Every finding on record at Brightmoor Nursing Center, LLC

Based on interviews, record review, and a review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three sampled residents (R) (R6) was free from abuse.Findings included:A review of the electronic medical record (EMR) revealed that R6 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, coronary artery disease (CAD), hypertension, benign prostatic hyperplasia, hyponatremia, and hyperlipidemia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R6 presented with a Brief Interview for Mental Status (BIMS) score of three, indicating a severe cognitive deficit. A review of the EMR revealed that R6 was discharged to another facility on 1/30/2026. A review of the EMR revealed that R5 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, non-traumatic brain dysfunction and dementia. A review of the admission MDS assessment dated [DATE] revealed that R5 presented with a BIMS score of three, indicating a severe cognitive deficit. A review of the EMR revealed that R5 was discharged to another facility on 1/2/2026. A review of the facilities investigation dated 1/6/2026, R5 placed a pillow over R6's face. R5 was stopped by the verbal direction of the Certified Nursing Assistant (CNA) BB. R5 was sent out of the facility for psychiatric consultation. R5 transferred to another facility. R6 was assessed and suffered no injury. Resident-to-resident abuse was substantiated. A telephone interview was attempted with CNA BB, but was unsuccessful. During an interview on 3/18/2026 at 12:30 pm, the Director of Nursing (DON) expressed that the documentation does show that the facility did confirm resident-to-resident abuse, as R5 did place a pillow over the face of R6. The facility did act quickly, separating the residents. The DON stated that R5 never exhibited any of those behaviors before that incident. During an interview on 3/18/2026 at 12:30 pm, the Administrator (also the Abuse Coordinator) expressed that the incident was investigated and abuse was confirmed related to the incident on 1/6/2026 between R5 and R6. A review of facility policy titled Abuse, Neglect, and Exploitation noted that the intent of this policy is to actively preserve each individual's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property.

Based on observations, staff interviews, and review of the facility's policies titled Food Safety and Sanitation, the facility failed to ensure proper food labeling, dating, and storage, and failed to ensure food items were not available for resident consumption past their expiration date. These deficient practices had the potential to place the 118 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of the facility's policy titled Food Safety and Sanitation, dated 2021, revealed the Food Storage section included, All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored.When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food.Leftovers are used within 72 hours (or discarded). Note: 2017 Federal food code guidelines allow 7 days for food safety, with the day of preparation counted as day 1 of the 7 days, and then the food is discarded. Check local and state regulations and determine which regulation should be followed.Perishable foods with expiration dates should be used prior to the use-by date on the package.Canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines. During a kitchen tour on 12/19/2025 at 7:44 am, with the Assistant Dietary Director (ADD), the ADD stated that all personnel should check for expiration dates, past use, and/or expired foods, as well as for dented cans, and stated they should label food items being stored. Observation of the dry food storage revealed: One unlabeled and undated wrapped powder, which was confirmed by the ADD as cake mix. One five-pound (lb) container of cornmeal with no open or discard date, One gallon of Worcestershire sauce with no open or discard date, One 32 fluid oz of liquid smoke with no open or discard date, One 24-ounce (oz) container of gelatin with no open or discard date, One 36 oz container of baking soda with no open or discard date, One 128 oz of pomace oil with no open or discard date, One gallon of vegetable oil with no open or discard date, One 32 oz container of confectioners' powdered sugar with an expiration date of 11/19/2025 and no open date.Observation of the reach-in refrigerator revealed: nine unlabeled and undated containers of sliced oranges, 15 containers of yellow pudding. Observation of the walk-in freezer revealed: two half-sheet pans of dressing with an expiration date of 12/17/2025, one-half turkey with no use-by date on the label. Continued observation of the kitchen revealed a rack containing 91 assorted puddings intended for lunch, which were neither labeled nor dated. An interview with [NAME] MM, who confirmed that she had prepared the pudding-like food items at 7:00 am upon her arrival and planned to label them after placing the items in the cooler. In an interview on 12/20/2025, at 2:20 pm, [NAME] KK confirmed that she received training on storage, labeling, and dating. She emphasized the importance of labeling and dating everything that you handled.In an interview held on 12/20/2025 at 3:20 pm, the Registered Dietitian (RD), who also serves as a Dietary Manager (DM), stated that all items should be labeled and dated with the received date, open date, and expiration or use-by date. The RD/DM affirmed all observations and validated the visual inspections conducted during the tours.

Based on staff interview, record review, and review of the facility policy titled Resident Rights, the facility failed to obtain consent from the resident or responsible party (RP) for the use of psychotropic medication treatment for two of five residents (R) (R16 and R21) sampled for the use of unnecessary medications. This deficient practice had the potential to place R16 and R21 at risk of medical complications. Findings include:Review of the facility policy titled Resident Rights, revised December 2016, revealed the Policy Interpretation and Implementation: section included, 1. Federal and state laws guaranteed certain basic rights to all residents of this facility. These rights include the Residents to . P. Be informed of, and participate in, his or her care planning and treatment. 1. Review of the admission Record for R16, located under the Profile tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, unspecified, undifferentiated schizophrenia unspecified psychosis not due to a substance or known physiological condition. delusional disorders, major depressive disorder, recurrent, unspecified, generalized anxiety disorder. Continued review revealed the resident's responsible party was documented as a daughter. Review of the Quarterly Minimum Data Set (MDS) assessment for R16, with an Assessment Reference Date (ARD) of 10/10/2025, revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating the resident was severely cognitively impaired. Review of the Order Summary Report for R16 revealed active orders for: Klonopin oral tablet 0.5 milligram (mg) (Clonazepam), one tablet by mouth every 12 hours as needed for anxiety, quetiapine fumarate oral tablet, give 12.5 mg by mouth at bedtime, related to unspecified psychosis, escitalopram oxalate oral tablet 10 mg, give one tablet by mouth one time a day, related to depression. Review of the EMR for R16 revealed no signed consent to administer the psychotropic medications. In a telephone interview on 12/21/2025 at 10:53 am, the RP for R16 stated that she was not familiar with a consent to administer the psychotropic medications to R16. She stated that she did not remember signing a consent to administer psychotropic medication to R16. 2. Review of R21's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R21 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Continued review revealed the resident's responsible party was documented as a daughter. Review of the Quarterly MDS for R21, with an ARD of 10/6/2025, revealed that Section C (Cognitive Patterns) documented a BIMS score of eight out of 15, indicating the resident was moderately cognitively impaired. Review of the Order Summary Report for R21 revealed active orders for: lorazepam oral tablet 1 mg, give one tablet by mouth every 24 hours as needed for anxiety, quetiapine fumarate oral tablet 25 mg, give one tablet by mouth at bedtime for sleep, escitalopram oxalate oral tablet 10 mg, give one tablet once a day for depression.Review of the EMR for R21 revealed no signed consent to administer the psychotropic medications. During an interview on 12/20/2025 at 10:00 am with the Director of Nursing (DON) regarding consent to treatment for R16 and R21 with psychotropic medication, she acknowledged that there were no consents for the use of psychotropic medications for R16 and R21. She stated that if a resident is on psychotropic medications, there should be a signed consent for the medication use by the resident and/or the RP.

Based on observations, staff and resident interviews, and review of the facility's policy titled Self-Administration of Medications, the facility failed to assess one of 48 sampled residents (R) (R8) for the ability ot safely self-administer medications before leaving medications at the bedside. This deficient practice had the potential to place R8 at risk of overmedicating and medical complications. Findings include: Review of the facility's policy titled Self-Administration of Medications, revised December 2012, documented Policy Statement: Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. 1. Policy Interpretation and Implementation: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: Ability to read and understand medication labels; Comprehension of the purpose and proper dosage and administration time for his or her medications; Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them; and Ability to recognize risks and major adverse consequences of his or her medications.Review of the facility's electronic medical records (EMR) revealed R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Sjogren syndrome, muscle weakness, and symptoms and signs involving cognitive functions following cerebral infarction.Review of the Quarterly Minimum Data Set (MDS) assessment for R8, dated 12/16/2025, revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R8 had intact cognition. Review of the Physician's Orders for R8 revealed an order dated 3/28/2023 for cyclosporine emulsion 0.05 % [percent], instill one drop in both eyes two times a day for dry eyes due to inflammation. Further review revealed no order for self-administration of medication. Review of the care plan for R8, dated 12/16/2025, revealed no care plan for self-administration of medication.Review of the clinical record for R8 revealed no assessment for self-administration of medication.Observation and interview on 12/20/2025 at 8:24 am during medication administration with Registered Nurse (RN) GG revealed there was a cup containing eight vials of cyclosporine ophthalmic solution 0.05 percent at R8's bedside. RN GG removed one container of eyedrops from the cup and stated that it was kept at R8's bedside and that she used the medication herself.In an interview on 12/20/2025 at 2:15 pm, in the presence of Licensed Practical Nurse (LPN)/ Unit Manager (UM) DD, R8 stated that she had taken the eye drops by herself when she needed them. She stated she usually took them around lunchtime each day for her dry eyes. She further stated that she had been self-administering the eyedrops at the facility for a long time.In an interview on 12/20/2025 at 2:16 pm, LPN/UM DD confirmed the cup with eight plastic vials of cyclosporin eyedrops on R8's bedside table. She stated she was not aware that R8 was using the eyedrops unattended. She stated that the nurses administer the eyedrops. LPN/UM DD confirmed there was no order for R8 to self-administer medications. LPN/UM DD stated that when the nurses administer the eye drops to R8, and she also self-administers them, she could have adverse effects. In an interview on 12/20/2025 at 5:55 pm, LPN HH stated that residents who self-administer medications must be alert and have an order for self-administration. She stated that a negative outcome would be that the residents may not know how to administer the medication effectively, and they could overdose. She stated it could be a harmful situation for R8 if there was no doctor's order for her to take the medication herself, in addition to the nurses administering it to her.In an interview on 12/21/2025 at 9:04 am, the Director of Nursing (DON) stated that an assessment was completed to determine whether the resident was appropriate to self-administer medications. The DON stated that R8 should not have medications at the bedside nor self-administer the eye drops. She further stated that the eyedrops R8 had were not prescribed by the facility, and she did not know they were at the bedside. She stated that R8 went to the eye doctor and received that prescription, and she was not aware that R8 was taking it on her own.

Based on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to protect one of 49 sampled residents (R) (R75) rights to be free from verbal abuse by another resident (R49). This deficient practice had the potential to place R75 at risk of a diminished quality of life.Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, revised 6/14/2024, included It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. We believe that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusions. The Definitions section included, . 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes sparing and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include (but are not limited to), threats of harm, saying things to frighten a resident, such as telling resident that she will never be able to see her family again. 1. Review of the clinical record for R75 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, anxiety disorder, hypertension, and major depressive disorder.Review of the MDS for R75, dated 10/21/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 15 (indicating little to no cognitive impairment). Review of the Progress Notes for R75 revealed an entry dated 9/8/2025 documenting, (R75's name) expressed the desire to move to another room after his roommate had an unpleasant conversation between the two of them. He stated that his roommate kept repeating foul language to him over several times and that made him feel very uncomfortable. SSD made aware that resident is requesting a room change.2. Review of the clinical record for R49 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction, major depressive disorder, Alzheimer's disease, restlessness and agitation, unspecified psychosis not due to a substance or known diagnosis, rank insignificant physiological condition, and hypertension.Review of the Quarterly Minimum Data Set (MDS) for R49, dated 11/19/2025, revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of nine (indicating moderate cognitive impairment). Section E (Behaviors) documented that no behaviors were exhibited. Review of the care plan for R49 revealed a Focus, dated 7/3/2024 and revised 4/29/2025, that the resident was at risk for behaviors and had a history of yelling at staff and making inappropriate sexual comments. Interventions included, but were not limited to, intervening as needed to protect the rights and safety of others. Review of the Progress Notes for R49 revealed an entry dated 9/9/2025 documenting, Social Services (SS) spoke with R49 regarding his threatening statements toward another resident. R49 was observed rummaging through his roommates' belongings. The staff continued to redirect R49, and the redirection was unsuccessful. R49 and his roommate were separated, and R49 continued to yell out with aggression that he would kill his roommate. R49 admitted to making the statement of wanting to kill his roommate. SS initiated a 1013 (an involuntary mental health evaluation) for transport to (name of a mental health facility). SS called the representative, and she was appreciative of the information provided. She was also encouraged to call the facility for an update.In a telephone interview on 12/20/2025 at 10:30 am, the Social Service Director (SSD) disclosed that she had been made aware of the allegation of abuse by Certified Nurse Assistant (CNA) TT. The SSD stated that CNA TT visited her office to report that R49 had threatened to kill R75 and exhibited aggressive behavior in his pursuit. The SSD indicated that she took the threat seriously because R49 had the means but attempted to de-escalate the situation with R49; however, she was unable to redirect his aggression.In an interview on 12/20/2025 at 11:07 am, Licensed Practice Nurse (LPN) II indicated that she observed R49 rummaging through the items of R75 while using inappropriate language. She stated that she attempted to intervene but was unsuccessful, prompting her to leave in order to seek assistance from the SSD. In an interview on 12/21/2025 at 10:43 am, CNA TT confirmed that he was assigned to R49 and R75 on the day of the alleged abuse. He stated that he recalled a verbal threat made by R49, which was derogatory words towards R75. CNA TT noted that R49 typically uses vulgar language and has previously exhibited aggressive behavior with different roommates. CNA TT explained that, after multiple attempts to redirect R49, he informed LPN II, who also attempted to redirect R49 but without success. CNA TT stated he reported the situation to the SSD.

Based on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure a thorough investigation was conducted in a timely manner following an allegation of resident-to-resident verbal abuse involving two residents (R) (R75 and R49) from a sample of 49. Findings include:A review of the facility's policy Abuse, Neglect, and Exploitation, revised 6/14/2024, revealed the Investigation section included, . 4. Interviews will be conducted all pertinent parties. Written signed statements from any involved parties will be obtained and notarized, if possible. Statements will be gathered from the suspect person making accusations resident involved, reliable resident who may have witness the incident and any other persons who may have some information identify any possible conflicts between witnesses. 5. Past performances and/or previous incident of involved parties will be evaluated. Review of schedules and assignments showing when and where suspect was working at the time of the alleged incident. 6. Describe actions taken by facility to protect the resident and to prevent a possible reoccurrence during the investigation. 7. All investigative information will be kept on file in a secured location. All information gathered is confidential in nature.1. Review of the clinical record for R75 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, anxiety disorder, hypertension, and major depressive disorder.Review of the MDS for R75, dated 10/21/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 15 (indicating little to no cognitive impairment). Review of the Progress Notes for R75 revealed an entry dated 9/8/2025 documenting, (R75's name) expressed the desire to move to another room after his roommate had an unpleasant conversation between the two of them. He stated that his roommate kept repeating foul language to him over several times and that made him feel very uncomfortable. SSD made aware that resident is requesting a room change.2. Review of the clinical record for R49 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction, major depressive disorder, Alzheimer's disease, restlessness and agitation, unspecified psychosis not due to a substance or known diagnosis, rank insignificant physiological condition, and hypertension.Review of the Quarterly Minimum Data Set (MDS) for R49, dated 11/19/2025, revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of nine (indicating moderate cognitive impairment). Review of the Progress Notes for R49 revealed an entry dated 9/9/2025 documenting, Social Services (SS) spoke with R49 regarding his threatening statements toward another resident. R49 was observed rummaging through his roommates' belongings. The staff continued to redirect R49, and the redirection was unsuccessful. R49 and his roommate were separated, and R49 continued to yell out with aggression that he would kill his roommate. R49 admitted to making the statement of wanting to kill his roommate. SS initiated a 1013 (an involuntary mental health evaluation) for transport to (name of a mental health facility). SS called the representative, and she was appreciative of the information provided. She was also encouraged to call the facility for an update.In a telephone interview on 12/20/2025 at 10:30 am, the Social Service Director (SSD) disclosed that she had been made aware of the allegation of abuse by Certified Nurse Assistant (CNA) TT. The SSD stated that CNA TT visited her office to report that R49 had threatened to kill R75 and exhibited aggressive behavior in his pursuit. The SSD indicated that she took the threat seriously and attempted to de-escalate the situation with R49; however, she was unable to redirect his aggression. The SSD confirmed that she did not contact law enforcement or the Ombudsman. She stated that she remembered conducting an interview with R75 but did not document it. The SSD further stated that she did not perform any other investigative tasks and was unable to provide additional information. In a concurrent interview on 12/20/2025 at 11:07 am, Licensed Practice Nurse (LPN) II indicated that she observed R49 rummaging through the items of R75 while using inappropriate language. She stated that she attempted to intervene but was unsuccessful, prompting her to leave in order to seek assistance from the SSD. LPN II stated she had no further documentation of the incident. The Director of Nursing (DON) stated that allegations of abuse, neglect, or exploitation should be reported within two hours. The residents should be separated, interviews should be conducted, interventions implemented, and any necessary actions should be taken.In an interview on 12/20/2025, at 11:09 am, the Administrator stated that he expected staff to promptly inform him of any instances of abuse. He stated that he typically would call the police in such situations. The Administrator also acknowledged that he was aware of an incident that took place on 9/9/2025, although he was not the Administrator at that time. Further interview revealed that, to his knowledge, the investigation of the incident could not be located.

Based on observation, staff interviews, record review, and review of the facility policy titled Care Plan-Comprehensive, the facility failed to develop a comprehensive person-centered care plan for two of 48 sampled residents (R) (R109 and R14). This deficient practice had the potential to place R109 and R14 at risk of unmet needs, medical complications, and a diminished quality of life. Findings include:Review of the facility policy titled Care Plan-Comprehensive, last revised October 2010, revealed that the facility's interdisciplinary and care plan teams would develop and maintain a comprehensive care plan for each resident, which would incorporate identified problems.1. Review of the admission Minimum Data Set (MDS) assessment for R109, dated 10/11/2025, revealed that Section H (Bowel and Bladder) documented that R109 had an indwelling urinary catheter.Review of the Order Summary Report for R109 revealed active orders for an indwelling urinary catheter and catheter care.Review of the care plan for R109 revealed no care plan for the indwelling urinary catheter. Observations on 12/19/2025 at 8:50 am, 12/20/2025 at 12:35 am, and 12/21/2025 at 8:30 am revealed R109 with an indwelling urinary catheter.2. Review of the physician's orders for R14 revealed that the resident has an active order of an electronic alert system device in place related to exit-seeking behavior.Review of the care plan for R14revealed no care plan for the electronic alert system device. During an interview with the Minimum Data Set Coordinator (MDS EE) on 12/19/2025 at 6:05 pm, she explained that the admission assessment typically identifies care areas for residents based on their needs and clinical status. She also mentioned that the MDS uses the physician's orders to help determine which care areas need to be developed for each resident. MDS FF acknowledged that R109 did not have a care plan created for the indwelling urinary catheter, attributing this to an oversight.During an interview with the Minimum Data Set Coordinator (MDS FF) on 12/20/2025 at 3:46 pm, she explained that daily clinical meetings were held with multiple disciplines and MDS staff. During these meetings, any new or existing resident issues are discussed, and MDS staff update interventions and care plans based on residents' clinical status. MDS FF noted that resident R14 should have been care planned for the use of an electronic alert system device. During an interview with the Administrator on 12/20/2025 at 3:53 pm, he stated that he expects all residents with an indwelling urinary catheter or electronic alert system device to have those specific needs addressed in their care plans.

Based on record review, staff interview, observation, and review of the facility's policy titled Hazard Communication Program, the facility failed to ensure that one of 49 sampled residents (R) (R135) rooms was free from accident hazards. This deficient practice had the potential to place R135 at risk of avoidable accidents and to diminish its quality of life. Findings include:Review of the facility's policy titled Hazard Communication Program revealed the Policy Statement section included, The purpose of the hazard communication program is to ensure that the hazards of all chemicals used in this facility have been classified and that the information concerning the hazard is communicated to employees. Review of the electronic medical record (EMR) revealed R135 was admitted on [DATE] with diagnoses including unspecified anxiety disorder and unspecified rheumatoid arthritis.Review of the Quarterly Minimum Data Set (MDS) for R135, dated 11/24/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the R135 was cognitively intact. Section GG (Functional Abilities and Goals) documented that the resident used a walker or wheelchair and required partial to moderate assistance, with the helper performing less than half the effort. Review of the physician's orders for R135 revealed no orders for rubbing alcohol, hydrogen peroxide, or Benadryl.Observations on 12/19/2025 at 10:18 am and 3:30 pm and on 12/20/2025 at 8:17 am revealed a container of rubbing alcohol, a container of hydrogen peroxide, and a four-ounce container of liquid Benadryl stored on the back of the resident's room door. In an interview on 12/20/2025 at 10:35 am, Certified Nursing Assistant (CNA) SS confirmed the rubbing alcohol, hydrogen peroxide, and Benadryl in R135's room. She stated that such items should not be in the resident's room.In an interview on 12/20/2025 at 11:03 am, Licensed Practical Nurse (LPN) II confirmed the rubbing alcohol, hydrogen peroxide, and Benadryl were present in R135's room and stated she had not previously seen them. She acknowledged that the items should not have been in the room. The resident gave the LPN permission to remove the items.In an interview on 12/22/2025 at 8:29 am, the Director of Nursing (DON) confirmed that the items identified should not be in the resident's room. She further stated that the facility provides education to the family regarding these expectations.

Based on observations, staff interviews, record review and review of the facility's policies titled Security of Medication Cart, Administering Medications and Storage of Medications, the facility failed to lock one of six medication carts, remove expired medication from one of two medication rooms and failed to place open dates on blood glucose strips in one of six medication carts. This deficient practice had the potential to place residents at increased risk of medical complications. Findings include: Review of the facility's policy titled Security of Medication Cart, revised April 2007, documented Policy Interpretation and Implementation: When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.Review of the facility's policy titled Administering Medications, undated, documented Policy Interpretation and Implementation: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Review of the facility's policy titled Storage of Medications, revised April 2007, documented The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.1. Observation and interview on 12/20/2025 at 11:45 am revealed one medication cart unlocked and unattended on the 500 Hall. Registered Nurse (RN) BB was observed walking from the end of the 500 Hallway and came to lock the medication cart. RN BB confirmed the medication cart was left unlocked and unattended. She stated that residents may open the cart and take medications from the cart. She further stated that the medications may not be the medications they should take, and the residents could get hurt.Observation and interview on 12/20/2025 at 3:21 pm revealed one medication cart unlocked and unattended on the 500 Hall. RN BB was at the nurses' station and stated she had left it unlocked and unattended.2. Observation and interview on 12/20/2025 at 11:55 am, during review of the medication room at the 500 Hall with Licensed Practical Nurse (LPN) AA, revealed one bag containing 30 Heparin Lock Flush solution 50 units/5 milliliters (ml), 5 ml single-use, sterile solution syringes, which were located in the bottom cupboard beside the refrigerator, had expired on 9/30/2025. LPN AA confirmed that all the syringes had an expiration date of 9/30/2025. She further stated that the heparin solution in the syringes was used to keep intravenous (IV) ports free of blood clots, and that if the solution had expired, it could be ineffective.3. Observation and interview on 12/20/2025 at 4:38 pm during review of the medication cart on the 600 Hall with LPN AA revealed one bottle of blood glucose strips with no open date. LPN AA stated that there should be an open date on the blood glucose strips because 30 days after they were opened, they could lose their effectiveness, which could result in inaccurate blood glucose test results. Review of the blood glucose strips bottle instructions revealed that it documented Indicate the first opening date on the bottle.In an interview on 12/20/25 at 5:55 pm, LPN HH stated that expired medications should not be in the medication room. She stated that expired medications could have altered effectiveness past the expiration date and could cause adverse effects for the residents. LPN HH stated that blood glucose strips should have open dates because the strips had a life span of up to 30 days after they are opened, and could then lose their effectiveness. She stated that if there were no open dates and the strips were used for residents, there could be inaccurate glucose readings. In an interview on 12/21/2025 at 9:04 am, the Director of Nursing (DON) stated that expired medication should not be in the medication rooms. She stated her expectations were for the nurses to remove expired medications and dispose of them per protocol. The DON further stated that if residents received expired medications, the medications may not be as potent after expiration dates and would not be beneficial for the residents. She stated that blood glucose strips should have open dates and should be discarded 30 days after opening. She further stated that if the container did not have an open or discard date, the resident could have inaccurate blood sugar readings and be treated for the inaccurate readings if there were no open dates.

Based on observations, staff interviews, and review of the facility's policies titled Infection Control and Handwashing/Hand Hygiene, the facility failed to implement infection control protocol by not practicing hand hygiene between glove changes. This deficient practice had the potential to place residents at risk of infections due to cross-contamination. The facility census was 119. Findings include:Review of the facility's policy titled Infection Control, revised December 2012, documented Purposes of Infection Control Programs: The major purposes of Infection Control Programs in the nursing facility are to minimize the effects of infections on residents and employees, and to educate the staff. A successful Infection Control Program requires an underlying commitment and facility-wide participation. It should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve care and prevent problems.Review of the facility's policy titled Handwashing/Hand Hygiene, revised April 2012, documented This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Observation on 12/20/2025 at 9:20 am revealed Licensed Practical Nurse (LPN) CC removed and disposed of gloves when exiting resident room [ROOM NUMBER]. She then donned (put on) a new pair of gloves without sanitizing her hands, and cleaned the blood pressure cuff attached to the blood pressure machine beside the medication cart. LPN CC then removed the second pair of gloves, disposed of them in the bin, and went to the medication storage room to get medications for the medication cart. Observation revealed LPN CC did not sanitize her hands after removing the second pair of gloves. During an interview on 12/20/2025 at 9:20 am, LPN CC confirmed that she did not sanitize her hands between glove changes. She stated that she should have sanitized her hands to prevent the spread of infection and cross-contamination. In an interview on 12/21/2025 at 9:04 am, the Director of Nursing (DON) stated her expectations were for the staff to wash their hands or use hand sanitizer between glove changes and after removing gloves. She stated that if staff did not hand-sanitize between glove changes, residents could contract infections. In an interview on 12/21/2025 at 10:35 am, Infection Preventionist (IP) OO stated hand hygiene should be performed between glove changes and after removing gloves to prevent cross-contamination and the spread of infection to the residents.

Based on observations and staff interviews, the facility failed to maintain a clean, sanitary environment related to dusty vent covers in four rooms on one hall, (rooms 112, 113, 114, and 115) with the potential to affect eight residents in these four rooms. Findings included: A policy for environmental services and cleaning was requested, but one was not provided. Observations during the initial tour and screening of residents on 5/2/2023, and subsequent observations on 5/3/2023 and 5/4/2023, revealed a build-up of dust on the ceiling vent covers in the bathroom of Room (Rm) 112, Rm 113, Rm 114, and Rm 115 as follows: Observation in room [ROOM NUMBER] on 5/2/2023 at 10:27 a.m. and 5/3/2023 at 9:10 a.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:37 a.m. and 5/3/2023 at 1:00 p.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:42 a.m. and 5/3/2023 at 8:20 a.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:48 a.m. and 5/3/2023 at 9:20 a.m. revealed a dusty vent in the bathroom. During a walk-through on 5/4/2023 starting at 11:00 a.m. with the Maintenance Director (MD) and the housekeeping supervisor, dusty vent covers in the bathroom of Rm 112, Rm 113, Rm 114, and Rm 115 was confirmed as follows: Observation at 11:01 a.m. dusty vent in bathroom [ROOM NUMBER]. Observation at 11:02 a.m. dusty vent in bathroom [ROOM NUMBER]. Observation at 11:03 a.m. dusty vent in bathroom [ROOM NUMBER]. Observation at 11:04 a.m. dusty vent in bathroom [ROOM NUMBER]. Interview on 5/4/23 at 11:05 a.m. with MD confirmed that the vents were dusty and needed cleaning. He revealed that housekeeping was responsible for dusting the outside of the ceiling vents, and maintenance was responsible for deep cleaning up the inside of the vent. He revealed that the vents are checked monthly, and cleaned as needed, and revealed there was a constant exhaust fan and that is why it was dirty. His expectation was that the vent covers should be clean and should not have a build-up of dust on them. The Maintenance Director provided a work history report for the past year showing that the exhaust fans were checked monthly, and documented, as clean if necessary.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Care Planning-Interdisciplinary Team, the facility failed to follow/develop the comprehensive care plan for two of eleven residents (R) (#18, #176) reviewed for oxygen therapy. Findings include: Review of the undated policy provided by the facility titled, Care Planning-Interdisciplinary Team, policy interpretation and implementation revealed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 3. The IDT includes but is not limited to a. attending physician; b. registered nurse; c. nursing assistant; d. food and nutrition services staff; e. resident or resident's representative; f. other staff as appropriate. 1. Record review of the most recent quarterly Minimum Data Set (MDS) for R#18 dated 3/14/2023 revealed in section J-health conditions included shortness of breath (SOB), section O-special treatment, procedures, and programs included oxygen. Record review of the care plan R#18 revealed a goal and interventions that included oxygen via n/c as needed (prn) for shortness of breath/respiratory distress, diagnosis (Dx) Hypoxia. Interventions included administering oxygen as ordered. Observation on 5/2/2023 at 11:09 a.m. R#18 was lying in bed, and appeared to be asleep, oxygen (O2) was coming from a concentrator at the bedside, with a flow rate of five liters per minute (5/LPM) via nasal cannula (n/c). The n/c was in the resident's nose, a water bottle dated 4/29/2023. Observation on 5/3/2023 at 8:30 a.m. R#18 was sitting up in bed, had just finished eating breakfast, n/c in the nose, O2 concentrator at the bedside with a flow rate at 5/LPM via n/c. Interview on 5/4/2023 at 9:55 a.m. with the Administrator revealed that R#18 was evaluated for hospice, and the order for oxygen may have been changed. The Administrator further stated that the oxygen settings should be set as ordered by the physician, and care plans followed. 41429 2. Record review of the physician orders for R#176 revealed an order dated 11/17/2022 for oxygen via NC (nasal canula) at two LPM (liters per minute) continuous. Record review of the comprehensive care plan did not reveal a care plan for oxygen use. Observation on 5/2/2023 at 9:17 a.m. and 2:25 p.m. R#176 was observed lying in bed with oxygen (O2) via nasal cannula in use at three liters per minute from a concentrator located at the bedside. Observation on 5/3/2023 at 11:37 a.m. and 12:55 p.m. R#176 was observed lying in bed with O2 via nasal cannula in use at four liters per minute from a concentrator located at the bedside. Interview on 5/4/2023 at 3:25 p.m. with LPN AA revealed that the charge nurses are responsible for developing comprehensive care plans and confirmed oxygen administration was not care planned for R#176 and should have been included. Interview on 5/4/2023 at 12:58 p.m. with Director of Nursing (DON) revealed her expectations of staff is to develop and implement a person-centered care plan based on the resident care needs. The DON reported that care plans are revised to reflect new medications and treatments and she was unsure why R#176 oxygen therapy was not care planned. She reported she was aware of her oxygen orders and confirmed oxygen administration should have been care planned because it's a medication. Cross refer F695.

Based on observations, staff interviews, and record review the facility failed to follow the physician's order for one of eleven residents (R) (#18, #176) reviewed for receiving oxygen therapy. Findings include: Observations on 05/02/2023 at 01:22 p.m., 05/03/2023 at 01:44 p.m., and 05/04/2023 at 11:21 a.m. revealed R#176's nasal cannula was operating at the rate of 3LPM while no orders for oxygen were found in the medical record. Observation and interview 5/4/2023 at 2:27 p.m. with Licensed Practical Nurse (LPN) AA confirmed the care plan did not reveal information involving respiratory care utilizing oxygen via nasal cannula at 3LPM. Record review of the most recent MAR & TAR for R#176 dated 5/4/2023 at 12:55 p.m. revealed no instructions for the administration of oxygen. LPN AA confirmed that R#176's oxygen was being delivered to R#176 at three LPM and did not have a physician's order for this medication. LPN AA reported that she had not checked her O2 settings. Interview on 5/4/2023 at 12:58 p.m. with Director of Nursing (DON) revealed her expectation of nurses was to ensure oxygen was administered per physicians' orders. She will investigate this matter and find out exactly why this happened. Interview on 5/4/2023 at 1:06 p.m. with Nursing home Administrator (NA) revealed the expectations of nurses were to ensure oxygen was administered per physicians' orders. She will investigate this matter and find out exactly why this happened. She will further make sure that all parties involved receive education on the proper steps to administer any medication including obtaining the necessary orders before doing so. 41429 2. Record review of the physician order for R#18 revealed oxygen (O2) two liters per minute (LPM) via nasal cannula (n/c) continuously for shortness of breath (SOB) to keep O2 saturations (Sats) greater than 90%-order dated 10/22/2023; oxygen therapy three liters via mask at hours of sleep (hs) for hypoxia-order dated 3/31/2023, clean oxygen concentrator and change O2 tubing every (q) week every Friday. Observation on 5/3/2023 at 11:11 a.m. R#18 was lying in bed sleeping, n/c in the nose, and the O2 concentrator at the bedside with a flow rate at five LPM. Observation and interview on 5/3/2023 at 11:30 a.m. in the room of R#18 with Licensed Practical LPN she confirmed the oxygen concentrator was running at five LPM via n/c and was in R#18's nose. LPN AA revealed she worked here as needed (prn) and was not at the facility often. LPN AA was not sure what the oxygen setting should be set at but would check the order for the correct setting. LPN AA checked the order and confirmed the oxygen setting should be set at two LPM, and she did not know who or why they would have turned it up to five LPM. Interview on 5/4/2023 at 9:55 a.m. with the Administrator revealed her expectation was that orders from the physician should be followed, and oxygen setting should be set as ordered by the physician.

Based on observation, policy review and staff interviews, the facility failed to ensure frozen food items in the walk-in freezer were properly labeled, dated, and discarded. In addition, the facility failed to maintain the cleanliness of the main ice machine located in the kitchen. This deficient practice had the potential to effect 107 residents receiving an oral diet. Findings include: 1. During the initial tour observation and interview on 10/26/21 at 9:00 a.m. with the Dietary Director (DD) revealed the following items were located in the freezer without proper labeling to include a date indicating when the item was received, when the item was opened, the expiration date, and/or the use-by date: One large, clear, plastic bag of Beef Ravioli with a hand-written date of 2/23/21 and no indication of what this date represents. One large, clear, plastic bag of Minit Chocolate Puree Dessert with a hand-written date of 3/2/21 and no indication of what this date represents. One medium, clear, plastic bag of Salmon with a hand-written date of 4/6/21 and no indication of what the date represents. One medium, clear, plastic bag of Salisbury Steak with a hand-written date of 9/18/21 and no indication of what this date represents. One medium, clear, plastic bag of hot dogs with a hand-written date of 10/20/21 and no indication of what this date represents. DD verified the frozen food items were improperly labeled and missing dates indicating when the item was received, when the item was opened, the expiration date, and/or use-by date. DD continued to state she could not confirm if the dates written on the clear, plastic, Ziploc bags was the date the package was opened or the date the package was received. Additional items in the freezer: One frozen package of pork, unlabeled Three 3-pound (lb.) bags of Medium Cheese Ravioli, unlabeled Four 2 lb. boxes of Fried Green Tomatoes, unlabeled One 1 lb. box of Assortment Mini Quiches, unlabeled One 12.7-ounce (oz.) box of Wrapped Cocktail [NAME], unlabeled DD verified the listed items do not have a label to include a date indicating when the item was received, when the item expires, and/or the use-by date. Review of the undated facility policy titled Food Storage revealed sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Further review revealed frozen foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 2. On 10/26/21 at 10:30 a.m., during an observation of the kitchen with Assistant Maintenance Director (AMD) revealed the ice machine was dirty with a dark, grease-like substance located on the back wall of the ice machine. Continued observation revealed dark grease-like substance located underneath the ridge of the ice machine door opening. An interview with AMD on 10/26/21 at 10:30 a.m. confirmed the dirty, dark, grease-like substance located on the back wall of the ice machine and the dark grease-like substance located underneath the ridge of the ice machine door opening. An interview with Maintenance Director (MD) and the AMD on 10/27/21 at 10:30 a.m. revealed it is the responsibility of the maintenance staff to maintain the cleanliness in the kitchen as well as the ice machines in the building. AMD stated the policy used for maintaining the cleanliness of the ice machines is entitled Ice Machines. Review of undated facility policy entitled Ice Machine revealed check water filters, clean coils, sanitize interior, sanitize interior of ice machine per manufacturer's instructions and clean out and sanitize the ice bin, and clean exterior. Review of the maintenance log for cleaning ice machines dated 6/30/21 through 9/30/21 revealed electronic documentation states due date, Category (ice machines/ice bins), Task Description (Ice Machines: check filters clean coils, sanitize interior, delime as necessary), and Task Completion (marked done on time by). Continued review of maintenance log for the ice machines revealed no indication which ice machine was cleaned.

Based on observations, interview, record review, and policy review, the facility failed to ensure the reach-in freezer temperature was cold enough to ensure food remained frozen affecting 119 residents who received meals prepared in the kitchen (three residents received tube feeding) out of a total of 122 residents. The failure to ensure frozen foods were maintained at proper temperatures created the potential for the spread of food borne illness. Findings include: 1. Facility Policy The Refrigerators and Freezers policy dated (MONTH) 2008 indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The policy indicated the following: 1. Acceptable temperatures should be 35 (degrees) F to 41 (degrees) F for refrigerators and less than 0 (degrees) F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures . 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. 5. The supervisor will take immediate action if temperatures are out of range. 2. The initial kitchen inspection was conducted on 10/16/18 from 9:16 a.m. through 9:44 a.m. with the Dietary Director. The reach-in freezer by the three-sink pot washing area had an internal temperature of 22 degrees Fahrenheit (F) according to a thermometer inside. The thermometer gauge on the exterior of the freezer read 10 degrees F; there were cases of pies with individually boxed boxes of pies in the reach-in freezer. 3. A follow-up observation was made in the kitchen with the Dietary Director on 10/19/18 at 11:15 a.m. The temperature of the reach in freezer by the three-sink pot washing area had an internal temperature of 31 degrees F according to a thermometer inside. The thermometer gauge on the exterior of the freezer read 20 degrees F. The freezer contained individually portioned cups of ice cream, and individual cups of fortified ice cream/pudding, boxes of apple pie, and boxes of sweet potato pie. The surveyor checked five ice cream cups located within different areas in the freezer for firmness. All the ice cream cups were soft with the sides of the Styrofoam cups being easily pushed in. 4. The Reach In by Pot and Pan Sink Freezer Temperature Record for the month of (MONTH) (YEAR) was reviewed in the kitchen with the Dietary Director on 10/19/18 at 11:23 a.m. The temperatures were measured twice daily, once in the morning and once in the evening. The Dietary Director stated the morning temperatures were taken between 7:00 a.m. and 8:00 a.m. Although it was after 11:00 a.m., the morning temperature had not been recorded yet for 10/19/18. Out of the 36 temperatures recorded in the log for the month of (MONTH) (YEAR), there were 12 temperatures above the maximum allowable temperature of 0 degrees F per the Refrigerators and Freezers policy dated (MONTH) 2008. The elevated temperatures were all recorded on the morning temperature check and were as follows: 1) 20 degrees F on 10/1/18 2) 20 degrees F on 10/2/18 3) 30 degrees F on 10/4 18 4) 30 degrees F on 10/5/18 5) 30 degrees F on 10/6/18 6) 30 degrees F on 10/7/18 7) 30 degrees F on 10/8/18 8) 20 degrees F on 10/9/18 9) 18 degrees F on 10/10/18 10) 30 degrees F on 10/13/18 11) 30 degrees F on 10/14/18 12) 19 degrees F on 10/16/18 Upon review of the temperature log in the kitchen with the Dietary Director at 11:28 a.m., the Dietary Director stated staff had not notified her of the elevated temperatures of the reach-in freezer and she stated she had not been aware of the elevated temperatures. 5. A third kitchen observation was made on 10/19/18 at 11:45 a.m. with the Dietary Director. The individual portioned cups of ice cream, fortified ice cream/pudding, boxes of apple pie, and sweet potato pie had just been moved to the walk-in freezer per the Dietary Director. Five more individual cups of ice cream, fortified ice cream/pudding were checked, and they continued to be soft and not firm/frozen. The case with three apple pies inside was removed from the freezer, the individually boxed pies were removed from the larger cardboard box. Each of the three individually boxed apple pies had a sticky coating of the apple filling covering the exterior of the boxes, indicating the pies had not been frozen solid. 6. On 10/19/18 at 12:13 p.m. the Dietary Director was interviewed in the Chapel and stated the dietary staff were to notify her if the temperature of the freezer was 32 degrees and above. The Dietary Director stated she checked the freezer logs a couple times a month; however, had not identified the issue with the reach in freezer. When notified the policy indicated the temperature should be less than 0 degrees for the freezer and not 32 degrees, she agreed it should be less than 0 degrees F. The Dietary Director stated she would educate her staff about the required temperatures for the freezer. When asked if she had notified maintenance about the elevated freezer temperature, she stated she had not, but would put in a work order now.

Based on record review and staff interview, the facility failed to develop a care for the use of antidepressant medication for one (1) resident (#18) from a sample of thirty (30) residents. Findings include: Record review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident received an antidepressant for the seven (7) days of the assessment period. Continued review of the Care Area Assessment Summary revealed that the [MEDICAL CONDITION] Drug Use triggered and would be care planned. Review of the current physician's orders [REDACTED]. Review of the resident's care plan revealed no evidence that a care plan for [MEDICAL CONDITION] Drug use had been developed. Interview with the Minimum Data Set (MDS) Director on 04/08/2015 at 11:35 a.m., revealed that a care plan should have been developed but was not.

Based on complaint allegation, record review and staff interview the facility failed to allow the resident to remain in the facility. Problems were found on one (1) resident from a sample of four (4) residents. Findings include: Resident # 1 was admitted to the facility after being hospitalized for [REDACTED]. A daily skilled nursing note dated 3/22/2014 revealed that the resident was transferred to the hospital at the request of the family member. PAR (Patients At Risk) notes dated 3/25/2014 revealed that the resident was transferred back to the facility 3/24/2014. Social Service Progress notes dated 3/24/2014 indicated that the resident had been discharged for m the facility 3/22/2014 when he was admitted to the hospital. Social Service Progress notes notes dated 3/12/2014 indicated that the resident was participating in therapy and the intention was to return to the assisted living facility where he previously resided. Social Service Progress notes dated 3/24/2014 indicated that the resident had been discharged for m the facility 3/22/2014 when he was admitted to the hospital. The note further indicated that upon return the family member inquired about long term admission and was reminded that the resident's admission was for short term rehabilitation. A Social Services Progress note dated 3/28/2014 indicated that a meeting was held with the resident's family and at that time the family inquired about long term admission. The note further indicated that the resident's admission was for short term therapy only and the family was reminded again. A Discharge Planning Note dated 4/8/2014 indicated that the family came by to discuss discharge issues. The family member had been to the assisted living facility and the spoken with the person there about the resident's mobility issues. Social Services and therapy discussed the resident's progress. The note further indicated that the family member was reminded that the admission was for a short term therapy stay only. physician's orders [REDACTED]. Review of the facility Admit/discharge to/from Report revealed that the resident discharged for m the facility 4/22/2014. Interview with the Social Services Person on 4/23/2014 at 12:00 p.m. revealed that the resident was never offered a bed to stay long term. On admission the family was told he was here for short term therapy and the family signed an agreement that he was short term stay. This social worker statedshe was not part of the admission process. Interview with the administrator at 2:00 p.m. on 4/23/2014 indicated that the family had signed the short term agreement and were made aware that he was short term stay.

Based on observation, record review, and staff interview, the facility failed to revise the Care Plan related to fall-prevention for two (2) residents (#5 and #139), who had a history of [REDACTED]. This failure resulted in actual harm for Resident #5, who experienced a fall and sustained a 3 centimeter (cm) by 1 cm skin tear to the left ankle, and a 7 cm by 7 cm area of swelling and blue discoloration to the right ankle. Findings include: 1. Record review for Resident #5 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 04/03/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS indicated that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 09 at that time, thus indicating that the resident had only moderate cognitive impairment. Additionally, this MDS further documented, in Section G - Functional Status, that Resident #5 required the extensive physical assistance of two-plus persons with bed mobility, but required the extensive physical assistance of only one (1) person for dressing. Review of the current Care Plan for Resident #5 revealed a Focus area, dated as having been initiated on 04/22/2013, which identified that the resident was at risk for falls related to a history of multiple falls secondary to poor safety awareness and attempting to transfer unassisted. Interventions to address Resident #5's fall-risk included to answer the call light promptly, to place the bed in the lowest position, to place a Dycem to the wheelchair, to provide frequent check rounds, and to keep the call light and most frequently used personal items within reach. The 04/22/2013 Care Plan also included a Focus area which indicated that Resident #5 required assistance with his/her daily care needs related to cognitive deficits and physical limitation. Interventions included to allow sufficient time for daily Activities of Daily Living (ADL) care, to assist with ADLs daily, to give baths as scheduled, to check for incontinence upon rounds and as needed, and to give the resident choices of attire. A Significant Change MDS having an Assessment Reference Date of 07/10/2013 for Resident #5 documented in Section - Cognitive Patterns that as of that date, the resident's BIMS score had declined to 03 (a decline from a BIMS score of 09 as documented on the 04/03/2013 MDS referenced above), thus indicating that the resident's cognitive status had declined and was now severely impaired. Section G - Functional Status of this 07/10/2013 MDS also indicated that Resident #5 continued to require the extensive physical assistance of two-plus persons for bed mobility, but also noted that the resident's status had declined to now require the extensive assistance of two-plus persons for dressing (a decline from requiring only one-person physical assistance with dressing as reflected on the 04/03/2013 MDS referenced above). Review of the Care Plan for Resident #5 revealed that the Focus area for fall-prevention was dated as having been reviewed/revised on 07/19/2013, with Interventions added to include the use of a body alarm while in the wheelchair, and the use of a shoulder harness to the wheelchair when out of bed for upright positioning. Additional Care Plan Interventions which were added for fall-prevention included the 08/30/2013 addition of the use of a bed alarm, fall mat, and bed bolsters; a 10/08/2013 addition for the provision of pain management as needed; and, a 10/13/2013 addition specifying the use of a thrust cushion in the wheelchair. The Care Plan Focus area for ADL care for Resident #5 was also dated as having been reviewed on 07/19/2013, but with no Care Plan revisions added at that time. The only subsequent Care Plan revision related to ADL Care Plan for Resident #5 was dated 10/11/2013, and specified referral to the Restorative Nursing Program/Functional Maintenance Program. However, even though the 07/10/2013 Significant Change MDS referenced above for Resident #5 had identified that the resident's cognitive status had declined to reflect severe cognitive impairment, and even though the resident's ADL status had declined to require the extensive assistance of two-plus staff persons during dressing (verses requiring the assistance of only one (1) staff person per the earlier 04/03/2013 MDS), further review of the fall-prevention and ADL/dressing Care Plan Interventions for Resident #5 revealed no evidence to indicate that the existing Interventions on the Care Plan of 04/22/2013 had been assessed for effectiveness to ensure the resident's safety during dressing. There was also no evidence to indicated that any revisions had been made to the original Care Plan of 04/22/2013 for Resident #5 to reflect the need for two (2) staff persons to assist the resident during dressing, or to reflect new interventions, to ensure the resident's safety while being assisted with dressing by staff. Clinical record review for Resident #5 revealed a Nurse's Notes entry of 10/23/2013 at 11:00 a.m. which documented that a certified nursing assistant had been attempting to place a shirt on the resident while the resident was sitting on the side of the bed and the resident had fallen to the floor. A later 10/23/2013, 2:30 p.m. Nurse's Notes entry documented that Resident #5 had sustained a 3 centimeter (cm) by 1 cm skin tear to the left ankle, and a 7 cm by 7 cm area of swelling and light blue discoloration on the inside of the right ankle. However, further review of Resident #5's current Care Plan revealed that, even after Resident #5's fall from the bed on 10/23/2013 while being assisted with dressing by the CNA, there was no evidence to indicate that the Care Plan Interventions for the identified Focus areas of fall-prevention and ADL/dressing had been reviewed for their effectiveness or to reflect additional interventions to ensure the resident's safety during dressing after this fall. Subsequent record review revealed that Interventions had been added to Resident #5's Care Plan on 11/20/2013 (during this standard survey), for both fall-prevention and ADL Focus areas, to specify that staff were not to dress the resident while sitting on the side of the bed, but there remained no reference to the number of staff persons needed to assist the resident while dressing. During an interview with the Director of Nursing (DON) conducted on 11/21/2013 at 9:40 a.m., the DON stated that it was the Unit Manager's responsibility to update resident Care Plans, and further acknowledged that the Care Plan for Resident #5 had not been updated to ensure the resident's safety until after surveyor inquiry on 11/20/2013. Cross refer to F323 for more information regarding Resident #5. 2. Record review for Resident #139 revealed an Annual MDS having an Assessment Reference Date of 09/18/2013 which documented in Section C - Cognitive Patterns that the resident had a BIMS score of 09, indicating moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #139 required the extensive assistance of staff for toilet use, and also that the resident was not steady moving on and off the toilet. Review of Resident #139's Care Plan revealed a Focus area, dated as having been initiated on 10/03/2012 and reviewed as recently as 10/23/2013, which identified that the resident was at risk for injury from falls related to impaired mobility, cognitive deficits, diuretic medication use, [MEDICAL CONDITION] medication use and senile dementia. This Care Plan identified multiple Interventions to address this resident's risk for falls, such as a 10/03/2012 Intervention specifying that staff monitor for proper footwear, 10/07/2013 Interventions which specified the use of a bed alarm, the use of a chair alarm in the recliner, and the use of a floor mat at the bedside, and a 10/23/2013 Intervention which specified the application of Blue Bolsters to the bed. During an observation of Resident #139 conducted on 11/20/2013 at 9:30 a.m., the resident was noted to be seated in a wheelchair in the room, with a chair alarm attached to the back of the wheelchair and non-skin socks applied to the feet, in accordance with the Care Plan. Additionally, a floor mat was noted to be placed on the floor by the resident's bed, per the current Care Plan. During a later observation on 11/20/2013 at 10:40 a.m., Resident #139 was observed to be seated in the facility's common area in a wheelchair, and at that time, a chair alarm was applied to the back of the wheelchair and non-skid socks were applied to the feet, per the current Care Plan. Clinical record review for Resident #139 revealed a Nurse's Notes (NN) entry of 10/19/2013 at 7:30 p.m. which documented that the resident was noted in the restroom on the knees between the toilet and the wheelchair. This NN entry documented that the resident had slid down onto the knees, with the CNA being unable to stop the fall. The NN also documented that there were no apparent injuries, and that the physician was notified of the fall. A Patients At Risk (PAR) notes entry of 10/20/2013 for Resident #139 documented that the resident had been lowered to the floor in the bathroom on 10/19/2013. This PAR notes entry documented that Resident #139 was being assisted by staff when the resident voiced he/she was coming off the toilet, and staff then lowered the resident to the floor. This PAR notes entry further documented that staff had been educated to make sure that the resident was all the way back on the toilet during toileting, and to stay close by the resident during toileting. However, review of Resident #139's current Care Plan revealed no evidence to indicate that the Care Plan had been reviewed since the time of the 10/19/2013 fall from the toilet referenced above to assess the effectiveness of the current Interventions related to fall-prevention during toileting. There was also no evidence to indicate that the resident's Care Plan had been review and revised to reflect the need for the staff to ensure that the resident was seated all the way back on the toilet during toileting, and the need for staff to stay close to the resident during toileting, as reflected in the 10/20/2013 PAR note referenced above. Further record review for Resident #139 revealed that it was only on 11/20/2013, during this standard survey, that an Intervention was added to Resident #139's Care Plan Focus area for fall-prevention which specified, as referenced in the 10/20/2013 PAR note, that staff were to encourage the resident to sit back on the commode seat during toileting. However, the resident's Care Plan for fall-prevention still did not reference the need for staff to stay close to the resident during toileting, as had been indicated in the 10/20/2013 PAR notes entry. During an interview conducted on 11/21/2013 at 9:40 a.m., the DON acknowledged that the Care Plan for Resident #139 had not been revised after the resident's fall from the toilet on 10/19/2013 to reflect the new 10/20/2013 fall-prevention intervention involving resident placement on the commode seat, as indicated in the PAR notes entry, until after surveyor inquiry on 11/20/2013.

Based on record review, Physical Restraint Flowsheet review, Resident ADL Record review, and staff interview, the facility failed to ensure that one (1) resident (#5) who was at risk for falls, of four (4) sampled residents reviewed for falls, from a total sample of twenty-eight (28) residents, received the necessary supervision to prevent a fall. This failure resulted in actual harm for Resident #5, who fell from the bed and sustained a 3-by-1 centimeter (cm) skin tear to the left ankle and a 7-by-7 cm area of swelling and blue discoloration to the right ankle. Findings include: Clinical record review for Resident #5 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/02/2013 which indicated in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Section G - Functional Status indicated that Resident #5 had required the extensive physical assistance of two-plus persons for bed mobility, and had also required the extensive physical assistance of two-plus persons for dressing (including putting on and removing all items of clothing). A Physical Restraint Flowsheet for Resident #5 documented a 04/03/2013 entry which indicated that the resident was unaware of his/her safety needs, and would lean forward at times. Resident #5's Care Plan referenced a Focus Area, dated as having been originally initiated on 04/22/2013, which identified that the resident was at risk for falls. A CAT Module dated 07/18/2013 also documented that the resident was at risk for injuries related to falls, and documented that the resident had a history of [REDACTED]. A Bed Safety Assessment form having an Assessment Date of 10/11/2013 for Resident #5 documented that the resident was unaware of his/her safety needs (had made unsafe attempts to get out of bed), had physical weakness, was unable to support his/her trunk in the upright position, and had a balance deficit. A subsequent Fall Risk Evaluation dated 10/19/2013 documented a Total Score of 26 for Resident #5, thus indicating that the resident continued to be at high risk for falls. A Nurse's Notes (NN) entry of 10/23/2013 at 11:00 a.m. for Resident #5 documented that a certified nursing assistant (CNA) reported that she had lowered the resident to the floor. This NN entry further documented that the CNA was attempting to put a shirt on the resident while the resident was sitting on the side of the bed. The CNA further reported that Resident #5 then started leaning over forward and was too heavy for the CNA to support, and thus the CNA lowered the resident to the floor. A later NN entry of 10/23/2013 at 2:30 p.m. documented that Resident #5 was noted to have sustained a 3 centimeter (cm) by 1 cm skin tear to the left ankle, and a 7 cm by 7 cm area of swelling with light blue discoloration to the inside of the right ankle. This NN entry documented that an ice pack was applied and that the physician was notified. A physician's orders [REDACTED]. A Patients At Risk (PAR) Note of 10/25/2013 documented Resident #5's 10/23/2013 fall during which the resident had slid off the bed and was lowered to the floor while being assisted with dressing by the CNA. This PAR note further documented that the CNA had been educated after Resident #5's fall that, when dressing the resident, he/she was not to sit the resident on the bedside, but rather to sit the resident upright in the bed until ready for transfer utilizing two people. During an interview with the Director of Nursing (DON) conducted on 11/21/2013 at 9:40 a.m., the DON stated that the CNA who had sat Resident #5 up on the side of the bed while assisting the resident with dressing on 10/23/2013, thus allowing the resident to fall, was not the resident's normally-assigned CNA. The DON stated that the Resident ADL Record for Resident #5 had been in the resident's room on 10/23/2013 when the resident fell while being assisted with dressing by the CNA, but stated that the Resident ADL Record did not instruct staff on how to assist the resident with dressing. The DON further acknowledged that this CNA had not had specific instructions on how to assist Resident #5 with dressing at the time of the 10/23/2013 fall which resulted in the skin tear to the left ankle and swelling and bruising to the right ankle. Review of the Resident ADL Record form for Resident #5 revealed a section entitled "Bathing & Dressing" which only indicated to "Assist" the resident. A hand-written notation on this Resident ADL Record did instruct staff to not dress the resident on the side of the bed, but this notation was dated 11/20/2013 (during this standard survey). Based on the above, for Resident #5, despite the resident having been assessed to require the assistance of two-plus persons for dressing, despite the resident having a history of falls and being assessed as being at high risk for falls, despite the resident having dementia and poor safety awareness, and despite the resident being unable to support his/her trunk in the upright position and having a history of leaning forward, the facility failed to ensure that the CNA providing care to the resident was knowledgeable about, or had specific instructions regarding, the safe procedure by which to assist the resident with dressing. This failure resulted in this staff member, who was providing care to the resident without assistance, allowing Resident #5 to sit on the side of the bed while placing a shirt on the resident, resulting in the resident sustaining a fall to the floor which caused a 3 cm by 1 cm skin tear to the left ankle and a 7 cm by 7 cm area of swelling and bruising to the right ankle.

Based on observation, record review, and staff interview, the facility failed to assess the use of a positioning device as a potential restraint and for potential negative outcomes for one (1) resident (#5), of three (3) sampled residents reviewed for restraints, from a total survey sample of twenty-eight (28) residents. Findings include: Resident #5 was observed on 11/19/2013 at 11:11 a.m. seated in a wheelchair with a shoulder harness device in place. The device was attached to the back of the resident's wheelchair and had Velcro straps that wrapped around the resident's shoulders. A review of the clinical record for Resident #5 revealed a 06/06/2013 entry on a Physical Restraint Flowsheet form that documented the use of a table top (in the wheelchair) was discontinued and that the use of a shoulder harness while up in the wheelchair was added for upright positioning. This form also documented that the harness was the less restrictive device. However, there was no evidence in the clinical record of an initial assessment of the shoulder harness device for safety and as a potential restraint. Further review of Resident #5's clinical record revealed that nursing staff completed a significant change Minimum Data Set (MDS) assessment for the resident on 07/10/2013. Even though there was no evidence to indicate that the shoulder harness device had been assessed for safety and as a potential restraint at that time, review of this 07/10/2013 MDS revealed that Section P - Restraints indicated that no physical restraints were in use for Resident #5 at that time. This MDS thus indicated that the use of the shoulder harness for Resident #5 was not coded as a restraint, with no evidence of an actual assessment of the device at that time to determine if the device did, or did not, serve as a restraint. The 07/18/2013 fall CAT module form accompanying the 07/10/2013 MDS for Resident #5 documented the self-release shoulder harness used while in the wheelchair was for upright positioning and as a reminder to the resident to call for assistance with transfers. Further record review for Resident #5 revealed no evidence to indicate that the resident could remove the shoulder harness until 08/28/2013, when a subsequent entry on the Restraint Flowsheet form indicated that the device was not a restraint and that the resident was able to remove it when he/she wanted. During interviews conducted on 11/20/2013 at 12:35 p.m. with Certified Nursing Assistant "AA", and on 11/21/2013 at 10:45 a.m. with the Director of Nursing and at 1:55 p.m. with the Therapy Director, these staff members stated that Resident #5 could remove the shoulder harness straps.