B (CNA) stated she had been trained on the need to check the black O-ring and make sure it popped up so the loop stayed on the hook. At 12:15 p.m., Staff G (CNA) stated she had received training every few months regarding the Hoyer use. Staff G stated she had been trained about the black O-ring and the need to make sure it comes up to keep the loop on the hook. Staff G stated she had been trained on this since the start. Review of facility documentation revealed Staff D had received Hoyer lift training last on 11/22/13. Further review of Hoyer lift staff education, revealed Staff E had received no training. A facility policy dated 5/2009, included a section titled Training. The policy documented prior to using the equipment with residents, each staff member must demonstrate his or her competency utilizing the manufacturer ' s competency checklist. 2. During the initial facility tour on 2/24/14 at 10:10 a.m., observation revealed a surge protector in Room 17 with a running fan and an electric razor plugged into it. During the facilty environmental tour on 2/27/14 at 8:25 a.m., observation revealed the surge protector remained in Room 17 with the electric razor plugged into it. At that time the Maintenance Director stated the facilty did not have the Dire Marshall guidelines. On the Department website in he February 2004 Insight, the State Fire Marshal's Office documented clarification about the use of surge protectors. The posted information documented the electrical surge protector shall be of metal or steel construction and approved by Underwriters Laboratories or another recognized laboratory. The paper documented items that should be used with an electrical surge protector and items prohibited from use with a surge protector that included clocks, lamps, personal grooming and care devices, battery chargers, and motor drive appliances.

Based on record review, staff interviews and review of facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self and failed to utilized a mechanical lift to ensure the resident ' s safety was not compromised (Resident #1). The sample consisted of 4 residents and the facility reported a census of 58 residents. The Care Plan directed staff to transfer the resident with a mechanical lift. A staff member transferred the resident without the mechanical lift, while another staff member stood behind the wheelchair. The resident had paralysis of both legs and during the transfer; the resident had to be lowered to the floor. The resident expressed pain and an x-ray identified a fractured hip. The mechanical lift did not have an operational battery so the staff person attempted to manually transfer the resident. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of 8/10/13. The MDS identified the resident required extensive staff assistance of two staff for transfers. Review of the resident ' s Care Plan reflected a problem with the resident at risk for falling in regards to a history of spinal stenosis (narrowing of the spine) and [DIAGNOSES REDACTED] (paralysis to lower part of the body). The problem started on 11/16/2011. The approach directed staff to transfer the resident with a Hoyer (mechanical) lift The transfers with a Hoyer lift started on 8/24/2011. The Director of Nursing revealed Caretracker (software) information was reviewed quarterly and updated as needed with resident changes. Caretracker documentation dated 9/3/13, directed staff to transfer the resident with a Hoyer lift and the assistance of 2 staff persons. An Incident Report dated 9/4/13 identified an incident had occurred on 9/2/13 due to staff unable to find a charged battery (for mechanical lift). Resident #1 had requested to be transferred to bed in order to receive cares. Staff A informed the resident the facility had no batteries for the mechanical lifts. Staff A attempted to transfer the resident without the lift and the resident ' s knees began to buckle. Staff A sat the resident on the floor. Nurse ' s Notes revealed staff entries for 8/28/13 and no other documentation until 9/3/13 at 10:25 a.m. The entry dated 9/3/13 at 10:25 a.m. described the resident as tearful and complained of right hip pain. Staff D, LPN, documented notification to the physician and the administration of Hydrocodone (narcotic analgesic) 5/325 one tablet. Nurse ' s Notes dated 9/3/2013 at 10:50 a.m. revealed the ARNP (Advanced Registered Nurse Practitioner) ordered a portable x-ray. At 1:40 p.m. the ARNP called the facility and ordered the resident be sent to the hospital Nurse ' s Notes documentation as late entry, dated 9/4/13 at 2:30 p.m. for 9/2/13 at 10:00 p.m. revealed Staff A, Licensed Practical Nurse), transferred Resident #1 from the chair to bed without incident. Staff A, documented after Resident #1 received incontinency care, Staff A, lifted the Resident off the bed for a stand pivot transfer. The note reflected the resident ' s knees buckled, sat the resident on the floor and called for extra assistance. An assessment was performed and the physician notified. The documentation revealed range of motion within normal limits and no complaints of pain. Another nurse arrived and obtained a battery (for the mechanical lift). The hospital History and Physical report reflected the surgeon, resident and resident ' s family agreed to non-operative treatment and to admit into the hospital for evaluation and pain control. Record review revealed a Major Injury Determination Form completed by the physician on 9/5/13 at 9:30 a.m. The record documented the date and time of injury as 9/2/13 at 6:10 p.m. The documentation identified the injury as a right proximal femoral neck fracture. The record documented the circumstances of the incident as a transfer of the resident from bed to the wheelchair when the resident's knee buckled and the staff lowered the resident to the floor. The documentation revealed the resident had been transferred by the staff and with-out the use of the Hoyer lift. The Data Collection Tool dated 9/6/13 identified the return-admission of the resident to the facility with a [DIAGNOSES REDACTED]. The facility transfer policy dated 1/1/01, defined transfer as the resident's ability to move between surfaces in order to improve or maintain their ability. The policy procedure directed the staff to apply a gait belt around the resident whenever he/she would be transferred. The transfer policy documented the resident's plan of care will be developed/revised to reflect the goals and interventions to be used for the resident. The facility provided the Resident Lift Policy, dated 12/15/11. The policy explained, directed and defined expectations for the staff to follow. The policy reflected any staff member that is found physically lifting a resident who had been designated as an equipment lift/transfer will be subject to disciplinary action, up to and including termination. On 10/1/13 at 10:30 a.m. Resident #1 was interviewed and stated a Hoyer lift was needed to transfer from the bed to the chair. The resident stated the incident occurred the evening of 9/2/2013, around 5:00 p.m. The resident stated she/he had soiled their pants and cried. Staff A felt sorry for the resident. The resident stated Staff A revealed there were no batteries available to work with the Hoyer. Resident #1 stated that Staff A had no problem when he/she transferred from the wheelchair to the bed. The resident stated Staff A used no gait belt during the transfer. The resident identified the problem of the transfer occurred when Staff A transferred from the bed back into the wheelchair. The resident denied the use of a gait belt for the transfer. The resident described the right leg went over the left, denied any pop or snap sounds. The resident recalled he/she stated at the time "it hurts so badly". Staff A, repositioned the leg and that eased the discomfort. Staff E, CNA (Certified Nursing Assistant) present at the time of the bed to chair transfer moved from behind the wheelchair and helped Staff A, ease the resident to the floor. The resident stated he/she did not fall and staff had eased her/him to the floor. The resident stated Staff B, Registered Nurse, came and checked me out (assessed) and helped get up with a Hoyer lift (Hoyer from the south side of the facility). The resident questioned why Staff A had not used the south side Hoyer lift. The resident stated he/she had pain that night and in the morning the pain had increased. On 10/1/13 at 3 p.m. Staff A was interviewed and stated Resident #1 transferred by a Hoyer lift and the assistance of 2 people. Staff A stated at suppertime, around 5 p.m., he knowingly transferred the resident with-out a Hoyer lift from the wheelchair to the resident's bed, and from the bed back into the wheelchair. Staff A stated he put 2 gait belts together and placed on the resident. Staff A identified Staff E present during the transfers. Staff A stated he had checked 7 or 8 batteries for the Hoyer lifts and all were dead or in need of a charge. Staff A stated none of the batteries would hold enough charge to complete a transfer from the wheelchair to a bed. Staff A explained the maintaining of a charged battery for the Hoyer lifts had been an ongoing concern brought to the attention of the maintenance person, Director of Nursing and Administrator in the last 2 months. Staff A recalled he asked the resident if they could wait 20 minutes or so. Staff A stated in that time a battery for the lift would be semi-charged. Staff A stated the resident yelled and cried that his/her bottom hurt and needed up. Staff A explained to the resident that he could be fired if a Hoyer was not used and he would feel awful if something would happen. Staff A stated he and Staff E, CNA, first transferred the resident with 2 gait belts from the wheelchair to the resident's bed. Both staff cleansed the resident. The resident requested to get back into the wheelchair for supper. Staff A stated he and Staff E, CNA, sat the resident to the edge of the bed, with 2 gait belts. Staff A stated he counted to 3 and stood the resident up. The resident stated " My leg buckled " . Both staff lowered the resident to the floor and paged for a nurse to come and assist. Staff A stated Staff B came to the resident ' s room and assessed the resident. Staff B went and obtained a Hoyer lift. The resident transferred back into the wheel chair. The resident when assessed by Staff A and Staff B denied pain or any injury. Staff A stated the resident continued to voice he/she was fine. Staff stated multiple times he had used Hoyer batteries with a 25% charge to transfer a resident even if it meant to use more than one battery for the transfer to be completed. Staff E stated she entered the resident's room and Staff A was present. Staff A asked for assistance with resident's transfer from the bed to the wheelchair. Staff E stated she positioned herself behind the wheelchair so the wheelchair could be moved under the resident. Staff E stated she knew we shouldn't have, however, the resident was crying, and very upset. Staff A used 2 gait belts. When the resident raised up, the resident said to stop because his/her leg had given out. Then we both lowered the resident to the floor. Staff E stated the leg was in a weird position and bent in an angle. Staff E stated the identified battery charging for the Hoyer lifts had been a prior noted concern and stated the current revision for charging the batteries had been an improvement. Staff B was interviewed on 10/1/2013 at 9:30 a.m. and stated she was asked to the resident ' s room. Upon entering, she observed the resident lying on the floor. The resident was crying but denied pain. Staff stated she went to the south side, returned with a Hoyer lift and transferred the resident into the wheelchair. An interview conducted on 10/2/13, at 8:45 a.m. with Staff C, Registered Nurse described Resident #1 as total care, required several care changes related to incontinency and transferred by a Hoyer lift and the assistance of 2 staff members. Staff C stated has had battery issues with not being fully charged. Staff C stated Staff A had informed her that Resident #1 needed to be transferred due to incontinency and he did not have an available battery for the Hoyer lift. Staff C stated she had informed Staff A not to transfer the resident without a Hoyer lift. On 10/2/13 at 2:30 p.m. the Administrator and the Director of Nursing was interviewed. The Administrator stated the Hoyer lift batteries can work at 25% remaining and may need more than1 battery. On 10/1/2013 at 2:15 p.m., Staff L (Certified Nursing Assistant) was interviewed and stated keeping the batteries charged has been a problem. A new plan in place and working. On 10/1/2013 at 8:20 a.m., the Director of Nursing (DON) was interviewed and stated the facility now has a new checking grid to ensure proper charging of the batteries are done. The DON stated the staff had not always placed the batteries in the chargers correctly and have now revamped the system by using a star and sun sticker on the Hoyer batteries. This will remind staff to check level and ensure a full charge. The Hoyer Lift Battery Charging Schedule dated 9/11/2013 directed the 6 a.m. to 6 p.m. Charge Nurse would be responsible for collecting all batteries from the north and south lifts upon arrival. The nurse will take the batteries that are marked with ' star ' stickers and replace them with the batteries on the chargers that are marked with ' sun ' stickers ' . The batteries with ' sun ' stickers will then be placed on the lifts and left on the lifts until 6 p.m. The 6 p.m. to 6 a.m. south charge nurse will be responsible for collecting all batteries from the north and south lifts upon arrival. The nurse will take the batteries that are marked with ' sun ' stickers and replace them with the batteries on the chargers that are marked with the ' star ' stickers. The batteries with the ' star ' stickers will then be placed on the lifts and left on the lifts until 6 a.m. The batteries need to be left on the chargers for 12 hours to insure they are ready for the next shift. The chargers are located in the following areas: north clean utility room, north nurse ' s station; south clean utility room and south nurse ' s station.

Based on observation, record review and staff interviews, the facility failed to perform adequate assessments when a resident has an onset of adverse symptoms and change in physical condition and failed to provide timely interventions for 3 of 6 residents reviewed (Resident #1, #3 & #5). The facility reported a census of sixty-seven (67) residents. Resident #5 was observed with severely dry and cracked heels. Special instructions dated 3/27/12, directed staff to apply Cocoa Butter skin care lotion to bilateral feet at bedtime. Record review revealed the treatment was not completed the month of June and the record lacked assessments of the heel condition. The resident voiced heel pain. Resident #3 voiced complaints of pain in the great toe on 3/15/2012. The Nurse ' s Notes reflected the staff documented [MEDICAL CONDITION] present, however, lacked a complete assessment (capillary refill, pedal pulses, warmth, pain level, radiating etc). The resident continued to express pain on 3/28/2012. Additional [MEDICATION NAME] were prescribed by the physician ([MEDICATION NAME] Patch). On 4/23/2012 the second toe was noted to have a pink area present. Although a pink area occurred, a circulatory assessment had not been performed. On 5/8/2012 the great toe turns black (necrotic). On 5/14/2012, the pedal pulses were assessed and determined to be weak (lack of circulation). On 5/25/2012, all digits on the left foot appeared necrotic and tender to touch per the Nurse ' s Notes. On 6/8/2012, the resident had a partial amputation of the left foot. Resident #1 had a [MEDICAL CONDITION] which required surgical repair. Upon return to the facility on [DATE] from the hospital, the record revealed the staff had only assessed the surgical incision twice. Although the incision had healed on 6/19/2012, complications could have occurred and without an assessment, could delay identification of a problem promptly (infection, dehisce, etc). Findings include: 1. A Minimum Data Set (MDS) assessment tool dated 5/4/12 documented Resident #5 with [DIAGNOSES REDACTED]. The MDS documented Resident #5 with a cognitive score 15 of 15 (intact) with no long or short memory problems. The assessment documented the resident required assistance of one staff for personal hygiene, transfers, dressing, and toileting. The MDS Skin Condition assessment documented the resident at risk for pressure ulcers. The Treatment Sheet dated 6/1/12, through 6/30/12, documented the resident with [DIAGNOSES REDACTED]. Special instructions dated 3/27/12, directed staff to apply Cocoa Butter skin care lotion to bilateral feet at bedtime. Record review revealed the treatment was not completed the month of June. On 6/13/12 at 7:55 PM, observation revealed Resident #5 sitting in his/her wheel chair as Staff A, Licensed Practical Nurse (LPN), removed the resident's shoes and socks. When the socks were removed, Resident #5 complained both heels as sore. Observation revealed the skin on both heels severely dry and cracked. At 8:06 PM, observation showed Staff B, LPN at the nurse's desk on the telephone. Staff B reported she just called the physician and family to inform them staff did not complete the resident's skin treatments as ordered and requested the order changed to "as needed," rather than every night at bedtime. Staff B reported the Assistant Director of Nursing (ADON) requested she call the physician. The ADON, also in attendance, stated she removed the resident's shoes and socks to check the resident heels prior to the surveyor observing the skin treatment. Staff A then stated she found the Cocoa Butter skin care lotion in the resident's closet. During an interview on 6/13/12 at 8:35 PM, Resident #5 stated he/she could not remember when staff did his/her heel treatment last. The resident stated his/her heel is sore to the touch. 2. The Resident Admission Record sheet indicated Resident #3 had an initial admission date of [DATE] and [DIAGNOSES REDACTED]. The MDS assessment with a reference date of 4/27/12 documented Resident #3 with [DIAGNOSES REDACTED]. The MDS revealed the resident did not walk and was dependent on staff for transfers, dressing, toileting and personal hygiene. The Skin Condition assessment documented Resident #3 without pressure ulcers. The Nurse's Notes contained the following entries: a. On 3/15/12, at 10:15 AM, the nurse documented the resident remained on antibiotic therapy for cellulites. The nurse also documented bilateral (both) lower extremities showed 2 plus (+) [MEDICAL CONDITION] and complained of great (big) toe pain this AM. b. On 3/16/12 at 6:30 AM, staff documented Resident #3 continued on antibiotics for cellulites and 2+ bilateral lower extremities [MEDICAL CONDITION]. c. On 3/16/112 at 4:30 PM, the nurse documented the resident remained on an antibiotic for bilateral lower extremity cellulites. Staff noted 2+ [MEDICAL CONDITION] with no redness or warmth. d. On 3/17/12 at 12:30 AM, the nurse documented 2+ [MEDICAL CONDITION] to the bilateral lower extremities with no redness or warmth noted. Staff observed the resident displayed increased agitation with [MEDICATION NAME] (anti-anxiety medication) given with little effect. Staff noted the resident complained of severe pain to the left 2nd toe and [MEDICATION NAME] (narcotic [MEDICATION NAME]) given. The documentation revealed staff failed to complete an assessment of the resident's pedal pulses or capillary refill. e. On 3/18/12 at 5:15 PM, documentation revealed the resident remained on antibiotics for cellulites with bilateral lower extremity [MEDICAL CONDITION] noted and have complaints of toe pain. On 3/19/12, at 4:30 AM the resident has 2 plus pedal [MEDICAL CONDITION], remains on antibiotics for cellulites and complains of toe pain. The assessment lacked pedal pulses or capillary refill check. On 3/19/12, at 5:50 PM the resident has 3 plus bilateral lower extremity [MEDICAL CONDITION]. The assessment lacked pedal pulses for check for capillary refill. On 3/20/12 at 1:00 AM the antibiotic completed for cellulites with no adverse reaction noted. The bilateral lower extremities have 2 plus [MEDICAL CONDITION] and the resident complains of left 2nd toe pain. The assessment lacked pedal pulses or check of capillary refill. On 3/28/12, at 10:40 AM the resident complained of pain to his/her feet, kicking the pillow off the recliner, and increased agitation, scheduled [MEDICATION NAME] (narcotic [MEDICATION NAME]) given. The documentation lacked an assessment of the resident's pedal pulses. On 4/16/12, at 4:00 PM new orders received for [MEDICATION NAME] Patch (pain patch) to the dorsal aspect on 12 hours off 12 hours. On 4/23/12, at 4:40 PM noted a pink area in between the left great toe and 2nd toe, the physician ordered a new treatment, place [MEDICATION NAME] between the toes twice a day to keep the toes apart until healed. The assessment lacked an assessment of pedal pulses. On 5/8/12 at 9:00 PM the resident's toe remains black with pink tissue in between the great and 2nd toe. The resident complains of toe pain. On 5/9/12, at 3:10 AM and 2:15 PM documented the left great toe and 2nd toe remain with necrotic tissue with black discoloration and some pink tissue. The assessment lacked an assessment of pedal pulses. On 5/10/12, at 5:50 AM documented the left great toe remains necrotic with some pink tissue. The assessment lacked pedal pulses. On 5/11/12, at 5:10 AM documented the left great toe remains black with some pink surrounding the area. The assessment lacked pedal pulses. On 5/11/12, at 11:15 AM documented the left great toe and 2nd digit remain dark in color with minimal warmth and very weak to no pedal pulses. The Nurse's Notes dated 5/12/12, documented the left great toe and 2nd toe remain necrotic. The assessments lack an assessment of pedal pulses. On 5/13/12, at 11:00 PM documented the left great and 2nd toe is necrotic. The assessment lacked pedal pulses. On 5/14/12 at 9:30 PM and 3:00 AM, documented the resident with very weak pedal pulses. On 5/16/12 and 5/18/1 the staff did not fail to assess the resident's pedal pulses. The Nurse's Notes dated 5/19/12, at 2:35 PM documented the resident's feet remain dark in color the left greater than the right, the resident complains of pain when his/her feet are touched. The assessment lacked pedal pulses. The Nurse's Notes dated 5/21/12, at 12:14 PM documented the left great toe remains dark and necrotic. The resident denies pain. The assessment lacked pedal pulses. The Nurse's Notes date 5/23/12, at 4:35 AM, documented the left great toe with necrotic black tissue. The Nurse's Note dated 5/23/12, at 7 PM documented the left great toe remains black and shriveled the 2nd digit has a reddened pink area and remains tender to touch. The assessment lacked pedal pulses. The Nurse's Notes dated 5/24/12, at 8 PM documented the resident's toes remain black with redness noted the physician here to see the resident and ordered [MEDICATION NAME] (antibiotic) 1 gram daily for 7 days, if no improvement will refer to surgery. The following nurse's notes documented an assessment of the resident's temperature and assessed the resident for pain and adverse reactions related to the antibiotic but lacked an assessment of the resident's pedal pulses. The Nurse's Notes dated 5/25/12 at 2 PM documented all digits on the left foot appear necrotic and tender to touch. The Nurse's Notes dated 5/25/12, at 9:40 PM documented the left foot digits remain necrotic and tender to touch with a foul odor. The Nurse's Notes dated 5/26/12, at 11 AM and 4:45 PM documented the resident's left foot great toe to 3rd digit remain black in color and tender to touch. The assessment lacked pedal pulses. The Nurse's Notes dated 5/27/12, at 11 PM, 11:50 AM, and 5:30 PM documented the resident's left foot great toe to 3rd digit remain black and very painful when touched The Nurse ' s Notes continued to reflect the following: On 5/28/12 at 1:35 AM the left great toe to 4th digit is necrotic. The assessment lacked an assessment of pedal pulses or capillary refill. On 5/29/12 at 2:55 AM, 11:15 PM, and 9 15 PM documented the left great toe to 4th digit remain black/necrotic with no capillary refill and the digits are beginning to diminish in size. On 5/30/12 at 4:50 AM the resident's left great to 4th digit is necrotic/black and with foul odor noted. The assessment lacked pedal pulses or capillary refill check. On 5/30/12, at 5:55 AM documented the resident complained of increased pain in the left foot and increased anxiety, as needed pain medication and [MEDICATION NAME] given. The assessment lacked documentation of pedal pulses. On 5/31/12, at 4:15 AM, 1:55 PM and 5 PM documented the resident's great toe to 4 digit remains necrotic/black and tender to touch. The assessment lacked an assessment of the residents pedal pulses. On 6/4/12, at 4:45 AM, and 12:30 AM, documented the resident's left foot and toes remain black in color, and the resident complained of tenderness. The assessments lack an assessment of the resident's pedal pulses. On 6/5/12, at 1:00 AM, 2:15 PM, and 9:00 PM documented the resident's left great toe 2nd and 3rd toe remain black/necrotic in color and shrinking in size. The assessments lacked an assessment of the resident's pedal pulses. On 6/6/12, at 5:10 PM, 2:00 PM and 9:00 PM documented the Resident's left great toe to 4th toe remains black in color and the great toe is decreasing in size. The assessment lacked documentation of the resident's pedal pulses. On 6/7/12, at 4:40 AM, 2:10 PM, and 5:30 PM documented the resident's left great toe remains black in color, and decreasing in size. The assessments lacked an assessment of the resident's pedal pulses. On 6/8/12 at 4:50 AM, 8:00 AM and 5:45 PM documented the resident's great toe to 4 digit remain black in color and the great toe continues to diminish in size. The assessments lack assessment of the resident's pedal pulses. On 6/9/12, at 3:00 AM, 10:30 AM, 8:50 PM and 11:00 PM documented the resident's left great toe to the 4th digit is black in color and shrinking in size. The assessments lacked an assessment of the resident's pedal pulses. The hospital post report dated 6/10/12, documented the resident returned from surgery to have a partial amputation of the left foot. 3. The Plan of Care dated 5/30/12 documented Resident #1 had an admitted into the facility on [DATE] following surgery. The MDS assessment with a reference date of 6/6/12 identified Resident #1 with [DIAGNOSES REDACTED]. The assessment documented the resident required assistance of 2 staff for bed mobility, transfers, and toileting. The Medicare Daily Skilled Nursing Notes dated 6/5/12, documented Resident #1, admitted to the facility post surgery of a right [MEDICAL CONDITION]. Record review revealed 2 assessments of the post surgery incision. The Initial Wound Evaluation sheet dated 5/30/12, documented the resident with a right hip incision that measured 22.5 centimeters. The Weekly Wound Progress Note dated 6/19/12, documented the right thigh healed. The clinical record lacked Weekly Progress Notes from 5/30/12 to 6/19/12.

Based on observation, record review and staff interviews, the facility failed to provide the necessary treatment and services to prevent the development of new pressure ulcers (Resident #2, #6). The sample consisted of 6 residents and the facility reported a census of 67 residents. Resident #2 developed toe ulcers on 5/15/2012. Review of the record revealed the ulcers were not routinely assessed. The assessments included dates of 6/15/2012 and 6/19/2012. On 6/15/2012 the wound sheet indicated the resident should wear heel lift boots when in bed. During the afternoon of 6/19/2012, observation revealed the resident in bed and wearing anti-embolism socks (puts pressure on wounds) and shoes (adds pressure to toe wounds). On 6/13/2012 and 6/19/2012, observation revealed the left foot 2nd toe had a 1 centimeter (cm) black area. Findings include: 1. The Resident Admission Record identified Resident #2 had a readmission to the facility on [DATE] after a recent hospitalized from [DATE], to 5/15/12. The Minimum Data Set (MDS) assessment with a reference date of 5/27/12, documented Resident #2 had [DIAGNOSES REDACTED]. The Skin Condition assessment identified no pressure ulcers or skin concerns. According to the MDS Resident #2 required extensive assistance of 1 staff for bed mobility, transfers, ambulation, dressing and toileting. The Braden Scale - For Predicting Pressure Sore Risk sheet dated 5/15/12, documented Resident #2 with a score of 17. The Braden Scale assessment dated [DATE], 5/29/12, and 6/6/12, documented a score of 16, the assessment sheet indicted a score of 12 or less represents High Risk. The Initial Wound Evaluation sheet dated 5/15/12, documented: Wound #1- to the left foot, second digit, blister type wound, measured 0.8 centimeters (cm) in length and 1.2 cm in width. Wound #2 - left foot 3rd digit blister type wound, measured 2.4 cm in length by 2.4 cm in width. Wound #3- left foot 4th digit, blister type wound measured 1 cm in length by 1.8 cm in width. The Weekly Wound Progress Note dated 6/15/12, documented the left 2nd toe Stage II pressure sore measured .8 cm in length and .4 cm in width, and the treatment remained the same; paint the blood filled vesicles with [MEDICATION NAME] twice a day, apply heel lift boots while in bed. The Weekly Wound Progress Note dated 6/19/12, documented the left great toe Stage II pressure ulcer measured 1 cm in length and 0.4 cm in width. The assessment documented the treatment remains [MEDICATION NAME] twice daily and heel lift boots on while in bed. Review of Resident #2's clinical record revealed no other skin assessment sheets. The Objective Findings and Physician /MLP Orders dated 5/21/12, directed staff to paint the blood filled vesicles on the left foot 1st, 2nd toe and 2nd toe and the right foot 3rd toe with [MEDICATION NAME] 2 times daily. The assessment documented the resident with lower extremity are very [MEDICAL CONDITION] and vesicles filled with dark red drainage noted on the 1st, 2nd, toe of the left foot and 3rd toe of the right foot. The Mercy Clinics Geriatric Service sheet (physician visit sheet) dated 5/17/12, documented the [AGE] year old resident post hospitalization with a urinary tract infection, and debility, with a history of deep vein [MEDICAL CONDITIONS] and oxygen dependent. Treatment Sheet dated 6/6/12 indicated no treatment completed to the left and right foot on the 6 PM to 6 AM shift. On 6/13/12, at 10:00 PM observation of the left foot treatment showed the 2nd toe with a black area Approximately 1 cm in length. Observation showed the 3rd toe with a scabbed area around the toe nail. On 6/19/12, at approximately 2:10 PM observation revealed the resident in bed with shoes on and feet resting on the mattress. The resident reported not feeling well. On 6/19/12, at 4:40 PM observation revealed the resident in bed with shoes and TED (anti-Embolism) hose on with bilateral feet resting on the mattress. Staff D removed the resident's TED hose and shoes. Observation revealed the left foot 2nd toe with an area measuring approximately 1 cm black in color. Staff E and F reported coming on duty at 2 PM with the resident in bed at that time, and denied providing any cares prior to this time. Staff D Licensed Practical Nurse (LPN) reported she completed the Weekly Wound Progress Note this AM and stated she started this new assignment a week ago to assist the ADON with skin assessments. Staff D checked her records and found no other skin assessment records for Resident #2. 2. The Admission Record identified Resident #6 had an admission date of [DATE], with a primary [DIAGNOSES REDACTED]. According to the quarterly MDS assessment with an assessment date of 2/10/12, described Resident #6 as non-ambulatory and depended upon staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene. The assessment documented the resident had [DIAGNOSES REDACTED]. The Skin Condition assessment documented the resident at risk for pressure ulcer development. The Braden Scale For Predicting Pressure Sores dated 5/18/12, documented the resident's score as 12 and at risk for pressure sore development. The Initial Wound Evaluation sheet dated 6/4/12, documented Resident #6 with a superficial abrasion to the right shoulder which measured 0.5 cm in length by 1.0 cm in width, and had a reddened coccyx. The Weekly Wound Progress Note dated 6/14/12, documented the upper coccyx facility acquired Stage I pressure ulcer measured 0.4 cm in length by .02 cm in width and depth less than 0.1 cm. (Stage 1 pressure ulcers have intact skin and should not have depth present). The Initial Wound Evaluation sheet dated 6/14/12, documented the right heel facility acquired wound measured 2.2 cm in length by 1.7 cm in width. The assessment documented the resident with an intact blister to the right outer heel On 6/19/12, at 2:10 PM, observation revealed Resident #6 in bed lying on left side with bilateral foam boots to the feet. Staff D removed the gauze dressing to the right lateral heel. Observation revealed a quarter size fluid filled blister. Staff D raised the right heel for observation and an indentation in the right heel was present. The heel had a soft and spongy when touched. The air mattress control box hung at the foot of the bed. The cord to the air mattress was observed wrapped around the box. On 6/19/12, at 4:18 PM, Staff H and Staff I provided incontinency care as Staff B distracted the resident during cares by talking to the resident. The resident laid on his/her left side during cares and observation revealed a reddened area to the right shoulder. Staff D estimated the reddened area to be the size of a silver dollar. Two additional reddened areas were observed on the coccyx. Each coccyx area measured approximately 1.5 cm to 2 cm in size with the top layer of skin absent (Stage II). The Encompass air mattress remained unplugged. The electrical cord wrapped around the control box hanging on the foot of the bed. Observation revealed the air mattress without air and flat on the bed. On 6/19/12 at approximately 4:30 PM, Staff D reported she was not aware of the area to the resident's right shoulder and reported she has only been doing skin assessments for 1 week. She reported prior to this the ADON was responsible for completing the skin assessments. A check of her records showed no additional assessment of the right shoulder reddened area. The Portable X-Ray Inc. sheet dated 3/3/12 documented Resident #6 with proximal tibia and fibula fractures. The Nurse ' s Notes identified the following: On 3/3/12, at 11:30 AM a portable X-Ray indicated a Tibia/Fibula fracture with new orders to transfer to the emergency room for evaluation. On 3/3/12, at 5:15 PM the resident returned to the facility with a knee immobilize to the left leg. On 3/4/12, at 4:30 AM the left lower knee immobilizer in place with positive pedal pulses and 2 plus [MEDICAL CONDITION] to the area. On 3/5/12, at 11:05 AM the knee immobilizer in place to the left lower extremity, pedal pulses present with 2 plus [MEDICAL CONDITION] to the area. On 3/5/12, at 4:10 AM the resident in bed with the immobilizer to the left lower extremity in place. The left ankle/foot [MEDICAL CONDITION] and warm to touch. Antibiotic therapy continues for cellulites. There are no signs or complaints of pain with repositioning/rolling. On 3/6/12 at 8:30 PM the immobilizer remained to the left lower extremity with 2 plus [MEDICAL CONDITION], warm to touch and pedal pulses present. On 3/8/12 at 2:10 AM the left lower extremity with immobilizer in place with 2 plus [MEDICAL CONDITION] noted to the left foot. A small discoloration is noted to the left inner aspect of the ankle, dark purple in color and is located where the immobilizer ends. On 3/7/12, at 10:30 AM the left lower extremity immobilizer in place at all times except showers with 2 plus [MEDICAL CONDITION] noted to the left lower extremity with a small discoloration to the inner aspect of the left ankle, and some mild purple discoloration noted to the skin at the lower end of the immobilizer. A pillow case used to line and cover the skin and protect the skin from the immobilizer. On 3/7/12, at 10:45 AM a skin audit completed of the resident's left leg revealed no open areas on the left leg upon removal of the immobilizer. The area below the knee as light purple in color, adjusted the immobilizer to eliminate direct skin contact with the lower edge of the immobilizer. On 3/9/12 at 4:30 PM the resident returned from a physician's appointment with new orders to open the immobilizer with assistance of 2 staff to check skin integrity. On 3/9/12, at 11:25 P.M. upon inspection of the left lower extremity a small nickel sized blister with redness surrounding it located where the immobilizer ends, slightly above the ankle on the dorsal side. The facility sent a fax to the resident's physician dated 3/17/12, at 1:51 PM. The fax sheet dated 3/9/2012 informed the physician of a blister on the left lower extremity where the immobilizer ends and slightly above the ankle. The faxed sheet contained a response from the physician dated 3/17/12. The Physician order [REDACTED]. Opsite and monitor the site daily. Review of the March 2012 Treatment Sheet documented orders received on 3/17/12, that directed staff to apply [MEDICATION NAME] or Opsite over the blister and do not change until 21 days. Cover with a 4 by 4 gauze and monitor the site every day. The Treatment sheet indicated the area assessed by nursing staff occurred only on day April 1, April 7 and April 8. Review of the April 2012, Treatment Sheet revealed the above order directed the 2-10 shift to monitor the area. The Physician Telephone Orders sheet with a physician order [REDACTED]. The order contained a noted date of 3/9/12 and an additional note dated of 4/9/12 at 10:30 AM. The Physician Telephone Orders dated 3/10/12, directed staff to paint open areas with [MEDICATION NAME], allow to dry and cover with a [MEDICATION NAME] pad. Cover the left back ankle with an ABD pad and have the Advanced Registered Nurse Practitioner (ARNP) address the area on Monday. Review of the March 2012, Treatment sheet revealed a Nurse's Order dated 3/10/12, to check the skin under the left leg immobilizer every shift, (seven days after the immobilizer was ordered). The Nurse's Notes dated 3/10/12, at 10:20 AM documented the skin inspection under the immobilizer revealed 4 open areas to the back of the resident's left ankle. #1 - .4 by .4 centimeter by .2 centimeter #2 - 1 cm by .2 cm #3 - 1 cm by .2 cm #4- 1 cm by .2 cm the wound beds are pink The Physician's Telephone Order dated 4/9/12, documented it is okay to undo the left leg knee immobilizer to check the skin and let the skin breath. The Weekly Wound Progress Note dated 3/16/12, documented the facility acquired wound #1 to the anterior left ankle measured 2 cm in length by 0.5 cm in width. The next Weekly Wound Progress sheet dated 4/5/12, documented the Stage II facility acquired pressure ulcer to the left anterior ankle measured 3.0 cm in length by 1.8 cm in width. The Weekly Wound Progress Note dated 5/4/12, documented the left anterior Stage II pressure ulcer resolved.

Relates to complaint # Based on observation, record review and staff interview, the facility failed to ensure one of three residents with a history of pressure sores received the necessary wound care to prevent further pressure sores (Resident #11). The facility identified a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 8/4/10 reflected Resident #11 had [DIAGNOSES REDACTED]. The MDS assessment identified the resident as dependent upon staff for bed mobility, transfers, dressing, toileting, eating and personal hygiene. The MDS assessment documented the resident had a Stage II pressure sore. The Resident Care Plan dated 8/11/10, directed staff to: a. Float the resident's heels when in bed. b. To assist the resident in turning and reposition at frequent intervals. c. To float the resident's heels on pillows per family request. The nurse ' s notes dated 7/28/10, at 11:00 p.m., documented staff noted an open area in the crease of the resident's buttocks that measured 0.1 centimeters (cm) by 0.5 cm by 0.2 cm. The assessment documented the wound bed as beefy red with a scant amount of serous sanguineous drainage. The nurse ' s notes dated 9/13/10 at 12:15 a.m., documented the wound on the resident's coccyx as 2.0 cm by 0.5 cm by 3 cm. The edges were raised, white and macerated. The Weekly Wound Progress Notes documented the following: a. An assessment dated [DATE], documented the area to the buttock cleft measured 2 cm in length, 1 cm in width and 0.2 cm in depth. b. An assessment dated [DATE], documented the Stage II pressure sore as acquired at the facility and measured 1.2 cm in length, 0.2 cm in width and 0.1 cm in depth and the wound bed is beefy red. c. An assessment dated [DATE], documented the coccyx wound acquired at the facility measured 2.0 cm in length, 0.2 cm in width and less than 0.1 cm in depth, the wound bed is beefy red. The Weekly Wound Tracking Forms documented: a. The week of 8/2/10, the coccyx area measured 1.0 cm by 0.5 cm by 0.2 cm. b. The week of 8/9/10 to 8/16/10, the coccyx area measured 1.0 cm by 0.5 cm by 0.2 cm. c. The week of 8/15/10 to 8/22/10, the coccyx measured 2.0 cm by 1.0 cm by 0.2 cm. d. The week of 8/23/10, the coccyx area measured 1.8 cm by 0.2 cm by 1 cm. e. The week of 8/30/10, the coccyx area measured 1.2 cm by 0.2 cm by 0.1 cm. f. The week of 9/6/10, the coccyx area measured 2.0 cm by 0.2 cm by less than 0.1 cm. The nurse's notes dated 9/8/10, at 4:15 p.m., documented the nurse as called to the shower room by the Certified Nurse's Aide (CNA) and was noted to have two open areas to the resident's left heel. The assessment documented the left heel open areas measured 1.8 cm by 0.6 cm and the 0.2 cm by 0.5 cm. The assessment documented the area in the middle as pink with white edges and appeared to rest on the resident's foot pedals. On 9/14/10 at 10:30 a.m., while reviewing the resident's clinical record, Staff A reported the resident's current pressure sores to the heels were facility acquired. Staff A reported the resident had pressure sores to the right and left heels approximately a year ago that had healed. On 9/15/10, at 5:40 p.m., Staff B and Staff C provided incontinency care for the resident. Observation revealed the resident's heels resting on the mattress. During an interview on 9/16/10, at 10:59 a.m., Staff D stated the resident did not move around per self in bed; the resident stayed in one position until repositioned by staff. Staff D reported she/he had found the resident's heels resting on the mattress. During an interview on 9/16/10, at 11:13 a.m., Staff A reported the resident may only move his/her arms when in bed. Staff A reported the resident required staff assistance for positioning of his /her feet and legs. On 9/16/10 at 11:21 a.m., observation identified the resident's heels resting on the mattress. The nurse's notes dated 9/9/10, at 2:50 p.m., indicated an Occupational Therapy (OT) evaluation form as completed. On 9/14/10, at 10:30 a.m., Staff A stated she/he did not know of the OT evaluation order. Staff A notified OT and requested the evaluation be completed as soon as possible. The OT Plan of treatment for [REDACTED]. The resident required an 18 inch wheel chair for improved positioning and prevention of further skin breakdown. Foot rests removed to prevent breakdown on resident's heels. Discussed with nursing prevention of skin breakdown while patient in bed as well as when in chair.