Every finding on record at Calhoun County Medical Care Facility

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 4/22/26 at 9:42 AM, observation of the main ice scoop holder found the bottom with white and brown crusted debris. An interview with Dietary Manager (DM) J found that it should get cleaned weekly. When asked why the inside bottom was roughed up, DM J stated they replaced the scoop and the old one had some rough edges, we will replace it. On 4/22/26 at 9:43 AM, observation of the underside of the tabletop mixer found some white accumulation of debris in the crevices of the under arm of the unit. On 4/22/26 at starting at 10:20 AM, observation of the [NAME] Court kitchen found the air gap for the ice machine had fallen below the overflow rim of the drain and was no longer creating a physical gap between the plumbing. An interview with DM J found that maintenance would take care of those issues.On 4/22/26 at 10:40 AM, observation of the Blue Spruce kitchen found yellow accumulation on the underside spout of the water dispenser in the drink station area. DM J removed the dispenser and cleaned the debris. On 4/22/26 at 10:50 AM, observation of the Red Oak kitchen found accumulations of crumbs and debris inside of the clean utensil drawers. When asked how often these drawers get cleaned, DM J stated they should get cleaned weekly. Observation of the ice machine drain found the air gap had fallen into the drain no longer creating a physical gap between the plumbing.On 4/22/26 at 11:06 AM, observation of the [NAME] Ridge kitchen found accumulations of crumbs and debris inside of the clean utensil drawers, with the metal spoon drawer observed with yellow sticky staining on the bottom of the drawer.On 4/22/26 at 11:33 AM, observation of the Beechwood and Maple upstairs kitchens found accumulation of debris in the utensil drawers. Further observation of the undercounter cabinetry found holes behind and near plumbing access points where pests could enter. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 4/22/26 at 1:24 PM, an interview with Facilities Operations Manager (FOM) K, regarding the facilities Water Management Plan, found that housekeeping staff flush the domestic water lines in the soiled utility rooms that are not used regularly. When asked if there were other rooms, or fixtures, that needed to be regularly flushed, FOM K stated that they typically don't have empty resident rooms for long and there were no other fixtures that would need flushing. When asked if the facility was performing any testing for disinfection or legionella, FOM K stated that they were not performing any sampling of the water. On 4/22/26 at 1:24 PM, observation of the [NAME] Ridge spa room found the spa tub disconnected from the water supply and moved into the far side of the spa. It was also observed that the shower fixture was taken off, indicating it was not used regularly. An interview with Maintenance Lead L found that the water lines run through the ceiling in this area. A further interview with FOM K found that staff and residents do not use this spa for showering and bathing residents, and that they take residents of this hall to another spa. When asked if these fixtures are on a flushing schedule, FOM K stated no. On 4/22/26 at 2:20 PM, observation of the Red Oak spa tub room, found that the room had been used for storage of boxes and supplies. The commode and sink portion of the tub room was not accessible for use or easy flushing of the water fixtures. The spa tub had been disconnected from the water supply, when asked how long the tub had been disconnected, FOM K stated it's been a while. A record review of the facility provided document entitled Water Management Program - Legionella, last revised on 4/15/2026, found that, The purpose of this Water Management Plan is to provide guidance on recognition, evaluation, and control of Legionella, as well as, verify and validate that control measures are effective. A further review of the policy, found under the heading Prevention, states that the facility would Eliminate any dead legs from the systems. and Avoid Stagnation. Under the heading High Risk Conditions states, These will be systems where: Stagnant water is present, i.e. dead legs, unused sections of the building. A final review under the heading, Control Measures states that, Residual chlorine should be checked to ensure proper disinfection is available.

Based on observation, interviews and record review, the facility failed to protect the resident's (R1) right to be free from mental and physical abuse by facility staff. This citation pertains to intake number 2672519.Findings Included:Per the facility face sheet Resident #1 (R1) was a [AGE] year-old female with diagnoses of cognitive communication deficit, dementia, muscle weakness, and need for assistance with personal care.Review of R1 Minimum Data Set, dated [DATE], revealed R1 had a Brief Assessment of Mental Status or BIMS score of nine out of 15 which indicated R1 had a moderate impairment with her cognition. The MDS also revealed R1 was on a scheduled pain medication but did not routinely have pain.Review of an incident report dated 11/7/2025, revealed R1 was noted to have, New areas of dark discoloration measuring 6.0 X 4.5cm (centimeters) was observed on Right wrist/thumb area and 7.0cm X 5.0cm to dorsum (back of hand) of her left hand, There is also a bleeding skin tear measuring 0.5cm X 0.5cm within the discoloration of her left hand. Resident (R1) was noted to be distressed and agitated.The incident report further revealed, Resident stated, two girls came in and beat me up. The incident report revealed under, Injuries Observed at Time of Incident that on the back of R1's right and left hand was bruising and additionally on the back of the left hand was a skin tear. The incident report revealed R1 had a pain score of seven out of 10. The report also indicated R1 was noted to have emotional distress immediately following care that was provided.Further review of the incident report revealed the bruising measurements were, Right had wrist thumb area bruising 6cm X 4.5cm and 1.0cm X 1.5 cm bruising at right wrist. Left back of hand 7.0cm X 5.0cm X bruising with a 0.5cm X 0.5cm skin tear in the bruised area. The incident report revealed R1 presented with agitation and appeared to be angry. The report revealed R1 continued to repeat those girls whooped on me and was expressing discomfort to both of her hands. Review of the facility's five-day investigation dated 11/17/2025, revealed that Director of Nursing DON B interviewed Certified Nurse Aid (CNA) D. CNA D reported to DON B that R1 told her that her legs were painful while she was assisting her with getting her pants on. CNA D told DON B that R1 was fine until she assisted R1 to sit up at the side of the bed, and it was then that R1 became distressed and started to repeat that CNA D was hurting her; then hit CNA D on the shoulder. The investigation further revealed that CNA L reported that she heard R1 yelling from the hall, so she went into R1's room and told CNA D to go get the nurse. CNA L also reported that when she entered R1's room R1 was sitting at the side of her bed, and she noted that R1's hands were discolored, and a skin tear was also present. CNA L indicated to DON B that R1 wanted to lie back so she assisted R1 with lying back down and provided incontinence care for R1. CNA L reported to DON B that R1 continued to yell out while she provided the incontinence care, telling CNA L that she was hurting her. Registered Nurse (RN) G reported to DON B in a statement that upon her entering R1's room R1 was noted to be in distress and alleging that those girls were beating her up. Review of R1's Physician's orders dated 11/7/2025, revealed an order to, Observe Bruising on bilateral wrists and hands. Observe skin tear on back of left hand keep clean and dry. and Document every shift in Progress Notes any findings or residents' mood and behaviors.Record review of R1's care plans revealed a Focus that was in place titled I am at risk for pain r/t (related to) osteoarthritis. Date Initiated: 01/19/2021 Interventions included: Observe for probable cause(s) of each pain episode. Remove or limit causes where possible ., date Initiated: 01/19/2021.Review of the Facility Investigation Report (FRI) dated 11/7/2025, revealed CNA L reported that R1 was yelling out that she was hurting when she was providing care to her, and was asking CNA L to leave her room, but CNA L did not leave R1's room, continued to provide care to R1,and did not stop what she was doing because CNA L perceived R1 needed the care as she was incontinent of her bladder. The incident report revealed that R1's Durable Power of Attorney (DPOA) was contacted by the facility, and the DPOA stated that she had been at the facility the evening prior to the incident, 11/6/2025. The DPOA was documented to have stated that R1 did not have any injuries to her hands. Further review of the incident report revealed R1's DPOA then went to the facility to see R1's hands and confirmed that the discoloration or bruising was not present during her prior visit on 11/6/2025. The facility reported incident also revealed that the facility Social Worker performed an interview with R1, and R1 showed the Social Worker the bruise on her left wrist and said, This hurts, Them girls did this to me. The Social Worker further documented that R1's sister arrived to see her and R1 told her sister that, The girls did this. They pinched me, I guess.Review of a progress note dated 11/17/2025 (10 days after the incident), revealed R1 was assessed for psychosocial status, and was asked about the bruising to her hands in which R1 stated, Oh it was those girls, and they laughed at me when they did it.Review of an Employee Warning Record dated 11/11/2025 revealed CNA D was discharged from her employment at the facility for reasons of, during providing care R1 became distressed, yelling out repeatedly that CNA D was hurting her. R1 continued to be in distress while sitting on the side of the bed and demanding that the police be called, alleging that those girls were beating her up. Upon DON B assessing R1's hands it was noted that R1 had dark discoloration to both of her hands that appeared to be fresh bruising and had a skin tear to her left hand which was actively bleeding. It was documented that R1 stated that her hands were painful and when asked what happened R1 was documented to have stated, those girls were whooping on me.Review of an Employee Warning Record dated 11/11/2025 revealed CNA L was discharged from her employment at the facility for reasons of, during providing care R1 became distressed, yelling out repeatedly that CNA C was hurting her. R1 continued to be distressed while sitting on the side of the bed and demanding that the police be called. alleging that those girls were beating her up. Upon DON B assessing R1's hands it was noted that R1 had dark discoloration to both of her hands that appeared to be fresh bruising and had a skin tear to her left hand which was actively bleeding. It was documented that R1stated that her hands were painful and when asked what happened R1 was documented to have stated, those girls were whooping on me.Review of R1's progress notes dated 11/7/2025 revealed, Licensed Practical Nurse (LPN) H made a note that revealed, at approximately 8:00 AM on 11/7/2025 he entered R1's room and found R1 to be yelling get out and leave me alone, and R1 stated that Two girls were beating her up and hurting her. The noted further revealed that R1 made the statement that the two girls were grabbing her arms and twisting them The note revealed R1 held her hands up and indicated her hands were painful, and LPN H observed discoloration to the left hand that measured 7.0 cm X 5.0 cm with a skin tear in the center measuring 0.5 cm Z 0.5 cm with active bleeding. It was also documented that R1's right hand was also discolored from her thumb to her outer wrist that measured 6.0 cm X 4.5 cm. The note revealed R1 stated she wanted to go back to sleep and to not let those girls back into her room.Review of a progress note dated 11/7/2025 at 11:00 AM revealed, Mood changes (different from baseline): Describe before vs (versus) after allegation and f/u (follow-up) done: Resident (R1) presented with agitation and appeared to be angry. She continued to repeat that those girls whooped on me.Observation of a picture of both of R1's hands revealed on the back of her right hand a very dark large bruise that extended from the base of her thumb to just below her wrist, and on the back of R1's left hand a large dark bruise was observed that extended from just before the thumb to the middle of R1's hand and another bruised area that was over R1's top of her wrist.Review of CNA L's written statement dated 11/7/2025, revealed CNA L entered R1's room upon hearing R1 yelling out, and when CNA L entered she noted a skin tear, and R1's hands were covered in puffy blood like pockets. CNA L's statement revealed R1 wanted CNA D out of her room and for CNA D to not touch her. CNA L's statement revealed R1 was yelling out in pain, and CNA L documented that she had never seen R1 in so much pain and distress before.In an observation on 11/20/2025 at 4:00 PM, R1's hands were noted to have faint blue areas on both hands that resembled fading bruising.In an interview on 11/20/2025 at 4:06 PM, Registered Nurse (RN) I stated that she worked with R1 until 11:00 PM on 11/6/2025, and then on 11/7/2025 she was asked by management at 8:30 AM if she had noticed any bruising on R1 hands. RN I said she reported no. RN I said the interview was via phone call and that was her day off, but she decide to go to the facility to see R1's hands for herself, and upon observation of R1's hands RN I stated the bruising was very obvious and there was no way that she would have missed the bruising when she cared for R1 on 11/6/2025 if it was present. RN I said there was also a skin tear, and when she asked R1 what happened R1 stated that girls grabbed her, but did not say who those girls were, but R1 did indicate it was the girls (CNA L & D) from that morning (11/7/2025). In an interview on 11/24/2025 at 9:44 AM, Certified Nurse Aid (CNA) J stated he worked from 7:00 AM to 11:00 PM on 11/6/2025 and did not see a skin tear nor bruising to R1's right or left hand. CNA J said that he arrived for work on 11/7/2025 at 11:00 AM, and that was when he noticed the bruising on R1's hands. CNA J described the bruising as dark on R1's right and left hands with one of the bruises extending from her thumb to her wrist area. CNA J said he could not recall which hand had which bruise or the skin tear. CNA J said he had walked up to R1 while she was in the dining room, and the bruising was the first thing he noticed which caused him to be surprised. CNA J said he had never seen R1's hands that bruised. During interview CNA J stated that R1 is not combative when care is provided for her and said it would take a lot to make R1 upset.In an interview on 11/24/2025 at 10:32 AM, LPN H, who was the Nurse Manager of the Special Care unit, stated that about 8:00 AM he went to R1's room, and R1 was screaming and being difficult. LPN H said R1 she was screaming and being difficult when he walked into the room and R1 was saying get them out of here, get those two girls out of here. LPN H said R1 had held her hands up and on the back of her left-hand there was actual bruising, and a skin tear. LPN H said on the back of R1's right hand below the thumb and down her wrist and arm there was bruising that was dark purple. LPN H said R1 stated that those two girls were beating her up.During the interview LPN H stated that CNA L and CNA D were asked by R1 to get out of her room and leave her alone but stated CNA L and CNA D did not stop and did not leave R1 alone as R1 requested. LPN H said CNA L did not stop because R1 was wet and she needed to change R1's brief even know R1 told CNA L to get out and leave her alone.In an interview on 11/24/2025 at 10:57 AM, CNA K stated that she had worked the previous day, 11/6/2025, from 7:00 AM to 7:00 PM. CNA K said she received a phone call regarding the bruising on R1's hands, but stated the bruising was not present on 11/6/2025 when she worked. CNA K said when she returned to work on 11/8/2025 at 7:00 AM, she then saw R1 did have a skin tear to her left hand along with bruising on R1's wrist and down her wrist, and stated that R1's right hand had a bruise that CA K stated resembled a palm print, and also had a skin tear. CNA K said the bruises were a dark purple, and it was painful to R1 to touch them. CNA K said it is not R1's nature to be combative when care is being provided and said R1 complies with everything that is asked of her. In an interview on 11/24/2025 at 11:35 AM, LPN G stated that CNA D had approached her and told her she was having problems getting R1 out of bed and told me she had bruising. LPN G said R1 stated that the girls beat her, and she wanted the police. LPN G said CNA D was providing care but R1 would not let her, so CNA L said she would take over. LPN G said R1 had a skin tear on the back of one of her hands that was actively bleeding and black, blue, and purple bruising all on the very top of both hands. Despite the residents request to notify the police, the facility did not notify law enforcement of the incident against R1. In an interview on 11/24/2025 at 11:57 AM Director of Nursing (DON) B stated she received a phone call after 8:00 AM to go upstairs to look at R1's hands, and upon entering R1's room she found R1 agitated and upset. DON B said R1 showed her hands to her, and what DON B stated she saw was dark discoloration with a skin tear on the left hand that was actively bleeding. DON B said R1 told her That those girls whipped me but did not say who the girls were. DON B said she asked CNA L and D what happened, and CNA D said she went to get R1 up and when she assisted R1 to a sitting position on the edge of bed that was when R1 got upset. DON B said CNA L then entered R1's room and laid her back down. DON B said CNA L noted that R1 needed a brief change however, R1 told CNA L to stop (changing her brief) because she was hurting her. DON B said CNA L did not stop when she was asked by R1 to stop.Upon concluding the interview DON B stated that she immediately suspended CNA L and D, because the facility could not disprove either CNA L or D harmed R1 including the fact that CNA L did not respect R1's rights to have the care being provided to stop upon R1's request. In an interview on 11/20/2025 at 1:21 PM, CNA L gave a statement of what she stated happened. CNA L stated it was in the morning time when she heard R1's room call light go off so she stated that she responded to the call light and upon approaching R1's room door she heard R1 screaming. CNA L said CNA D was attempting to get R1 dressed all while R1 was screaming CNA D was hurting her. CNA L said R1 said she was not ok because CNA D was hurting her. CNA L said she asked CNA D to go get the nurse, and while that was happening, she asked R1 how she could help her and R1 said she wanted to get back in bed. R1 said upon assisting R1 to lay back down in bed, R1 started screaming it hurt. CNA L said R1 was soaking wet and said she told R1 that she needed to have her brief changed and said as soon as she started rolling R1 over R1 started yelling out in pain again. However, CNA C said she went ahead and changed R1's brief anyway because R1 was already rolled over in the bed. CNA L said she cleaned R1 up, and then rolled her back over. CNA L said that was when R1 yelled that she wanted me out of her room, and that she wanted the police called. CNA L said she originally went into R1's room to see if she could calm R1 down, and once she was able to get R1 safe and back in bed she continued to place a new brief on R1 and roll her back over. CNA L said even though R1 had asked her to stop once she had R1 rolled over, she continued to conduct the care because R1 was already turned over.CNA L further stated that R1 said that she and CNA D had abused her, and because the facility investigation revealed abuse, she was terminated for abusing R1. In an interview on 11/20/2025 at 2:24 PM, CNA D gave a statement of what she stated happened. CNA D stated that she went into R1's room to get her ready, and while providing care R1 yelling out that I hurt her hands. CNA D denied she ever touched R1's hands. CNA D said she had never seen R1 act that way before. CNA D said CNA L came in R1's room to assist her and said she handed the wash clothes and brief to CNA L along with a Kleenex, because R1 had a skin tear on her hand. CNA D said she went to the nurse and told the nurse what was happening and reported the discoloration on R1's hands. Then stated she went back to R1's room, and noted CNA L had turned R1 onto her side, and R1 was yelling get out, get out, you are hurting me. CNA D said R1 wanted CNA L out of her room, and wanted the police called. Review of CNA D's education revealed that on 3/23/2025 CNA D had received training on abuse prevention and the Elder Justice Act including dementia training on 7/26/2025.Review of CNA L's education revealed she was educated on preventing, recognizing, and reporting abuse on 1/21/2024, and abuse prevention and the Elder Justice Act on 7/24/2023, including dementia training on 4/29/2024. Further review of CNA L's employee file revealed email documentation that a resident was standing next to her bed raising her voice. Another staff member entered the room and asked if everything was alright in which CNA L stated yes but the resident stated no, she (CNA L) keeps pushing me and pulling on my arms telling me to lay down. The facility investigation revealed that the facility was able to substantiate the allegations of abuse against CNA L and D, and that CNA L and D's actions caused and/or contributed to the emotional distress and physical injuries R1 sustained on 11/7/2025. The 5-day revealed CNA L and CNA D were both terminated from their employment at the facility on 11/11/2025.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During an interview with Facilities Operations Manager (FOM) M, starting at 10:23 AM on 2/20/25, it was found that the facility does not currently have any routine testing on the facilities water supply. When asked if there was a team that oversaw the Water Management Program (WMP), FOM M stated she was unsure of a team. When asked what facility established control limits were in place in order to decrease the risk of Legionella and OPPP from growing a spreading in the facility, FOM M was unsure and stated she was slightly newer to the position and had not had much to do with WMP before. During a tour of the facility, with FOM M, starting at 10:53 AM on 2/20/25, the following water fixtures were identified as having an increased risk of developing OPPP / Legionella: A review of [NAME] Ridge soiled utility room hopper found discolored water momentarily dispensed from the faucet over the hopper. A review of the Red Oak janitors closet found the cold-water line was shut off and a sewer gas odor was present with air coming from the drain for the Janitors sink. This indicates that faucet has not been used in so long that the p-trap for the wastewater line has evaporated. A review of the Maple soiled utility room hopper found that brown and discolored water ran from the faucet above the hopper for roughly 10 seconds before becoming clear. When asked if she could see the discolored brown water, FOM M stated yes. Further review found that the foot pedals to the hopper spray were found turned off, creating a stagnant line. A review of the upstairs Service Hall found a large commercial humidifier attached to the water line that was left on. When asked if the facility uses the humidifier, FOM M stated no, it's been down for as long as she knows. A review of the Beachwood soiled utility hopper found that dark brown water dispensed from the hot water supply for roughly seven seconds. A review of the facilities policy entitled, Water Management Program - Legionella, revised 1/12/24, found that under the Preventative Maintenance heading, it states System Flushing - Flush all drain outlets (both hot and cold) that are used less than once per week. Purging should be approx. 1-3 minutes or until temperature stabilizes. The document goes on to state that these flushing's should happen weekly. A further review found that an example given under High Risk Conditions, states anywhere is the building where Stagnant water is present . and where Biofilm is present - sediment, sludge, scale, organic materials, and iron oxide . The document goes on to state, under the sub paragraph entitle Control Measures, that Conditions throughout the building water system are not always uniform. For this reason, control measures should be monitored in multiple locations throughout the building. Under monthly frequency it states Disinfection levels - Residual chlorine should be checked to ensure proper disinfection is available from municipal source. No Centers for Disease Control (CDC) Legionella tool-kit was observed completed as part of the facilities WMP.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During an evaluation of the kitchen, at 10:02 AM on 2/18/2025, it was observed that clear plastic scoops of the bulk storage containers were found hanging on the outside perimeter of the containers facing where staff would walk by. Observation found two of the scoops with discolored dingy surfaces. When asked if the scoops are normally stored open exposed on the front of the bin about a foot or so off the ground, Certified Dietary Manager (CDM) K stated that's where they have been kept. Further observation found that neither of the three containers were labeled with the common name of the ingredients they contained. According to the 2022 FDA Food Code section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the FOOD with their handles above the top of the FOOD and the container .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food . During a tour of the main kitchen, at 10:22 AM on 2/18/2025, it was observed that the two compartment preparation sink was found directly connected to the waste water line. When asked if there was a basement under the kitchen, staff were unsure and were not aware of the drain having an air gap. When asked what the sink is used for, CDM stated staff use the sink for food preparation. During a tour of the Beachwood kitchenette, at 1:24 PM on 2/18/2025, it was found that the overhead dish spray was observed hanging below the overflow rim of the sink. It was also observed that the small two compartment sink, had a sink sprayer on the back side of the sink that could be pulled out and lay below the overflow rim of the sink. These plumbing set ups create the potential for cross connections between potable water and wastewater. During an interview with Facilities Operations Manager M at 1:55 PM on 2/20/2025, it was found that there is no basement under the kitchen and that all plumbing is in the floor indicating an air gap would not be present. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . According to the 2022 FDA Food Code section 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). During a tour of the main kitchen, at 10:21 AM on 2/18/2025, it was observed that a container of germicidal wipes was present on the three-compartment sink. The manufactures label stated the product was a high-level disinfectant and a further review of the label found it was not approved for food contact surfaces. When asked what staff use these wipes for, CDM K stated she doesn't think they use the wipes and are not sure why the container was stored there. During a tour of the janitors closet of the main kitchen, at 11:04 AM on 2/18/2025, it was observed that an open bottle of chemical (Spic and Span) was observed with no cap sealing the container. According to the 2022 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. During an initial tour of the facility, the following areas were observed to have an excess accumulation of debris: under the racks of the walk-in cooler floor, structural portions of the ventilation hood in the main kitchen, and behind the oven in the Red Oak kitchenette. When asked about the accumulation behind the oven on Red Oaks, CDM K stated that it's on our list to get done. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . 49272 During a tour of the kitchen, at 10:35 AM on 2/18/25, an interview with CDM K found that the facility does not regularly test their sanitizer buckets. When asked about the availability of test strips, it was found that the only test strips available had manufacture expiration date of [DATE]. Further review found that the test strips were for bleach based sanitizer and the facility uses quaternary ammonium. According to the 2022 FDA Food Code section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided. During an evaluation of the kitchen, at 11:00 AM on 2/18/25, an interview with CDM K found that the large floor mixer is used approximately five times per week. At this time, the mixer was observed to have dried, white, food debris on the grated splash guard and the mixer was not in use. During an evaluation of the kitchen, at 11:10 AM on 2/18/25, the meat slicer was observed to have an accumulation of dried food debris in the back under side portion of the blade. During an evaluation of the satellite kitchen in the [NAME] hall, at 12:04 PM on 2/18/25, the ice dispenser was observed to have a buildup of an orange substance inside the shoot. During an evaluation of the satellite kitchen on the Red Oak hallway, at 12:49 PM on 2/18/25, it was observed that the ice dispenser shown a buildup of an orange substance inside the dispensing shoot. During an evaluation of the satellite kitchen on the Blue Spruce hallway, at 1:04 PM on 2/18/25, the ice dispenser was observed to have a buildup of an orange substance inside the dispensing shoot. During an evaluation of the satellite kitchen on the Beechwood Hill hallway, at 1:24 PM on 2/18/25, the ice dispenser was observed to have a buildup of an orange substance inside the dispensing shoot. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based observation, interview, and record review the facility failed to ensure proper storage of medication in three of three medication carts and one medication room of three reviewed for medication storage. Findings include: During an observation and interview on 2/20/25 at 7:57 a.m., Registered Nurse (RN) T opened the Maple Grove Medication cart. RN T verified three opened undated eye drops including xalatin, cosopt, and alphagan. RN T reported should be dated when opened and reported some staff document items open date in binder on medication cart and verified was not documented. During an observation on 2/20/25 at 8:51 AM, Licensed Practical Nurse (LPN) U opened the [NAME] Court Medication cart. LPN U verified open undated eye drop prednisolone Acetate Ophthalmic Suspension 1 % and was unsure when it had been opened. During an interview on 2/21/25 at about 3:30 PM, Director of Nursing(DON) B reported would expect multidose medications including eye drops to be dated when opened and staff to follow, Medication with Shortened Expiration dates, guide placed in medication cart binders yesterday. DON B reported staff were educated on process starting yesterday. 49272 During an observation and interview on 2/20/25 at 10:51 AM, Licensed Practical Nurse (LPN) H opened the Red Oak Trail Medication cart. LPN H verified two opened undated eye drops including Brimonidine 0.2% and Latanoprost 0.005%. LPN H reported eye drops should be dated when opened. During an observation and interview on 2/20/25 at 11:19 AM, with LPN H the medication room on Red Oak Trail was reviewed, inside of an unlocked cupboard the following expired medications were found: an opened tube of triple antibiotic ointment labeled with a residents first initial and last name with a manufactures expiration date of 12/19, an opened tube of triamcinolone 0.1% ointment labeled with a residents first initial and last name with a manufactures expiration date of 12/13 and a bottle of carbamide peroxide ear drops with a manufactures expiration date of 7/24. When asked how expired medications should be handled, LPN H reported that they should be discarded. Review of the facilities policy titled Storage and Labeling of Drugs and Biologicals updated 12/30/24, documented in part All drugs must have an expiration date on the manufacture's container and will not be kept beyond this identified date .Specific medications such as insulins, ophthalmics and inhaler, for example, with shortened expiration dates once the medication is opened, will be dated when opened and will be discarded according to specific pharmaceutical guidelines .

Based on interview and record review the facility failed to perform a Minimum Data Set (MDS) significant change in condition assessment for one of 19 residents (Resident #87) resulting in the potential for care needs to be unmet. Findings Included: Per the facility census R87 was admitted to the facility on [DATE]. Review of a, Supportive Care Goals Worksheet document dated 1/21/2025, revealed 87's family consented for R87 to have no measures to sustain life, a do not resuscitate (DNR) order, no hospitalization , no routine testing, no routine weights, only essential medication and vital signs were to be given. At the bottom of the form under Supportive Care it was revealed that 87's authorized decision maker signed the form on 1/21/2025 stating that consent was given for Supportive Care, and to provide treatments to promote quality of life and comfort, rather that achieve improvement in health for R87. The Nurse Practitioner signed the form on 1/21/2025, and the Physician signed the form on 1/24/2025. Review of a, Statement of Likely Terminal Illness revealed R87 was determined on 1/29/2025 to have deterioration of health or natural death may occur within six months. The document was signed by the Physician eight days after the family consented to 87's supportive care. Review of a Change in Condition (not a significant change in condition MDS assessment) assessment dated [DATE], revealed R87 had a decrease in responsiveness, weakness, swallowing difficulty, when stimulated R87's breathing would get louder, moaning with repositioning, and not respond to stimulation. The assessment revealed that R87 would transition to Comfort Care. In an interview on 2/21/2025 at 12:14 PM, Registered Nurse (RN) L RN, who was the MDS nurse, stated that she did do a significant change MDS assessment in October of 2024, and said the assessment was conducted because R87 had transitioned to Supportive Care. The last significant change MDS assessment was completed October 14 2024. Under Section J1400. of the October 2024 assessment, revealed, Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . there was no check mark. R87 was not placed on supportive care until 1/21/2025. In an interview on 2/21/2025 at 1:10 PM, Director of Nursing (DON) B stated that Supportive Care was to provide the resident with all their wants and wishes. DON B said the resident would have no more hospitalization s, would become a DNR, would have no more blood drawn for laboratory testing. DON B said when the resident would have more changes that show end of life, the family would be encouraged to be around the resident more, comfort care would be provided, and what ever the resident needs and wants were would be provided. No significant change MDS assessment was completed for R87 as a result of R87's transition to Supportive Care, identification of a terminal illness with a life expectancy of less than six months to live.

Based on observation, interview, and record review the facility failed to insure that one resident (R57) was free from significant medications errors out of one resident reviewed for significant medication errors resulting in the potential for adverse physical reactions/outcomes to residents. Findings Included: Resident #57 (R57) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R57 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, congestive heart failure(CHF), chronic obstructive pulmonary disease, history of lung cancer with lung removal, diabetes mellitus, history pneumonia, anxiety and depression. The MDS reflected R57 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required set up dressing, hygiene; supervision with bathing and toileting; and partial/moderate assist with transfers. During an observation and interview on 2/18/25 at 10:07 a.m., R57 in room sitting upright in recliner and appeared able to answer questions without difficulty. R57 reported had concern about medications related to medication error that occurred on 2/15/25 afternoon shift. R57 reported had been sleeping and was waken by male nurse who who administered medications and later came in and apologized after reporting had administered R57 another residents medications. R57 reported staff informed R57 that Nurse Practitioner had been notified who said R57 would be okay. R57 stated, I felt fuzzy the next day. R57 reported staff did not follow up with her after medication error and reported usually reviews her medications but had been sleeping that day. Review of R57 Nurse Progress Note, dated 2/15/2025 at 10:44 p.m., reflected, Patient given Percocet[controlled narcotic] 10-325mg, Atorvastatin[used to treat high cholesterol] 40mg, Gabapentin[used to treat seizure disorder or nerve pain] 300mg given in error. No adverse effects noted during this time. [Named Assistant Director of Nursing(ADON) N, Nurse Practitioner(NP) O, and Nursing Home Administrator(NHA) A] all notified of the event at 19:50[7:50 p.m.]. Medication error form was completed. BP: 143/76 R: 16 P: 74 O2: 97% Resident is alert and oriented. Review of R57 Medication Administration Record(MAR), dated 2/1/25 through 2/20/25, reflected R57 was administered Hydrocod [NAME]-Chlorphe [NAME] ER Oral Suspension Extended Release 10-8 MG/5ML Give 5 ml by mouth as needed for cough on 2/16/25 at 1:03 a.m.(cough syrup with codeine, controlled narcotic, five hours after given Percocet 10mg((controlled narcotic)) R57 was not prescribed, in error). Review of the facility, MEDICATION AND TREATMENT ERRORS AND OMISSIONS, dated 2/15/25 at 7:30 p.m., reflected R57 received another resident medications in error that included Percocet 10/325mg, Atrovastatin 40mg, and Gabapentin 300mg. The document included description, [named LPN Q] pulled meds to pass, I thought she instructed me to take them to [named R57], but they were intended for [named other Resident S]. Review of the facility, CONTROLLED DRUG RECEIPT/RECORD/DISPOSITION FORM, dated 2/15/25 through 2/20/25, reflected LPN Q signed out Percocet 10/325mg for other resident S at 7:29 p.m. The record reflected hand written note on document by same entry, med error, given to another res. During a telephone interview on 2/20/25 at 3:00 PM, Licensed Practical Nurse(LPN) P reported had worked at the facility for three weeks and was currently still with preceptor. LPN P reported worked 2/15/25 night shift from 7:00 p.m. to 7:00 a.m. with preceptor LPN R. LPN P reported received report from day nurse LPN Q. LPN P reported preceptor LPN R stepped away and while waiting for LPN R to return, day nurse LPN Q asked LPN trainee P to deliver prepared medications to R57. LPN R reported must have misunderstood day nurse LPN Q because he thought LPN Q said R57 first name but actually medications were for another resident S with similar name. LPN P reported discovered about 10 minutes later after day nurse LPN Q had left the facility. LPN P reported assessed R57, informed of the medication error, completed paperwork, informed Nurse Practitioner (NP) O and Assistant Director of Nursing (ADON) N. LPN P reported NP O ordered to hold xanax, ibuprofen and R57 lesser dose of Atrovastatin. LPN P verified R57 was given Percocet 10/325mg(controlled narcotic pain medication), Atrovastatin 40mg, Gabapentin 300mg in error. LPN P reported monitored R57 through out night, however, was unsure if assessments had been documented with exception of vitals at the time of the medication error. LPN P reported R57 complained of feeling hazy in morning and was unsure if that was documented. LPN P reported had not worked since event and reported after the medication error Preceptor LPN R educated LPN P not to pass resident medications prepared by another staff. During a telephone interview on 2/20/25 at 3:32 PM, LPN Q reported had worked at the facility for about three months and was a new nurse. LPN Q reported had worked 2/15/25 on day shift and given to report to LPN R and Trainee LPN P around 7:00 p.m. and reported that another resident needed pain medications. LPN Q reported did not recall asking Trainee LPN P to pass medications she had prepared. LPN Q reported if she had prepared controlled narcotic medications they would be signed out by her on the, Controlled Drug Record. LPN Q reported received call from Director of Nursing(DON) B that day(2/20/25) about R57 medication error and reported was not aware of medication error until today. LPN Q reported had not yet received education related to incident. During a telephone interview on 2/20/25 at 4:02 pm, Preceptor LPN R reported had worked at the facility about 3 months and was a new nurse. LPN R reported was LPN P preceptor on 2/15/25 for first time. LPN R reported was not asked prior to having to mentor new staff but felt comfortable. LPN R reported received report from LPN Q, who was behind and finishing medication pass at shift change. LPN R reported LPN Q prepped another resident medications and informed LPN R resident had also requested hair and tooth brush. LPN R reported she went to obtain items and returned to medication cart less than five minutes later and LPN Q was gone and Trainee LPN P reported LPN Q told him to administered prepared medications to R57. LPN R verified another resident medications had been given to R57 in error. LPN R reported medication error to Assistant Director of Nursing (ADON) N, NP O and R57 and orders were obtained to hold three of R57 own medications. LPN R reported monitored R57 and completed medication error report and reported unsure if R57 monitoring was documented. LPN R reported R57 did report she felt fuzzy to LPN P in the morning and was unaware of documented or reported to provider. LPN R reported, new nurses usually work seven shifts with preceptors. LPN R stated she did educated LPN P not to administer medications prepared by someone else. During an interview and record review on 2/21/25 at 1:02 PM, -02/21/25 01:50 PM, Staff Educator Registered Nurse G reported had been staff educator for five years. RN G reported new hire nurse staff received one to two day classroom orientation then received training with preceptor on floor for several shifts depending on skill level. RN G reported preceptors receive training on how to train prior to being asked to be preceptor. RN G reported schedules are completed by facility scheduler along with DON B and RN G was not involved. RN G reported LPN R had not been trained to be a trainer and had not been asked prior to shift if she could be preceptor. LPN G reviewed the 2/15/25 schedule and reported there was a more seasoned nurse on night shift who would have been qualified and trained to be LPN P preceptor. RN G reported would expect nurse who prepared medication to administer medications especially controlled narcotic medications. During an interview on 2/21/25 at 1:54 PM, Director of Nursing(DON) B reported was made aware of R57 medication administration error on 2/17/25 and ADON N was notified shortly after incident. DON B reported called individuals involved and reported Trainee LPN P was working with LPN R on 2/15/25 7:00 p.m. to 7:00 a.m. shift with LPN Q on day shift 2/15/25. DON B reported LPN Q prepped medications and asked LPN P to administer to another resident but LPN P heard R57. DON B reported would expect nurse who prepares medication to administer medications. DON B reported staff schedule completed by scheduler and Staff Educator G during training and reported DON B was not involved in scheduling new staff.

Based on observation, interview and record review, the facility failed to ensure proper storage, cleaning and labeling of oxygen/respiratory equipment for two Resident (R57 and R61), of four residents reviewed for oxygen and respiratory care, resulting in the likelihood for cross contamination, respiratory illnesses/disease. Findings include: Resident #57(R57) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R57 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, congestive heart failure(CHF), chronic obstructive pulmonary disease, history of lung cancer with lung removal, diabetes mellitus, history pneumonia, anxiety and depression. The MDS reflected R57 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required set up dressing, hygiene; supervision with bathing and toileting; and partial/moderate assist with transfers. During an observation and interview on 2/18/25 at 10:07 a.m., R57 was in room sitting upright in recliner(no bed in R57 room) with oxygen in use via nasal cannula set at 3 liters per minute with tubing dated 2/10/25. R57 had nebulizer equipment including mask that was un-bagged/undated on bedside table and Continuous positive airway pressure(CPAP) machine on dresser un-bagged. R57 appeared able to answer questions without difficulty. R57 reported long history of respiratory issues including right lobecomy related to cancer and several episodes of pneumonia with hospital admissions. R57 reported used CPAP nightly and staff add water to chamber but do not rinse or clean mask and reported prior to admission to facility rinsed mask daily at home. During an interview on 2/21/25 at 11:19 AM, Licensed Practical Nurse(LPN) H reported oxygen tubing was changed weekly, every Monday, and nebulizer equipment was not reused. LPN H reported CPAP equipment and un-used oxygen tubing was stored in black cloth bags and changed monthly. Resident #61(R61) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R61 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus, dementia and manic depression. The MDS reflected R61 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. During an observation and interview on 2/18/25 at 11:31 AM, R61 was sitting in chair in room with oxygen running via nasal cannula. R61 appeared pleasant and able to answer questions without difficulty. Observed R61 Bilevel Positive Airway Pressure(BiPAP) equipment in room with mask resting directly on bed. R61 reported staff fill water chamber and connect oxygen but do not rinse mask. During an interview on 2/21/25 at 12:05 p.m., LPN H reported if residents had CPAP or BiPAP they usually had orders to clean masks weekly in Treatment Administration Record(TAR) and verified R57 or R61 did not have orders to clean CPAP/BIPAP and was unsure why. LPN H verified R61 had respiratory mask laying directly on bed and did not have black bag available in room for storage. During an observation on 2/21/25 at 12:15 PM, R57 was sitting in recliner in room with oxygen running via nasal cannula from room concentrator with tubing dated 2/10 (11 days old). During an interview on 2/21/25 at 1:54 PM, Director of Nursing(DON) B reported would expect CPAP/BiPAP equipment to be stored in black bags and orders in Treatment Administration Record for nurse to clean weekly. DON B reported would expect oxygen tubing to be changed weekly.

Based on observation, interview, and record review the facility failed to ensure three out of 19 residents (Resident 26, 57, and 87) received care and services that met their care needs resulting in the potential for unmet care needs. Findings Included: Resident #87 (R87): Per the facility census R87 was admitted to the facility on [DATE]. During the entrance conference on 2/18/2025 at 10:04 AM Administrator A stated that the facility did not offer outside contracted Hospice services, but did offer services provided by the facility to residents. Review of the facility, Supportive Care Protocol policy dated 12/20/2022 and revised on 5/10/2023, revealed that the facility provided, .comfort, dignity, and support, as residents enter the last stages of their life. The policy revealed, This will allow the resident to focus their goals of care to support how they (the resident) choose to live rather than try to cure or aggressively treat their chronic health conditions. Further review of the policy revealed under POLICY INTERPRETATION & IMPLEMENTATION:, I. Clinical Dementia scale assessment and a Palliative Performance Scale assessment will be completed by an MDS (Minimum Data Set) nurse. The scoring of these assessments tools will be utilized by the interdisciplinary team (IDT) along with the resident's clinical signs and symptoms indicating a general decline. Under II. If the resident meets the criteria for Supportive Care (a terminal stage less than 6 months of life) by the IDT or the family members/resident's request, a care conference will be scheduled ASAP (as soon as possible) to discuss the resident's goals of care., A Statement of Likely Terminal Illness will be initiated by the NP (Nurse Practitioner) or designee, and then approved by the physician when deemed appropriate to do so. Review of a, Supportive Care Goals Worksheet document dated 1/21/2025, revealed 81's family consented for R87 to have no measures to sustain life, a do not resuscitate (DNR) order, no hospitalization , no routine testing, no routine weights, only essential medication and vital signs were to be given. At the bottom of the form under Supportive Care it was revealed that R87's authorized decision maker signed the form on 1/21/2025 stating that consent was given for Supportive Care, and to provide treatments to promote quality of life and comfort, rather that achieve improvement in health for R87. The Nurse Practitioner signed the form on 1/21/2025, and the Physician signed the form on 1/24/2025. Review of an IDT care conference dated 1/21/2025, revealed R87's decision maker was present at the meeting, and supportive care was discussed. No other IDT care conference was documented in R87's electronic medical record (EMR). Review of a, Statement of Likely Terminal Illness revealed R87 was determined on 1/29/2025 to have deterioration of health or natural death may occur within six months. The document was signed by the Physician eight days after the family consented to R87's supportive care. Review of Physician's orders dated active as of 2/4/2025, revealed R87 still had laboratory orders in place for annual complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel, thyroid screen, C-reactive protein (measures inflammation) that were ordered on 1/2/2025, and had not been discontinued per R87's family supportive care decision as outlined on the Supportive Care Goals Worksheet. The orders all revealed these were active orders. The orders also revealed R87 had an order that was still active as of 1/2/2025, and not discontinued, to obtain a weight every month. Review of R87's weight log revealed R87 continued to be weighed by staff after 1/21/2025 when R87 was placed on Supportive Care, and weighing R87 was discontinued. R87 was weighed on 1/23, 2/7, and 2/12/2025. Review of the facility policy titled, End of life Care Protocol dated 11/24/2000, last revised on 5/10/2023, and last reviewed on 12/27/2024, revealed that it was the policy of the facility to provide comfort, dignity and support, during the dying process. The policy revealed, This End of Life process will be known as Comfort Care. Review of a Change in Condition assessment dated [DATE], revealed R87 had a decrease in responsiveness, weakness, swallowing difficulty, when stimulated R87's breathing would get louder, moaning with repositioning, and not respond to stimulation. The assessment revealed that R87 would transition to Comfort Care. In an interview on 2/20/2025 at 11:12 AM, Staff Educator (SE) G stated that she provided end of life training for the staff on Supportive and End of Life Care with a power point presentation. SE G said Supportive Care is provided when a resident is determined to have six months or less to live, and Comfort Care or End of Life is when a resident is determined to have days to weeks to live, and actively dying. Review of the power point presentation SE G provided as the educational tool used to train staff revealed, no date of the creation of the educational power point presentation in order to determine current standards of practice, and no references to educational content to validate facts and best practices for end of life care (Palliative, Supportive, Comfort, End of Live Care). The education tool did not specify how a resident who receives these services, in regards to Supportive Care and End of Life Care, has an increase in care needs, nor how to provide for the resident and family those extra care needs. The education power point tool focused mostly on the symptoms a resident will show once in the active dying stage. In an interview on 2/20/25 at 3:34 PM, with CNA I and CNA J both stated that when a resident had six months to live that meant they could give the resident whatever the resident wanted. Both CNAs said they did receive the power point training which was from SE G, and said every year they have to review the training. In a continued interview with CNA I and J both CNAs stated that they did not provide any additional care to residents who receive Supportive or End of Life Care, and both agreed that they have not been told or trained that they are to provide any other extra care, that was more than the care they already provided. In an interview on 2/21/2025 at 1:10 PM, Director of Nursing (DON) B stated that Supportive Care was to provide the resident with all their wants and wishes. DON B said the resident would have no more hospitalization s, would become a DNR, would have no more blood drawn for laboratory testing. DON B said when the resident would have more changes that show end of life, the family would be encouraged to be around the resident more, comfort care would be provided, and what ever the resident needs and wants were would be provided. 45038 Resident #26 (R26) Review of the medical record demonstrated R26 was admitted to the facility 01/19/2024 with diagnose that included chronic respiratory failure, venous insufficiency (improper functioning of the vein valves in the leg), peripheral vascular disease (PVD), Alzheimer's disease, dementia, hypertension, morbid obesity, congestive heart failure (CHF), type 2 diabetes, stage 3 kidney disease, obstructive sleep apnea, blepharoconjunctivitis (inflammation of both the eyelids and the conjunctiva), bilateral cataracts, chronic pain, gastro-esophageal reflux, hypothyroidism (low thyroid hormone), constipation, intellectual disabilities, and mental and behavioral disorder. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2024 demonstrated a Brief Interview for Mental Status (BIMS) of 00 (most server level of cognitive impairment) out of 15. During observation and attempted interview on 02/18/2025 at 11:47 a.m. R26 was observed sitting up in a wheelchair in his room. R26 did not answer questions. R26 left lower eye lid was observed to be red and drooping. Review of R26 medical record did not demonstrate any change of condition assessment or clinical documentation demonstrating observation of conjunctivas (redness/swelling of lower eye lid) for R26. Review of physician orders and plan of care did not demonstrate any treatment for conjunctivas. In an interview on 02/20/2025 at 10:50 a.m. Licensed Practical Nurse (LPN) D explained that R26 had a history of blepharoconjunctivitis (inflammation of both the eyelids and the conjunctiva). LPN D explained that she recently had observed that R26 currently had a dropping, red, and swollen left lower eye lid but that she had not written a condition change or called the physician for orders in the treatment of R26 lower eye lid. LPN D explained that she would notify the physician and document any orders as given. During observation and interview on 02/21/2025 at 09:35 a.m. R26 was observed sitting up in his wheelchair in his room. It was also observed that R26 had visible matting on bilateral eye lashes and redness and swelling was visible on his lower eyelid. When asked if R26 eyes itched or/and were painful he responded yes. Review of R26 medical record after the above observation still did not demonstrate any documentation of a change of condition or documentation of R26 matted bilateral upper eyelids or his red lower eyelid. R26 medical record did not demonstrate any orders for observation or treatment of the matting or treatment for the redness of his lower eye lids. In an interview on 02/21/2025 at 09:35 a.m. Director of Nursing (DON) B explained that it was her expectation that if a resident experienced a change in medical condition the nurse would notify the residents physician, the family, the Nursing Home Administrator, and the Director of Nursing or Assistant Director of Nursing. DON B confirmed that R26's record did not contain any information demonstrating an assessment of R26 lower left eye lid or any orders for treatment to date as of 02/18/2025. DON B could not explain why documentation of a condition change had been completed since the Licensed Practical Nurse was aware of R26 possible left eye conjunctivitis. 34705 Resident #57 (R57) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R57 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, congestive heart failure(CHF), chronic obstructive pulmonary disease, history of lung cancer with lung removal, diabetes mellitus, history pneumonia, anxiety and depression. The MDS reflected R57 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required set up dressing, hygiene; supervision with bathing and toileting; and partial/moderate assist with transfers. During an observation and interview on 2/18/25 at 10:07 a.m., R57 in room sitting upright in recliner and appeared able to answer questions without difficulty. R57 reported was taking long acting insulin daily and staff were not monitoring blood sugars. Review of R57 physician orders, dated 2/7/25, reflected Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously one time a day for DM[diabetes mellitus]. Continued review of R57 Physician Order, dated 11/5/24 through 2/6/25, reflected, Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously one time a day for Steroid induced DM. Review of Physician order, dated 10/16/24 through 1/30/25, reflected, Admelog Injection Solution 100 UNIT/ML (Insulin Lispro) [fast acting insulin] Inject as per sliding scale .subcutaneously before meals for hyperglycemia. Review of the Medication Administration Record, date 1/1/25 through 1/31/25, reflected R57 blood sugars, were monitored three times daily and ranged from 72 to 353. R57 required use of fast acting insulin via sliding scale on 25 occasions in month of January. Review of R57 Electronic Medical Record(EMR), dated 1/31/25 through 2/18/25, reflected no evidence R57 blood sugar was monitored. Review of R57 Physician Orders, dated 2/1/25 through 2/18/25, reflected R57 had physician orders for two prophylactic antibiotics and daily steroids for chronic respiratory condition. (These types of medications known to cause increased blood sugar). Review of R57 Dietary Note, dated 1/30/2025 at 12:09 p.m., reflected, Quarterly nutrition assessment completed. Regular diet with thin liquids. Tolerating current diet texture well at this time .Significant weight gain x 3 months. Weight trend: 176# (1/18/25), 172# (12/18/24), 161# (10/16/24), and 166# (7/18/24). Resident remains at risk for weight fluctuations due to diagnosis of CHF with diuretic use .12/3/24 labs: Glucose 106 .HA1c[test to monitor blood sugar over past two to three months] 7.6%[normal level below 5.7%]. Sliding scale insulin in place to help prevent hyperglycemia. Resident is on a steroid which likely impacts blood glucose levels. Will follow up and update residents meal preferences as needed. Will follow weight trend. Continue current nutrition POC. Follow up as needed. Review of R57 Physician Progress Note, dated 2/6/25, reflected, Patient has increasing heartburn. Omeprozole will be added patient is on chronic steroid use and NSAID[class of medications for heartburn] sometimes and also i will increase lantus to 20 units once a day from 15 units. accu-check[method to monitor blood sugar] will be monitored. (Review of the EMR reflected no evidence of blood sugar monitoring.) During an interview on 2/21/25 at 11:19 AM, Licensed Practical Nurse(LPN) H verified R57 received Balsagar long acting insulin daily that was recently increase related to elevated blood sugars on 2/7/25 and R57 did not have physician order for blood sugar monitoring. LPN H reported after review of R57 EMR, reported last recorded blood sugar was 1/30/25. LPN H reported residents on insulin usually have a physician order for blood sugar. During an interview on 2/21/25 at 1:54 PM, Director of Nursing(DON) B reported would expect staff to follow physician orders including orders to monitor blood sugar. DON B reported reviewed R57 orders and reported appeared to be transcription error and R57 should have had a physician order to monitored blood sugar.

Based on observation, interview, and record review, the facility failed to provide restorative services for two of two residents reviewed for limited mobility (Resident #17 & #40), resulting in unmet needs and goals. Findings include: Resident #40 (R40) On 2/25/24 at approximately 12:50 PM R40 was observed seated in a wheelchair at a table eating lunch. R40 held a fork in her right hand that was arthritic and appeared to be struggling with picking up food with her fork. On 2/26/24 at 12:44 PM R40 was observed eating lunch using a spoon; she was able to grip and control the spoon more easily when compared to a fork. R40's Minimum Data Set (MDS) assessment with assessment reference date of 12/06/23 revealed she was admitted to the facility on [DATE]; had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 10 (08-12 Moderate Cognitive Impairment). The same MDS assessment indicated R40 did not have deficits in functional range of motion (ROM), in her upper and lower extremities. R40's Activities of Daily Living (ADL) Care Plan revised 11/14/23, revealed R40 had a memory deficit and arthritis in both of her hands; interventions included to provide functional maintenance/restorative program. R40's electronic medical record, under tasks, included restorative activities to be completed three times a week or as tolerated: open and close fists, one set of 10 repetitions to each hand as tolerated. Bend and straighten elbows, one set of 10 repetitions, to each arm as tolerated; turn head left to right, one set of 10 repetitions as tolerated. And to use an exercise machine 10 minutes as tolerated 2 to 3 times a week. Restorative Nurse/Licensed Practical Nurse (LPN) C was interviewed on 2/27/24 at 9:16 AM and stated she had three restorative nursing assistants that worked Monday through Friday from 7:00 AM to 3:00 PM. LPN C stated her restorative assistants and herself have been pulled to work on the units as nurse/nurse assistants to meet staffing needs. Restorative services may not be provided three to five times a week per therapy recommendations. LPN C confirmed R40 had not received restorative services since 2/16/24. LPN C stated restorative nursing assistants would document the resident was not available if they were in an activity or during a meal; and may not be able to provide services at another time during the day. LPN C stated the restorative assistant that was assigned to R40 worked on the floor, as a nurse assistant, the week prior for two days and was not able to provide restorative activities per plan of care. Nursing Rehabilitation and Restorative Care Policy revised 6/19/23, indicated residents would be given appropriate treatment and services to maintain or improve ability to carry out activities of daily living. 38383 Resident #17 (R17): Review of the medical record reflected R17 admitted to the facility on [DATE], with diagnoses that included diffuse traumatic brain injury with loss of consciousness of unspecified duration, contracture of right elbow, contracture of left elbow, contracture of right wrist and contracture of left wrist. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/23, reflected R17 had impairments of both arms and both legs. During an observation on 02/25/24 at 12:12 PM, R17 was observed lying on his left side, in bed. His left arm was bent at the elbow and under his head. His right hand was observed to be clenched into a fist. On 02/25/24 at 12:30 PM, R17 was observed being assisted into the dining room by Certified Nurse Aide (CNA) I. R17 was seated in a high-back wheelchair, holding onto the left armrest with his right hand. R17's Care Plan reflected he had contractures (joint stiffness/limited range of motion) of both elbows and wrists. R17's Care Plan included an intervention for, Restorative nursing tasks per assigned tasks in POC. A Maintenance Care Program form, with an effective date of 2/6/24, revealed restorative recommendations that were consistent with R17's NURSING REHAB programs. The form was signed by Physical Therapy on 1/31/24. The task section of R17's medical record reflected, NURSING REHAB (PT): Seated bean bag grab and toss. Place bean bags and basketball net on left side, have resident grab bags with left and right hand and place in basketball net as tolerated. 3x/week [three times per week] or as tolerated. On 2/26/24, documentation for the past 30 days reflected the task has been signed out as being completed once, for five minutes, on 2/7/24. The task section of R17's medical record reflected, NURSING REHAB: Seated BLE [bilateral lower extremity] exercises. Add 3# [pound] ankle weights and use yellow theraball to kick 3 sets of 15 reps or as tolerated. 3x/week or as tolerated. On 2/26/24, documentation for the past 30 days reflected the task has been signed out once, for three minutes, on 2/7/24. For both of R17's NURSING REHAB programs, Resident Not Available was documented on 2/15/24. Not Applicable was documented on 2/6/24, 2/8/24, 2/9/24, 2/12/24, 2/13/24, 2/14/24, 2/16/24, 2/19/24, 2/20/24, 2/21/24, 2/22/24 and 2/23/24. No resident refusals were documented. Documented reasons for not available or not applicable included spa day/day of rest being documented 12 times and still in bed/sleeping being documented two times. During an interview on 02/26/24 at 2:17 PM, Restorative Licensed Practical Nurse (LPN) C reported the restorative department had three CNAs. It was reported that restorative CNAs were pulled from restorative to work the floor sporadically and not able to complete their programs. LPN C indicated the frequency of pulling restorative CNAs to work the floor had increased over the prior two weeks.

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive care plan for 1 (Resident #25) of 19 residents reviewed, resulting in the potential for unmet care needs. Findings include: Review of the medical record revealed that Resident #25 (R25) was admitted to facility 11/1/2018 with diagnoses including hypertensive heart disease with heart failure and personal history of other venous thrombosis and embolism. Review of the Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 12/4/23 revealed that R25 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of an active Activities of Daily Living Care Plan reflected that R25 required extensive assist of 1 with upper and lower body dressing and was dependent for footwear placement. In an observation and interview on 2/25/24 at 1:44 PM, R25 was observed sitting in room, in high back wheelchair, with back of chair reclined slightly and lower extremities elevated on wheelchair leg rests. Blue non-skid socks were noted to bilateral feet with swelling observed to R25's lower legs, ankles, and feet. R25 stated that she used to wear special knee-high stockings on her legs that helped with the swelling but that she hadn't for the last couple of months as the girls don't get them to put them on me. R25 stated that she was unable to put the stockings on herself, did not even know where they were, but that they had seemed to help with the swelling when she had worn them. In an observation and interview on 2/26/24 at 11:53 AM, R25 was observed sitting in room, in high back wheelchair, with back of chair reclined slightly and lower extremities elevated on wheelchair leg rests. Blue non-skid socks were again noted to bilateral feet with ongoing swelling observed to R25's lower legs, ankles, and feet. R25 stated that staff had not assisted with placement or mentioned plan to place her special stockings yet that day. Review of R25's Physician Order dated 9/6/23 stated, apply knee high ted hose [TED hose-thromboembolic deterrent hose-compression socks designed to help prevent blood clots and swelling in legs] in AM [morning] and remove at HS [bedtime]. Review of R25's Activities of Daily Living Care Plan was noted to include an associated intervention which stated, I have swelling in my lower legs and need assistance putting compression stockings on in the morning and removing them at bedtime . with an initiated date of 5/13/19. Review of the Resident Care section of R25's Kardex (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) reflected, I have swelling in my lower legs and need assistance putting compression stockings on in the morning and removing them at bedtime . Review of R25's Treatment Administration Record (TAR) dated 2/1/2024 - 2/29/2024 reflected order for knee high TED hose with order noted to be signed out as completed on both 2/25/24 and 2/26/24 although the hose had not been noted to be in place at R25's bilateral lower extremities on either date. In an interview on 2/26/24 at 11:59 AM, Certified Nurse Aide (CNA) D confirmed familiarity with R25 and stated that she was her assigned CNA that date. Per CNA D, R25 was conversant, able to make all needs known, and was able to feed self but required total assist for dressing including sock placement. CNA D stated that R25 had TED hose but that she did not currently have them on as believed they were only used at night. Upon review of R25's Kardex, CNA D stated that the Kardex reflected that R25 should have compression socks placed in the morning, confirmed that she had not placed them herself yet that date, and would have to check to see if they were on. On 2/26/24 at 12:12 PM, CNA D was observed to enter R25's room, questioned her as to whether her stockings were in place at which time R25 denied, with CNA lifting R25's pant leg to confirm that the compression stockings were not in place. In an interview on 2/26/24 at 12:15 PM, Licensed Practical Nurse (LPN) E confirmed familiarity with R25 as stated that she resided on the unit where she was routinely assigned. LPN E stated the R25 was alert, able to use her call light to alert staff of needs, but required staff assist with both dressing and sock placement. LPN E initially denied that R25 had any specialized splints or stockings, then stated that she may have compression hose but could not say with any certainty and would have to reference R25's medical record to verify. LPN E further stated that any resident that had compression stockings would have an order to reflect and that the assigned CNA would assist the resident with placement each morning but again denied knowledge of whether R25 had an order for them. Upon referencing R25's medical record, LPN E stated that R25 had an order for knee high TED hose that were to be placed in the AM and removed at HS, confirmed that she had signed out R25's TED hose order earlier that date, thought that R25 had the hose on, but stated that she had not placed R25's TED hose herself that morning or verified that R25's assigned CNA had placed them. On 2/26/24 at 12:22 PM, LPN E entered R25's room, R25 again denied that she had TED hose in place with LPN E observed to lift R25's pant leg to confirm that the ordered hose were not in place. In an interview on 2/26/24 at 12:24 PM, Registered Nurse/Unit Manager (RN/UM) F confirmed familiarity with R25, stated that she had intermittent lower extremity edema, had an order for compression hose to be placed upon rising and would expect that the hose would be in place, at that time, per R25's physician order and as reflected on her care plan. Review of the facility policy titled, Resident Assessments with a 12/29/22 date of revision stated, .Comprehensive Care Plans: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs .

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, plumbing leaks, and resident foodborne illness. Findings include: On 12/06/22 at 09:17 A.M., An initial tour of the food service was conducted with Culinary Services Director L. The following items were noted: One-half gallon of Prairie Farms 2% Milk was observed within the walk-in cooler, without an open or discard date. The manufacturer's use-by-date was observed to read 12/19/22. On 12/06/22 at 09:28 A.M., An interview was conducted with Culinary Services Director L regarding facility date marking practices. Culinary Services Director L indicated dietary staff have been instructed to place an open date on the container and use the manufacturer use-by-date printed on the container as the maximum discard date. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The hand sink hot water valve assembly was observed leaking water, adjacent to the mechanical dish machine. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Red Oak Trail (600 Hall) Kitchenette: The mechanical ventilation hood filters were observed heavily soiled with accumulated dust and dirt deposits. Culinary Services Director L indicated he would have staff thoroughly clean the soiled hood filters as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. One quart of Prairie Farms egg nog was observed with an open date that read 12-6-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-21-22. One-half gallon of Prairie Farms 2% Milk was observed with an open date that read 12-5-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-19-22. One-half gallon of Prairie Farms Chocolate Milk was observed with an open date that read 12-6-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-10-22. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Blue Spruce (200 Hall) Kitchenette: One-half gallon of Prairie Farms 2% Milk was observed with an open date that read 12-6-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-19-22. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Beechwood Hill (700 Hall) Kitchenette: The Juice Machine (backsplash, undersplash, and dispensing spouts) were observed soiled with accumulated and encrusted food residue/splash. The Ice Machine water dispensing spout, backsplash, and drip tray were observed soiled with accumulated mineral (lime and calcium) deposits. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. One-half gallon of Prairie Farms Chocolate Milk was observed with an open date that read 12-5-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-17-22. One-half gallon of Prairie Farms 2% Milk was observed with an open date that read 12-6-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-19-22. One quart of Lactaid fat free milk was observed with an open date that read 12-6-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 1-23-23. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Maple Grove (700 Hall) Kitchenette: One-half gallon of Prairie Farms Chocolate Milk was observed with an open date that read 12-1-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-10-22. One-half gallon of Prairie Farms 2% Milk was observed with an open date that read 12-2-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 12-10-22. One quart of Lactaid fat free milk was observed with an open date that read 12-6-22. No discard date was observed printed on the container. The manufacturer's use-by-date was observed to read 1-23-23. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The hand sink basin cold water valve assembly was observed installed backwards, allowing the valve handle to stop 90 degrees behind the faucet assembly. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The Ice Machine (water dispensing spout, backsplash, and drip tray assembly) were observed soiled with accumulated mineral (lime and calcium) deposits. The Juice Machine (undersplash and dispensing spouts) were observed soiled with accumulated and encrusted food residue/splash. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/08/22 at 01:30 P.M., Record review of the Policy/Procedure entitled: Food Storage dated 11/15/22 revealed under Policy Interpretation & Implementation: (5) All products should be stored in covered containers or securely sealed/wrapped: For food removed from original packaging: Food will be dated when opened and with a dispose of date 7 days following. In case there is no manufacturer recommendation, the time periods on the Date/Label charts in each kitchen shall be referenced. (6) Culinary and Neighborhood staff are to ensure that foods placed in refrigerator or freezer are covered, labeled, and dated properly. (7) Refrigerated ready-to-eat, potentially hazardous food prepared and held for more than 24 hours shall be clearly marked to indicate the date by which the food shall be used or discarded, a maximum of seven days.

Based on observation, interview and record review, the facility failed to revise Care Plans for one (Resident #75) of 15 reviewed for Care Plans, resulting in the potential for unmet care needs. Findings include: Review of the medical record reflected Resident #75 (R75) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified convulsions, hemiplegia and hemiparesis following cerebral infarction, chronic diastolic (congestive) heart failure and long-term (current) use of anticoagulants (blood thinning medication). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/27/22, reflected R75 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R75 did not walk and required supervision to total assistance of one to two or more people for activities of daily living. On 12/06/22 at 01:53 PM, R75 was observed seated in a wheelchair, participating in an activity. Review of R75's medication list revealed she was admitted to the facility on Eliquis (an anticoagulant medication), with a start date of 3/23/22. R75 was also being administered Lasix (a diuretic medication, given to reduce edema associated with congestive heart failure), with a start date of 3/25/2022 and a dosage increase on 7/6/2022. A Physician progress note dated 7/5/2022 revealed R75 was experiencing increased edema with signs of CHF [congestive heart failure]. A nurses note on the same date revealed facility physician in to see resident today. Resident was noted during exam to have some pretty extensive edema noted to her left hand and ankle area. After chart review by physician, a new order was obtained to increase lasix from 20mg [milligrams] to 40mg . A Physician progress note dated 8/2/2022 revealed R75 had a new diagnosis of CHF. In an interview on 12/07/22 at 4:06 PM, MDS Registered Nurse (RN) O reported that anything that was a high risk diagnosis or a high risk medication needed to be included on the Care Plan, but, unfortunately they don't always get updated when they should . Usually initial revisions to the Care Plan are done during the initial care conference, then Care Plans are revised quarterly. MDS O reported, anticoagulant medications normally have a Care Plan as well as diagnoses of congestive heart failure. MDS O reported that the Care Plan revisions were new at some point and did not get added. R75's medical record reflected they were diagnosed with chronic diastolic (congestive) heart failure as of 8/2/2022, however, an altered cardiovascular status Care Plan was not initiated until 12/7/2022, after the interview with RN O. Furthermore, R75's medication list revealed that she was being administered an anticoagulant beginning 3/23/33, however, an anticoagulant Care Plan was not initiated until 12/7/2022, after the interview with RN O.

Based on observation, interview, and record review, the facility failed to provide clinical rationale for routine indwelling urinary catheter changes in 1 (Resident #34) of 3 residents reviewed with chronic indwelling urinary catheters resulting in the potential for increased risk of urinary tract infections. Findings include: Resident #34 (R34) was admitted to facility 6/24/2022 with diagnoses including hereditary spastic paraplegia, obstructive and reflux uropathy, and presence of urogenital implants. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 revealed that R34 had a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired cognition). Section G of MDS revealed that R34 required extensive one-person physical assistance for bed mobility and dressing, and extensive two-person physical assistance with transfers and toileting. Section H of MDS reflected that R34 had an indwelling catheter. In an observation and interview on 12/06/22 at 9:53 AM, R34 was observed sitting in room at bedside in electric wheelchair. R34 confirmed that she continued to have an indwelling catheter, denied urology follow-up, and stated that catheter was changed monthly by facility staff. Review of R34's medical record was completed with the following findings noted: Order to Change 16Fr. 10mL indwelling Foley Catheter using sterile technique every evening shift starting on the 16th and ending on the 16th every month for maintenance and as needed for leaks or drainage difficulties dated 6/24/2022 (date of R34's admission to facility). Treatment Administration Record (TAR) reflected monthly indwelling catheter changes on the 16th of July, August, September, and November. Entry on the October TAR noted to be blank. Physician History and Physical (dated 6/24/2022) and follow up Physician Progress Notes (dated 7/12/22, 8/9/22, 9/6/22, 9/20/22, 10/6/22, 11/10/22) indicated chronic indwelling catheter placement but provided no indication of or rationale for monthly changes. R34's I have a persistent indwelling urethral Foley catheter Care Plan provided no indication of or rationale for monthly changes. In an interview on 12/7/22 at 1:45 PM with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B, DON B stated that the frequency of a catheter change was based on clinical necessity and physician order but deferred additional questions to Infection Control Director. NHA A provided policy titled Foley Catheter Care with 6/30/22 revision date but deferred to Infection Control Director for additional information and denied knowledge of any facility policies/procedures that pertained to chronic indwelling catheters (i.e., when/why a chronic catheter would be changed). In an interview on 12/7/22 at 1:55 PM, Infection Control Director (ICD) N stated that current standard of practice would be to not change an indwelling catheter at routine intervals and acknowledged that Center for Disease Control guidelines advised against routine indwelling catheter changes. ICD N further stated that each resident had a resident specific plan of care and when the physician ordered monthly changes, the catheter would then be changed monthly. In the same interview, ICD N confirmed that R34 was admitted with the catheter and with the order for monthly changes and that the facility had continued the monthly change order since admission. ICD N denied physician follow up for rationale or ongoing necessity of the monthly indwelling catheter changes. In a follow up interview on 12/7/22 at 2:40 PM, DON B stated that as there was no documentation in R34's medical record regarding clinical rationale for monthly catheter changes, she questioned why the catheter was changed monthly. On 12/07/22 at 3:29 PM, RN M provided documentation from prior to R34's facility admission regarding 1/2020 emergency room visits but denied knowledge of any additional documentation and was unable to provide documentation pertaining to rationale for R34's monthly catheter change order since facility admission. In a follow up interview on 12/07/22 at 3:38 PM, ICD N stated that after review of R34's medical record, no additional information was available to provide regarding monthly catheter changes. ICD N also denied knowledge of any facility policies related to chronic indwelling urinary catheter management as stated that each resident and catheter was managed on an individualized basis. ICD N did not provide requested facility policies prior to end of survey. Review of the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) dated 2009, revealed .III. Proper Techniques for Urinary Catheter Maintenance .E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . Within the same guideline under section titled Formulating Recommendations .Category II .1. For patients: Most people in the patient's situation would want the recommended course of action .2. For clinicians: Different choices will be appropriate for different patients, and clinicians must help each patient to arrive at a management decision consistent with her or his values and preferences . (https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html) However, R34's medical record reflected no coordination between Physician, Infection Control Director, and Nursing staff regarding rationale for routine indwelling catheter changes or resident/family education regarding risks associated with the routine replacement of a chronic indwelling catheter and no facility documentation was provided prior to end of survey.

Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of psychotropic medications for 1 (Resident # 63) of 5 residents reviewed for unnecessary medications resulting in the potential for adverse side effects including increased risk of falls. Findings Include: Resident #63 (R63) was initially admitted to facility 10/11/2019 with multiple rehospitalization s and facility readmissions including most recent 10/28/22 facility readmission. R63's medical diagnoses included fracture of right lower leg, Alzheimer's disease, obsessive-compulsive disorder, bipolar disorder, major depressive disorder, excoriation (skin-picking) disorder, post-traumatic stress disorder, anxiety disorder, insomnia, hypertension, and congestive heart failure. Review of Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/4/2022 reflected Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired cognition). Section G of MDS revealed that R63 required extensive assist of two for bed mobility, transfers, and toileting and extensive assist of one for dressing. Section D reflected Resident Mood Interview (PHQ-9) score was 6 (mild depression). Section E reflected that R63 did not exhibit physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), delusions, or hallucinations. Review of Annual MDS with an ARD of 10/3/22 reflected BIMS score of 13 (cognitively intact). Section G of same MDS revealed that R63 was independent with bed mobility, transfers, walking in room, and toileting. On 12/06/22 at 11:04 AM, R63 was observed laying in bed with cushioned plastic boot on right lower extremity. Review of R63's medical record complete with the following findings noted: Order for Orthostatic BP (blood pressure) every month on the 15th: STANDING, order for Orthostatic BP every month on the 15th: SITTING, order for Orthostatic BP every month on the 15th: LAYING with 9/23/2020 order revision date and 10/24/2022 order end date. Order for Orthostatic BP every month on the 15th-standing with 10/27/2022 order date. No additional orders noted for either laying or sitting blood pressure monitoring included when obtaining Orthostatic BP. Order for Seroquel Tablet (antipsychotic) 100milligrams (mg) and Seroquel Tablet 50mg tablet (for total dose of 150mg) every night at bedtime for diagnosis of bipolar disorder. October 2022 Treatment Administration Record (TAR) reflected order for Orthostatic BP, but entries noted to be blank for each of the Laying, Sitting, Standing administration boxes. November 2022 TAR reflected order for Standing Orthostatic BP with value of 102/60 noted to be documented on 11/15/22. December 2022 TAR reflected order for only Standing Orthostatic BP, as well. R63's Blood Pressure Summary record reflected no recorded BP values on 10/15/22. BP value of 102/60 (indicated as standing BP) noted to be documented on 11/15/22 with no additional BP entries noted for that date. R63's Cognition and mood care plan reflected under the intervention section I take antipsychotic medication. Check Orthostatic BP every month on the fifteenth with 10/11/19 initiated date and 10/4/22 revision date. R63's Progress Notes reflected no entry for 10/15/22 or 11/15/22 in relation to Orthostatic BP values. Skilled Evaluation note dated 11/15/2022 at 2:37 PM reflected BP value of 135/74 indicated to be obtained in sitting position on 11/14/2022 at 11:36 AM. Nurses Notes dated 10/22/2022 at 11:50 AM reflected that CNA (Certified Nurse Aide) was assisting resident in bathroom. Resident was standing, holding the grab bar, when she lost strength and fell on to the toilet seat with her right leg and buttocks, breaking the right side of the toilet seat. Resident was assisted to the ground by CNA. Resident sustained minimal bruising on her right buttocks, bruising and swelling to her right knee, bruising, and swelling to her right ankle, and bruising on top of her left foot . Pharmacist Medication Regimen Review dated 10/12/22 and 11/11/22 reflected no recommendations. In an interview on 12/7/22 at 1:45 PM, Director of Nursing (DON) B stated that the facility policy for antipsychotic use and monitoring included antipsychotic batch orders. Per DON B, these orders included side effect monitoring, monthly blood glucose monitoring, every 6-month CRP (C-Reactive Protein-lab test to aid in identifying inflammation in your body) monitoring, annual lipid panel monitoring, and monthly Orthostatic BP monitoring. DON B stated that the monthly Orthostatic BP monitoring included obtaining laying, sitting, and standing BP values (if resident could tolerate) and would be documented on the MAR, TAR, Vital Sign record, or within a progress note. Upon review of R63's medical record, DON B confirmed that there was only a current order to monitor the standing Orthostatic BP monthly and stated that she would provide additional documentation regarding October Orthostatic BP values. In a follow-up interview on 12/7/22 at 2:36 PM, DON B stated that the November readmission orders for R63 were entered incorrectly and therefore only a standing Orthostatic BP was done and recorded. DON B stated that the order had now been corrected to reflect the laying and sitting values as well so that the December Orthostatic BP monitoring would include laying, sitting, and standing values. DON B confirmed that ordered October Orthostatic BP monitoring was not completed as it should have been. Review of facility policy titled Behavior Management Program & Behavior Committee with 9/23/2022 revision date indicated within section titled Orthostatic Blood Pressure: Orthostatic blood pressures will be completed monthly on residents who receive an antipsychotic. Those residents who are unable to sit or stand with minimal assistance or are transferred by a mechanical lift, will not have orthostatic blood pressure completed. This will be noted in the care plan. Orthostatic blood pressure checks are done by the Charge Nurse monthly on the 15th. However, there is no indication within R63's medical record that Orthostatic BP monitoring was unable to be completed in October or that a laying and sitting BP value could not be obtained in November as a standing BP was indicated to be obtained on 11/15/22.

This citation pertains to MI 724 Based on observation, interview, and record review the facility failed to prevent the elopement of one resident (Resident #2) of two reviewed, resulting in immediate jeopardy when on 1/30/22 at approximately 8:05 PM, R2 eloped from the facility and was found approximately 50 minutes later outside, behind a barn, on his hands and knees in the snow. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, [CONDITION(S)] with behavioral disturbance, history of falling, diabetes, major depressive disorder, and anxiety. R2 had a Durable Power of Attorney and was not his own person. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/22 revealed R2 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required supervision and one person assist for transfers and walking. On 8/31/22 at 8:36 AM, R2 was observed eating breakfast while seated in a wheelchair in the dining room. Review of the Elopement Risk assessment dated [DATE] revealed R2 ambulated independently, had dementia, was a recent admission within the last month, was accepting of placement, was easily redirected with behaviors, wandered occasionally, and made no attempts to elope. The comments section revealed One incident at home of walking to the neighbor's, looking for his wife. This was when she stopped leaving him home alone. Review of the Elopement Risk/Wanderer care plan initiated on 1/21/22 and revised on 1/31/22 revealed I am an elopement risk/wanderer AEB [as evidenced by] disoriented to place and impaired safety awareness. I will often report that I am going home. Interventions initiated on 1/21/22 and revised on 1/31/22 revealed Distract me from wandering by offering pleasant diversions, structured activities, food, conversation. I am often content to sit in my recliner with my television on and Talk with me about my history. I am a farmer, and I once drove a race car. I enjoy sharing my stories. Review of the Nurse's Note dated 1/22/22 revealed Res. [Resident] wandered aimlessly all day and inquired w/ [with] all staff on multiple occasions about, where the exit is and how do I get out of here and where is my house. Res. was found x2 near the ADC [Adult Day Care] entrance (near Willow Court), set off the alarm, and trying to find a way out. CN [charge nurse] immediately placed a code alert sensor and band around his left ankle and was useful when he was trying to get into ADC. Res. is very ambulatory and motivated to get home. Review of the Physician's Order dated 1/24/22 revealed an order for a wanderguard to R2's left ankle. Review of the Nurse's Note dated 1/24/22 revealed Res. noted to not be in room when 3rd shift CNC checked at approx. 2325 [11:35 PM]. Res noted to be sitting in ADC relaxing by himself. Resident was assisted back to his room w/out incident. 15 minute visual checks to patients room started for resident safety. Review of the Social Work Note dated 1/25/22 revealed R2 was moved to a different room, on the second floor in the secured special care unit. Review of the Nurse's Note dated 1/29/22 revealed Resident up and about neighborhood, gait slow and steady. Says he's going home, and looking for his wallet. Reminded him that his wife has his wallet. Redirected easily . Review of the Investigation Note dated 1/30/22 at 8:05 PM revealed Resident elopement, building departure Aprox 805 pm. Police notified by writer and responds within 5 minutes. Resident found and returned to the facility by staff within 45 minutes .abrasion to the right elbow .Resident displays some agitation and resistance to care before the departure. Reentry into the building: resident is calm and cooperative with care .only complains of being cold upon return to the unit . Review of the Nurse's Note dated 1/30/22 revealed Writer alerted by staff to the resident being unaccounted for. Building search initiated for all staff and units. All resident and non resident areas searched. DON [Director of Nursing] and Administrator alerted and reported to the building. Police called and responded on campus within 5-8 minutes. Resident observed on hands and knees by the facility barn behind the facility. Resident escorted back to the unit by the DON and immediate assessment and vitals taken. 2x2 cm abrasion noted to the right elbow. Warming blankets applied to resident for warmth. EMS [Emergency Medical Services] assessed resident and no transfer required. Resident receptive to care and responded to all assessments appropriately. Family and Medical director notified of the resident's condition and no new orders given. Neuro checks initiated and continues through the shift. Review of a second Nurse's Note dated 1/30/22 revealed DON received a call from facility CN at 8:22pm alerting that they were unable to locate resident in the facility after initiating the elopement protocol. Facility administrator and Police we immediately notified and arrived at the facility to assist with the search. DON notified resident's wife at approximately 8:40pm. Risk Manager evaluated facility surveillance footage while the DON and Administrator assisted Police with the outside search. At 8:55pm, resident was observed by the facility barns on his hands and knees. He was wearing tennis shoes, blue jeans, a baseball cap, and a button up shirt. Resident was immediately wrapped in a coat and assisted into a vehicle. An abrasion was noted to his right elbow but he denied any other discomfort with the exception of being cold. Resident was then brought into the facility and up to his room wear [sic] the DON and CN assisted him with changing in to dry clothing and assessed him. VS assessed and stable. Temp was 97.2. EMS also present and evaluated Resident. They indicated that he was not showing any signs of hypothermia or frost bite and they did not feel he needed to be taken to the ER. He was wrapped in warm blankets and was given hot chocolate to drink. He remained in good spirits during these events and stated, I don't think I will do that again. Call placed to Resident's wife to notify her that he was found and safe. Resident's vital signs remained stable and he was assisted to his bed after approximately an hour of one on one monitoring. In an interview on 8/31/22 at 10:17 AM, Nursing Home Administrator (NHA) A reported when she reviewed surveillance video footage of R2's elopement, it was identified that prior to the elopement, R2 was exit seeking and frustrated. NHA A reported that Certified Nursing Assistant (CNA) C did not provide appropriate redirection and was also frustrated. NHA A reported it was not a patient, calm, appropriate redirection. On 8/31/22 at 10:27 AM, surveillance camera footage was reviewed with NHA A and DON B. On 1/31/22 at approximately 7:57 PM, R2 can be seen entering the camera at the left side of the nurse's station. Within one minute, R2 wandered in front of the nurse's station and approached the exit door to the stairway. R2 pushed on the door and the door was observed to open slightly. At approximately 7:57:51, R2 began to walk away from the door as CNA C approached R2. CNA C was observed pointing back towards the dining room and grabbing onto R2's right arm. R2 was resistive as CNA C continued to hold his arm. R2 then stumbled into CNA C. The altercation moved to the wall across from the door as CNA C held onto R2's arm until R2 broke free at approximately 7:58:17. CNA C was then observed giving R2 a bearhug from behind with both arms around R2, with his hands locked on R2's chest. At 7:58:26, CNA C released his arms from around R2. CNA C stood in front of R2. R2 was visibly frustrated and pushed CNA C. CNA C then grabbed R2's left wrist and at 7:58:42, had R2 restrained by his wrist, near the wall by the stairway exit door. A physical altercation between CNA C and R2 continued. R2 wandered behind the nurse's station and attempted to go into the medication room and the other door. At approximately 8:00 PM, R2 wandered back to the stairway exit door as CNA C placed himself in front of R2. R2 grabbed CNA C and CNA C then engaged in another physical altercation. At 8:00:16, CNA C had R2 pinned up against the wall with his right forearm across R2's chest. At 8:00:28, CNA C and R2 entered a supply room. The actions in the supply room could not be observed on camera. At 8:01:46, CNA C exited the room and R2 followed. A physical altercation continued and at 8:01:56, CNA C had a hold of both of R2's wrists as he appeared to attempt to drag R2 away from the doors. R2 was resistive. At 8:02:02, CNA C grabbed R2's left wrist with both hands and pulled him out of view of the camera. At 8:02:08, CNA C approached the nurse's station and picked up the phone as R2 approached the stairway door again. While on the phone, CNA C approached R2, grabbed his left wrist and pulled him away from the door. R2 punched CNA C. CNA C then wrapped his right arm around R2's neck in what appeared to be a headlock. R2 continued to punch CNA C. At 8:02:41, R2 sat on the nurse's station desk. CNA C released his arm from around R2's neck and hung up the phone. At 8:03, CNA C was observed on the phone again. R2 was observed breathing heavily. At 8:03:11, CNA C walked away, out of camera view. At 8:04:14, R2 opened the stairway exit door and entered the stairway, out of camera view. At 8:06:36, CNA C reapproached the nurse's station, looked in the window of the supply room, but did not look into the stairway nor exit into the stairway. At 8:08 PM, CNA C pushed on the stairway exit door but did not exit into the stairway. NHA A reported at 8:03:11, CNA C left the unit, but instead should have called someone else in the building. NHA A reported the previous NHA responded to the facility and was the person who found R2 outside behind the barn. NHA A reported CNA C acknowledged that he did wrong, was frustrated and lost his cool. In a telephone interview on 8/31/22 at 11:09 AM, CNA C reported R2 was trying to get out and he was trying to contain him and get him calmed down and find the keys to the truck. CNA C stated He [R2] was trying to fight me. I was trying to keep him in. CNA C stated I was doing 16 hours, was just fed up with it. CNA C reported he got R2 calmed down and ran to the other unit to get the nurse and when he came back, R2 had snuck out the door. CNA C reported when he realized R2 was missing, he alerted the nurse and began searching everywhere. CNA C reported he got in his vehicle and drove around the parking lot but did not get out of his vehicle or search around the barn out back. CNA C stated it was freezing outside .there was so much snow. CNA C reported he should not have left the unit. When asked about the bearhugging, pulling on R2's arms, and the headlock, CNA C stated, That wasn't a headlock. I had my arm around his shoulder. If you want to see a headlock, I will show you a headlock .I was trying to talk to him and calm him down. R2 denied pulling on R2's arms and reported he was holding R2's arms and bearhugging him to prevent R2 from hitting him. In a telephone interview on 8/31/22 at 12:15 PM, Licensed Practical Nurse (LPN) D reported R2 always talked about going home, going to work. LPN D reported at the time of R2's elopement, she was the only nurse working on the second floor for both units. LPN D reported she was on the other unit covering for the CNA's break. LPN D stated at this point, there was an issue on the other hall, but I could not leave. LPN D reported CNA C came over and said you better come get him [R2], he can't keep hitting on me and then left the unit. LPN D reported CNA C came back ten to fifteen minutes later and said the resident was gone. LPN D reported the search began and when she entered R2's unit, the door alarm was not sounding because when the exit door closed, the alarm stopped. LPN D reported when R2 was brought back into the building, he was cold. LPN D reported they had to change R2's clothes because they were wet and placed blankets around him to keep him warm. In an interview on 8/31/22 at 12:41 PM, LPN E reported when R2 was admitted to the facility, we were all alerted in an email format when he arrived that he may be interested in leaving the facility. LPN E reported the email further explained that if R2 was informed he was there for therapy and his wife would come visit him the next day, he would usually calm down. On 9/1/22 at 8:50 AM, NHA A was notified of the Immediate Jeopardy that began on 1/30/22 and was identified on 9/1/22 due to the failure to prevent the elopement of R2. On 9/1/22, it was verified that the facility implemented the following to remove the immediate jeopardy: On 1/30/2022 1. Resident was identified by staff as missing, and a search immediately began by staff throughout the building. 2. Resident was found and safely returned to the building. 3. Resident was assisted in dry clothing and assessed by staff and EMT responders. EMS determined outside medical care was not necessary as he did not present with any signs of hypothermia or frostbite. 4. Resident's physician was also contacted at this time, with no new orders given. 5. Staff completed vitals every hour for 4 hours. 6. Resident was started on 15 minutes checks and closely monitored by staff until determined by the IDT that changes were appropriate. 7. Resident's care plan was revised on 1/31/2022 to include additional interventions for staff when resident wants to go home or is anxious. 8. The Facility Operations Director checked the stairwell door, where the resident was confirmed to have exited and ensured it was operating appropriately. No issues were identified. On 1/31/22 1. The Facility Operations Director, Director of Nursing, Administrator and Risk Management Director met in an emergency QAPI meeting to further review the incident, including the Facility's Missing Resident procedures. 2. Revisions were made by the Facility Operations Director to the Missing Resident plan to ensure all areas of the building and outdoor areas are assigned to staff while some neighborhoods are not in operation, and focusing on more intense outside searching in cases of inclement weather. 3. The Facility Operations Director checked all the stairwell doors throughout the Facility to verify that they were alarming properly. 4. A continuous alarm was added to the Maple Grove Stairwell, as the previous alarm ceased sounding once the door closed and did not require staff intervention to silence it. 5. Staff were informed about the alarm change the same day, with on-the-spot education by the Staff Educator and at shift reports. 6. Two-way radios were made available on the Special Care neighborhoods for staff to carry to ensure adequate communication in the evening and night shift hours. 7. The DON and Administrator met with resident's wife to discuss the events of the elopement and interventions being done. 8. Social Work visited with and assessed resident several times in the days to follow. On 2/1/22 1. The IDT discussed the neighborhood acuity of both special care neighborhoods as well as staffing of the neighborhoods. 2. All other neighborhoods were equipped with two-way radios on 2/1/22 for staff to utilize, in times of needed increased communication. 3. All staff education began related to prevention and procedures related to elopement, dementia and behavior management, and abuse prevention. Information on the updated egress alarm was also included in these meetings. Any staff that were out of the building during these trainings were provided with this education during their next scheduled shift. 4. Additional changes were attempted to change the functions of all stairway door alarms. When determined it was not possible to be handled by Facility staff, additional continuous alarms were ordered and mounted to the door jam of each of all stairwell egress doors. These were immediately installed upon arrival on 2/4/22. 5. Medication adjustments were made for resident. On 2/2/22 1. The Director of Nursing reviewed and revised the Facility's Elopement and Wandering Resident policy. 2. On or before 2/2/22, all other residents in the building had elopement risk assessments completed by a Social Worker, with follow-up done as needed by a Nurse Manager or MDS Supervisor. 3. New QAPI processes were finalized to ensure staff understanding of missing resident drill procedures, verbalization of proper management of a resident that is at risk for elopement and completion of elopement risk assessment that ensure necessary interventions are in place for residents. Although the Immediate Jeopardy was removed on 1/31/22, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. The following Past Non-Compliance was reviewed and accepted at the time of the survey: ELEMENT 1: On 1/30/22, upon identification of the potential elopement of R2, CNA C searched the neighborhood and notified the Charge Nurse for assistance. A Facility-wide search was initiated indoors and outdoors. The resident was located outside at approximately 8:55p.m. and was returned safely to the building with staff. EMS was contacted to come evaluate resident and potential need for emergency room care. The resident was assisted into dry clothing by staff, and a complete body assessment performed by the Director of Nursing. Resident was observed with a 2cm x 2cm abrasion to his right elbow with no other injury noted. He denied pain when asked and his only complaint was being cold. His temperature upon returning to the building was 97.2 degrees, and all other vitals were within normal limits. Upon assessment, EMS determined outside medical care was not necessary as he did not present with any signs of hypothermia or frostbite. Resident's physician was also contacted at this time, with no new orders given. Staff completed vitals every hour for 4 hours and there were no further concerns. The DON spent approximately one hour with him for continued assessment. Resident was started on 15 minutes checks and closely monitored by staff. He was noted to sleep well throughout the night. He continued on 15 minute checks until 2/15/22, when the Facility's IDT determined one-hour checks were appropriate. The IDT team will continue to review the resident's status and whether checks may be reduced. His care plan was revised on 1/31/2022 to include additional interventions for staff when R2 wants to go home or is anxious. There have been no further elopement concerns with this resident. ELEMENT 2: On or before 2/2/22, all other residents in the building had elopement risk assessments completed by a Social Worker, with follow-up done as needed by a Nurse Manager or MDS Supervisor. There were 7 residents identified with potential elopement concerns. Their care plans were reviewed or updated to ensure appropriateness and one resident had a wandergaurd put in to place that did not already have one. On 1/30/22, the Facility Operations Director checked the stairwell door, where the resident was confirmed to have exited and ensured it was operating appropriately. No issues were identified. On 1/31/22, the Facility Operations Director, Director of Nursing, Administrator and Risk Management Director met in an emergency QAPI meeting to further review the incident. On 1/31/22, the Facility Operations Director checked all of the stairwell doors throughout the Facility to verify that they were alarming properly. No concerns were identified. This task is also a task on the maintenance department weekly rounds. Weekly rounds from the previous month were reviewed by the Facility Operations Director and there had been no identified concerns. ELEMENT 3: On 1/31/22, a continuous alarm was added to the Maple Grove Stairwell, as the previous alarm ceased sounding once the door closed, and did not require staff intervention to silence it. This new alarm will ensure that if it is triggered, it does not turn off until a staff member physically does so. Staff were informed about the change the same day, with on-the-spot education by the Staff Educator and at shift reports. This alarm was intended to be in place on a temporary basis while awaiting a more permanent solution. Revisions were made on 1/31/22 to the Missing Resident plan to ensure all areas of the building and outdoor areas are assigned to staff while some neighborhoods are not in operation due to low census, and focusing on more intense outside searching in cases of inclement weather. On 2/1/2022, the IDT discussed the neighborhood acuity of both special care neighborhoods as well as staffing of the neighborhoods. The facility will continue to monitor this periodically as part of our on-going Facility Assessment. On 2/2/22, the Director of Nursing reviewed and revised the Facility's Elopement and Wandering Resident policy. On 1/31/22, two-way radios were made available on the Special Care neighborhoods for staff to carry to ensure adequate communication in the evening and night shift hours. All neighborhoods were equipped with two-way radios on 2/1/22 for staff to utilize, in times of needed increased communication. These are in addition to phones and overhead paging to get additional assistance when necessary. On 2/1/22, 2/3/22, and 2/4/22, the Facility Operations Manager completed Missing Resident drills with all shifts. On 2/1/22, 2/2/22, 2/3/22 and 2/4/22, the Staff Educator completed stand-up education meetings with all staff related to prevention and procedures related to elopement, dementia and behavior management, and abuse prevention. Information on the updated egress alarm was also included in these meetings. Any staff that were out of the building during these trainings were provided with this education during their next scheduled shift. On 2/1/22, the Facility Operations Director attempted to change the functions of all stairwell doors to continuously alarm until manually reset by a key (on Maple Grove and Beechwood Hill) or a proximity card (Red Oak Trail and Blue Spruce Way). The Facility Operations Director was unable to make the changes necessary, and our vendor was contacted the same day to come out and make the changes needed. In the event that desired changes could not be made to the doors by our vendor, the Facility ordered additional continuous alarms on 2/1/22, to be mounted on the door jam of each of all stairwell egress doors. There were installed by Facility maintenance staff on 2/4/2022. On 2/7/11, a technician from the door vendor arrived to evaluate whether changes could be made to the permanent hardware of the egress doors for continuous alarming. He returned on 2/11/22 to implement the change and test on Maple Grove and Beechwood Hill. The temporary alarms were removed at that time from Maple Grove and Beechwood Hill. He returned again on 2/14/22 to implement the change and test on Red Oak Trail and Blue Spruce Way. The temporary alarms were removed at that time from Blue Spruce and Red Oak Trail. As a result of the changes to these four Delayed Fire Egress doors, any time these doors are opened, the alarm will sound until manually reset by proximity card or key. ELEMENT 4: The Facility will monitor the change in egress alarms for functionality during routine weekly maintenance rounds and any issues identified will be reported to the QAPI committee. The Facility will monitor elopement risk assessments for necessary interventions and report to the QAPI Committee. The Facility will complete interviews with staff to ensure they are able to appropriately verbalize proper management of a resident that is at risk of elopement. Findings from these interviews will be reported on and reviewed to the QAPI committee. The Facility will increase missing resident drills to be done on a monthly basis with any identified issues reported to the QAPI Committee. The facility alleges substantial compliance on 2/4/22.

This citation pertains to MI 724 Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) was free from abuse of three reviewed, resulting in Resident #2 being abuse by a staff member. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had a Durable Power of Attorney and was not his own person. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/24/22 revealed R2 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 8/31/22 at 8:36 AM, R2 was observed eating breakfast while seated in a wheelchair in the dining room. Review of the facility reported incident and ivestigation revealed Based upon the investigation findings of potential physical abuse prior to the elopement, the facility substantiated that CNA [C] did exhibit behaviors and interaction that appeared inappropriate and meet the definition of physical abuse. On 8/31/22 at 10:27 AM, surveillance camera footage was reviewed with NHA A and DON B. On 1/31/22 at approximately 7:57 PM, R2 can be seen entering the camera at the left side of the nurse's station. Within one minute, R2 wandered in front of the nurse's station and approached the exit door to the stairway. R2 pushed on the door and the door was observed to open slightly. At approximately 7:57:51, R2 began to walk away from the door as Certified Nursing Assistant (CNA) C approached R2. CNA C was observed pointing back towards the dining room and grabbing onto R2's right arm. R2 was resistive as CNA C continued to hold his arm. R2 then stumbled into CNA C. The altercation moved to the wall across from the door as CNA C held onto R2's arm until R2 broke free at approximately 7:58:17. CNA C was then observed giving R2 a bearhug from behind with both arms around R2, with his hands locked on R2's chest. At 7:58:26, CNA C released his arms from around R2. CNA C stood in front of R2. R2 was visibly frustrated and pushed CNA C. CNA C then grabbed R2's left wrist and at 7:58:42, had R2 restrained by his wrist, near the wall by the stairway exit door. A physical altercation between CNA C and R2 continued. R2 wandered behind the nurse's station and attempted to go into the medication room and the other door. At approximately 8:00 PM, R2 wandered back to the stairway exit door as CNA C placed himself in front of R2. R2 grabbed CNA C and CNA C then engaged in another physical altercation. At 8:00:16, CNA C had R2 pinned up against the wall with his right forearm across R2's chest. At 8:00:28, CNA C and R2 entered a supply room. The actions in the supply room could not be observed on camera. At 8:01:46, CNA C exited the room and R2 followed. A physical altercation continued and at 8:01:56, CNA C had a hold of both of R2's wrists as he appeared to attempt to drag R2 away from the doors. R2 was resistive. At 8:02:02, CNA C grabbed R2's left wrist with both hands and pulled him out of view of the camera. At 8:02:08, CNA C approached the nurse's station and picked up the phone as R2 approached the stairway door again. While on the phone, CNA C approached R2, grabbed his left wrist and pulled him away from the door. R2 punched CNA C. CNA C then wrapped his right arm around R2's neck in what appeared to be a headlock. R2 continued to punch CNA C. At 8:02:41, R2 sat on the nurse's station desk. CNA C released his arm from around R2's neck and hung up the phone. At 8:03, CNA C was observed on the phone again. R2 was observed breathing heavily. At 8:03:11, CNA C walked away, out of camera view. At 8:04:14, R2 opened the stairway exit door and entered the stairway, out of camera view. At 8:06:36, CNA C reapproached the nurse's station, looked in the window of the supply room, but did not look into the stairway nor exit into the stairway. At 8:08 PM, CNA C pushed on the stairway exit door but did not exit into the stairway. NHA A reported at 8:03:11, CNA C left the unit, but instead should have called someone else in the building. NHA A reported the previous NHA responded to the facility and was the person who found R2 outside behind the barn. NHA A reported CNA C acknowledged that he did wrong, was frustrated and lost his cool. In a telephone interview on 8/31/22 at 11:09 AM, CNA C reported R2 was trying to get out and he was trying to contain him and get him calmed down and find the keys to the truck. CNA C stated He [R2] was trying to fight me. I was trying to keep him in. CNA C stated I was doing 16 hours, was just fed up with it. When asked about the bearhugging, pulling on R2's arms, and the headlock, CNA C stated, That wasn't a headlock. I had my arm around his shoulder. If you want to see a headlock, I will show you a headlock .I was trying to talk to him and calm him down. R2 denied pulling on R2's arms and reported he was holding R2's arms and bearhugging him to prevent R2 from hitting him. Review of CNA C's Employee Disciplinary Report dated 2/4/22, with an incident date of 1/30/22, revealed On 1/30/22, you were working the Maple Grove Neighborhood. [R2] was exhibiting exit seeking behaviors when you intervened with him near the emergency stairwell door just prior to 8 p.m. Upon surveillance of the Facility's video surveillance system following the elopement of [R2], you were observed to be inappropriate with your approach and interaction with [R2], including forcefully grabbing his arms, and bear hugging him, pulling his arms, and putting your arm around his neck while trying to get him away from the door. After he moved from the door area you continued to attempt to block him from other areas of the neighborhood, including areas that were locked and/or were no harm for him to wander in You admitted to being very frustrated at the situation . CNA C's employment was terminated due to five violations of work rules which included Committing of, or failure to report, any resident abuse (including verbal, sexual, physical, and mental abuse, corporal punsishment, and involuntary seclusion.), mistreatment, neglect, and misapporpriation of resident property, and exploitation of residents. The following Past Non-Compliance was reviewed and accepted at the time of the survey: ELEMENT 1: On 1/30/22, upon identification of potential abuse, CNA C was immediately suspended pending investigation. He did not return to work at the Facility. On 1/30/22, R2 had a body assessment completed and the only identified concern was a small skin tear to the elbow. It is not believed this was caused by the inappropriate actions of CNAC. Additionally, EMS assessed resident and determined outside medical care was not necessary. Resident's physician was also contacted at this time, with no new orders given. Staff completed vitals every hour for 4 hours and there were no further concerns. Social Work visited with, and assessed R2 several times in the week to follow. R2 has a BIMS of 7/15 and he does not have a recollection of this incident. Additionally, he has not exhibited any distress and has been in good spirits. His care plan was revised on 1/31/2022 to include additional interventions for staff when R2 wants to go home or is anxious. On 2/1/22 he was noted to exhibit restless and showing signs of anxiety, likely due to his recent admission and transition to living at the Facility. Facility Nurse Practitioner assessed him and gave orders for routine [MEDICATION(S)] once daily and PRN (as needed) [MEDICATION(S)] for anxiety. On 2/3/2022, Facility Psychiatrist completed a consultation with R2 and gave an order to increase routine [MEDICATION(S)] to twice daily. Social Work has also spoken with regular neighborhood staff, and resident's wife since the incident. None have reported any signs or symptoms of psychosocial changes/behaviors as a direct effect of the incident. He is continuing his normal routine and activities. ELEMENT 2: On 1/31/22 interviews were conducted with all staff that had been working closely with CNA C. No new issues or concerns were identified related to the CNA's care during these interviews. On 1/31/22 interviews were conducted with all residents that were able to be interviewed in which CNA C had been caring for. No concerns were identified during these interviews. On or before 2/1/22, all residents recently cared for by CNA C had body audits/skin assessments completed by the Charge Nurse and Nurse Manager for any signs of injury. No concerns were identified for the residents assessed. ELEMENT 3: On 1/31/22, two-way radios were made available on the Special Care neighborhoods for staff to carry to ensure adequate communication in the evening and night shift hours. All neighborhoods were equipped with two-way radios on 2/1/22 for staff to utilize, in times of needed increased communication. These are in addition to phones and overhead paging to get additional assistance when necessary. On 2/1/2022, the IDT discussed the neighborhood acuity of both special care neighborhoods as well as staffing of the neighborhoods. The facility will continue to monitor this periodically as part of our on-going Facility Assessment. On 2/1/22, The Director of Risk Management and LMSW reviewed the Facility's policies related to abuse including: Abuse Program, Investigations & Reporting, EJA- Reporting of Reasonable Suspricion of a Crime, Required Staff Training, Staff Education & Prevention of Resident Abuse to ensure they were appropriate and covered the Facility's current procedures. On 2/1/22, 2/2/22, 2/3/22 and 2/4/22, the Staff Educator completed stand-up education meetings with all staff related to prevention and procedures related to dementia, behavior management, and abuse prevention. Any staff that were out of the building during these trainings were provided with this education during their next scheduled shift. ELEMENT 4: The Facility will complete interviews with staff to ensure they are able to appropriately verbalize proper response for residents exhibiting behaviors or other situations that may lead to abuse. Findings from these interviews will be reported on and reviewed to the QAPI committee. The facility alleges substantial compliance on 2/4/22.

Based on observation, interview and record review the facility failed to ensure that a fan used in the Beechwood kitchen was kept clean resulting in the potential for dust, allergens and debris to land on newly washed dishware used by 13 residents that eat food from this kitchen unit. Findings include: On 8/2/21 at approximately 12:30 pm, a large, round, gray floor fan was observed on the Beechwood kitchen floor, turned on and facing the dishwasher from approximately ten feet away. There were clean dishware observed on the counter. The fan was running at high speed. The fan was blowing towards the dishwasher and sink. Both sides of the front and back screens of the fan were filthy with gray dust/debris. The fan blades were also coated with gray dust/debris on the leading edges. There was clean dishware observed on the counter. On 8/3/21 at approximately 12:30 am, Activities Aide S was asked about the cleaning schedule for the kitchen. Aide S said that everything that needed to be cleaned was listed on the facility document titled Neighborhood Kitchen Food Temperature Log, dated July 25 - 31/21. A review of the facility's Food Temperature Log reflected no mention of cleaning fans used in the kitchen.

This citation pertains to intake MI 685 Based on interview and record review the facility failed to maintain private medical information, for one Resident (#78) from one reviewed for privacy. This deficient practice resulted in the potential for anger, resentment and family disruption. Findings include: According to the electronic medical record (EMR), Resident #78 was admitted to the facility on [DATE] with Alzheimer's disease, and dementia, and was severely cognitively impaired. Resident #78's wife was his Durable Power of Attorney. During a phone interview on 8/3/21 at 8:28 a.m., Family Member (FM) Bb reported that Resident #78 was admitted to the facility on [DATE]. FM Bb said a few days after the Resident's admission, estranged family members contacted her in anger about the admission. The estranged family members included the Resident's brother and mother, who wanted information about Resident #78. FM Bb said Resident #78 was estranged from his brother and mother for years and would not want them involved in his life now. FM Bb said she called the facility and was told by the Administrator that a staff person in medical records disclosed information concerning Resident #78's admission, but the staff person was fired as a result. FM Bb confirmed she could not validate that was true. During an interview on 8/3/21 at 11:17 a.m., the Administrator (NHA) confirmed the allegation of a HIPAA (Health Insurance Portability and Accountability Act) violation. The NHA said the facility was contacted on 7/8/21 by FM Bb alleging someone violated Resident #78's privacy by disclosing his admission and other information to the estranged family. The NHA said the allegation was confirmed, through an internal investigation, Staff Cc in Medical Records admitted disclosing the information to the estranged family member who was a neighbor. The NHA said Staff Cc was terminated and provided the termination notice, dated 7/12/21. The termination notice included a hand written statement by Staff Cc, dated 7/8/21, which revealed, I told my husband that our old neighbor was admitted to (facility name) yesterday. My husband .told .(a different) neighbor [Resident #78] was admitted where I work .I know that I shouldn't have said a word, I know it is a HIPAA violation . The NHA said she understood the documentation of the incident was not comprehensive and the facility fell short on that. The NHA also confirmed nothing more was done in follow up to Staff Cc's termination because she didn't want the word to get out (meaning to staff and community) because she had a reputation to preserve. The pamphlet, Rights of Residents in (State Name) Nursing Facilities, dated 11/28/16, provided by the facility as part of its admission packet, revealed, .You have a right to personal privacy and confidentiality of your personal and medical records. You have a right to secure and confidential personal and medical records .

Based on observation, interview and record review, the facility failed to implement infection control measures to prevent the spread of COVID-19 and follow the Centers for Disease Control (CDC) guidelines for isolating suspected positive COVID-19 residents, respiratory protection, sanitizing face shields, handwashing, food service, and updating policies and procedures to reflect CDC guidelines for 8 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident, #5, Resident #6, Resident #7, Resident #8) of 8 residents reviewed, resulting in an Immediate Jeopardy on [DATE]. This deficient practice places up to 92 residents at risk for serious harm, injury, and/or death related to the COVID-19 virus. Findings include: Review of the facility policy titled Coronavirus COVID-19 last revised on [DATE] revealed: (Facility) will respond promptly upon suspicion of illness associated with novel coronavirus in efforts to identify, treat, and prevent the spread of [MEDICAL CONDITION]. Procedure when COVID-19 is suspected: . b. Place resident in a private room with the door closed. Screen visitors of persons with known or suspected COVID-19 symptoms of acute respiratory illness. will continue to follow guidance for residents with suspected or confirmed COVID19 along with additional long-term care guidance from CDC as it becomes available. Review of the facility policy titled, Respiratory Protection Program, Last reviewed [DATE], reflected, Policy Statement, . The Program ensures that proper respiratory protection is provided when necessary to protect staff from respiratory hazard. The facility policy section of implementation reflected that, OSHA requires that each employer must provide respirators to protect workers from workplace hazards . and that the facility, provides respirators suitable for their intended purpose. The facility policy reflected that employees selected to use the respirator must pass an appropriate fit test. Review of the CDC Guidance dated [DATE]. Section 2, titled, Adhere to Standard and Transmission - Based Precautions, reflected, Health Care Providers (HCP) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator. This Guidance reflected Use N95 or Higher Respirator, when respirators are not available use the best alternative like a face mask https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html In an interview and record review upon entrance to the facility on [DATE] at approximately 11:00 a.m., the Nursing Home Administrator (NHA) reported there is 27 residents who tested positive for COVID 19 and are on a unit of the building designated for COVID 19 positive residents. NHA reported there were 5 other residents in the facility not on the COVID unit that are presumptive positive for COVID 19 and remain on their unit in their room until the test results show they are positive for COVID 19. The COVID unit had designated staff to care for the residents who tested positive for COVID 19. The facility provided a list of residents who are on the COVID unit and those pending COVID 19 test results. Resident #1 Review of a Face Sheet revealed Resident #1 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) indicating she is cognitively intact. Resident #2 Review of a Face sheet revealed Resident #2 is [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #2 had a (BIMS) indicating she is moderately cognitively impaired. Resident #3 Review of a Face Sheet revealed Resident #3 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Resident #4 Review of a Face Sheet revealed Resident #4 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #4 had a (BIMS) indicating she is cognitively intact. Resident #5 Review of a Face Sheet revealed Resident #5 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #5 had a (BIMS) indicating she is severely cognitively impaired. Resident #6 Review of a Face Sheet revealed Resident #6 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a (BIMS) indicating she is moderately cognitively impaired. Resident #7 Review of a Face Sheet revealed Resident #7 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #7 had a (BIMS) indicating she is cognitively intact. Resident #8 Review of a Face Sheet revealed Resident #8 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #8 had a (BIMS) indicating she is moderately cognitively impaired. Resident #1 During an initial observation on [DATE] around 11:00, Resident #1 had a caddy on the outside of her door indicating she is in droplet isolation precautions and was in her room with the door open. During an observation and an interview on [DATE] at 11:27 a.m., Licensed Practical Nurse (LPN) O reported Resident #1 in room [ROOM NUMBER] is on droplet isolation precautions since this morning due to a sore throat. LPN O reported staff had collected swab samples to test Resident #1 and a few other residents for COVID -19 this morning and will get the results within 24 hours. No hand sanitizers noted in hallways near the resident rooms. During an observation and an interview on [DATE] at 11:30 a.m., Certified Nursing Assistant (CNA) M entered a droplet isolation room [ROOM NUMBER] (Resident #1's room) and exited the room a few minutes later with the same mask (KN95) and face shield and no disinfecting of face shield noted. CNA M observed touching her mask in the hallway and did not perform hand hygiene and entered room [ROOM NUMBER] which is not an isolation room, to pass out a fruit cup. CNA M had contact with the resident who resided in room [ROOM NUMBER] with no hand hygiene before leaving the room and then entered room [ROOM NUMBER] where she gave the resident a fruit cup, assisted the resident in her wheelchair, adjusted her pillows and removed trash from her room with no hand hygiene when leaving the room. CNA M took trash down the hallway to the soiled utility room and then performed hand hygiene. When queried, CNA M confirmed she did not clean her face shield or change her mask when she left room [ROOM NUMBER] and did not normally practice cleaning/disinfecting face shields after leaving isolation rooms. CNA M reported she had the same concern about cleaning and disinfecting PPE (personal protective equipment) but did what the facility expected her to do. There is no hand sanitizer in the hallway in this area and CNA M reported she did not carry any hand sanitizer in her pockets. CNA M reported there were a couple spots at the end of the hall near the dining room and the nurses' cart if she needed hand sanitizer and it is in the resident rooms as well. CNA M reported she gets 2 KN95 masks per pay period and reuses them often at work during the 2 week duration. CNA M reported she stores her masks and face shield in her locker at the end of her shift. In an interview on [DATE] at 12:47 p.m., CNA Q reported Resident #1 who is in droplet isolation precautions pending COVID-19 testing results still had her meal tray, but when she is done eating, CNA Q reported she will take the tray out of the room to the kitchenette without PPE on because she is not to leave the room with gloves or a gown on in the hallway. CNA Q reported she will put the meal tray in a bin with the other dishes. In an interview on [DATE] at 1:00, Culinary Aide (CA) P reported staff bring the meal trays from the presumptive positive for COVID-19 residents to the dining area and put the plates and utensils in the black bins with the other dishes. CA P did not have extra PPE on for the handling of potentially contaminated dishes other than gloves. Review of Progress notes for Resident #1 revealed: [DATE]: COVID Screening Note: res (resident) states she has had moth (mouth) pain for a couple days that has now moved into her throat. phys (physician) notified and stated to continue to monitor at this time. [DATE] at 9:35 a.m.: Nurses Notes: res presents (with a) (complaint of) sore throat and change in taste and smell. Res placed on droplet precautions and re-tested for covid-19 [DATE] at 11:12 a.m.: Nurses Notes: updated DPOA (durable power of attorney) . (related to change of condition) with resident (related to) sore throat, change in taste and appetite, .Covid test had been performed this morning. [DATE] at 10:50 a.m.: Updated DPOA . (related to) POSITIVE covid 19 test result. Informed (DPOA) resident is moving to room [ROOM NUMBER] on the covid unit. (sic) Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #1 revealed: Order Date [DATE]: Res to remain on droplet precautions until test results are returned [DATE] at 3:07 a.m.: Nurses Notes: (Resident #1) pulse ox(imetry) 83% on 3 L (liters oxygen), some confusion and period of blank stare. Resident wheezing. Sent to (hospital emergency room ) for evaluation. [DATE] at 11:13 a.m.: Nurses Notes: . (Resident #1) on [MEDICAL CONDITION] at the hospital . At this point, resident was in need of mechanical ventilation. Resident currently on a vent. (sic) Resident #2 Review of the Progress Notes for Resident #2 revealed on [DATE] she had a fever of 101.4 degrees Fahrenheit, a pulse of 119 and pulse oximetry of 90%, fatigued and less alert than normal and placed on droplet precautions. COVID 19 test done and came back positive the same day and then moved to the COVID unit. [DATE] at 6:29 p.m.: Nurses Note: Resident noted to be trembling and shivering in room before dinner. Resident (complains of) having the chills and being cold. Resident sent to (hospital emergency room ) for evaluation . Resident #3 Review of the Progress notes for Resident #3 revealed: [DATE] at 5:26 p.m.: COVID Screening Note: blood pressure ,[DATE] [DATE] at 10:37 p.m.: Nurses Note: This resident's BS (blood sugar) =75, and BP (blood pressure) = ,[DATE] at (4:30 p.m.). Pushed fluids and her BP cam up to ,[DATE], had to sit (with) her at suppertime to get her to drink her supper. BS at (bedtime) =167. Call NP (nurse practitioner) to apprise her of situation. She had me place resident on droplet precautions and obtain a Covid test. XXX[DATE] at 3:09 p.m.: Updated (DPOA) (related to) POSITIVE Covid 19 test. [DATE] at 7:35 p.m.: .she was moved to COVID Unit at approximately 4:00 p.m. [DATE] at 7:20 p.m.: Nurses Notes: Resident continued to be unresponsive to verbal stimuli throughout the shift. Resident not alert enough today to take any medications. Daughter requesting her mother be sent to (hospital emergency room ) . (sic) Resident #4 During an observation of the 500 hall on [DATE] at approximately 12:00 p.m., Resident #4 in room [ROOM NUMBER] bed 2 had a caddy on the outside of her door indicating she is in droplet isolation precautions and was in her room. Resident #4 is the isolated resident and Resident #7 is her roommate in bed 1 that is not in isolation but share the same room. During an observation and an interview on [DATE] at approximately 12:00 p.m., Culinary Aide (CA) S reported she is aware the facility is testing a few residents on the hallway for COVID-19 and did not do anything different for meal serving or cleaning with those residents. CA S reported she uses regular dishes and trays to serve food to those residents. At this time, staff observed removing meal trays from room [ROOM NUMBER], Resident #4's room, a presumptive positive for COVID-19 resident, and walked down the hallway to the kitchenette located at the end of that hall with no barrier, PPE (personal protective equipment), or a cart for transportation of meal trays. There were no contact precautions noted during the transfer of the used meal tray. CA O reported that residents who were Presumptive Positive for COVID-19 did not use special utensils or dinner ware. CA O reported she runs the dirty dishes through the dishwasher twice to make sure they are clean and disinfected since the outbreak of COVID-19. Review of the Progress Notes for Resident #4 revealed: [DATE] at 11:08 a.m.: Nurses Note: Updated residents' brother about COC (change of condition) (related to) fever and need for additional COVID 19 test. [DATE] at 11:39 a.m.: Physician/NP/PA's Progress Note: . She is febrile at 100.3 . Orders for droplet precautions and a COVID Swab placed . [DATE] at 12:43 p.m.: COVID Screening Note: Vital signs 100.3 (temp) . slight cough. XXX[DATE] at 10:56 a.m.: . POSITIVE covid 19 test. [DATE] at 5:12 p.m.: . she was moved to COVID Unit at approximately 9:00 a.m. [DATE] at 10:38 a.m.: Physician/NP/PA's Progress Note: (Resident #4 is reported to have fever, increased cough with increased sputum production and increased shortness of breath. She has demonstrated a functional decline. [DATE] at 12:13 p.m.: Nurses Notes: Explained that resident did develop a fever last night of 102.2 with cough, chills, loss of appetite ect. (sic) Review of COVID-19 test results for Resident #4 revealed they collected the sample on [DATE] at 10:39 and last resulted on [DATE] and is positive for COVID-19. Resident #5 During an observation of the 500 hall on [DATE] at approximately 12:00 p.m., Resident #5 in room [ROOM NUMBER] bed 1 had an isolation caddy hanging on her door and is presumptive positive for COVID 19 and had a roommate, Resident #6 in bed 2 who is not in isolation. Review of the Progress Notes for Resident #5 revealed: [DATE] at 2:26 a.m.: Nurses Notes: res. up with assist to use (bathroom) at 1:45 a.m. and pt. (patient) hot to touch, (vital signs) obtained and revealed res. with (temperature) 103.4 temporal artery. Orders received to screen resident for covid 19 virus later this morning. [DATE] at 10:58 p.m.: (Resident #5) being febrile at 103.4 and being reswabbed for Covid 19 virus via voicemail. [DATE] at 8:27 a.m.: Physician/NP/PA's Progress Note: (Resident #5) has a runny nose, cough and fever that persist. She also has a poor appetite. I will repeat her COVID test today. Review of Resident #6's progress note revealed Resident #5 tested positive for COVID-19. Resident #5 had no further progress notes since [DATE] and is out of the building as of [DATE]. Resident #6 Review of Progress Notes for Resident #6 revealed: Physician/NP/PA's Progress Note: [DATE] at 11:00 a.m.: COVID swab was performed due to proximity of resident to other positive resident. (Resident #6) is NEGATIVE for COVID. Droplet precautions have been discontinued Resident #7 During an observation of the 500 hall on [DATE] at approximately 12:00 p.m., Resident #7 is in room [ROOM NUMBER] bed 1 and has a roommate, Resident #4 in bed 2 who is presumptive positive for COVID-19. Resident #7 is not on isolation precautions. During an observation and an interview on [DATE] at approximately 12:15 p.m., CNA T and CNA U reported Resident #5 and Resident #6 shared a room with droplet precautions in place for Resident #5 only in room [ROOM NUMBER] bed 1. Resident #7 shared a room with Resident #4 who is in droplet isolation precautions only in room [ROOM NUMBER] bed 2. Resident #3 is the only resident in room [ROOM NUMBER] and is on droplet isolation precautions. Review of Progress Notes for Resident #7 revealed: [DATE] at 9:26 a.m.: Physician/NP/PA's Progress Note: (Resident #7's) roommate has tested positive for COVID 19. A screen test has been performed and (Resident #7) will remain in droplet precautions until her screening test is resulted. [DATE] at 11:12 a.m.: Physician/NP/PA's Progress Note: COVID screening has come back positive. (Resident #7 had an exposure to positive roommate. She has been moved to the COVID unit for continued droplet precautions. She remains asymptomatic. (sic) Resident #8 Review of the Progress Notes for Resident #8 revealed: [DATE] at 2:17 p.m.: Nurses Notes: CNA reported resident being sleepier than normal with a decreased appetite and resident coughing more than her normal. Noted a dry barky cough this shift, LS (lung sounds) are clear bil (bilaterally) and diminished on exhale. new orders for covid swab and CXR (chest xray), droplet precautions are in place. [DATE] at 7:29 p.m.: Resident confirmed to be positive for the Coronavirus. Droplet precautions already in place. was moved to COVID Unit at approximately 6:30 p.m. On [DATE] at 12:10 PM, Certified Nurse Aide (CNA) E reported obtaining PPE has not been a concern. On [DATE] at 12:22 PM, LPN Unit Manager I reported no problems obtaining appropriate PPE. In an interview on [DATE] at 12:35 p.m., CNA T and CNA U reported they did receive training for COVID-19 and said they clean their face shields if they are visibly soiled with Sani-wipes which are located at the end of the hallway near the nurses' station. CNA T went in to room [ROOM NUMBER] (Resident #5) that is under droplet isolation precautions while pending COVID-19 test results, and handed Resident #5's used meal tray to CNA U who then walked the tray down the hallway to the kitchenette with her bare hands and no barrier or PPE. When queried, CNA T reported the tray removed is from Resident #5 and confirmed she had a roommate that is not in isolation precautions. On [DATE] at 12:37 PM Culinary Director CD L reported meals are delivered in an enclosed Cambro cart dedicated to the COVID-19 unit. CD L reported that following the meal the plates, plate covers, and trays are returned to the kitchen in the dedicated enclosed cart. CD L reported the items inside the cart from the COVID unit are washed separately from other facility kitchenware. CD L reported while these plates, plate covers, and trays are moving through the high temperature wash process the enclosed cart is sanitized. Once the dishes and cart are cleaned and sanitized by staff, the dishes are placed in the enclosed cart by staff to be used for the next meal for the dedicated COVID-19 unit. In an interview conducted [DATE] at 1:25 PM, Infection Control Coordinator IC B reported: Staff are expected to clean their face shields daily and as needed. IC B reported that a face shield is like a mask as it does not come in to contact with a resident like gloves or a gown. IC B reported that the staff who care for residents that are presumptive positive for COVID-19 wear the same face masks and face shields with no extra precautions or disinfection of PPE after leaving the COVID-19 droplet precaution, isolation room. IC B reported the first confirmed case of COVID -19 was a nurse on [DATE]. The first resident confirmed case at the facility was on [DATE] who died on e week following the diagnosis. IC B reported that a recent mass testing of employees the week before this interview revealed five employees tested positive for COVID-19 and were asymptomatic. Those employees are now on a medical leave. IC B reported that residents who display symptoms of COVID-19 and tested for [MEDICAL CONDITION] are placed in droplet precaution isolation while waiting for their test results. IC B reported the roommates of the symptomatic residents are not tested for COVID-19 unless the test results are confirmed positive by the resident being tested . The roommates continue to cohort in the same room pending the test results. This indicates that a symptomatic resident suspected of having COVID-19 is not isolated from an asymptomatic resident which is not in accordance with the CDC Guidance last updated on [DATE]. IC B stated, we are changing policies as we go along. When queried about removal of used meal trays from presumptive positive resident rooms, IC B reported he is not concerned with staff removing the trays from the isolation rooms down the hall to the kitchenette because it is transferred in the open air and more concerned with the actual droplet and air transmission of the potential COVID-19, not too concerned with contact precautions. During several observations and record review on [DATE] of Residents with suspected COVID-19 cared for by Certified Nursing Assistants M, Q, T, and U wearing KN95 masks when entering their rooms. Review of a document provided by the facility revealed eleven staff members fit tested for N95 masks to care for residents with COVID 19 and the staff mentioned are not on that list and did not have N95 masks as recommended by the CDC. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of the email dated [DATE] at 12:06 PM Risk Management Director (RDA) A reported, . at this time we have adequate supply of N95 masks to meet CDC Guidance. We use approximately ,[DATE] N95 masks per day and have a ,[DATE]-week supply on hand. We regularly seek out additional community resources and suppliers to obtain additional N95 masks to ensure we continue to have ample supply for usage. On [DATE] at 9:57 AM a telephone interview conducted with Public Health Department Registered Nurse (HDRN) : AA. HDRN AA reported she is in frequent contact with the facility. HDRN reported she has instructed the facility to follow COVID-19 Guidance from the CDC. HDRN reported the facility has not raised any issues regarding a shortage of PPE other than gowns. HDRN AA reported the Health Department is prepared to provide the facility with gowns if needed but that, to date, the facility has not requested a supply of gowns or other PPE. Facility administrator was notified of identified Immediate Jeopardy on [DATE] and a plan for removal was requested. Following ongoing dialogue with the facility, on [DATE] the facilities removal plan was approved by the state agency. On [DATE], surveyors verified the facility completed the following to remove the Immediate Jeopardy: 1. On [DATE] the facility identified residents affected or likely to be affected. At this time, no other residents were identified to meet the criteria for potentially being COVID-19 positive. 2. On [DATE] all residents at the facility are considered at risk and the facility continues to screen all residents daily on each shift for COVID-19. 3. On [DATE] a resident was identified as having symptoms of COVID-19 and was moved to the COVID-19 unit the same day. 4. On [DATE] the facility re-educated staff on the expectations and procedures for persons under investigation (PUI's) residents. 5. On [DATE] the facility updated the policy and procedures to reflect the CDC (Centers for Disease Control) guidelines. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the fact that sustained compliance for infection control had not yet been verified by the State Agency. In an interview on [DATE] at 11:14 a.m. Certified Nursing Assistant (CNA) C reported she takes her face shield home every day at the end of her shift. Reported she did not sterilize her face shield or masks. CNA C reported she gets 2 KN95 masks per pay period. In an interview on [DATE] at 11:25 a.m., Licensed Practical Nurse (LPN) V reported she puts her face masks in a plastic baggie at the end of her shift to store for the next shift and takes her masks and face shield home. LPN V reported staff could put them in their lockers if they wanted to at the end of their shift. In an interview conducted [DATE] 11:27 a.m. LPN W reported she stores her PPE in a plastic bag and keeps it in her car. LPN W reported, everyone does it differently, but that she does not like to leave her PPE at the facility. In an interview conducted [DATE] at 11:35 a.m. at CNA Z reported she takes her face shield home with her. In an interview on [DATE] at 11:37 a.m. Certified Nursing Assistant (CNA) J reported she is allotted 2 masks per pay period and stores them in a baggie at the end of her shift. CNA J reported she cleans her face shield before and after every shift and stores them in her locker. CNA J reported the facility hands them 2 new masks in a baggie and at the end of her shift she stores the masks in the same baggie. In an interview conducted [DATE] at 12:30 IC B indicated that there is no documentation of the expectation or specific direction for the care and storage of PPE issued to and used by staff. IC B reported the facility does not have a policy or procedure for the reuse of PPE. IC B reported staff get updated and informed verbally about PPE use and infection control practices that is consistent with the facility policy that reflects the CDC Guidance. When queried, the Director of Nursing (DON) and IC B reported they expected staff to place their used masks in a paper bag after their shift and reported the brown bags were readily available in their offices. When queried if staff knew where the brown bags were the DON and IC B reported staff knew where the brown bags were. When queried if their brown bag supply had been decreasing, they reported they did not think about that. The DON and IC B confirmed the staff are handed their 2 mask allotment in a plastic baggie and are not given a brown bag to store their used masks at the same time. The DON and IC B reported they needed to educate the staff about the storage of their masks and were not as concerned about the face shields. Review of the CDC Guidance of [DATE] reflected, Use N95 or higher Respirator. Review of the CDC Website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Frespirator-supply-strategies.html) included a list of acceptable NIOSH approved alternatives to the N95 respirators and included: N99, N100, P95, P100, R95, R99, and R100, that may be used if N95 respirators are not available. The list did not include the KN95 mask as an acceptable alternative for respiratory protect if N95 respirators were not available. Review of the CDC guidance last updated [DATE] revealed: . If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html The CDC Guidance of [DATE], reflected, Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Review of the CDC guidance titled Strategies for Optimizing the Supply of Facemasks revealed: Purpose: This document offers a series of strategies or options to optimize supplies of facemasks in healthcare settings when there is limited supply. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays. Implement limited re-use of facemasks. Limited re-use of facemasks is the practice of using the same facemask by one HCP for multiple encounters with different patients but removing it after each encounter. As it is unknown what the potential contribution of contact transmission is for [DIAGNOSES REDACTED]-CoV-2, care should be taken to ensure that HCP do not touch outer surfaces of the mask during care, and that mask removal and replacement be done in a careful and deliberate manner. HCP should leave patient care area if they need to remove the facemask. Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag or breathable container. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html Review of the CDC Guidance of [DATE] reflected, Use N95 or higher Respirator. Review of the CDC Website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Frespirator-supply-strategies.html) included a list of acceptable NIOSH approved alternatives to the N95 respirators and included: N99, N100, P95, P100, R95, R99, and R100, that may be used if N95 respirators are not available. The list did not include the KN95 mask as an acceptable alternative for respiratory protect if N95 respirators were not available.

Based on observation, interview and record review the facility failed to prevent staff to resident abuse for 2 of 3 sampled residents (Resident #1 and Resident #2), resulting in (Resident #1) a smack to the buttock, pain, change in behavior, feelings of intimidation to a reasonable person, and bruising and the potential for pain to (Resident #2). Findings Include: Resident #1 (R1) Resident #1 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS: resident assessment tool) dated 8/15/19 reflected R1 had memory problems, required extensive assistance of 2 persons for transfers, hygiene, dressing, bathing, was frequently incontinent of urine and always incontinent of her bowels. On 8/22/19 at 8:44 AM R1 was observed sitting at a table by herself, cleanly dressed and groomed. R1 was feeding herself breakfast independently and tolerating it well. A conversation was attempted with R1, however she would not make eye contact, and would not answer the writer when attempting to be questioned about the incident dated 8/13/19. The facility reported a staff to resident abuse concern to the state agency on 8/14/19. According to the incident report dated 8/13/19 at 8:40 PM a staff to resident incident occurred in R1's room. The investigation summary completed by DON B on 8/16/19 reflected, Following the facility's investigation, based upon confirmation from both the witnesses CNA F, and the perpetrator CNA E, the facility was able to substantiate that CNA [NAME] smacked R1's butt while they were providing care. The facility determined that CNA [NAME] did act inappropriate with her actions towards R1, and therefore her employment was terminated on 8/16/19. The Employee Warning Record, used as the termination form dated 8/16/19, signed by DON B and CNA [NAME] reflected: On 8/13/19 at 8:40 PM, a conduct violation took place. On 8/13/19 at 8:43 PM it was reported to the DON that you were working on the (name of hall) when you and another CNA (CNA F) were in R1's room providing care to her in the bathroom. The resident was being combative and resistive to care when you In total desperation (I) smacked her butt cheek so she would loosen her muscles. The Facility submitted a Facility Reported Incident as required for an allegation of abuse and the State may choose to investigate further. This is against union work rules: Group 1, Letter H: Failure to meet facility expectations with regards to work performanceGroup 2, Letter J: Discourtesy to an employee or visitor, and /or other inappropriate behavior Group 3, Letter I: Committing of, or failure to report, any resident abuse (including verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.), mistreatment, neglect, and misappropriation of resident property, and exploitation of residents. The facility's Abuse Program policy revised 4/29/19 reflected as the POLICY STATEMENT: It is the policy of (name of facility) to maintain a safe environment free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents have the right to be free from abuse, neglect and corporal punishment of any type by anyone. Under POLICY INTERPRETATION & IMPLEMENTATION reflected: Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition, cause physical harm, pain or mental anguish It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 8/21/19 at 3:27 PM CNA F was interviewed and asked to recall the incident between CNA [NAME] and R1. CNA F revealed: I told CNA [NAME] I was going to get R1 ready for bed. Also, that I would call her (CNA E) when I was ready to put her (R1) to bed because she gets sundowners. When I took R1 to the room she was kind of getting agitated and combative. I pulled the call light and called CNA [NAME] from the hall to come and help me get her (R1) dressed. We laid her (R1) down, and got her in a gown, and I noticed she had a bowel movement. I was cleaning her up and stuck a new brief under her. CNA [NAME] was getting agitated, I could tell. R1 was squirming around. I rolled R1 toward me and CNA [NAME] said I missed a spot under her (R1's) butt. CNA [NAME] asked for a wash cloth and she started to clean her (R1) up. R1 started to squeeze her butt cheeks together and CNA [NAME] said, 'Stop squeezing your butt cheeks' 5 times yelling loudly. I was in shock like why is she yelling at her, and then she smacks her (R1) on the butt pretty firm. CNA F was asked to demonstrate the smack. CNA F then smacked her right hand on the top of her left hand, which made a loud smacking sound. When asked to rate the pain (0= no pain, 5= moderate pain and 10= worst pain; 0-10 point pain scale explained) CNA F voiced it stung at a 5 to 6. CNA F revealed CNA E's smack to R1, left a mark on her upper left cheek/buttock that was pink in color, and that you could see the mark of the 3 fingers she used on her bottom. As soon as CNA [NAME] hit her, R1 stopped moving and talking. She had been babbling and grabbing at my shirt. I felt bad for her. I knew she would not remember but I will. CNA [NAME] got her cleaned up. I fastened her brief and put her cover on her, and bagged everything up. Then CNA [NAME] said to me, You did not see me hit her. I said okay as in not trying not to escalate the situation. We still had 2 people to put to bed .CNA [NAME] left to help someone else. I went and told Licensed Practical Nurse (LPN G) what happened, and she questioned if it was playful, because she could not see CNA [NAME] doing that. I said, does it matter?. She (LPN G) went to call DON B, DON B called Administrator (ADM A). By the time we came back to check her (R1) bottom the marks were gone .I was shocked like what the H*LL did I just see, like how can you be that comfortable to do that in front of me. When asked what kind of abuse did CNA [NAME] display towards R1 on 8/13/19, CNA F replied, Physical and mental. On 8/22/19 at 8:26 AM LPN G was interviewed in person and asked to recall incident dated 8/13/19, and revealed: I was in the charting room and CNA F came in and said, 'LPN G's name, CNA [NAME] smacked R1 on the butt'. I said you mean a tap, smack. CNA F said no, a smack. I said oh, where is she at. CNA F said she was not in the room with R1, and that CNA [NAME] told CNA F she did not hit R1. I told CNA [NAME] she had to leave, I called ADM [NAME] Me and CNA F checked her over for welts on her butt. LPN G denied noticing anything on R1's bottom. I was really shocked that she (CNA E) did that in front of somebody. I never thought she (CNA E) would do something like that. Did R1 appear different in any way? Usually she is constantly moving. She was not busy as she usually is. She seemed quiet. Is that abnormal for her? Honestly yes, I think so. She talked about (name of) cottage a lot. When asked what type of abuse would she describe CNA [NAME] smacking R1 on the bottom as and LPN 'G stated, Physical. Later the same day at 10:02 AM CNA [NAME] was interviewed by phone, asked to recall the incident dated 8/13/19 and revealed the following: Myself and another CNA was helping a lady to bed. We knew she had already had a bowel movement in her brief. We were getting her ready for bed. The other CNA said she did not want to put her (R1) on the toilet first because she can get combative. I usually put her on the toilet, because its easier to clean her. And if she is still going, she can go on the toilet. We put her in the bed, and we were turning her. She doesn't cooperate and is very combative. I'm on one side, and the aide was on the other side. She cleaned her on one side, we finally got her clean on the front. Getting her legs open was like a vice. We turned her and she had bowel movement in her crack. She tightened her butt, and I could not get the towel in to clean her bottom. We only had wash clothes not wipes. We decided to put the brief on her and call it a day. CNA [NAME] was then questioned if anything else happened? CNA [NAME] then replied, In my effort to get her to unclamp her bottom. I tapped her bottom, like you would a baby giving them an enema and it was considered abuse. CNA [NAME] was asked if the tap was painful or uncomfortable? CNA [NAME] replied, No, there was no reaction. I never hurt a resident. CNA [NAME] was asked if R1's mannerism/behavior changed after she tapped her bottom. CNA [NAME] replied, She was combative the whole time, I think probably because she wasn't done with her bowel movement, she is a lot of work . CNA [NAME] was asked if she was supposed to tap a resident's bottom to get them to unclench their butt check, and if it was a part of her training. CNA [NAME] replied, No, it was not part of my training. I was just trying anything to get her to open her bottom. CNA [NAME] denied the tap to R1's bottom was any form of abuse. However, the statement written by CNA [NAME] on 8/13/19 reflected: .While cleaning her (R1) she does not relax, she tightens every muscle, this includes her buttocks. I couldn't get the wash cloth between her butt cheeks, In total desperation I smacked her butt cheek so she would loosen her muscles . The 2019 online dictionary reference defined SMACK as: a sharp slap or blow, typically one given with the palm of the hand. Interviews conducted by the facility during the investigation of the incident dated 8/13/19 reflected: LPN I: Revealed CNA E's patience with residents was short and she had used a harsh tone of voice occasionally, and had been talked to about the concern with a unit manager and LPN I. The statement was dated 8/16/19. CNA J: Revealed CNA [NAME] did not have the patience to work with the residents on the special care floor. The statement was dated 8/15/19. CNA K: Revealed CNA [NAME] was fast-pace, pushy, tried to rush through care. Also, the way CNA [NAME] talked to residents was rude, and kind of stand offish. The statement was dated 8/14/19. A interview took place during the survey 8/21/19 to 8/22/19, with a staff person who desired to remain anonymous. The staff person was asked if they had observed CNA [NAME] being rough or abusive toward residents. The anonymous staff person revealed, CNA [NAME] had been observed to get frustrated with care, and have a frustrated like demeanor. Resident #2 (R2) R2's Minimum Data Set (MDS), dated [DATE], introduced the Brief Interview for Mental Status (BIMS) was 05 (scale 00-07 indicated severe impairment). R2's room was observed on 8/22/19 at 7:53 AM, the left side of bed was against the wall, a one-quarter rail was noted on the right side of the bed. On 8/22/19 at 7:56 AM, R2 was observed sitting in the dining room at a table. R2's Behavior, cognition, and mood care plan dated 8/24/18, revealed I am confused and disoriented related to dementia. I enjoy singing and visiting with other residents and staff. I have been more tired lately, and sleeping more often. My Patient Advocate plans for me to stay here for long term care. My mood is overall pleasant, but I may resist care by yelling out, and grabbing onto things within my reach and may grab at staff. The same care plan included the intervention added on 8/19/19, If I am resisting care, stop and re-approach as needed. Give me cues and give me time to process directions. Certified Nurse Assistant (CNA) L was interviewed on 8/22/19 at 8:55 AM and stated on 8/18/19 at 8:30 PM, she was in a residents room, the housekeeper knocked on the door and informed her R2 was getting out of her bed. CNA L stated when she entered R2's room, she was sitting on the edge of her bed, CNA L assisted her to a lying position. CNA L stated R2 needed to be repositioned over to the middle of her bed, R2 had both hands on the bed rail so she rubbed her hands and asked her to let go of the rail. CNA L stated R2 finally let go of the rail. Housekeeper N was interviewed on 8/22/19 at 11:15 AM, and stated on 8/18/19 at approximately 8:30 PM, he was walking by R2's room and observed her getting up from the bed. Housekeeper N stated CNA L was across the hall helping another resident, he knocked on the door and CNA L went to assist R2 back into bed. Housekeeper N stated he observed R2 grab onto the bed rail on the right side of her bed, CNA L told R2 to let go of the rail, then grabbed onto R2's wrists aggressively and pulled her hand away from the bed rail. Housekeeper N stated in the same interview R2 screamed and said ow. Housekeeper N observed the event from the hallway. During an interview on 8/22/19 at 8:17 AM, Licensed Practical Nurse (LPN) G stated CNA L had reported R2 had attempted to crawl out of bed on 8/18/19. LPN G stated in the same interview, after the incident on 8/18/19, she assessed R2 and did not observe any bruises. Grievance Official C was interviewed on 8/22/19 at 11:32 AM and stated they did not determine R2's bruises were related to the incident on 8/18/19. Grievance Official C stated it was possible R2 she hit the bed rail or something else with her hand. R2's Progress Note dated 8/19/19 at 2:45 PM, reflected three small light purple bruises were noted to the back of R2's right hand; Bruise #1 measured 2.0 centimeters (cm) by 0.5 cm, Bruise #2 measured 1.0 cm by 3.0 cm, Bruise #3 measured 2 cm by 2.5 cm. Registered Nurse (RN) M was interviewed on 8/22/19 at 10:45 AM and stated R2's bruises on the back of her right hand were horseshoe shaped. RN M stated in the same interview, R2 becomes fearful before things happen and she holds onto her wheelchair or the rail on bed. On 8/22/19 at approximately 10:50 AM, R2 was observed sitting in a chair with dark purple, horseshoe shaped bruises on the back of the right hand, 2 bruises were side-by-side, under the fourth and fifth digit, and the third bruise was approximately 1.0 cm below the bruise under R2's fifth digit. On 8/22/19 at 11:50 AM, in a interview with the Director of Nursing (DON) B, she stated staff were trained to move resident's hands that had dementia, when they were resistive, by reproach, distract with something else, and/or turn on the call light for someone to else to assist.

Based on observation, interview and record review the facility failed to ensure 1 of 1 sampled resident (#14) assessed for hydration from a sample of 19 was assessed and treated for [REDACTED]. Findings include: Based on the Minimum Data Set (MDS) assessment, with Assessment Reference Date of [DATE], Resident #14 was a [AGE] year old cognitively intact female whose [DIAGNOSES REDACTED]. Based on the above MDS Resident #15 was independent with transfers, ambulation with a walker or wheelchair, eating, personal hygiene, required minimal assistance with dressing and was occasionally incontinent of urine. On [DATE] at 8:17 AM Resident #14 was interviewed/observed in her room. Resident #14 was dressing herself in preparing for an appointment outside the facility and requested to continue the interview while she dressed. Resident #14 was observed with large tremors of her arms and legs and was not able to put on her pants while she was talking during the interview. Resident #14 declined assistance of staff at the end of the interview. Resident #14 stated she had a concern that her worries about developing a UTI had not been taken seriously by the facility staff or the physician and there had been a delay in beginning treatment. Resident #14 stated she normally didn't run a fever like other people and 98.8 degrees Fahrenheit (F) was a high temperature for her. The Resident stated I tried telling staff I was running a fever, they said no. I was talking and staff couldn't understand me. I got worse and didn't recognize my daughter. The doctor (Medical Doctor RR) was here (in the building) three times that week but didn't see me until the fourth visit and ordered UA and C/S (urinalysis and culture and sensitivity) and a broad spectrum antibiotic, Bactrim. The antibiotic didn't work and was changed [MEDICATION NAME] had to extend that. I was septic and he told my daughter I may have died in a few more days. He (MD RR) said he was sorry (he didn't see me sooner). It's someone's responsibility to make sure he (MD RR) knew I was sick. My daughter (Family KK) filed a complaint (with the facility). There was no follow-up I am aware of. On [DATE] at 2:50 PM Resident #14 and Family KK were interviewed in the Resident's room. Family KK stated she started noticing confusion in Resident #14 on a Monday in April and the confusion increased on Tuesday. Family KK stated she asked staff to have MD RR see the Resident but he did not see her that day. Family KK stated Housekeeper SS call Family KK on Wednesday to report Resident #14's urine had a very strong smell and Housekeeper SS had thought it was stool but it was urine. Housekeeper SS was not available for interview during the survey. Family KK stated she did not report the information from Housekeeper SS to the facility. Family KK stated she went to Unit Manager Registered Nurse (UM RN) OO on Thursday and again asked to have MD RR see Resident #14 who had more confusion but again the Resident was not seen by MD RR. Family KK stated on Friday Resident #14 was more confused, didn't recognize Family KK, was weak and stayed in bed. Family KK stated when she got off work on Friday at 3:00 PM she called MD RR's office and gave the office the information about Resident #14. Family KK stated she did not talk with Resident #14's nurse or UM RN OO on Friday, I was mad. Family KK stated that at 3:30 PM on Friday LPN MM obtained a urine sample by catheter from Resident #14 and stated she (LPN MM) didn't believe it was a UTI. Family KK stated the urine collected was brown and cloudy. Family KK stated Resident #14 was started on the antibiotic Bactrim on Friday and it was changed on Monday when the culture and sensitivity results were available. Family KK stated she filed a facility complaint form with Social Worker BB. SW BB came back and stated MD RR was sorry and SW BB didn't know what else she could do. Family KK stated SW BB told her Director of Nursing (DON) B and Nursing Home Administrator (NHA) A would be in contact with her but she had not seen either one of them. On [DATE] at 4:40 PM SW BB confirmed she had assisted Family KK in filing a complaint form related to Resident #14. SW BB stated the form was given to UM RN OO and DON B and after their investigation SW BB followed up with Family KK who signed the complaint form and said she (Family KK) was satisfied with the investigation. SW BB stated the form then went to NHA A. Review of the facility Resident Assistance Form for Resident #14, dated [DATE], reflected in the Information About Your Concerns section Dtr (daughter) (Family KK's first name) asked on ([DATE]) for Dr (RR's last name) to address confusion and see resident(Resident #14's first name). On ([DATE]) housekeeper notified (Family KK's first name) that (Resident #14's first name) urine smelled. On ([DATE]) (Resident #14's first name) was more confused & not eating/drinking. (Family KK's first name) asked (LPN R's first name) to (sic) her to be seen-(LPN R's first name) asked (UM RN OO's first name). On ([DATE]) (Family KK's first name) noticed that (Resident #14's first name) even more confused, lethargic asked (UM RN OO's first name) to address issues-(UM RN OO's first name) had discharge & illness. At 3:30 PM (Family KK's first name) called Dr. (RR's last name) office to follow up on concerns (s/s UTI) the office ordered UA. UM RN OO was not available for interview on [DATE] or [DATE]. On [DATE] at 9:40 AM DON B stated she was not in the facility when the concern from Family KK happened. DON B stated she talked with UM RN OO about making sure the request for Resident #14 to been seen by MD RR was followed up on and that the physician visit was done. DON B stated the unit nurses were monitoring Resident #14 and stated she thought one of the nurses called MD RR and was instructed to monitor Resident #14 for a little bit. There was no documentation in the clinical record this notification occurred. DON B stated Housekeeper SS did not report the observation of the urine to the unit nurse. DON B stated MD RR was notified to see Resident #14 on [DATE] and for the second time on [DATE]. DON B stated she met with Family KK on the day before or the day the she (DON B) signed the Action to be taken section of the Resident Assistance Form. The Action to be taken section of the Resident Assistance Form was signed by DON B on [DATE]. The Action to be taken section of the Resident Assistance Form reflected DON B had spoken with Family KK, Resident #14, UM RN OO and MD RR. DON B stated she verified with Family KK that MD RR had messed up, and explained the facility couldn't just jump into treatment without evaluating the Resident, monitoring vital signs for up to three days and encouraging fluid intake. In addition, DON B stated she explained antibiotic stewardship (use of antibiotics only when indicated) to Family KK who stated she (Family KK) understood. The Facility Follow-up section of the Resident Assistance Form reflected Dr (MD RR's last name) was asked by unit manager to see (Resident #14's first name) on Tuesday [DATE] Dr (MD RR's last name) apologized to (Family KK's first name and Resident #14's first name) and said he got busy and it slipped his mind. Re-educated unit manager on making sure follow up gets done when requested by resident and/or family. DON B stated she did not do any education of the unit nursing staff related to timely notification of the physician for resident changes in condition. Review of the nursing progress notes from [DATE] at 3:34 AM-[DATE] at 2:10 PM in the electronic medical record (EMR) reflected the following; 1) [DATE] at 2:47 PM written by LPN R-Res. (resident) very unsteady. [MEDICAL CONDITION] (sic) s/sx (signs/symptoms) elevated with res. being unable ti (sic) sit up for any length of time ., 2) [DATE] at 2:39 PM written by LPN R-Res. lied (sic) in bed most of shift d/t (due to) increased [MEDICAL CONDITION] symptoms. She is having uncontrollable tremors and states that her hands are not functioning well. Assistance given by staff as needed., 3) [DATE] at 1:13 PM written by LPN CC-Weekly: Resident alert and routine pain med given per order, which is effective. Resident able to make her needs known. Assist of one for transfers. Continent of b&b (bowel and bladder) Assist with adl (activities of daily living) care .feeds self .ate ,[DATE]% of breakfast ., 4) [DATE] at 2:20 PM written by LPN R-Res. remained in bed much of the day with c/o (complaints of) increased [MEDICAL CONDITION] s/sx. Uncontrolled tremors prevent her from sitting up for any length of time. CENA (competency evaluated nursing aide) assisted her with toileting., 5) [DATE] at 3:30 PM written by LPN MM-Talked with Dr. (RR's last name) at this time regarding resident. Resident daughter complained that her mother (resident) was confused, had slurred speech and had trouble walking with walker. This nurse observed resident lying on bed, no slurred speech noted, resident stated she was tired. MD ordered UA at this time. At 3:50 PM on the same date LPN MM documented UA obtained at this time per straight cath (catheter inserted into the bladder to obtain urine then removed), .Noted urine to be dark yellow/brownish tint with a foul odor . The dark foul smelling urine was a possible indication of a UTI and decreased fluid intake. At 10:11 PM the same nurse documented Received results of UA at this time. Positive of UTI, MD notified, received order to start resident of (sic) Bactrim DS (antibiotic) BID (twice daily) times 5 days. Resident resting comfortably at this time. VS (vital signs): ,[DATE] (blood pressure), P (pulse)-76, R (respirations)-18, T (temperature) 98.7 (F)., and 6) The first documentation of confusion for Resident #14 was not until [DATE] at 6:40 AM by RN TT-Resident recently started on atb (antibiotic). treatment at HS (bedtime). VS: WNL (within normal limits) for resident. She has noted to be lethargic and very confused. She was noted to be walking in the hallway at around 0400 (4:00 AM) with w/c (wheelchair) in front of her and she was noted to be unsteady .thought it was time for breakfast 'up front where daughters were sleeping' staff reassured resident that it was very early and her daughters were not present at this time. Resident didn't seem to understand .urine still noted to be dark with sediment noted . Confusion for Resident #14 was documented on [DATE] at 2:05 PM, 9:21 PM and 10:45 PM, [DATE] at 2:34 PM and 9:36 PM and [DATE] at 2:10 PM. Dark urine color was noted on [DATE] at 7:24 AM. The nursing progress note dated [DATE] at 7:34 PM by LPN MM reflected the Bactrim was discontinued related to the culture and sensitivity results and the [MEDICATION NAME] begun. The urinalysis report dated [DATE] reflected elevated white blood cells (normal ,[DATE]/HPF), bacteria (normal-none) and leukocytes (normal-none) which can indicate a UTI. The culture report received by the facility on [DATE] reflected the bacteria escherichia coli was present at > 100,000/HPF. The sensitivity report received by the facility on [DATE] indicated the bacteria was not sensitive to the antibiotic Bactrim so it would not effectively treat the UTI. The same report indicated the bacteria would be sensitive to the [MEDICATION NAME] effectively treat the UTI. The nursing progress notes for Resident #14 reflected the development of urinary incontinence between [DATE]-[DATE] which may have been related to urinary urgency often associated with a UTI. On [DATE] at 10:25 AM LPN R stated she had noticed an increase in [MEDICAL CONDITION] symptoms (increased tremors and decreased coordination) for Resident #14 early in [DATE] (documented in the nursing progress notes by LPN R on [DATE], [DATE] and [DATE]) and notified UM RN OO. LPN R stated she had also talked with Family KK about the same observations. LPN R stated she did not recall if Resident #14 was confused at that time. LPN R stated foul smelling urine for Resident #14 was not reported to her by any facility personnel. LPN R stated Resident #14's temperature was not in a range I would call elevated. On [DATE] at 11:45 AM LPN E was interviewed by telephone and stated Resident #14 mental status varied from clear to foggy in early [DATE] and that it happens for the Resident at times. LPN E stated Resident #14's [MEDICAL CONDITION] symptoms varied day to day and sometimes during a shift and the [MEDICAL CONDITION] medications weren't always effective. LPN E stated Resident #14 continued to bring up that MD RR told her she would have been septic (blood infection) and died in a few more days if she had not been treated. However, LPN E stated UM RN OO had told LPN E that Family KK had made the statement while UM RN OO and MD RR were in Resident #14's room and MD RR had not agreed with the statement. On [DATE] at 2:08 PM LPN MM was interviewed by telephone and stated MD RR had telephoned her at the facility on [DATE] after Family KK had telephoned MD RR. LPN MM stated Resident #14 didn't seemed confused, had no temperature and her vitals signs were good on [DATE]. LPN MM stated Family KK had mentioned something about a UTI a few days before and had gone to see UM RN OO. LPN MM stated UM RN OO had told LPN MM she (UM OO) was aware of the concern but Resident #14 did not meet the criteria for a UTI diagnosis. LPN MM stated Resident #14's urine was nasty on [DATE] (documented in the nursing progress note on the same date by LPN MM as dark yellow/brownish with a foul odor). On [DATE] at 3:35 PM Certified Nursing Aide (CNA) II stated Resident #14 had no confusion symptoms before being diagnosed with [REDACTED]. At 3:38 PM the same day CNA JJ stated Resident #14 was confused a few days after the UTI was diagnosed . A Change of Condition assessment was not documented until [DATE] at 11:15 PM by LPN E, two days after the UTI was diagnosed and treatment begun and five days after Family KK stated Resident #14's confusion started. The facility policy Resident Change of Condition Notification, dated [DATE] and revised [DATE], reflected Policy Statement: It shall be the policy of (facility name) to perform a comprehensive physical assessment on all residents who experience a febrile and/or functional or physical change in status. Policy Interpretation & Implementation: The Facility will notify the resident, physician and appropriate representative when any of the following occur: .c. A significant change in the resident's physical, mental, or psycho social status . On [DATE] at 9:40 AM DON B stated the Change of Condition assessment for Resident #14 should have been done on [DATE] when the the nurse was in contact with the physician related to the UA results and subsequent order for antibiotic therapy. On [DATE] at 2:08 PM during a telephone interview LPN MM stated a Change of Condition assessment was to be completed with any resident change. The fluid intake documentation in the EMR for Resident #14 between [DATE]-[DATE] reflected an average oral intake of 2179 ml/day from [DATE]-[DATE], 2099 ml/day from [DATE]-[DATE], 2000 ml/day from [DATE]-[DATE] and 1983 ml/day from [DATE]-[DATE]. A decline of 286 ml/day. Based on Resident #14's current weight of 60.45 kg her fluid intake should have been ,[DATE] ml/day (,[DATE] ml/kg) under normal circumstances. The presence of a UTI would increase the daily fluid need at the same time Resident #14's fluid intake was declining, creating the potential for less circulating blood volume and oxygen flow to the kidney. The decreased circulating blood volume would also cause the kidneys to conserve fluids for the body creating a decreased urine volume and an increased concentration of the urine (urine changes from the usual yellow color to a brown color). Nursing progress notes reflected fluids were encouraged on [DATE] at 9:22 PM, [DATE] at 2:34 PM and 11: 46 PM and [DATE] at 9:45 AM. The food intake documentation in the EMR between [DATE]-[DATE] for Resident #14 reflected an intake of ,[DATE]% for 86% of the 36 meals offered from [DATE]-[DATE]. From [DATE]-[DATE] the Resident's intake declined to 53% of meals at ,[DATE]%, 16% at ,[DATE]% and 20% with zero intake or refused out of 45 meals recorded. Nursing progress notes reflected a poor appetite on [DATE] at 2:04 PM, [DATE] at 1:56 PM and [DATE]/at 6:46 PM. Review of the nursing progress notes from [DATE] at 10:56 PM-[DATE] at 6:46 PM reflected Resident #14 had low blood pressure readings (less than the ,[DATE] mmHg) evelen times; 1) ,[DATE] on [DATE] at 10:56 PM, 2) ,[DATE] at 9:56 PM on [DATE], 3) ,[DATE] at 10:55 PM on [DATE], 4) ,[DATE] at 9:23 AM on [DATE], 5) ,[DATE] at 10:11 PM on [DATE], 6) ,[DATE] at 1:56 AM on [DATE], 7) ,[DATE] at 12:52 PM on [DATE], 8) ,[DATE] at 2:10 PM on [DATE], 9) ,[DATE] at 8:49 PM on [DATE], 10) ,[DATE] at 1:56 PM on [DATE] and 11) ,[DATE] at 1:12 AM on [DATE]. Resident #14's pulse rate with the above blood pressure readings ranged within normal limits from ,[DATE] beats per minute (a slow pulse is less than 60 and a fast rate is more than 100). Low blood pressure decreases the blood circulation to the kidneys and may affect the kidney function. Decreased fluid intake can also decrease the circulating blood volume and oxygen supply to the kidneys. Review of laboratory results from a Comprehensive Metabolic Panel (CMP) of the blood for Resident #14 reflected a creatinine level (a measure of kidney function and hydration) of 0.97 mg/dl (reference range 0XXX,[DATE].10 mg/dl) and slightly elevated blood urea nitrogen level (BUN-a measure of kidney function and hydration) of 26 (reference range ,[DATE] mg/dl) on [DATE]. On [DATE] the BUN had increased to 75 mg/dl and the Creatinine had increased to 2.91 mg/dl indicating a decrease in kidney function and potential dehydration. The physician order [REDACTED]. On [DATE] a physician telephone order reflected an order for [REDACTED]. Dehydration is a serious acute condition in older adults associated with significant morbidity and mortality. Hypodermoclysis (HDC; the infusion of fluids into the subcutaneous tissue) can provide an alternative to intravenous (i.v.) rehydration of older adults (https://www.ncbi.nlm.nih.gov/pubmed/ 137). On [DATE] the BMP results reflected decreased (improved) levels of BUN at 25 mg/dl and creatinine at 1.35 mg/dl after two days of fluid replacement. On [DATE] the CMP results reflected continued improvement of the BUN at 1.17 mg/dl and the creatinine had returned to within normal range at 12 mg/dl after fluid resuscitation.

Based on observation, interview, and record review the facility failed to provide supervision and respond to a bed alarm for 1 sampled resident (# #101) of a total sample of 4 reviewed for falls resulting in a fall with a fracture. Findings include: According to Resident #101's Minimum Data Set (MDS) assessment dated [DATE] ,Resident #101 was an [AGE] year old female with [DIAGNOSES REDACTED]. Resident #101's Nurse Aide Care plan dated 12/19/12 revealed an intervention that included a"bed alarm sensor." Resident #101's Nursing Care Plan "impaired mobility related to [DIAGNOSES REDACTED]. Review of Resident #101's Incident Report dated 7/15/13 at 7:15 AM stated, "resident laying on floor in hall outside of her bedroom." The report "Fall Analysis & Investigation" indicated the alarm was sounding at the time of the fall. Review of Resident #101's x-ray report dated 7/15/13 at 3:09 PM, stated "right subcapital fracture with no displacement." On 9/4/13 at 2:40 PM, during an interview, Registered Nurse (RN) #5 reported she was receiving report from the midnight nurse at "shortly after 7:00 AM at shift change"when she was informed that resident #101 had fallen and had later reviewed the facility video and discovered resident had tripped when the blanket was wrapped around her feet. On 9/4/13 at 4:30 PM, during an interview, Administrator (ADM) #1 was questioned if CNA's were alerted by pagers when the the bed alarms sounded. ADM #1 reported when the bed alarms are alerted, the Certified Nurse Aides (CNA) are alerted on their pagers. The CNAs pagers were reported to be initially alerted and then again after 3 minutes along with the nurses pagers. Resident #101's bed alarm was reported to have been initially alerted to the CNA's and to have alerted for a second time before staff responded for a total of 3 minutes and 38 seconds before staff responded. ADM #1 reported "They knew that bed alarm was going off." ADM # 1 reported the shift started at 7:00 AM and if the staff had been out on the floor instead of at the desk the fall might have been prevented. They may have been in another resident room and providing care but, they (the staff) may have been closer (to he resident's room). ADM #1 reported Maintenance staff #4 was reported to have walked by the room (Resident #101's) when the alarm was activated and ,"He should have responded." ADM #1 was asked if Maintenance staff #4 had been in-serviced on responding to alarms following the incident and responded,"No." "I should have talked to him." The administration reported it was the expectation of the facility that every staff member responded to resident alarms. On 9/4/13 at 4:40 PM, review of the facility video with ADM #1 dated 7/15/13 from 7:07 AM until 7:13 AM revealed maintenance staff #4 was observed to have (pointed out by administrator) walked by Resident #101's room. Resident #101's bed alarm was reported by ADM #1 to have been alarming at that time. Resident #101 was observed to have immediately exited her room directly behind Maintenance staff #4 and was observed to have fallen on the floor at 7:09. A second review of the video showed facility staff sitting/conversing/working at the nurses station during the time the alarm was reported to have been sounding, and the page was reported to have been going to their pagers. None of the staff on the video were observed to have immediately responded to the alarm or their page until 7:11 AM when Resident #101 was observed on the floor in the hall on the video. Review of the Facility Policy "Quality of Care-Falls, Supervision and Accidents," stated, "In accordance with Federal and State guidelines the facility must ensure that each resident receives adequate supervision and assistive devices to prevent accidents." Review of Resident #101's Nurse Aide Care Guide dated 12/19/12 revealed Resident #101 had been walked with the assistance of 2 staff, had been documented to have been walked to the dining room, was toileted every 2 hours in the bathroom, and was assisted with eating her meals. Resident #101's Nurse Aide Care Guide dated 7/23/13 revealed Resident #101 had a documented decline in her activity of daily living and was required to be transferred with the use of a Hoyer lift (transfer lift) and no longer walked. Resident used a bedpan and disposable briefs, had developed a skin issue (rash on her buttock area) and was no longer assisted with her meals but was required to be fed her meals. ( )

THIS CITATION PERTAINS TO MI 186 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING (IMMEDIATELY PERFORM CARDIOPULMONARY RESUSCITATION (CPR) AND ACTIVATE THE EMERGENCY MEDICAL SERVICES (EMS) SYSTEM) IN 1 OF 5 SAMPLED RESIDENTS (RESIDENT #501) WHO HAD ADVANCE DIRECTIVES FOR CPR IN PLACE, FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #501, WHO WAS A FULL CODE, WAS FOUND UNRESPONSIVE ON [DATE] AT 7:44 AM AND CPR AND THE EMS RESPONSE SYSTEM WERE NOT INITIATED BY FACILITY STAFF. THIS DEFICIENT PRACTICE PLACED 44 RESIDENTS, IDENTIFIED AS BEING FULL CODE, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET DATED [DATE] AND MINIMUM DATA SET ((MDS) dated [DATE], REVEALED RESIDENT #501 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. THE MDS INDICATED RESIDENT #501 HAD NO COGNITIVE IMPAIRMENTS (BRIEF INTERVIEW MENTAL STATUS WAS 13), WAS ABLE TO MAKE HERSELF UNDERSTOOD, HAD CLEAR COMPREHENSION, AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, DRESSING, AND HYGIENE. REVIEW OF A [DIAGNOSES REDACTED]. REVIEW OF THE CARE DIRECTIVE WORKSHEET, DATED [DATE], REVEALED RESIDENT #501 GAVE THE FACILITY CONSENT TO PERFORM CARDIOPULMONARY RESUSCITATION (CPR) IF HER HEART STOPPED AND BREATHING CEASED. THE WORKSHEET REVEALED CPR INCLUDED CHEST COMPRESSIONS, VENTILATION, AND TRANSFER TO AN ACUTE CARE HOSPITAL. REVIEW OF THE FACILITY'S CPR CERTIFIED STAFF NURSES POLICY, DATED [DATE] AND REVISED [DATE], REVEALED IT WAS THE FACILITY'S POLICY TO PROVIDE CARDIO-PULMONARY RESUSCITATION BY CPR CERTIFIED STAFF NURSES ON ALL [MEDICAL CONDITION] FOR THOSE RESIDENTS CLASSIFIED AS FULL CODE STATUS AND WHO EXPERIENCED CARDIO AND/OR [MEDICAL CONDITION] ARREST. PER THE AMERICAN RED CROSS FIRST AID AND SAFETY HANDBOOK (2011), "A PERSON IN [MEDICAL CONDITION] IS UNCONSCIOUS, NOT BREATHING AND HAS NO HEARTBEAT." THE HANDBOOK REVEALED THAT A PERSON IN [MEDICAL CONDITION] WILL HAVE THE GREATEST CHANCE OF SURVIVAL IF THERE IS 1) EARLY ACCESS TO THE EMERGENCY MEDICAL SERVICES (EMS) SYSTEM, 2) EARLY CPR, 3) EARLY DEFIBRILLATION, AND 4) EARLY ADVANCED MEDICAL CARE. THE HANDBOOK ALSO REVEALED THAT "WITHOUT EARLY CPR AND DEFIBRILLATION, THE CHANCE FOR SURVIVAL IS GREATLY REDUCED." THE HANDBOOK MENTIONED THAT "ONCE YOU BEGIN CPR, DO NOT STOP EXCEPT IN ONE OF THESE SITUATIONS....ANOTHER TRAINED RESPONDER OR EMS PERSONNEL TAKE OVER." IN AN INTERVIEW ON [DATE] AT 1:12 PM, CERTIFIED NURSING ASSISTANT (CNA) #10 REPORTED ON [DATE] AT APPROXIMATELY 6:15 AM, SHE CHANGED RESIDENT #501'S WET BRIEF. CNA #10 REPORTED RESIDENT #501 DID NOT APPEAR TO BE IN DISTRESS AND HER CONTINUOUS POSITIVE AIRWAY PRESSURE ([MEDICAL CONDITION]) MACHINE WAS IN PLACE AND WORKING PROPERLY. IN AN INTERVIEW ON [DATE] AT 11:30 AM, REGISTERED NURSE (RN) #3 REPORTED ON [DATE] AT APPROXIMATELY 7:10 AM, HE OBSERVED RESIDENT #501'S [MEDICAL CONDITION] WAS IN PLACE AND HER CHEST WAS RISING AND FALLING. RN #3 REPORTED RESIDENT #501 APPEARED TO BE SLEEPING AND IN NO DISTRESS AT THAT TIME. IN AN INTERVIEW ON [DATE] AT 12:50 PM, CNA #8 REPORTED ON [DATE] AT 7:44 AM, SHE CALLED OUT RESIDENT #501'S NAME WITH NO RESPONSE. CNA #8 REPORTED SHE SHOOK RESIDENT #501'S SHOULDERS AND HER SKIN FELT COLD TO THE TOUCH. CNA #8 REPORTED SHE REMOVED RESIDENT #501'S [MEDICAL CONDITION] AND HER FACE FELT COLD TO THE TOUCH AND OBSERVED RESIDENT #501 WAS NOT BREATHING. CNA #8 REPORTED SHE IMMEDIATELY NOTIFIED RN #3. IN AN INTERVIEW ON [DATE] AT 11:30 AM, RN #3 REPORTED ON [DATE] AT 7:45 AM, HE WENT INTO RESIDENT #501'S ROOM AND OBSERVED RESIDENT #501'S TO BE UNRESPONSIVE, COOL TO THE TOUCH, TONGUE PROTRUDING FROM HER MOUTH, LIPS WERE CYANOTIC, AND EYES WERE OPEN, FIXED, AND DILATED. RN #3 REPORTED HE CHECKED RESIDENT 501'S PULSE OXIMETRY (MEASUREMENT OF OXYGEN IN THE BLOOD) WITH NO RESULTS AND LISTENED TO RESIDENT #501'S APICAL PULSE AND LUNG SOUNDS WITH A STETHOSCOPE AND NONE WERE HEARD. RN #3 REPORTED HE CALLED RN #4 TO CONFIRM RESIDENT #501'S DEATH AND CNA #8 BEGAN POST-MORTEM CARE. RN #3 REPORTED HE NOTIFIED GUARDIAN #14 ABOUT RESIDENT #501'S DEATH. RN #3 REPORTED HE THEN SAW RN #5 AND NOTIFIED HER OF RESIDENT #501'S DEATH. RN #3 REPORTED HE DID NOT CHECK RESIDENT #501'S CODE STATUS BECAUSE SHE HAD NO SIGNS OF LIFE. REVIEW OF AN INTERVIEW STATEMENT, DATED [DATE] AND WRITTEN BY DIRECTOR OF NURSING (DON) #2, REVEALED RN #3 STATED HE DID NOT INITIATE CPR NOR DID IT OCCUR TO HIM TO CHECK AND VERIFY RESIDENT #501'S CODE STATUS. IN AN INTERVIEW ON [DATE] AT 11:51 AM, RN #4 REPORTED ON [DATE] AT 7:47 AM, SHE WENT INTO RESIDENT #501'S ROOM AND CHECKED HER BLOOD PRESSURE AND CAROTID PULSE WITH NO RESULTS AND CONFIRMED RESIDENT #501'S DEATH. IN AN INTERVIEW ON [DATE] AT 12:15 PM, RN #5 REPORTED ON [DATE] AT 8:00 AM, SHE WAS NOTIFIED BY RN #3 THAT RESIDENT #501 HAD EXPIRED. RN #5 REPORTED SHE IMMEDIATELY WENT INTO RESIDENT #501'S ROOM AND NOTIFIED DON #2. RN #5 REPORTED DON #2 INFORMED HER RESIDENT #501 WAS A FULL CODE AND "NURSES STAT" WAS CALLED OVER THE INTERCOM SYSTEM. RN #5 REPORTED ON [DATE] AT 8:03 AM, SHE BROUGHT THE CRASH CART DOWN TO RESIDENT #501'S ROOM AND NURSING STAFF TRANSFERRED RESIDENT #501 TO THE FLOOR AND INITIATED CPR. RN #5 REPORTED ,[DATE] WAS CALLED ON [DATE] AT APPROXIMATELY 8:04 AM. RN #5 REPORTED STAFF CONTINUED PERFORMING CPR ON RESIDENT #501 UNTIL EMERGENCY MEDICAL SERVICES (EMS) ARRIVED. REVIEW OF A SURVEILLANCE RECORDING REVEALED EMS ARRIVED to the facility on [DATE] AT 8:10 AM. REVIEW OF THE EMS PRE-HOSPITAL CARE REPORT SUMMARY, DATED [DATE], REVEALED THE PHYSICIAN ORDERED THE TERMINATION OF RESUSCITATION EFFORTS FOR RESIDENT #501 ON [DATE] AT 8:30 AM. ON [DATE] AT 9:48 AM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AND WAS IDENTIFIED ON [DATE], WHEN THE FACILITY FAILED TO PROVIDE CARDIOPULMONARY RESUSCITATION (CPR) AND ACTIVATE THE EMERGENCY MEDICAL SERVICES (EMS) SYSTEM FOR RESIDENT #501 WHO WAS FOUND UNRESPONSIVE ON [DATE] AT 7:44 AM. ON [DATE], THIS SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], A CURRENT LIST OF RESIDENT (44 RESIDENT WITH FULL CODE STATUS) WAS PRINTED BY MEDICAL RECORDS AND CROSS REFERENCED WITH THE PAPER MEDICAL CHART BY THE MEDICAL RECORDS AND SOCIAL WORK DEPARTMENTS. ALL CRASH CARTS WERE INSPECTED BY THE IN-SERVICE AND NURSE MANAGERS, AND WERE FOUND TO BE ACCEPTABLE FOLLOWING THE EVENT WITH RESIDENT #501. 2. ON [DATE], THE FACILITY DEVELOPED THE "USE OF VISUAL IDENTIFIERS FOR RESIDENT CODE STATUS" POLICY WHICH ASSISTED THE RESPONDING NURSE TO IDENTIFY RESIDENTS QUICKLY. AT THE DIRECTION OF THE ADMINISTRATOR AND DIRECTOR OF NURSING, THE VISUAL IDENTIFIERS WERE PLACED ON THE RESIDENT CLOSET DOOR FOR FULL CODE RESIDENTS, THE BACK OF THEIR WHEELCHAIRS, AND/OR WALKER BY THE NURSE MANAGERS AND SOCIAL SERVICES DIRECTOR. THE VISUAL CUES WERE NOT A REPLACEMENT FOR THE SIGNED LEGAL DOCUMENT LOCATED IN THE RESIDENT'S CHART, BUT WOULD ACT AS A VISUAL REMINDER FOR NURSES TO VERIFY THE RESIDENTS' LEGAL DOCUMENT. 3. ON [DATE], THE DIRECTOR OF NURSING, IN-SERVICE DIRECTOR, AND CERTIFIED AMERICAN HEART ASSOCIATION CPR INSTRUCTOR REVIEWED THE FOLLOWING POLICIES AND PROCEDURES WITH NO CHANGES IDENTIFIED: A) CPR CERTIFIED STAFF NURSES B) AUTHORIZATION TO MAKE MEDICAL DECISIONS C) HEARTSTART ONSITE DEFIBRILLATOR 4. ON [DATE], MANDATORY NURSES MEETINGS WERE HELD BY THE DIRECTOR OF NURSING AND IN-SERVICE DIRECTOR. 31 OF 35 NURSES HAD BEEN IN-SERVICED. ANY NURSE NOT IN ATTENDANCE WERE PULLED FROM THE SCHEDULE UNTIL THE IN-SERVICE WAS COMPLETED. TWO OF THE NURSES WHO HAD NOT ATTENDED WERE ON VACATION AND TWO WERE ON MEDICAL LEAVE. THE FOLLOWING WAS ADDRESSED DURING THE MEETING: A) CHECKING THE CODE STATUS IN A RESIDENT'S MEDICAL RECORD UPON IDENTIFYING AN EXPIRED RESIDENT. B) FULL CODE PROCEDURE REVIEWED BY THE CERTIFIED AMERICAN HEART ASSOCIATION CPR INSTRUCTOR. C) REVIEW OF CPR CERTIFIED STAFF NURSES POLICY. D) CURRENT STATUS OF RESIDENTS IDENTIFIED AS FULL CODES IN THE BUILDING WERE REVIEWED. E) NEW VISUAL IDENTIFIERS IN ROOMS AND ON WHEELCHAIRS/WALKERS WITH NEW POLICY EXPLANATION. F) AUTOMATIC EXTERNAL DEFIBRILLATOR (AED) REVIEW AND DEMONSTRATED BY THE CERTIFIED AMERICAN HEART ASSOCIATION CPR INSTRUCTOR. 5. AT THE DIRECTION OF THE ADMINISTRATOR AND DIRECTOR OF NURSING, ALL NURSING STAFF HIRED AFTER [DATE] WILL BE TRAINED ON THE VISUAL IDENTIFIER USE, THE CPR POLICY, AND THE AED MACHINE. 6. ON [DATE], THE FACILITY SECURITY CAMERAS WERE REVIEWED TO IDENTIFY A TIMELINE OF EVENTS. 7. ON [DATE], AT THE DIRECTION OF THE ADMINISTRATOR AND DIRECTOR OF NURSING, ALL LICENSED NURSES' PERSONNEL FILES WERE REVIEWED BY THE HR (HUMAN RESOURCES) DIRECTOR TO ENSURE THAT ALL LICENSED NURSES WERE CURRENT IN THEIR CPR CERTIFICATION. THE FACILITY ALSO CONSULTED THEIR CERTIFIED AMERICAN HEART ASSOCIATION CPR INSTRUCTOR TO CONFIRM THEIR RECORDS ON [DATE]. 8. ON [DATE], THE ADMINISTRATOR AND DIRECTOR OF NURSING HELD A MEETING WITH ALL SUPERVISORY NURSES TO FURTHER DISCUSS THE INCIDENT. AT THAT TIME ALL STEPS WERE REVIEWED AND THEIR ROLE AS LEADERS IN DIRECTING STAFF DURING PERIODS OF EMERGENCY. 9. ON [DATE], AT THE DIRECTION OF THE ADMINISTRATOR AND DIRECTOR OF NURSING, A QUALITY ASSURANCE STUDY HAD BEEN DEVELOPED TO ENSURE COMPLIANCE. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM WITH A POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT IMMEDIATE JEOPARDY DUE TO ALL EDUCATION HAD NOT YET BEEN COMPLETED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

This citation pertains to MI 231, MI 354, and MI 429. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for 3 of 4 Sampled residents who were at high risk for falls (Resident #101, Resident #102, and Resident #103), from a total of 4 Sampled Residents who were at a high risk for falls, resulting in Resident #101 falling and sustaining a hip fracture, Resident #101 falling and sustaining a hip fracture, and Resident #103 falling and sustaining a neck fracture. Findings include: Per the "Bed-Check Sensormat User Manual", "WARNING: Before installing this system, please read and follow these instructions carefully. Failure to do so could result in injury or death...Test your Sensormats (alarm pads) and Classic-Check monitor (control boxes) before each use...Nursing personnel should test the system's effectiveness daily...(Control boxes) - This Limited Warranty begins on the date the product is delivered to the purchaser and continues for a period of two years (new units) or one year (refurbished units). (Sensor pads) - This Limited Warranty begins on the date the product is delivered to the purchaser and continues for a period of one year or for the duration of the warranty stated on the (sensor pad) label from the date first installed, whichever comes first..." On [DATE] at 10:40 AM, in the presence of Maintenance worker #21 and Facility Operations Manager #22, this Surveyor observed bed and chair sensor pads in their original packaging in a drawer in an office. The pads were not dated with the date they were delivered to the facility, and there was a statement written on the pads that said, "30 day limited warranty. Use of Sensor mat beyond the warranty period is not recommended". Resident #101 An onsite investigation was conducted [DATE]-[DATE]. On [DATE] at 3:50 PM, Resident #101 was observed sitting in a wheelchair in her room, with oxygen tubing on and a pressure alarm on the wheelchair and on the bed. Per the MDS/Minimum Data Set, dated dated [DATE], Resident #101 was admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Per psychiatric progress notes, dated [DATE], Physician #25 assessed Resident #101 and diagnosed her as having "Dementia, Alzheimer's type mild". Per a facility "Resident Incident/Accident Report", Resident #101 was "found in her room...on the floor beside her wheelchair" on [DATE] at 8:00 PM. Per an imaging report of Resident #101's right hip, dated [DATE], "...There is an intertrochanteric (upper part of the thigh bone) fracture on the right". Per Resident #101's falls Care Plan, signed and dated [DATE] by MDS Coordinator #9, "Bed and wheelchair alarm". In an interview, on [DATE] at 9:05 AM, nurse aide #13 stated she observed Resident #101 "laying on the floor" on [DATE] at 8:00 PM. Nurse aide #13 stated, "There was no alarm going off" and said she wrote a witness statement. Nurse aide #13 stated she remembered writing in the witness statement that no alarms had been triggered. In an interview, on [DATE] at 12:55 PM, LPN/Licensed Practical Nurse #26 told this Surveyor that she was the nurse on duty on [DATE] at 8:00 PM, and stated, "My CNA (nurse aide) may have shut the alarms off (when she found Resident #101 on the floor)". When this Surveyor asked LPN #26 if she had checked Resident #101's alarm or other residents' alarms after Resident #101 fell she stated, "I don't remember checking the alarms afterwards". On [DATE] at 10:27 AM, this Surveyor observed a pressure alarm in Resident #101's bed; the expiration date was not written on the pressure pad and the control box manufacturer's recommended expiration date was "[DATE]". ( ) Resident #102 An onsite investigation was conducted [DATE]-[DATE]. Resident #102 no longer resided at the facility at the time of the investigation. Per the MDS/Minimum Data Set, dated dated [DATE], Resident #102 was admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Per a facility "Resident Incident/Accident Report", Resident #102 was "observed laying on floor along side of bed" on [DATE] at 10:05 PM. Per an imaging report of Resident #102's left hip, dated [DATE], "...Complete, mild to moderately displaced fracture extending from the intertrochanteric femur (upper part of the thigh bone)..." Per Resident #102's falls Care Plan, signed and dated [DATE] by MDS Coordinator #9, "wheelchair alarm related to unassisted transfers. Bed alarm to alert staff of movement related to fall risk". In an interview, on [DATE] at 11:24 AM, nurse aide #23 stated she observed Resident "on the floor" on [DATE] at 10:05 PM. When this Surveyor asked nurse aide #23 if any alarms were sounding when she observed Resident #102 on the floor on [DATE] at 10:05 PM, nurse aide #23 reported there were no alarms sounding. Nurse aide #23 also said, "I don't think his bed alarm sounded when I got him up at 3:30 PM". Nurse aide #23 said, "(Director of Nursing/DON #2) asked me if alarm was sounding and I told her it wasn't working". In an interview, on [DATE] at 11:29 AM, RN/Registered Nurse #24 told this Surveyor that she was the nurse on duty on [DATE] at 10:05 PM, and stated, "No, I did not hear an alarm...I did not check the expiration date on the alarm. Maintenance checks them regularly...I didn't go and check other (residents') alarms (to see if they were functioning properly)...(Resident #102) would set off his alarm on average ,[DATE] times/shift". ( ) Resident #103 An onsite investigation was conducted [DATE]-[DATE]. Resident #103 no longer resided at the facility at the time of the investigation. Per the MDS/Minimum Data Set, dated dated [DATE], Resident #103 was admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Per a facility "Resident Incident/Accident Report", Resident #103 was "on floor on back in front of WC (wheelchair)..." on [DATE] at 10:10 AM. Per an imaging report of Resident #103's cervical (neck) spine, dated [DATE], "Impression: Type 2 dens fracture (neck bone fracture)". Per Resident #103's falls Care Plan, signed and dated [DATE] by MDS Coordinator #9, "Bed alarm per family request". Per Resident #103's falls Care Plan, signed and dated [DATE] by MDS Coordinator #9, "Chair alarm to alert staff of unassisted transfers". In an interview, on [DATE] at 8:55 AM, RN #10 told this Surveyor that she was the nurse on duty on [DATE] at 10:10 AM. RN #10 told this Surveyor, "She (Resident #103) was a low fall risk...There were no alarms in her wheelchair...When (Resident #103) came back from the hospital on [DATE], she (Resident #103) was comfort measures only". Per Resident #103's "Fall Risk Assessment", dated [DATE], Resident #103 was at "HIGH RISK" for falls. In an interview, on [DATE] at 4:15 PM, MDS Coordinator #9 stated, "I was walking by (Resident #103's) room and glanced in and saw her lying on the floor (on [DATE] at 10:10 AM). I heard her say help me...No, I did not hear any alarms". In an interview, on [DATE] at 9:20 AM, nurse aide #11 stated stated she was assigned to Resident #103 on [DATE] at 10:10 AM. When this Surveyor asked nurse aide #11 if she Resident #103's wheelchair alarm was functioning properly nurse aide #11 did not answer the question directly but instead stated, "I was always in her room anyway...(Resident #103) never leaned forward... Yes, her left side was weak". On [DATE] at 10:22 AM, this Surveyor observed a pressure alarm pad in off sample Resident #14's wheelchair; the expiration date was marked "[DATE]" and the control box's manufacturer's recommended expiration date was "[DATE]". On [DATE] at 10:25 AM, this Surveyor observed a pressure alarm pad in off-sample Resident #16's bed; the expiration date was marked "[DATE]". On [DATE] at 10:25 AM, this Surveyor observed a pressure alarm pad in off-sample Resident #17's bed and wheelchair; the expiration dates were not marked on either of the pads. On [DATE] at 10:27 AM, this Surveyor observed a pressure alarm's control box on off-sample Resident #18's wheelchair; the manufacturer's recommended expiration date was "[DATE]". On [DATE] at 10:28 AM, this Surveyor observed a pressure alarm on off-sample Resident #19's bed; the expiration date was not marked on the pad. Nurse aide #12 made 4 attempts to activate the alarm, by pressing on the bed and sitting on resident #19's bed, without success. In an interview, on [DATE] at 10:32 AM, Maintenance worker #21 stated, "We don't hold on to pressure alarms that are expired". In an interview, on [DATE] at 10:40 AM, this Surveyor asked Facility Operations Manager #22 if the facility honored the manufacturer's expiration recommendations for alarms, and Manager #22 stated, "No, I think its a marketing ploy". On [DATE] at 8:00 AM, Administrator #1 told this Surveyor, "Our policies (regarding safety alarms) are not sufficient...(LPN/In-service Director #27) was not instructing staff per manufacturer's guidelines (regarding checking for functionality of the alarms)...We are only going to use pads and boxes as recommended by the manufacturer". In an interview, on [DATE] at 9:15 AM, LPN #27 stated, "I used to show them (newly hired nurse aides) the alarms, sat on them and made them go off. I was never properly trained or looked at manuals for alarms...I did not teach the CNA's to check for functionality at the beginning of each shift". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS RISK FACTORS AND/OR IMPLEMENT CARE PLAN INTERVENTIONS IN ORDER TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR TWO OF FOUR RESIDENTS (#8 AND #34) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 14 RESIDENTS, AND FAILED TO INTERVENE TO PREVENT THE WORSENING OF A PRESSURE ULCER FOR ONE RESIDENT (#4), RESULTING IN RESIDENTS #8 AND #34 DEVELOPING NEW PRESSURE ULCERS AND RESIDENT #4 BEING PLACED AT INCREASED RISK FOR INFECTION AND PAIN RELATED TO AN EXISTING PRESSURE ULCER. FINDINGS INCLUDE: ACCORDING TO THE DECEMBER 2011 physician's orders [REDACTED]. A physician's orders [REDACTED]. THE NURSING PROGRESS NOTE DATED 12/27/11 REFLECTED RESIDENT #4 HAD COCCYX (TAILBONE AREA) PRESSURE WOUND THAT MEASURED 1.9 CM X 1.7 CM X 0.3 CM. THE WOUND BED WAS RED AND HAD SMALL AMOUNT OF TAN DRAINAGE. THE NOTES STATED THAT THE RESIDENT RECEIVED "[MEDICATION NAME]," A NARCOTIC MEDICATION ADMINISTERED ROUTINELY FOR PAIN CONTROL. THE NEXT WOUND MEASUREMENT WAS DOCUMENTED 5 DAYS LATER ON 1/1/12. THE NOTE DESCRIBED THE COCCYX WOUND AS MEASURING SLIGHTLY LARGER, AT 1.9 CM X 1.8 CM X 0.3 CM, AND AS HAVING A MODERATE AMOUNT OF ODOROUS TAN DRAINAGE, AND RED EDGES WITH DARK AREAS. THE DESCRIPTION THAT WAS DOCUMENTED ON 1/1/12 WAS INDICATIVE OF AN INFECTED WOUND. THE NOTE CONCLUDED THAT THE RESIDENT WAS EXPECTED TO DECLINE, AND THE DIRECTION OF CARE WAS COMFORT BASED. ACCORDING TO A PHYSICIAN'S PROGRESS NOTE DATED 1/5/12 (FOUR DAYS AFTER NURSES HAD DOCUMENTED A MALODOROUS WOUND WITH RED EDGES), RESIDENT #4 HAD A STAGE III DECUBITUS ULCER. (A STAGE III DECUBITUS ULCER IS A PRESSURE ULCER CHARACTERIZED BY FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO, OR NECROSIS OF, SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO THE MUSCLE). THE WOUND WAS LOCATED ON THE RESIDENT'S COCCYX, WAS BIGGER THAN QUARTER SIZE, AND WAS FOUL SMELLING. THE physician progress notes [REDACTED]." THE PHYSICIAN DOCUMENTED: "...LONG-TERM PROGNOSIS IS EXTREMELY POOR...WILL START [MEDICATION NAME] (ANTIBIOTIC) AND [MEDICATION NAME] PATCH (NARCOTIC)." DURING AN OBSERVATION ON 1/10/12 AT 10:00 A.M., RESIDENT #4 WAS OBSERVED IN HER ROOM RECEIVING A.M. CARE PROVIDED BY NURSE AIDE "D". THE RESIDENT WAS HEARD MOANING AND WAS OBSERVED GRIMACING WHEN SHE WAS TOUCHED. AS THE RESIDENT WAS TURNED ON HER RIGHT SIDE, HER COCCYX PRESSURE ULCER DRESSING COULD BE SEEN. THE DRESSING WAS SATURATED WITH A LARGE AMOUNT OF BLOODY DRAINAGE THAT HAD SOAKED THROUGH THE DRESSING AT THE BOTTOM. NURSE AIDE "D" WAS HEARD TO STATE THAT THE WOUND WAS GETTING WORSE BECAUSE THE RESIDENT WAS NOT EATING WELL. ALTHOUGH THE DRESSING WAS HEAVILY SOILED, THE DRESSING WAS NOT CHANGED DURING THAT OBSERVATION. DESPITE THE RESIDENT HAVING "AS NEEDED" PAIN MEDICATION AVAILABLE, THE DRESSING CHANGE WAS POSTPONED UNTIL AFTER THE RESIDENT ATE LUNCH AND WAS ADMINISTERED HER "ROUTINE" PAIN MEDICATION. THE HEAVILY SATURATED DRESSING PROVIDED A RESERVOIR FOR BACTERIA TO MULTIPLY, INCREASED THE RESIDENT'S RISK OF SKIN INJURY DUE TO MACERATION (PROLONGED MOISTURE), AND GENERALLY INCREASED THE POTENTIAL FOR THE RESIDENT TO EXPERIENCE DISCOMFORT AND PAIN. AT 12:15 P.M., THAT SAME DAY ON 1/10/12, RESIDENT #4 WAS OBSERVED BEING FED HER MEAL IN THE DINNING ROOM. SHE WAS OBSERVED TO BE ALERT AND ABLE TO DRINK SOME FLUIDS. AT 1:30 P.M. THAT DAY (THREE AND A HALF HOURS AFTER THE RESIDENT HAD BEEN OBSERVED IN BED WITH A SOILED AND SATURATED DRESSING), THE DRESSING WAS OBSERVED CHANGED IN RESIDENT #4'S ROOM. AT 1:30 P.M., RESIDENT #4'S ENTIRE WOUND WAS OBSERVED FILLED WITH BROWNISH-TAN SLOUGH (SEPARATED DEAD TISSUE) AND BLACK NECROTIC (DEAD) TISSUE AT THE EDGES, AND THERE WERE TUNNELINGS AT SEVERAL PLACES. THE WOUND MEASURED APPROXIMATELY 6 CM LONG BY 7 CM WIDE, WITH AN INDETERMINATE DEPTH. THE SIZE AND CONDITION OF THE WOUND WAS SIGNIFICANTLY DETERIORATED AS COMPARED WITH THE DESCRIPTION OF THE WOUND DOCUMENTED ON 1/1/12. BASED ON REVIEW OF THE JANUARY 2012 TREATMENT SHEET, THE physician's orders [REDACTED]." DURING AN INTERVIEW ON 1/13/12 AT 11:00 A.M., WOUND CARE NURSE "B" " SAID THE FACILITY WAS NO LONGER MEASURING RESIDENT #4'S WOUND BECAUSE THE RESIDENT'S STATUS WAS COMFORT CARE ONLY. NURSE "B" PRESENTED AN EXCERPT FROM AN ARTICLE, CALLED "ADVANCES IN SKIN AND WOUND CARE," FEBRUARY 2010, PUBLISHED BY LIPPINCOTT WILLIAMS AND WILKINS. UNDER THE SECTION OF "PRESSURE ULCER ASSESSMENT" THE ARTICLE STATED, "HEALING IS SELDOM THE GOAL FOR THOSE INDIVIDUALS RECEIVING HOSPICE OR PALLIATIVE (COMFORT) CARE, AND THEREFORE, THERE IS NO PURPOSE TO FREQUENTLY MEASURING THE WOUND SIZE OR DETERIORATION BECAUSE NO PLANS TO INTERVENE WILL BE DERIVED IN THESE MEASUREMENTS...THE ULCER WILL LIKELY WORSEN AS DEATH NEARS..." HOWEVER, UNDER THE RECOMMENDATIONS THE ARTICLE DIRECTED, "...ASSESS THE PRESSURE ULCER WITH EACH DRESSING CHANGE, AT LEAST WEEKLY (UNLESS THE INDIVIDUAL WAS ACTIVELY DYING), AND DOCUMENT FINDINGS." DURING THE INTERVIEW ON 1/13/12 AT 11:00 A.M., NURSE "B" STATED THE FACILITY'S RATIONALE FOR NOT MEASURING RESIDENT #4'S WOUND WAS THAT RESIDENT #4 WAS ACTIVELY DYING. NURSE "B" WAS ASKED TO PROVIDE THE DATA THE FACILITY HAD TO SUPPORT THAT RESIDENT #4 WAS "ACTIVELY DYING." NURSE "B" STATED, "SHE IS GOING TO DIE, HER WOUND IS NOT GOING TO HEAL, HER DOCTOR SAID SO." THE NURSING PROGRESS NOTE DATED 1/12/12 REFLECTED: "...RESIDENT IS ABLE TO EXPRESS HER PREFERENCE IN REGARDS TO TIME SPENT IN AND OUT OF BED, ATTENDANCE AT ACTIVITIES, MEALS...SHE IS ABLE TO RESPOND TO 'YES' OR 'NO' QUESTIONS..." ( ) ACCORDING TO THE FACE SHEET (UNDATED), RESIDENT #34 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 1/10/12 AT 10:15 A.M., RESIDENT #34 WAS OBSERVED IN HER ROOM BEING ASSISTED TO TRANSFER FROM HER BED TO HER MOTORIZED WHEEL CHAIR BY MEANS OF A MECHANICAL LIFT DEVICE. AFTER SHE WAS SEATED IN HER WHEELCHAIR, A SEAT BELT WAS FASTENED IN ACCORDANCE WITH HER WISHES. RESIDENT #34 WAS OBSERVED TO BE ALERT AND ABLE TO COMMUNICATE HER NEEDS. ACCORDING TO THE "PRESSURE SORE RISK ASSESSMENT" DATED 9/6/11 RESIDENT #34 HAD SCORED "14", INDICATING THAT SHE WAS AT MODERATE RISK FOR DEVELOPING PRESSURE SORES. ACCORDING TO THE NURSING CARE PLAN INITIATED 12/16/11, RESIDENT #34 HAD A POTENTIAL FOR SKIN BREAKDOWN DUE TO INCONTINENT BOWELS, VERY LIMITED MOBILITY, [MEDICAL CONDITION] AND HISTORY OF STROKE. THE CARE PLAN INTERVENTIONS INCLUDED USING A LOW AIR LOSS (PRESSURE REDUCTION) MATTRESS AND A PRESSURE REDUCTION CUSHION, ENSURING THAT THE HEAD OF THE BED WAS NOT ELEVATED MORE THAN 30 DEGREES (TO AVOID SHEARING FROM SLIDING DOWN IN BED), MONITORING NUTRITIONAL STATUS, REPOSITIONING EVERY 2 HOURS (EVERY ONE HOUR WHEN UP IN A CHAIR), AND DOCUMENTING ANY REFUSALS TO REPOSITION OR LAY DOWN FOR A NAP. ACCORDING TO FACILITY "PROGRESS NOTES" (UTILIZED BY ALL DISCIPLINES) DATED 12/29/11, RESIDENT #34 DEVELOPED A NEW OPEN AREA ON 12/29/11. THE NOTES DOCUMENTED: "...CNA (NURSE AIDE) REPORTED AN OPEN AREA TO BUTTOCKS. OPEN AREA NOTED TO BE 2 CM (CENTIMETERS) X 1 CM X (AND LESS THAN) 1 CM (DEPTH), NO DRAINAGE NOTED, WOUND BED PINK, SURROUNDING TISSUE RED AND INTACT, MINIMAL PAIN NOTED DURING APPLICATION OF "POLYMEM #3 (ABSORBANT, [MEDICATION NAME] DRESSING)." AREA CLEANSED WITH NS (NORMAL SALINE) AND DRIED PRIOR TO APPLICATION. EDUCATED RESIDENT ON IMPORTANCE OF POSITION CHANGES WHILE IN BED AND ALSO GETTING UP OOB (OUT OF BED). WILL CONTINUE TO MONITOR AND REPOSITION EVERY 2 HOURS." ON 1/11/12 FROM 12 NOON THROUGH 3:00 P.M., RESIDENT #34 WAS OBSERVED SITTING IN HER WHEEL CHAIR, FIRST IN THE DINING ROOM THEN IN THE MAIN ACTIVITY HALL. AT NO TIME DURING THE OBSERVATION WAS THE RESIDENT OBSERVED BEING ASSISTED TO REPOSITION, OR SHIFT HER WEIGHT IN HER CHAIR, IN ACCORDANCE WITH THE INTERVENTIONS DOCUMENTED IN THE CARE PLAN. DURING AN INTERVIEW AT 9:30 A.M. ON 1/11/12, THE 200 WING UNIT MANAGER REGISTERED NURSE (RN) "A" WAS ASKED TO EXPLAIN WHAT MIGHT HAVE CAUSED RESIDENT #34'S PRESSURE ULCER. NURSE "A" SAID THAT SHE COULD NOT EXPLAIN WHAT THE CAUSES WERE. NURSE "A" STATED THAT RESIDENT #34 PREFERRED TO STAY IN BED, BUT GOT UP FOR 2 TO 3 HOURS AFTER EACH MEAL. DURING AN INTERVIEW ON 1/11/12 AT 1:00 P.M., A NURSE WHO IDENTIFIED HIMSELF AS A "CERTIFIED WOUND NURSE" STAFF "B" WAS ASKED TO PROVIDE RESIDENT #34'S WEEKLY SKIN ASSESSMENTS FROM 12/29/11 (DATE THAT THE PRESSURE ULCER WAS DISCOVERED) TO THE PRESENT. HE WAS UNABLE TO PROVIDE THAT INFORMATION. BASED ON REVIEW OF THE RESIDENT'S CLINICAL RECORD, NO DOCUMENTATION OF WOUND ASSESSMENTS COULD BE FOUND, EVEN THOUGH DRESSING CHANGES WERE DOCUMENTED AS HAVING BEEN DONE ON 1/1/12, 1/4/12, 1/7/12 AND 1/9/12. ACCORDING TO THE FACILITY POLICY (PRESSURE SORES), REVISED DECEMBER 8, 2011, THE INITIAL ASSESSMENT OF ALL PRESSURE SORES WOULD INCLUDE THE TYPE OF WOUND, WOUND ETIOLOGY (CAUSE OR REASON FOR DEVELOPMENT), MEASUREMENT, CHARACTERISTICS OF WOUND, ASSESSMENT OF PAIN AND CURRENT TREATMENTS. THEN, ON A WEEKLY BASIS, THE CERTIFIED WOUND SPECIALIST WOULD PERFORM AN EVALUATION OF THE PRESSURE SORE WITH FINDINGS DOCUMENTED IN THE RESIDENT'S PROGRESS NOTES AND IN THE "CHRONIC WOUND LOG." ( ) ACCORDING TO THE FACE SHEET, RESIDENT #8 WAS A [AGE] year OLD MALE admitted to the facility on [DATE], THEN REadmitted on [DATE]. RESIDENT #8'S [DIAGNOSES REDACTED]. RESIDENT #8'S SKIN CARE PLAN INITIATED 12/16/11 REFLECTED THE RESIDENT WAS INCONTINENT OF BLADDER AND BOWELS, CHAIR-FAST, OBESE, VERY LIMITED IN MOBILITY AND AT RISK OF DEVELOPING SKIN BREAKDOWN. CARE PLAN INTERVENTIONS INCLUDED: CONDUCTING PRESSURE SORE RISK ASSESSMENTS, IMPLEMENTING A PRESSURE-REDISTRIBUTION MATTRESS AND PRESSURE-REDISTRIBUTION CUSHION, REPOSITIONING THE RESIDENT EVERY 2 HOURS, MONITORING HIS NUTRITIONAL STATUS, AND PROVIDING HIM WITH TOILETING ASSISTANCE AND INCONTINENCE CARE. RESIDENT #8'S PRESSURE SORE RISK assessment dated [DATE] HAD A SCORE OF "13", REPRESENTING A MODERATE RISK FOR DEVELOPMENT OF PRESSURE ULCERS. NURSING PROGRESS NOTES DATED 1/4/12 REFLECTED RESIDENT #8 HAD DEVELOPED AN OPEN AREA ON HIS RIGHT BUTTOCK. THE NEW AREA MEASURED 0.5 CM WITH A PINK SURROUNDING AREA. ACCORDING TO NOTES DATED THE FOLLOWING DAY, ON 1/5/12, THE WOUND MEASURED 0.5 CM X 0.25 CM X (LESS THAN) 0.1 CM (IN DEPTH). THE WOUND HAD A SMALL AMOUNT OF BLOODY DRAINAGE. THE PROGRESS NOTE SAID THAT THE RESIDENT WAS NON-COMPLIANT WITH REPOSITIONING. THE PROGRESS NOTE DATED 1/8/12 REFLECTED THE RESIDENT'S RIGHT BUTTOCK WOUND MEASURED 0.25 X 0.25 X (LESS THAN) 0.1 CM. THE WOUND WAS DESCRIBED AS AN "ABRASION" RATHER THAN A PRESSURE SORE. A [MEDICATION NAME] (OCCLUSIVE, ABSORBANT) DRESSING HAD BEEN APPLIED TO THE WOUND. THE NOTE SAID THAT RESIDENT #8 WAS NOT BEING COMPLIANT WITH REPOSITIONING, WAS STATING THAT HE COULD NOT SEE HIS TELEVISION, AND HAD PAIN IN HIS NECK WITH TURNING. ON 1/13/12 AT 11:00 A.M., RESIDENT #8 WAS OBSERVED LYING ON HIS RIGHT SIDE IN HIS PRIVATE ROOM. HIS BED WAS OBSERVED PLACED AGAINST THE WALL, WITH THE LEFT SIDE NEXT TO THE WALL. THE RESIDENT'S TELEVISION SET WAS LOCATED ON THE RIGHT SIDE OF HIS ROOM. WITH THE ROOM ARRANGEMENT THE WAY THAT IT WAS, RESIDENT #8 WOULD NOT HAVE BEEN ABLE TO WATCH HIS TELEVISION (COMFORTABLY, OR AT ALL) IF HE WAS POSITIONED ON HIS LEFT SIDE (IN ORDER TO REDUCE PRESSURE TO THE OPEN WOUND ON HIS RIGHT BUTTOCK). AT THE TIME OF THE OBSERVATION, RESIDENT #8 WAS INTERVIEWED AND HE STATED THAT HE LIKED TO BE ABLE TO SEE WHO WAS COMING THROUGH THE DOOR. HE ALSO STATED THAT HIS OVER BED TABLE, WITH ALL OF THE ITEMS THAT HE NEEDED, WAS ALWAYS ON HIS RIGHT SIDE. DURING AN OBSERVATION OF WOUND CARE, CONDUCTED ON 1/12/12 AT 2:00 P.M. IN THE RESIDENT'S ROOM, RESIDENT #8'S RIGHT BUTTOCK WOUND WAS OBSERVED TO BE APPROXIMATELY DIME SIZED (THE DIAMETER OF A DIME IS ABOUT ONE AND A HALF CENTIMETERS). THE WOUND PRESENTED AS A RAW OPEN AREA, WITH A SCANT AMOUNT OF SEROUS (WATERY) DRAINAGE, WITH REDDENED TISSUE SURROUNDING THE WOUND. THE WOUND WAS CONSISTENT IN APPEARANCE WITH A STAGE II PRESSURE ULCER (A WOUND THAT IS CHARACTERIZED BY PARTIAL THICKNESS SKIN LOSS). DURING AN INTERVIEW ON 1/13/12 AT 11:30 A.M., THE "500" WING UNIT MANAGER, (STAFF "C") WAS ASKED WHAT THE CAUSE OF RESIDENT #8'S DEVELOPING PRESSURE ULCER MIGHT BE. MANAGER "C" STATED THAT THE RESIDENT HAD PARALYSIS, WAS INCONTINENT, PERSPIRED A LOT DUE TO OBESITY AND WAS OFTEN NON-COMPLIANT WITH REPOSITIONING AS EVIDENCED BY HIS SELF-REMOVAL OF THE PILLOWS FROM BEHIND HIS BACK. DURING THE INTERVIEW, MANAGER "C" DID NOT IDENTIFY THE REASONS WHY THE RESIDENT MIGHT NOT HAVE WANTED TO COMPLY WITH REPOSITIONING. WHEN THE PREVIOUSLY DESCRIBED OBSERVATIONS OF THE RESIDENT'S ROOM ARRANGEMENT WERE SHARED WITH MANAGER "C", MANAGER "C" STATED THAT CHANGES WOULD BE MADE, INCLUDING PLACING THE RESIDENT'S BED IN A DIFFERENT LOCATION SO THAT HE COULD SEE PEOPLE COMING THROUGH HIS DOOR AND WATCH TELEVISION MORE COMFORTABLY, WHEN POSITIONED ON HIS LEFT SIDE, AND SO THAT HE COULD REACH THE ITEMS THAT HE NEEDED ON HIS OVER-BED TABLE WHEN HE WAS ON HIS LEFT SIDE. ( )