Every finding on record at Chelsea Retirement Community

Based on observation, interview and record review the facility failed to provide a bed hold for two residents (#10, #38) of five residents reviewed for notification of a bed hold and the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman for two resident (#10, #90) of five discharged of five residents reviewed.Findings include: Resident 90 (R90) Review of the medical record reflected R90 was admitted to the facility on [DATE], with diagnoses that included weakness. R90 was transferred to the hospital on 6/18/26 and did not readmit. On 7/16/2026 at 10:47 AM, the list of transferred or discharged residents sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman was provided and reviewed. R90 was not on the list that was provided. In an interview on 07/16/2026 at 11:12 AM, Social Worker (SW) F stated that the facility sends out the log of transferred and/or discharged residents to the LTC ombudsman on a monthly basis. SW F stated that the residents who were transferred to the hospital are to be included on the list provided to the LTC Ombudsman. SW F confirmed that R90 was sent out on 6/18/2026 and did not return to the facility. SW F stated that R90 should have been on the list that was sent to the LTC Ombudsman at the end of June 2026, however, noted that R90 was not on the list of residents that was sent to the LTC Ombudsman in June 2026. Resident #38 (R38) Review of the medical records reflected that R38 was admitted to the facility on [DATE]. Diagnoses of multiple myeloma, fracture of tibia and fibula, heart failure and dementia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2026 revealed R38 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impairment) out of 15. Record review of R38's medical record revealed the following discharges and readmissions within the last year: 03/01/2026-discharged -readmitted [DATE] and 07/03/2026- discharged -readmitted [DATE]. Further record review of R38's medical record did not reveal that a bed hold/transfer had been provided to the resident/responsible person for the discharge that had occurred 03/03/2026. During an interview on 07/16/2026 at 11:09 AM, admission Director (AD) L stated the facility nursing staff provided a copy of the bed hold policy to the resident when they were discharged to the hospital. AD L explained that he was responsible to call the resident/responsible person the following day to inquire if a bed hold had been requested. AD L was asked to provide Bed Hold/Transfer for R38 for hospitalization date 03/01/26, and the reason for the Bed Hold/Transfer was three days late from hospitalization on 07/03/26, dated 07/07/26. AD L later confirmed a bed hold had not been provided on 03/01/2026, as he could not find the bed hold/transfer documentation that it was given to R38 and he had not called to verify if a bed hold had been requested. During an interview on 07/16/2026 at 11:37 AM, DON B was explained the nursing roles in bed hold/transfer process. DON B stated nursing staff was responsible to give the bed hold/transfers with the resident when they are sent out to the hospital. DON B then stated that AD L followed up the next day, making sure it is signed and received. DON B stated if AD L was not working, they had another staff member who would verify it was signed and received. DON B stated nurses usually add that to the progress note that stated they were being sent out to the hospital and that bed hold/transfer form was given. DON B confirmed there was no documentation for the hospitalization on R38 for 03/01/2026 to show it had been given. DON B stated there only documentation to support it had been given for R38's hospitalization on 07/04/2026. DON B confirmed the Bed Hold/Transfer was signed and scanned into R38s medical record four days later. DON B conveyed she thought the 24-hour regulation requirement for Bed Holds/Transfers was extended due to a holiday weekend. Resident #10 (R10) Review of the medical record revealed R10 was admitted [DATE] with diagnoses that included fracture of left clavicle, congestive heart failure (CHF), back pain, polyneuropathy (malfunction or damage of multiple peripheral nerves throughout the body, hypertension, muscle spasm, Parkinson's Disease (a progress neurological disorder), anxiety, depression, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/2026, revealed R10 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on 07/14/2026 at 10:47 a.m. R10 was observed sitting on the side of her bed. R10 explained that she had been discharged from the facility in the past but could not recall the dates. Review of R10's medical record revealed the following discharges and readmissions within the last year: 11/28/2025- discharged – readmitted [DATE] 02/02/2026-discharged -readmitted [DATE] 03/13/206- discharged -readmitted [DATE] 04/14/2026-discharged -readmitted [DATE] 04/23/2026-discharged -readmitted [DATE] Review of R10 medical record did not reveal that a bed hold had been provided to the resident/responsible person for the discharge that had occurred 04/23/2027. During an interview on 07/16/2026 at 11:03 a.m. admission Director (AD) L explained that the facility nursing staff provided a copy of the bed hold policy to the resident when they were discharged to the hospital. AD L explained that he was responsible to call the resident/responsible person the following day to inquire if a bed hold had been requested. AD L confirmed that a bed hold had not been provided on 04/23/2026 because he could not find the bed hold document and he had not called to verify if a bed hold had been requested. During the review of the facility list of transferred or discharged residents sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman was provided and reviewed. R10 was not on the list that was provided. In an interview on 07/16/2026 at 11:12 AM, Social Worker (SW) F stated that the facility sends out the log of transferred and/or discharged residents to the LTC ombudsman monthly. SW F stated that the residents who were transferred to the hospital are to be included on the list provided to the LTC Ombudsman. SW F confirmed that R10 was sent out to the hospital 11/28/25, 02/02/2026, 03/13/2026, 04/13/2026, and 04/23/2026, however R10 was not on the list that was sent to the Long-Term Care Ombudsman in November 2025, February 2026, March 2026, or April 2026. In an interview on 07/16/2025 at 11:55 a.m. Nursing Home Administrator (NHA) A confirmed that R10 was not on the list that was sent to the Long-Term Care in November 2025, February 2026, March 2026, or April 2026.

Based on interview and record review, the facility failed to provide showers/bed-bath to one resident (R55) of two residents reviewed for assistance with activities of daily living. Findings Include;Resident #55 (R55)Review of the medical records reflected that R55 was admitted to the facility on [DATE] and signed onto hospice on 03/04/26. Diagnoses of congestive heart failure, respiratory failure, chronic obstructive pulmonary disease, chronic kidney disease and chronic kidney disease.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026 revealed R55 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15.During an interview on 07/14/2026 at 10:07 AM, family member Q stated the facility staff were not putting R55's oxygen on R55 all the time. Family member Q stated Sunday night she left here at 5:30 PM and was concerned about R55 not wearing her oxygen from the concentrator, which was turned off when she left. Family member O stated she saw the portable tank was empty on red. Family member Q also stated R55 had soiled the bed, so she told facility staff she would change the bedding. When Family member Q went to change the bedding, the bottom sheet was off the bed, and the bed/mattress cover was covered in powder and a large wet spot in the middle of the mattress cover. Family member Q stated she was unsure when the last time R55 had her bedding changed since the staff were powdering R55, thinking she was on the bedding, when the bedding was totally off the mattress. Family member Q stated the facility staff are not showering R55. Observation of shower preferences schedule sheet by room number hanging on the wall in the nurse's office. R55's room was scheduled for a shower or bed-bath on Monday and Thursday with the letter H behind it. During an interview on 07/15/2026 at 1:42 PM, Licensed Practical Nurse (LPN) P stated the hospice CNAs came in on Mondays and Thursdays but this week they were coming in on Thursday and Saturday. LPN P stated if hospice doesn't show up on the scheduled day, then the facility CNA would do it. Writer asked which days the facility CNA's give R55 her shower. LPN P stated they didn't give showers or baths unless hospice was not showing up.On 07/15/2026 at 1:59 PM via email to LNA A, writer requested the last 3 months of shower sheets.During an interview on 07/15/2026 at 2:04 PM, Certified Nursing Assistant (CNA) R, stated the residents' showers were listed in the nurse's office by room. Writer asked CNA R when the facility CNAs gave the showers then. CNA R stated they don't, only the hospice aides gave the showers.During an interview on 07/16/2026 at 12:02 PM, Director of Nursing (DON) B, writer asked about the care plan for R55, and Activities of Daily Living (ADL's) listed.Care plan read Adjust provision of ADLs to compensate for her changing abilities. Dressing was marked as requiring one person to assist, nothing further. Oxygen was listed on the care plan, but no further instruction. No resident specific information was noted in the resident plan of care. Record review of the shower sheets for the last three months did not reveal that facility staff provided showers or bed baths to R55.

Based on observation and interview, the facility failed to ensure one resident (R39) of 18 sampled residents, were observed taking their medication in front of the licensed nurse as part of meeting professional standards. Findings Include;Resident #39 (R39)Review of the medical records reflected that R39 was admitted to the facility on [DATE]. Diagnoses of Stroke, aphasia (a neurological disorder that impairs ability to speak, write and understand language), and dysphagia disorder caused by brain damage that affects your ability to speak, understand, write or write language.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2026 revealed R39 had a Brief Interview of Mental Status (BIMS) of 14 (Cognitively intact) out of 15.During an observation and interview (R39 used a sheet of paper with letters printed on it to communicate) on 07/14/2026 at 10:58 AM, a cup with medications (4 different shaped white pills and 2 large white pills, that had been broken in half) was observed on R39s over the bed table beside the resident's lunch tray. R39 indicated they were her medications and then put her hand out over the medication cup. LPN P was the nurse on this hall that would have passed medications to R39. During an interview on 07/14/2026 at 11:15 AM, LPN P stated they had to leave them with her so she can take them one at a time throughout her lunch. LPN P then stated that's what works best for R39.Record review of the care plan and review of the electronic medical record did not reveal an assessment for self-administration of medications for R39.During an interview on 07/16/2026 at 1:01 PM, DON B was informed of the medications sitting at the bedside for R39.

Based on interview and record review, the facility failed to provide hospice coordination of care for one resident (R55) of one resident reviewed, resulting in lack of collaboration of care and ensuring R55 was receiving adequate end of life services. Finding Include;Resident #55 (R55)Review of the medical records reflected that R55 was admitted to the facility on [DATE] and signed onto hospice on 03/04/2026. Diagnoses of congestive heart failure, respiratory failure, chronic obstructive pulmonary disease, chronic kidney disease and chronic kidney disease.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026 revealed R55 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15.Record review did not reveal coordination of care between the hospice agency and the facility. Hospice binder in the nurse's office with R55's name on it did not contain any documentation from the admission or a current benefit period of 06/02/2026 through 08/30/2026, calendar of pre-scheduled disciplinary visits, plan of care for each discipline, medication list, no communication notes between the hospice nurses or CNAs with the facility staff. No care plan to show the task the CNAs and nurses would be responsible for. During an interview on 07/15/2026 at 1:42 PM, Licensed Practical Nurse (LPN) P stated the hospice CNAs come in on Mondays and Thursdays but this week they were coming in on Thursday and Saturday. LPN P stated if Hospice doesn't show up on the scheduled day, then the facility CNA would do it. Writer asked which days the facility CNA's give R55 her shower. LPN P stated the facility didn't give showers or baths, hospice did that.Writer requested standard hospice documentation on 07/15/2026 at 2:27 PM from LNA A to include shower sheets for the last three months, Hospice POC/Recertification from 06/02/26 to 08/30/26. CNA hospice care plan, calendar of scheduled visits, visit notes from nursing and HHA for the last 3 months. Equipment supplies and medication that were listed on the plan of care by hospice and collaboration between hospice and facility.During an interview on 07/16/2026 at 10:30 AM, RN S stated the hospice agency had a gentlemen/care transition coordinator that came in frequently, every week or so to see how things are going but never brought in any paperwork or documents to be scanned into resident's electronic medical record.During an interview on 07/16/2026 at 12:02 PM DON B stated she was unaware that required documentation and coordination of care between the hospice agency and facility was not taking place. DON B also looked under nursing progress notes and under miscellaneous tab for hospice documentation and nothing had been uploaded in the R55s electronic medical record. Review of R55's care plan did not specify the coordination of care between the hospice and facility. Care plan generically read Adjust provision of ADLs to compensate for her changing abilities.

Based on observation, interview, and record review the facility failed to ensure opened food items were dated, and had a use by date in a current facility census of 83 residents.Findings Included:During the initial kitchen tour on 8/04/2025 at 9:15 AM with Dietary Director (DD) J in the [NAME] one kitchen it was observed in one of the refrigerators a bag of opened English muffins that did not have a date that the muffins were opened nor a dated that the muffins were to either be used by (UBD-use by date) or discarded. Further observation revealed that in the same refrigerator there were six loaves of opened bread that did not have the date the loaves were opened nor a UBD. During the main Kitchen tour, it was observed in a refrigerator that a carton of opened milk was not dated with the dated the mild was opened nor was the carton dated with a UBD. Further observation of the main kitchen freezer revealed one opened bag of chicken nuggets, one bag of opened chicken tenders, including patties, and wings that were all opened. None of the bags of chicken were sealed closed and all four of the bags of chicken were not dated with the date they were opened nor did any of the bags have a UBD on them. Another refrigerator in the main kitchen revealed a package of opened ham that was not dated with the date the ham was opened, nor did the package of ham have a UBD. During the tour DD J stated that it was her expectation that when the food product was opened the kitchen staff were to place a sticker with the opened date, and the use by date on the product. Review of the facility policy and procedure titled, Date Marking for Food Safety with an effective date of 9/2024, revealed under, Policy Explanation and Compliance Guidelines for Staffing, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded., 3. The individual opening or preparing a food shall be responsible for the date marking the food at the time the food is opened or prepared., 4 The marking system shall consist of an Adhesive Label, the day/date of opening, and the day/date the item must be consumed or discarded . Per the 2022 Food Code U.S. Food and Drug Administration , section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking .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., and .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded .

Based on observation, interview, and record review the facility failed to ensure one out of one resident (Resident 91) received toileting assistance per the plan of care.Findings Included:Per the facility face sheet Resident 91 (R91) resided at the facility since 7/31/2025. R91 had diagnoses of muscle weakness and need for assistance with personal care. In an interview on 8/04/2025 at 11:17 AM, R91 stated that he had some incontinence of urine at times because he could not make it to the bathroom on time and said when that occurred, he had to use the commode/urinal. In another interview on 8/06/2025 at 2:04 PM, R91 stated that he used a urinal at times rather than the toilet, because he could not get to the toilet on time. R91 said staff would not be able to get to assist him on time, because he would have urgency to urinate. R91 stated that he had to wear a brief and occasionally would have a wet brief or would have to use the urinal. R91 said he would rather use the toilet and added that he has gotten up on his own to go to the bathroom. Review of a care plan that was in place and active for R91 revealed, I (R91) have bladder incontinence., dated 8/5/2025. The interventions listed on the care plan included, BRIEF/PULL UP/PAD/LINER: as ordered. dated 8/5/2025, INCONTINENT: Check and change w (with) rounds and prn (as needed). dated 8/5/2025, Wash, rinse and dry perineum. dated 8/5/2025, Offer and assist me to the bathroom UR (upon rising), HS (at bedtime), between meals and prn. Check for incontinence w rounds and assist w care Date Initiated: 08/05/2025. Review of the Certified Nurse Aid (CNA) Kardex (a document that informs the CNAs how to care for a resident based on the resident's plan of care) revealed for R91's toileting needs, Offer and assist me to the bathroom UR, HS, between meals and prn. Check for incontinence w rounds and assist w care. Review of R91's Physician orders revealed that on 7/31/2025 an order was written for R91 to receive, Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for edema. Which is a diuretic and causes an increase in urination. Review of the CNA task documentation for R91 from 8/1 through 8/4/2025 R91 only received toileting assistance nine times over the four days. On 8/2/2025 R91 only received toileting assistance one time that day at 11:56 AM. ON 8/3/2025 R91 only received toileting assistance two times once at 2:36 AM and again at 8:04 AM. Further review of the CNA task documentation revealed that on 8/5/2025 when the very specific toileting plan was put into place R91 was only assisted to the toilet two times that day once at 11:28 AM and at 10:26 PM. Per R91's toileting plan he was not offered toileted after breakfast, after lunch, or after dinner per documentation. In an interview on 8/06/2025 at 11:14 AM, Director of Nursing (DON) B stated R91's urination pattern was discussed, and the toileting plan for R91 was put into place by the assessment nurse, and stated the team talked about the protocol weekly for R91 to assure the protocol was being followed and it was working. In an interview on 8/06/2025 at 2:00 PM, CNA K stated that R91 did not have a specific toileting plan/schedule in place but was toileted every two hours. CNA K stated R91 was not incontinent but wore a brief for accidents, and said CNAs had to get to R91 fast in order to get him to the bathroom with a dry brief. In an interview on 8/06/2025 at 2:08 PM, Registered Nurse (RN) G stated that R91 was not on a specific toileting plan/schedule but was toileted every two hours. In another interview with DON B on 8/06/2025 at 3:10 PM, DON B stated that the facility did not usually use a toileting plan/protocol like the one R91 had in place. DON B said the CNAs would toilet R91 more often than they documented, but that was not able to be proven. DON B said R91's toileting plan was an unusual toileting intervention.

Based on observation, interview and record review, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that 1 of 2 residents (R34) reviewed received timely follow-up PASSAR II evaluations and coordination of care, resulting in the delay in mental health services appropriate to their needs. Findings include: Resident #34 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R34 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included major depression, generalized anxiety, bipolar disorder, unspecified dementia, frequent falls and epilepsy. Review of the Pre-Admission Screening And Resident Review (PASARR) Level I, dated 6/10/24, reflected R34 had marked yes for the person has current diagnosis and received treatment for mental illness and has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. The PASARR reflected R34 had diagnosis of Bipolar and was taking Ability, Vistaryl, Lexapro and Lamictal. Continued review of the level 1 PASARR reflected, DISTRIBUTION: If any answer to items 1 - 6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. Review of the Electronic Medial Record(EMR), dated 6/13/24 through 8/7/24, reflected no evidence of Level 2 PASSAR. During in interview on 8/07/24 at 2:32 PM, Social Worker F reported R34 had a competed Level 1 PASARR that reflected the need for PASARR Level 2 to be completed. SW F reported facility either has the level 2 or a letter that one had been completed. SW F reported was able to locate letter for R34 from the Department of Health and Human Services that PAD-OBRA Level 2 Evaluation was completed and made a recommendation on placement and services. The letter reflected, Determination: Nursing Facility - Other Mental Health Services. The individual qualifies for the level of services provided by a nursing facility and does not require specialized mental health/developmental disabilities services but may need other mental health/developmental disabilities services . SW F reported R34 had not been seen by mental health services and did not have a referral but could send one. SW F reported facility had to petition for guardianship for R34 and was appointed emergency guardian 7/18/24. SW F verified R34 signed consents including consents for antipsychotic on 6/13/24 and was seen by first provider for capacity on 6/14/24 and second on 6/17/24 deemed incapable to make health choices. SW F reported consents should be completed by emergency guardian. Review of the Provider Visit note, dated 7/2/24, reflected plan that R34 should be considered for referral to in house psychiatric care. Review of R34 Provider Visit Note, dated 7/16/24, reflected, Bipolar 1 disorder(CMS/HCC) No change in medications, will make psychiatric referral if patient continues to stay long-term. Review of R34 Physician Orders, dated 7/9/24, reflected, psych evaluation for medication management and therapy one time only for bipolar disorder During an interview on 8/07/24 at 4:05 PM, SW F provided R34 level 2 PASARR and OBRA assessment completed just prior to admission at this facility that reflected mental health services needed. SW F verified provider note, dated 7/16/24, reflected plan for mental health consult and reported should have been completed after emergency guardian obtained 7/18/24. SW F reported was not aware of need for referral and reported usually notified by nursing or provider. SW F reported mental health service plan to be at facility tomorrow and will plan to have R34 on list to be seen. Review of the Preadmission Screening Comprehensive Level 2 Evaluation, dated 6/12/24, reflected R34 was marked for mental illness. The Evaluation included diagnosis of Major depressive disorder, recurrent episode. with psychotic features-primary, post-traumatic stress disorder, and generalized anxiety disorder. The evaluation recommended Nursing Facility/Other Mental Health Services including Individual therapy and psychiatric medication review. Continued review of the evaluation reflected, Historically , [named R34] does not manage stress, triggers, or symptoms well and would frequently experience suicidal ideation's. This often led to psychiatric treatment/hospitalization s. [Named R34] should be closely monitored of any signs and symptoms of increased depression, which may include but is not limited to: tearfulness, agitation, lack of appetite, sleep disturbance .[named R34 does have history of psychosis along with depression and should also be monitored for paranoia, delusions, suspicions, and hallucinations. Any evidence of signs or symptoms should be reported to [named R34] treatment team immediately .[named R34] should be connected to appropriate mental health services while admitted to the nursing facility, such as the facility's contracted mental health provider. [named R34] would benefit from talk therapy and psychiatric medication review . During an interview on 8/8/24 at 1:10 p.m., SW F reported admission staff should have obtained PASSAR Level 2 on admission for any resident major mental health diagnosis including for R34 with diagnosis of Bipolar. Review of the facility, PASARR Coordination Program, undated, reflected, The Social Services Department shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority .

Based on observation, interview and record review, the facility failed to implement care plan interventions for one of 18 residents reviewed for care plans (Resident #52), resulting in the likelihood of aspiration of food or liquid into the lungs and choking during meals. Findings include: Resident #52 (R52) On 8/06/2024 at 12:36 PM, R52 was observed sitting in a chair in her room eating lunch. A male friend was sitting next to her and stated R52 could not talk, but could shake her head yes or no. R52's care plan dated 6/29/2024 instructed not to share or speak with R52 about medical Information with male visitor present; he was just a friend, and ask him to leave first per family. R52's nutrition at risk care plan dated 7/02/2024 revealed a dysphagia 3 diet (moist, chopped/bite-sized pieces) was ordered and she required full one to one supervision with meals. R52's Minimum Data Set (MDS) with assessment reference date of 7/03/2024, revealed she was admitted to the facility on [DATE] and her cognitive skills for daily decision making was moderately impaired (decisions poor; cues/supervision required). R52's same MDS revealed R52 had signs and symptoms of a swallowing disorder including holding food in mouth/cheeks or residual food in mouth after meals; and coughing or choking during meals or when swallowing medications. R52's same MDS, under care area assessment (CAA), indicated she was recently hospitalized for a stroke and had aphasia (language disorder, may have trouble understanding, speaking, reading or writing). R52's same CAA indicated was to have one to one, full supervision with meals. In review of speech therapy notes dated 8/01/2024, R52 required skilled services for dysphagia to assess and determine least restrictive diet and develop and instruct in compensatory strategies; to enhance her quality of life, by improving ability to safely swallow without signs/symptoms of aspiration. It was determined R52's difficulties learning new information would impact her treatment. In review of speech therapy notes dated 8/05/2024, R52's goal was to tolerate her diet with no overt signs or symptoms of aspiration/pulmonary (lung) compromise with use of safe swallowing strategies and cues. Progress on R52's goal dated 8/05/2024 indicated she had an intermittent cough with thin liquids, and benefited from alternating liquids/solids to aid in timing of oral clearance/swallow initiation. Alternating liquids/solids was not included in R52's care plan or in the kardex (nurse assistant care plan instructions). Physician Progress Note dated 8/06/2024 revealed R52 was seen for follow-up and was now able to speak a few words on occasion. R52 communicated she still had a poor appetite, needed assistance with eating, and was messy at times. The same note indicated R52 had lost five pounds over the last three weeks and staff were encouraging her to eat snacks whenever possible. R52's speech therapy recommendations dated 8/07/2024 included: one to one supervision, slow rate, small bites and sips, sit upright, alternate liquids and solids and ensure oral cavity was clear following meals. Instructions including slow rate, small bites and sips, sitting upright, were not included in R52's care plan or kardex. On 8/07/2024 at 8:17 AM, R52 was observed lying in bed with the head of her bed elevated in a reclined position. R52's breakfast tray was placed on a table to the right of her bed with the cover on, and juice uncovered. Later, on 8/07/2024 at 8:54 AM, R52 was observed sitting in her room in a dining chair eating breakfast placed on a table directly in front of her. No staff were observed assisting or supervising her during her breakfast meal. On 8/07/2024 at 12:19 PM R52 was observed sitting in a chair in room eating lunch. R52's male friend was the only person in her room, no staff were present. On 8/08/2024 at 12:05 PM R52 was observed sitting in her room eating lunch unassisted, no staff, friends or family were present. Certified Nurse Assistant (CNA) O was interviewed on 8/08/2024 at 12:19 PM and stated she thought R52 was no longer one to one supervision with meals . Rehabilitation Director P was interviewed on 8/08/2024 at 12:33 PM and stated she had verified with Occupational Therapy and Speech Therapy that recommendations for one to one supervision with meals continued to be recommended for R52's care.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 73 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 05/22/23 at 09:26 A.M., An initial tour of the main food production kitchen was conducted with Chef Manager C. The following items were noted: The South Bend conventional oven(s) exterior surfaces were observed soiled with accumulated and encrusted food residue. The South Bend griddle and side plates were observed soiled with accumulated and encrusted food residue. The MagiKitch'n char broiler backsplash and side plates were observed with accumulated and encrusted food residue, adjacent to the two grate plates. Chef Manager C indicated he would have dietary staff thoroughly clean and sanitize the conventional oven(s), griddle, and char broiler 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. The AltoShaam blast chiller interior was observed with pooling water, adjacent to the interior refrigeration fan unit. Chef Manager C indicated he would have maintenance complete necessary repairs as soon as possible. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 05/22/23 at 10:55 A.M., An initial tour of the [NAME] 2 Kitchenette was conducted with Chef Manager C. The following items were noted: The Continental one-door reach-in cooler interior light assembly was observed loose-to-mount. Chef Manager C indicated he would have maintenance repair the faulty interior light assembly as soon as possible. The metal filter assembly was observed missing on the Accurex ventilation range hood. Chef Manager C indicated he would have maintenance replace the missing metal filter assembly as soon as possible. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 05/22/23 at 11:09 A.M., An initial tour of the [NAME] 1 Kitchenette was conducted with Chef Manager C. The following item was noted: The SouthBend char broiler and side plates were observed soiled with accumulated and encrusted food residue. 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 05/24/23 at 05:00 P.M., Record review of the Policy/Procedure entitled: Cooks Cleaning List dated (no date) revealed under Daily: (2) Wipe down stovetop, (7) Broiler needs to be cleaned and scraped after usage, (8) Oven(s) need to be cleaned, and (19) Wipe down sides of equipment and backsplashes. On 05/24/23 at 05:15 P.M., Record review of the Policy/Procedure entitled: Food Safety Requirements dated (no date) revealed under Policy Explanation and Compliance Guidelines: (6) All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. (a) Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. (b) Clean dishes shall be kept separate from dirty dishes. (c) Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils.

Based on interview, and record review the facility failed to complete a level I Preadmission Screening/Annual Resident Review (PASARR) for one (Resident #18) of one residents reviewed for PASARR, resulting in the potential for lack of appropriate mental health treatment and services. Findings include: Resident #18 (R18) R18's Minimum Data Set (MDS) assessment dated [DATE] revealed he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-12 Moderate Impairment). Social Worker (SW) U was interviewed on 5/23/23 at 12:44 PM, and confirmed the last completed level 1 was completed on 9/27/21. Following the interview SW U sent a completed level 1 screen dated 5/23/23.

Based on observation, interview, and record review, the facility failed to offer sufficient fluids and prevent weight loss, in one of four residents reviewed for weight loss and hydration (Resident #51), resulting in a severe weight loss in 1 month and unmet hydration needs. Findings include: Resident #51 (R51) On 5/23/23 at 8:00 AM R51 was observed lying flat in bed, her breakfast tray was observed on the over the bed table and covered. R51 stated waiting for help to eat. R51's lips were dry and flaking. R51 was observed approximately 15 minutes later with staff physically assisting with her meal. R51's Minimum Data Set (MDS) with assessment reference date of 4/21/23 indicated she was admitted to the facility on [DATE]; and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 13 (13-15 Cognitively Intact). R51's 4/21/23 MDS revealed she required set up assistance for eating. The same MDS indicated R51 had diagnosis of urinary tract infection (UTI) in last 30 days of assessment date. R51's electronic Weight Summary indicated the following: 4/19/23 103.8 pounds (lbs.) 4/19/23 103.8 lbs. 5/02/23 96.8 lbs. 5/02/23 96.8 lbs. 5/04/23 98.8 lbs. 5/20/23 94.8 lbs. On 04/19/23, R51 weighed 103.8 lbs.; on 05/20/23, R51 weighed 94.8 lbs., in which was a severe weight loss of 8.67 percent (%) in one month. In review of R51's May 2023 Medication Administration Record, R51 was on a regular texture diet with thin liquids. The same source indicated R51 had a history of urinary retention, anorexia and constipation. The same MAR indicated to obtain weights for 3 days on admit and then weekly for weight monitoring. R51's weight summary did not include weight documentation on 4/20/23 and 4/21/23. On 5/24/23 at 1:27 PM, R51 was observed lying flat in bed with her eyes closed. R51's lunch tray was observed on her over-the-bed table, which included a hot dog sliced and potato chips. There was a full glass of water on the tray with the lid on. Per surveyor observation, R51's intake at lunch was less than 25 % of meal and zero fluid intake. Certified Nurse Assistant (CNA) V was interviewed on 5/24/23 at 1:30 PM and stated R51 ate a few bites of hot dog for lunch. In review of R51's electronic food acceptance record dated 5/24/23, she accepted 51 to 75 % of the lunch meal. Registered Dietician (RD) D was interviewed on 5/24/23 at 2:07 PM and stated R51 had a decline in intake over the last couple of days. RD D stated R51 was offered gelatin at 12:00 PM with her medications. RD D stated R51 was started on boost supplement due to her decline. RD D calculated R51's hydration needs at 1300 to 1400 milliliters (ml) daily. RD D stated R51 was not meeting her needs based on her fluid acceptance documentation. RD D stated R51's food acceptance was around 25 %. In review of R51's May 2023 MAR, there was an order for nursing to provide a gelatin snack, related to malnourishment that was started on 4/21/23. The same document did not include how much of the gelatin was accepted. The same MAR reflected a supplement was ordered on 5/24/23, 237 ml daily at 12:00 PM.

Based on observation, interview, and record review, the facility failed to promote resident bathing preferences in two of two residents reviewed for choices (Resident #44 & #67), resulting in choice of bathing schedule not honored and dissatisfaction. Findings include: Resident #44 (R44) On 5/23/23 at 9:11 AM, R44 was observed sitting in her wheelchair in her room. R44's 1/17/23 and 4/19/23 Minimum Data Set (MDS) assessment, 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 15 (13-15 Cognitively Intact). R44's 1/17/23's MDS assessment indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. R44's 4/19/23 MDS indicated she did not reject care during the 7-day look-back period and required extensive assistance with personal hygiene and bathing. During an interview on 5/23/23 at 9:11 AM, R44 stated her shower was scheduled on Wednesday and Sunday, twice weekly, but would prefer a shower three times a week. R44 indicated she had previously requested her preference for showers three times a week. R44 stated she had chronic issues with diarrhea and needed more than two showers a week. Assistant Director of Nursing (ADON) T was interviewed on 5/24/23 at 10:38 AM and stated the interdisciplinary team (IDT) created the shower schedule; R44 could have showers three times a week entered into the system (care plan), but it was not a guarantee she would receive more than 2 showers per week. ADON T stated in the same interview R44's bathing preference depended on staffing ratios. Resident #67 (R67) R67's 4/23/23 MDS revealed she admitted to the facility on [DATE], had a BIMS score of 15 (13-15 Cognitively Intact), and required extensive assistance for personal hygiene. R67 was interviewed on 5/22/23 at 4:21 PM and stated two months ago, she requested to change her bath schedule from afternoons to mornings. R67 stated the staff would offer to assist her with her shower between 9:30 PM and 10:00 PM, and she did not like a shower at that time. R67 stated she had a bed bath the night prior. R67 stated she preferred a shower, but if it was late at night, she opted for a bed bath. R67 stated therapy had helped her with a shower twice in the morning, because they took pity on her, and she stated she appreciated it.

Based on observation, interview and record review, the facility failed to follow Professional Standards of care and facility policy for nebulizer administration and blood sugar monitoring/documentation for two Residents (R39 and R73) of 18 residents reviewed, resulting in medications not being administered according to professional standards of care and/or facility policy, and lack of appropriate monitoring and management of diabetes including not following physician orders. Findings include: Review of the, Nebulizer Therapy policy, dated 7/2022, provided by the Director of nursing (DON) B on 5/25/23, reflected, It is the policy of the facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Place ordered medication into nebulizer cup .Assist resident into comfortable position .Connect the nebulizer to a power source .Instruct resident on how to use the nebulizer .Turn the machine on .Keep nebulizer vertical during treatment .Observe resident periodically during the procedure for any change in condition. If resident unable to manage delivery device independently may need to stay with resident during the procedure .When medication delivery is complete, turn the machine off .Disassemble and rinse the nebulizer with water and allow to air dry . Resident #39(R39) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R39 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, hypertension, respiratory failure, rib fractures, chronic obstructive pulmonary disease, and depression. During an observation and interview on 5/24/23 at 9:35 a.m., Licensed Practical Nurse (LPN) Q prepared several medication for R39 at the medication cart including Ipratropium Bromide Inhalation Solution 0.02 %, 2.5 ml. LPN Q entered R39 room, administered oral medications to R39, added Ipratropium Bromide Inhalation Solution to nebulizer mask equipment and positioned mask on R39 and turned-on nebulizer at 9:39 a.m. R39 appeared confused. LPN Q stated would return in about five minutes after treatment was completed and left R39 alone in room. No evidence of respiratory assessment was observed or directions for R39 to take deep breaths with nebulizer treatment. Observed R39 nebulizer continue to run at 9:58 a.m. with no staff present while LPN Q was preparing other resident medications at cart. This surveyor continued to follow LPN Q for medication pass until 10:10 a.m. to other residents. At 10:10 a.m. LPN Q reported planned to continue other named resident medication pass. This surveyor entered R39's closed door, after being granted permission, at 10:12 a.m. and observed two Certified Nurse Assistance (CNA) R and S providing resident care including brief change and dressing with nebulizer mask located on bedside table. During an interview on 5/24/23 at 4:35 p.m., Director of Nursing (DON) B reported would expect nurse to perform respiratory assessment prior to administration of nebulizer treatment, remain with resident throughout treatment or return within 10 minutes to remove nebulizer equipment, rinse and store equipment in bag. DON B reported nurse was expected to remove nebulizer equipment, not CNA staff, and perform respiratory assessment after nebulizer treatment was complete. 46954 Resident #73 Review of an Admission Record revealed Resident #73 (R73) admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction due to embolism (stroke to due a blood clot), prediabetes, unspecified atrial fibrillation (irregular heart rate), and essential hypertension (high blood pressure). The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/17/23, reflected R73 scored five out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R73 required total dependence of two or more people for most activities of daily living including toilet use and transferring. R74 required extensive assistance of one person for eating. In an observation on 5/25/23 at 11:50 AM, R73 was seated in her recliner in her room with her legs elevated. R73 was dressed appropriately and resting with her eyes closed. R73 was receiving her tube feeding at the time of observation. Review of the Physician's Order's revealed R73 had an order dated 5/8/23 which stated Accucheck once daily one time a day for diabetes mellitus. Review of the Physician's Order revealed R73 had an order dated 2/10/23 which stated Humalog Solution 100 UNIT/ML (milliliter) (Insulin Lispro-- a fast acting insulin). Inject 10 unit subcutaneously (below the skin) every 2 hours as needed for for blood sugar over 300 repeat and retreat if needed in 2 hours. Review of the Medical Administration Record revealed R73 had a checkmark in the box under each day from 5/8/23 until 5/24/23, indicating her blood sugar was checked for the day, as ordered. Review of the Electronic Medical Record reflected R73 had no documented blood glucose readings for the dates of: 5/9/23 5/11/23 5/13/23 5/14/23 5/15/23 5/16/23 5/17/23 5/18/23 5/20/23 5/21/23 5/23/24 In an interview on 5/25/23 at approximately 11:00 AM, Director of Nursing (DON) B reported that R73 is a pre-diabetic. DON B stated that the expectation would be for the daily blood sugar reading to be documented in the Electronic Medical Record. DON B reported that when the Physician Order was placed in R73's chart that typically there is a prompt that would force the staff to document the daily blood sugar reading but the prompt was not activated with the order.

Based on interview and record review, the facility failed to provide a written notice for facility indicated transfer for one of four residents reviewed for notice of transfer (Resident #18), resulting in the potential for inappropriate resident transfers/discharges. Findings include: Resident #18 (R18) R18's Minimum Data Set (MDS) assessment dated [DATE] revealed he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-12 Moderate Impairment). Director of Nursing (DON) B was interviewed on 5/23/23 at 12:44 PM and confirmed R18 was transferred to the hospital 4/22/23 and returned 4/22/23. DON B also confirmed R18 had a hospital stay from 3/12/23 to 3/14/23. DON B stated she was not able to locate a transfer notice for the above dates.

Based on interview and record review, the facility failed to provide a notice of the bed hold policy prior to transfer to the hospital for one of four residents reviewed for transfers (Resident #18), resulting in the potential for information not received. Findings include: Resident #18 (R18) Director of Nursing (DON) B was interviewed on 5/23/23 at 12:44 PM and confirmed R18 was transferred to the hospital 4/22/23 and returned 4/22/23. DON B also confirmed R18 had a hospital stay from 3/12/23 to 3/14/23. DON B was not able to provide evidence from R18's medical record of the bed hold policy provided at time of resident transfer. R18's Minimum Data Set (MDS) assessment dated [DATE] revealed he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-12 Moderate Impairment). In review of R18's record, there was not documentation of bed hold policy provided at time of transfers. Review of the facility's Bed Hold Notice Upon Transfer Policy dated 7/14/22, at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for one resident (#16) of one resident reviewed resulting in the potential for worsening contractures and pain. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 03/05/2019 with diagnoses that included Huntington's Disease, depression, insomnia, osteoporosis, dysphagia, panic disorder, dementia, stage 3 kidney disease, gastro-esophageal reflux, hypertension, and vitamin D deficiency. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2023, revealed R16 did not have a Brief Interview of Mental Status (BIMS) completed because he was rarely/never understood. Section G0400-Functional Limitation in Range of Motions, MDS with same ARD, demonstrated that R16 had impaired upper and lower extremities. The MDS with the same ARD section O- demonstrated that R16 was not receiving skilled therapy services or a Restorative Nursing program. During observation and attempted interview 05/23/2023 at 09:05 a.m. R16 was observed lying down in bed. R16's hands were observed curled inward toward his forearms. R16 did not respond to verbal stimulation during attempted interview. R16's legs were not observed, as they were covered with a sheet. During record review it was revealed that R16 had care plan interventions that stated, Contracture: I have contracture of arm. R16's Point of Care (POC) task did not demonstrate that CNA'S had conducted any Range of Motion (ROM) completed during his daily care. R16's medical record demonstrated a skilled therapy screen, completed 4/5/2023, documented that there had not been any change in his ROM, upper or lower extremities, during the last quarter. The therapy screen did not identify is R16 had contractures of his upper and lower extremities. In an interview on 05/25/23 at 09:49 a.m. Certified Nursing Assistant (CNA) G explained that Range of Motion (ROM) that she provided to R16 consisted of turning him. When asked if she provided ROM by moving his upper and lower extremities, she explained that type of ROM was provided by therapy staff. CNA G explained that she did not know if R16 had contractures of his upper or lower extremities. In an interview on 05/23/2023 at 11:23 a.m. Team Lead of Therapy F explained that that the facility does not have a Restorative Nursing Program. She explained that the Therapy Department would conduct quarterly evaluations for residents. She explained that if a resident needed a Restorative Program, her department would create a program for that resident and provide education to the nursing staff. Team Lead of Therapy F could not identify if R16 had contractures of his upper and lower extremities, after reviewing R16's therapy documentation. She explained that R16 was not receiving ROM by the therapy staff or nursing staff. During observation (with Team Lead of Therapy F present) on 05/25/2023 at 11:48 a.m. R16 was sitting up in a Geri-Chair at the side of his bed. His arms and hands were covered with a blanket. Team Lead of Therapy F asked R16 if she could remove the blanket to allow her to look at his arms. It was observed that R16 left and right hands were curled toward his forearms. Once leaving the room Team Lead of Therapy F explained that it appeared that R16 had contractures to both his wrist. She explained that he would benefit from a Range of Motion (ROM) program and that she would obtain and order to complete a skilled therapy evaluation. Team Lead of Therapy F could not explain why a ROM program had not been initiated prior to this observation of R16. In an interview on 05/25'2023 at 12:01 p.m. Director of Nursing (DON) B explained that the facility did not have a Restorative Nursing Program. She explained that the nursing department would refer the resident to that department to create a Range of Motion (ROM) program for the residents. DON B could not explain why R16 was not receiving an restorative therapy for contractures that were present.

Based on observation, interview, and record review, the facility failed to develop an individualized care plan in one of 18 reviewed for care plans (Resident #51), resulting in unmet needs and the potential for delayed treatment for infection. Findings include: Resident #51 (R51) On 5/23/23 at 8:00 AM R51 was observed lying flat in bed, her breakfast tray was observed on the over the bed table and covered. R51 stated waiting for help to eat her breakfast. R51's lips were observed dry and flaking. R51's Minimum Data Set (MDS) with assessment reference date of 4/21/23 indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 13 (13-15 Cognitively Intact). The same MDS indicated R51 had diagnosis of urinary tract infection (UTI) in last 30 days of assessment date. In review of nurse's notes dated 5/20/23 at 2:08 AM, identified as a late entry for 5/19/23 at approximately 2:00 AM, the nurse attempted to collect a urine sample via catheter due painful urination. The same note indicated R51 reported burning and frequency; R51's nurse assistant reported R51 had increased confusion. R51's same nurse's note indicated 10 milliliters (ml) of medium yellow, very cloudy urine with a foul odor was collected. R51's note indicated she did not drink very much and encouraged her to increase her fluid consumption so a sample could be collected in the morning. The same note indicated the day shift nurse was able to obtain a sample and awaiting laboratory pickup. Director of Nursing (DON) B was interviewed on 5/24/23 at 2:25 PM and stated there was not a physician's order to obtain a urine specimen for R51 on 5/19/23 and there were no results for a urine analysis (UA). DON B stated the facility had a magnet they place on the resident's door to alert staff of the need to encourage fluids. In review of R51's care plans, there were no care plans related to current UTI signs and symptoms. There were no interventions for a hydration magnet to be placed on R51's door. In review of R51's May 2023 Medication Administration Record, R51 had a history of urinary retention, anorexia and constipation. In review of R51's physician orders, an order dated 5/24/23 indicated to collect urine for suspected UTI; the UA was originally ordered 5/20/23; and the UA sample not taken by lab.

This Citation Pertains to Intake MI00129641 Based on interview and record review, the facility failed to ensure one out of one (Resident#1) had been provided copies of medical records upon written request and within two working days of the advanced notice resulting in resident rights being infringed upon. Finding include: According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident #1 (R1) was a [AGE] year old female admitted to the facility on [DATE] with a readmitted [DATE]. R1 scored 12 of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility grievance log reflected a facility form titled Resident/Family Concern was filed on on 7/13/2022 the form was filled out by R1's spouse and reflected their complaint was that there had been no action taken by Medical Records staff F regarding their request for a copy of R1's medical record. The resolution of the concern form reflected the Director of Nursing (DON) B assisted R1 and her spouse in completing a request for the medical records. Review of the facility form titled Request For Medical Records Consent For Release of Information reflected R1 completed a written request that medical records be released to R1's spouse, the form was signed by R1, DON B and was dated 7/13/2022. A second Request For Medical Records was signed and dated 7/26/2022 by R1 and Medical Records staff F On 05/09/23 at 1:00pm, during an interview with Medical Records staff F he reported he had no recollection of R1, her spouse or any written medical record requests from them. Medical Records staff F stated the facility had no such policy or practice in place that was designed to have the recipient of the person receiving the medical records sign when medical records were received. Medical Records staff F stated he maintained a spread sheet on his computer that tracked the date of the request, the resident, who made the request, completion date of the request, whether it was mailed/faxed or other, the amount due and date payment for the request was received. Surveyor and Medical Record staff F reviewed the spread sheet which reflected R1 made a request for her medical records on 7/13/22 , the spread sheet line which revealed the completion date of the request, whether it was mailed/faxed or other, the amount due and date payment for the request was received was blank. The same spread sheet reflected a second request was made on 7/26/22 , completed on 7/26/22 that the records were provided 7/26/22 with a charge of $102.31. Medical Records staff F reported he thought he fulfilled the initial request for medical records on 7/13/22.

This citation is related to Intake #MI 624, #MI 361, #MI 567, #MI 282. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the needs of six sampled residents (#5, #53, #60, #66, #301 and #425), 11 confidential resident interviews, and one confidential family interview within the facility population of 74 residents. This deficient practice resulted in actual and potential avoidable episodes of incontinence, actual and potential delayed assistance for care such as transfer to bed (#310) and with walking (#66) and frustration and helplessness with call lights going unanswered and needs not being addressed. Findings include: A review of the Resident Council minutes included concerns of: 12/21 - Call lights not answered in a timely manner, especially during meals and at bedtime - Need for more CNA (Certified Nursing Aide) staff, especially midnights. 2/22 - Need more CNAs - only one CNA for 3 halls on midnights 3/22 - Long call light wait times after lunch - From 5:00 AM to 7:00 AM staff not answering call lights in a timely manner The facility was asked to offer alert and cognitively intact residents the opportunity to meet and share meaningful discussion regarding their home in the facility. A confidential group meeting took place on 6/28/22 at 3:30 PM, and it was noted the residents stressed their desire to remain anonymous. The group for the most part had Brief Interview for Mental Status (BIMS) scores of 13-15 indicating intact cognition. The group voiced a main concern that the facility was understaffed. Resident C2 stated, staff don't show up and the newer people are not sure of what they are supposed to be doing. Resident C6 stated the midnight shift recently had scheduled one CNA for in excess of 20 people and it is humanly impossible to provide the needed care. The residents in the group felt the CNAs at night hid or were sleeping and not providing care. Resident C7 stated, The management has not fixed this. Resident C8 said call lights were on and not answered. Resident C6 said many residents had confided that often briefs were not being changed and residents were left soaking wet. Resident C6 stated, At night it takes forever (for the staff to answer the call lights) and has caused me to wet . They (staff) are supposed to come in every 2 hours but it takes 3-4 hours and sometimes later. Resident C7 added she often had to wait for an hour and a half at night and added we tell them (management), but things do not change. Resident C8 stated she felt helpless and frustrated, and said she knew others felt helpless too. Resident #66 A review of Resident #66's medical record revealed an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating intact cognition. During a room visit on 6/28/22 at 8:34 AM, Resident #66 stated there were not enough staff to provide care. He said he had to sit on the toilet usually for more than an hour and wait as the staff do not come when the call light is on. Resident #66 stated, I had my light on for 2 hours yesterday, if you can believe that. I am unstable when I walk and if they don't come, I worry about falling and that is a dangerous situation. Resident #66 also stated, They started walking me when they had a full staff, but they got away from that and do not walk me anymore. I am not stable on my prosthesis (artificial lower leg) and need help. Resident #66 was frustrated there were not enough staff to assist him with walking. On 4/20/21 a confidential complaint was filed with the State Agency (SA). This intake stated, There is not enough staff to meet my needs or the needs of other people who live here. We aren't getting showers, teeth brushed, help to the bathroom when we need to go. Sometimes I want to ask the housekeeper for help because she is the only one I've seen in hours. When a CNA does come in, they apologize, but say they sometimes have 20 patients. Confidential Interviews During a confidential interview on 6/27/22, Resident C5 (with a BIMS score of 14 indicating intact cognition) stated, At night they have no help . you can just forget it if you think someone will help you. Resident C5 said I potty myself and thank God. I know there are people who do not get changed. Resident C5 asked she remained anonymous saying, I certainly would not want anyone to know my name when talking to you. During a confidential interview on 6/27/22, Resident C11 stated, Things are not good. The resident would not elaborate on why things at the facility were not good as there was a fear of retaliation. Resident C11 ask that no name be given. During a confidential interview on 6/27/22, Resident C10 (with a BIMS score of 14 indicating intact cognition) stated he was not interested in talking because the facility would know it was him who had reported issues to the SA. He stated that care was not being done due to the lack of staff. He asked me to leave and not use his name. During a confidential interview on 6/28/22, Resident C3 stated he had to wait so long to get help he finally called the facility receptionist to get her to send someone to help. During a confidential interview on 6/28/22, Resident C9 stated there was not enough staff and the staff who were there did not know the residents. Resident C9 said the facility did not have consistent staffing and the CNAs moved around to different halls and did not get to know the residents. Resident C9 stated, You know it is a bad day when an employee who has not worked with you is assigned to you. They want to do things their way not your way. During a confidential telephone interview on 6/27/22 at 1:25 PM, family member C12 stated they had witnessed call lights going unanswered for 25 minutes or longer when they visited. Family member C11 said they did not have enough staff to care for the residents and reported other care issues such as application of the needed leg brace that went undone. Family member C11 said the staff either did not know how to apply the brace or there were not enough staff to complete this procedure. The Facility Assessment Staffing Plan read in part: Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. The facility determined that based on our resident's needs . The Facility Assessment also included an Individual staff assignment which read in part: .group assignments are subject to change, however, remain very consistent to ensure continuity of care for the residents. During an interview on 6/29/22 at 2:08 PM, the Director of Nursing (DON) stated, Staffing is a challenge everywhere. The DON stated they were using agency staff and staffing was not an urgent problem. She said she had seen grievances filed by residents and family members on lack of call light response. She said management had provided education for the staff to answer the call lights promptly. Resident #5 Review of Resident #5's 3/18/22 Quarterly MDS assessment revealed an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 required extensive two person assist for transfers and bed mobility. On 6/28/22 at 10:47 a.m., Resident #5 was observed in his wheelchair in front of his television in his room. Resident #5 was noted to be requesting loudly to lay in his bed multiple times with Housekeeper/Staff H being the only staff on the hallway. On 6/28/22 at 11:04 a.m., Resident #5 requested from an unidentified staff member to lay down in bed. The unidentified staff member stated that they would be right back to assist Resident #5. Resident #5 was again observed in his wheelchair in front of his television. On 6/28/22 at 11:30 a.m., Resident #5 was noted to be sitting in his wheelchair. Resident #5 requested from this Surveyor to be assisted to bed. When asked how Resident #5 felt, he stated, Tired. On 6/28/22 at 11:41 a.m., Resident #5 was assisted to his bed and changed by two unidentified staff members. Resident #53 Review of Resident #53's Minimum Data Set (MDS) significant change assessment, dated 6/03/22, revealed Resident #53 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53 required extensive two-person assistance with bed mobility, was unable to transfer during the assessment period, and required extensive two-person assistance for toileting and hygiene. Resident #53 was occasionally incontinent of urine and always incontinent of bowel. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15, which indicated Resident #53 was cognitively intact. During an interview on 06/28/22 at 11:47 a.m., Resident #53 reported he waited up to an hour for the call light to be answered, mainly to urinate. When asked about continency, Resident #53 reported he had some control of his bladder and bowels. He reported this causing him feelings of frustration and helplessness. An observation on 6/29/22 at 8:22 a.m. revealed Resident #53 in his bed. He required extensive two-person assistance by staff for positioning side to side for bed mobility during a positioning observation, which indicated he would need extensive assistance for toileting needs as well. Resident #60 Review of Resident #60's MDS assessment, dated 6/06/22, revealed Resident #60 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60 required extensive one-person assistance for bed mobility, transfers, and limited one-person assistance for toileting and hygiene. Resident #60 was always continent of bladder and bowel. The BIMS assessment revealed a score of 15/15, which indicated Resident #15 was cognitively intact. During an interview on 6/28/22 at 10:52 a.m., Resident #60 reported they wait up to 15 minutes for their call light to be answered, which seemed too long of a time for toileting needs, as she was struggling to obtain toileting supplies. She reported with the extended call wait times this made her feel fearful of having an incontinence episode. Resident #425 Review of Resident #425's Baseline Care Plan revealed Resident #425 was newly admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #425 required one-person assistance for transfers, walking with device, dressing/toileting and hygiene. The Care Plan revealed Resident #425 was on diuretic medication (to increase the excretion of water through the kidneys), which placed her at risk for increased urgency. During an interview on 6/28/22 at 10:14 a.m., Resident #14 reported she had waited from 45 minutes to 1 hour at times for her call light to be answered for her toileting needs. She reported she held her bladder as long as she could but had to start just urinating on her depends due to the long wait times, and was feeling frustrated. Resident #14 had been provided with no explanation of long call wait times. During an interview with the DON on 6/29/22 at 3:34 p.m., the Director of Nursing (DON) was asked what the expectation would be for resident call wait times. The DON reported the expectation would be about five minutes for call lights to be answered timely. Review of the policy, Answering the Call Light, dated 2/21/20, provided by the DON on 6/29/22, revealed, The purpose of this procedure is to respond to the resident's requests and needs. [The facility] is a No Pass Zone for resident safety. Any staff member may answer a light at any time in addition to hourly rounding of our residents. General Guidelines: 9. Staff are to answer the resident's room call and bathroom call as soon as possible If any additional assistance is needed to help meet the resident need, inform the resident you are leaving to get help and return promptly . Review of the policy, Quality of Life - Dignity and Privacy, provided by the DON, undated, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Resident shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: b. Promptly responding to the resident's request for toileting assistance . Review of the [State] Resident Rights, received from the DON, revised 11/15/16, revealed, E. Respect and Dignity .The resident has the right to be treated with dignity and respect .

This citation pertains to intake MI 624, MI 361, and MI 567 Based on observation, interview, and record review, the facility failed to provide dignified care including timely answering of call lights and/or not providing medical supplies for five Residents (#5, #53, #60, #66, and #425) of 19 residents and six Confidential Residents reviewed for dignity and resident rights. This deficient practice resulted in feelings of frustration, helplessness, and incontinence episodes. Findings include: Resident #53 Review of Resident #53's Minimum Data Set (MDS) significant change assessment, dated 6/03/22, revealed Resident #53 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53 required extensive two-person assistance with bed mobility, was unable to transfer during the assessment period, and required extensive two-person assistance for toileting and hygiene. Resident #53 was occasionally incontinent of urine and always incontinent of bowel. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15, which indicated Resident #53 was cognitively intact. During an interview on 06/28/22 at 11:47 a.m., Resident #53 reported he waited up to an hour for the call light to be answered, mainly to urinate. When asked about continency, Resident #53 reported he had some control of his bladder and bowels. He reported this causing him feelings of frustration and helplessness. An observation on 6/29/22 at 8:22 a.m. revealed Resident #53 in his bed. He required extensive two-person assistance by staff for positioning side to side for bed mobility during a positioning observation, indicating he required extensive assistance with toileting and was unable to perform the task independently. Resident #60 Review of Resident #60's MDS assessment, dated 6/06/22, revealed Resident #60 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60 required extensive one-person assistance for bed mobility, transfers, and limited one-person assistance for toileting and hygiene. Resident #60 was always continent of bladder and bowel. The BIMS assessment revealed a score of 15/15, which indicated Resident #15 was cognitively intact. During an interview on 6/28/22 at 10:52 a.m., Resident #60 reported that they wait up to 15 minutes for their call light to be answered, which seemed too long of a time for toileting needs, as she was struggling to obtain toileting supplies. Resident #60 reported she had asked for incontinence briefs many times, and staff never brought her any, so she had to wear underwear. She stated she wanted incontinence briefs on all day and night as she has urinary leakage and has had incontinence episodes. She reported that no one had explained to her why they would not give her any briefs when she asked staff. She reported that with the extended call wait times and no brief, she feels fearful of having an incontinence episode. Resident #425 Review of Resident #425's Baseline Care Plan revealed Resident #425 was newly admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #425 required one-person assistance for transfers, walking with device, and dressing/toileting and hygiene. The Care Plan revealed Resident #425 was on a medication to increase the excretion of water through the kidneys, which placed her at risk for increased urinary urgency and frequency. During an interview on 6/28/22 at 10:14 a.m., Resident #425 reported that she has waited from 45 minutes to an hour for her call light to be answered. She reported that she held her bladder as long as she could but had to start urinating on her depends, and she was feeling frustrated. Resident #425 also reported she had trouble obtaining toileting supplies, such as briefs, and again felt frustrated. Resident #425 added that previously she had to ask several times before getting necessary supplies and equipment. Staff provided her no explanation of long call wait times or supply issue concerns when she asked staff. During an interview on 6/29/22 at 3:34 p.m., the DON was asked what the expectation would be for resident call wait times. The DON reported that the expectation would be about five minutes. When asked about the supply concerns, the DON acknowledged the concern that residents were not getting medical supplies timely and stated that she had not been made aware of this concern previously. Resident #5 Review of Resident #5's 3/18/22 Quarterly MDS assessment revealed an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 required extensive two person assist for transfers and bed mobility. On 6/28/22 at 10:47 a.m., Resident #5 was observed in his wheelchair in front of his television in his room. Resident #5 was heard loudly requesting to lay in his bed multiple times; Housekeeper/Staff H was the only staff in the hallway. On 6/28/22 at 11:04 a.m., Resident #5 requested from an unidentified staff member to lay down in bed. The unidentified staff member stated that they would be right back to assist Resident #5 and left the room. Resident #5 was observed in his wheelchair in front of his television during this encounter. On 6/28/22 at 11:30 a.m., 26 minutes later, Resident #5 was noted sitting in his wheelchair. Resident #5 requested from this Surveyor to be assisted to bed. When asked how Resident #5 felt, he stated, Tired. On 6/28/22 at 11:41 a.m., 37 minutes after the original request, two unidentified staff members assisted Resident #5 to his bed and incontinence briefs were changed once Resident #5 was in bed. Resident #66 A review of Resident #66's medical record revealed an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating intact cognition. During a room visit on 6/28/22 at 8:34 AM, Resident #66 stated there were not enough staff to provide care. He said he had to sit on the toilet usually for more than an hour and wait as the staff do not come when the call light is on. Resident #66 stated, I had my light on for 2 hours yesterday, if you can believe that. I am unstable when I walk and if they don't come, I worry about falling and that is a dangerous situation. Resident #66 was frustrated there were not enough staff. On 4/20/21 a confidential complaint was filed with the State Agency (SA). This intake stated, There is not enough staff to meet my needs or the needs of other people who live here. We aren't getting showers, teeth brushed, help to the bathroom when we need to go. Sometimes I want to ask the housekeeper for help because she is the only one I've seen in hours. When a CNA (Certified Nurse Aide) does come in, they apologize, but say they sometimes have 20 patients. Confidential Group Meeting The facility was asked to offer alert and cognitively intact residents the opportunity to meet and share meaningful discussion regarding their home in the facility. A confidential group meeting took place on 6/28/22 at 3:30 PM, and it was noted the residents stressed their desire to remain anonymous. The group for the most part had Brief Interview for Mental Status (BIMS) scores of 13-15 indicating intact cognition. Resident C6 stated the midnight shift recently had scheduled one CNA (Certified Nurse Aide) for in excess of 20 people and it is humanly impossible to provide the needed dignified care. The residents in the group felt the CNAs at night hid or were sleeping and not providing care. Resident C7 stated, The management has not fixed this. Resident C8 said call lights were on and not answered. Resident C6 said many residents had confided often briefs were not being changed and residents were left soaking wet. Resident C6 stated, At night it takes forever (for the staff to answer the call lights) and has caused me to wet . They (staff) are supposed to come in every 2 hours but it takes 3-4 hours and sometimes later. Resident C7 added she often had to wait for an hour and a half at night and added we tell them (management), but things do not change. Resident C8 stated she felt helpless and frustrated, and said she knew others felt helpless too. Confidential Interviews During a confidential interview on 6/27/22, Resident C5 (with a BIMS score of 14 indicating intact cognition) stated, At night they have no help . you can just forget it if you think someone will help you. Resident C5 said I potty myself and thank God. I know there are people who do not get changed. During a confidential interview on 6/28/22, Resident C3 stated he had to wait so long to get help he finally called the facility receptionist to send someone to help. During a confidential telephone interview on 6/27/22 at 1:25 PM, family member C12 stated they had witnessed call lights going unanswered for 25 minutes or longer when they visited. Family member C11 said they did not have enough staff to care for the residents and reported other care issues such as application of the needed leg brace that went undone. Review of the policy, Answering the Call Light, dated 2/21/20, provided by the DON on 6/29/22, revealed, The purpose of this procedure is to respond to the resident's requests and needs. [The facility] is a No Pass Zone for resident safety. Any staff member may answer a light at any time in addition to hourly rounding of our residents. General Guidelines: 9. Staff are to answer the resident's room call and bathroom call as soon as possible If any additional assistance is needed to help meet the resident need, inform the resident you are leaving to get help and return promptly . Review of the policy, Quality of Life - Dignity and Privacy, provided by the DON, undated, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Resident shall be treated

This citation pertains to intake #s MI 417 and MI 282. Based on observation, interview and record review, the facility failed to properly and appropriately assess, investigate, supervise and consistently implement assistive safety devices and interventions for five (#s 409, 410, 414, 415, 420) of nine sampled residents reviewed for accidents from a total of 20, resulting in abrasions, bruising, prolonged pain, head injury, falls, fractures, delayed care and emergency hospital treatment. Findings include: The facility reported to the State Agency that residents #414 and #415 had accidents with injuries in the facility. Resident #414- On [DATE] at 3 PM, the clinical record and a facility reported incident investigation for resident #414 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's ADL (activities of daily living) Guide (a care guide used by nurse aides) noted that the resident was to be transferred to and from bed and other surfaces via mechanical lift and two-person assistance. Per progress notes: On [DATE] by a physical therapist (P.T.)- At 3 PM patient was brought to the (therapy) gym patient complained of increased pain on right heel and tearful that she couldn't perform activity well. She stated that (nurse aide) tried stand pivot her from bed to wheelchair and hurt her foot. Communicated with the (aide) regarding this and educated that (mechanical) lift should be used. On [DATE] at 4:24 PM by an occupational therapist (OT)- Patient was approached in her room Patient reported 'excruciating' pain in right heel with suspicion of that being 'crushed' during a stand pivot transfer completed by (nurse aides) She was unable to stand due to intolerable pain in her right heel or to bear weight Patient requested to have an x-ray of the right heel Concern form filled out with description of complaint from resident. (Aide) educated on importance of following care guide for all transfers. On [DATE] at 10:25 PM by afternoon shift nursing staff- order from primary care physician to get x-ray of right foot. There was an undated order written for an x-ray of the right foot/ankle. The order did not specify that it was to be done STAT (immediately). On [DATE] at 3:47 PM by OT- Patient required assist for legs off/on bed secondary to increased pain to right ankle and heel (pain rated 9 on a scale of ,[DATE] with 10 being the worse) to touch and movement. On [DATE] at 9:50 PM by nursing staff- facility notified of the x-ray results; orders to send resident to (hospital) emergency room A review of the x-ray report revealed that the x-ray was not performed until 7:03 PM on [DATE]. It showed possible fracture. The incident investigation noted: Timeline- [DATE]-It was shared in morning meeting that two (nurse aides) transported the resident from her bed to chair the day before (on [DATE]), for therapy. The transfer occurred as a two-person transfer (by manual stand and pivot) versus (mechanical total body) lift per resident's care guide. During therapy resident complained of pain and was not able to tolerate standing per therapy. Therapy reported pain to nurses. There was no documentation indicating that therapy staff reported the resident's complaints to nursing staff. Hospital records noted that the resident was seen in the emergency room from ,[DATE]/-[DATE] for a fractured calcaneous (the largest bone of the foot that forms the heel). Per a hospital physician note dated [DATE]: Patient complaining of right foot pain Yesterday ([DATE]) Patient twisted her foot/ankle as she pivoted. Patient then had her foot caught under her chair as she sat back. A hospital x-ray report of the right ankle noted: Patient states: acute pain right foot and ankle, mostly in right heel and posterior ankle for one day; foot rolled and buckled under while trying to stand from wheelchair with assistance. A hospital CAT scan report of the foot revealed: Patient states she rolled her right foot and it buckled underneath her yesterday Patient's foot and ankle is swollen and red acute and nondisplaced dorsal posterior calcaneal fracture (new heel fracture) and longitudinal nondisplaced acute fracture which transverses the dorsal medial aspect of the base of the great toe proximal phalanx (new fracture running lengthwise through the big toe). On [DATE] at 4:30 PM, when asked about the incident, the Administrator and the Director of Nursing (DON) explained that the resident's assigned nurse aide, who was female, was about to transfer the resident then realized that she was supposed to use a mechanical lift. A male aide came to assist and said that the two of them could do it without using the lift and as a result, the resident was injured. The Administrator and DON said, They should have used a lift for the transfer. On [DATE] at 12:15 PM, when queried about the resident not receiving emergency care until the night of [DATE], the DON said, I wasn't aware of the incident until morning meeting on ,[DATE] (2017). When asked what happened to the concern form written by the OT on [DATE], she said, The concern forms go to social services and they log them first and said, Therapy (P.T. and OT) should have notified someone. The DON said, A note should have been written, when asked if the afternoon shift nurse should have documented about the resident's pain that prompted the order for the x-ray. Regarding the delay in obtaining the x-ray, the DON said, It wasn't ordered STAT. Resident #415- On [DATE] at 3 PM, the clinical record, an Incident report and a facility reported incident investigation for resident #415 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS completed [DATE] noted: The resident required extensive two-person assistance for transfers and was unsteady, only able to stabilize with staff assistance when moving from seated to standing position, turning around, during surface to surface transfers and when moving on and off toilet. The resident's cognition was not coded in the MDS, but according to nursing progress notes dated [DATE], [DATE], [DATE] and [DATE], the resident was alert with confusion. The resident's Admission assessment dated [DATE] noted: The resident was confused, unable to make own decisions, alert to person and place only and had long-term memory impairment. The resident was prescribed Aspirin 81 milligrams daily as an anticoagulant (blood thinner). The resident scored 10 on a Fall Risk assessment dated [DATE]. A score of 10 or greater meant high risk for falls. The Incident report noted: On [DATE] at 12:35 AM, the resident was found on the floor in the hallway; The resident was barefoot, required extensive assistance according to his pre-incident ambulation status and the contributing factor for the fall was unassisted ambulation. Per nursing progress notes regarding the incident dated [DATE]: At around 12:50 AM, I was leaving from (a room) and headed toward the nursing station and I turned my head towards (the north hall), when I noticed two (nurse aides) standing over (resident #415) who is lying supine on the floor. As I approached the resident, I noticed the patient's eyes looking upward and breathing heavily. I tapped the resident to gain his attention, there was no response. Patient is conscious but not responding I observed bright red blood underneath resident's head I interviewed the assigned (nurse aide) and she stated, told me he needed to go to the bathroom. After I assisted him to the bathroom, he pushed the door closed for privacy. I stepped outside of his door During that time (another resident) was yelling for help. I went to go help the patient as I went back, he was lying flat on his back on the floor in the doorway The Facility Investigation Summary of the incident noted: On [DATE] at approximately 12:30 AM, a nurse aide had assisted the resident to the bathroom. Moments later, the aide left the resident alone in the bathroom to assist another resident. At approximately 1 AM, the aide returned and observed the resident lying on the floor in the doorway of his bathroom. The resident was transported to the hospital due to possible head injury Per nursing assessment resident had altered level of consciousness per question number 5 (on the incident report form submitted to the State Agency). Question #5's response noted: The resident lost consciousness, suffered a skull fracture, facial fracture, C2 (second vertebra of the neck) fracture, confirmed closed head injury, lost blood resulting in lowered blood pressure or died as a result of the fall. The resident's Post Fall (nurse aide) Follow Up noted that the resident had a body and a bed fall safety alarm. The alarms were not noted as interventions on the resident's ADL Guide or nursing care plans, including an At Risk for Fall care plan initiated [DATE]. On [DATE] at 4:30 PM, when asked if the resident should have been left alone on the toilet, the Administrator and DON said, If residents have alarms, our practice is not to leave residents alone on the toilet. Resident #410- On [DATE] at 11 AM, resident #410 was observed lying in bed. The resident was unable to move the lower extremities when turned by a nurse that was in the room. The resident's feet appeared enlarged and deformed. There was a motorized wheelchair in the room used by the resident. At 11:30 AM, the resident's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS' completed [DATE] and [DATE] noted that the resident had moderate cognitive impairment, was non-ambulatory and required extensive two-person assistance for transfers. A Fall Risk assessment dated [DATE] noted a score of 5 (low risk for falls). At 4:50 PM, an incident report for the resident was reviewed with the Administrator and DON and noted, on [DATE]: Resident was being weighed and she stood up with the (nurse aide), went to turn to the weight chair and her knees gave out. She then went to the floor on her knees. There was no noted injury. At that time, the resident was to be weighed daily. The corrective action post fall: We changed her weights to weekly instead of daily to make it easier for the resident. When asked if this was an appropriate intervention to prevent reoccurrence of falls, the DON said, No, that's not the answer. She should have been a two-person assist. There should have been some staff education. Resident #420- On [DATE] at 9:30 AM, resident #420 was observed lying in bed on a sensor pad fall safety alarm mat with a personal body alarm (PBA) attached to his shirt. The resident had severe speech impairment and was unable to move the right side. The resident's clinical record was then reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident required extensive two-person assistance for transfers, bed mobility, was non-ambulatory and had moderate cognitive impairment. A PBA was ordered on admission and the sensor pad was ordered on [DATE]. The resident's Fall Risk scores on [DATE] and [DATE] were 11. Scores on [DATE], [DATE] and [DATE] were ,[DATE]. At 12:10 PM, incident reports for the resident were reviewed with the DON and revealed the following: On [DATE]-resident found on floor by bed; alarm did not sound; no noted injury. The DON explained that the resident's roommate announced to staff that the resident fell and said that the alarm was not on. There were no documented corrective actions to prevent reoccurrence. On [DATE]-resident on the floor by bed; no noted injuries; no mention of PBA sounding; sensor pad alarm implemented. On [DATE]-resident on floor by bed; no noted injuries. On [DATE]-resident on floor by bed; no noted injuries; alarms not sounding; The PBA had to be adjusted (the distance between the resident and the alarm control box was shortened). There was no documented reason why the sensor pad did not alarm. On [DATE]-resident on floor by the bed; no noted injuries; no mention of the alarms sounding; no corrective actions to prevent reoccurrence. On [DATE]-resident on floor by bed; no noted injuries; no mention of alarms sounding. The DON said, It (incident report) says alarms in place and functioning. The DON was informed that the resident had been seen lying in bed during the initial tour of the facility on [DATE] at 9 AM with the sensor alarm turned off. When a nurse was asked about the alarm, she entered the room and turned on the alarm, which was fully functional, but could not sound when turned off. On [DATE] at 8 am, per review of the facility's undated Falls and Fall Risk, Managing policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling The staff will identify appropriate interventions to reduce the risk of falls Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. On [DATE] at 5 PM, per review of the facility's Safety and Supervision of Residents policy dated [DATE]: (Facility) strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Implementing interventions to reduce accident risks and hazards shall include ensuring that ordered safety interventions are implemented and utilized as ordered Resident #409 On [DATE] at 9:00 a.m., R#409 was observed seated in a wheelchair with the left arm resting on a foam padded platform armrest. At that time when asked if he had any falls while in the facility, R#409 reported, Yeah, I've had a few. On [DATE] at 3:15 p.m., review of the clinical record revealed R#409 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE], R#409 had moderate cognitive impairment (score ,[DATE] on brief mental status exam), exhibited no behavior concerns, required extensive assistance of two people for transfers and bed mobility, required extensive assistance of one person for toilet use, and had no falls during this assessment period. Review of the care plans included, (Name of R#409) is at risk for falls R/T (related to) weakness r/t old cva and left sided hemiparesis, h/o (history of) falls, incontinent at times requiring assistance with transfers, dementia and the use of psychotropic medications. Start Date: [DATE]. Approaches identified for R#409 included: Follow transfer/ambulation recommendations per resident care guide. Start Date: [DATE] Do not leave alone in bathroom. Start Date: [DATE] Complete IDT (interdisciplinary) review of fall events and assess for further interventions. Start Date: [DATE] Not to be left alone in bathroom (due to) poor safety awareness. Start Date: [DATE] Review of the fall risk assessments identified R#409 was a high risk for falls on [DATE], [DATE], [DATE], and [DATE]. Review of the incident/accident reports provided since last survey for R#409 included: On [DATE] at 9:50 a.m., Called to res room per CENA (Certified Nursing Assistant - CNA I). Res lying on back next to nightstand. Res had been AMB (ambulating) from restroom with CNA I and res attempt to sit down before he was at w/c (wheelchair) and w/c moved causing him to fall. Right brake not closing properly . There was no documentation of the facility's investigation of whether the w/c was evaluated for proper function, or what interventions were reviewed or revised to prevent this issue from reoccurring. On [DATE] at 1:00 p.m., A family member of another res walked up to CENA (did not identify which CNA) in hallway and told her that res had fallen in the restroom. Upon arrival, res sitting upright with back up against the wall next to the toilet with R (right) knee bent .Resident's Description 'I was trying to walk over to the w/c and spun around and sat down.' 'I got sick of sitting here.' . There was no documentation of the facility's investigation following this fall available for review. On [DATE] at 2:30 p.m., obs (observed) laying on left side feet in front of toilet and his head laying on the wall (res self-transferred) - abrasion to L (left) breast fold .Sensor pad alarm applied to w/c and bed in them and due to alarms he cannot be in bathroom alone. There was no documentation of the facility's investigation following this fall available for review. Review of the interdisciplinary progress notes from [DATE] - [DATE] included: There were no progress notes which pertained to the fall on [DATE] available for review. On [DATE] at 10:23 p.m., .Up with standby assist .Neuro checks continued per protocol for fall earlier today on dayshift . On [DATE] at 6:08 p.m., Resident is alert with confusion at times .he was calling his wife a lot today and upset that she was not answering .Resident has asked for Tylenol today this AM for left rib pain from [DATE] fall it was given with relief, he has some small bruising on his rib area also, then this afternoon, he called requested to use the bathroom, (name of CNA L) put him o the bathroom with his right hand glove on as requested by R#409 and his urinal, when she came back he was observed laying on the floor on his left side in front of the toilet, head against the wall . On [DATE] at 11:50 a.m., an interview was conducted with the Director of Nursing (DON) to review R#409's falls which included: In regards to the fall that occurred on [DATE], when asked about the lack of investigation as to what the facility had done following the fall, the DON reported, The I/A (from [DATE]) was completed by the nurse manager - the policy is to address the incident report the next day. When asked why the investigation was not provided with the i/a reports, the DON reported, They are QA (quality assurance) protected. When asked how this information could be reviewed, the DON reviewed additional paperwork brought with her which were not included with the i/a reports. At that time the DON reported the facility had done a late entry for [DATE] on [DATE]. When asked about the delay in investigating the fall, the DON reported, We had staffing challenges, were without nurse managers for six months, and weren't getting to the incident reports. The DON was asked about whether the Physician had been notified of the fall since the i/a section of the form was blank for the physician and reported, There is no documentation as such, and it should've been. If no injury, staff notify via physician book to make aware and it doesn't look like it was done. Should've been here (pointed to blank Physician notification entry on the i/a form). When asked about whether the facility had evaluated the Resident's wheelchair at the time of the fall, the DON reported, It must've. The DON was asked if there was any documentation such as a work order to ensure it had been addressed, however there was no further documentation regarding work orders provided by the end of the survey. In regards to the fall that occurred on [DATE], when asked about the lack of investigation as to what the facility had done following the fall, the DON reported, This wasn't completed timely. When asked when it had been completed, the DON reported, Today (5 months after the fall occurred) upon pulling it, was made aware it wasn't completed. In regards to the fall that occurred on [DATE], when asked about the lack of investigation as to what the facility had done following the fall, the DON reported, Same thing. The investigation wasn't completed, just made aware today (5 months after the fall occurred). We had major education in May and August of expectation to complete the forms. The DON was unable to offer any further explanation as to the lack of investigation into the falls. On [DATE] at 11:46 a.m., Licensed Practical Nurse (LPN K) was attempted to be interviewed by phone, however there was no return call by the end of the survey. On [DATE] at 11:47 a.m., CNA I was attempted to be interviewed by phone, however there was no return call by the end of the survey.

THIS CITATION PERTAINS TO MI 325. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT ACCIDENTS AND PROVIDE APPROPRIATE SUPERVISION IN 1 OF 4 SAMPLED RESIDENTS (#501) WHO WERE AT RISK FOR FALLS, IN A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN hospitalization AND RIGHT HIP SURGERY WHEN RESIDENT #501 WAS FOUND ON THE BEDROOM FLOOR AND SUSTAINED A RIGHT HIP FRACTURE. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD DATED 1/20/12 REVEALED THE RESIDENT OF CONCERN WAS AN [AGE] year OLD MALE admitted to the facility on [DATE]. REVIEW OF THE physician's orders [REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #501 HAD SEVERE COGNITIVE IMPAIRMENTS AND REQUIRED ONE PERSON LIMITED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE FALL RISK assessment dated [DATE] REVEALED RESIDENT #501'S FALL RISK SCORES WERE 12 ON 10/6/11, 17 ON 1/3/12, AND 19 ON 1/13/12. THE ASSESSMENT REVEALED RESIDENT #501 WAS CONSIDERED A HIGH FALL RISK. REVIEW OF THE RISK FOR INJURY CARE PLAN DATED 6/24/11 AND UPDATED ON 1/18/12 REVEALED INTERVENTIONS INCLUDED TO ASSIST RESIDENT #501 WITH TOILETING NEEDS, CHECK ON RESIDENT #501 FREQUENTLY, AND MAKE SURE PERSONAL BODY ALARM (PBA) AND BED AND CHAIR SENSOR ALARMS FUNCTIONED PROPERLY. REVIEW OF THE POLICY AND PRACTICES IN-SERVICE DOCUMENT UNDATED REVEALED ALARMED RESIDENTS WERE NOT TO BE LEFT ALONE IN THE BATHROOM. REVIEW OF THE OCCURRENCE REPORT DATED 1/13/12 REVEALED ON/13/12 AT 1:30 PM, RESIDENT #501 WAS FOUND ON THE FLOOR OUTSIDE OF THE BATHROOM DOOR. IN AN INTERVIEW ON 1/30/12 AT 1:40 PM, CERTIFIED NURSING ASSISTANT (CNA) #4 REPORTED SHE WENT TO TOILET RESIDENT #502 AND HEARD A CALL LIGHT GOING OFF. CNA #4 REPORTED SHE LEFT RESIDENT #502 ON THE TOILET AND WENT TO ANSWER A CALL LIGHT. CNA #4 REPORTED SHE SAW RESIDENT #501 STANDING BY HIS ROOM'S DOOR AND HE STATED HE NEEDED TO USE THE BATHROOM. CNA #4 REPORTED RESIDENT #501'S SENSOR ALARMS DID NOT SOUND AT THAT TIME. CNA #4 REPORTED SHE SAT RESIDENT #501 ON THE TOILET AND LEFT HIS ROOM TO CHECK ON RESIDENT #502 WHO WAS AT RISK FOR FALLS. CNA #4 REPORTED SHE THEN HEARD A NOISE FROM RESIDENT #501'S ROOM AND OBSERVED HIM ON THE FLOOR OUTSIDE OF THE BATHROOM. CNA #4 REPORTED SHE IMMEDIATELY NOTIFIED REGISTERED NURSE (RN) #3. CNA #4 REPORTED SHE HAD CHECKED RESIDENT #501'S ALARMS AT THE BEGINNING OF THE SHIFT ON 1/13/12. IN AN INTERVIEW ON 1/30/12 AT 1:30 PM, RN #3 REPORTED SHE WAS CHARTING AT THE NURSE'S STATION WHEN SHE WAS NOTIFIED BY CNA #4 THAT RESIDENT #501 HAD FALLEN. RN #3 REPORTED SHE AND CNA #4 TRANSFERRED RESIDENT #501 BACK TO BED AND RESIDENT #501 WAS UNABLE TO STRAIGHTEN OUT HIS RIGHT LEG. RN #3 REPORTED SHE NOTIFIED FAMILY AND THE PHYSICIAN. RN #3 REPORTED THE PHYSICIAN ORDERED AN X-RAY FOR RESIDENT #501. RN #3 REPORTED SHE COULD NOT RECALL CALL LIGHTS GOING OFF AT THE TIME OF RESIDENT #501'S FALL. REVIEW OF AN X-RAY DATED 1/13/12 REVEALED RESIDENT #501 SUSTAINED A RIGHT HIP FRACTURE. REVIEW OF A NURSE'S NOTE DATED 1/13/12 REVEALED RESIDENT #501 WAS SENT TO THE HOSPITAL. REVIEW OF A HOSPITAL RECORD DATED 1/15/12 REVEALED RESIDENT #501 HAD RIGHT HIP SURGERY DUE TO A FRACTURE. IN AN OBSERVATION ON 1/30/12 AT 9:15 AM, RESIDENT #501 WAS IN THE DINING ROOM IN A WHEELCHAIR WITH A SPLINT ON HIS RIGHT HIP. ON 1/30/12 AT 2:30 PM, RESIDENT #501 WAS OBSERVED IN BED WITH THE PBA AND BED SENSOR ALARM IN PLACE AND FUNCTIONING. ( )