Every finding on record at Christian Care Nursing Center

This citation refers to Intake 3066198. Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 4 residents (R1) reviewed for abuse and/or neglect. Findings include: A review of R1's admission Record, dated 8/24/26, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed multiple diagnoses that included Alzheimer's Disease, dementia with behaviors, urinary incontinence, and activity limitations due to disability. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 6/8/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R1 was severely cognitively impaired. In addition, R1's MDS revealed they were dependent on staff (staff does all of the work and the resident cannot help) for toileting, needed substantial/maximal assistance (staff does more than half of the work by lifting/holding the body or limbs) to roll from one side to the next in bed, and needs substantial/maximal assistance for personal hygiene. A review of R1's Administration progress note, dated 6/29/26 for 6/19/26, revealed the facility reported an allegation to the State Survey Agency (SSA). However, the note did not indicate what type of allegation was reported. A review of the facility's 5-Day Investigative Report, dated 6/29/26, revealed on 6/17/2026, a 3rd shift aide, Certified Nursing Assistant (CNA) B, received report from CNA C (a 2nd shift aide) indicating all of her residents were dry and received care. CNA B entered R1's room at approximately 10:15 pm and noticed that R1 was soaked and laying in BM (bowel movement- stool). The facility indicated in the report that they terminated CNA C's employment after the investigation for poor resident care. A review of R1's functional mobility and activities of daily living (ADL's) care plan, dated 3/19/25 and revised on 6/9/26, revealed R1 needed the assist of one staff member for bed mobility and personal hygiene due to poor coordination, poor control of movements, and decreased cognition from Alzheimer's Disease. A review of CNA Cs typed and undated statement revealed during her shift she had last provided care to R1 on 6/17/26 at 9:15 PM. She stated that she had rolled R1 onto his side, changed his brief, put on a new brief, and repositioned him. CNA C also stated she gave shift report to CNA B and she left at 10:00 PM. A review of Registered Nurse (RN) E's typed and undated statement revealed on 6/17/26 right after she received shift report from Licensed Practical Nurse (LPN) D, CNA B came out of R1's room pushing a mechanical lift and stated, I found this next to [name of R1]'s bed, and he is a mess. RN E stated she and LPN D went into R1's room to assist CNA B. She stated R1's bed was soaked with urine, requiring a full bed (linen) change and a quick bed bath. RN E also stated R1 had dried stool between his butt cheeks and CNA B had to scrub his skin to get it clean. She stated R1 became angry as he was cleaned up. RN E also stated that R1 was still wearing his shirt from that morning which implied that R1 probably had not received care prior to bed. During an interview on 8/24/26 at 3:30 PM, LPN D stated she thought that CNA C had performed personal care on R1 before her shift ended. She stated apparently CNA C had gone into R1's room to do the care, left the room, and did not do the care. LPN D stated when the 3rd shift aide, CNA B found R1 wet and soiled she was told what had happened. She stated RN E went into R1's room with her and she saw that R1 was up against the rail. She stated R1 cannot move himself in bed and he was totally dependent on staff for bed mobility. She stated that based on what she saw they figured out that CNA C had rolled R1 onto his side and she had left him that way. LPN D stated that she could see that R1 was soaked with urine and his sheets were also soaked. She stated she did not see the stool on him because she had offered to help CNA B to clean R1 up, but RN E had said she would help CNA B clean up and change R1 and she could go home. During an interview on 8/24/26 at 4:10 PM, CNA B stated she normally comes to work at 10:00 PM for 3rd shift. She stated she would then start her rounds. CNA B stated on 6/17/26 the previous aide, CNA C, left as soon as she got there and did not give her any type of report. CNA B stated she went into R1's room sometime around 10:10 PM and she saw him lying on his side in a fetal position facing the wall. She stated she saw that he had his head against the rail. CNA B stated when she approached R1 she could see that his forehead was red and had an indent in it from the rail. She stated the arm that R1 was laying on was also discolored from laying on it. CNA B stated R1 was completely dependent on staff for bed mobility and care, so she knew the previous aide had left him that way. CNA B stated she could see that R1 was soaked from his waist, up his back, and to his shoulders. CNA B stated she then went and got the nurse and they changed R1. She stated when they removed R1's brief she could see that he had stool caked to his skin. She stated she had to scrub his skin to get it off and this caused R1 to become upset and combative. CNA B also stated she noticed that the urine on R1's sheets had started to turn brown and dry. She stated in her forty years of nurse aide experience she knew that when the urine starts to turn brown or darken on linens and stool is dry and caked to the skin and you have to scrub it off, it usually means neither is fresh and the resident had been wet and soiled for a long time- possibly hours. CNA B stated she and the nurse had to completely change R1's clothes and his bed linens after they washed him up. Finally, CNA B stated that as far as she was concerned CNA C had neglected R1 by not proving care to him. She stated leaving a resident wet and/or soiled, especially for an extended period of time where the stool dries and the urine changes to a dark color and starts to dry, was neglect. A review of R1's Weekly Skin Check form, dated 6/17/26 at 10:15 PM, revealed R1 had a small area of redness with indentation from assist bar on forehead. A review of CNA C's termination of employment letter, dated 6/29/26, revealed that the facility determined that her actions were inconsistent with the facility's core values and standards. The facility stated that some of her actions were specifically related to documented instances of inconsistent care involving allegations of abuse, neglect, or poor resident care. The letter further revealed that CNA C's actions were a violation of their organizational policies, code of conduct, and the ethical standards that are expected of all their employees who provide care in alignment with the facility's principles of dignity, respect, and integrity. A review of the facility's Abuse. Neglect and Exploitation policy and procedure, dated 7/1/21 and revised 4/3/26, revealed, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

This citation refers to Intake 3066198. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of neglect to the State Survey Agency (SSA) in accordance with section 1150B of the Act for one of four residents (R1) reviewed for abuse and/or neglect. Findings include: A review of R1's admission Record, dated 8/24/26, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed multiple diagnoses that included Alzheimer's Disease, dementia with behaviors, urinary incontinence, and activity limitations due to disability. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 6/8/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which revealed R1 was severely cognitively impaired. In addition, R1's MDS revealed they were dependent on staff (staff does all of the work and the resident cannot help) for toileting, needed substantial/maximal assistance (staff does more than half of the work by lifting/holding the body or limbs) to roll from one side to the next in bed, and needs substantial/maximal assistance for personal hygiene. A review of R1's Administration progress note, dated 6/29/26 for 6/19/26, revealed the facility reported an allegation to the State Survey Agency (SSA). However, the note did not indicate what type of allegation was reported. A review of the facility's 5-Day Investigative Report, dated 6/29/26, revealed on 6/17/2026, a 3rd shift aide, Certified Nursing Assistant (CNA) B, received report from CNA C (a 2nd shift aide) indicating all of her residents were dry and received care. CNA B entered R1's room at approximately 10:15 pm and noticed that R1 was soaked and laying in BM (bowel movement- stool). In addition, the report revealed the Director of Nursing (DON) was notified of the incident on 6/18/26 at 3:20 PM and the Nursing Home Administrator (NHA) was notified of the incident on 6/18/26 at 3:30 PM (approximately 17 hours after the incident occurred). A review of Registered Nurse (RN) E's typed and undated statement revealed on 6/17/26 right after she received shift report from Licensed Practical Nurse (LPN) D, CNA B came out of R1's room pushing a mechanical lift and stated, I found this next to [name of R1]'s bed, and he is a mess. RN E stated she and LPN D went into R1's room to assist CNA B. She stated R1's bed was soaked with urine, requiring a full bed (linen) change and a quick bed bath. RN E also stated R1 had dried stool between his butt cheeks and CNA B had to scrub his skin to get it clean. She stated R1 became angry as he was cleaned up. RN E also stated that R1 was still wearing his shirt from that morning which implied that R1 probably had not received care prior to bed. However, RN E's statement failed to reveal if she notified the DON and/or NHA of the incident. During an interview on 8/24/26 at 12:00 PM, the DON stated the incident happened on 2nd to 3rd shift on 6/17/26. She stated the 3rd shift aide had found R1 wet and soiled and had alleged that the 2nd shift aide left him that way. The DON stated she found out about the incident from Unit Manager (UM) F the next day (6/18/26). She stated she did not recall how she found out about it- whether UM F told her directly or mentioned it in the morning stand-up meeting. During an interview on 8/24/26 at 12:15 PM, UM F stated she came in on the morning of 6/18/26 and saw that CNA B had written a note to her about what had occurred on 6/17/26. UM F stated the note had been slipped under her office door. She said she immediately went to the NHA and DON and showed them the note. UM F stated all three of them agreed that the note described an allegation of abuse and/or neglect. During an interview on 8/24/26 at 3:30 PM, LPN D stated when the 3rd shift aide, CNA B, found R1 wet and soiled she was told what had happened. She stated RN E went into R1's room with her and she saw that R1 was up against the rail. She stated R1 cannot move himself in bed and he was totally dependent on staff for bed mobility. She stated that based on what she saw they figured out that CNA C had rolled R1 onto his side and she had left him that way. LPN D stated that she could see that R1 was soaked with urine and his sheets were also soaked. She stated she did not see the stool on him because she had offered to help CNA B to clean R1 up, but RN E had said she would help CNA B clean up and change R1 and she could go home. During the interview on 8/24/26 at 3:30 PM, LPN D stated she knew she should notify someone, but RN E had told her to go home, and she would take care of it. She stated she thought RN E would notify someone. LPN D stated she found out later that no one had notified the DON or the NHA about the incident until the next day. She stated she was told by management that since she was still in the facility when the incident was discovered then she should have called the DON to make sure it was reported. During an interview on 8/24/26 at 4:10 PM, CNA B stated on 6/17/26 she went into R1's room sometime around 10:10 PM and she saw him lying on his side in a fetal position facing the wall. She stated she saw that he had his head against the rail. CNA B stated when she approached R1 she could see that his forehead was red and had an indent in it from the rail. She stated the arm that R1 was laying on was also discolored from laying on it. CNA B stated R1 was completely dependent on staff for bed mobility and care, so she knew the previous aide had left him that way. CNA B stated she could see that R1 was soaked from his waist, up his back, and to his shoulders. CNA B stated she then went and got the nurse and they changed R1. She stated when they removed R1's brief she could see that he had stool caked to his skin. She stated she had to scrub his skin to get it off and this caused R1 to become upset and combative. CNA B also stated she noticed that the urine on R1's sheets had started to turn brown and dry. She stated in her forty years of nurse aide experience she knew that when the urine starts to turn brown or darken on linens and stool is dry and caked to the skin and you have to scrub it off, it usually means neither is fresh and the resident had been wet and soiled for a long time- possibly hours. CNA B stated she and the nurse had to completely change R1's clothes and his bed linens after they washed him up. Finally, CNA B stated that as far as she was concerned CNA C had neglected R1 by not proving care to him. She stated leaving a resident wet and/or soiled, especially for an extended period of time where the stool dries and the urine changes to a dark color and starts to dry, was neglect. During the interview on 8/24/26 at 4:10 PM, CNA B stated that she wrote her statement on a piece of paper and slid it under UM F's office door. She stated she thought the nurse would call the DON or NHA since her job was done by reporting it to the nurse and the nurse's job was to report it to the DON or NHA. CNA B stated she would not call the DON or NHA herself because that's the nurse's and nurse manager's job to report an allegation of abuse or neglect. A review of R1's Facility Reported Incident (FRI) details on the SSA'a reporting website, dated 6/29/26, revealed that the facility reported an allegation of neglect that had occurred on 6/17/26 at approximately 10:15 PM and was discovered on 6/19/26 at 9:00 AM (34.75 hours after incident) on 6/19/26 at 3:20 PM (over 6 hours after discovery and over 40 hours since the incident occurred). The FRI details also revealed that the 5-Day Investigation Summary was submitted to the SSA on 6/29/26 at 9:22 PM (over 6 business days after the incident was reported to the SSA). During an interview on 8/25/26 at 7:35 AM, the NHA insisted that he had reported R1's allegation of neglect on 6/18/26, not 6/19/26. After the NHA was notified that the SSA date/time stamps every submission and the FRI details in the SSA computer system indicated that he had reported the incident on 6/19/26 at 3:20 PM and his Investigation Summary was submitted on 6/29/26 at 9:22 PM (plus the FRI Submission Confirmation e-mail that the SSA sent him confirmed the reporting date and time), the NHA confirmed that he had reported the allegation to the SSA on 6/19/26, even though he had been made aware of the allegation on 6/18/26. The NHA further stated that if he can delay reporting an incident to the SSA until a Friday, then he will. He stated that if he reports something on a Friday (6/19/26 was a Friday), then that gives him an extra two days to submit a 5-Day Investigation Report since the 5-Day Investigation Report submission date was based on five working days (Monday through Friday from 9:00 AM to 5:00 PM), excluding holidays and weekends. He also stated that he tries to max out the time (use the full amount of time that he was allotted) to complete and submit his 5-Day Investigation Report. The NHA stated with allegations like this one (an allegation of neglect) he tries to report it within 24 hours or as close to it as possible after he is made aware of the allegation. He also stated that he always uses the full five days to submit his summary, and he always submits it by the deadline the State gives him in the system. However, he was unable to provide information on the deadline that the State gave him that would demonstrate his report could be submitted after the five working day deadline per the State Operations Manual. During a second interview on 8/25/26 at 10:40 AM, the NHA stated that slipping a note under a unit manager's office door (or his or the DON's) was not an appropriate way to notify them of an incident of abuse or neglect. A review of the facility's Abuse. Neglect and Exploitation policy and procedure, dated 7/1/21 and revised 4/3/26, revealed, Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. In addition, this policy revealed, 1. Reporting of all alleged violations to the Administrator, state agency, and other agencies as required, such as adult protective services and law enforcement when applicable within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The Administrator will follow up with government agencies during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies .

This citation pertains to intake 2727057.Based on interview and record review, the facility failed implement dietary orders and care plan interventions to ensure safety with evening snacks for 5 residents (R52, 33, 34, 44, 45), of 5 residents reviewed for eating safety.Findings include:R52Review of a Face Sheet revealed R52 admitted to the facility on [DATE] with pertinent diagnoses of acute respiratory failure with hypoxia (low oxygen), dysphagia (difficulty swallowing), and pneumonitis due to inhalation of food and vomit. R52 was cognitively intact.Review of the Physician orders revealed on 12/18/25 R52's diet was to be NPO (nothing by mouth)- PEG tube (percutaneous endoscopic gastrostomy tube) diet.Review of the Facility Reported Incident (FRI) submitted to the State Agency on 12/23/25 revealed on 12/20/25 at approximately 8:00 PM, Licensed Practical Nurse (LPN) U entered R52's room and noticed brown all over resident from brief to face. First thought was that it was stool. After entering closer with the light on I saw the pudding cup in his groin. First question I asked was [R52], what are you doing? Then I noticed the pudding cup looked like a velociraptor ripped it open. Majority of pudding was in his groin, you could tell he ripped the top open any way he could. I then asked if he ate any of the pudding, he smiled and states yeah. He admits he was not supposed to eat. He was assisted to be cleaned up. After, I heard coughing. His through (sic) sounded wet and he was unable to clear it. At this time, order received for stat (immediate) chest Xray.This resident is alert and oriented X3 at the time of the incident per nursing assessment.Review of a statement from the Dietary Aide (DA) V revealed she was doing snack cart rounds and he (R52) stated he wanted a pudding and (DA V) gave it to him.Further review of the FRI for R52 revealed he was admitted to the facility 2 days prior to the incident and expressed dissatisfaction with the inability to eat and had a hard time with his new NPO status. Staff were educated about providing food to residents with an NPO status and steps were taken to ensure residents with an NPO status moving forward would not be provided. The interventions did not address residents who would require supervision or cueing by staff for eating to avoid aspiration was not identified or addressed.Review of a Hospital Emergency Department note dated 12/21/26 for R52 revealed he went to the hospital with concerns of aspiration and was diagnosed with Aspiration pneumonitis. In an interview on 4/29/26 at approximately 9:00 AM, the Dietary Manager (DM) M reported DA V who provided R52 with a pudding cup no longer worked at the facility. DM M reported the Dietary Aides pass out evening snacks using a list that identifies each resident and their dietary needs. They update this list frequently. If a newly admitted resident is not on the list, the Dietary Aides check with nursing staff to confirm that resident's dietary needs before giving them an evening snack. The Dietary Staff were educated to not pass out snacks to Residents who were NPO.Review of the Dietary Resident list provided by DM M showed that several residents required supervision, 1:1 assistance, and had conflicting dietary needs or assistance among the orders, Kardex, and Dietary Resident list.R33Review of a Face Sheet for R33 revealed he was admitted to the facility on [DATE] with pertinent diagnoses of dysphagia and pneumonia.Review of the Physician Orders dated 4/9/26 for R33 revealed an ordered for 1:1 feeding assistance with meals and to use a cup and a straw for liquids.Review of the Eating and Nutrition portion of the Kardex for R33 revealed: Eating: I need supervision. No mention of needing a cup and a straw for liquids.Review of the Dietary Resident list used for passing out evening snacks revealed R33 required a mechanical soft diet with liquids in a cup with a straw but does not mention he requires supervision.R34Review of a Face Sheet for R34 revealed she was admitted to the facility on [DATE] and had pertinent diagnoses of dysphagia, morbid obesity and spondylosis (degenerative changes to spine).Review of the Physician Orders for R34 revealed on 1/12/26 an order for a regular diet with regular texture, nectar consistency, for aspiration. No straws, sippy cups.Review of the Eating/Nutrition Kardex for R34 revealed to Provide, serve Regular, Puree, Nectar Thick liquids diet as ordered. Monitor intake and record [every] meal. Assist 1:1 with meals. Use divided plate at meals to increase ease of getting food on utensils. No mention of straws or sippy cups.Review of the Dietary Resident list for passing out evening snacks revealed R34 in on a regular diet (not pureed). No mention of straws, sippy cups, or 1:1 assistance.Review of a Face Sheet for R44 revealed he originally admitted to the facility on [DATE] with pertinent diagnoses of abnormal posture, epilepsy, and malnutrition.Review of a Physician Order for R44 revealed an order dated 3/13/26 for Carb consistent diet, regular texture, thin consistency. Offer/encourage fruit instead of dessert.Review of the Eating/Nutrition Kardex for R44 revealed Eating: I need supervision.Review of the Dietary Resident list for passing out evening snacks does not show he needed supervision while eating.R45Review of a Face Sheet for R45 revealed she originally admitted to the facility on [DATE] and had pertinent diagnoses of dysphagia, dementia, and hemiplegia and hemiparesis (one-sided weakness.)Review of the Physician Orders for R45 dated 11/16/25 revealed an order for Regular diet, regular texture, nectar consistency.Review of the Eating/Nutrition Kardex for R45 revealed: Eating: [R45] requires supervision for eating and should be encouraged to have meals in the dining room. Provide, serve Regular, thin liquids diet as ordered. Monitor intake and record every meal. Resident to use divided plate to help with self-feeding related to low vision and decreased activity tolerance.Review of the Dietary Resident list used for passing out evening snacks by the dietary staff does not mention the need for 1:1 supervision or thin liquids.In an interview on 4/29/26 at 11:30 AM, the DON agreed that the information in the Physician Orders, the Resident Kardex, and the Dietary Resident List conflicted or lacked necessary details for residents with special needs or who required supervision. The DON acknowledged that the dietary staff could not address residents' special eating needs or supervision requirements and stated she would re-evaluate the practice of having Dietary Aides pass out snacks.

Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders and nursing professional standards of practice for 4 residents (Resident #2, #34, #23, and #53) out of 15 residents reviewed for medication administration.Findings:R53 Review of a Face Sheet revealed R53 admitted to the facility on [DATE] with pertinent diagnoses of hypertension (high blood pressure) and ventricular tachycardia (irregular heart rate in lower heart chamber). R53 is cognitively intact. During an interview on 4/27/26 at 9:02 AM, R53 was asked about the admission process to the facility and reported his medications were not available until very late. Review of R53's Medication Administration Record (MAR) showed that on 4/24/26 he had orders for the following medications: Atorvastatin 10 mg at bedtime — the dose was not given. Clonidine 0.1 mg twice a day for hypertension — the evening dose was not given. Pregabalin (Lyrica) 75 mg twice a day for pain management — the evening dose was not given. Review of R53's blood pressure readings showed the following: 4/24/26 at 4:20 PM – 154/75 4/25/26 at 7:13 PM – 171/98No blood pressure readings were documented between these times. During an interview on 4/28/26 at 10:04 AM, Registered Nurse (RN) A reported that many of R53's medications could have been pulled from the medication Pyxis if the pharmacy had not delivered them on time. RN A verified that the pharmacy delivered R53's medications before midnight, but staff did not administer them. RN 'A' stated there was sufficient time to give R53 his evening medications on 4/24/26 and stated the physician should have been notified if the medications were unavailable or not given. RN 'A' acknowledged the concern regarding R53's elevated blood pressure. In an interview on 4/28/26 at 10:30 AM, the Director of Nursing (DON) stated the nurse should have administered R53's medications on the night of his admission on [DATE] and confirmed that the pharmacy had delivered the medications. The DON explained that if the medications had not been delivered, the nurse could have obtained some of them from the medication Pyxis. She further stated that if any medications were unavailable or could not be given, the physician should have been notified. Resident #2 (R2) Review of an admission Record revealed R2 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R2's Order Summary dated 3/18/26 revealed, Toprol XL Oral Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth two times.Hold if SBP less than 100 or HR (heartrate) less than 60. To be administered in the morning and evening. Review of R2's Blood Pressure Summary and Pulse Summary from 4/1/26 through 4/27/26 revealed: On 4/3/26 the morning blood pressure and pulse were not assessed. On 4/5/26 the morning and evening blood pressure and pulse were not assessed. On 4/7/26 the evening blood pressure and pulse were not assessed. On 4/9/26 the morning and evening blood pressure and pulse were not assessed. On 4/10/26 the morning and evening blood pressure and pulse were not assessed. On 4/13/26 the morning and evening blood pressure and pulse were not assessed. On 4/15/26 the morning and evening blood pressure and pulse were not assessed. From 4/18/26 through 4/27/26 there were no morning or evening blood pressures or pulses assessed. Review of R2's April Medication Administration Record revealed that all doses of R2's Toprol were administered from 4/1/26 through 4/27/26 despite assessments of her blood pressure and pulse to ensure it was within the parameters to safely administer. During an interview on 04/28/2026 7:35 AM, Registered Nurse (RN) A reported that when the provider orders medications with parameters the vitals are to be assessed and documented prior to the administration. RN A reported that on the electronic medication administration record (EMAR) screen there is a heart icon to prompt the nurse to obtain the required/ordered assessment. When the heart icon is clicked, an additional screen opens for the nurse to input the assessment data. During an interview on 04/29/2026 at 1:54 PM, the Director of Nursing (DON) confirmed the licensed nurses had not obtained a blood pressure or pulse assessment prior to the Toprol administration for the above dates. The DON reported that the facility provider transcribed his own order for R2's Toprol and did not include the prompt to input vital signs. DON reported that when the licensed nurses transcribed orders for the providers, they would include the prompt to input vital sign data in order to prevent missed assessments. Resident #34 (R34) Review of an admission Record revealed R34 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R34's Order Summary dated 12/4/25 revealed, HYDROcodone-Acetaminophen (Norco) Oral Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Moderate pain. Review of R34's Controlled Substance Proof of Use form revealed: On 4/16/26 at 3:30 AM a Norco tablet was dispensed. On 4/18/26 at 11:00 PM a Norco Tablet was dispensed. Review of R34's Medication Administration Record revealed no documentation that the Norco dispensed on 4/16/26 or 4/18/26 was administered. Resident #23 (R23) Review of an admission Record revealed R23 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety. Review of R23's Order Summary dated 3/30/26-4/8/26 revealed, LORazepam Oral Tablet 0.5 MG (Ativan) Give 1 tablet by mouth every 6 hours as needed for Anxiety or agitation. Review of R23's Controlled Substance Proof of Use form revealed that on 4/3/26 a dose of Ativan was dispensed at 6:50 AM. Review of R23's Medication Administration Record revealed no documentation that the Ativan dispensed on 4/3/26 was administered. During an interview on 04/28/2026 7:35 AM, RN A reported that signing out a controlled drug happens at the time the pill is dispensed from the medication cart, further reporting that the date, time, amount dispensed, and the signature were to be documented in the narcotic book (located on the medication cart). Following the administration of the controlled drug, it is to be signed out of the EMAR to ensure providers and other nurses are aware of when the medication was last administered (to prevent the as needed medications from being administered too soon and for the providers to assess for adequate pain control). During an interview on 04/29/2026 at 1:54 PM, the DON reported that the expectation was for the licensed nurses to follow nursing professional standards of practice with medication administration which included the documentation of the administration of controlled drugs in the EMAR as well as on the Controlled Substance Proof of Use form. The DON reported she would be immediately reeducating the licensed nurses on medication administration. Review of the facility policy, Medication Administration last reviewed/revised 4/29/26 revealed, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation.20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. 21. If medication is a controlled substance, sign narcotic book.

This citation pertains to 2628080.Based on observation, interview and record review, the facility failed to prevent the physical restraint of 1 Resident (R200) out of 3 reviewed for restraints. Findings include:Review of a Facility Reported Incident (FRI) 5-day investigation reflected the incident occurred on 8/10/25 at approximately 8:30 AM. R200 was observed in the dining room with a gait belt around his waist and his wheelchair.R200A review of R200's admission Record, dated 9/25/25, revealed R200 was an [AGE] year-old resident initially admitted to the facility on [DATE] with multiple diagnoses that included Alzheimer's Disease and Dementia.A review of R200's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/19/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed R200 was severely cognitively impaired.During an interview on 9/26/25 at 9:27 AM, Registered Nurse (RN) D revealed that on the day of the incident the resident had been jumping up and down, he was wandering, agitated, combative, and had urinated on another resident's room floor. RN D stated she had given R200 his medication at the nurse's station and then walked him with his gait belt on and his wheelchair down to the dining room for breakfast. RN D stated staff had asked if they could leave the gait belt on R200 so they could assist him better to help prevent a fall. RN D stated it wasn't even 10 minutes later when CNA E asked if I had saw the gait belt on R200. I thought she meant around his waist, I had not seen it around the wheelchair until she brought it to my attention. The gait belt was around R200 and his wheelchair. I told the aides to take it off him immediately, because it was being used as a restraint. R200 seemed fine, he was just at the table eating breakfast. I then called and left messages for the DON and the Unit Manager (UM) J and reported what happened. I talked to the Nursing Home Administrator (NHA). RN D stated a skin assessment was completed on R200 with no concerns. She stated she had not talked to R200's family or physician about the incident. RN D clarified she had three aides in the dining room besides CNA E and none of them admitted to restraining R200 with a gait belt. RN D revealed she reported the incident because she considered it to be abuse.During an interview on 9/26/25 at approximately 3:00PM, CNA E revealed that she had been on light duty, so she came in at 8:00 AM that day and was told to go assist R200 because he was being combative. I went into the dining room, said good morning to him and saw the gait belt around him. I saw him from the front and thought he had it on for safety reasons. He was eating just fine by himself, so I left to grab some paperwork. When I came back, I noticed the gait belt was around him and his wheelchair. I went to RN D and asked if she knew that R200 had a gait belt on and that it was a restraint/abuse. RN D saw it on and told (CNA I) to take the gait belt off R200.During a phone interview on 9/25/25 at 2:59 PM, R200's wife (Wife A) revealed her husband has dementia. Wife A was asked if she had been notified about an incident that happened in the facility dining room during breakfast on 8/10/25 where R200 was found tied with a gait belt to his wheelchair. Wife A stated NO, and I would remember being told about that.During an interview on 9/26/25 at 12:13 PM, CNA I revealed, R200 was in a mood that day. I did not see a gait belt around the wheelchair; I was told about it but did not see it. He was having major behaviors that morning. He was not sitting in his wheelchair at all because he kept getting up. CNA I revealed she had been interviewed and had received education by administration because a Gait belt wrapped around the wheelchair (and resident) is considered a restraint and needs to be reported because it's a type of abuse. Review of Nursing Home Guide: Restraints education provided to facility staff from 8/22/25 - 9/16/25 revealed the following is considered a physical restraint, Lap belts, bed rails, locked chairs, wrist/ankle ties.

This citation pertains to intake 2628080.Based on observations, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act regarding reportable incidents for 1 Resident (Resident#200) of 4 residents reviewed for reporting. Findings include: A review of R200's admission Record, dated 9/25/25, revealed R200 was an [AGE] year-old resident initially admitted to the facility on [DATE] with multiple diagnoses that included Alzheimer's Disease and Dementia.Review of R200's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/19/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed R200 was severely cognitively impaired.Review of a Facility Reported Incident (FRI) 5-day investigation reflected the incident occurred on 8/10/25 at approximately 8:30 AM. (Name of R200) was observed in the dining room with a gait belt around his waist and his wheelchair. Further review of the report indicates the DON (Director of Nursing), Physician and Family were notified of the incident on 8/10/25 at 9:46 AM and the NHA (Nursing Home Administrator) was notified at approximately 10:00 AM. Law Enforcement was noted as Not Applicable (N/A). In addition, the FRI revealed the incident was reported to the State Survey Agency on 9/16/25 at 8:15 PM (37 days after the incident occurred).During an interview on 9/25/25 at 9:40 AM, the NHA stated, The incident on 8/10/25 had been reported late because of problems with the new system.During a meeting on 9/25/25 at approximately 1:11PM, Survey Manager (SM) K revealed she had not been notified by the facility (through email, phone call or text) that they were having problems reporting a FRI's.During an interview on 9/25/25 at 1:55 PM, NHA stated he got a call via the phone on 8/10/25 and someone reported to me about the gait belt being used as a restraint. When the NHA was asked if he reported the incident to the police he stated, No, was I supposed to? I guess I didn't look at it like it was abuse. Maybe I should have.During a second interview on 9/26/25 at 2:53 PM, the NHA stated I don't know why I didn't report [the incident timely]. I usually do report them. The NHA further stated that he did not notify Law Enforcement that a resident R200 was restrained in a wheelchair because he did not believe that it was reportable.A review of the facility's Abuse, Neglect and Exploitation policy and procedure, revised 6/25/2025, defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Further review of the facility's Abuse, Neglect and Exploitation policy and procedure, revised 6/25/2025, defined Willful means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm.A review of the facility's Reporting of Incidents policy and procedure, revised 2/2024, reflected, 3. A reasonable suspicion of a crime against a resident, possible incidents of abuse, neglect, mistreatment, exploitation, or resident property or injuries of unknown origin reported to the Administrator will be evaluated and the following will be considered when making a decision regarding reporting to the State Agency and Local Law Enforcement. a. Allegations involving alleged abuse must be reported immediately but not more than 2 hours after the allegation is made. c. Allegations not involving abuse or a reasonable suspicion of a crime without bodily injury must be reported no later than 24 hours after the allegation is made or suspicion is formed. d. Any reasonable suspicion of a crime against a resident will also be reported to the local Law Enforcement Agency in addition to the State Agency. Further review of the facility's Reporting of Incidents policy and procedure, revised 2/2024, reflected, 5. The Administrator will complete the 24-hour report via the online reporting system established by [Name of State Survey Agency]. The following statement was reviewed on the bottom of the first page NOTE: WHEN IN DOUBT AS TO WHETHER THE INCIDENT/OCCURRENCE IS REPORTABLE TO THE STATE AGENCY/LAW ENFORCEMENT AGENCY THE FACILITY SHOULD REPORT THE EVENT.

This citation pertains to intake 2628080Based on interview and record review, the facility failed to complete and report a thorough investigation for an allegation of abuse for 1 Resident (R200) of 3 residents reviewed. Findings include: A review of the facility's Abuse, Neglect and Exploitation, policy and procedure, reviewed/revised 6/25/2025, revealed Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Further review of the facility's Abuse, Neglect and Exploitation, policy and procedure, reviewed/revised 6/25/2025, reflects under section V, Investigation of Alleged Abuse, Neglect and Exploitation that A. An immediate Investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Review of a Facility Reported Incident (FRI) 5-day investigation reflected the incident occurred on 8/10/25 at approximately 8:30 AM. (Name of R200) was observed in the dining room with a gait belt around his waist and his wheelchair. Further review of the report indicates the DON (Director of Nursing) Physician and Family were notified of the on 8/10/25 at 9:46 AM and the NHA (Nursing Home Administrator) was notified at approximately 10:00 AM. Law Enforcement was noted as Not Applicable (N/A). In addition, the FRI revealed the incident was reported to the State Survey Agency on 9/16/25 at 8:15 PM.R200A review of R200's admission Record, dated 9/25/25, revealed R200 was an [AGE] year-old resident initially admitted to the facility on [DATE] with multiple diagnoses that included Alzheimer's Disease and Dementia. Review of R200's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/19/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed R200 was severely cognitively impaired.A review of R200's medical record failed to reveal any information related to the incident that occurred on 8/10/25.In an interview on 9/25/25 at 2:20 PM, R200's daughter (Daughter B) revealed she is usually at the facility visiting her father daily. During the interview she stated, No, I was not made aware of an incident where my dad was tied with a gait belt to his wheelchair during breakfast and I would remember if someone told me something like that. Daughter B further stated, My mom would have definitely told me about this (the incident).During a phone interview on 9/25/25 at 2:59 PM, R200's wife (Wife A) revealed her husband has dementia pretty bad. Wife A was asked if she had been notified about an incident that happened in the facility dining room during breakfast on 8/10/25 where R200 was found tied with a gait belt to his wheelchair. Wife A stated NO, and I would remember being told about that. I know they did not call my (oldest) daughter because she would have called me and her sister right away. During an interview on 9/26/25 at 9:27 AM, Registered Nurse (RN) D revealed that on the day of the incident the resident had been jumping up and down, he was wandering, agitated, combative, and had urinated on another resident's room floor. RN D stated she had given R200 his medication at the nurse's station and then walked him with his gait belt on and his wheelchair down to the dining room for breakfast. RN D stated staff had asked if they could leave the gait belt on R200 so they could assist him better to help prevent a fall. RN D stated it wasn't even 10 minutes later when CNA E asked if I had saw the gait belt on R200. I thought she meant around his waist. I had not seen it around the wheelchair until she brought it to my attention. The gait belt was around R200 and his wheelchair. I told the aides to take it off him immediately because it was being used as a restraint. R200 seemed fine, he was just at the table eating breakfast. I then called and left messages for the DON and the Unit Manager (UM) J and reported what happened. I talked to the Nursing Home Administrator (NHA). RN D stated a skin assessment was completed on R200 with no concerns. She stated she had not talked to R200's family or physician about the incident. RN D clarified she had three aides in the dining room besides CNA E and none of them admitted to restraining R200 with a gait belt. RN D revealed she reported the incident because she considered it to be abuse.

This citation pertains to intake 2628080Based on interview and record review, the facility failed to ensure the medical records for 1 of 3 residents (R200) was complete and accurate.Findings include:R200A review of R200's admission Record, dated 9/25/25, revealed R200 was an [AGE] year-old resident initially admitted to the facility on [DATE] with multiple diagnoses that included Alzheimer's Disease and Dementia.A review of R200's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/19/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed R200 was severely cognitively impaired.A review of the Facility Reported Incident (FRI) revealed the incident occurred on 8/10/25 at approximately 8:30 AM. [Name of R200] was observed in the dining room by staff with a gait belt around his waist and his wheelchair.A review of R200's Electronic Medical Record (EMR), dated 8/07/25 to 9/22/25, failed to reflect documentation (e.g., a progress note, a physician note, assessment) that indicated on 8/10/25 R200 was observed being restrained by a gait belt to his wheelchair while he was in the dining room eating breakfast.During an interview on 9/26/25 at 3:23 PM, the NHA (Nursing Home Administrator) revealed he did not see any documentation in R200's EMR that he had been being restrained by a gait belt to his wheelchair while he was in the dining room eating breakfast on 8/10/25. The NHA further revealed they had completed an incident report. A copy of the incident report was requested from the NHA.A review of R200's incident report, dated 8/10/25 at 9:39 AM, revealed, It was reported to me [Unit Manager (UM) J] via Phone by nurse [Name of RN D] that resident had been progressively combative over the weekend peaking on Sunday, hitting, kicking, walking in the hallways and urinating, staff assisted him to a wheelchair and he was attempting to get out of w/c and hit staff. He was assisted to the dining room to eat and that is when it was observed by [Name of CNA E] that there was a gait belt around the resident's chair. In addition, the following statement on bottom of page one of the incident report revealed, Privileged and Confidential - Not part of the Medical Record - Do not Copy.

This citation pertains to intake 2572210.Based on interview and record review, the facility failed to report verbal abuse and intimidation from a staff member to the State Agency for 1 Resident (Resident #2) of 3 residents reviewed for reporting. Findings include:Resident #2 (R2)Review of Resident #2's admission Record revealed R2 was a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses of Sepsis, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and major depressive disorder. A review of the facility's Abuse, Neglect and Exploitation policy and procedure, revised 6/25/2025, defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or an enabled through the use of technology.During an interview on 8/12/25 at 2:27 PM, the NHA (Nursing Home Administrator) was asked to provide any incident, accident, concern or grievance forms that were generated for R2 during the resident's stay. The NHA revealed he only had one form involving the resident for an incident on 7/20/25. Review of R2's incident report form revealed #2804 Alleged Abuse dated 7/20/2025 at 8:40 AM. The report was for an incident that occurred in R2's room and it was prepared by the DON (Director of Nursing).During an interview on 8/12/25 at 2:27 PM, the NHA revealed that they had not reported the incident to the State Agency and that the DON would need to provide any further information. Review of R2's #2804 Alleged Abuse report under Resident Description revealed, R2 had an interaction with CNA B (Certified Nursing Assistant) and felt the aide had an attitude towards her because she did not want to get out of bed and CNA B said that makes her job more difficult and that was not appropriate for her to say to R2. The report also reflected that CNA B came back to R2's room again after being asked not to and stood with her hands on her hips and was speaking loudly.Further review of #2804 Alleged Abuse report reflected LPN C (Licensed Practical Nurse) was made aware of how she (the resident) felt, and LPN C removed CNA B from her section and CNA I took over. When LPN C spoke with the resident the resident stated that not working with CNA B was a good intervention. LPN C asked if she felt safe and R2 stated she does as long as CNA B doesn't care for her. Further review of the report revealed an investigation was conducted. The report contained interventions, and interviews with staff, family and residents.During a phone interview on 8/13/25 at 11:44 AM, Certified Nurse's Aide (CNA) I revealed, she went into (R2's) room for something and R2 was upset and teary. CNA I stated R2 was emotional, was upset and did not want CNA B coming back into the room. CNA I' told her she would just help take care of her for the rest of the day. She stated the nurse went in behind her and talked with her and she took care of R2 the rest of the day. During an interview on 8/12/25 at 1:39 PM, LPN C revealed that R2 had told her one of girls had told her she was making their job harder. LPN C stated she switched out CNA B for CNA I. LPN C further revealed that R2 would not tell her about her hurt feelings. During an interview on 8/12/25 at 1:43 PM, CNA B stated the resident (R2) told her to leave her alone she was tired. CNA B revealed she went back in to get her up for breakfast and the resident refused. She went back in again after breakfast and R2 did not want to get up because she was still tired. CNA B stated she had to get R2 cleaned up because she was soaked and that she ended up putting a brief on her because when she is in bed she can soak through everything. CNA B revealed she then went back into R2's room after her care to give her water, and she was crying. She (R2) kept saying I'm tired, can't you understand. CNA B stated she was told by another aide that R2 did not want her back in her room but that she went back to drop off a condiment that was missing on R2's lunch tray and R2 told her to get out because she wasn't supposed to be in her room.During an interview on 8/13/25 at 12:32 PM, Ombudsman J confirmed that she had received a call/complaint from the resident about an incident that happened in the building but was unable to connect with R2. During an Interview on 8/13/25 at 3:44 PM, R2's Sister L revealed R2 was currently in the hospital. When asked if she knew of an incident that happened back in July involving an aide. R2's Sister L stated she came up to the building on that day because her sister called her because she was afraid. R2 had told her that someone had come in and tried to get her up and dressed at like 5:00 in the morning on the weekend and that R2 told the aide she was not getting her up. R2 then revealed to her sister that the next aide came in and was upset because she (R2) made more work for her because she would not get up and then the aid yelled at her for wetting the bed and not getting up. R2's Sister L further stated the nurse did give her a different aide to help her out for the rest of the day. However, the aide (CNA B) that yelled at her still came in several times and intimidated her sister during her shift for making her job more difficult and reporting her. One of the times the aide came in was during breakfast/lunch. The aide shut the door so no one could hear my sister yelling for help because the other staff were assisting other residents with their meal. R2's sister stated R2 said the aide had her hands on her hips wanting to know why she reported her and why she was making her job harder. and that (R2) was very frightened of this aide (CNA B). R2's Sister L further revealed that R2 called in a complaint to the Ombudsman.On 8/13/25 at 2:43 PM, Licensed Practical Nurse (LPN) M revealed she was aware of the incident involving R2 and CNA B. When I was taking R2's blood sugar outside at dinner time she asked me if I had heard of the saga. R2 told me that it (the incident) happened early in the morning because she wanted to sleep-in. She told the aide several times she was tired and did not want to get up. She told me CNA B said she was making her job hard/difficult, and she wanted to know why she was ruining her day. (Name of R2) also told me her aide had been very aggressive with her brief change and was upset because everything was wet. (Name of R2) was very upset and teary. She said it happened early in the morning, and she thought the aide was going to hurt her. R2 revealed that CNA I had told her to yell if CNA B went back into her room. R2 told me she had yelled for help during breakfast when CNA B came back in, but the staff could not hear her because CNA B shut the door. LPN M stated the incident happened on the weekend, and that she called/reported the incident right away to the DON. LPN M further revealed that the DON did not talk to the resident until Monday. LPN M was asked why she reported it. LPN replied because it was emotional abuse and R2 was upset about it for days. During an interview on 8/13/25 at 1:45 PM, DON stated the resident seemed to be in a mood that day, and as the day went on, she became more worked up and teary. Resident had a room across from the nurse's station and LPN C had heard the resident yelling at CNA B. LPN C went in and removed CNA B and told the resident she would have CNA I take over her care. Resident thought not having CNA B for an aide was a good intervention. A second shift nurse reported the 1st shift aide told the resident she made her job harder. DON stated that based on LPN C's assessment she did not feel it was reportable. DON revealed the resident had stated to me, she had her hand on her hips and told me, You make my job harder. The DON confirmed she had completed an Alleged Abuse report for the resident; however, she did not think this situation was abuse so she didn't report it,

This citation has two Deficient Practice Statements DPS A Based on observations, interviews and record review, the facility failed to meet standards of care for infection control related to tracking and trending employee/resident illnesses, maintaining up to date infection control policies and procedures, practicing appropriate hand hygiene for 3 residents (R1, R4 and R25) of 3 residents reviewed for care, and medication storage in 1 of 2 medication storage rooms. Findings included: During the infection control task interview with Infection Preventionist (IP) K on 3/27/25 at IP K she does not track or do anything with employee illnesses. IP said they had a COVID outbreak in September 2024, and she did not have any data on employee sick calls for absences in September 2024. IP K verified she did not have a way to track all sources of outbreaks without monitoring employee illness. Review of the facility September 2024 Facility Infection Tracking Report revealed that they had 3 Residents positive for COVID. Review of the facility Infection Surveillance Policy dated reviewed/revised 1/1/2024 (over one year since review) revealed, Infection surveillance refers to an ongoing systematic collection, analysis, interpretation and dissemination of infection-related data. 6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including .ii Observations of staff including the identification of ineffective practice, if any; 10. Employee, volunteer, and contract employee infections will be tracked, as appropriate such as influenza or gastrointestinal infections outbreaks. Review of the facility Influenza Education and Immunization Policy was dated devised: 5/2/2010. Review of the facility Pneumococcal Vaccinations Policy was dated 7/28/2016. During an interview with the Nursing Home Administrator (NHA) on 3/27/25 at 2:18 PM, the NHA was informed that the infection control policies that were provided were all more than a year old and some were several years old. The NHA said he would look into it. Upon exit no new infection control policies were provided. 37573 Hand Hygiene and Used Supplies Storage Resident #1 (R1) Review of a policy titled Non-Sterile Dressing Change last revised 5/2019 revealed: Designated staff members will use non-sterile dressing techniques for all dressing changes unless otherwise indicated by physician or manufacturer guidelines. Clean aseptic technique should be used. In the event of multiple wounds, each wound is considered a separate treatment. 4. Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare work surface. Optional: Cover work surface with clean dry paper or cloth towel, to prevent contamination of supplies. 10. Remove soiled dressing, place it in trash bag. 11. Remove gloves, wash hands, apply new gloves. During an observation and an interview on 3/26/25 at 11:23 AM, Licensed Practical Nurse (LPN) T had R1 transferred to bed for a pressure ulcer dressing change and placed the wound dressing supplies on a table beside the bed with no barrier and did not clean the table. R1's brief was saturated with urine and soaked through her brief with an extra liner, her pants, the transfer sling, and her cushioned wheelchair. Peri care was provided after the pressure ulcer dressing change. The nurse removed the old dressing from R1's sacrum which was packed with gauze. LPN T used the same gloves to remove the old dressing and the gauze from her packed wound which was saturated with serosanguinous drainage. With the same gloves that removed the old dressing, LPN T cleansed the wound and packed it with gauze soaked in Dakins solution with her soiled glove via her finger. An antifungal cream mixed with a zinc-based cream was applied to the surrounding area of the wound, then an ABD (abdominal pad) was applied over the packed wound and adhered with hypafix tape. LPN T then changed her gloves post wound care to assist with peri care. At this point Certified Nursing Assistant (CNA) F provided peri care for R1 and used the same gloves that touched a urine-soaked brief, soaked clothing, a soaked transfer sling, then provided pericare to then apply a clean brief and clothing, and placing a new transfer sling under the resident. Then CNA F removed her gloves and lifted her Enhanced Barrier Precautions gown to reach in her pocket for new gloves. No hand hygiene was performed until after the resident was transferred back to her chair via Hoyer lift. In an interview on 3/26/25 at 11:57 AM, LPN T was questioned about hand hygiene and changing gloves during wound care. LPN T then replied, I don't know but I am guessing you think I should have changed my gloves? In an interview on 3/26/25 at 12:01 PM, CNA F reported that she is aware that if her gloves are wet or soiled, she should have changed her gloves and agreed that the urine saturated brief is dirty, and she should have changed her gloves. In an interview on 3/26/25 at 2:03 PM, the Director of Nursing (DON) reported that changing gloves and performing hand hygiene during wound care after removing the old dressing would depend on if the gloves are visibly soiled. The DON then reported R1's dressing is not a sterile one and R1's germs are her own germs, and did not see the concern of using the same gloves throughout. The DON would expect wound care supplies to be placed on a cleaned table or a table with a clean barrier. When queried about changing gloves and hand hygiene during pericare with a urine saturated brief, the DON reported she never heard of that before and would expect staff to change gloves if they were visibly soiled. When asked if urine is dirty, she reiterated that unless hands/gloves are visibly soiled, there is no need to change gloves. In an interview on 3/26/25 at 2:22 PM, Registered Nurse (RN)/Infection Control Nurse K reported that for wound care, a cleaned table or a barrier for supplies should be set up and hand hygiene should be done. New gloves and hand hygiene should be done after removing old dressing. Left over wound care supplies in the residents' room should not be taken to the cart. When asked about changing gloves during peri care when moving from dirty to clean surfaces, RN K reported she never heard of that and gloves should only be changed if visibly soiled with stool and since urine is clear, there was no need to change gloves and perform hand hygiene during care. RN K reported she follows the Centers for Disease Control (CDC) information and guidance. In an interview on 3/27/25 at approximately 9:00 AM, the DON walked down the hall and told this surveyor she will eat crow because gloves and hand hygiene should be done after removing a soiled dressing. When asked about during peri care, the DON reported that unless hands are visibly soiled there is no need to change gloves during care. Resident #4 (R4) During an observation on 3/26/25 at 10:46 AM, LPN T gathered wound care dressing supplies out of the wound cart and took them to R4's room and placed them on the uncleaned bedside table with no barrier. Old dressing was removed from the wound on R4's toes and the new treatment/dressing applies with the same gloves and no hand hygiene. When LPN T completed care, she took the left-over supplies that included mupirocin, calcium alginate in the opened wrapper, and opened gauze back to the wound care cart. Resident # 25 (R25) During an observation and an interview on 3/26/25 at 11:11 AM, LPN T gathered wound care supplies and took them to R25's room and placed them on an uncleaned table with no barrier. After LPN T provided wound care, the scissors she used fell into the trash can and she pulled them out and took the scissors, along with other opened left-over supplies out of the room and placed them into the wound care cart. When questioned about the supplies LPN T reported the supplies are not resident specific and are multi use for all residents. When asked about the scissors, LPN T reported she forgot to clean them and pulled them back out of the drawer and cleaned them with sanitizing wipes. Review of a policy titled Hand Hygiene last revised 1/1/24 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table: Condition: Hands are visibly dirty, hands are visibly soiled with blood or other bodily fluids, . After handline contaminated objects, . Before applying and after removing personal protective equipment (PPE), including gloves, . Before and after handling clean or soiled dressings, linens, ect. Before performing resident care procedures, After handling items potentially contaminated with blood, body fluids, secretions, or excretions, When, during resident care, moving from a contaminated body site to a clean body site, After assistance with personal body functions (e.g., elimination .) Review of the Clinical Safety: Hand Hygiene for Healthcare Workers. Clean Hands, Centers for Disease Control, 27 Feb. 2024, www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, accessed 27, Mar. 2025 revealed: KEY POINTS: Protect yourself and your patients from deadly germs by cleaning your hands. All healthcare personnel should understand how to care for and clean their hands. Why it matters: Hand hygiene protects both healthcare personnel and patients. Recommendations: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task . Before moving from work on a soiled body site to clean a body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, bodily fluids, or contaminated surfaces. Immediately after glove removal. Review of a policy titled Non-Sterile Dressing Change last revised 5/2019 revealed: Designated staff members will use non-sterile dressing techniques for all dressing changes unless otherwise indicated by physician or manufacturer guidelines. Clean aseptic technique should be used. In the event of multiple wounds, each wound is considered a separate treatment. 4. Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare work surface. Optional: Cover work surface with clean dry paper or cloth towel, to prevent contamination of supplies. 10. Remove soiled dressing, place it in trash bag. 11. Remove gloves, wash hands, apply new gloves. Medication Storage Room During an observation and an interview on 3/27/25 at 8:35 AM, the medication storage room on the Love Unit had a refrigerator with medications stored in it along with a urine sample that belonged to a newly admitted resident at the facility. Licensed Practical Nurse (LPN) T reported the urine sample should not have been stored in the medication refrigerator for infection control purposes. Review of a policy from the pharmacy titled Medication Storage in the Facility last revised 1/2018 revealed: G. Potentially harmful substances such as urine test reagent tablets, household poisons . are clearly identified and stored in a locked area separately from medications. 38905 DPS B Based on interview and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During an interview with Maintenance Director S regarding the facilities Water Management Plan (WMP), at 1:40 PM on 3/25/25, it was found that no annual review had been completed on the plan. When asked when the last time members of the Water Management Team met to discuss the plan, MD S was unsure, When asked who was a part of the WMP team, MD S stated he was unsure and that he is the one that carries out the tasks for the plan which includes taking free chlorine samples, flushing stagnant lines, and having dead end lines removed (over the last year). When asked if there was a control limit for free chorine in the water supply, MD S was unsure. A review of the facilities WMP binder, found no completed CDC toolkit. A record review of the facility document entitled Water Management Program, copyright 2017, under the headline Water Management Team it was found that The water management team is an interdisciplinary team composed of dedicated professionals who represent multiple facets of resident care at Christian Care Nursing Center. The team is charged to facilitate a program focused on the safety of the building water systems and devices across the care continuum by providing vision and direction for water systems management within the facility. The water Management Team will work collaboratively to identify and implement strategies for improving the management and efficiency of the facility's water systems. This committee will be empowered to address all aspects of water systems at Christian Care Nursing Center, including: detecting, monitoring process improvement, quality, Legionella prevention and staff education, as well as control measures and corrective actions. The policy goes on to state that The primary focus of the Water Management Team is to ensure that residents have the safest and sanitary environment based on best practice processes throughout their continuum of care Establishment of a Water Management Team. The Team will meet routinely on a quarterly basis. The meetings to assess aspects of the water management such as implantation of engineering controls as needed, water quality testing as needed, water pressure, scald control, any results from water testing for Legionella, whether any engineering controls were not within specified limits and why that may have occurred, whether any corrective actions were taken on engineering controls and whether there have been any cases of Legionella diagnosed at or potentially associated with the facility .Conducting an annual review of water management program and updating as necessary.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, at 9:40 AM on 3/25/25, and interview with Certified Dietary Manager (CDM) R found that the facility rarely cools down food from service or makes large meals in advance that require a cooling and reheating step before being served. Observation of the walk-in cooler, at 9:42 AM on 3/25/25, found a six inch deep quarter pan of gravy dated 3/24/25. At this time, a temperature of the gravy was found to be 42F. Further observation of the walk-in cooler found two ambient air thermometers that read 35F and digital thermometer of the unit also read 35F. A product temperature of a container of mushrooms was found to be 35F. At this time, it was asked if the facility maintains a cooling log, CDM R provided a log entitled HACCP Cooling Log which had two of four cooling entries completed. The first completed entry was a Roast Beef logged on 1/7. The log stated that the item was 131F at 5:00 PM and was 79F at 7:00 PM. The second completed entry was Turkey on 2/15. The log stated the Turkey was 132F at 5:30 PM and was measured at 88F at 7:30 PM. A review of the logs instructions found that staff should Record corrective actions taken, if applicable. The supervisor of food operation will verify proper cooling procedures by routinely monitoring work activity and reviewing this log. Cooling Guidelines - Cooked time/temperature control for safety foods will be cooled: (a) From 135F to 70F within 2 hours. When asked if any of the improperly cooled food was served to residents, CDM R was unsure. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During a tour of the preparation area, at 9:49 AM on 3/25/25, a sanitizer bucket of quaternary ammonium was tested and found to be well over the 200-400 parts per million (ppm) that is required for its concentration. When asked what the concentration usually is, CDM R stated they normally find it around 300 ppm. At this time the bucket was dumped and a new sanitizer bucket from the three-compartment sink was dispensed. Once tested , with the facility provided QT-40 test strips, it was found that the concentration was over the 500 ppm maximum on the test strip. When asked if they had anyone out working on the chemical dispenser, CDM R stated they had not. According to the 2022 FDA Food Code section 7-204.11 Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P, or (B) Meet the requirements as specified in 40 CFR 180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. An interview with CDM R, at 9:53 AM on 3/25/25, found that clean pans are stored under the preparation table, it was observed that one shallow half pan was found stacked and stored with stuck on food debris. Observation of the juice gun, at 9:57 AM on 3/25/25, found increased accumulation of debris on the spout once the cap was taken off. An interview with CDM R found that staff clean the juice gun nightly and soak it. When asked if they ever take the spout off and wipe away the inside, CDM R was unsure. An interview with CDM R, at 10:03 AM on 3/25/25, found that staff don't use the meat slicer much anymore, but the mixer gets used three or four times a week. At this time, observation of the meat slicer found dried meat shavings at the top backside of the blade and the underside of the mixer was found with increase accumulation of dried cake debris and splatter. During an observation of the Love kitchenette, at 10:33 AM on 3/25/25, it was observed that the top gasket on the refrigeration unit was found with an increased amount of black spotted accumulation. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a tour of the dry storage room, at 10:18 AM on 3/25/25, it was observed that a open half full container of soy sauce was found stored on the bottom shelf of the dry storage room. A review of the manufacturer's directions found the container states Refrigerate After Opening. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less.

Based on observations, interviews and record review, the facility failed to follow policies and procedures to accurately assess, monitor and treat/improve pressure ulcers for 2 Residents (R1, and R350) of 4 Residents reviewed for pressure ulcers. Findings included: R350 Review of R350's face sheet dated 3/26/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE], her diagnoses included: acute kidney failure, chronic kidney disease, dysphagia (difficulty swallowing), osteomyelitis (bone infection), and vascular disease. She was her own responsible party. Review of R350's admission skin assessment dated [DATE] and locked on 3/21/25 revealed that R350 had a stage 1 ulcer on her gluteal clef that measured 3.4 x 2 x 0.3. there was no mention of any skin issues on R350 thighs or other areas of her buttock. Review of R350's admission skin assessment dated [DATE] at 16:36 (4:36 PM) and locked on 3/27/25 (during the survey) revealed R350 had a stage 3 pressure ulcer on her coccyx that measured 3.7 x 1.3 x .3 and indicated that her right and left thigh (front) were excoriated. No mention of open areas in the excoriated area. R350 was observed on 3/25/25 at 10:10 AM in bed on her back with the head of her bed elevated about 20 degrees. R350 did not respond to calling her name. R350 was observed sleeping on her back in bed on 3/26/25 at 8:20 AM. R350 was observed in bed on her back with the head of the bed elevated about 45 degrees on 2/26/25 at 10:00 AM. R350 was complaining of severe butt pain. R350 was not able to operate the bed controller and reported she was not able to shift her weight or roll in bed. R350 said staff do not roll her in bed. R350 was assisted with her call light to get staff assistance. R350 was observed in bed on 3/26/25 at 10:45 AM. R350 was still in the same position she was in at 10:00 AM. R350's Physician B was in the room. The Surveyor expressed concern over the lack of turning and positioning. Physician B said he would follow up with the staff. On 3/26/25 at 11:00 AM, Licensed Practical Nurse (LPN) D and Certified Nurse Aide (CNA) M changed R350's brief. The brief was soaked and full of loose bowel movement (BM). The BM covered the buttock and no dressing was visible. CNA M said there was gauze on R350's buttock, and she wiped it off with the disposable wipe and put it in the trash. R350 cried out in pain with the brief change and clean up. R350 had a wound on her coccyx area that was approximately 1.5 inches by .5 inches and open another open area that was approximately 1/4 in diameter on her right upper buttock. R350 had about 10 other open, weeping areas approximately 1/4 in diameter on both inner thighs. LPN D said she did not see a treatment in the system for these wounds so she would need to see if the treatments are listed on another shift. CNA M said she had been assigned to R350 since 6:00 AM this morning. CNA M reported that was R350's first brief change and she had not repositioned R350 as she was not on a turning schedule. R350 required assistance of 2 people to turn for the brief change. (5 hours without a brief change or repositioning) On 3/26/25 at 11:19 AM the Director of Nursing (DON) came in the assist LPN D and CNA M with R350. The Surveyor explained that CNA M indicated that she had not repositioned R350 today because she was not on a turn schedule. The DON responded it was standard of care to reposition residents every 2 hours if they are not able to turn independently. The DON helped LPN D reposition R350 on her right side (Assist of 2 people). R350 continued to cry in pain and reported the painful area was her butt. Review of R350's Kardex (nurse aide care information) dated 3/26/25 revealed R350 needed extensive assistance of 2 people for bed mobility, and she required reposition/shift weight to reposition frequently. During an interview with the DON on 3/26/25 at 12:27 PM, R350's nursing admission skin assessment dated locked 3/21/25 was reviewed and it only showed one ulcer on her gluteal clef that measured 3.4 x 2 x 0.3 and it was noted as a stage 1. The DON said she assisted the nurse that did this assessment on the day of admission and the DON said she would have staged the wound in the coccyx area as stage 2 and she saw a total of 6 stage 2 ulcers. The DON could not locate any notes in R350's medical record that matched her memory of the admission assessment for R350. The DON said she had the information somewhere on a note. She looked through her piles of notes and could not locate any written skin assessment for R350 dated 3/20/25. The DON reported she is doing education for accurate skin assessments. I reported that I observed 2 open areas on the buttock and at least 10 open areas on her inner thighs. The Surveyor requested R350's hospital records as they had not been placed into R350's medical record. The DON had access to hospital records on her computer. The DON reviewed the hospital records for R350 and the hospital had documentation reporting R350's pressure ulcer on her coccyx was a stage 3 and they did not document any other open areas on the buttock or thighs. On 3/27/25 at 9:30 AM, Physician B saw the Surveyor in the hall and asked if R350 was being positioned off her butt today. The Surveyor reported that when she saw R350 today, she was still on her butt and the assessments completed last night did not reflect the observations made yesterday. Physician B went to his office and called Nurse Practitioner (NP) A after he reviewed her documentation from 3/24/25. Physician B said NP A would be in today to assess R350 and order her wound care. Physician B said he and NP A just need to hit send on her notes, and they go to the printer in the administration office. We went to the printer, and Physician B handed me his note. The Nursing Home Administrator (NHA) was at the printer. The NHA confirmed that they were not having any problems with getting the NP A's notes or Physician B's notes. The Surveyor informed the NHA that R350 NP A notes were still not in her medical records. During an interview with the DON on 3/27/25 at 10:44 AM, the DON said she located an order for R350's coccyx wound dated 3/25/25 (5 days after admission). The DON reviewed the surveyors screen for orders in R350's electronic medical records (EMR) and confirmed that the surveyor did not have that information. The DON could not locate wound treatments for R350's coccyx pressure ulcer prior to 3/25/25. The DON reported that all other open area's on R350's buttock and thighs were excoriation. The DON said they do not count, or size open weeping areas that are excoriated. The DON was not able to explain how they are able to determine if the excoriated area was improving or declining if they did not document any description or indicate the skin was open. The DON did not have any response. During an interview with NP A on 3/27/25 at 11:45 AM, NP A said she had assessed R350 on 3/24/25 and R350 only had the stage 3 ulcer on her buttock area. NP A said all the other open areas were a rash and they were not present on 3/24/25. NP A said she ordered a new treatment for the rash. The NP said the rash was most likely due to R350 having loose stools and she was also started on bowel medication today. Review of R350's Treatment Administration Record (TAR) dated March 2025 revealed, Multiple Wounds: All stage 2 Posteriorly - BL (bilateral thigh fold, Left inner buttock 3/24/25. Anteriorly - BL (bilateral) upper thigh fold near groin. Cleanse with normal saline, pat dry and apply hydrocolloid dressings to each wound. Change every 3 days, sooner if soiled. Started 3/21/25 and discontinued on 3/24/25. It was only marked as completed on 3/21/25. This same order was noted on the March TAR as starting and ending on 3/25/25 and marked as completed on 3/25/25. No wound care order was found on the March 2025 TAR for R350's coccyx stage 3 pressure ulcer. 37573 Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] with pertinent diagnoses of Wedge compression fracture of first lumbar vertebra, morbid obesity and a stage III sacral pressure ulcer. Review of the Minimum Data Set (MDS) dated [DATE] for R1 revealed she is at risk for pressure ulcers and had one stage III pressure ulcer. She has limited range of motion (LROM) with impairment to bilateral lower extremities and dependent on staff for toileting, transfers, and mobility. Review of the Facility Matrix provided 3/25/25 at the beginning of this survey revealed R1 had a Stage III Pressure Ulcer. Review of a Braden Scale for Predicting Pressure Sore Risk dated 2/7/25 for R1 revealed she is a high risk. During an observation and an interview on 3/25/25 at 10:28 AM, R1 was in bed with a wedge under her left side. She reported she had the pressure ulcer on her backside prior to admission and thinks it is getting better. During an observation 3/26/25 at approximately 8:00 AM, R1 was observed in her specialty Broda wheelchair. During an observation and an interview on 3/26/25 at 11:23 AM, Licensed Practical Nurse (LPN) T had R1 transferred to bed for a pressure ulcer dressing change and placed the wound dressing supplies on a table beside the bed with no barrier and did not clean the table. R1's brief was saturated with urine and not cleaned up prior to dressing change. The nurse removed the old dressing from R1's sacrum which was packed with gauze. The wound was approximately a golf ball size round and deep. LPN T used the same gloves to remove the old dressing and packed wound that was saturated with serosanguinous drainage to clean and apply the new dressing which consisted of packing the wound with gauze soaked with Dakins solution and packed in the wound with her soiled glove via her finger. An antifungal cream mixed with a zinc-based cream was applied to the surrounding area of the wound, then an ABD (abdominal pad) was applied over the packed wound and adhered with hypafix tape. LPN T then changed her gloves post wound care to assist with peri care and transferred R1 back to her wheelchair. When she was done with wound care supplies, she took them out of the room to the wound cart and placed them in the drawer. In an interview on 3/26/25 at 11:57 AM, LPN T reported R1 should be offloading while up in her wheelchair and could not confirm that it was being done. When asked about hand hygiene and changing gloves during a dressing change after removing old dressing and applying a new one, LPN T said What about it? I don't know, but I am guessing you think I should have changed my gloves? When asked about packing the wound with her soiled gloves with her finger, she reported there is no undermining so packing the wound with her finger verses a cotton swab was appropriate. LPN T reported wound care rounds are done weekly on Mondays with the wound care nurse and did not know why there was no documentation in the EMR to reflect R1's wound care visit. When asked about the unused wound care supplies being place outside the room in the wound care cart, LPN T reported she could not leave them in the room. In an interview on 3/26/25 at 12:01 PM, Certified Nursing Assistant (CNA) F reported R1 normally lays back down after breakfast but this day she stayed up to get her hair done but the hairdresser canceled her appointment, so R1 stayed up in her wheelchair. During an observation on 3/26/25 at 1:49 PM, R1 was transferred to her bed. Review of a Skin integrity Care Plan for R1 initiated 12/20/24 revealed: is at risk for skin breakdown [related to] admitting with pressure Ulcers on her coccyx 12/4/23. No meaningful interventions or revisions for a stage III or a stage IV pressure ulcer on the care plan. No frequent repositioning or offloading is on the Care Plan. Review of the Activities of Daily Living (ADL) Care Plan for R1 revealed: BED MOBILITY: The resident is totally dependent on (2) staff for repositioning and turning in bed, initiated 12/20/24. Review of a Wound Care Note for R1 dated 2/3/25 revealed: Sacral wound is 5.8 x 3.5 x 4 cm. (Stage IV pressure ulcer.) Review of a Wound Care Note for R1 dated 3/17/25 revealed: Incontinent of urine with removal of the old dressing. The sacral wound is 6 x 4 x 3.8 cm (centimeters and is 100% granulation without any maceration/erythema around. Moderate amount of serosanguineous drainage on the old dressing. Assessment/Plan: coccyx/sacrum wound stage IV pressure ulcer after sharp debridement by [Physician] on 4/29/24. Continue with turning from side-to-side and she was on her left side today. Wound is slowly improving. Review of a Skin assessment dated [DATE] for R1 revealed she has a Stage III pressure ulcer on her coccyx measuring 6.0 x 4.0 x 3.8 (cm) with no drainage and 100% granulation. (Wound Care notes reflect a stage IV pressure ulcer.) Review of the Electronic Medical Records (EMR) on 3/26/25 for R1 revealed no skin assessments or wound care documentation for 3/24/25. In an interview on 3/26/25 at 2:03 PM, the Director of Nursing (DON) reported the Wound Care Nurse was here on Monday (3/24/25) and was not sure where the progress notes of R1's pressure ulcers were or why there was no skin assessment documented in the EMR. She reported the Wound Care Nurse will dictate the notes and the facility will then upload them into their computer. When queried about changing gloves and performing hand hygiene after removing old soiled wound dressings, the DON reported it would depend on if the gloves are visibly soiled. When it comes to packing wounds, the DON reported whether she used the same glove using her finger or a cotton swab would depend on the wound, but she usually uses a cotton swab. When given the observed scenario of LPN T's dressing change on R1, the DON did expect a barrier or a cleaned table prior to setting wound care supplies down. Regarding the changing of gloves during a dressing change, the DON reported R1's dressing change is not sterile and her germs are hers, but she would personally have changed her gloves. When asked about the wound care supplies that have been in the residents' room and taken outside the room to the wound care cart, the DON reported the supplies should be resident specific and left in the room or prepped before going into the room so no supplies would be left over. In an interview on 3/26/25 at 2:22 PM, Registered Nurse (RN)/Infection Control Nurse K reported that for wound care, a cleaned table or a barrier for supplies should be set up and hand hygiene and new gloves should be used after removing old dressing. A wound can be packed with a gloved finger for shallow wounds but deeper wounds or tunneling should use a cotton swab. Left over wound care supplies should not be taken to the cart. In an interview on 3/27/25 at approximately 9:00 AM, the DON walked down the hall and told this surveyor she will eat crow because gloves and hand hygiene should be done after removing a soiled dressing. Review of a Wound Care note dated 3/24/25 for R1 which was provided by the end of this survey on 3/27/25 revealed: patient turned on her right side with 2 assist. Old dressing was removed. Incontinent of urine during the removal of the old dressing. Sacral wound is 6 x 4 x 3.8 cm, 100% granulation . Review of a policy titled Pressure Injury Prevention and Management last revised 12/2022 revealed: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injures. 3. Assessment of Pressure Injury Risk: b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. c. Assessments of pressure injuries will be performed by a licensed nurse and documented on the Weekly Skin Assessment form. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. d. After completing a thorough assessment/evaluation, the interdisciplinary team should develop a relevant care plan that includes measurable goals for prevention and management of pressure ulcers/pressure injuries with appropriate interventions. 4. Interventions for Prevention and to Promote Healing: a. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment . b. Evidenced-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Pressure prevention interventions could include but are not limited to: Redistribute pressure . Minimize exposure to moisture with use of incontinence management . use of up down schedule. 5. Monitoring: a. The Unit Manager or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. Change in care plan interventions will be completed. Review of a policy titled Non-Sterile Dressing Change last revised 5/2019 revealed: Designated staff members will use non-sterile dressing techniques for all dressing changes unless otherwise indicated by physician or manufacturer guidelines. Clean aseptic technique should be used. In the event of multiple wounds, each wound is considered a separate treatment. 4. Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare work surface. Optional: Cover work surface with clean dry paper or cloth towel, to prevent contamination of supplies. 10. Remove soiled dressing, place it in trash bag. 11. Remove gloves, wash hands, apply new gloves.

Based on observation, interview, and record review, the facility failed to: 1) post daily nurse staffing data in a prominent place readily accessible to residents and visitors and 2) list the facility census and actual hours worked by category of licensed and unlicensed nursing staff (i.e., Registered Nurse, Licensed Practical Nurse, Nursing Assistant) directly responsible for resident care per shift on the historic daily nurse staffing data sheets. Findings include: During an observation on 03/27/25 at 08:35 AM, the daily Faith's Terrace Staffing data sheet was observed on a bulletin board next to nurse's station facing nurse's station. The staffing data was not visible to residents and/or visitors in hallway or walking by the nurse's station. The Faith's Terrace Staffing data sheet was posted next to other staff only schedules/postings (i.e., On Call Manager Schedule for March 2025, On Call Maintenance person, a thank-you card). The Faith's Terrace Staffing data sheet had the facility census, names of nursing staff members scheduled per shift, and schedule nurse staffing hours listed by category (i.e., Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant (CNA), and nursing staff orientees). During an observation on 03/27/25 at 08:45 AM, the daily Love's Garden Staffing data sheet was observed on a bulletin board next to nurse's station facing nurse's station. The staffing data was not visible to residents and/or visitors in hallway or walking by the nurse's station. The Love's Garden Staffing data sheet was posted next to other staff only schedules/postings (i.e., On Call Manager Schedule for March 2025, On Call Maintenance person, a thank-you card). The Love's Garden Staffing data sheet had the facility census, names of nursing staff members scheduled per shift, and schedule nurse staffing hours listed by category (i.e., RN, LPN, CNA, and nursing staff orientees). During an interview on 03/27/25 at 08:50 AM, CNA Q stated the daily nurse staffing data sheets are only for nurse and nurse aide use and reference. She stated the nurse staffing sheets are only posted where staff can see them and not residents. CNA Q verified that the current location of the Love's Garden Staffing data sheet was in an area where residents and/or visitors could not see or read it. A review of the historic daily nurse staffing data sheets, dated 2/25/25 to 3/24/25, revealed the daily resident census was not entered on the data sheets and the actual hours worked by nursing staff were inaccurately recorded on and/or not recorded on the staffing data sheets (e.g., all nurse hours actually worked were entered under the RN category and none were entered under LPN category, even though the majority of the nurses scheduled were LPN's). During an interview on 03/27/25 at 09:00 AM, the Nursing Home Administrator (NHA) stated the daily census numbers are not always recorded on the daily nurse staffing data sheets. The NHA stated they also do not always record the actual working hours of licensed and unlicensed personnel on the daily nurse staffing data sheets. He stated they only list the nursing staff and their scheduled hours and he keeps track of the actual hours worked himself.

Based on observations, interviews and record review, the facility failed to provide care in a dignified manner for four Residents (R5, R30, R35 and R40) of 15 Residents reviewed. Findings included: R5 Review of R5's face sheet dated 3/27/25 revealed she was admitted on [DATE] and had diagnoses that included: Diabetes, stage 4 kidney disease, diverticulosis of intestine, irritable bowel syndrome with diarrhea, and urine retention. She was her own responsible party. R5 was observed in bed on 3/25/25 at 10:58 AM and R5 was very upset with the facility's poor response to her needs for assistance. R5 said she has talked to management about the ineffectiveness of the call light system, but they tell her it would take $80,000 to fix the current call light system. R5 said there is no light in the hall that goes off when she puts her call light on. The staff are supposed to carry iPads (as identified by R5) around their neck to know when someone needs assistance. The staff must take the iPad off when they provide care as it gets in the way and bumps the residents when they are doing care. R5 said her care may take staff 20 to 30 minutes and when she is getting care they cannot see if other patients need care. R5 had a metal call bell on her bedside table, and she reports she starts ringing it when they do not respond in 15 minutes to her light. R5 said she does not like to have a bowel movement in her bed, and it is painful and frustrating to hold it more than 15 minutes. R5 said they keep trying to take my call bell away, but I will not let them. R30 R30 was observed being lifted from her wheelchair to bed with a full body electronic lift on 3/26/25 at 9:42 AM by Certified Nurse Aides (F and G). CNA F and G did not talk to R30 during the transfer or care. They did not indicate when they were going to lift her, turn her or remove her brief. R30's eyes were open, and she did not speak during this observation. When R30 was lifted out of her wheelchair she had a wet spot about 3 to 4 inches in diameter in the center of her buttock. R30's wheelchair had a strong urine smell. CNA F removed the cushion cover and said she would get a new cover from therapy. After the cover was removed the wheelchair and cushions still had a strong urine smell. R35 Review of R35's face sheet dated 3/27/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease, chronic pain, rheumatoid arthritis and generalized anxiety disorder. She was not her own responsible party. Review of R35's Brief Interview for Mental Status (BIMS) dated 2/24/25 revealed she scored 10/15, indicating she has moderate cognitive impairment. R35 was observed in bed on 3/25/25 at 11:39 AM. R35 was upset about the quality of the incontinence briefs. R35 said the staff have to put two diapers on me to keep my bed clean. She reported all the staff know about the problem with these briefs, but no one is doing anything. R35 also complained that the food quality has gotten bad, and no one is doing anything about it. They don't write down the concerns, they just don't care. R40 Review of R40's face sheet dated 3/27/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease, hemiplegia, convulsions, heart disease, cardiomegaly, and psychotic disorder with delusions. She was not her own responsible party. During an interview with R40's responsible party on 3/25/25 at 10:33 AM, he expressed concern about the facility purchasing cheap briefs for R40. He said they leak and cause more laundry issues and more frequent changes. He said the staff all know it and are upset too, but management does not care about it. On 3/26/25 at 10:30 AM, R40 was in bed and her responsible party was in the room. R40 had her eyes open but did not speak. R40's wheelchair had a fabric seat cushion in it and the wheelchair had a strong urine smell. R40's responsible party said since the facility started buying cheap briefs she frequently has urine soak through to her clothing. During an interview with the Director of Nursing (DON) on 3/26/25 at 11:30 AM, the DON was asked about concerns related to the quality of the briefs. The DON responded she was aware of the concerns but did not offer any solutions to the concerns. During an interview with the Nursing Home Administrator (NHA) on 3/26/25 at 2:00 PM residents concern about having to use two briefs, increased laundry use and urine soaking through to their clothing, soiled wheelchair cushions, residents' frustration, and lack of dignity related to residents not feeling their concerns were being heard were discussed. The NHA said he was aware of some of the concerns but not the extent of the problem. He said he would start working on trialing different products.

Based on interview and record review, the facility failed to inform 1 of 5 residents (R350) reviewed for unnecessary medications of the risks versus benefits and indications for use of a psychotropic medication prior to administering it. Findings include: A review of R350's Admission Record, dated 3/27/25, revealed they were a [AGE] year-old resident who admitted to the facility on [DATE] with multiple diagnoses that included dementia and cerebral infarction (a condition where blood flow to the brain is interrupted causing brain tissue damage). In addition, R350's Admission Record revealed they were their own responsible party. A review of R350's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/27/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R350 was cognitively intact. A review of R350's March 2025 Medication Administration Record revealed they were being administered aripiprazole (Abilify- an antipsychotic medication) and had been since admission. A review of R350's electronic medical record failed to reveal any documentation that R350 was informed of the reason why they were receiving aripiprazole (indications for use) and/or the risks and benefits of its use. On 3/27/25 at 1:55 PM, the Nursing Home Administrator (NHA) was informed via e-mail (the NHA's verbalized preferred method of receiving document requests) that the surveyor could not locate any documentation that R350 had been informed of the reason why they were receiving aripiprazole and/or the risks and benefits of it's use. The surveyor requested that the NHA provide any documentation that they may have that R350 had received this information prior to them receiving the aripiprazole. During an interview on 3/27/25 at 3:00 PM, the NHA stated he could not locate any documentation that R350 had been informed of the reason why they were receiving aripiprazole and/or the risks and benefits of its use. He stated he contacted the physician (whom he indicated was at the facility) and the physician stated he would immediately talk to R350 about their aripiprazole, including why they were receiving it and the risks and benefits of it. The surveyor requested a copy of the physician's note after he spoke with R350 that would reveal he spoke to R350 about their aripiprazole. The NHA stated that the physician's note would probably not be available until the next day (after the survey team exited the facility) and hinted that the physician may not presently be at the facility but may visit the facility later today or tomorrow and/or they may not dictate their notes until tonight or tomorrow. The surveyor requested any documentation that the physician spoke to R350 about their aripiprazole prior to exit from the facility, if the notes/documentation became available. The NHA verbally acknowledged this request. As of the completion of the survey and exit from the facility, the facility failed to provide this documentation.

Based on interview and record review, the facility failed to record the reason for a transfer to the hospital emergency department in the resident's medical record for 1 of 1 resident (R47) reviewed for hospital transfers. Findings include: A review of R47's admission Record, dated 3/27/25, revealed they were a [AGE] year-old resident who admitted to the facility on [DATE]. In addition, R47's admission Record revealed they had multiple diagnoses that included liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. A review of R47's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/4/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R47 was cognitively intact. A review of R47's Health Status note, dated 1/4/25, revealed, [Name of R47] requested to go to ED (emergency department) for evaluation. Contacted on call nurse, called on call, [name of healthcare provider] at 1105 (11:05 am) to get order to send out. Called [name of ambulance company] at 1108 (11:08 am) for transport. Left with [name of ambulance company] around 1130 (11:30 am) to ED. A review of R47's electronic medical records failed to reveal any other documentation that would indicate the reason (besides the resident wanted to go) that R47 had been transferred to the hospital emergency department for evaluation on 1/4/25 (e.g., a transfer form, physical assessment, physician communication note, physician note, etc.). During an interview on 03/27/25 at 08:30 a.m., the Nursing Home Administrator (NHA) was notified that the surveyor could not locate any documentation in R47's electronic medical record that would indicate the reason that R47 had been transferred to the hospital emergency department for evaluation on 1/4/25. The NHA stated he would review R47's medical record and see if he could find any documentation. The surveyor requested copies of any documentation that he may be able to locate. During an interview on 03/27/25 at 10:03 a.m., the Director of Nursing (DON) stated they did not do a transfer form for R47. She stated that the transfer form was a new development that they added to the assessments tab recently. The DON stated they did do a progress note that stated R47 requested to go to the ER. She stated she did not know why R47 wanted to go to the ER, just that he wanted to go so the facility sent him. The DON stated that because R47 requested to go to the ER, then the facility would not have done an assessment before sending him. She stated she does not expect the nurses to do an assessment on a resident before they go to the ER if the resident requested the transfer since they would send them anyway, even if the transfer was not medically necessary.

Based on interview and record review, the facility failed to provide to the resident and/or the resident representative written notice which specified the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 resident (R47) reviewed for hospital transfers. Findings include: A review of R47's admission Record, dated 3/27/25, revealed they were a [AGE] year-old resident who admitted to the facility on [DATE]. In addition, R47's admission Record revealed they had multiple diagnoses that included liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. A review of R47's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/4/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R47 was cognitively intact. A review of R47's Health Status note, dated 1/4/25, revealed, [Name of R47] requested to go to ED (emergency department) for evaluation. Contacted on call nurse, called on call, [name of healthcare provider] at 1105 (11:05 am) to get order to send out. Called [name of ambulance company] at 1108 (11:08 am) for transport. Left with [name of ambulance company] around 1130 (11:30 am) to ED. A review of R47's electronic medical records failed to reveal any documentation that would indicate the facility had presented, or attempted to present, R47 or their responsible party with the facility's bed hold policy prior to or immediately following their transfer to the hospital on 1/4/25. During an interview with the Nursing Home Administrator on 03/27/25 at 08:30 a.m., the Nursing Home Administrator (NHA) was notified the surveyor could not locate any documentation that would indicate the facility had presented, or attempted to present, R47 or their responsible party with the facility's bed hold policy prior to or immediately following their transfer to the hospital on 1/4/25. The NHA stated he would look for the documentation and provide the surveyor with a copy of it, if it was located. During an interview on 03/27/25 at 10:03 a.m., the Director of Nursing (DON) stated that R47 should have been given the bed hold policy and it should have been explained to him. The DON was informed that the surveyor could not locate any documentation that R47 had been given the bed hold policy and had it explained to him. She stated she would look into it and give me a copy of anything that she finds. During a second interview on 03/27/25 at 10:59 a.m., the DON stated Admissions Coordinator (AC) P went over the bed hold policy with R47 and their family. She stated that AC P did not document her discussion with R47 or their family in R47's medical record, but there were e-mails back and forth between AC P and R47's family. During a third interview on 03/27/25 at 01:00 PM, the surveyor requested a copy of the e-mails between R47's family and AC P that would reveal the facility's bed hold policy was discussed with them. The DON stated, I might have misspoke. She stated she did not actually know if AC P spoke with R47 or their family about the facility's bed hold policy. The DON stated she knew AC P went to the hospital to speak with R47 and their family after R47 went to the hospital. She stated the e-mail that she was referring to was the one AC P sent to the facility notifying them that R47 had been admitted to hospice, would be discharged to a hospice home when discharged from the hospital, and would not be returning to the facility. She stated that information was entered as an Alert Note, dated 1/4/25. A review of R47's Alert Note, dated 1/4/25, revealed, [ Name of hospital] ER called and resident is on Hospice now and is transferring to [name of hospice house] tomorrow. He will not be returning to this facility. A review of the facility's Bed Hold Notice Upon Transfer policy, revised 5/17/2023, revealed, Policy: 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 . 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: The resident requires the services which the facility provides; The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services . 5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.

Based on observation, interview and record review, the facility failed to assess, monitor and provide care for one (R30) of one resident reviewed for dental care. Findings include: Review of a Face Sheet revealed R30 originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia, and abnormal posture. During an observation on 3/25/25 at approximately 11:00 AM, R30 was observed at a table near the nurses' station clenching her shirt. She was nonverbal had limited movement. In an interview on 3/25/25 at 12:11 PM, R30's husband reported concerns of his wife not being able to get her tooth extracted timely and she is having pain. He reported he can tell she had pain by her behaviors and the clenching of her teeth. Review of a dental consultation dated 1/3/25 for R30 revealed she needed to have diagnostics done and oral surgery to get her tooth extracted while sedated and was given a referral for oral surgery. Review of a Nursing Progress note dated 3/6/25 for R30 revealed she went to a dental appointment the day before with her husband. No after visit summary, follow up paperwork or appt. (appointment) reminder. Per husband, (R30) had an Xray done, but no dental procedures. No follow up documentation in the EMR indicating the facility followed up on this. Review of a Physician Progress note dated 3/25/25 for R30 revealed no mention of dental concerns or follow up care. No nonverbal signs or symptoms of pain or discomfort observed. Care plans reviewed and updated to reflect (R30's) strengths, preferences and concerns. Review of the Care Plan for R30 revealed no focus for dental concerns. In an interview on 3/27/25 at 9:44 AM, Social Worker (SW) X reported that the local surgeons are not able to meet the physical needs R30 has do a tooth extraction safely with sedation while having contractures and need for a high-backed wheelchair. Some claim the room is too small for her too. The facility is doing their due diligence to seek care for her. SW X was asked about R30's pain and reported R30 has anxiety and thinks pain is also contributing more to her anxiety. R30 has contractures and clenches her teeth at a baseline so assessing her pain may be difficult. Review of the March Medication Administration Record (MAR) for R30 revealed she has an order for Tylenol 500 milligrams (mg), 2 tablets, three times day for dental pain ordered 12/24/24. Review of her pain assessment revealed all month her pain was rated as a 0/10 scale. No monitoring for infections ordered/documented. In an interview on 3/27/25 at 10:57 AM, Unit Manager (UM) K was questioned about monitoring of pain and infection for R30 when she is not able to express it, and she reported it is hard to tell because she has a history of ticks and clenching her teeth. R30 was on an antibiotic in the beginning and is already getting Tylenol for her arthritis. The Social Worker is working on pursuing an oral surgeon but is not having any success locally per the husband's request. UM K was not clear if the physician was aware or updated on the concerns of R30 needing her tooth extracted. In a follow-up interview on 3/27/25 at 2:03 PM, UM K was questioned about expectations for monitoring R30 for pain and infection is related to her tooth and UM K reported she just put in an order for nursing to monitor for signs and symptoms of swelling, discharge, or infection and document that into the computer. She then talked to the physician today about R30's care and is waiting for an order for Ultram to be put into the computer.

Based on observations, interview, and record review, the facility failed to provide the care of contractures for one (R3) of one resident reviewed for contractures. Findings include: Review of a Face Sheet revealed R3 originally admitted to the facility on [DATE] and has pertinent diagnoses of contractures, spastic hemiplegia (one sided weakness) affecting left nondominant side, and brain injury. Review of the Minimal Data Set (MDS) dated [DATE] revealed R3 is moderately cognitively impaired and has limited range of motion in bilateral upper and lower extremities and is dependent on staff for mobility. During an observation on 3/25/25 at 10:39 AM, R3 was observed in the hallway with contractures in bilateral upper extremities at both wrist and hands. No devices in place on his right or left hands. During an observation and an interview on 3/26/25 at 9:18 AM, R3 was in his room eating breakfast in bed. He reported he did not know where his hand splints were, and staff have not put them on his hand in a while. R3 reported staff do not ask him if he wants to wear them either. One hand splint was observed across the room on top of a container. In an interview on 3/26/25 at 9:12 AM, Physical Therapy Assistant/Manager (PTA) V reported R3 was just picked up yesterday (the first day of this survey) for an evaluation because he was having trouble eating and was to provide the last Occupational Therapy (OT) notes regarding his contractures. Review of a Care Plan for R3 related to his decreased functional mobility and ADL's (activities of daily living) related to deficits secondary left sided hemiparesis with contractures . revealed an intervention: Right hand splint: Encourage (R3) to wear up to 4 hrs (hours) during the night as tolerated: monitor skin integrity on removal, last revised 3/26/24. Review of the electronic medical records (EMR) for R3 revealed a task list for staff to chart daily cares and did not have a task to chart applying splints. In an interview on 3/27/25 at 10:31 AM, Occupational Therapist (OT) W reported they picked R3 up for therapy this week for feeding and positioning in his chair. His left arm is extremely contracted and has some spastic tone and no function in his left hand. His right is contracted but he still has some use in it. OT W reported he does have one hand splint for his right hand but is not sure if he is wearing it at night per his care plan or if it even fits his hand. He used to have a splint for his left hand. The rationale for him to wear a splint at night for his right hand was so he can use his right hand more for things such as eating. Review of an OT Discharge Summary dated 9/9/2022 for R3 revealed that he was wearing his right-hand splint per the established schedule up to 4 hours a day. Pt (patient) has splint wear schedule n place with third shift nursing. Review of an OT Discharge Summary dated 3/14/24 for R3 revealed: pt (patient) has R (right) hand splint to wear per previously established schedule. Review of an OT Evaluation & Plan of Treatment for certification period of 3/25/25 to 6/22/25 for R3 revealed his right upper extremity (RUE) (ROM) range of motion is impaired at his wrist with a flexion contracture and his LUE (left upper extremity) ROM is impaired with arom (active range of motion) to 45 degrees, passive to 90 at shoulder flexion, he has extensor tone at his elbow, flexor tone in hand, and has flexion contractures at his right wrist and digits. In an interview on 3/27/25 at 10:55 AM, Unit Manager (UM) K reported there is no documentation in the task list to show splints for R3 were being placed on him at night and reported she just fixed it so staff can document it is being done.

Based on observations, interviews and record review, the facility failed to respond timely to resident grievances for 2 Residents (R10 and R40) of 15 residents sampled. Findings include: R10 Review of R10's face sheet dated 3/27/25 revealed, she a [AGE] year-old female that was admitted to the facility on [DATE] and had diagnoses that included: generalized weakness, unsteady on feet, vascular dementia, kidney disease and major depressive disorder. She was not her own responsible party. During an interview with R10 on 3/26/25 at 11:26 AM, R10 complained of problems with wheelchair comfort. R10 was scooted down in her wheelchair sitting on her low back. R10 was not able to reposition herself in her wheelchair. R10 also complained that the meals have decreased in quality and said she used to be able to get more fresh fruits. R10 was asked if she attended resident council and if the residents were able to address concerns in the meeting. R10 said she was the resident council president and reported they do talk about the concerns but was unaware of any formal written grievance forms. R10 said all they do is talk, nothing gets done. During an interview with Occupational Therapist (OT) U on 3/27/25 at 10:15 AM, OT said she had worked with R10 on wheelchair seating. OT U reviewed her notes and noted she had provided a low back cushion for R10 prior to therapy ending. OT U was not able to locate any communication form that would have given nursing instruction for the use of the cushion. OT U could not locate any information on R10 Kardex for the use of the cushion. OT U had not received any information on R10's having any concerns with wheelchair comfort after therapy ended. During an interview with OT on 3/27/25 at 12:12 PM, OT U confirmed R10 had the low back cushion she had provided, but R10 was not positioned well. OT U instructed nursing to do frequent wheelchair positioning checks and provided nursing a written communication form for the use of the cushion and frequent positioning today. Review of the February 27th, 2025, Resident Council minutes revealed R10 called the meeting to order. The dietary section revealed, Residents brought up concerns regarding dessert amounts, type of meat being served and quality of meat served, types of bread served, amount of canned food used, and temperature of food upon service. Concern form filled out and emailed to Adm (Administrator) and Dietary Manager for review. Review of the January 2025 Resident Council minutes revealed R10 called the meeting to order. The dietary section included: Residents state that they are tired of all white bread, and they would like to be offered a variety, and that white bread is not healthy. Residents would like butter on the bread/rolls and/or to be served butter packets with their meals. One resident states that they do not received enough fresh fruit and that he was promised offerings of butterscotch pudding and the staff state they do not have any. Review of the December 2024 Resident Council minutes revealed that R10 called the meeting to order. The dietary complaints included requests for more fresh fruit, vegetables and ice cream. Review of a Grievance/Complaint Report dated 2/20/25 revealed, the Nursing Home Administrator (NHA) received this form from the Resident Council revealed, On behalf of the resident council, it was identified concerns are not completely communicated resolved. The Resolution of grievance//complaint revealed, this will be closed in April and monthly audits are being conducted for 4 months. This was signed by the NHA on 3/27/25 (during the annual survey). R40 Review of R40's face sheet dated 3/27/25 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease, hemiplegia, convulsions, heart disease, cardiomegaly, and psychotic disorder with delusions. She was not her own responsible party. During an interview with R40's responsible party (RP) on 3/25/25 at 10:33 AM he was very concerned about the amount of canned and processed food R40 receives. R40's (RP) said he feeds her daily. He reports he tastes the food, and it is all very salty. R40 was very concerned as R40 has multiple medical concerns and has always been told she should be on a low sodium diet. R40's RP said he has attended multiple meetings he expressed frustration that complains are not resolved. He was concerned about her sodium intake due to her multiple medical concerns. During an interview with the Dietary Manager (DM) R on 3/26/25 at 10:00 AM he was questioned about assessing and monitoring R40's sodium intake. DM R said they do not offer low sodium diets just no added salts. DM confirmed that most of meals come from canned or processed food and he does not calculate the amount of sodium she received daily. During an interview with the Director of Nursing (DON) on 3/26/25 at 12:38 PM, the DON confirmed that R40's responsible party has many concerns. The DON could not recall specifics to the concerns and was not sure if she had completed concern forms. The DON said the food concerns would have been followed up by the Dietary Manager. During an interview with the Nursing Home Administration (NHA) on 3/26/25 at 2:00 PM, he was not completely aware of R40's Responsible Party's concerns and said he had been doing education with the Dietary Manager and Activity Director related to completing grievance forms for concerns.

Based on interview and record review, the facility failed to ensure admission orders were thoroughly reviewed and transcribed accurately, and pertinent physical assessment findings recognized and promptly addressed for 1 resident (Resident #49) out of 3 closed records reviewed, resulting in two hospitalization s due to missed orders and failure to address a change in condition in a timely manner. Findings: Resident #49 (R49) Review of an Admission Record reflected R49 admitted to the facility on [DATE] with diagnoses that included sepsis, localized edema, atrial fibrillation, sick sinus syndrome, atrial flutter, pulmonary hypertension, high blood pressure, acute embolism and thrombosis of unspecified deep veins of lower extremity, muscle weakness and bladder neck obstruction. Review of a hospital After Visit Summary dated 3/21/2024 (the day R49 admitted to the facility) reflected Instructions: Patient (R49) has been having labile INR (international normalization ratio, a measure of how long it takes for blood to clot) measurements. He typically takes warfarin (a blood thinning medication) 5 mg (milligrams)daily but suspect he will need lower dosing for now. His INR was 2.8 on 3/19 and warfarin 2.5 mg was given which raised his INR to 3.5 on 3/20. No dose was given on 3/20 and his INR was 3.2 today on discharge. He will need daily INR monitoring until he reaches a more steady state. (Normal range for PT is 11-35 seconds. INR of 0.8 to 1.1) Review of a hospital Encounter Summary dated 3/21/2024, scanned into the facility Electronic Medical Record (EMR) on 4/7/2024 reflected a Discharge Summary which included Continue daily weights and strict I & O (intake and output), Continue PO (oral) Lasix (a diuretic) 20 mg daily. Review of the facility History and Physical (H & P) report dated 3/27/2024 written by Medical Director (MD) N reflected R49 had a Past Medical History of congestive heart failure (CHF), warfarin induced coagulopathy, history of recurrent DVT (deep vein thrombosis) and bladder outlet obstruction status post Foley catheter. The H & P also noted R49 had labile INRs. Review of Systems reflects R49 felt his weight has been stable, MD N noted lower extremity edema. Physical Exam findings indicate Lungs are clear to auscultation . He (R49) had trace to +1 pretibial edema, but he also had edema extending up to his posterior thighs bilaterally. The Assessment and Plan reflects,.Recommend routine follow-up with cardiology. He has significant lower extremity edema. Recommend increasing his furosemide (Lasix, a diuretic) from 20 mg a day to furosemide 40 mg a day. Recommend rechecking a basic metabolic profile in approximately 10 days. Continue Coumadin (warfarin) 5 mg at bedtime. Recommend weekly protimes (PT) and as needed. INR checked on 3/25/2024 was 2.81 . Review of the March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did NOT reflect R49 was being weighed as ordered in the discharge summary. Weekly protimes were ordered as per MD N recommendation despite hospital discharge instructions directing daily PT/INR monitoring. Review of a Dietary Note dated 3/28/2024 reflected Continue to monitor weight, however, no frequency for weight monitoring was indicated. Review of a Health Status note dated 3/30/2024 reflected, .Resident wanted his oxygen level checked. Lungs sounds are clear but dim bilaterally, O2 (oxygen) is 93% on RA (room air). Resident stated he just likes to have it checked because he feels short of breath once in a while but not right now. Reassured resident we are happy to do that and his O2 level is good. Will inform oncoming nurse and continue to evaluate. Review of a Health Status note dated 3/31/2024 reflected, .Resident noted with edema to bilateral hands and legs, resident states this is an ongoing issue, does receive routine Lasix. The note references edema in R49's hands, which is a progression from the physical exam noted by MD N on 3/27/2024. Review of a Health Status note dated 4/1/2024 reflected the weekly scheduled PT/INR lab had not been drawn. The nurse notified the provider who ordered the lab to be drawn the following lab day which was scheduled for three days later. No adjustments were made to R49's dose of blood thinning medication. Review of an IDT Note (Interdisciplinary Team) dated 4/2/2024 reflected R49 was at the facility for IV (intravenous) antibiotics, physical and occupational therapy. The note indicated His (R49's) biggest barrier is endurance and SOB (shortness of breath). Resident does have pulmonary hypertension diagnosis. Alternative options are being considered at this time. Will follow up in next week's Medicare meeting. The note did not specify any alternative options. Review of a Health Status note dated 4/2/2024 reflected, .(R49's) Transfers are stand pivot with x2 EA (extensive assist). He needs EA assist (sic) with both upper and lower body dressing as he is very deconditioned, and caution needed with the PICC (peripherally inserted central catheter) line. He is not able to ambulate at this time and can barely stand long enough for staff to complete hygiene post toileting . Review of a Health Status note dated 4/3/2024 at 11:51 a.m. reflects, (R49) is swollen around his groin area and his hands, C/O (complains of) SOB, went and asked MD N to look at him. Review of R49s Weight Summary accessed from the EMR reflected on 3/21/2024 R49 weighed 167.0 pounds. On 4/3/2024 at 1:59 p.m. R49 weighed 191.4 pounds, a 24.4-pound gain in 13 days. Review of a Health Status note dated 4/3/2024 at 4:38 p.m. reflected, Resident was seen by provider today r/t (related to) fluid retention. Labs and medications reviewed. Catheter placement adjusted is patent and draining. Provider gave new orders with verbal instruction if resident declines or does not seem to be improving to call provider or on-call and send resident to hospital . Weekly weights were ordered at this time, as well as increased dose of diuretic (Lasix) medication. (The diuretic was increased to twice daily). Review of a Health Status note dated 4/3/2024 at 9:05 p.m. reflected R49 continued to have edema to hands and groin and was started on 1 liter of supplemental oxygen via nasal canula (NC) for a pulse oximetry reading of 88%. The note indicated R49 had 200 milliliters of urine output. Review of a Health Status note dated 4/4/2024 at 1:14 p.m. reflected, Bladder scan completed a pt (patient, R49) had such low urinary output on MN (midnight) shift. 20 cc (cubic centimeters) found to be in bladder mid am (morning) .Pt did ask to have O2 on .O2 @ 2L (liter) per NC applied. He does have firm edema up to mid torso. The note does NOT indicate the physician was notified of the increased need for supplemental oxygen or progressive edema. Review of a Health Status note dated 4/4/2024 at 6:41 p.m. reflects, Resident sent to (Hospital) ER (emergency room ) per doctor's order for critical labs. PT 82.3 INR 8.53. All appropriate parties notified. Review of a Health Status note dated 4/5/2024 at 4:17 a.m. reflected R49 returned from the ER at 2:15 a.m. after getting a dose of Vitamin K (to help clot blood) and IV lasix. Review of a Health Status note dated 4/5/2024 reflected, Resident seen by PCP (primary care provider) for acute visit on 4/4/2024. Review of a Health Status note dated 4/7/2024 at 11:20 a.m. reflected, This pt admitted on ,d+[DATE] with a wt. (weight) of 167. He was on Lasix 20 mg daily, on 3/29 his Lasix increased to 40 mg daily. On 4/3 his wt. was 191.4 and his Lasix was increased to 40 mg BID (twice a day). Today his wt. is 193.6 His lungs are fairly CTA (clear to auscultation), but quite diminished. He states he is more tired than he has been in a long time. He has firm edema up to the nipple line. I placed a call to the on-call Dr. (name of provider) who instructed me to send him to the hospital to be admitted for diuresis. He is now on 2L O2 per NC. This is new over the past couple days. Review of the Weight Summary reflected R49 weighed 193.6 pounds on 4/7/2024 at 7:55 a.m., indicating he had gained an additional 2 pounds since his weight on 4/3/2024, for a total weight gain of 26.6 pounds in 17 days at the facility. During an interview on 4/16/2024 at 1:53 p.m., Assistant Director of Nursing (ADON) A was asked about R49 course of stay at the facility. ADON A said that she was not involved in completing admissions at the facility, Registered Nurse (RN) B was. ADON A reviewed the concerns identified in the clinical record and said it was concerning that weights had not been monitored for R49 and no physician notification had been done despite documented changes in R49's condition (SOB/use of supplemental O2/increased edema/low urine output). During an interview on 4/16/2024 at 2:00 p.m., the Director of Nursing (DON) was asked if she had reviewed R49's clinical record due to his unplanned hospitalization s. The DON said she had not reviewed the clinical records. ADON B explained the concerns that had been identified due to the surveyor review. The DON said that it would be a good idea to review the clinical record of residents who discharge to the hospital to evaluate for areas of improvement and to prevent hospitalization s in the future. During an interview on 4/17/2024 at 8:13 a.m., Registered Nurse (RN) B reported she completes most of the admissions at the facility. RN B said that the facility gets a packet of information from the hospital, and she makes sure that the packet matches what is in the chart via (name of hospital EMR) which the facility has direct access to. According to RN B, she did not see the order for daily PT/INR laboratory draws. RN B said she did not see that hospital providers recommended daily weights or strict input and output monitoring. During an interview on 4/17/2024 at 9:08 a.m., MD N said that upon admission, R49's heart failure was not a top priority, and he did not see an order for daily weights or strict I & O and did not order weight monitoring. MD N said that monitoring strict I & O is just not done in Long Term Care because of the inaccuracy and resident access to fluids. According to MD N, he did not note the hospital discharge instruction to monitor PT/INR daily for R49. MD N said he was very concerned about R49's PT/ INR and was very worried about the missed lab draw for PT/INR on 4/1/2024. MD N reported he has not been happy with the current laboratory provider and had spoken to the facility about getting a contract with another lab even before the missed PT/INR lab for R49. MD N said that R49 was a very sick person, and his fluid retention/edema was compounded by other diagnoses which was why the resident was still in the hospital as of the date of the interview on 4/17/2024. Review of a hospital History and Physical dated 4/7/2024 reflects, (R49) was referred to into the emergency department today due to progressive weight gain, noting a weight of 196 pounds, and a previous weight of 167 pounds on 3/21/2024. Patient seen by primary care at (facility) noting increased peripheral edema, Lasix increased from 20 mg to 40 mg. Patient also describes shortness of breath with activity and orthopnea (discomfort when breathing while lying down flat) .In the emergency department, patient was noted to have clinical evidence of anasarca (extreme generalized edema or massive edema). BNP (Brain Natriuretic Peptide, a measure of heart function) is elevated 785 (normal range for BNP is less than 100 picograms per milliliter pg/mL). Chest x-ray shows progressive pulmonary edema with increasing bilateral pleural effusions.

Based on interview and record review, the facility failed to ensure appropriate neurological assessments were completed for 1 resident (Resident #1) out of 4 residents reviewed for falls, resulting in the potential for a delay in treatment after an unrecognized acute change in condition. Findings include: Resident #1 (R1) Review of an Admission Record revealed R1 admitted to the facility with pertinent diagnosis that included a history of a stroke, high blood pressure, osteoporosis and a history of a traumatic fracture. Review of R1's Progress Notes in the Electronic Medical Record (EMR) indicated R1 sustained an unwitnessed fall on 12/16/23 at approximately 10:15 p.m. R1 had another unwitnessed fall on 12/17/23 sometime before 5:00 a.m. when a Certified Nursing Assistant (CNA) discovered R1 on the floor in her room during rounds. Review of R1's December 2023 Medication Administration Record (MAR) revealed that R1 was prescribed and taking 2 anticoagulant (blood thinning) medications: Aspirin 81 Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to PAROXYSMAL ATRIAL FIBRILLATION and Xarelto Tablet 15 MG (Rivaroxaban) Give 1 tablet by mouth one time a day related to PAROXYSMAL ATRIAL FIBRILLATION. No side effect monitoring was ordered along with the anticoagulants. Incident Reports (IR) for R1 were requested from November 2023-January 2024. An incident report relating to R1's unwitnessed fall on 12/16/23 was reviewed and included an investigation packet with witness statements and a copy of neurological exams performed. An incident report, related investigation and documented neurological exams were not completed according to policy pertaining to R1's unwitnessed fall on 12/17/23. Review of a facility Head Injury Flow Sheet reflected staff were to complete a neurological exam upon initial assessment (immediately after a known or suspected head injury), then every 15 minutes for the first hour, hourly for the next two hours, every 2 hours for 6 hours then every shift for three days. The flow sheet did not reflect that the neurological exam had been restarted after R1's second unwitnessed fall in less than 12 hours. During an interview on 3/7/24 at 12:00 p.m., Registered Nurse (RN) A reported that there was not an incident report for R1's unwitnessed fall at 5:00 a.m. on 12/17/23. RN A also reported there was no evidence neurological assessments had been restarted for R1 after the unwitnessed fall on 12/17/24. During an interview on 3/7/24 at 12:27 p.m., the Director of Nursing (DON) reported that the expectation was that neurological examinations would be re-started after an unwitnessed fall with known or suspected head injury if a previous course of neuro exams was already in progress. A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. ([NAME] & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article.) The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003).

This citation pertains to intakes: MI00130551 and MI00132977 Based on interview and record review, the facility failed to prevent abuse and neglect for 2 residents (Resident #3 and #5) reviewed for abuse and neglect, resulting in the physical and verbal abuse of R3 and the neglect of R5 and the potential for serious physical and psychosocial harm. Findings: On 12/19/2022 an abbreviated survey was commenced to review Facility Reported Incidents (FRIs) pertaining to alleged abuse and neglect. The facility census during the survey was 23. Resident #3 (R3) Review of an Admission Record revealed R3 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 9/27/22 revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated R3 was severely cognitively impaired. Review of R3's Facility Reported Incident (FRI) revealed, Investigation Summary: On 7/22/22, at approximately 11:45pm, notification was provided to DON (Director of Nursing) by the 3rd shift charge nurse reporting an allegation of mistreatment of (R3) on the previous shift by (Waiver Aide/WA H). Upon receipt of this information, (WA H) was asked to leave the facility and the Nursing Home Administrator was notified of the allegation . As a result of multiple falls, behavior concerns, frequent exit seeking and poor safety awareness, she has required one-to-one (1:1) supervision for the majority of most shifts, since her admission. When 1:1 is not required (Sleeping or resting peacefully in her room), a remote video monitor is used to monitor for safety, when she is alone in her room. Safety alarms are also in use to alert staff of independent transfer attempts by the resident. On 7/21/22, the second shift aide assigned 1:1 with (R3) was (WA H) . Per statements of staff present during this shift, (WS H) was allegedly overheard by Certified Nursing Assistant (CNA) (CNA D) telling (R3) to be quiet, while (R3) was speaking to her. A second CNA (CNA E) states that on the previous day, she witnessed (R3) remove her feet from the wheelchair footrests several times while asking (WA H) to stop the chair. Per (CNA E's) statement, (WA H) replaced the resident's feet back onto the foot pedals at least twice before stating to resident, When you fall on your face, I don't want to hear about it. Both aides state they did not report their observations to their supervisor. (CNA E) planned to speak with the Unit Manager the next day. (CNA C) also worked second shift on 7/21. She and (CNA D) report observations of what they described as the resident's legs being roughly thrown into bed by (WA H) during a time when resident was attempting to transfer out of bed without assistance. Both aides, confirm that they did not report what they witnessed to their supervisor, but assumed the nurses overheard their conversation describing what they'd seen as the 2nd and 3rd shift nurses were present at the nurse station during the discussion. Both nurses deny hearing the conversation as they were in the middle of giving report. The second shift nurse, (Registered Nurse/RN B) states that after supper, she heard (WA H) raise her voice when speaking with (R3) and that she addressed this with her by reminding her to use an appropriate tone when speaking with residents. She mentioned this to the third shift nurse, (Licensed Practical Nurse/LPN F) who later attempted to speak with the aide. Per (LPN F's) statement, (WA H) was not receptive to being approached to discuss concerns and abruptly ended the conversation by asking to leave the unit for a break . The severity of (R3's) cognitive impairment precludes her ability to contribute any information to this investigation . Other Resident interviews resulted in no concerns regarding (CNA H's) care . Body audits completed 7/22/22 identified no new injuries .The nursing staff members present during shifts from 7/20/22 through 7/22/22 have reviewed the facility's Abuse policy and have been reeducated on abuse reporting protocol. The requirement for the Abuse policy review and reeducation was then extend to all nursing staff members. The nurses have been reeducated on the correct protocol for managing a resident who presents with aggression and agitation. This includes a rotating staff assignment when this type of behavior occurs and/or 1:1 is needed, rather than assigning one aide for an entire shift which was reported to have been in place on the date the allegation occurred. Supported by the consistency of the numerous statements of staff members present on 7/21 and 7/22, detailing their observations and interactions with this employee, in addition to the description of her demeanor by both peers and supervisors, this investigation concludes that the allegation of mistreatment cannot be excluded. Review of R3's Health Status Note dated 7/21/22 at 11:32 PM revealed, Resident has been extremely agitated all shift. She was combative, yelling and trying to take her clothing off in the lounge area. Hitting and kicking at staff. Accepted only bites of her dinner and declined offers of snacks. Did accept liquids. Attempts to calm her down by 1:1 staff, different staff talking with her 1:1 and walks around the unit all ineffective. Since bedtime she has been up and down repeatedly. Will continue to monitor. Review of R3's Health Status Note dated 7/22/22 at 3:43 AM revealed, It was reported to this CN (Charge Nurse) at approx. 11:30pm that a NA (Nurse Aide) was rough with resident. CENA reported that she heard staff from previous shift state that another staff member was being rough with the resident. This CN talked with CN from previous shift about these allegations. CN from previous shift stated that this was not reported to her. This CN contacted (DON) of these allegations. CN was instructed to send the staff member that committed the alleged abuse home. Review of CNA C's Witness Statement (no date or time) revealed, (CNA C) was contacted by this writer on 7/22/22 at approximately 12:45am to confirm statement of potential abuse attributed to her by a coworker. (CNA C) was on duty on second shift on 7/21(2022) along with aide (WA H). Per her statement, (R3) was in bed when her safety alarm was activated. (WA H) responded to the alarm and was observed by (CNA C) throwing the resident's legs into her bed .She voiced concern for what she witnessed, describing the action as rough .Per (CNA C), this observation was made while viewing the remote monitor which was at the nurse station. She did not formally report her observation to the CN (Charge Nurse), but states that both the second and third shift nurse and at least one aide were present at the desk, and she thought they heard her comment. CNA C's Witness Statement did not reveal the approximate time the abuse was first observed during CNA C's shift. Review of CNA D's Witness Statement (no date or time) revealed, (CNA D) was on duty second shift on 7/21/22. Per her statement, she witnessed (R3) with upper body in bed and legs dangling side of bed. (WA H) was in resident's room, and she saw her, throw (R3's) legs back into bed, and believes that she was intentionally rough. This observation was made via remote monitor during shift change. She did not report her observations to a CN but states they were in proximity while she and other aides were discussing. She also reports hearing (WA H) earlier in the shift telling this resident (R3) to, be quiet while the resident was speaking to her. CNA D's Witness Statement did not reveal the approximate time the abuse was first observed during CNA D's shift. Review of CNA D's handwritten Witness Statement (no date or time) revealed, I seen (WA H) telling (R3) to be quiet. And towards the end of the shift I witnessed (WA H) throw (R3's) legs back in bed on the monitor. Indicating CNA H's abusive behavior towards R3 was ongoing throughout the shift. Review of CNA E's Witness Statement (no date or time) revealed, (CNA E) was one of four aides covering second shift on 7/21/22. Per her statement, she observed (WA H) transporting (R3) in her wheelchair. Twice, (R3) removed her feet off the foot pedals and yelled for employee to stop. (WA H) placed the resident's feet back onto the foot pedals and continued to push resident throughout the unit. Per (CNA E's) statement, (WA H) then said to resident, When you fall on your face, I don't want to hear anything, and continued to push her around the unit. (CNA E) states she mentioned her observations to an aide that evening, but that she planned to report to the Unit Manager the next day. Review of RN B's Witness Statement (no date or time) revealed, (RN B) was the CN covering second shift on 7/21/22. Per her shift notes and statement, (R3) was verbally and physically aggressive towards staff throughout the shift. (WA H) was assigned 1:1 with this resident (R3) .at approximately 7pm (RN B) heard (WA H) using what she described as an inappropriate tone and that she was, short with the resident. she addressed this with her as being inappropriate. After reports from aides that (WA H) had her cell phone in residents room, (RN B) turned on monitor to make her own assessment. she observed multiple attempts by the resident to get out of bed and (WA H) repeatedly returning her to bed. She denies any report from aides concerning observations of rough treatment or overhearing their discussion of concerns. Review of RN B's handwritten Witness Statement dated 7/22/22 revealed, Thursday, July 21, 2022 1:45p-10p .about this time 6:30-7:00pm I noticed (WA H) was raising her voice to (R3) and should have been relieved to a different assignment .(WA H) was mandated to 3rd shift + during report both 2nd + 3rd shift CNAs were talking with each other. I was giving report to (LPN F) + didn't hear any accusations that may have been made concern (WA H). Indicating RN B identified the signs of CNA H's burnout (inappropriate tone/short with R3 because of her difficult behaviors) but did not intervene and assign a different staff member as R3's 1:1 at approximately 7 PM and then allowed her to continue as R3's 1:1 after WA H was mandated to 3rd shift. Review of CNA G's Witness Statement (no date or time) revealed, This writer spoke with (CNA G) on 7/21/22 to obtain details regarding an allegation reported to her supervisor. She states that when she arrived for 3rd shift (approximately 10 PM), she overheard a discussion between the 2nd shift aides that included observations of inappropriate treatment of a resident by a 2nd shift aide. It was her (CNA G's) 3rd night at (facility), and she expressed concern because of what she believed to be inaction on the nurse's part in addressing the allegation. She states she attempted to locate the contact information of the facility's abuse coordinator before finally approaching the nurse . Review of LPN F's Witness Statement (no date or time) revealed, On 7/21/22 at 11:30pm, Charge Nurse (LPN F) was approached by (CNA G) who reported that during shift change at approximately 10pm, she heard a conversation among 2nd shift staff discussing what she believed to be abuse. She was concerned that nothing was being done to address the allegation. Per (LPN F), she had received no reports of concerns from staff. She spoke with the 2nd shift nurse who was still in the building (RN B). This nurse also denied reports from staff members during her shift .During shift report, (LPN F) states that 2nd shift Charge Nurse (RN B) described (WA H) as being, short with the resident. Once report was completed, she located (WA H) in the room of (R3) and attempted to speak with her. She states that the aide abruptly ended the conversation after stating, what now, and requested to take a break. She returned from break and because (R3) was asleep, completed other tasks on the unit. She returned to the resident's room for a short time once she awakened, but informed her that she had to leave after the allegation was reported. Review of LPN F's handwritten Witness Statement (no date or time) revealed, On 7/21/22 at approximately 11:30pm, (CNA G) reported to me that she heard two CENA (CNAs) (CNA C) and (CNA D) discussing alleged abuse of (R3) by a staff member (WA H) .It was reported to me by the 2nd shift CN (RN B) that (WA H) was being short with (R3) during the shift. I talked with (WA H) about this. She asked to go to break d/t (due to) being mandated. This was at approx. 10:30pm. I talked with (RN B) and she stated that this was not reported to her. I called (DON) and was instructed to send (WA H) home. This witness statement confirms that LPN F was notified of the allegation of WA H abusing R3 and WA H was allowed to continue to care for other residents on the Unit as well as R3 despite exhibiting signs of burnout to LPN F. The witness statements detailed reasonable suspicion WA H was experiencing burnout (a serious risk factor for abuse/mistreatment) which led to mistreatment and abuse of R3. R3's abuse that was ongoing throughout 2nd shift on 7/21/22 and was identified by multiple facility staff. Facility staff did not intervene and allowed WA H to continue to provide 1:1 care to R3 resulting in R3's abuse to continue throughout 2nd shift and into 3rd shift. The inaction of staff who failed to recognize signs of burnout and who witnessed the abusive actions perpetrated by WA H to R3 contributed to an escalation of abuse that were highly likely to result in additional serious harm or injury. Review of the Staff Schedule dated 7/21/22 revealed WA H worked 2nd shift (beginning at 2pm) and was mandated to 3rd shift. The Staff Schedule revealed WA H was documented as working until 7/22/22 at 12:00 AM. Review of R3's FRI investigation revealed: *2 resident interviews related to the abuse identified on 7/21/22. The 2 resident Witness Statements were dated 7/27/22 (6 days after the incident making accurate recall difficult). There were no other resident interviews documented in the investigation notes. *There was no documentation that non interviewable residents on the unit were assessed for signs and symptoms of abuse. (Witness statements revealed that WA H provided care to other residents residing on the unit on 7/21/22). *The police were not notified of the staff to resident abuse identified on 7/21/22. As of 12/28/22, DON and interim Nursing Home Administrator (NHA) reported that they were not aware that alleged staff to resident abuse and neglect would constitute a reasonable suspicion of a crime and would require police notification. *There was no documentation that facility wide Abuse Policy Review was provided to the facility staff as reported in the Investigation Summary submitted to the State Agency. (Requested facility wide Abuse Policy Review on 12/28/2022 at 12:58 PM. No additional documentation was received prior to survey exit and was not included in the additional documentation sent via email on 12/29/22 at approximately 1:20 PM. *Review of the abuse education provided to the nursing staff members present during shifts from 7/20/22-7/22/22 revealed: Review of the Staff Schedules dated 7/20/22-7/22/22 revealed a total of 6 nurses, 14 CNAs/WAs, and 4 orientees scheduled to work. The following staff received abuse education: LPN F revealed a post test score of 1 incorrect answer out of 9 dated 7/27/22. On 7/27/22 the DON reviewed with employee by phone. CNA E revealed a post test score of 2 incorrect answers out of 9 dated 7/23/22. On 7/27/22 incorrect responses reviewed with Unit Manager. CNA C revealed a post test score of 2 incorrect answers out of 9 dated 7/22/22. No follow up regarding incorrect answers reviewed with CNA C documented. CNA J revealed a post test score of 1 incorrect answer out of 9 dated 7/27/22. On 7/27/22 the DON Reviewed by phone with employee CNA R revealed a post test score of 2 incorrect answers out of 9 dated 7/23/22. On 7/26/22 incorrect answers reviewed with (CNA R). CNA D revealed a post test score of 0 incorrect answers out of 9 dated 7/22/22. 6 out of 24 scheduled staff received abuse education. No additional abuse education documentation for the staff working 7/20/22-7/22/22 provided prior to survey exit, confirming that all staff, including nurse and CNA orientees, did not complete abuse education as documented in the FRI investigation submitted to the State Agency. (The delay/omission in review of incorrect answers suggests the education was not completed in person with an intent to clarify any misunderstandings related to the facility Abuse prevention protocols and prevent further instances of abuse and delayed reporting of alleged abuse.) Review of the FRI investigation summary submitted to the State Agency for R3's substantiated abuse identified on 7/21/22 revealed that during the investigative process, all residents cared for by WA H on 7/21/22 were not interviewed and/or immediately assessed following R3's substantiated abuse (2 interviewable resident statements were documented 7/27/22). Review of the FRI investigation/notes revealed no documentation that all residents residing on the unit were interviewed and/or immediately physically assessed for abuse to determine if the abuse was widespread or isolated to R3. Review of documents received via email after survey exit on 12/29/22 at approximately 1:20 PM did not include any additional/new interviews, education, or assessments. During an interview on 12/28/2022 at 12:58 PM, Director of Nursing (DON) reported that R3's investigation summary (MI00130551) submitted to the State Agency wasn't the final version that was sent to me and she was surprised at what was turned into the State. DON reported that the investigation summary implied that other residents were assessed, and no other concerns were identified. DON stated that the summary leads the reader to believe that something happened that didn't happen (physical assessments). DON reported that NHA reported that (Unit Manager) UM A completed resident assessments but I don't see where that was done. DON reported that there was no documentation related to other resident assessments following the incident on 7/21/22. DON reported that it is the facility protocol to assess all residents that may have had contact with the alleged perpetrator following an allegation of abuse/neglect. DON reported that all staff were education on the facility Abuse Policy after R3's abuse was substantiated, and late/delayed reporting of abuse was identified on 7/21/22. DON reported that all staff signed a sign in sheet after receiving the education and those documents were given to the NHA to submit as part of the final investigation to the State Agency. (Requested copy of the all staff education sign-in sheets at this time. No additional documentation received prior to survey exit or with documents received after exit via email on 12/29/22 at approximately 1:20 PM.) DON reported that following R3's substantiated abuse on 7/21/22, she was not aware the police needed to be notified. DON reported that she had never contacted the police regarding a FRI as part of the investigation process. During an interview on 12/28/2022 at 2:16 PM, NHA reported that if a crime is committed the police would be notified. NHA reported that she didn't feel that the abuse perpetrated by WA H on R3 was criminal hence the police were not contacted. On 12/27/2022 a social media post created by WA H and publicly posted on 7/18/2022 (nearly 5 months prior) was reviewed. The social media post/picture reflected WAH in an occupied unknown resident room (the foot of a resident bed is visible in the picture, the feet of the resident covered with a blanket is visible, personal/recognizable items and decor in the background) standing in front of a mirror taking a selfie with her middle finger extended. The gesture is offensive and would make the reasonable recipient of care feel abused by the vulgar gesture and exploited by the public posting of the image on social media. Review of WA H's Employee File revealed the following: *WA H was not a Certified Nursing Assistant and was working as a Waiver Care Aide. WA H completed temporary nurse aide 8-hour training on 1/10/22. *Review of WA H's Employee Orientation Checklist revealed a Date of Hire of 1/7/22. Subject-Abuse & Reporting from the Administrator was not documented as reviewed (no initials or date). Review of WA H's education revealed no Abuse Education. *Notice of Employee Reprimand dated 2/9/22: On 2/1/22 .employee failed to follow a resident's care guide, resulting in a fall. On 2/8/22, employee again failed to follow a resident's prescribed plan of care which resulted in the resident being lowered to the floor. Although neither fall resulted in injury, employee's action put residents and employee at significant risk for injury and therefore results in a Final Written Warning . *Disciplinary action/write up dated 6/5/22: On 5/31/22, mandatory in-services were scheduled for all facility staff. A make up in-service was held on 6/1/22. You did not attend as required and did not contact a supervisor to notify of your inability to attend. Failure to attend required in-services is subject to disciplinary action as addressed in the employee handbook. Please review the education you missed. The Unit Manager or Director of Nursing will follow up with you soon. *Notice of Employee Reprimand dated 7/29/22 .The facility has been provided a picture (see attached) dated 7/18/22 of this employee taking a cell phone picture of herself inside a resident's room which was posted on social media. In addition to the above violation, an allegation of mistreatment of a resident by this employee on 7/21/22 has been substantiated, and employee also remains noncompliant with the facility's employee TB policy. NHA reported that a Past Noncompliance had not been implemented related to the following deficient practices identified during the facility's FRI investigations: substantiated abuse (MI00130551), late abuse reporting (MI00130551), substantiated neglect (MI00132977). (Past noncompliance occurs when noncompliance has occurred in the past, but the facility corrects the deficiency and is in substantial compliance at the time of the current survey). 29073 Resident #5 (R5) Review of an Admission Record reflected R5 admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), congestive heart failure (CHF), type 2 diabetes, and difficulty in walking. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R5 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15/15 and needed limited assistance from one person for bed mobility, transferring, walking in room and toilet use. R5 required extensive assistance from one person for dressing. Review of a Care Plan initiated on 3/25/2020 reflected I (R5) need assistance with Activities of Daily Living (ADL) & mobility d/t (due to) weakness, chronic arthritic discomfort & chronically impaired respiratory status. I am A&O (alert and oriented) x3, able to make my needs known. Despite my cognitive strengths, I may choose not to advocate for myself when I have a need for assist. This may include not asking for incontinent care or assist with walking . The goal of the care plan was that R5 would continue to actively participate in cares and continue to self-propel the wheelchair. Interventions to reach the goals included See Care Guide for current assist needs and toilet plan. Review of a Visual/Bedside Kardex Report (care guide) dated 11/22/2022 reflected R5 needed Minerin cream to upper and lower extremities AM and HS (morning and hour of sleep); 1 assist with transfers during the night and PRN (as needed); assist with incontinent care at least once per shift, Res (R5) will likely not ask for assistance; offer assistance with toileting upon waking, after meals and HS. Review of an Incident Note dated 11/18/2022 reflected Resident (R5) sitting in w/c (wheelchair) head downwards. She appears embarrassed. Her friend was in her room to offer support. She began by telling the UM (unit manager) her aide was (Certified Nurse Aide (CNA) N) and the other aides say she is nice. Resident stated that (CNA N) came in to assist resident with HS cares and told resident she was tires (sic) Resident assisted to her commode and assisted with getting her nightgown on. After toileting (CNA N) pulled the brief up and did not wash resident's bottom or peri-area. Per resident's CG (Care Guide) she is to have Aloe Vesta to buttocks PRN and Minerin cream to BLE (bilateral lower extremities) and no creams were applied. Resident told aide her brief was not tight enough and the aide told her it was. As resident was ambulating to her bed, she could feel the brief begin to slide down (CNA N) did refasten brief tighter so it would stay up. Aide went to leave resident's room without placing the bedside table next to the bed. She did so after the resident asked her too (sic). Call light was not placed in resident's line of sight, and she was unable to find it. Resident fell asleep and when she woke up the aide was sitting in her recliner and appeared to be sleeping. She asked aide what she was doing and the aide said she was tired. This morning, the resident noticed her phone was unplugged as if someone used her cord to charge their own phone and resident noticed the stuffed animals which sit in her recliner were on the floor next to the recliner .Resident was apologizing and did not want to cause problems. She sated she had to say something because she was concerned other residents may have been neglected at bedtime the night before. She was assured a thorough investigation would be done and neglect would not be tolerated . During an interview on 12/27/2022 at 10:09 AM, R5 recalled the events from 11/17/2022. R5 said that she knew CNA N had been mandated to work overtime and that the aide seemed exhausted. According to R5, CNA N helped her to the toiled but did not wash her up or provide per-care and did not apply creams to her skin and did not give her the call light. R5 said that CNA N flopped down into her recliner and fell asleep. R5 said she also noticed that her cell phone was not plugged into the charger, and assumed it was because CNA N use the cord to charge her personal phone. R5 said everyone uses my charger. Review of a Facility Reported Incident 5-day summary dated 11/22/2022 reflected a reiteration of R5's complaint and a summary of witness statements obtained from staff who worked with CNA N from 11/17-11/18/2022 who described CNA N as distracted and in the breakroom on her phone frequently during the shift. The investigation revealed that CNA N did not document any cares performed for R5 or any other resident on her assignment 11/17-11/18/2022. CNA N was interviewed during the investigation and admitted she did not review R5's Kardex (care guide). The facility substantiated that CNA N neglected to follow the plan of care for R5 and the preponderance of information suggested R5's account of what occurred was likely true. CNA N was an agency employee and was not allowed to return to the facility again as the result of the investigation. During an interview on 12/27/2022 at 3:30 PM, the Director of Nursing (DON) reported that the investigation file provided for the FRI related to R5's alleged neglect on 11/17/2022 was all the information the facility had to offer. The DON said that there was no documented evidence all other residents cared for by CNA N had been interviewed or physically assessed for evidence of neglect. The DON said Registered Nurse (RN) A, unit manager, told her she did a sweep of the other residents who may have been neglected by CNA N but did not have proof the review was done. During a follow-up interview on 12/28/2022 at 1:14 PM, the DON reported that if any aspect of an investigation is not in the file (education, interviews, physical assessments etc.) it was not done. During an interview on 12/28/2022 at 5:00 PM, RN A reported she did not document her investigation into other residents who may have been neglected by CNA N but reported she investigated it to the DON. RN A said that residents with dementia are not interviewable and did not have documentation related to investigation/interviews. References: Review of the facility policy Abuse Policy and Prevention Program last revised 7/1/21revealed, .Procedure for Prevention of Abuse .E. Education for staff on how to identify signs of staff burn out, precursors of burnout, and techniques for prevention .Procedure for Reporting Abuse, Alleged Abuse, & Suspected Abuse .1. Any person observing an incident or who has become aware of alleged abuse, neglect .must immediately report the incident to the charge nurse .C. Remove alleged perpetrator (staff, family, visitor) from contact with all residents pending outcome of the investigation. If the suspected abuser is an employee, the employee should punch out and be escorted from the premises. The employee shall remain on leave until the investigation is completed .Procedure for Reporting Reasonable Suspicion of Crimes .2. If the events that cause the suspicion result in serious bodily injury to the resident the Administrator or DON will report the incidents to the State Agency (State of Michigan, Department of Licensing and Regulatory Affairs, Bureau of Community and Health Systems) and the Muskegon Township Police Department immediately but not later than 2 hours after the suspicion is formed. 3. If the events that cause the suspicion do not result in serious bodily injury, then the report to the above agencies by the Administrator or DON must be filed within 24 hours .Education .Employees will receive education on abuse reporting and prevention on their first day of orientation. No Employee will be allowed contact with residents until training is completed. Employees will also receive annual re-education on abuse reporting . (NHA verified that the Abuse Policy and Prevention Program last revised on 7/1/21 was the current policy being used by the facility.) F-Tag 608 was effective beginning November 28, 2017, through October 21, 2022. Regulatory requirements S483.12(b)(5)(ii)(iii) have been relocated to F607. Regulatory requirements for S483.12(b(5)(i)(A)(B) have been moved to F609.

This citation pertains to intake MI 2349 Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview, and records review, the facility failed to safely transfer one resident (Resident #1) resulting in a fall and serious injury requiring a transfer to the hospital and surgery to treat an impacted and angulated intertrochanteric fracture of the right proximal femur. Findings: Review of a facility policy Assessment and Procedures for Safe Lifting and Moving of Residents last reviewed 1/4/2021 reflected To protect the safety and well being of residents, staff and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy specified that Staff responsible for direct resident care will be trained in the use of mechanical lifting devices . Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order . All transfers using a Hoyer lift must be completed with 2 staff persons. Resident #1 (R1) Review of an Admission Record reflected R1 was a [AGE] year-old woman originally admitted to the facility on [DATE] with pertinent diagnoses of Alzheimer's disease, high blood pressure, [CONDITION(S)], [CONDITION(S)], contractures of the hand, [CONDITION(S)] and anxiety. A Minimum Data Set (MDS) quarterly assessment dated [DATE] reflected R1 was totally dependent on two people for transfers. Review of a Care Plan initiated on 8/24/ reflected R1 had ADL (Activity of Daily Living) self-care deficits due to mobility and cognitive impairments. The goal of the care plan was for R1 to continue to actively participate in ADLs and accept staff assistance for task completion and safety. An intervention/task to attain the goal reflected R1 needed total assistance from 2 people with a Hoyer lift (mechanical lift) for all transfers (initiated on 8/25/2017). Review of a Plan of Care Guide dated 2/2021 reflected R1 needed the assist of 2 with a mechanical Hoyer lift. Care plan details included on the guide reflected, Hoyer transfer: Full sling, top loop purple, bottom loop black *no split leg sling*. Review of an Incident Note dated 8/6/2021 at 8:19 a.m. reflected Staff reported that resident had slid out of the Hoyer sling and was partially lowered to the floor, ROM (Range of Motion) was assessed and WNL (within normal limits) per this resident, skin assessed, small abrasion to the right knee observed, bruising to the outer right knee an inner left knee noted, resident c/o right knee, hip and leg pain, neuros WNL per this resident, VSS (Vital Signs Stable), eyes PERRL (Pupils equal, round, reactive to light), assess using a different type of sling. Notifications made, Resident sent to ER for eval and tx (treatment), will continue to monitor. Review of an Orthopedic Surgery Consultation note dated 8/6/2021 reflected a History of Present Illness (Includes Chief Complaint): (R1) is a [AGE] year-old female who presented to the emergency department today after falling from a Hoyer lift onto a bedside table at her ECF (extended care facility), (Name of Facility). The patient unfortunately has significant dementia which makes obtaining further history as well as review of systems difficult; she is apparently at her baseline mental status according to staff. X-ray does confirm displaced right intertrochanteric hip fracture. There is no reported loss of consciousness or open wounds or bleeding. CT scan of her head was unremarkable, however due to motion artifact, her cervical (neck) CT did not rule out cervical fracture. Patient does not take anticoagulants. She last ate breakfast at 7:30 a.m. An x-ray result included in the consult notes reflected There is an intertrochanteric fracture of the right proximal femur. There is impaction and angulation at the fracture site. There is no subluxation or dislocation. There are moderate to severe arthritic changes in both hip joint spaces. The bony pelvis appears intact. The SI (sacral iliac) joints and pubic symphysis are unremarkable. Impression: 1. Impacted and angulated intertrochanteric fracture of the right proximal femur. During an interview on 9/9/2021 at 10:30 a.m., Certified Nurse Aide (CNA) C reported she was working on the day that R1 fell from the Hoyer lift. CNA C said that she was not in R1's room when the incident occurred. CNA C said two people are required to transfer a resident in a Hoyer and on that morning, they were rushing to get everyone up for breakfast. CNA C said that once residents who need a Hoyer transfer are ready to be moved, they use their walkie-talkies (two-way radios) to call for assistance. CNA C said she knew Licensed Practical Nurse (LPN) K was on her way to assist CNA G with the transfer when, for an unknown reason, CNA G began the transfer alone. On 9/9/2021 at 10:56 a.m., a telephone call the last known contact information to CNA G was placed. A voice mail was not able to be left, and a message prompting the caller to send an SMS (short messaging service) message with contact information was available and utilized. On 9/9/2021 at 10:58 a.m., a text message was sent to CNA G, introducing the surveyor and asking for a return call at the number texted from. No return call was received as of the writing of the report (9/15/2021). On 9/9/2021 at 11:27 a.m., a telephone call was placed to the contact information provided for LPN K. A voice mail was left and as of the date of exit (9/9/2021), no return call was received. Review of the facility investigation reflected the facility implemented to following interventions that identified the non-compliance: On 8/6/2021: 1. The facility validated that two CNA's (CNA G and CNA C) as well as LPN K were present on the unit at the time of the occurrence. 2. CNA G was interviewed and provided a re-enactment of the occurrence for the Nursing Home Administrator (NHA) and Director of Nursing (DON). Re-education and review of facility policy for transfers completed at that time with CNA G and all nursing staff present. 3. Mandatory re-education on mechanical lift protocol initiated for all nursing staff, including review of Safe Lifting and Moving policy and procedure. All nursing staff have been required to demonstrate competency with Hoyer lift transfers during observation by a Registered Nurse (RN). 4. All nursing staff and some recently separated were interviewed by NHA to determine if occurrence was an isolated incident or a facility wide practice. 5. All mechanical lift slings were inspected. 6. All Hoyer lifts were inspected. On 8/9/2021: 1. Random mechanical lift audits initiated. On 8/13/2021: 1. CNA G was terminated from employment at the facility. On 9/9/2021, this surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 8/13/2021. .

Based on observation, interview, and record review, the facility failed to follow CDC (Center Disease Control) and CMS (Centers for Medicare and Medicaid Services) guidelines and recommendations to contain and prevent the spread of COVID-19, resulting in an Immediate Jeopardy (IJ) when the facility staff did not appropriately utilize or don (apply) PPE (personal protective equipment) and follow basic infection control practices, resulting in nine additional residents contracting COVID-19 subsequent to Resident #1 contracting COVID-19 and contributing to three resident deaths (Resident #2, Resident #5 and Resident #6) and the continued risk for infectious disease spread in the facility. This deficient practice placed all residents and staff at risk for serious harm, injury, and or death from COVID-19 and other infections. Findings include: Review of a facility provided Covid Positive Resident Data revealed 9 residents had tested positive for COVID-19 since [DATE]. The facility verbally reported on [DATE] an additional resident had tested positive for COVID-19 for a total of 10 residents cumulatively positive for COVID-19. During an entrance conference with the facility Nursing Home Administrator (NHA) starting at approximately 10:50 AM on [DATE], he stated that Resident #1 had initially tested positive for COVID-19 and had readmitted to the facility after briefly discharging to the hospital. After Resident #1's positive test results, other residents that were initially in the same hall as Resident #1 began to test positive (within a few days of the initial Resident #1 COVID-19 positive result). Review of facility provided Covid Positive Staff Data revealed fourteen staff members had tested positive for COVID-19 since [DATE]. The first staff member in the current outbreak tested positive [DATE]. Resident #2 Review of face sheet and Electronic Medical Record (EMR) revealed Resident #2 was an [AGE] year-old resident who initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility provided Covid Positive Resident Data revealed Resident #2 initially tested positive for COVID-19 on [DATE]. Review of resident EMR Progress notes revealed they had no signs of life at 10:15 am on [DATE]. Resident #5 Review of face sheet and EMR revealed Resident #5 was a [AGE] year-old resident who initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility provided Covid Positive Resident Data revealed Resident #5 initially tested positive for COVID-19 on [DATE]. Review of resident EMR Progress notes revealed they had Res expired at 1235 (12:35 AM) on [DATE]. Resident #6 Review of face sheet and EMR revealed Resident #6 was a [AGE] year-old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. Review of facility provided Covid Positive Resident Data revealed Resident #6 initially tested positive for COVID-19 on [DATE]. Review of resident EMR Progress notes revealed they had At 6:14 pm Resident (#6) was assessed by two nurses and resident was noted to have no signs of life on [DATE]. Per facility provided policy Handwashing/Hand Hygiene with a most recently revised date of [DATE] revealed: This facility considers hand hygiene the primary means to prevent the spread of infection .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to personnel, residents, and visitors. Per facility provided policy Infection Control Policy with a date of [DATE] the goal of the infection control program is to prevent and control the spread of infection. The procedure is to include: A. Educating employees .B. Conducting surveillance. C. Monitoring for outbreaks of infectious disease. D. Taking corrective action to remedy deficient practices. E Keeping records of surveillance, outbreaks and corrective action taken by the facility. Per information retrieved from facility education website https://rcortes96.wixsite.com/covid-19 retrieved on [DATE]: procedure for PPE/Isolation Management in COVID19 Unit includes: At the isolation cart, use hand sanitizer, don hair covering, goggles, booties and gloves. Directions for Use of PPE for Nursing Staff include: Once on the unit, place your labelled bag (date, your name and clean written on the outside) on the table in the quiet room. This is considered your clean mask because you will not be wearing it into an isolation room .As you are preparing to enter the room of a resident who is NON-COVID but in isolation (transmission based precautions/TBP; isolation cart should be outside room), place your clean mask inside a paper bag found in the isolation cart, label with your name and clean (you can also use your clean bag from the quiet room). Set the clean mask and bag on top of the overbed table located outside the isolation room. Obtain another mask and bag from the isolation cart. Write on bag your name, the date and soiled. Lay bag on top of overbed table outside room. Wear this mask into the isolation room. Complete care. Remove gloves and wash hands. Standing in the doorway of the room, place the soiled mask inside the soiled bag that you just labelled. Fold the top of the bag down. Set the soiled bag on top of the overbed table located just outside the isolation room. NOT on top of the isolation cart. Step over the doorway. USE HAND SANITIZER. Retrieve your clean mask from the clean bag. This soiled mask will remain on the overbed table until the next time that you need to enter the room. This mask can be used for one week. At the end of the week, replace with a new mask. In reference to gown use: Anytime you must leave the unit, remove the gown near the receptacle near double doors at end of unit. TO REMOVE THE GOWN carefully fold the inside of the gown toward the outside, roll up and place in trash receptacle. Use hand sanitizer. A clean gown MUST be worn each time you enter a unit and removed before leaving. This helps prevent the spread of disease. **If you will be off the unit for only a short period of time, remove the gown, fold the inside toward the outside and place over railing near double doors at end of unit. PPE use for non-nursing staff include: Dietary, EVS, Activity, and other non-clinical staff will use the re-usable/washable yellow gowns rather than the thinner, disposable yellow gowns. Apply gown before proceeding onto unit. During a facility tour on [DATE] at approximately 11:45 AM, CNA (Certified Nursing Assistant) A was viewed providing care in a room with a resident on transmission-based precautions and exiting the room. CNA A was viewed to have the lower strap of their face mask dangling and wearing a face shield. They were viewed to doff (remove) their PPE in the doorway of the resident room, including their face mask. During facility tour on [DATE] at approximately 11:50 AM, a reusable gown was viewed folded over the handrail near the entrance to a facility resident hall. This gown was viewed to still be in the same place at approximately 1:25 PM on [DATE]. At that time, an additional gown was viewed in the same approximate area in a plastic trash bag and tucked inside the handrail. Both gowns remained in the same place and were viewed at approximately 2:00 PM on [DATE]. On [DATE] during an observation that began at approximately 12:15 PM, staff were viewed delivering meals to residents. CNA B was viewed to walk into a resident room to give them lunch and go back to the kitchenette area to pick up two more resident meals. CNA B delivered a meal to the first resident and then entered another resident room to deliver their meal. CNA B realized they had given the wrong meal to the wrong resident, so went back to room [ROOM NUMBER] to retrieve the resident meal and take back to room [ROOM NUMBER]. CNA B then realized they had not given the resident in room [ROOM NUMBER] silverware, so took silverware to their room. No hand hygiene was observed during this observation. CNA B was also viewed to have both straps of their face mask high on their head above their ponytail and the straps were on top of one another. On [DATE] during an observation that began at approximately 12:25 PM, Housekeeping Staff C was viewed removing laundry from the soiled laundry bin without a gown on and a glove on only their left hand. The soiled laundry was viewed to not all be in trash bags. Staff C placed all the soiled laundry in an uncovered laundry bin and exited the unit without completing hand hygiene. Staff C went through two additional doors to arrive to the laundry sorting area. Staff C removed the glove on their left hand, donned a washable gown over their head that was already tied at the neck, they did not tie the bottom ties on the back of the gown. Staff C then put plastic gloves on both their hands and began sorting laundry. After sorting laundry Staff C removed their gloves, took the washable gown off by slipping it over their head, and then opened the door to the main laundry area, Staff C then washed their hands with soap and water. On [DATE] at approximately 12:45 PM during an interview with CNA D they stated they work both on the non-isolation unit as well as the COVID-19 isolation area. CNA D stated they change their mask and all their PPE while entering and exiting the COVID-19 unit or when caring for a resident on isolation. They are issued 2 masks a week , a clean mask that they wear to provide care for residents not on precautions and a dirty mask they use for the COVID-19 unit and for other residents on transmission-based precautions. CNA D stated you could choose whether to wear goggles or a face shield in the COVID-19 unit depending on your preference. On [DATE] at approximately 12:50 PM an interview was completed with Housekeeping Staff E. Staff E stated they are issued 2 masks each week and they alternate using every other day. Staff E stated after they use a mask for the day, they spray the inside with an alcohol solution before placing in the paper bag to store. Staff E stated they store their masks in the housekeeping closet (this was viewed to be down the hall about 10 resident rooms from the hall entrance) and change from a surgical mask to their weekly issued masks when they retrieve their cleaning cart. Staff E was asked about what cleaners they use for resident rooms and stated they use a quat solution for mopping. Staff E stated they were not sure of the contact time for disinfection and stated, I would assume until it dries, my previous job I think the cleaners needed 10 minutes. Staff E had a plastic covered container with rags in it on top of the cleaning cart and was asked what the cleaning solution was in that container. Staff E stated that its a bleach solution that is about a third cup of bleach and another cleaner. Staff E retrieved a bottle of Comet Disinfecting Bathroom Cleaner from the cart and stated again this is what was mixed with bleach to clean high touch surfaces, such as railings and bedside tables. Staff E stated they thought other people may use a bleach and water solution for wiping down surfaces. Staff E was asked what the contact time for the cleaning solution would be and they retrieved the bottle again from the cart and read the label, it looks like about 10 minutes. On [DATE] at approximately 1:00 PM an interview was completed with LPN F. They stated they receive 2 masks each week and use one for the isolation rooms and one for the rest of the unit. LPN F stated they change masks in the doorway of the resident room. When entering the unit, LPN F stated they enter the unit in a surgical mask and then enter the Quiet room to switch into their KN95 or N95 mask. The masking room was viewed to be past several resident rooms from the unit entry. LPN F was asked about the PPE (Personal Protective Equipment) protocol for the different precautions and they stated they were not sure of everything off the top of their head. LPN F stated they get texts and reminders to regularly look at the webpage. During the interview with LPN F, CNA G approached the same area and they were asked about PPE Protocol and they reached in their pocket and produced instructions that were several pages thick and folded up. CNA G stated that there has been changes recently so they try keep an up to date copy on them. On [DATE] at approximately 1:25 PM, Housekeeping staff H was viewed on the unit without the bottom of their gown tied. CNA A was again viewed with the bottom strap of their mask dangling and they were providing care to a Resident #4 in the hall in front of the nursing station and then transported the Resident #4 to their room. CNA A was in view of LPN I and was having a conversation with them and regarding the resident and LPN I did not prompt CNA A to fix their mask. An opened trash bag was viewed on the floor just outside a resident room who was on transmission-based precautions. The trash bag was viewed to have discarded gloves and disposable gowns in it. On [DATE] at approximately 1:30 PM an interview was completed with LPN I. LPN I stated they work on both halls of the facility and work on the COVID-19 unit. LPN I stated both nursing staff and aides must work both the general unit and COVID-19 unit because some residents on the COVID-19 unit are 2 person assists. LPN I stated you switch all PPE and wear goggles, hair cover and booties in the COVID-19 area. LPN I stated they have not been fit tested for the N95 they are wearing and they get a different one every week, last week I had a KN95 mask so I put a surgical mask over it. LPN I indicated they enter the unit with a surgical mask on and they put on their N95 or KN95 in the Quiet room was viewed to be past several resident rooms from the unit entry. The masks worn on the general unit are to be placed in a bag marked clean and the mask used on the COVID-19 unit is dirty. On [DATE] at approximately 1:45 PM, LPN K was viewed entering the unit. They took a gown from the PPE cart at the entrance and started to walk down the hall with the gown and personal belongings in their hands, then turned around and went back to the PPE cart and placed their coat, a pop and a backpack down. They donned the disposable gown, picked up their pop, put the coat over their arm and slung the backpack over one shoulder. They were not viewed to complete hand hygiene. CNA L was viewed entering the unit shortly after. CNA L put the bag they were carrying on the floor, took their coat off and laid it on top of the soiled linen and garbage containers and then donned a disposable gown, they then picked up their bag and place over their shoulder and carried their coat with them on the unit. No hand hygiene was viewed. LPN K was then viewed coming out of the Quiet Room with the top ties of their gown untied and they went into a resident room. On [DATE] at approximately 1:50 PM, CNA A was viewed to exit one resident room and then enter another without completing hand hygiene, their lower mask strap was still dangling. Housekeeping Staff H was viewed with their bottom gown straps still untied and then viewed to place their personal belongings in a cloth chair in a resident common area along with a trash bag with a reusable gown in it and they went into the restroom. After exiting, Staff H completed hand hygiene, removed their mask while standing in the common area and put on their surgical mask without completing hand hygiene in between. They walked towards the quiet room with their mask while wrapping the straps tightly around the mask. Staff H returned to the common area, picked up their personal belonging and the trash bag with a gown in it. Staff H put their personal belongings on the PPE cart, doffed the gown they were wearing and placed in the trash bag with the other gown and placed in soiled laundry. Staff H then picked up their personal belongings and exited the unit with no hand hygiene. On [DATE] at approximately 1:55 PM, CNA J was viewed coming onto the unit. CNA J placed their coat, and a bag on top of the soiled laundry and garbage containers and placed a cup and what appeared to be a mask bag on the PPE cart and donned a disposable gown. They picked up all their personal items and began walking onto the unit, paused, then put alcohol based hand rub on their hands while struggling to hold all their items and wiped their hands together a couple times before continuing to the unit. On [DATE] at approximately 2:00 PM an interview was completed with CNA A. CNA A was questioned about using only one strap on their mask and they said Oh no! It's a bad habit when removing gear quickly that happens sometimes! CNA A then stepped aside to a table in the common area, took off their face shield, took off their glasses and then removed their mask in the hall. The mask straps fell into the cup of the mask and CNA A reached into the mask cup to retrieve the straps and donned the mask again. CNA A then replaced their glasses and face shield. Hand hygiene was not completed during this interaction. On [DATE] at approximately 2:55 PM, observations were completed on the COVID-19 isolation unit. CNA L was viewed to have no shoe covers/booties on their feet and no gloves on. Their gown was pushed up on their forearms. They were viewed to enter and exit resident rooms multiple times with no gloves on. LPN K was viewed to leave one resident room and enter another without completing hand hygiene or changing their gloves. They were viewed placing hands on a resident, leaving the room to obtain the thermometer, re-entering the resident room to obtain a temperature and touching the resident then leaving the room to sanitize the thermometer without completing hand hygiene or changing gloves. The thermometer was later taken by CNA L into another resident room. A discarded N95 mask was viewed sitting on an isolation cart in the hall. CNA L was asked about the mask and they were not aware of where it came from or whose it was. CNA L advised the first room inside the COVID-19 isolation unit is where supplies like linens and cleaning supplies were stored for the unit and a makeshift nurse's station. The door to the room was open to the rest of the unit and clean linens such as blankets, sheets and towels were viewed on a table uncovered. Also, in this room a ziplock bag was viewed with a CNA L's name on it and clean and a mask was viewed in the ziplock bag. CNA L was questioned if there were 2 person assist residents on the COVID-19 Isolation unit, they stated that there were. CNA L stated that sometimes the nurse on the hall helped with transfers, but at times the aide on the non-isolation hall will come to assist. An interview was completed with the DON (director of nursing) and UM (unit manager) M on [DATE] related to infection control policies and procedures. The DON confirmed that staff in the COVID-19 unit are to wear gowns, goggles, shoe covers, gloves, hair covering and N95. It was questioned if face shields were allowed as an alternative to goggles and the DON stated that specifically goggles are to be worn in the COVID-19 unit. The DON acknowledged there are residents on the COVID-19 isolation unit that are 2 person assists and they ask that the nurse do the transfers with the aide assigned to the COVID-19 unit to limit the people on the unit. Laundry staff are expected to use PPE consisting of N95, gown, protective eye wear and gloves. The DON and UM M were asked about a cumulative list of residents and staff that have tested positive for COVID-19 since a weekly list with all infections was all that was received. UM M was noted to oversee completing the infection surveillance and stated they had not yet had time to do a cumulative list specific to COVID-19 infections. After review of some of the surveillance data, there was some concerning and incomplete information noted by the surveyor to UM M and the DON. Dates of symptoms and specific dates of positive tests were not all documented, and last day worked and time off for employees was not documented in a clear manner. UM M stated they could understand how the information was confusing and verbally explained some of the discrepancies and concerns. On [DATE] at 11:10 PM, the Nursing Home Administrator (NHA) was informed of an Immediate Jeopardy (IJ) that began on [DATE] when the facility became aware that Resident #1 tested positive for COVID-19 and the facility subsequently failed to follow CDC and CMS guidelines to reduce the potential for the spread of COVID-19 due to staff not wearing PPE properly, housekeeping staff not being aware of contact times and mixing unapproved chemical cleaners together that were potentially hazardous, soiled PPE material not being secured, laundry staff not wearing PPE or completing hand hygiene while collecting and sorting laundry, staff donning PPE after entering the unit, and contaminating with personal items, and staff not completing necessary hand hygiene. On [DATE] at approximately 4:55 PM, the facility plan to remove the Immediate Jeopardy was accepted and the state agency began to validate the removal plan with which included: On [DATE], the Administrator assured that there was proper PPE available to all staff. All KN95 masks were locked up in the Admin office and have not been distributed except for management and non-nursing staff to optimize N95. 1. On [DATE], The EVS (Environmental Services) Director confirmed that the mixing ratios for bleach water is from the CDC guidance. The employee who made a unilateral decision to mix bleach in any other manner who was investigated and disciplined appropriately. The housekeeping chemicals are automatically metered via mixing devices from our Chemical Vendors. The EVS Director will assure that the CDC bleach ratio will be posted in the housekeeping closets on a laminated sheet with a warning to not deviate from the posted chemicals due to the hazard it poses and if they have any questions to see their supervisor immediately. Beginning on [DATE] the EVS trained the housekeeping staff on the use of chemicals per policy including the kill time of each and observed the housekeeping staff properly mixing the chemical. The EVS included a post-test with the kill test of each chemical. 2. On [DATE], the DON reviewed the policy and procedure for use of PPE and deemed it appropriate. Immediately the administrator updated the website and mass message all staff that they must use a buddy system when donning to ensure that PPE is donned correctly but, also to assist in your fell ow staff members back tying of gowns. Beginning [DATE], the DON trained the nursing staff on proper use of PPE. This included donning and doffing, proper wearing, and proper discarding of soiled PPE. The DON included a return demonstration of proper donning and doffing of PPE. 3. On [DATE], the DON reviewed the policy and procedure for hand hygiene and deemed it appropriate. Beginning [DATE], the DON trained the nursing staff on proper hand hygiene. The DON included a return demonstration of proper donning and doffing of PPE. 4. On [DATE], The NHA investigated laundry staff why they were not wearing a linen gown to collect the linen. The NHA reviewed the policy for transport of linens to and from the units as well as the policy to handle soiled linens using the proper PPE. Beginning on [DATE] the EVS trained the laundry staff on the proper handling of soiled linen including use of PPE and hand hygiene. 5. On [DATE], the NHA communicated to all staff that no personal items are allowed on the unit and must be placed in the main break room outside of the care units. The DON assured that there are soiled waste and soiled in containers with lids and/or soiled linen containers with lids for doffing of PPE including gowns before one exits the unit. All linen gowns will be doffed into soiled laundry when exiting units. A mass message will be sent out to ensure that all staff understand as well as manager sign off sheets for all subordinates. 6. On [DATE], the DON reviewed the policy for waste (doffed PPE) and determined it is appropriate as it should be doffed into a plastic bag in a container with a lid. When full the staff wearing full PPE, removes the liner, ties the liner in a knot, and places in the proper disposal area. 7. Beginning on [DATE] the NHA assigned the following observation/monitoring audits: 1. Nursing managers will observe at least ten staff working various non-COVID units and 3 staff working on the COVID unit on various shifts daily for proper donning and doffing of PPE, proper wear of PPE throughout the shift, and proper disposal of soiled PPE. This includes observation of personal items and where these are placed when entering and leaving the unit. The observer will take immediate correction if needed and provide results of audits to the IP for further action. 2. EVS will observe at least 2 housekeepers mixing chemicals Monday through Friday to assure the chemicals are mixed and use properly. This audit will include asking the housekeeper about the kill time of products he/she is using. The observer will take immediate correction if needed and provide results of audits to the IP for further action. 3. The IP / designee will observe ten people daily on various shifts to assure they are performing hand hygiene when needed and performing it correctly. The observer will take immediate correction if needed and provide results of audits to the IP for further action. 4. The EVS will observe at least two times per day that soiled linen is properly handled and transported by laundry personnel. The observer will take immediate correction if needed and provide results of audits to the IP for further action. Per information retrieved from facility education website https://rcortes96.wixsite.com/covid-19 retrieved on [DATE]: Until further notice, personal items are no longer allowed on the nursing units due to cross contamination concerns and potential. Personal items must be placed in the main break room outside of the care units. Check locker availability for storage in main break room off of nursing units. ALL STAFF - You are now required to use the buddy system when donning PPE. This is to ensure that you have a buddy to help tied your isolation gown back and to double check your PPE donning to ensure appropriate fitment. This is mandatory with NO exceptions. You are not to proceed until a buddy has verified that your PPE is donned correctly. We will be performing audits with immediate disciplinary action against those who willfully deviate from our PPE policy and procedures. All EVS staff transporting linens to and from the units must follow the PPE Use for NON-Nursing Staff procedure located on this website. All laundry staff must wear a washable isolation gown, eye/face shield, N95 mask and gloves on both hands when collecting soiled laundry. Laundry staff will practice standard hand hygiene throughout entire shift as needed. When laundry staff exit non-COVID nursing units, they must follow doffing procedures. Laundry staff must don a new isolation gown when exiting non-COIVD nursing units. Washable gown will be available at non-COVID nursing unit entrance. Per facility provided education Contact 'Kill' times for disinfecting chemical the cleanser Mint Quat was listed with a 10 minute kill time. The education also revealed do not deviate from the posted chemicals due to hazards it poses. On [DATE] at 10:45 AM, CNA N was viewed exiting a resident unit with personal items, they placed a purse and coat on the handrail while preparing to doff their PPE. UM O approached CNA N and reminded them that personal items were to be placed on the table by the door and CNA N moved them. CNA N was then viewed to doff gown, eyewear and N95 mask and then don a surgical mask without hand hygiene. When touring the unit, an isolation cart and bedside table were noted by the room of one resident with the door ajar and a bedside table with PPE on it was viewed outside Resident #4's room, the room door was viewed to be about halfway open. UM O was asked if the residents were now on transmission based precautions and they stated, I understand they tested positive for Covid this morning and rooms are being prepped for them (in the COVID-19 unit). UM O stated they did not yet have an isolation cart for Resident #4's room but they were working on it. On [DATE] at approximately 11:10 AM an interview was completed with UM M who was completing COVID-19 rapid testing. UM M advised that two residents had tested positive for COVID-19 today: Resident #4 and an additional resident on the same unit. On [DATE] during observations beginning at approximately 11:15 AM, an isolation cart was still not present outside of Resident #4's room. A personal coat was viewed draped over a chair at the nurse station. CNA N was viewed entering the unit again with personal items. They were viewed to doff their surgical face mask, don a gown, don an N95, touch their hair, adjust their mask, put on eyewear before performing hand hygiene again. LPN I was viewed to pick up the coat from the nurse station and went to exit the unit. LPN I was viewed to doff gown, N95 mask and placed on their surgical mask and then complete hand hygiene. On [DATE] at approximately 11:30 AM, CNA Q was viewed preparing to enter Resident #4's room, who was on transmission-based precautions due to testing positive for COVID-19. They were viewed to unfold a paper bag for a mask by placing their hand inside without completing hand hygiene first, they took a gate belt with keys on it off their shoulder and place it on the railing outside the room, they doffed their gown and then realized there was no trash can available, so they shouted for the housekeeper for assistance. They were viewed with the door open to the resident room and talking to the resident with no mask on. CNA Q continued to don PPE and yelled to Housekeeping again and then LPN I that there were no gloves. Resident #4 came to the doorway where CNA Q was donning PPE while waiting for gloves. After donning PPE, CNA Q put the gait belt and keys over the gown and entered the resident room, the door was left fully open. On [DATE] at approximately 11:45 AM LPN I was viewed delivering medication to a resident on transmission-based precautions who had just tested positive for COVID-19. LPN I did not don shoe covers prior to entering the room. When leaving the room, LPN I was viewed to doff gown and gloves, adjust the trash, take off goggles and switch N95 mask and donned a new gown without completing hand hygiene in between steps. During this time, lunch service was beginning, and 4 different rooms were viewed to have food delivered on a reusable tray. During an entrance conference with the facility NHA starting at approximately 10:50 AM on [DATE], the NHA had advised that dining services were using all disposable dining wear throughout the entire facility. On [DATE] at approximately 11:55 AM Housekeeping staff S was interviewed. They stated they were recently reeducated on PPE use and chemical cleaners. They were asked what solution was in their mop bucket and they stated it was a quat solution. Staff S stated the kill time was 2 minutes. On [DATE] at approximately 12:05 PM CNA N was viewed handing CNA Q a reusable lunch tray with containers on it into the room of Resident #4, who was on transmission-based precautions due to a positive COVID-19 result. Shortly thereafter, the tray was (TRUNCATED)

Based on observation, interview and record review the facility failed to operationalize the facility abuse policy and have procedures in place to identify, report and thoroughly investigate allegations of staff to resident abuse and injuries of unknown (significant bruising and a fracture) origin for 3 of 11 sampled residents (Residents #3, #10, and #2) reviewed for abuse, from a total sample of 15 residents, resulting in Immediate Jeopardy and the potential for all allegations of abuse and neglect to continue undetected, not be reported or investigated. Findings include: Review of the facility Abuse Policy and Prevention Program last revised 8/26/14 indicated some of the goals of the program were to 4. Establish a process for reporting abuse or suspected abuse to government agencies. 5. Establish a process for investigating abuse or alleged abuse within the facility. 6. To assist our staff members in recognizing incidents/suspected incidents of abuse, and to know any reports of abuse/suspected abuse be made without fear of retaliation from the facility or its staff members. Definitions and Terminology in the policy did not include a description of injuries of unknown origin. The policy did not indicate when allegations of abuse were to be reported or to whom. Resident #3 Review of a facility Admission Record dated 7/25/16 indicated Resident #3 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was severely cognitively impaired and needed extensive assistance from one person for transfers and toilet use. Review of incident reports indicate Resident #3 had a fall without injury on 5/11/16 and on 5/17/16. An x-ray of Resident #3's right shoulder was ordered on [DATE] due to Resident #3's complaint of pain with range of motion to the right upper extremity and bruising following the fall on 5/17/16. The results of the x-ray taken on 5/17/16 were negative for a fracture. Review of Progress Notes from the entry 5/20/16-6/4/16 did not reflect any further mention of any pain or difficulty with ROM for Resident #3. A Progress Note dated 6/5/16 at 9:20 a.m. documented by Licensed Practical Nurse (LPN) E reflected Resident #3 was sitting in her chair near the nurse's cart and almost crying and rubbing her right arm, from the pain. Review of a Progress Note from 6/8/16 indicated an x-ray had been ordered for Resident #3's right shoulder due to continued pain and swelling. Review of a radiology report dated 6/8/16 at 6:26 p.m. indicated Since the last examination on 5/17/16, there is evidence of development of a comminuted displaced fracture arising from the lateral aspect of the acromion process of the scapula with bony fragments in this region with one of the bony fragment appearing to be considerably displaced inferiorly and is now seen adjacent to the lateral aspect of the proximal shaft of the right humerus. Possible mild subluxation of the right humeral head appears to be present in relation to the glenoid rim. Mild spur function seen at the right acromioclavicular and shoulder joints. A collection of calcifications is again seen along the superior aspect of the acromioclavicular joint from possible calcific tendinitis or bursitis without change. During an interview on 7/26/16 at 4:00 p.m., Nursing Home Administrator A said he was not notified immediately of the fracture of unknown origin on 6/8/16. NHA A reported he did not report to the state agency the injury of unknown origin discovered on Resident #3. NHA A said as soon as he was informed of the fracture on 6/9/16, he and the Director of Nursing (DON) B began interviewing staff at the facility in relation to the injury of unknown origin. When asked why he began interviewing staff NHA A said To rule out abuse. NHA A was asked for the incident report and complete investigation file pertaining to the injury of unknown origin identified on 6/8/16. No incident report was made pertaining to the injury of unknown origin and there was not a complete investigation file into the injury of unknown origin. NHA A stated he did not report the injury of unknown origin because he thought he knew how the fracture occurred. Review of a radiology consult emailed to the facility on [DATE] reflected Our radiology consultation is complete. It has been reported by the radiologist that: The May 17 report reveals no fracture. The June 8 report shows fragments that were not present in the May x-ray but they are present in the June x-ray. It is the impression of the radiologist that some form of trauma occurred between the May x-ray and the June x-ray which caused the fracture. ( ) Resident #10 Review of a facility Admission Record indicated Resident #10 was an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set quarterly assessment dated [DATE] indicated Resident #10 was severely cognitively impaired and needed the assistance of two people for bed mobility, transfers, hygiene, bathing and toileting. A review of a Psychiatric Evaluation dated 6/22/16 revealed Resident #10 had been transferred from the facility to a psychiatric facility for increasing depression and confusion. The evaluation documented a Past Psychiatric History which reflected The patient has a known history of depression, Alzheimer's type dementia, and possibly some personality issues. The note a baseline personality as being very negative, pessimistic, and cantankerous. She often presented with a barrage of complaints against staff and alleged mistreatment. Review of a physician progress notes [REDACTED].#10) has somewhat of a disjointed complaint. She states that the ladies come in there and toss her around in bed. She seems to be complaining just about everything but cannot really explain herself well. Incident and Accident or occurrence reports for Resident #10 were requested from Director of Nursing (DON) B, Quality Assurance Nurse (QA) C and Social Worker (SW) H in order to identify when and what Resident #10 had alleged. DON B, QA C and SW H reported there were no incident reports into allegations of mistreatment. Review of the clinical record for evidence Resident #10 alleged mistreatment revealed a Progress Notes dated 5/15/16 which reflected Resident is moody, and argumentative with staff. Buttock is slightly pink, continue nutrashield. Resident repositioned during the night related to buttocks being red and was upset with staff this morning that she refused to go to the dining room and take her medicine. Morning care done, ate a snack for breakfast, and later she drank her med pass supplement. Complained of being sore, nurse brought Tylenol for resident and she refused to take it, said she was not in pain or sore. Asked the nurse where she should have pain at. She continued to deny pain, nurse made another attempt to give resident her morning meds, and she continued to refuse unless I could answer her questions about the staff. No indication what the questions about staff were and no documentation about why she was upset with staff was found. During an interview on 7/28/16 at 9:15 a.m., Nursing Home Administrator (NHA) A was shown the documentation from the psychiatric hospital and the physician progress notes [REDACTED]. NHA A said he would have reported the allegations to the State Agency if he had been made aware. ( ) Resident #2 Review of Resident #2 ' s face sheet dated7/25/16 revealed she was an [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #2's last Brief Interview of Mental Status (BIMS) was 5/20/16 and Resident #2 scored 7/15 (indicating moderate mental impairment. Resident #2 was observed in bed on 7/26/16 at 8:16 AM. Resident #2 had a dark colored bruise under her right great toe nail and her left foot was bruised and swollen from her mid foot to 2 above her ankle. Resident #2 was asked what happen to cause these injuries and Resident #2 said she did not know how they happened and denied any pain in her feet at that time but said she hurt all over. Licensed Practical Nurse (LPN) E came into Resident #2's room on 7/26/16 at 8:22 AM and Resident #2 reported she had pain at level 8 on a scale of 1-10 and said the pain was all over. LPN E explained to Resident #2 she was given the pain medication [MEDICATION NAME] (narcotic pain medication) at 5 AM and now she could get her [MEDICATION NAME] (narcotic pain medication). LPN E gave Resident #2 a [MEDICATION NAME] (narcotic pain medication at 8:28 AM. LPN E was asked how Resident #2 injured her feet and LPN E said she did not know about the right toe but had discovered the left foot/leg bruise last week and when she called Resident #2's family contact they indicated the injury might have happened when resident #2 had gone out to a doctor's appointment. LPN E did not know who was with Resident #2 when she went to the doctor or why the family thought the injury could have occurred at that time. LPN E said she documented finding the injury on the incident report but did not know where she should document the information family provided. Certified Occupational Therapist (COTA) F came into Resident #2's room on 7/26/16 at 930 AM. COTA said she did not know how Resident #2 injured her feet and said Resident #2 was picked up by therapy about a week ago. COTA F she had not observed Resident #2 using her feet to move her wheel chair since she started therapy about a week ago. On 7/26/16, at 10:10 AM, COTA F and Physical Therapist G assisted Resident #2 to the edge of her bed and walked with Resident #2 to the bathroom with a front wheeled walker (approximately 10' to 15'. With each step Resident # 2 yelled out in pain my ankle, my ankle. COTA F said she walked with her yesterday and she yelled out in pain too, but as she got moving she complained less. (Resident #2 had received narcotic pain medication less than 2 hour before walking and was still yelling out in pain). During an interview with Licensed Practical Nurse C and the Director of Nursing B on 7/26/16 the Surveyor asked what happened to Resident #2's feet and said 7/25/16 all incident/accident reports with full investigation for Resident #2 were requested and the last incident/accident report provided was 6/23/16 which indicated Resident #2 had a bruised right great but there were no interviews or indication of a thorough investigation to determine how the right great toe became bruised. LPN C said she does an investigation when she returns to work after an incident report is complete. LPN C said she was not aware of the request yesterday for all incident/accident reports and she had the incident/accident report for Resident #2 dated 7/21/16. LPN C said she did not have any interviews for any of the incident/accident reports. LPN C documented on 7/22/16 in the note section of the incident report dated 7/21/16 at 14:37 (2:37 PM), Name of Resident #2 has been social in building with self-propelling (sp) of wheelchair to and from activities on and off the unit. She is currently working with OT (occupational therapy) and PT (physical therapy). Will f/u (follow up) with therapies for review of self-propelling/wheelchair management NSG (nursing to continue monitoring area. COTA F said in the interview at 9:30 AM, on 7/26/16 she had not observed Resident #2 self-propel her wheelchair in the last week and did not indicate she felt the injury was related to self-propelling her wheelchair. LPN F could not find any interview that confirmed any problem with Resident #2 propelling her wheelchair and could not note a date or time she had observed Resident #2 having any difficulty self-propelling her wheelchair. LPN F was asked for interviews and investigations for Resident #2 incident reports indicating injuries of unknown origin dated 1/13/16, 4/18/16, 6/5/16, 6/20/16 and 6/23/16. LPN F said she did not have any interviews and could not provide any additional information as to how these injuries occurred. DON B and LPN F said they were not aware Resident #2 was yelling out about ankle pain when walking for the last two days and said an x-ray of Resident #2's ankle had not been done, but would get an x-ray ordered today. DON B was asked on 7/26/16 at 1L:06 PM, if the facility had a policy on reporting injuries of unknown origin to the state and doing an investigation of injuries of unknown origin an and DON B said, No. Nursing Home Administrator (NHA) A was asked on 7/26/16 at 1:15 PM if the facility had a policy on reporting injuries of unknown origin to the state and doing an investigation of injuries of unknown origin an and NHA A said, No but he was aware he needed to report injuries of unknown origin. NHA was asked why he did not report Resident #2 ' s multiple injuries of unknown origin and he said, I will have to talk to my staff and get back to you. Later NHA said staff did not think Resident #2's injuries were suspicious so he did not report them. NHA A said he was not aware LPN F was not doing interviews to determine the cause of injuries of unknown origin and was not aware of her investigation process. At 4:45 PM, on 7/26/16, NHA A provided a copy of Resident #2's x-ray done on 7/26/16 at 16:03 (4:03 PM) that documented there was no evidence of fracture of dislocation of Resident #2's left foot/ankle. ( ) On 7/27/16 at 12:54 p.m., NHA A was informed of an Immediate Jeopardy (IJ) that was identified on 7/26/16, and began on 1/13/16, as a result of the facility's failure to identify, thoroughly investigate and report to the State Agency injuries of unknown origin for two residents (Resident #2 and Resident #3) and for failing to operationalize the facility abuse program policy and abuse program procedure. This deficient practice placed all residents, who live at the facility, at risk for serious physical and psychosocial harm, injury and/or death. On 7/27/16 at 9:00 a.m. the State Agency surveyors were able to verify the following interventions had been started to remove the Immediate Jeopardy: · Beginning on 7/27/2016 Resident #3 has been assessed by a licensed nurse. Her cognition was at baseline. Range of motion was within normal limits to all extremities with exception of left ankle which was minimally impaired due to presence of ace wrap. She had no indicators of pain during range of motion assessment. She was laughing and smiling during the assessment. She complained of overall discomfort. No numbness or tingling noted to lower extremities. Pedal pulses present. Slight [MEDICAL CONDITION] to left foot with fading bruises. Resident #2 has been assessed by a licensed nurse. Her cognition was baseline. Range of motion was within normal limits to all extremities. No indicators of pain. · The investigation process has been relaunched for both residents #3 as of 7/27/16. · Other residents who could be affected include any resident who had an injury of unknown origin that meets the definition of Injury of Unknown Source as defined in the facility ' s abuse policy. Residents who meet this criteria in the previous 6 months have started to be assessed in relation to any patterns that can be established relative to ongoing risk as of 7/27/2016. · Residents with BIMS 8 or higher have started to be interviewed for abuse, the rest of the residents will be included into a skin sweep to identify potential Injuries of Unknown Source as of 7/27/2016. · Education of all staff in relation to changes in the abuse policy in regard to reporting abuse/suspected abuse and reporting injury of unknown source has begun on 7/27/16. · As of 7/27/2016 an auditing tool has been developed and implemented to assure compliance with this plan of correction. All incidents of unknown origin will be reviewed during the morning meeting and QAPI meetings for the next 3 months. Further review will be determined by the QAPI Committee. Although the Immediate Jeopardy (IJ) was removed on 7/27/16, the facility remained out of compliance at a scope of widespread and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency. ( )

This citation has 2 Deficiency Practice Statements, A and B. Deficiency Practice Statement A Based on observation, interview and record review the facility failed to identify, report and thoroughly investigate allegations of staff to resident abuse and injuries of unknown (significant bruising and a fracture) origin for 5 residents (Residents #3, #10, #13, #14 & #14) out of 11 sampled residents and 4 residents added for an extended survey resulting in Immediate Jeopardy due to the potential for abuse and neglect to continue undetected, not be reported or investigated. Findings include: Review of the facility Abuse Policy and Prevention Program last revised 8/26/14 indicated some of the goals of the program were to 4. Establish a process for reporting abuse or suspected abuse to government agencies. 5. Establish a process for investigating abuse or alleged abuse within the facility. 6. To assist our staff members in recognizing incidents/suspected incidents of abuse, and to know any reports of abuse/suspected abuse be made without fear of retaliation from the facility or its staff members. Definitions and Terminology in the policy did not include a description of injuries of unknown origin. The policy did not indicate when allegations of abuse were to be reported or to whom. Resident #3 Review of a facility Admission Record dated 7/25/16 indicated Resident #3 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was severely cognitively impaired and needed extensive assistance from one person for transfers and toilet use. Review of incident reports indicate Resident #3 had a fall without injury on 5/11/16 and on 5/17/16. An x-ray of Resident #3's right shoulder was ordered on [DATE] due to Resident #3's complaint of pain with range of motion to the right upper extremity and bruising following the fall on 5/17/16. The results of the x-ray taken on 5/17/16 were negative for a fracture. Review of Progress Notes from the entry 5/20/16-6/4/16 did not reflect any further mention of any pain or difficulty with ROM for Resident #3. A Progress Note dated 6/5/16 at 9:20 a.m. documented by Licensed Practical Nurse (LPN) E reflected Resident #3 was sitting in her chair near the nurse's cart and almost crying and rubbing her right arm, from the pain. Review of a Progress Note from 6/8/16 indicated an x-ray had been ordered for Resident #3's right shoulder due to continued pain and swelling. Review of a radiology report dated 6/8/16 at 6:26 p.m. indicated Since the last examination on 5/17/16, there is evidence of development of a comminuted displaced fracture arising from the lateral aspect of the acromion process of the scapula with bony fragments in this region with one of the bony fragment appearing to be considerably displaced inferiorly and is now seen adjacent to the lateral aspect of the proximal shaft of the right humerus. Possible mild subluxation of the right humeral head appears to be present in relation to the glenoid rim. Mild spur function seen at the right acromioclavicular and shoulder joints. A collection of calcifications is again seen along the superior aspect of the acromioclavicular joint from possible calcific tendinitis or bursitis without change. During an interview on 7/26/16 at 4:00 p.m., Nursing Home Administrator A said he was not notified immediately of the fracture of unknown origin on 6/8/16. NHA A reported he did not report to the state agency the injury of unknown origin discovered on Resident #3. NHA A said as soon as he was informed of the fracture on 6/9/16, he and the Director of Nursing (DON) B began interviewing staff at the facility in relation to the injury of unknown origin. When asked why he began interviewing staff NHA A said To rule out abuse. NHA A was asked for the incident report and complete investigation file pertaining to the injury of unknown origin identified on 6/8/16. No incident report was made pertaining to the injury of unknown origin and there was not a complete investigation file into the injury of unknown origin. NHA A stated he did not report the injury of unknown origin because he thought he knew how the fracture occurred. Review of a radiology consult emailed to the facility on [DATE] reflected Our radiology consultation is complete. It has been reported by the radiologist that: The May 17 report reveals no fracture. The June 8 report shows fragments that were not present in the May x-ray but they are present in the June x-ray. It is the impression of the radiologist that some form of trauma occurred between the May x-ray and the June x-ray which caused the fracture. ( ) Resident #10 Review of a facility Admission Record indicated Resident #10 was an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set quarterly assessment dated [DATE] indicated Resident #10 was severely cognitively impaired and needed the assistance of two people for bed mobility, transfers, hygiene, bathing and toileting. A review of a Psychiatric Evaluation dated 6/22/16 revealed Resident #10 had been transferred from the facility to a psychiatric facility for increasing depression and confusion. The evaluation documented a Past Psychiatric History which reflected The patient has a known history of depression, Alzheimer's type dementia, and possibly some personality issues. The note a baseline personality as being very negative, pessimistic, and cantankerous. She often presented with a barrage of complaints against staff and alleged mistreatment. Review of a physician progress notes [REDACTED].#10) has somewhat of a disjointed complaint. She states that the ladies come in there and toss her around in bed. She seems to be complaining just about everything but cannot really explain herself well. Incident and Accident or occurrence reports for Resident #10 were requested from Director of Nursing (DON) B, Quality Assurance Nurse (QA) C and Social Worker (SW) H in order to identify when and what Resident #10 had alleged. DON B, QA C and SW H reported there were no incident reports into allegations of mistreatment. Review of the clinical record for evidence Resident #10 alleged mistreatment revealed a Progress Notes dated 5/15/16 which reflected Resident is moody, and argumentative with staff. Buttock is slightly pink, continue nutrashield. Resident repositioned during the night related to buttocks being red and was upset with staff this morning that she refused to go to the dining room and take her medicine. Morning care done, ate a snack for breakfast, and later she drank her med pass supplement. Complained of being sore, nurse brought Tylenol for resident and she refused to take it, said she was not in pain or sore. Asked the nurse where she should have pain at. She continued to deny pain, nurse made another attempt to give resident her morning meds, and she continued to refuse unless I could answer her questions about the staff. No indication what the questions about staff were and no documentation about why she was upset with staff was found. During an interview on 7/28/16 at 9:15 a.m., Nursing Home Administrator (NHA) A was shown the documentation from the psychiatric hospital and the physician progress notes [REDACTED]. NHA A said he would have reported the allegations to the State Agency if he had been made aware. ( ) Resident #13 Resident #13 was an [AGE] year old female admitted to the facility 7/1/16, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated Resident #13 was severely cognitively impaired. Review of the Incident /Accident report dated 7/7/16, at 4:40 PM, revealed Resident #13 was found on the floor with, head under head board of bed' .Alarm was not sounding . Blood pooled under head. The report indicated Resident #13 was transported to the hospital via Emergency Medical Services. Review of the Nursing Progress Note dated 7/8/16, at 3:34 AM, revealed Resident #13 had 2 staples to (left) top of head and 2 staples to lower (right) region of head. On 7/28/16, at 10:30 AM, an interview was conducted with Quality Assurance Nurse (QAN) C. QAN C was asked, because Resident #13 sustained an injury to the left side of her head and the right side of her head was she suspicious of abuse? QAN C reported, Did I ever think of abuse? - No, because of the witness statement, because the licensed nurse did an incident report on an unwitnessed fall. QAN C did not indicate the incident was reported to the state agency even though the planned safety alarm was not functional at the time of the incident, therefore planned services had not been provided. Resident #14 Resident #14 was a [AGE] year old female admitted to the facility 7/6/09, with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed Resident #14 suffered significant cognitive impairment. Review of the Skin Assessment completed 7/9/16, did not reveal any documented skin issues or concerns. Review of Nursing Progress Note dated 7/20/16, at 10:04 AM, Skin check done during shower, bruise noted to right upper chest area near shoulder. Resident also has a couple of red marks noted to her left neck collar area, and center chest. Cause of injury is unknown. Resident shows no abnormal (signs or symptoms) of pain/discomfort. Continues with some crying out/moaning per usual. Alert to self. Unable to verbalize how marks may have happened, per usual. The Incident /Accident Report dated 7/20/16, at 9:45 AM, was reviewed. The report indicated the bruise and red marks on Resident #14 as indicated in the Progress Note of 7/20/16. The report indicated Resident #14 was unable to verbalize how the marks may have appeared. The report indicated the location of the incident was, unknown. The report revealed an entry to the report on 7/25/16, by QAN C that suggested the marks were caused by call light placement, I saw present her call light attached to her sheet present at right shoulder location .Call light is approximately the length of the area of discoloration. New intervention added to attach call light at waist level in bed. In an interview conducted 7/28/16, at 10:30 AM, QAN C indicated the information contained in Incident/Accident report for Resident #14 dated 7/20/16, at 9:45 AM, was the investigation of the bruise and red marks in it entirety; no further information was available. Resident #2 Review of Resident #2 ' s face sheet dated7/25/16 revealed she was an [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #2's last Brief Interview of Mental Status (BIMS) was 5/20/16 and Resident #2 scored 7/15 (indicating moderate mental impairment. Resident #2 was observed in bed on 7/26/16 at 8:16 AM. Resident #2 had a dark colored bruise under her right great toe nail and her left foot was bruised and swollen from her mid foot to 2 above her ankle. Resident #2 was asked what happen to cause these injuries and Resident #2 said she did not know how they happened and denied any pain in her feet at that time but said she hurt all over. Licensed Practical Nurse (LPN) E came into Resident #2's room on 7/26/16 at 8:22 AM and Resident #2 reported she had pain at level 8 on a scale of 1-10 and said the pain was all over. LPN E explained to Resident #2 she was given the pain medication [MEDICATION NAME] (narcotic pain medication) at 5 AM and now she could get her [MEDICATION NAME] (narcotic pain medication). LPN E gave Resident #2 a [MEDICATION NAME] (narcotic pain medication at 8:28 AM. LPN E was asked how Resident #2 injured her feet and LPN E said she did not know about the right toe but had discovered the left foot/leg bruise last week and when she called Resident #2's family contact they indicated the injury might have happened when resident #2 had gone out to a doctor's appointment. LPN E did not know who was with Resident #2 when she went to the doctor or why the family thought the injury could have occurred at that time. LPN E said she documented finding the injury on the incident report but did not know where she should document the information family provided. Certified Occupational Therapist (COTA) F came into Resident #2's room on 7/26/16 at 930 AM. COTA said she did not know how Resident #2 injured her feet and said Resident #2 was picked up by therapy about a week ago. COTA F she had not observed Resident #2 using her feet to move her wheel chair since she started therapy about a week ago. On 7/26/16, at 10:10 AM, COTA F and Physical Therapist G assisted Resident #2 to the edge of her bed and walked with Resident #2 to the bathroom with a front wheeled walker (approximately 10' to 15'. With each step Resident # 2 yelled out in pain my ankle, my ankle. COTA F said she walked with her yesterday and she yelled out in pain too, but as she got moving she complained less. (Resident #2 had received narcotic pain medication less than 2 hour before walking and was still yelling out in pain). During an interview with Licensed Practical Nurse C and the Director of Nursing B on 7/26/16 the Surveyor asked what happened to Resident #2's feet and said 7/25/16 all incident/accident reports with full investigation for Resident #2 were requested and the last incident/accident report provided was 6/23/16 which indicated Resident #2 had a bruised right great but there were no interviews or indication of a thorough investigation to determine how the right great toe became bruised. LPN C said she does an investigation when she returns to work after an incident report is complete. LPN C said she was not aware of the request yesterday for all incident/accident reports and she had the incident/accident report for Resident #2 dated 7/21/16. LPN C said she did not have any interviews for any of the incident/accident reports. LPN C documented on 7/22/16 in the note section of the incident report dated 7/21/16 at 14:37 (2:37 PM), Name of Resident #2 has been social in building with self-propelling (sp) of wheelchair to and from activities on and off the unit. She is currently working with OT (occupational therapy) and PT (physical therapy). Will f/u (follow up) with therapies for review of self-propelling/wheelchair management NSG (nursing to continue monitoring area. COTA F said in the interview at 9:30 AM, on 7/26/16 she had not observed Resident #2 self-propel her wheelchair in the last week and did not indicate she felt the injury was related to self-propelling her wheelchair. LPN F could not find any interview that confirmed any problem with Resident #2 propelling her wheelchair and could not note a date or time she had observed Resident #2 having any difficulty self-propelling her wheelchair. LPN F was asked for interviews and investigations for Resident #2 incident reports indicating injuries of unknown origin dated 1/13/16, 4/18/16, 6/5/16, 6/20/16 and 6/23/16. LPN F said she did not have any interviews and could not provide any additional information as to how these injuries occurred. DON B and LPN F said they were not aware Resident #2 was yelling out about ankle pain when walking for the last two days and said an x-ray of Resident #2's ankle had not been done, but would get an x-ray ordered today. DON B was asked on 7/26/16 at 1L:06 PM, if the facility had a policy on reporting injuries of unknown origin to the state and doing an investigation of injuries of unknown origin an and DON B said, No. Nursing Home Administrator (NHA) A was asked on 7/26/16 at 1:15 PM if the facility had a policy on reporting injuries of unknown origin to the state and doing an investigation of injuries of unknown origin an and NHA A said, No but he was aware he needed to report injuries of unknown origin. NHA was asked why he did not report Resident #2 ' s multiple injuries of unknown origin and he said, I will have to talk to my staff and get back to you. Later NHA said staff did not think Resident #2's injuries were suspicious so he did not report them. NHA A said he was not aware LPN F was not doing interviews to determine the cause of injuries of unknown origin and was not aware of her investigation process. At 4:45 PM, on 7/26/16, NHA A provided a copy of Resident #2's x-ray done on 7/26/16 at 16:03 (4:03 PM) that documented there was no evidence of fracture of dislocation of Resident #2's left foot/ankle. ( ) On 7/27/16 at 12:54 p.m., NHA A was informed of an Immediate Jeopardy (IJ) that was identified on 7/26/16, and began on 1/13/16, as a result of the facility's failure to identify, thoroughly investigate and report to the State Agency injuries of unknown origin and for failing to operationalize the facility abuse program policy and abuse program procedure. This deficient practice placed all residents, who live at the facility, at risk for serious physical and psychosocial harm, injury and/or death. On 7/27/16 at 9:00 a.m. the State Agency surveyors were able to verify the following interventions had been started to remove the Immediate Jeopardy: · Beginning on 7/27/2016 Resident #3 has been assessed by a licensed nurse. Her cognition was at baseline. Range of motion was within normal limits to all extremities with exception of left ankle which was minimally impaired due to presence of ace wrap. She had no indicators of pain during range of motion assessment. She was laughing and smiling during the assessment. She complained of overall discomfort. No numbness or tingling noted to lower extremities. Pedal pulses present. Slight [MEDICAL CONDITION] to left foot with fading bruises. Resident #2 has been assessed by a licensed nurse. Her cognition was baseline. Range of motion was within normal limits to all extremities. No indicators of pain. · The investigation process has been relaunched for residents #3 as of 7/27/16. · Other residents who could be affected include any resident who had an injury of unknown origin that meets the definition of Injury of Unknown Source as defined in the facility ' s abuse policy. Residents who meet this criteria in the previous 6 months have started to be assessed in relation to any patterns that can be established relative to ongoing risk as of 7/27/2016. · Residents with BIMS 8 or higher have started to be interviewed for abuse, the rest of the residents will be included into a skin sweep to identify potential Injuries of Unknown Source as of 7/27/2016. · Education of all staff in relation to changes in the abuse policy in regard to reporting abuse/suspected abuse and reporting injury of unknown source has begun on 7/27/16. · As of 7/27/2016 an auditing tool has been developed and implemented to assure compliance with this plan of correction. All incidents of unknown origin will be reviewed during the morning meeting and QAPI meetings for the next 3 months. Further review will be determined by the QAPI Committee. Although the Immediate Jeopardy (IJ) was removed on 7/27/16, the facility remained out of compliance at a scope of pattern and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency. ( ) Deficiency Practice Statement B Based on interview and record review the facility failed to ensure that 7 of 19 facility staff (CNA's Q, R, and S, Janitor U, Licensed Practical Nurse V, Secretary W, and Central Supply staff X ) who were employed greater than a year, received annual abuse prevention training and/or training in managing difficult behaviors in dementia residents, from a total of 19 staff reviewed, resulting in the potential for abuse to occur or go undetected. Findings include: During a review of employee files on 7/25/16 at approximately 4 p.m. with Human Resources Director (HRD) Y and Infection Control Coordinator and Staff Training Educator, Registered Nurse (RN) D, revealed that previously, continuing education was obtained via an on-line computer training program. However, earlier in the year the facility had made changes to their training program and returned to in-services. RN D stated that she had scheduled training's for staff and had arranged them based on the calendar quarters and had not considered for the CNA's, that annual training's coincided around their anniversary/hire date. The following 3 CNAs did not receive annual abuse prevention training based on their hire dates: 1. CNA Q's date of hire was 6/20/90. There was no documentation that Q had received any abuse prevention training or training in managing difficult behaviors in dementia residents from 6/20/15 through 6/20/16. 2. CNA R's date of hire was 6/20/08. There was no documentation that R received any abuse prevention training or training in managing difficult behaviors in dementia residents from 6/20/15 through 6/20/16. 3. CNA S's date of hire was 6/19/86. There was no documentation that S had received any abuse prevention training or training in managing difficult behaviors in dementia residents from 6/19/15 through 6/19/16. Additionally, these same 3 CNAs did not complete their annual training in managing difficult behaviors in dementia residents. The following four staff (employed greater than a year) did not receive annual abuse prevention training over the past year: 4. Janitor U's last documented abuse prevention training's were received on 5/28/15 and 6/30/ 15. 5. LPN V's last abuse prevention training was recorded as received on 1/19/15. 6. Secretary W's last abuse prevention training was recorded as received on 12/23/14. 7. Central Supply staff X's last abuse prevention training was recorded as received as 12/9/14. RN D stated that LPN U, Secretary W and Central Supply staff X all took several of their training modules in one setting (at one time; i.e., read training information, and answered questions on several different training topics over a couple of hours) to get them done. In doing so, they did not complete the modules in the scheduled time frames, thus putting them behind). ( )

This citation pertains to intake MI 504. Based on observation, interview and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 7 sampled residents (Resident #101) , from a total sample of 7 residents, resulting in an Immediate Jeopardy (IJ) when Resident #101, who had been identified as an elopement risk and at risk for falls, exited the facility on 10/4/12 unbeknownst to facility staff, and was witnessed by a passerby, falling and striking his head on the sidewalk, approximately two blocks from the facility. Resident #101 was taken to the hospital after 911 was called. This deficient practice placed 37 residents, who had been identified as elopement risks, at risk for serious injury, harm and/or death. Findings include: Review of the medical record revealed Resident #101 was an [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101's Minimum Data Set (MDS), dated [DATE], indicated Resident #101 was cognitively impaired and had demonstrated wandering behavior. Review of the Elopement care plan, dated 11/11/11, revealed Resident #101 was at risk for elopement due to cognitive impairment, his desire to go back to assisted living with his wife, and a lack of safety awareness and limitations. Interventions listed on the elopement care plan included for Resident #101 to wear a WanderGuard (bracelet which will set off alarm if near exit door), have an up-to-date picture in medication record and chart, and for Resident #101 to have a red identification bracelet. Review of the Fall care plan, dated 11/9/11, revealed Resident #101 was at risk for falls due to being unaware of his safety needs, short-term memory loss, and his need for frequent redirection. The care plan interventions included: provide a safe environment with even floors, free from spills and/or clutter, adequate light, be sure call light is within reach, prompt response to calls for assistance, and ensure Resident #101 wears proper footwear. Review of the Facility Incident Report dated 10/4/12, revealed that at approximately 9:30 am, staff became aware that Resident #101 had not been seen since breakfast and began a search, but prior to completing the search, an off-duty staff member came into the facility to get her paycheck and reported seeing a gentleman who resembled Resident #101 outside. The incident report indicated that staff left the building and found Resident #101 at a local construction business with an ambulance. In an interview on 10/12/12 at 9:00 am, Director of Nursing (DON) #2 stated Resident #101 was wearing a WanderGuard bracelet at the time he eloped from the facility, but the North door exit and the East door exit did not have a WanderGuard alarm system on them. DON #2 stated all managers were in the morning meeting in the small dining room, which was located on the same hall as the North door, and did not hear the door alarm sound around the time Resident #101 would have eloped from the facility. DON #2 stated even if the door did not alarm, when the North door opened, it would send an alert to all nurse and Certified Nurse Aide (CNA) pagers. DON #2 stated when she conducted staff interviews after Resident #101 eloped, she discovered that all nursing staff working at the time of the elopement received the page notifying them of the North door egress, but no staff member physically went to the North door. In an interview on 10/12/12 at 10:55 am, CNA #6 stated she last saw Resident #101 on 10/4/12 at approximately 8:32 am, when he attempted to exit the facility via the West door and at that time, the door alarm sounded. CNA #6 stated she observed several staff members bring Resident #101 back into the facility, then she went on break. CNA #6 stated at approximately 9:40 am, she looked in Resident #101's room to see if his Hospice aide was with him and did not see Resident #101, so she (CNA #6) and CNA #13 started looking room-to-room for Resident #101. CNA #6 stated when she and CNA #13 reached the end of Long Hall, they approached Licensed Practical Nurse (LPN) #4, who was talking with CNA #7. CNA #6 stated LPN #4 asked her (CNA #6) if she had seen Resident #101, because CNA #7 had seen a guy who looked like Resident #101 outside down the road. CNA #6 stated she told LPN #4 she was looking for him (Resident #101). CNA #6 stated she asked CNA #7 what color shirt the guy had on, to which CNA #7 replied yellow. CNA #6 stated at that time she and CNA #7 ran out the North door, which did not alarm, to where CNA #7 had seen the man. CNA #6 stated she and CNA #7 found Resident #101 in the back of an ambulance approximately 2 blocks from the facility, in the parking lot of a construction company. CNA #6 stated Resident #101 had cuts to his face, his glasses were broken, and she rode with him to the hospital. CNA #6 stated she received a page on her pager when the North door of the facility opened at approximately 9:30 am, but did not check to the door because the alarm was not sounding. In an interview on 10/12/12 at 10:40 am, CNA #7 stated she left her house at approximately 9:30 am to go the facility and get her check, and arrived around 9:45 am. CNA #7 stated she saw a man in a parking lot on her way to the facility that looked just like Resident #101. The Man was sitting in a chair with two men standing by him, so when she came into the facility, she (CNA #7) stated she asked LPN #4 immediately if anyone had seen Resident #101. CNA #7 stated she told LPN #4 there was a man who was a "dead ringer" for Resident #101 sitting in a chair down the street. CNA #6 then walked up and stated she had been looking for Resident #101. CNA #7 stated she and CNA #6 ran out the North door, and up the road to where CNA #7 had seen the man sitting in the chair. CNA #7 stated Resident #101 was approximately two blocks away from the facility, in the back of an ambulance, and the ambulance staff reported to her (CNA #7), that the man in the back of the ambulance was Resident #101. CNA #7 stated shortly after she and CNA #6 arrived, Registered Nurse (RN) #3 arrived on scene. In an interview on 10/12/12 at 1:15 pm, LPN #4 stated at approximately 9:30 am, CNA #7 came into the facility and stated she had just seen a guy who looked just like Resident #101 around the corner. LPN #4 stated at the same time CNA #6 came up to her and stated she couldn't find Resident #101. LPN #4 stated at that moment, her facility telephone rang, and she sent the two CNA's outside to the location where CNA #7 had seen the man to look for Resident #101. LPN #4 stated when she answered her telephone, it was the ambulance dispatcher calling to inform her that they had Resident #101 on scene at a construction company parking lot, that Resident #101 had fallen, sustained lacerations to his face and was being taken to the hospital. LPN #4 stated she walked into the Management meeting, which had been taking place in the small dining room, and reported the incident to the facility managers. LPN #4 stated Resident #101 did have a history of wandering prior to his elopement, and had a history of [REDACTED].#101 did wear a WanderGuard bracelet, but the North and East doors did not have a WanderGuard alarm system on them at that time, only a regular alarm. In an interview on 10/12/12 at 11:30 am, LPN #8 stated she was in the management meeting at the time of Resident #101's elopement on 10/4/12, and saw CNA #6 and CNA #7 run by the facility through windows in the small dining room at approximately 9:40 am. LPN #8 stated she and the Maintenance Director were informed Resident #101 had eloped out the the North Door, so they went to the North door to check the alarm and found the door alarm to be turned to the "off" position. During an observation of the computerized door alarm system with DON #2 on 10/12/12 at 12:10 pm, the North door of the facility was shown to be opened at 9:16 am on 10/4/12 for 6 (six) seconds. DON #2 stated the computer system clock is off by 15 minutes and that the actual time would have been 9:31 am. DON #2 stated she believed that to be the time and location Resident #101 eloped from the facility. In an interview on 10/16/12 at 9:15 am, Construction Company Office Manager #11 stated on 10/4/12, she witnessed a car drive into their business parking lot, a man got out of the car and ran next to their building. Office Manager #11 stated the Vice President went outside, then came in, grabbed a chair and told her to call 911 because an older gentleman had fallen. Office Manager #11 stated she called 911, went outside to make sure he was okay, then observed Resident #101 with blood on his face sitting in the chair. She stated that he was able to state his name and, when the Vice President asked if he was from the nursing home, he said, "Yes". Office Manager #11 stated after the ambulance arrived, she called the facility to inform them that Resident #101 was there, but when she called the facility the nurse she spoke to stated the ambulance service had already called. In an interview on 10/16/12 at 9:20 am, Construction Company Vice President #10 stated he found Resident #101 kneeling on the sidewalk next to his business with his face bleeding and his glasses broken. Vice President #10 stated he went into the office of his construction business and had his staff call 911, and that staff from the nursing facility did not arrive on the scene until after the ambulance had arrived and placed Resident #101 in the back of the ambulance. Review of the Ambulance run sheet, dated 10/4/12, revealed the call for Resident #101 was received at 9:40 am, the ambulance was on scene at 9:46 am, and witnesses stated they saw Resident #101 fall and strike the sidewalk. Review of hospital emergency room physician's notes, dated 10/4/12, revealed Resident #101 lost his balance, fell forward, striking the right side of his head, with superficial skin tears on the right upper cheek and lateral brow. The impression was listed as closed head injury and skin tears to his right face with steri-strip closure. In an interview on 10/12/12 at 1:00 pm, the surveyor asked DON #2 , once she was aware that the North door of the facility had been unsecured for an unknown amount of time and one resident (#101) had eloped from the facility unbeknownst to facility staff, for an unknown amount of time, if she had taken any measures to make sure all residents were accounted for, and DON #2 stated "no". According to a list provided to the surveyor by DON #2 on 10/12/12, there were 37 residents identified to be at risk for elopement in facility on 10/5/12. On 10/17/12 at 10:48 am, Administrator #1 and DON #2 were notified of the Immediate Jeopardy that began on 10/4/12, when Resident #101 was left unsupervised and eloped from the facility, unbeknownst to facility staff. On 10/18/12 at 2:45 pm, the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. Resident #101 had been reassessed for elopement risk on 10/5/12 and fall risk on 10/8/12. 2. Resident #101's Care Plan had been reviewed and revised to include 1:1 supervision as indicated and a breakfast program with 1:1 time with a care giver during breakfast and an activity, which began on 10/5/12. 3. New WanderGuard's were purchased and installed on the North and East doors on 10/5/12. All exit doors now have WanderGuard alarms in addition to door alarms that sound upon any egress. 4. Each resident in the facility had been reassessed for elopement risk and a list compiled, which began on 10/5/12 - updated list is kept in the DON's office. 5. Care plans for resident at moderate and high risk for elopement have been reviewed and revised based on that assessment, which began on 10/15/12. 6. Staffing assignments have been modified to allow one person to spend more time with at- risk residents, this implemented as a float position and is being tweaked to allow that staff member to implement programming throughout the day to decrease wandering - (ongoing). 7. The North, East, and West exit doors, which are each at the end of a hallway, have been covered with a brick like covering to disguise their usual function. Resident #101 has been observed walking up to and turning around from the door. 8. "Activity stations" have been placed throughout the building in a "wander-path format" to provide residents a variety of opportunities to engage in spontaneous activities for a few minutes as they walk by. 9. Elopement and missing person policies, which are located in the Policy Book in the DON's office, have been reviewed and deemed appropriate on 10/4/12 . 10. Beginning 10/8/12, all staff were in-serviced on their roles in relation to the policies, including the importance of reporting a resident missing, responding immediately to door alarms or pager notifications, the importance of looking for resident outside of doors following an alarm, in house search follow any unexplained door alarm to assure no resident is missing. 11. Staff continues to check the exit door alarms on an hourly basis, ongoing - Logs will be audited three times a week by DON #2 or Administrator #1. Deficits in the process will be addressed through education or counseling as indicated. Results of the audit will be shared with QA Committee on a monthly basis by the DON. Logs will be kept in a notebook in the DON's office. 12. As of 10/15/12, the facility implemented elopement/missing person drills for all staff to walk through the policy process. Documentation of drills will be found in notebook in the DON's office. 13. Licensed staff will continue to check WanderGuard's for functionality on a daily basis on the midnight shift. Documentation of the checks is done in the treatment record. (ongoing) Although the Immediate Jeopardy was removed on 10/8/12, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy, due to not all facility staff have received the in-service education and sustained compliance had not been verified by the state agency. #

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS ADMISSION BASELINE CLINICAL STATUS; FAILED TO REASSESS AND/OR CLARIFY STATUS AS SYMPTOMS DEVELOPED (INVOLVING COGNITIVE, BOWEL, HYDRATION AND SAFETY STATUS); AND, FAILED TO INTERVENE TO PROMOTE SAFETY BASED ON THE ASSESSED RISK FACTORS, FOR ONE OF ONE SAMPLED RESIDENTS (#3) REVIEWED FOR CHANGE OF CONDITION, FROM A TOTAL SAMPLE OF ELEVEN RESIDENTS, RESULTING IN A FALL WITH INJURIES (A [MEDICAL CONDITION] REQUIRING STAPLES) THAT OCCURRED AFTER THE RESIDENT BEGAN EXPERIENCING SYMPTOMS OF NAUSEA, INCREASED CONFUSION AND POSSIBLE MEDICATION WITHDRAWAL. FINDINGS INCLUDE: ACCORDING TO THE "PACE" (PROGRAM FOR ALL INCLUSIVE CARE FOR THE ELDERLY) physician progress notes [REDACTED].#3 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ("PACE" IS A SERVICE THAT PROVIDES PATIENT CARE SERVICES THAT ARE COORDINATED WITH THE FACILITY FOR PARTICIPATING RESIDENTS.) BASED ON REVIEW OF RESIDENT #3'S CLINICAL RECORD, THERE WAS NO COMPREHENSIVE NURSING ADMISSION ASSESSMENT FILED IN THE CLINICAL RECORD. HOWEVER, NURSING PROGRESS NOTES DATED 4/25/2012 (DATE OF ADMISSION) DOCUMENTED: "...RESIDENT APPEARS COMFORTABLE HERE, SHE IS CONCERN (SIC) ABOUT THE [MEDICATION NAME] MED (AND) WANTS IT DC'D (DISCONTINUED)..." THE 4/25/2012 NOTE REFLECTED THAT RESIDENT #3 WAS ALERT AND SUFFICIENTLY AWARE TO ASK SPECIFIC QUESTIONS ABOUT HER MEDICATIONS. BASED ON REVIEW OF NURSING PROGRESS NOTES, ENTERED INTO RESIDENT #3'S CLINICAL RECORD DURING THE PERIOD 4/26/2012 THROUGH 4/30/2012, RESIDENT #3 BEGAN DISPLAYING THE FOLLOWING SYMPTOMS: 4/26/2012 14:07 (2:07 P.M.) "...FOLLOWING BREAKFAST, RES (RESIDENT) C/O (COMPLAINED OF) NAUSEA...RES HAD "DRY HEAVES" BUT NEVER VOMITED. RES ALSO NOTED WITH 2 SMALL LOOSE STOOLS..." 4/26/2012 23:42 (11:42 P.M.) "...(RESIDENT #3) HAS BEEN DRY HEAVING SINCE FIRST SHIFT. HER BLOOD PRESSURE WAS 220/130 MORNING MEDS HELD CALL DR (DOCTOR) FOR ORDER FOR [MEDICATION NAME] SUPPOSITORY (MEDICATION FOR NAUSEA AND VOMITING)...AND GAVE HER BLOOD PRESSURE MED WHICH REDUCED B/P TO 170/102..." 4/27/2012 03:17 "...C/O PAIN IN STOMACH AREA...1:43 A.M. RESIDENT CONTINUES WITH ABDOMINAL PAIN, GIVEN A [MEDICATION NAME] (NARCOTIC PAIN RELIEVER) PRN (AS NECESSARY) WITH MINIMAL EFFECT...3:35 A.M...MEDIUM LOOSE STOOL, ALSO DRY HEAVES...5:00 A.M...RESIDENT AWAKE, MOANING OUT..." 4/27/2012 13:14 (1:14 P.M.) "...RES IN BED ENTIRE SHIFT. C/O NAUSEA, HAVING LOOSE STOOLS, BUT NO VOMITING...RES ALSO REFUSED ALL OFFERS OF PAIN MED...RES ACCEPTING CLEAR LIQUIDS..." 4/27/2012 21:18 (9:18 P.M.) "...STILL SMALL HEAVING...NO VOID (NO URINATION), DRANK 240 CC." 4/28/2012 22:12 (10:12 P.M.) "...RES CONTINUES TO C/O NAUSEA, EATING SMALL BITES OF SODA CRACKERS. WOULD NOT EAT FROM DINNER TRAY... ORDER OBTAINED FROM (PHYSICIAN AT PACE) FOR [MEDICATION NAME] (MEDICATION FOR NAUSEA)..." 4/29/2012 14:56 (2:56 P.M.) "...RESIDENT SENT OUT TO...ER (emergency room ) VIA AMBULANCE AT 2:00 TODAY....RESIDENT'S DAUGHTER...CAME TO VISIT AND WAS CONCERNED THAT HER MOTHER HAD NOT BEEN OUT OF BED AND HAD NOT BEEN EATING OR DRINKING MUCH SINCE HER ARRIVAL AT THIS FACILITY...(DAUGHTERS) DECIDED TO SEND THE RESIDENT TO THE ER..." 4/29/2012 22:11 (10:11 P.M.) "...NOTE TEXT: 9:20 P.M., RES RETURNED FROM...ER VIA AMBULANCE IN A WHEEL CHAIR. BOTH DAUGHTERS HERE...[DIAGNOSES REDACTED]." 4/30/2012 22:40 (10:40 P.M.) "...RESIDENT VERY COMBATIVE AND VERBALLY ABUSIVE TOWARD STAFF. VERY DIFFICULT TO GIVE MEDICATIONS TO. REFUSED INHALER AND EYE DROPS. FAMILY HAD TO CONVINCE HER TO TAKE PO (ORAL) MEDICATIONS. LATER IN SHIFT AROUND 9:00 PM, WAS CALLED TO RESIDENT'S ROOM AND FOUND RESIDENT ON BUTTOCKS ON FLOOR IN FRONT OF ROOMMATE'S RECLINER...RESIDENT IS CONFUSED AND DISORIENTED..." THE FACILITY'S INCIDENT REPORT DATED 4/30/2012 FOR THE FALL THAT OCCURRED ON 4/30/2012 AT 9:00 P.M. WAS REVIEWED. THE INCIDENT REPORT DOCUMENTED THAT RESIDENT #3 WAS FOUND "ON BUTTOCKS ON FLOOR (UNREADABLE) AT ROOMMATES RECLINER... (RESIDENT STATED) 'I WAS TRYING TO MOVE THE COUCH SO I COULD WALK'." THE NURSING ASSESSMENT REFLECTED, "NO PAIN STATED, ALL EXTREMITY WNL ROM (WITH IN NORMAL LIMITS FOR RANGE OF MOTION), ALERT, DISORIENTED/CONFUSED, COMBATIVE...SENSOR MAT (ALARM) PLACED ON BED." ON THE REPORT, UNDER THE HEADING OF "INJURIES", A CHECK MARK WAS MADE NEXT TO THE WORD, "NO". THE SECTION OF THE INCIDENT REPORT RESERVED FOR PHYSICIAN NOTIFICATION WAS LEFT BLANK. AN INTERVIEW WAS CONDUCTED WITH THE FACILITY'S DIRECTOR OF NURSING (DON), MDS NURSE "G", AND LICENSED PRACTICAL NURSE (LPN) CHARGE NURSE OF THE LONG HALL, STAFF "E" AT APPROXIMATELY 9:00 A.M. ON 5/3/2012. DURING THE INTERVIEW, THE DON VERIFIED THAT NO NURSING ASSESSMENTS OF BOWEL STATUS WERE DONE ON 4/26/2012 WHEN RESIDENT #3 HAD DEVELOPED NAUSEA AND DIARRHEA AND, ON 4/27/2012 WHEN RESIDENT #3 DEVELOPED ABDOMINAL PAIN, NURSING HAD MEDICATED RESIDENT #3 WITH NARCOTICS THAT WOULD POTENTIALLY HAVE MASKED UNDERLYING ABDOMINAL SYMPTOMS; AND, THEY DID NOT NOTIFY THE PHYSICIAN OF THE RESIDENT'S CHANGE IN CONDITION. DURING THE INTERVIEW, AT APPROXIMATELY 9:00 A.M. ON 5/3/2012, THE DON VERIFIED THAT, ON 4/27/2012 WHEN RESIDENT #3 WAS NOT EATING OR DRINKING SUFFICIENT AMOUNTS, THE DIETICIAN WAS NOT NOTIFIED OF THE PATIENT'S STATUS, AND THERE WERE NO NURSING ASSESSMENTS FOR DEHYDRATION DOCUMENTED. (LOOSE STOOLS AND DIMINISHED ORAL INTAKE INCREASE DEHYDRATION RISK, WHICH MAY, IN TURN, INCREASE CONFUSION AND FALLS RISK FOR ELDERLY PATIENTS.) THE DON VERIFIED THAT, ON 4/28/2012 WHEN RESIDENT #3 WAS EXPERIENCING LOOSE STOOLS, ABDOMINAL PAIN AND NAUSEA, THERE WERE NO NURSING ASSESSMENT OF BOWEL STATUS DOCUMENTED. THE DON VERIFIED THAT, ON 4/29/2012 WHEN RESIDENT #3 HAD RETURNED FROM THE emergency room FOLLOWING THE FIRST FALL, THERE WAS NO DOCUMENTATION TO SHOW THAT FACILITY NURSING STAFF HAD OBTAINED HOSPITAL DISCHARGE INSTRUCTIONS OR CALLED THE HOSPITAL IN ORDER TO CLARIFY OR CONFIRM THE DISCHARGE INSTRUCTIONS. THERE WAS NO FOLLOW-UP TO THE FACILITY'S NURSING PROGRESS NOTES FOR 4/29/2012 THAT REPORTED: "...ER...[DIAGNOSES REDACTED]." DURING THE INTERVIEW, AT APPROXIMATELY 9:00 A.M. ON 5/3/2012, THE DON ALSO VERIFIED THAT FACILITY NURSING STAFF DID NOT NOTIFY THE PHYSICIAN THAT THERE WAS A DROP IN THE RESIDENTS OXYGEN SATURATION LEVEL TO 81% AFTER THE RESIDENT'S RETURNED FROM THE hospital on [DATE]. (NORMAL OXYGEN SATURATION RANGE IS APPROXIMATELY 95-100%; AND THE RISK FOR CONFUSION, LOSS OF COORDINATION AND FALLS MAY INCREASE WITH SUBNORMAL LEVELS OF OXYGEN.) ACCORDING TO NURSING NOTES DATED 4/28/2012 1439 (2:39 P.M.), THE RESIDENT'S OXYGENATION ON ROOM AIR ON THAT DATE HAD BEEN 95%. FURTHERMORE, THE DON VERIFIED THAT ON 4/30/2012, FOLLOWING THE FIRST FALL WHEN THE RESIDENT WAS CONFUSED, COMBATIVE AND DISORIENTED, THE PHYSICIAN HAD NOT BEEN NOTIFIED. BASED ON REVIEW OF NURSING PROGRESS NOTES ENTERED INTO RESIDENT #3'S CLINICAL RECORD ON 5/1/2012, RESIDENT #3 SUSTAINED A SECOND FALL, JUST TWO DAYS LATER, THAT RESULTED IN INJURY: 5/1/2012 14:45 (2:45 P.M.) "...NOTE TEXT: 8:50 AM, CENA (CERTIFIED NURSING ASSISTANT) CALLED THIS NURSE INTO RES ROOM. RES NOTED TO BE LAYING ON FLOOR NEXT TO HER W/C (WHEEL CHAIR). HER HEAD WAS NEAR THE FOOT OF HER BED. RES LEGS WERE TANGLED IN THE W/C FOOT PEDALS...RES STATES SHE 'CRACKED' HER HEAD. NOTED WITH C-SHAPED LACERATION TO THE BACK OF HER HEAD, APPROX 2 INCHES. SMALL AMOUNT OF BLEEDING NOTED. A&O (ALERT AND ORIENTED) X 1. HAS BEEN HAVING INCREASED CONFUSION...RIGHT SIDE (PUPIL REACTIVITY) SLIGHTLY SLUGGISH. GRIPS EQUAL...DID C/O (COMPLAIN OF) HA (HEADACHE). GIVEN TYLENOL FOR THIS. (PACE GROUP) NOTIFIED. REQUESTING TO HAVE RES COME IN FOR EVAL..." ACCORDING TO NURSING NOTES ENTERED ON 5/1/2012, RESIDENT #3 WAS TAKEN TO A CLINIC AT THE PACE BUILDING WHERE STAPLES WERE PLACED TO THE BACK OF HER HEAD. REVIEW OF THE FACILITY INCIDENT REPORT FOR 5/1/2012, 8:50 A.M., REFLECTED THAT RESIDENT #3 HAD SUSTAINED AN UNWITNESSED FALL FROM HER WHEELCHAIR. HER CONDITION PRIOR TO THE FALL WAS DESCRIBED AS ALERT WITH "INCREASED CONFUSION." UNDER THE SECTION OF THE INCIDENT REPORT THAT DESCRIBED WHAT HAPPENED, THE FOLLOWING WAS DOCUMENTED: "...RES NOTED TO BE LAYING NEXT TO W/C WITH HEAD NEAR FOOT OF THE BED. RES LEGS WERE TANGLED IN FOOT PEDALS. O2 (OXYGEN) TUBE AND CALL LIGHT UNDER RES." RESIDENT COMMENT WAS 'I WAS JUST TRYING TO GO'." ACCORDING TO THE FACILITY'S CARE GUIDE FOR RESIDENT #3 (NOT TITLED AND NOT DATED) RESIDENT #3 REQUIRED ONE-PERSON ASSIST FOR CARE AND TRANSFERS, WAS INDEPENDENT WITH BED MOBILITY AND FEEDING AND REQUIRED ONE-PERSON ASSIST FOR TOILETING. THE CARE GUIDE ALSO IDENTIFIED THAT RESIDENT #3 WAS TO HAVE A SENSOR ALARM ON AT ALL TIMES BUT, ACCORDING TO THE DIRECTOR OF NURSING DURING AN INTERVIEW ON 5/3/2012 AT 9:00 A.M., THE BED ALARM WAS NOT PUT IN PLACE UNTIL AFTER THE FIRST FALL ON 4/30/2012 AND THE CHAIR ALARM WAS NOT PUT ON UNTIL AFTER THE SECOND FALL ON 5/1/2012. ACCORDING TO NURSING PROGRESS NOTES DATED 5/1/2012 21:07 (9:07 P.M.; NO NOTES FOR THE DAY SHIFT WERE FOUND), RESIDENT #3 WAS "...HALLUCINATING THROUGHOUT THE SHIFT, SAYING SHE SEES AUNTS (SIC), MICE, AND CHILDREN ON THE WALLS AND CRAWLING IN HER BED. ALERT EYES OPEN AND TALKATIVE WHEN RETURNED FROM PACE. STAPES (SIC) NOTED TO POSTERIOR HEAD. NEUROS PERFORMED, PERRLA (PUPIL EYE CHECK) RIGHT SIDE MORE SLUGGISH THAN LEFT. DAUGHTER AT BEDSIDE MOST OF SHIFT....POOR APPETITE..." DURING THE INTERVIEW WITH THE DON, MDS NURSE "G" AND LPN CHARGE NURSE "E" AT APPROXIMATELY 9:00 A.M. ON 5/3/2012, THE DON VERIFIED THAT ON 5/1/2012 WHEN RESIDENT #3 BEGAN HALLUCINATING AND NOT SLEEPING, THE NURSING STAFF DID NOT NOTIFY THE PHYSICIAN OF ACUTE MENTAL STATUS CHANGE. THE DON VERIFIED THAT THE CARE PLAN FOR RESIDENT #3 WAS NOT UPDATED TO REFLECT SIGNIFICANT CHANGES IN HER CONDITION UNTIL 5/2/2012. BASED ON REVIEW OF A FORM TITLE "ED (EMERGENCY DEPARTMENT) PAT (PATIENT) EDU (EDUCATION)" FACSIMILE DATE OF 5/3/2012, RESIDENT #3 HAD BEEN PROVIDED INFORMATION IN THE EMERGENCY DEPARTMENT REGARDING "[MEDICATION NAME] WITHDRAWAL" THAT STATED THE FOLLOWING: SEEK IMMEDIATE MEDICAL CARE IF: YOU HAVE A [MEDICAL CONDITION] YOU DEVELOP A HIGH FEVER YOU EXPERIENCE UNCONTROLLED VOMITING OR YOU VOMIT UP BLOOD. YOU BECOME AGITATED OR CONFUSED YOU DEVELOP UNCONTROLLED ANXIETY YOU BEGIN TO HAVE HALLUCINATIONS ( )