Every finding on record at Corewell Health Reed City Hospital Rehabilitation

Based on observation, interview and record review, the facility failed to maintain the kitchen/facilities equipment and fixtures so that they were clean, sanitary and in proper working order, potentially affecting all residents that receive food from the kitchen.Findings include: The following observations were observed on 12/02/25 from 10:15 AM to 11:20 AM, during the initial tour of the kitchen/facility with Prep [NAME] (PC) J.Observation of the cook line hand sink (on the wall closest to the hood system) was observed to be missing the proper signage. Also, hangers/clips were being used to hang/store dirty dustpan and broom equipment on the wall adjacent and level to the hand sinks basin.Review of the FDA 2017 Food Code Section, 6-301.14 Handwashing Signage Reflects the following, A sign or poster that notifies FOOD EMPLOYEES to wash their hands shall be provided at all HANDWASHING SINKS used by FOOD EMPLOYEES and shall be clearly visible to FOOD EMPLOYEES.Review of the FDA 2017 Food Code Section, 6-501.113 Storing Maintenance Tools Reflects the following, Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: (A) Stored so they do not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE USE ARTICLES;Observation of the can opener blade and the drip line of the housing unit (located beneath the can opener blade) were observed to have a build-up of a black sticky substance.Observation of a pinkish-orange slime on the ice deflector shield was observed inside the ice machine located inside the kitchen.Review of the FDA 2017 Food Code Section, 4-602.11 Equipment Food-Contact Surfaces and Utensils Reflects the Following, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred. (E) Except when dry cleaning methods are used as specified under 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not POTENTAILLY HAZARDOUS (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil tanks and distribution lines, Beverage and syrup dispensing lines or tubes, coffee bean grinders and water vending equipment: (b) Absent of manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.Observation of the cook line prep cooler revealed a build-up of food residues, debris and grime on the doors, door seals, opening, and bottom of the unit. Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. Reflects the following, (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of accumulation of dust, dirt, FOOD residue, and other debris.Observation of the Ice machine area reflected a tag (labeled New Filter) hanging from the water filter for the ice machine. The dates on the tag reflected the filter had been replaced on 3/22/24 and 6/11/24. No current dates were observed. Observation of the water filter for the coffee and juice machine area reflected a date of 6/23.Review of the FDA 2017 Food Code Section, 5-205.13 Scheduling Inspection and Service for a Water System Device. Reflects the following, A device such as a water treatment device or backflow preventer shall be scheduled for inspection and service, in accordance with manufacturer's instructions and as necessary to prevent device failure based on local water conditions, and records demonstrating inspection and service shall be maintained by the PERSON IN CHARGE.During the kitchen observation, wiping cloth towels were being used to move pots, pans and sheet pans to and from the oven and stove instead of potholders. The towels being used were observed to be thin and had loose threads hanging. This surveyor became concerned when the towel with the hanging threads came close to the open flame on gas stove while staff was adjusting a pot. During this observation Kitchen Employee ([NAME]) I revealed, we are now using our wiping cloth towels as potholders because we were told that's what real kitchens do. The towels/wiping cloths are not designed for this purpose. The potential for the towels catching on fire and the increased likely hood of staff burning themselves increases significantly because of their design and misuse.Review of the FDA 2017 Food Code Section, 4-102.11 Characteristics Reflects the following, Materials that are used to make SINGLE-SERVICE and SINGLE USE ARTICLES: (A) May not: (1) Allow the migration of deleterious substances, . (B) Shall be: (1) Safe and (2) Clean.During an observation on 12/4/25 at 12:23 PM, inside a Long-Term Care Dining Room the following was observed, 1.) the ice/water dispensing machine had an accumulation of mold, hard water, scale build-up. 2.) grime and debris were built-up on the coffee machine.Review of the FDA 2017 Food Code Section, 4-202.12 CIP (Clean In Place) Equipment Reflects the following, (A) CIP EQUIPMENT shall meet the characteristics specified under 4-202.11 and shall be designed and constructed so that: (1) Cleaning and SANITIZING solutions circulate throughout a fixed system and contact all interior FOOD-CONTACT SURFACES, and (2) The system is self-draining or capable of being completely drained of cleaning and SANITIZING solutions; and (B) CIP EQIPMENT that is not designed to be disassembled for cleaning shall be designed with inspection access points to ensure that all interior FOOD-CONTACT SURFACES throughout the fixed system are being effectively cleaned. Review of the FDA 2017 Food Code Section, 4-602.11 Equipment Food-Contact Surfaces and Utensils Reflects the Following, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred. (E) Except when dry cleaning methods are used as specified under 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not POTENTAILLY HAZARDOUS (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil tanks and distribution lines, Beverage and syrup dispensing lines or tubes, coffee bean grinders and water vending equipment: (b) Absent of manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.During an interview on 12/4/25 at12:44PM, NHA revealed she had requested to have the ice/water dispenser and the coffee machine in the dining room cleaned around the end of October. The amount of build-up observed on the equipment reflected they had not been cleaned in some time.

Based on observation, interview, and record review the facility failed to provide safe transfers for 2 residents (R17 and R36) and failed to implement meaningful interventions and increase supervision to prevent falls for 1 resident (R8) of 4 residents reviewed for accidents and falls. Findings include:R36 Review of R36's face sheet with a printed date of 12/4/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: chronic low back pain, stroke, dementia, and numbness and tingling of the left leg. On 12/3/25 at 10:00 AM, R36 was observed being pushed in the hallway in her wheelchair without footrests in place. R36 appeared uncomfortable attempting to hold her feet a few inches off the floor when being pushed in her wheelchair by Certified Nurse Aide (CNA) C. The Surveyor asked CNA C if she should be pushing residents without footrests on their wheelchair and she replied no. The Surveyor asked CNA C, what are you supposed to do when you need to push a resident in a wheelchair that does not have footrests? CNA C said, I guess I need to go find some. R36 responded they are on the shelf in my room. CNA C went to R36's room and returned with footrests. A review of the article Guidelines for Pushing Wheelchairs, dated 3/28/23, revealed, When pushing a wheelchair, safety should always be the top priority. Here are some safety guidelines to keep in mind: Always lock the wheelchair brakes before helping the user in or out of the chair. Use a firm grip on the wheelchair handles and keep your back straight and shoulders relaxed. Be aware of your surroundings and avoid obstacles and uneven surfaces. Always use the footrests when the user is sitting in the chair, and make sure they are properly adjusted. When going down ramps or inclines, always walk backward and use your body weight to control the wheelchair's speed . (https://alzheimerslab.com/guidelines-for-pushing-wheelchairs) R8 Review of R8's Activities of Daily Living (ADL) care plan dated, 6/1/25 to 6/18/25, revealed R8 required assistance with ADL's related to difficulty with memory and sequencing due to dementia. R8 would refuse to use her knee immobilizer at times and was heard of hearing. At times she will decline ADL assistance entirely. Review of R8's mobility care plan dated 6/1/25 to 6/18/25 revealed R8 required assistance with mobility related to dementia and was noted to self-transfer. She often declines assistance with bed mobility, or repositioning. Review of R8's Activity care plan dated 6/1/25 to 6/18/25 revealed, I have identified moderate need and desire to participate in independent type leisure of my choice to enhance my psycho-social well-being. I am a [AGE] year-old woman here for long-term care placement. Goal. I will participate in independent type in leisure interests of my choice and engage in 1 on 1 visits over the next 90 days. Interventions included: Provide for adaptations needed: I have multiple diagnoses including osteoarthritis, muscle weakness, low back pain, and difficulty in walking. I wear a right knee brace at times. Please provide transportation assistance with requested. (Recreational Therapy). Review of R8's fall care plan dated 6/1/25 to 6/18/25 revealed R8 was at risk for falls and injury related to impaired balance, impaired safety awareness, impaired gait, dementia and history of falls. The interventions did not reveal any increased supervision during wake times. Review of R8's Event Report from 12/1/24 to 12/3/25 revealed R8 had 11 falls in her room from 12/22/24 to 6/17/25. Review of the follow-Up Action documentation for the fall on 2/1/25 revealed the facility had identified that R8 had a fall Risk Score of 29, indicating she was high risk for falls. She had dementia, poor safety awareness and impulsiveness. Interventions listed after each fall revealed multiple changes to R8's toileting schedule and adjustments to equipment in her room. None of the interventions added indicated that the facility had increased R8's supervision. All falls occurred in R8's room and the majority indicated R8 was using the bathroom at the time or in need of using the bathroom when the falls occurred. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON) and Activity Director (AD) H on 12/4/25, R8's falls from 12/1/24 to 6/17/25 were reviewed. They confirmed all the falls had occurred in R8's room and they had not implemented any increased supervision during her awake time. The AD H reviewed R8's activity participation and said she will not attend bingo or other group activities. They confirmed that she was staying in her room most of the time. When asked about the activities for residents with advanced dementia that would be offered in a lower stimulating environment and geared toward residents that are impulsive with short attention span, they said they currently do not offer this type of activity program. They confirmed that R8 had a decline in physical function after her fall on 6/17/25 and no longer attempts to self-transfer and continues to spend most of her time in her room. R17 Review of a Face sheet revealed R17 admitted to the facility on [DATE] with pertinent diagnoses which included generalized weakness, alcohol abuse, and cognitive impairment. Review of R17's current Resident Care Summary, printed 12/4/2025 at 2:11 PM, revealed R17 required assistance with ambulation. In an observation and interview on 12/2/2025 at 10:56 AM in room [ROOM NUMBER], Certified Nursing Assistant (CNA) F entered room [ROOM NUMBER] to assist R17 from his toilet to his wheelchair. Upon exiting the room, CNA F reported she did not use a gait belt when assisting R17 to stand up from the toilet and pivot to his wheelchair. CNA F reported gait belt use is required for all residents who need assistance with ambulation. CNA F reported she did not use a gait belt because R17 was in a good mood at the time. R17 reported staff do not always use a gait belt when assisting him. In an interview on 12/3/2025 at 1:05 PM, CNA G reported R17 required assistance of one staff with the gait belt to stand and pivot to his wheelchair. CNA G reported all residents requiring assistance with ambulation require a gait belt to be used. Review of facility policy/procedure Levels of Assistance for Patient Care, effective 7/21/2024, revealed staff are required to use a gait belt when assisting residents requiring assistance with ambulation.

Based on observation, interview, and record review, the facility failed to accurately document medication administration times for 1 of 4 residents (R2) observed during the medication administration observation. Findings include: A review of R2's Face Sheet, dated 11/20/24, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R2's Face Sheet revealed they had multiple diagnoses that included osteoarthritis, neuropathic (nerve) pain of both feet, closed lumbar spine closed fractures with delayed healing, chronic pain syndrome, pneumonia, closed fracture of the humerus (bone in the upper arm), and right hand pain. During the medication administration observation on 11/19/24 from 6:45 AM to 7:30 AM, the surveyor observed Registered Nurse (RN) A administer Tylenol, docusate sodium (a stool softener), Vitamin B Complex, metoprolol (a blood pressure medication), Eliquis (a blood thinner), Lasix (a water pill), pantoprazole (a medication for gastric reflux- heartburn), gabapentin (a pain medication), and Oxycontin (a pain medication) to R2. RN A stated R2 also had a potassium packet (powered potassium) ordered. However, RN A did not have the packet because it looks like it's a new order, so pharmacy did not send it. She stated she will have to wait until pharmacy makes their next delivery of medications, which will probably be tomorrow. In addition, RN A stated R2 had an order change where she was only receiving 25 milligrams (mg) of metoprolol. She had 50 mg ordered before. But the doctor changed her pain medication, so she has not required that high of a dose. RN A verbally verified R2's medications and doses as she prepared them. The surveyor observed these medications being administered to R2. In addition, the surveyor heard RN A tell R2 that she was only receiving 25 mg of metoprolol because the physician changed her pain medications and the new pain medications had been helped to lower her blood pressure by reducing her pain. A review of R2's Medication Administration Record (MAR), dated 11/19/24 from 7:01 AM to 9:53 PM, revealed the following: - Voltaren (diclofenac sodium) gel (a medication for osteoarthritis) was documented as given at 7:16 AM (not observed by the surveyor during the medication administration observation) - Flonase (fluticasone) nasal spray was documented as given at 7:01 AM (not observed by the surveyor during the medication administration observation) - Metoprolol succinate (Toprol-XL- a medication for high blood pressure) 50 mg was documented as given at 7:01 AM (the surveyor only observed RN A administer a 25 mg dose to R2 during the medication administration observation) - Potassium chloride 20 mEq (millequivalents) packet (a medication for low potassium levels) was documented as given at 7:01 AM (not observed by the surveyor during the medication administration observation) A review of R2's physician orders revealed the physician discontinued R2's metoprolol 25 mg dose on 11/18/24 at 10:54 AM and started R2 on metoprolol 50 mg beginning with her daily morning dose on 11/19/24. During an interview on 11/20/24 at 10:26 AM, RN A stated stated she administered R2 her potassium packet later (she did not specify the time) after she received it from the pharmacy. She also stated she administered the Voltaren and Flonase after the nursing assistant had settled R2 in her chair with her blankets (the nursing assistant had toileted and dressed R2 immediately prior to the medication administration observation and had finished up getting her settled in her chair after RN A had administered the medications that the surveyor observed). RN A stated she did not remember the exact dose of metoprolol that she had administered to R2, but was sure that she had verified the dose with R2's MAR and the surveyor when she prepared it. However, the surveyor's procedure (which was adhered to) was to only check the medications when they are prepared with the packages that they come in, to have the nurse verbalize the medications and their doses, and to not view the MAR during the medication administration observation in case the physician's order does not match the MAR (this would be discovered when the medications are reconciled with the physician's orders after the observation was completed). During an interview on 11/20/24 at 11:32 AM, the Director of Nursing (DON) was notified that the surveyor had a concern with the administration times that were documented for R2's potassium chloride packet, Voltaren gel, and Flonase. The surveyor shared with the DON that these medications were administered after the medication administration observation was completed (after 7:30 AM) and RN A had verified this during their interview with the surveyor an hour before. The DON stated RN A should have documented the actual times that these medications were given and should not have documented that they were given at 7:01 AM or 7:16 AM if those were not the times they were given. A review of the facility's Medication Management policy, dated 4/21/23, revealed, All medications will be prepared and administered for one resident at a time following the rights of medication administration . right dose . right time, and right documentation .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to maintain proper temperature of sliced roast beef on the food preparation line. 2. Failing to discard expired food in the walk in cooler. These deficient practices have the potential to result in food borne illness among any and all 29 residents of the facility. Findings include: 1. On [DATE] at approximately 11:45 AM, during the noon meal observations in the kitchen, a stainless steel container was observed sitting on a bed of ice cubes. Sliced sandwich roast beef was observed in the pan, elevated above the bottom of the pan on a plastic grid. The internal temperature of the roast beef was measured using a metal stem probe digital thermometer, and found to be 50 F. An interview was conducted with Cook B at this time and learned the product had been in the pan for about 20 minutes. Cook B was requested to use a facility thermometer to measure the temperature of the roast beef, who then agreed and reported a temperature of 52 F. Cook B was then asked if the temperature of the product had been recorded 20 minutes prior, to which was the response Yes. It was 37 F When asked how the temperature had risen so much so fast, no explanation was given. The FDA Food Code 2017 states: ,d+[DATE].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 S,d+[DATE].19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54 C (130 F) or above;P or (2) At 5 C (41 F) or less. 2. On [DATE] at approximately 9:30 AM, the walk in cooler was observed during the initial tour of the kitchen. A 32 oz container of garlic in water was observed on a shelf with a stamp: Best if used by [DATE]. A 30 oz container of Basis Pesto was observed on the same shelf labeled: Opened ,d+[DATE]. Further review of the Pesto container revealed the following information about the product: Keep Frozen. Once thawed is considered perishable. An interview with Certified Dietary Manager (CDM) A was conducted on [DATE] at approximately 9:55 AM. CDM A confirmed the two mentioned products were expired and disposed of them. Additionally, CDM A stated the Pesto product was no longer used for menu items for the residents, as the residents didn't like it. On [DATE] the three week menu cycle provided to the survey team, was reviewed. Week 2, Thursday Dinner listed Basil Pesto Pizza for the entree. On [DATE] at approximately 10:40 AM, an interview with CDM A was conducted related to the disparity between the menu and the statement of the Pesto product not being used. CDM A stated, Oh. I gave you the wrong menus.

Based on observation, interview, and record review, the facility failed to secure 1 of 1 medication refrigerators and 2 of 3 medication carts, resulting in the potential for misappropriation of medications. Findings: During an observation on 01/03/23 at 9:58 AM, the refrigerator in the medication storage room, that contained controlled substances, was unlocked. During an interview at the same time, the Director of Nursing (DON) indicated that the refrigerator was to remain locked at all times. During an observation on 01/03/24 at 12:58 PM, the medication cart, identified as team 2 med cart, was unlocked and unattended by nursing staff. During an observation on 01/04/24 at 11:00 AM, the medication cart next to the bird aviary was unlocked and unattended by nursing staff. Review of the facility policy Medication Management, effective 04/21/23, revealed (a) the purpose was to outline safe storage of medications, (b) storage- all medications are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors, and (c) after receiving controlled substances and adding them to inventory, they are immediately placed into a double locked secure storage area.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% based on four errors out of 25 opportunities. This deficient practice resulted in the potential for negative resident outcomes due to inaccurate and ineffective medication doses. Findings include: During an observation of insulin administration for Resident #5 by Licensed Practical Nurse (LPN) D on 03/15/22 at 7:1., LPN D was observed attempting to prime a [MEDICATION(S)] insulin pen while holding the pen horizontally. When asked how the air would have been expelled from the insulin pen while holding the pen horizontally, LPN D said she did not know. On 03/15/22 at 7:51 a.m., Registered Nurse (RN) H was observed administering [MEDICATION(S)] forte eye drop medication to Resident #18. RN H did not apply a tissue or hold pressure on Resident #18's eye after placing the eye drop in her eye and the medication rolled out of her eye and rolled down her cheek. During a follow up interview on 3/15/22 at 7:56 a.m., RN H said she was not sure what steps should be taken to prevent the eye drop medication from rolling down her cheek. On 03/15/22 at 8:28 a.m., RN H said she had reviewed the eye drop administration policy and procedure. RN H reported the tear duct should have pressure held on it for a few minutes in order for the medication to absorb into the eye. RN H realized she had not held pressure on Resident #18's eye after administering the eye drop. On 03/15/22 at 8:47 a.m., RN E was observed priming Resident #6's insulin [MEDICATION(S)] and [MEDICATION(S)] sliding scale pens. RN E held each pen horizontally while priming the pens. When asked how the air would be expelled from the pens, RN E said the air would not be able to be expressed and would just keep going back and forth in the chamber of the pens. RN E said the pen should have been held upright to prime the pens correctly. On 03/16/22 at 8:13 a.m., the Director of Nursing (DON) said expectation would be to hold insulin pens straight up and down when priming the pens because if the pens were not held upright, the air bubbles could potentially remain in the pen, which could cause an incorrect dose of insulin to be given. The DON said there is a sheet the nurses could reference for guidance on insulin administration, but nurses have not had any medication administration in-service since she had started in June of 2021. The DON said when eye drops were administered, nurses should apply a tissue and slight pressure on the eye so the medication would be absorbed, if pressure was not applied to the eye after giving eye drops, it was impossible to determine if the resident had received the correct dose of medication. A copy of the facility's Medication administration policy- Insulin Administration with an effective Date of 6/21/17, contained the following information, in part, Insulin is a high risk drug and warrants additional precautions for the safe and effective administration. Insulin administration is performed by licensed nurses. Facility nursing procedures supersede this procedure if present .If using pen devices, there are several important consideration: check manufacturer instructions prior to use, as procedures my vary. many pens require priming or an 'air-shot' prior to administration . The AADE [American Association of Diabetic Education] Insulin Injection Know How Learning How to Inject Insulin website contained the following information in part, Preparing the pen for injection .prime the pen, pointing the needle up in the air, dial one or two units on the pen and press the plunger fully with your thumb (Retrieved from https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Insulin_Injection_How_To_AADE.pdf on 3/16/22). The facility's Medication Administration- Ophthalmic Drop Administration policy contained the following information, in part, To administer ophthalmic drops into the eye in a safe and accurate manner .Place hand against resident forehead to steady and instill drop inside eyelid close to outer corner of eye. (Do not allow dropper to touch any part of the eye.) 11. Instruct resident to close eyes to allow for even distribution over surface of the eye. a. if applicable, systemic effects of eye medications may be reduced by pressing the tear duct for one minute after eye drop administration or by gentle eye closing for approximately three minutes after the administration . The facility's [Name of Pharmacy] Medication Pass Guidelines contained the following information, in part, Eye drops .HOLD lacrimal duct for 1 minute [after administration] .Insulin pens .dial pen to 2 units point upward and press button to prime needle. The medication error rate was determined to be 16% based on four errors out of 25 opportunities.

Based on observation, interview, and record review, the facility failed to ensure medications were stored, labeled and/or disposed of appropriately for three of three medication storage areas inspected. This deficient practice resulted in the potential for residents experiencing negative outcomes due to receiving expired medications. Findings include: On 3/16/22 at 2:32 p.m., the [Name of Hallway] medication cart was inspected with Licensed Practical Nurse (LPN) D. Findings were as follows: An insulin [MEDICATION(S)] pen for Resident #15 was labeled with an opening date of 1/31/22. LPN D reported this insulin expired 28 days after opening and it should have been removed from the medication cart. An [MEDICATION(S)] inhaler was found to not contain a date in which it had been opened for Resident #23. LPN D said the policy was to label medications with a date when they were opened. A bottle of dry eye relief eye drops with an opening date of 12/16/21 for Resident #31 was observed to be buried under several other plastic bags containing resident eye drops for various residents. LPN D said the eye drops were probably expired and should not be in the cart, but if the eye drops were not expired, they should be placed in a plastic bag. A bottle of [name brand] [MEDICATION(S)] was observed to have a dried, white, crusty material around the cap and bottle of the container. LPN D said it was disgusting and stated concerns around bacteria growth. On 3/16/22 at 2:45 p.m., the [name of hallway] was inspected withe Registered Nurse (RN) F. Findings were as follows: A bottle of [MEDICATION(S)] eye drops for Resident #27 was labeled with an opening date 2/11/22. Resident #38's purse was observed to be stored in the narcotic drawer along with the narcotics. RN F said this was where Resident #38 requested it be kept. An observation of the medication storage room on 3/16/22 at approximately 2:55 p.m. with RN D revealed the following observations: A bottle of acetic acid solution contained a label with an opening date of 2/21/22 for Resident #9 and a bottle of acetic acid labeled with an opening date of 3/15/22 for Resident #30 were observed. RN D reported the acetic acid was used to flush the residents' indwelling catheters and they were only for single use. RN D said the bottles should have been discarded after use. A large, open, plastic bag containing one millimeter syringes was observed. The bag did not contain and expiration date for the syringes and the syringes were not packaged individually. RN D was unable to determine whether the syringes would be expired which would mean sterility could not be guaranteed. The facility's policy- Medication Management- Continuing Care (Rehab and Nursing Centers) with an effective date of 1/8/21, contained the following information, in part, Labeling of medications 1. Medications will be labeled to include the following: a. patient name, drug name, dose, route, dosing instructions, date opened .Once any medication or biological package is opened, manufacturer/supplier guidelines with respect to expiration dates will be followed for opened medications . The facility's Medications with Shortened Expiration Dates guidelines which was undated, contained the following information, in part, generic name: [MEDICATION(S)] vial/cartridge/kwikpen 28 days .expiration date: 28 days . Information obtained from the Patient Information website, contained the following information, in part, [MEDICATION(S)] eye drops for [CONDITION(S)] .[MEDICATION(S)] can be used alone or in combination with other treatments for [CONDITION(S)], such as [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], or [MEDICATION(S)] Always check the expiry information on the container. Eye drops in bottles only keep for four weeks once the bottle has been opened, so do not use the drops if the bottle has been open for longer than this. This will help to prevent the risk of eye infections . (Retrieved from https://patient.info/medicine/[MEDICATION(S)]-eye-drops-for-[CONDITION(S)]-timoptol-tiopex on 3/21/22). The Infection Control Today website contained the following information pertaining to the sterility of medical supplies, in part, Time versus event: Preserving Sterile Package Integrity .Events that can compromise package sterility include multiple handling that leads to seal breakage or loss of package integrity, moisture penetration and airborne contamination. [Event-related shelf life practice recognizes that the product should remain sterile until some event causes the item to become contaminated. Examples of events are tears in packaging, the package becoming wet, the package being dropped on a contaminated surface such as a floor and any compromise that destroys the barrier effectiveness of the packaged material.] .Commercial manufacturers predominantly use ERS [Event Related Sterility]. It doesn't matter who processes it; if the package integrity isn't there you don't use it. In the real world, [event-related sterility protocol] may not be followed because of a lack of knowledge resistance to change among healthcare workers (HCWs). No matter which shelf-life measure is used, from a process assessment standpoint, you must ensure all steps are followed sequentially, correctly, and appropriately .Recommended practices issued by the Association of periOperative Registered Nurses (AORN) support event-related sterility.5 According to AORN, the length of time an item is considered sterile depends on the following: Type and configuration of packaging materials used the number of times a package is handled before use Storage on open or closed shelves Environmental conditions of the storage area (e.g., cleanliness, temperature, humidity) Use of dust covers and method of sealing . (Retrieved from https://www.infectioncontroltoday.com/view/time-versus-event-preserving-sterile-package-integrity on 3/21/22).

Based on observation, interview, and record review, the facility failed to provide proper infection control measures pertaining the indwelling catheter (a tube inserted into the bladder to accommodate emptying of the bladder) for one (Resident #28) of two residents reviewed for indwelling catheters. This deficient practice resulted in the potential for infections, and illness due to improper catheter care. Findings include: Resident #28 Resident #28's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #28 was cognitively intact. On 3/14/22 at 2:59 p.m., Resident #28 was observed in her bed. An indwelling catheter urinary collection bag was observed on the floor. A moderate amount of cloudy urine was visible inside the bag. Resident #28 said she did not know why she had the catheter and had experienced a lot of urinary tract infections which had required hospitalization . On 3/14/22 at 3:56 a.m., Non-Certified Nurse Aide/Staff G was asked to observe Resident #28's catheter. Staff G observed the urinary collection bag laying on the floor and said it should not be on the floor because it increased the risk of urinary tract infections. An additional observation of Resident #28's catheter was made on 3/15/22 at 7:32 a.m. The urine collection bag was laying on the floor. On 3/15/22 8:09 a.m., Registered Nurse (RN) H observed Resident #28's catheter bag on the floor and said it increased the risk of urinary tract infections. RN H verified Resident #28 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN H said the catheter bag laying on the floor could be a contributing factor for urinary tract infections. On 3/16/22 at 8:13 a.m., the Director of Nursing (DON) said catheter urine collection bags should always be kept off the floor. Concerns around Resident #28's catheter bag being found on the floor. The DON said this could contribute to Resident #28's urinary tract infections. An ED (Emergency Department) Provider Note written on 12/29/21 by Physician J contained the following information, in part diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Severe [CONDITION(S)] [a severe infection throughout the entire body]. Patient is [age] with a history of multiple urinary tract infection in the [Name of Facility] treated with [MEDICATION(S)] multiple times in the past few months and has been [CONDITION(S)] in the 140's for past 3 days. Was brought to emergency room for further evaluation. Patient is re-evaluated and felt to be septic. Remains [CONDITION(S)] [rapid heart rate] and is found to have a lactic acidosis [a lab test which indicates severe infection] of 3.8 White blood count [indicates infection] 7.1. Acute kidney injury on chronic [CONDITION(S)] [inadequate kidney function] .Patient was discussed with the hospitalist service in [name of town] agrees to accept her for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .she does have urinary urgency and has urinary tract infections from time to time .her recent urinalysis is suspicious for infection. An additional ED provider note dated 2/23/22 by Physician J contained the following information, in part, Patient is [age] sent to the emergency room from [name of facility] for altered consciousness and fever. On arrival in the emergency room , she is orientated to person place and her Foley catheter had just been changed at the nursing center and was draining foul urine .has been in the nursing center on campus since last November over year ago and has a chronic indwelling Foley catheter for years . The facility's Urinary Catheter Care and Management' policy with an effective date of 3/3/20 contained the following information, in part, The purpose of this policy is to define various urinary collection methods and devices, both internal and external and their insertion/application, assessment, maintenance, removal and specimen collection modes .4. Infection prevention (a) use clean technique and standard precautions when handling or manipulating the drainage system and sterile technique when changing the drainage system .(b) maintain patent catheter tubing and position drainage bag off the floor.

Based on observation, interview, and record review, the facility failed to ensure routine dental care was offered to two Residents (#10 and #20) of 15 sampled residents reviewed for dental care. This deficient practice resulted in oral pain for Resident #20, and feelings of frustration related to missing teeth for Resident #10, with the potential to affect all facility residents. Findings include: Resident #10 On 3/14/22 at 12:59 p.m., Resident #10 reported that he had broken teeth. A review of Resident #10's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Area Assessment (CAA) for dentition linked to this MDS revealed, . has some of his natural teeth, others are missing/have been pulled in the past. he denies having any trouble chewing or swallowing. He does however state that there are a couple teeth towards the back that are occasionally painful, and that he feels they need attention from a dentist. On 3/16/22 at 11:45 a.m., the DON was asked to provide evidence of Resident #10's consent for dental services as well as any documentation that Resident #10 had received dental care related to his missing teeth. The DON reported she found no documentation in his record except for a 12/28/21 nutrition progress note that mentioned, . several missing top teeth . The DON reported she found no offer or consent of dental services in his record. On 3/16/22 at 3:33 p.m., Resident #10 reported that he did want to be seen by a dentist regarding his teeth. Resident #20 Review of Resident #20's Minimum Data Set (MDS) assessment, dated 11/26/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The dental assessment was marked no broken or loosely fitting denture, and no mouth discomfort. The Brief Interview for Mental Status (BIMS) assessment score was 13/15, which indicated Resident #20 had normal cognition. During an interview on 3/14/22 at approximately 2:15 p.m., Resident #20 was asked how they were doing. Resident #20 pointed to his mouth, and reported his teeth were hurting him. When asked to provide a number from 0 to 10, with 10 being the highest, Resident #20 reported, The pain is a 5 (of 10) now. Resident #20 was asked by Surveyor to show him their mouth, and dentures were visible both upper and lower, which Resident #20 confirmed. Resident #20's nurse, Registered Nurse (RN) E, was asked about his pain and teeth. RN E checked in with Resident #20, and told Surveyor, He does complain of pain in his mouth [at times] and he doesn't like them [his dentures] out. She explained he received Tylenol scheduled three times daily and reported in the past for pain they had used [brand name] topical gum pain reliever but there was no current prescription there. She reported she would take his teeth out today and see if she could see any sores or concerns. Registered Nurse B, the unit manager, was also present for the interview, and reported they had nothing to add. There was no mention of a scheduled dental appointment for tooth pain. On 3/14/22 at 3:47 p.m., Registered Nurse (RN) E followed up with Surveyor, and reported they removed his dentures, they appeared to be structurally intact, they fit in his mouth well, there were no issues with eating, and no sores found in his mouth. Review of two nursing progress notes showed reference to Resident #20's tooth pain, one dated 3/14/22 by Registered Nurse E, which explained they would follow up with provider. A second nursing progress note dated 11/21/21 mentioned complaints tooth pain, which resolved after taking medications. They noted this would be monitored. There was no evidence of provider follow up or monitoring for tooth pain found in the nursing or provider notes. During an interview on 3/16/22 at 8:57 a.m., Registered Dietician (RD) N was asked about Resident #20's diet, and if aware of any concerns there related to chewing, pain, or related concerns. RD N reported they were not aware of oral pain but had changed him to a pureed diet as Resident #20 ate very quickly. During an interview on 3/16/22 at approximately 11:01 a.m., Social Worker Director (SW) O was asked if they were aware of any upcoming dental appointments for Resident #20, and reported they were not aware of any. They reported they would check with the facility transportation aide. During an interview on 3/16/22 at 2:16 p.m., the Director of Nursing (DON) confirmed the transportation aide did not have a current dental appointment for Resident #20, and the expectation would be they would have a dental appointment scheduled annually at minimum. The Nursing Home Administrator (NHA) reported the residents had not had routinely scheduled dental appointments since March of 2020, when the COVID-19 pandemic started. The DON reported they were not aware of Resident #20's reported tooth pain on 11/14/22 or 3/14/22 when asked and confirmed the COVID-19 pandemic had affected routine dental visits. During an interview ono 3/16/22 at 2:30 p.m., Resident #20 was seated in the hallway outside the family room in his beige Geri chair. Surveyor asked how his day was going. Resident #20 responded, I'm ok but my teeth hurt. Surveyor found the NHA, and Resident #20 repeated the same to them. The NHA immediately addressed Resident #20's pain with nursing staff. During a follow-up interview with the NHA afterwards, they confirmed while there was no routine scheduled care at the facility, residents could see a dentist if their families took them, and an outside provider had been secured in February (2022), but required consents to be signed, and consents were still being signed by families. The NHA confirmed there was no signed contract for Resident #20 to receive dental services during the survey. The NHA showed Surveyor a copy of a newly scheduled next day urgent appointment for Resident #20 to be seen for his tooth pain. The NHA indicated the expectation would be residents would be seen at least yearly by a dental provider for routine visits and understood the concern. Review of the facility's dental contract, provided by the NHA, signed by both the facility and provider dental group, revealed a contract signed on 2/02/22 by both parties, with a commitment by the provider to begin providing dental services to the facility residents once the resident/representative consents were signed and received. The NHA confirmed there was no contract for Resident #20 signed during the survey. Review of the facility's policy, Dental Services for Residents and Patients - (Rehab and Nursing Centers), dated 2/03/21, revealed, The purpose of this policy is to articulate steps and guidelines to ensure residents obtain dental services, including assistance needed or requested for routine dental services and necessary referrals .Definitions: .Emergency Dental Services: Includes services to treat an episode of acute pain in teeth, gums, or plate, broken or otherwise damaged teeth, or any other problem of the oral cavity that requires immediate attention by a dentist. Routine dental services: an annual inspection of the oral cavity for signs of disease, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .g., taking impressions for dentures and fitting dentures

Based on observation, interview, and record review, the facility failed to ensure care was provided in a dignified matter while providing care for two (Resident #5 and Resident #28) of 15 residents reviewed. This deficient practice resulted in the potential for embarrassment and impaired psychosocial wellbeing. Findings include: Resident #5 Review of Resident #5's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 3/15/22 at 7:41 a.m., Licensed Practical Nurse (LPN) D lifted Resident #5's shirt to administer insulin into Resident #5's abdomen. The privacy curtain was not pulled, Resident #5 abdomen was exposed to passerby in the hall because Resident #5 was positioned by the door of her room. During an interiview on 3/15/22 at approximately 7:45 a.m. LPN D was asked what steps were taken to ensure privacy and dignity were maintained when administering the insulin, LPN D said I didn't, I should have pulled the [privacy] curtain, I know better. Resident #28 Review of Resident #28's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22 at 2:59 p.m., Resident #28 was observed in her bed. An indwelling catheter bag was observed on the floor, a privacy bag (a bag in which the urine collection bag is placed to maintain dignity) was not observed. During an interview on 3/14/22 at 3:56 p.m., Non-Certified Nurse Aide/Staff G, after observing Resident #28's catheter bag, was unable to provide information pertaining to a privacy bag not being in use for Resident #28's urine collection bag. An additional observation of Resident #28's catheter was made on 03/15/22 at 7:32 a.m. The urine collection bag was not placed in a privacy bag. During an interview on 3/16/22 at 8:13 a.m., the Director of Nursing (DON) said indwelling catheter urine collection bags should be placed inside a privacy bag unless the resident prefers not to have a privacy bag. The DON was unable to recall if Resident #28's care plan included her preference of the use of a privacy bag. During an observation with Registered Nurse (RN) B on 3/16/22 at 8:37 a.m., Resident #28 was in bed. A pillow covered with a pillowcase which had what looked like dried liquid stool on it was present on top of the blankets at the foot of Resident #28's bed. RN B said that was inappropriate and should not have been left there. On at 3/16/22 at approximately 9:00 a.m., the DON verified Resident #28's urine collection bag should have been kept in a privacy bag. Review of the facility's Resident Rights-Continuing Care (Rehab and Nursing Centers) policy with the effective date of 11/16/21 revealed the following information, in part, Every resident shall be entitled to humane care and treatment provided with dignity and respect .Residents have the right to a safe environment, including: a clean, comfortable, and homelike environment, which includes safely receiving treatment and supports for daily living . Privacy will be granted, to the fullest extent feasible, in medical treatment and in caring for personal needs with consideration, respect, and full recognition of their dignity and individuality .

Based on interview, and record review, the facility failed to report a major injury of unknown injury to the appropriate state agency for one (Resident #39) of four residents reviewed for falls. This deficient practice resulted in the potential for undetected and unreported abuse, placing residents in unsafe situations. Findings include: Review of Resident #39's face sheet revealed an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #39's Fall Event dated 1/18/22 contained the following information, in part, Elder was not able to tell staff what he was trying to do. Light in room was on. Call light had been unplugged from the wall but was within reach. Elder was observed with no socks or footwear on. Non ambulatory mat in place. Bed alarm not sounding at time of fall . A review of Resident #39's Fall Event' dated 2/9/22 contained the following information, in part, This nurse entered room to find elder in a praying position, on knees, hunched over the end of the bed. When asked elder what he was trying to do, elder stated [expletives] and swinging his left arm. Light was on in room and room free of clutter . Elder was only wearing regular socks on feet .When moving resident to a sitting position, elder yelled out. Right leg observed to be externally rotated. Family updated on condition and requests elder be sent to emergency room to be evaluated . The [Name of Facility] Fall Scene Investigation Form dated 2/9/22 contained the following information, in part, was the fall witnessed: No . mentation impaired . Review of an Emergency Department provider note written 2/9/22 by Physician Assistant (PA) I revealed the following information, Closed displaced comminuted fracture of shaft of right femur, initial encounter .Patient brought in after an unwitnessed fall for concerns of a leg fracture. On my exam, he has a deformity noted to the mid right femur. I obtained x-rays of this as well as the pelvis, given unwitnessed nature of the fall as well as anticoagulation .when they found him, he was leaning up against the bed and they did not note any other trauma .His x-ray images do show a mid-femoral fracture that this is displaced .Patient brought in by nursing staff from [Name of Facility] .They found him leaning up against the bed just prior to arrival after having a fall. The fall itself was unwitnessed. Patient does seem to be in significant pain . During an interview with the Nursing Home Administrator (NHA) on 03/15/22 on 11:56 a.m., the NHA reported Resident#39's femur fracture had not been reported to the state agency because after review of the information, it was believed there were not any concerns that warranted reporting. The NHA verified the accident had been unwitnessed and there was no way of determining what had caused the injury since nobody had seen it and Resident #39 was unable to explain how it happened. Review of the facility's Resident/ Patient Abuse Program Procedure (Rehab and Nursing Centers) policy with an effective date of 6/24/21, revealed the following information, in part, The purpose of this policy/procedure is to articulate standards and/or processes for proper screening, training, prevention, identification, investigation protection and reporting relative to any form of abuse .Serious Bodily Injury: The term serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation .Any alleged or suspected acts of physical, mental, or sexual abuse, involuntary seclusion, neglect, mistreatment, misappropriation, and injuries of unknown origin must be reported immediately to the Administrator or designee . Reporting/response .C. When abuse, neglect or exploitation is suspected, follow the appropriate steps: 1) [NAME] reporting: In compliance with Federal law, an immediate report is provided to the Administrator/designee and the State Survey Agency ([NAME]) of alleged violations involving physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation, and injuries of unknown origin. The Administrator/designee must report to [NAME] within two hours .The results of investigations must be reported to the administrator or designated representative and to the State Survey Agency by completing and submitting the electronic Facility Investigation Report - 5 Working Days form within 5 (state) working days of the incident. 1) Within five (5) working days, the Administrator, Director of Nursing, or designees will compile a final summary and report of the investigation. The report may include (as appropriate): a. Name and age of the resident/patient involved b. Name of the alleged perpetrator c. Cognitive and functional status of the resident/patient d. Description of the incident e. Date and approximate time of the incident f. Where the incident took place g. Type and location of injuries (if any) h. Name and position of person who discovered/observed the incident i. Name and position of person to whom the incident was reported j. Written statements and/or interview summary from all involved staff. Time, date, and the name of individuals outside the facility who were notified of the incident, such as the police, family/legal/representative, physician, facility personnel, State agency and Federal agency, the time l. Investigation summary m. Conclusion if an allegation was substantiated or not substantiated.

Based on observation, interview, and record review, the facility failed to provide quality of care related to ensuring one Resident (#15) out of 15 residents reviewed for cares received the highest practicable level of treatment and quality of care according to professional standards of practice, the comprehensive care plan, and resident choice for optimal quality of care. This deficient practice resulted in Resident #15's bed unaccommodating resident height and potential for the development of pressure areas to the feet and toes, and the development of plantar flexion posture and subsequent contractures of their feet, which would limit weight bearing for functional transfers, and result in pain, discomfort, and immobility. Findings include: Review of Resident #15's Minimum Data Set assessment, dated 1/12/22, revealed an admission on 9/01/18, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the assessment, Resident #15 required two-person assistance for bed mobility and transfers, and one-person assistance for dressing and toileting. The assessment also revealed Resident #15 was 67 inches tall and weighed 244 pounds. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, indicating Resident #15 had intact cognition. During an interview on 3/14/22 at 3:16 p.m., Resident #15 reported My bed is too short, and my feet are slipping down. Resident #15 reported this bothered them as their feet frequently pressed up against the footboard of the bed which was uncomfortable. Surveyor observed a wood footboard at the end of the Resident #15's bariatric bed, with an air mattress on the bedframe. It was noted Resident #15's head of bed was elevated to about 30 degrees, and they reported they liked this height to watch television. During this observation their right foot was 4 inches from the base of the bed, and their left foot was 6 inches from the base of the bed. There were two black metal posts anchored over the inside base of the bed footboard to hold the air mattress bed regulator outside the same footboard, which appeared to present a safety risk for skin integrity, if Resident #15 slid down in the bed. Resident #15 was asked if staff were aware of her feet sliding down the bed to press against the footboard, and responded, Yes, I have told staff about it off and on. I have told everyone around here. They say they'll have to look into it . Resident #15 reported nothing changed, and she believed she needed a longer bed. It was noted Resident #15's right foot was fully plantar flexed (toes pointed down) and their left foot was near fully plantar flexed as well, placing Resident #15 at risk for contractures. This would prevent their feet from flattening for weight bearing, and the potential for her toes to press against the foot board of the bed. Resident #15 reported she wished a brace had been trialed to prevent her toes from pointing but none had ever been, which concerned them. An observation on 3/15/22 at 11:38 a.m. revealed Resident #15's left foot (toes) pressed up against the footboard of the bed, and only 1 centimeter away from touching on one of the two black metal posts which hooked the air mattress regulator over the end of their bed. Specifically, the great toe pad (hallux) was firmly pressed against the foot board, as well as the second (long) toe at the top. The toes were red. The right foot was crossed over the left and not touching the base of the bed, only because it was over the footboard and elevated in air due to being elevated by the left foot, since Resident #15's feet were crossed at the ankles. Resident #15 acknowledged her toes pressing against the footboard was uncomfortable for her. During an interview on 3/15/22 at 11:51 a.m., the Certified Nurse Aide assigned to Resident #15, (CNA) M, was shown Resident #15's feet as the nurse was unavailable and confirmed them touching the footboard. CNA M reported the interventions they implemented when this occurred was to pull Resident #15 up in their bed, or place Resident #15's calves flat on pillows. CNA M acknowledged Resident #15 slid down in bed often, and they had not specifically reported to nursing staff as they would reposition the resident. During an observation on 3/15/22 at approximately 11:59 a.m., the Director of Nursing (DON) confirmed Resident #15's toes were firmly pressing against the foot of the bed. The DON acknowledged seeing the pressure area on the toes, with redness noted, which was initially non-blanchable but soon after became blanchable. The DON reported staff boosted Resident #15 up in bed as needed, and they would consider other options. Resident #15 reported they were not feeling well during this observation but was unable to specify further. Resident #15 was repositioned by staff to offload her feet from the footboard. The DON was asked about Resident #15's toes being pointed down, and the potential for contracture, and if this was being addressed. The DON reported they would need to follow up and demonstrated they could achieve some dorsiflexion with range of motion. Resident #15 did not have full active or passive range of motion in her feet, and the feet and toes remained plantar flexed [pointed down] unless range of motion was assisted by the DON. The DON soon after returned and reported the facility was going to order a bed extender to lengthen the bed (base) itself and add in a foam mattress filler which would be even in height with the mattress, so there would be no chance for Resident #15's feet to be pressed up against the baseboard again or another surface. In the meantime, they would continue frequent repositioning to prevent this from recurring. They did not mention Resident #15's foot range of motion impairment, or any plan to address during this interview. During an interview with the NHA on 3/15/22 at 4:32 p.m., they were made aware of the concerns regarding Resident #15's toes pushed up against the bed, causing potential pressure injury areas, and toes being plantar flexed. At that time, the NHA acknowledged the concern, and was asked if therapy had screened Resident #15. NHA followed up with Surveyor to discuss concerns with therapy on 3/16/22 when they were available. Review of Resident #15's Care Plan, provided by the Nursing Home Administrator (NHA), printed on 3/16/22 at 11:38 a.m., revealed a new problem area started on 3/16/22: Problem: [Resident #15] is at risk for decline in targeted function/ROM [range of motion]. Start 3/16/22. Description: [Resident #15] is at risk for decline in range of motion in her feet. She is able to perform active ROM [range of motion] in left foot, passive ROM in right foot .Interventions - left foot AROM [active range of motion], right foot PROM [passive range of motion] [Restorative]. There was no mention of a therapy referral. Further review of Resident #15's same Care Plan, revealed, Problem: Start: 9/02/18. Skin: [Resident #15] is at risk for breaks in skin integrity related to moisture, mobility deficit, friction/shear, nutrition/hydration, comorbidity: diabetes, medications that increase risk, history of pressure injury. Keeps head of bed elevated which causes her to slide down in bed. Goal: [Resident #15] will not experience any preventable pressure ulcers. Start date: 9/02/18. Assist in repositioning, check skin in showers .Ensure feet/toes are not touching the bed with q [every] 2 hour turns . During an interview on 3/16/22 at 10:12 a.m. with the Rehabilitation Director, Occupational Therapist (OT) L, and Physical Therapist (PT) K, they were asked about Resident #15's plantar flexion in their bilateral feet, and if they had addressed. Both confirmed there had been no referrals to screen Resident #15's feet or legs, at least in the past year. OT L reported nursing screened residents, so the only way they would get a referral would be if nursing referred the residents. It was confirmed there was no routine screening process on the longterm care unit by therapy. PT K reported they didn't recall Resident #15 walking and worked with them on transfers during the last course of therapy about a year or more ago. PT K confirmed a positioning brace and physical therapy would be of benefit for any resident developing plantar flexion posture, which could develop into plantar flexion contractures. PT K reported per their recall Resident #15 had achieved dorsiflexion (flat foot) posture to use a sit to stand lift at time of discharge. OT L reported they would facilitate a referral for physical therapy services for Resident #15. Both confirmed they had not received a referral for range of motion for Resident #15's decreased foot range of motion, by the time of this interview. Review of Resident #15's mobility Care Plan, printed on 3/16/22 at 11:38 a.m., showed Resident #15 currently used a [brand name] Sit to Stand Raising transfer aide, which would require their feet to be dorsiflexed [flat footed] to use the transfer assist device. This type of lift would preserve Resident #15's ability to use the toilet with this lift (verses being dependent on a full body lift which may not facilitate safe toileting), so preserving foot dorsiflexion would be essential for Resident #15 to continue to achieve toileting on the commode with staff assistance and the standing transfer lift. During a follow-up interview on 3/16/22 with the NHA, and interim NHA, at 11:27 a.m., they reported they were not aware of this concern and felt staff repositioned Resident #15 as needed. Surveyor conveyed Resident #15 self-reported they had told multiple staff of the concern of their bed being too short and their feet pressing up against the bed, and the risk for the potential for pressure injury was of concern due to the bed length not appearing to fit the resident, as well as the potential for the development of plantar flexion contractures which would impede or limit attempts at weight bearing. Review of the policy, Pressure Injury: Assessment, Prevention, and Care, dated 5/14/21, received from the NHA on 3/16/22, revealed, The purpose of this policy is to outline the process for skin assessment, prevention, and care of pressure injuries Turning and repositioning. A. Patients at risk for pressure injuries will be offered to be turned and repositioned every two hours unless otherwise specified. Other interventions will be reviewed to address the patient's risk for developing pressure injuries . The NHA acknowledged this was the only policy they were aware of which addressed positioning. Review of the policy, Resident Rights, dated 11/16/21, received from the NHA, revealed, .3.6. Rights, Privacy, and Quality of Care . Privacy and Quality of Care will be provided to residents, and authorized representatives, including but not limited to the following: .Participation in planning care, medical treatment, and determining appropriate changes is encouraged unless deemed incompetent or otherwise found to be incapable under state law .

Based on observation, interview, and record review, the facility failed to ensure that fall interventions were in place for two Residents (#17, #39) out of four residents reviewed for falls. This deficient practice resulted in resident falls and the potential for further falls and injury. Findings include: Resident #17 A review of Resident #17's medical record revealed she admitted to the facility on [DATE] with diagnoses including dementia, history of traumatic brain injury (TBI), and high blood pressure. A review of her 7/27/21 Minimum Data Set (MDS) assessment revealed she scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment indicating intact cognition. A review of Fall Risk Assessments for Resident #17 revealed the following risk scores: 2/3/22 score of 21; 2/24/22 score of 25; 3/10/22 score of 28. A score greater than 15 indicates high risk per the [NAME] Davis fall scale the facility used. A review of Resident #17's Fall Event Summary dated 2/17/22 revealed the following: Elder was found by (name of Aide) on the floor next to her bed on her knees facing the bed after hearing a noise. Alarm was noted to not be plugged in on the bed . A review of Resident #17's fall care plan revealed no interventions of ensuring the bed alarm was plugged in and functioning appropriately. On 3/16/22 at approximately 3:00 p.m., the Director of Nursing (DON) was asked about the alarm being unplugged and not in place. The DON reported that Registered Nurse (RN) B would have more information as she conducted the fall investigations. On 3/16/22 at 3:10 p.m., RN B was asked about Resident #17's fall and fall care plan. RN B reported that she did one on one education with the aid that was on duty about making sure the alarms were in place. RN B reported that she wasn't sure if checking the alarm function was on the care plan, but that it was being monitored for function on a task list. On 3/16/22 at approximately 3:30 p.m., RN B provided a note that revealed she was not able to find any tracking for checking that the alarm was functioning. Resident #39 Review of Resident #39's face sheet revealed an admitted [DATE] and medical diagnoses which included diabetes, falls, a stroke with right sided weakness, and dementia with behavior disturbances. A review of Resident #39's Fall Event dated 1/18/22 contained the following information, in part, Elder was not able to tell staff what he was trying to do. Light in room was on. Call light had been unplugged from the wall but was within reach. Elder was observed with no socks or footwear on. Non ambulatory mat in place. Bed alarm not sounding at time of fall . A review of Resident #39's Fall Event dated 2/9/22 contained the following information, in part, This nurse entered room to find elder in a praying position, on knees, hunched over the end of the bed. When asked elder what he was trying to do, elder stated [expletives] and swinging his left arm. Light was on in room and room free of clutter. Elder was only wearing regular socks on feet . A copy of the [Name of Facility] Fall Scene Investigation Form dated 2/9/22 contained the following information, Safety precautions (check all that were in place): call light within reach, bed in low position, anti-slip footwear on resident . On 3/16/22 at 8:13 a.m., the DON was unable to explain why Resident #39's alarm had not gone off when on his 1/18/22 fall. The DON said staff most likely failed to verify it was turned on and it should have been checked. The DON could not clarify what type of footwear Resident #39 was care planned to be wearing. On 03/16/22 at 9:56 a.m., the DON clarified Resident #39 should have had either shoes or grippy socks on to prevent falls. The DON said Resident #39 had a history of being resistant to care and they were not always able to ensure he had either shoes or grippy socks on. The DON said this information should be accessible in the resident care summary and that was what the Certified Nurse Aide (CNA)'s used for reference. Neither Resident #39's fall care plan dated 1/9/18 or the resident care summary (undated) contained information pertaining to footwear as fall interventions.

Based on observation, interview, and record review, the facility failed to ensure staffing information was posted for two of seven workdays for a period of approximately one and a half years. This deficient practice resulted in the lack of availability of staffing information for residents, staff, and visitors. Findings include: On 03/16/22 at 8:45 a.m., a staffing sheet was observed to be posted at the nurse's station. Secretary/Staff C reported she posted the staffing sheets Monday through Friday, but she was not sure who was responsible for posting the staffing sheets on the weekends. Staff C provided the staffing sheets for the month of March but reported there were no staffing sheets available for Saturdays and Sundays for the month. On 03/16/22 at 9:14 a.m., the Nursing Home Administrator (NHA) was asked to provide Saturday and Sunday staffing sheets for the months of February and March 2022. On 03/16/22 at 10:58 a.m., the NHA confirmed there were not any staffing sheets available for Saturdays and Sundays for the months of February or March 2022. The NHA reported there had been a part time secretary who had completed the weekend staffing sheets. The position had been vacated in mid 2020 and the sheets had not been being completed on the weekends since that time. The NHA reported this was an oversight because the task had not been reassigned when the position became vacant.

Based on observation, interview, and record review, the facility failed to provide safety supervision for one resident (Residents #1), resulting in an injury and the potential for injury for all facility residents who require supervision for safety. Findings: Review of the Incident Summary report submitted by the facility to the state agency, on 2/12/20, Resident #1 fell when left unattended in the bathroom. The report reflected on 2/13/20, Resident #1 complained of pain in her right foot, an X-ray was taken, and a bone fracture was identified in the right lower extremity. On 3/2/202 an unannounced onsite abbreviated survey was initiated. admitted to the facility 1/25/2020, Resident #1 was diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], reflected Resident #1 was non-ambulatory and required extensive assistance of two staff members for transfers. Section C of the MDS, titled Cognitive Patterns, reflected Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen which indicated severe cognitive impairment. This section also reflected that Resident #1 displayed a behavior of inattention that was continuously present, does not fluctuate. Review of the Electronic Medical Record (EMR) Care Plan, page nine of twelve, reflected that Resident #1 was, at risk for falls or injury related to impaired balance, impaired safety awareness .(history) of falls . One intervention of the Care Plan reflected, Do not leave resident in (bathroom) unattended. During an interview conducted 3/2/20 at 11:58 AM, Registered Nurse (RN) D reported she was the nurse assigned to Resident #1 on 2/12/20. RN D reported CNA G had taken Resident #1 to the bathroom, then left her unattended while the CNA went to another resident's room. RN D reported Resident #1 fell and was found face down on the floor. RN D reported she completed an assessment, although the Resident's right foot hurt a little, the assessment was essentially negative. RN D reported that the Resident Summary Template (RST, a summary of a resident's care needs) reflected Resident #1 was not to be left unattended in the bathroom. RN D reported that all staff are responsible for knowing what is on a resident's RST. RN D reported that CNA G did leave Resident #1 unattended, for just a few minutes, but, you know, that's when things happen. During an interview conducted 3/2/20 at 12:39 PM, CNA E reported she was working as a Laundry Aide at the time of the incident. CNA E reported CNA G was providing care for another resident and had asked her to check on Resident #1 in the bathroom. CNA E reported she visibly checked on Resident #1 who was sitting on the toilet just fine and indicated she told CNA G the Resident was ok. CNA E reported she had just returned to the Laundry area when the staff assist alarm (an alert on the phones use by staff to cue immediate assistance is needed) went off on her phone. CNA E indicated the phone showed the alert was for the room of Resident #1. CNA E reported she returned to the room to find Resident #1 on the floor. CNA E did not indicate that she knew that Resident #1 was not to be left unattended in the bathroom. CNA G, who had left Resident #1 unattended in the bathroom, has not been available during the facility investigation or for the abbreviated survey due to extenuating circumstances. Review of the Employee file for CNA G reflected the CNA had successfully completed facility training and orientation that included accessing the summary screen and was aware of measures to provide safe care. In an interview conducted 3/2/20 at 3:44 PM, the Director of Nursing (DON) reiterated that the RST is a summary of a resident's care needs. The DON reported that staff are expected to know the care needs of the residents they are providing care for. The DON reported that staff would know that Resident #1 was not to be left unattended in the bathroom. Review of the RST history for Resident #1 reflected Unattended in Bathroom - DO NOT LEAVE was on all RST documents in the EMR since at least 11/18/19 (11/18/19, 12/3/19, 2/4/19) which indicated this was a long-standing intervention. On 3/2/20 at 9:27 AM, Resident #1 was observed in a facility common area sitting in a wheelchair with foot pedals. A large boot that extended to just below the knee was observed on the Resident's right lower extremity. Review of the X-ray report of 2/13/20 at 2:01 PM reflected, Acute nondisplaced Weber type A [MEDICAL CONDITION] malleolus associated with lateral soft tissue swelling.

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety as evidenced by failing to maintain hot potentially hazardous foods at or above 135 F while being held wating to be served. This deficient practice has the potential to result in food borne illness among any or all 42 residents of the facility. Findings include: On 01/14/2020 at 7:25 AM, a pan of scrambled eggs and a pan of breakfast sausage was observed on the stove. The temperature of both products was measured using a metal stem digital Super Fast Thermapen which reported the eggs being held at 120° F and the sausage at 107° F. An interview with Cook J was conducted at this time who confirmed these two foods were being held to be placed on residents trays. Cook J was requested to measure the same products using a facility thermometer and reported the same temperatures. Cook J stated It is time to throw those out. A review of the food production sheet, which included food temperature documentation, showed the eggs were measured to be 170° F and sausage 165° F, however no time was documented when those temperatures were measured. A review of the facility policy FOOD HANDLING-SERVICE, REFERENCE # 8268; EFFECTIVE DATE 04/29/2018 was conducted. The only statement related to food temperature was: Serving of Foods: 1. Food temperatures will be taken before all service of food for consumption by resident, patients, staff and guests. a. Any temperature for a food item that does not fall within the acceptable range must be corrected to fall into the acceptable range prior to service. The corrective action taken must be documented. Nothing in the policy identified specific holding temperatures of potentially hazardous foods or what a corrective action would consist of. The FDA Food Code 2013 states in 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 §3-501.19, and except as specified under ¶ (B) and in ¶ (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above,or (2) At 5°C (41°F) or less.

This citation pertains in part to intakes MI 3 and MI 70 Based on observation, interview and record review, the facility failed to develop and implement care planned interventions for four residents (Resident #24, 25, 33 and 39) resulting in a fall and potential for serious injury for 1 resident (Resident #24), weight loss for 2 residents (Residents #25 and #33), and ongoing behavioral concerns for 2 residents (#33 and #39) as well as the potential for other facility residents care plan needs to be ineffective or unaddressed. Findings include: Resident #39 Review of Resident #39's face sheet revealed he admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #39's most recent MDS (Minimum Data Set) on 12/13/19 revealed a BIMS (Brief Interview for Mental Status) score or 4/15, indicating he is severely cognitively impaired. Review of Resident #39's RST (Resident Summary Template), or brief care plan, revealed: I can be flirtatious at time (sic), please redirect me and set limits with this behavior. Please ensure there is a table or chair between (Resident #14's initials) and myself .While I am in the commons area by the birds, I will be in visual site (sic) when females are present. Review of Resident #39's Care Plan Report revealed a problem area of behavior. Interventions include Monitor effectiveness of interventions with the disciplines responsible listed as Social Work and IDT (interdisciplinary team). Other interventions include: Evaluate behavior for potential contributing factors with Social Work as the responsible discipline and Please keep a table or chair between (Resident #39) and female residents that he may attempt to approach sexually. Keep me in visual site (sic) when I am in the common area by the aviary when female residents are present with the responsible disciplines listed as Social Work and All Staff. Review of facility reported incident Event Summary and Investigation Worksheet revealed: On 1/4/2020 (Resident #39) was observed by CNA getting himself out of his chair and ambulating toward another resident. CNA exited nurses' station and as she approached (Resident #39) he was near (Resident #14). His hand was in (Resident #14's) peri area, above her clothes. Resident was moved away from (Resident #14) immediately . The event occurred in the Common Area. In the section Describe any action taken by the facility: Resident #39 has an alarm in his chair to notify staff if he is attempting to get up and approach other residents. In the summary: The facility will not substantiate abuse; both residents had no ill intent and both residents were not in distress . Review of previous facility reported incidents regarding Resident #39 revealed: On 12/15/2018 Resident #39 kissed Resident #14 in the common area by the bird cages. Per review of facility Event Summary and Investigation Worksheet on 8/23/2019 at 7:50 AM there was an alleged incident with the boxes checked for abuse, sexual. On 8/23/19 (Resident #39) and (Resident #8) were seen making contact. (Resident #39) was standing next to (Resident #8) and was rubbing her arm and chest area as well as kissing (Resident #8). Staff immediately separated the residents .Staff will monitor residents to ensure they are not left alone in the same area . Per review of facility Event Summary and Investigation Worksheet on 9/4/2019 at 8:24 AM there was an alleged incident with the boxes checked for abuse, physical. On 9/4/19 at 8:24 in the morning (Resident #39) was leaning over (Resident #8) and the RN interjected, as the RN was trying to separate the residents (Resident #39) reached out and tapped (Resident #8) on her forehead with his fingers. Further review revealed Resident #39 kissed Resident #8 on the cheek while he was leaning over her and reached around the RN to tap Resident #8 on the forehead when the RN intervened. Per review of facility Event Summary and Investigation Worksheet on 10/4/2019 at 10:20 AM there was an alleged incident with the boxes checked for abuse, sexual. On 10/4/19 (Resident #32 and Resident #39) were mutually hugging when they began to kiss. When separated immediately by a staff member (CNA W) both residents were confused as to why they were being separated .care plans updated as needed. The event occurred in the common area. In the section Describe any action taken by the facility: Residents were separated and staff are attempting to not have residents be alone with each other. On 01/14/2020 at 01:45 PM an interview was completed with CNA U, who witnessed the 1/4/2020 incident with Resident #14 and Resident #39. CNA U was at the nurse's station charting at the end of her shift (the nurse's station is a partially closed room with a sliding glass reception window). CNA U stated she looked up and saw Resident #39 was self-transferring, so she got up immediately to intervene. CNA U stated as she came around the corner out of the nurses station, Resident #39 was above Resident #14 who was seated in her wheelchair and his hand was on her peri area, her vagina, over her clothes. CNA U stated neither resident said anything and Resident #14 did not move and she separated them. CNA U stated that Resident #39 often self-transfers and you must get in between him and other female residents to intervene, he usually is redirectable. CNA U stated they make sure he can always have an eye on him. CNA U stated at the time of the incident, she was the only one with eyes on him, and admitted Resident #39 didn't have her full attention because she was charting. CNA U no one is specifically responsible for watching Resident #39, you just make sure someone is watching. CNA U stated at the time of the incident no was else was around, the nurse was in the hall previously, but they had just gone into another resident room. CNA U stated that before this last incident it wasn't as big of a deal to have him eat in the dining room or not have constant supervision, but not anymore. She stated further we make sure to have him in a common area and have no female residents close to him; we separate him from female residents more than we ever have now. On 01/14/2020 at 02:50 PM and interview was completed with CNA W, who witnessed the incident with Resident #39 and Resident #32 on 10/4/2019. CNA W stated Resident #39 and #32 were both walking near the common area and Resident #39 walked over to Resident #32 and they were talking, he said something about her being a beautiful lady and they started kissing. CNA W stated Resident #32 said 'oh thank you,' but she is not cognitively intact, she was confused. CNA W stated she was sitting at the nurse's station answering phones at the time of the incident and the residents were mostly in view, she was the only staff in the area at the time. CNA W stated Resident #39 is friendly with the ladies and part of the intervention was to keep them separated in the future and encouraging other women to not be close to him. CNA W stated if women are in the area, someone is to keep an eye on (Resident #39). CNA W stated Resident #39 has a history of being inappropriate with other female residents and he can be difficult to redirect, he will yell, get mean and shake. CNA W stated there are a couple female resident staff know he has took a liking to and they know to be more vigilant if he is around him. CNA W was asked to name the residents he liked and she stated (Resident #14) is one of them. During an interview on 01/14/2020 at 03:50 PM with Social Worker (SW) S, Resident #39's behavior was discussed. SW S stated in general, when there is a resident to resident incident the nurse will make a note and SW S do a follow up visit with residents and will review and revise care plan. After the last incident with Resident #39 on 1/4/2020 one addition made to his care plan was when he is in the aviary area and females are present, he will be kept in sight. SW S stated in the past he has been monitored, distracted and was to be kept within arm's reach. SW S stated there was one resident who Resident #39 seemed to be attracted to, (Resident #14), and they were not to be in arms reach of one another. SW S was asked how the last incident occurred, if staff were aware these two residents had a history and she replied, they weren't being monitored closely. SW S was asked how the interventions have increased or changed over time after multiple incidents with Resident #39 and she could not answer. SW S was asked to review Resident #39's interventions and discuss the changes of his care plan in a follow up interview. A follow up interview was completed with SW S on 01/15/2020 at 08:50 AM regarding Resident #39. SW S stated there was a new behavior plan after the 9/25/2019 incident but could not recall the changes and after the 10/4/2019 incident, there was a phone call to the physician to put Resident #39 on [MEDICATION NAME] for disinhibition. SW S stated he is on a chair alarm after the 1/3/2020 incident and they may change it to a silent alarm, so it is less distressing. SW S was asked how the chair alarm increases the safety of other female residents, since Resident #39 was in full sight for most of the incidences and she stated it increases safety if he is in his room. If he is in the common area, he is in sight and staff can intervene. SW S was again asked how this increases safety if he was already in sight during the previous incidences and she could not answer. SW S was asked what her role is in care plan revision related to behaviors and she stated it is her job to write the behavior plan and make changes to RST. SW S stated the changes are reviewed in behavior management meetings and in morning meetings/huddle and it is a team effort. SW S was asked how residents are being protected from future sexual behavior by Resident #39 and she stated, someone dropped ball, I don't know what all specific circumstance were in these incidents and I defer to (the NHA). SW S was asked if as facility social worker she should be aware of the behavior concerns of residents she stated, my memory not the best and I rely on notes. SW S was asked why she did not review Resident #39's behavior concerns prior to a follow up interview and she stated the NHA had put together the requested paperwork to prepare for the follow up interview and she had not reviewed it all before meeting. SW S provided a Timeline for (Resident #39) consisting of 3 columns one with the date, one with a brief incident description and one with interventions. Also attached were progress notes related to behavior management. Review of facility provided Timeline for (Resident #39) revealed the incident with Resident #14 from (MONTH) (YEAR) was not listed. For the 8/23/2019 incident with Resident #8 the intervention column revealed incident with touching and no intervention. For the 9/4/2019 incident with Resident #8 the intervention was Keep in visual sight when in bird aviary. For the 10/4/2019 incident with Resident #32 there was no intervention listed, only a further description Mutual hugging and kiss. It was noted on 10/5/2019 Resident #39 was started on [MEDICATION NAME]. For the 1/4/2020 incident with Resident #14 the intervention is listed as: New intervention of alarm to notify staff when ambulating due to (Resident #39) being able to self transfer and ambulate. Review of attached clinical notes revealed a note from Behavior Management IDT mtg on 6/18/2019 revealing: Behaviors are baseline and non-problematic. It is noted on 6/1 he did attempt to kiss another resident. A case management note was added on 9/25/2019: New behavioral plan of care added r/t resident's behaviors of inappropriately reaching for others food and providing distance between resident and female residents due to past behaviors. A Behavior Management IDT mtg note on 10/03/2019 revealed: Resident's behavior over the last quarter is discussed with RST and Behavioral plan of care noting his difficulty at times adhering to appropriate boundaries .BCS review of 9/1 offered no recommendations that team believes resident would accept .nor be effective r/t his specific problem behaviors. IDT discussed possibility of pharmacologic intervention .should behavior re-occur. On 01/15/20 at 09:40 AM an interview was completed with the NHA regarding behavioral interventions for Resident #39. The NHA stated after last incident on 1/4/2020, when Resident #39 a common area with women, there are to be eyes on him. The NHA stated the incident on 10/4/2019 with Resident #32, was a mutual situation, but we did explore some drug interventions. It was discussed with the NHA that Resident #32 was a resident with dementia and could not consent and Resident #39 already had a history of [REDACTED]. It was discussed with the NHA Resident #39 was in visual sight with both recent interactions, as well as historical interactions. The NHA stated they also put a chair alarm in place for Resident #39 for the purpose of alerting staff when he is ambulating. When questioned, the NHA could not state how this would increase the safety of female residents, since Resident #39 was in visual sight during previous occurrences and staff could not respond quickly enough. Review of facility provided policy Resident/Patient Abuse Program Procedure (Rehab and Nursing Centers) with a most recently revised date of 5/31/2019 revealed Under the section Prevention, interventions include The identification, assessment, care plans and monitoring of residents with needs and behaviors which may lead to conflict or neglect, Identifying, correcting and intervening in situation in which abuse .is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavior symptoms, and Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded . In the section Reporting/Response, steps include All allegations and substantiated incidents will be reported, analyzed, and responded to with corrective actions to prevent further or repeated situations from occurring . and Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services; .Identification of staff responsible for monitoring and implementation of the plan. Resident #25 According to a facility face sheet dated 1/15/2020, Resident #25 was a [AGE] year-old admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. On 1/13/20 at 11:34 AM, Resident #25 was observed in bed. The left side of bed was against the wall. The right side of the bed, on the floor was a padded mat. Resident #25's wheelchair was observed at the end and to the right side of the bed. Review of Progress notes dated 1/10/20 reflected a 10% weight loss over past 6 months. On 1/15/20 at 09:50 AM during an interview and record review with Dietary Manager (DM) G, she revealed that Resident #25's weight was stable. She stated that she had just removed an Ensure (supplemental drink) that Resident #25 was not accepting. Resident #25 does better she revealed, in the dining room and it was on the RST (a care guide placed in the room that reflected resident specific care needs) to encourage Resident #25 to dine in the dining room. She stated Resident #25 needed verbal cueing while eating. Resident #25 had [MEDICAL CONDITION] and was [MEDICATION NAME] (fluid removed from his system by medication) and had a significant weight loss due to fluid loss. DM G stated she went to see if the resident had problems with chewing or feeding. DM G stated he did not need special equipment to assist with eating. Resident #25 was to be weighed weekly weight. DM G stated she had assessed his preferences through a screen in first 3 days of his stay along with food intolerance's and food allergies [REDACTED]. DM G stated she observed his weekly weights and observed him in the dining room. DM G stated she monitored his food acceptance record. DM G stated Resident #25 was on a regular diet with no fluid restriction and no sodium restriction. After review of the Breakfast intake (FAR) from 11/8/19 to 1/14/202 with DM G and the missing documentation, she confirmed that daily food acceptance documentation should be done and that she does use the FAR to make decisions on dietary interventions to prevent weight loss. She agreed that this documentation was missing documentation's of meals. Review of a Food Acceptance Record (FAR) for Resident #25 from 11/1/19 to 1/14/2020 reflected no documentation of food acceptance for Breakfast on 11/17 to 11/20, 11/24, 11/25, 11/28 to 12/6, 12/9, 12/12 to 12/17, 12/22, 12/25, 12/27 to 12/30, and 1/4/2020 to 1/13. No further documentation was provided regarding other meals by survey exit on 1/15/19 at 4:15 PM. There was no documentation noted under breakfast substitution offered or not offered or the reason not offered even though the column was available to document in. Review of a Food Acceptance Record (FAR) for Resident #25 from 11/1/19 to 1/14/2020 reflected sporadic documentation of food acceptance for Lunch. This documentation was provided by the facility on a web based spread sheet that was unable to be printed by the facility and when put into the smallest view for this surveyor to read, the dates and the documentation time and date was unable to be viewed together to correlate. If viewed in the smallest view, the documentation was not able to be read. This document did reflect 43 spaces under the lunch column that did not contain documentation of consumption of the meal. Review of a Food Acceptance Record (FAR) for Resident #25 from 11/1/19 to 1/14/2020 reflected no documentation of food acceptance for Dinner on 11/9 to 11/18, 11/23 to 11/25, 11/29, 11/30, 12/7 to 12/12, 12/18 to 12/28, 1/1/2020, 1/2 to 1/7, 1/9 to 1/12, 1/13 and 1/14. Review of a care plan for Resident #25 reflected referral to the see RST for specific resident care needs. The RST contained care plan interventions. The care plan and the RST did not reflect the need for food acceptance documentation. Review of a document for Resident #25 titled, Quarterly Nutrition Review dated 11/21/19 by DM G reflected, .Continue to monitor acceptance (food) and weighs (sic) for needed changes . Resident #33 According to a facility face sheet dated 1/15/2020, Resident #33 was a [AGE] year-old admitted on [DATE] with the Diagnoses: [REDACTED]. Resident #33 had a Brief Interview for Mental Status Score (BIMS) of 7 out of 15 indicating he was moderately cognitively impaired. Weight Loss On 1/14/20 at 7:58 AM, Resident #33 was observed in his room in bed. The head of bed his bed was up. The over bed table was over his lap with a tray of breakfast foods. The tray was up high, not lowered to his level. Resident #33 was observed to be chewing. There was no staff in the room. On 1/14/20 at 3:40 PM during an observation with Registered Nurse (RN) L, she stated they need to boost the resident up in bed. Resident #33 was observed to be in bed. Resident was asked by RN L if he'd like to go to the dining room for dinner. He agreed he'd like to and that he was hungry. On 1/15/20 at 7:26 AM Resident was observed sitting up in bed, overbed table in front of him. He had a cup of liquid with a straw that appeared to be orange juice and breakfast food in his right hand, he was observed to be chewing. There was no staff in the room. Review of a Food Acceptance Record (FAR) for Resident #33 from 11/8/19 to 1/14/2020 reflected no documentation of food acceptance for Breakfast on 11/7, 11/8, 11/13 to 11/20, 11/22, 11/24, 11/25 to 11/28, 11/30 to 12/6, 12/9, 12/12 to 12/17, 12/22 to 12/25, 12/28 to 12/31, 1/4/2020, 1/5, and 1/7 to 1/11. There was no documentation noted under breakfast substitution offered or not offered or the reason not offered even though the column was available to document in all but 3 instances. Review of a Food Acceptance Record (FAR) for Resident #33 from 11/8/19 to 1/14/2020 reflected sporadic documentation of food acceptance for Lunch. This documentation was provided by the facility on a web based spread sheet that was unable to be printed by the facility and when put into the smallest view for this surveyor to read, the dates and the documentation time and date was unable to be viewed together to correlate. If viewed in the smallest view, the documentation was not able to be read. This document did reflect 46 spaces under the lunch column that did not contain documentation of consumption of the meal. Review of a Food Acceptance Record (FAR) for Resident #33 from 11/8/19 to 1/14/2020 reflected no documentation of food acceptance for Dinner on 11/9 to 11/17, 11/21/ to 11/25, 11/29 to 12/4, 12/7 to 12/11, 12/15 to 12/28, 1/1/2020, 1/3 to 1/10, 1/12, and 1/14. On 1/15/20 at 10:00 AM during an interview and record review with the DM G, she revealed that Resident #33 had just currently had a 20-pound weight loss in past few months. She revealed he had a decline in what he was eating. She stated he needed more assistance. DM G stated she had consulted with the physician. After she had talked with physician Resident #33 was to be encouraged to go to dining room. DM G stated it was difficult to him to eat in his room with the overbed trapeze on his bed but Resident #33 refuses to go to dining room. She stated he was taking a nutritional supplement snack bar she had added well. Resident #33 was on weekly weights and food acceptance (FAR) was being documented. Monitors labs. DM G stated Resident #33 was not displaying as large of an intake of food that he had previously. During review of the FAR, DM G stated she would expect that staff would document food acceptance if on food acceptance. DM G stated she based some of her decisions on this information. DM G stated she wrote her own care planning. She stated she instructed the resident on need for nutrition for skin maintenance (resident had a history of [REDACTED].#33 was alert and confused. Review of the RST (care guide in resident room for resident care needs) for Resident #33 reflected, Set up, dining room .afternoon snack. Encourage me to get up for two meals a day. This document did not reflect what the DM G had stated about needing more assistance with his meals. Review of a care plan for Resident #33 reflected referral to the see RST for specific resident care needs. The RST contained care plan interventions. The care plan and the RST did not reflect the need for food acceptance documentation. Review of a document for Resident #33 titled, Quarterly Nutrition Review dated 12/3/19 by DM G reflected, .will monitor intake (food), wt (weight trends), skin and hydration status .CP (care plan) updated, nutritional goals remain. On 1/15/20 12:30 PM, Resident #33 was observed in bed. No mid-day meal was observed in his room. His eyes were closed. Resident #33 was not observed to leave his room for meals during the survey from 1/13/2020 at 9:00 AM to 1/15/202 at 4:15 PM. Behavior During an interview on 1/14/20 at 3:46 PM with Social Worker (SW) S she revealed that Resident #33 was in a bad accident. She stated Resident #33 made sexual statements. She revealed the facility has a behavior management team but goes on to say it hasn't been a great process but they're working on it. She revealed that behavior monitoring review was done by a team during the quarterly Minimum Data Set assessment completion team meeting. Review of a facility document titled, (MONTH) 2020 Physician order [REDACTED].#33 reflected, [MEDICATION NAME] 60 mg (milligrams) capsule delayed release (60 mg = I cap) capsule delayed release . On 1/15/20 at 8:32 AM during an interview with SW S, she revealed that Resident #33 was receiving [MEDICATION NAME] (an antidepressant) 60 mg (milligrams) every day. She stated Resident #33 was in a motor vehicle accident. Resident #33's admission was on 8/28/19. SW S stated his mood fluctuated. His PHQ9 (antidepressant scale) on admit was 00 (indicating no signs of depression) and have increased at times to 3 to 4. She stated Resident #33 was delusional (holding false beliefs) at times. SW S stated that no distressing hallucinations or delusions have persisted. SW S stated Resident #33 can be sexually inappropriate with staff. A request was made for the care plans and behavior documentation. Review of a facility document for Resident #33 titled, Care Plan Report reflected, Behavior (Name of Resident #33) has an actual or potential for mood/behavior impairment related to noncompliance with plan of care, medications, medical treatment, ADL (activities of daily living) care. Current 6/28/19 look back - no behaviors/refusals were documented. Readmission Sept(ember) 2019 no behaviors in the look back week. Dec(ember) '19 (2019) swearing .Interventions: Monitor effectiveness of interventions. Monitor mood/behavior. Document abnormalities give (Name of Resident #33) time to express concerns, feelings, fears. Assess family knowledge of (Name of Resident #33's) mood/behaviors, Provide education to (Name of Resident #33) of potential risks of noncompliant behavior (Resident #33 was moderately cognitively impaired), When noncompliance occurs, encourage (Name of Resident #33) to express feelings related to the care issue. When non-compliant, if (Name of Resident #33) is safe, reproach and try again. Assist to identify possible support systems, strategies to overcome obstacles. Evaluate behavior for potential contributing factors. Provide encouragement and supportive visits as needed. Offer cues, reminders, and clear explanations as needed. Monitor/track any behavioral concerns via periodic PHQ-9 assmts (assessments) and by staff observation. During supportive visits observe for changes in the (Name of Resident #33) condition, mood, and/or behavior. Nursing will monitor for medication side effects . Resident #33's care plan did not mention sexual behaviors, or the interventions implemented to address these behaviors. The Certified Nurses' Aide (CNA) RST (Resident Summary Template) for Resident #33 reflected, Behavior Interventions: Sometimes I (Resident #33) forget where I am and forget my current situation. When this happens, I may become verbally aggressive. Please speak to me calmly and attempt to reorient me. If this doesn't work and I continue to be aggressive, ensure that I am safe and have my personals/call light in reach and then leave the room. The care plan cited above doesn't address forgetfulness or being verbally aggressive. This RST does not address the sexual behaviors Resident #33 was exhibiting. This guide doesn't reflect the need to inform the nurse of behaviors or document behavior specifics such as where did the behavior occur, what was happening, who did it involve, what was done to assist in the behavior and did the intervention work. Review of documentation for Resident #33 submitted by the SW S reflected: 4/25/19 at 10:52 PM, .Elder inappropriate this shift with a cena (CNA), noted to making sexual comments to her, elder accepted his hs (HS or nighttime) snack, will monitor. 5/5/19 at 10:43 PM, .Elder noted with sexual behaviors this shift. Stated to staff, 'these are for boobie grabbing' as he held up his hands and, 'did you get some at the sleepover yesterday.' Elder informed that this was inappropriate and staff left elder in safe area. 7/2/19 at 6:21 PM, Quarterly MDS (minimum data set) assmnt (assessment) .in the look back week no behaviors or frequent refusals were noted - much improved from last quarter when he was noted to have frequent refusals . 7/20/19 at 8:50 PM, Resident (#33) appeared agitated throughout the day. Confused and not oriented to situation, time or place. When offering redirection resident was not receptive. Re approach at a later time was effective . 7/29/19 at 1:59 PM, Behavior management IDT (Interdisciplinary Team) mtg (meeting) .He (Resident #33) has additionally demonstrated improved compliance with regard to provision of cares - including repositioning .He is currently Rx'd (prescribed) [MEDICATION NAME] 60 mg and [MEDICATION NAME] 7.5 mg every day (another antidepressant) . 9/3/19 at 4:12 AM, (a note by SW S) Spoke with resident (#33) regarding nurse report of 9/2(2019) regarding resident having grabbed nurse's buttock during care. His facial expression was puzzled and he asked, 'Who and when? I don't remember.' 10/16/19 at 5:27 PM, Resident noted to be making inappropriate and sexual comments to staff members during shower and when in room. Will continue to monitor and document both verbal and physical inappropriate gestures/comments. 10/26/19 at 11:00 PM, CNA reported that the elder had stated while she was placing his legs back on the bed that if she touched his legs again he would hit her head off her shoulders. elders light noted to come on, this nurse entered the elder's room and elder asked if I was in charge of the help. This nurse verbalized that I could assist and would make sure that he was taken care of. Elder started to talk about a meeting on 9/2 and asked if I knew if it was still happening. As this nurse was leaving elder stated that he wanted to make sure that we would take care of him. This nurse stated that we would care for him but asked that he not stated that he was going to hit the staff. The elder stated, 'I told her that if she hit me I would hit her back just as hard as she hit me.' Elder denied being hit and just stated he was saying if she hit him . 11/6/19 at 2:42 AM, this nursing in to pass PM medication to roommate, elder yelling 'get over here now, I need to get out of here.' this nurse in to assess elder, confusion, swatting at staff, cursing with attempts to kick wedge from under heels and swinging legs out of bed x 4 (times 4). Staff assisting elder back into bed, elder continues to curse, elder with attempts to rip off brief, stating 'I'm going downtown and I won't be needing this.' Elder swatting and cursing at staff, refusing routine cares during HS (hour of sleep, bedtime) hour, refusing to pull brief up, refusing to allow staff's assistance, privacy provided . 11/13/19 at 12:58 AM, Elder with attempts to throw feet out of bed, elder agitated, yelling at staff, pulling at catheter tubing. Trapeze bar above head, elder attempting to pull upper body to turn, stated, 'I'm going to stand up and get to the hospital' elder reminded of location and reason for admission to (initials of facility). Elder stating 'you are all fired' with increasing agitation. Elder requesting to 'get washed up before I leave for the hospital' this nurse assisting with cares. Elder stating, 'I'm going to punch you in the face and beat you with this bar.' Elder continues to yell at staff, elder refusing to get out of bd with staff's assistance, elder assisted back in bed, (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure dignified care was provided to four facility residents (Residents #27, 31, 35, 41) and two of five residents present for the Confidential Group Interview resulting in embarrassment and loss of self-worth and the potential for all facility residents to experience similar feelings. Findings include: Confidential Group Interview On 1/14/2020 at 10:00 AM, a Confidential Group Interview was conducted with five alert and oriented residents. Five of five Residents reported call light concerns. Five of five residents reported that the facility had ample staff but that this does not mean timely attention to the need that caused the request for nursing assistance. Five of five residents reported that staff often will come into the room, turn off the call light and say they will return later. The residents reported staff too frequently do not return timely or return at all without a repeat call light initiation. Two of five residents reported care problems because of the delay but declined to discuss this further and indicated this was due to embarrassment Resident #31 Resident #31 was admitted to the facility 11/10/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which reflect the Resident was cognitively intact. The MDS functional status section (section G) reflected Resident #31 required two staff for bed mobility and toileting. On 1/13/2020 at 12:42 PM, during an interview Resident #31 reported she used a bedpan for toileting. Resident #31 reported she has had accidents (wet herself) while waiting for a response to her call light. The Resident reported staff may respond to the room but will turn off the call light and say they will return but do not return timely. Resident #31 reported on several occasions she had been unable to wait any longer and had voided in her bed. Resident #31 reported this has made her feel, like a big baby. Resident #31 stated, as many times as they have had a big mess to clean up you would think they would be right in (to answer call light and promptly assist with care). Resident #31 reported, a couple of weeks ago during the night she needed to use the bed pan and she initiated her call light. Resident #31 reported staff responded to her call light, turned off the light and said they would return soon to assist her. However, the Resident reported she voided in her bed and fell asleep while waiting. The Resident reported she remained wet throughout the night as staff did not return or wake her if they did return. The Resident stated she, didn't feel good about that. Resident #27 Review of Resident #27's face sheet revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #27's most recent MDS (Minimum Data Set) on 12/6/2019 revealed a BIMS (Brief Interview for Mental Status) score or 15/15, indicating she is cognitively intact. During an interview with Resident #27 on 1/13/2020 at 4:18 PM, call light response was discussed. Resident #27 stated that she waits 20-25 minutes for call light response most days. Resident #27 stated the wait gets me mad. Resident #35 Review of Resident #35's face sheet revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's most recent MDS on 12/11/2019 revealed a BIMS score or 15/15, indicating she is cognitively intact. During an interview on 01/13/20 at 11:56 AM call light response was discussed with Resident #35. She stated staff come in and shut off the call light and do not address the need and then you must put it on again. Resident #35 stated she has waited from 5 pm- 7 pm to a couple days ago to get her call light addressed. Resident #35 stated she has waited until 9:30 PM to go to bed and she likes to go to bed at 7:00 PM to put her legs up because they hurt. Resident #35's roommate agreed she had observed Resident #35 have long wait times and get put in bed late. Resident #35 stated I don't want to say to much because nothing changes, and I just get more mad or frustrated. Resident #35 stated she cries often out of frustration. Resident #41 Review of Resident #41's face sheet revealed she admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #41's most recent MDS on 11/08/2019 revealed a BIMS score or 15/15, indicating she is cognitively intact. During an interview with Resident #41 on 01/13/2020 at 4:18 PM, call light response was discussed. Resident #41 stated she regularly waits a half hour for assistance. Resident #41 stated she has not wet herself waiting but I've been very close, I feel worried.

Based on interview and record review, the facility failed to ensure an environment for Resident Council Meetings to promote resident participation. The facility also failed to ensure residents were able to convey concerns. The facility also failed to ensure residents were aware of their rights regarding Resident Council meetings, Residents Rights for care including informing the Resident Council of the facility grievance process and the availability of advocacy agencies resulting in resident concerns not being explored, resident issues and resolutions not documented for, or conveyed to, the Resident Council, and the potential for Resident Council members and all facility residents to feel vulnerable to staff influence. Findings include: Review of the facility documentation of the Resident Council Meeting Minutes for (MONTH) through (MONTH) 2019 reflected the Nursing Home Administrator (NHA) was the designated staff person (facilitator) responsible for responding to requests from the Resident Council for five of the six Resident Council Meeting minute meetings reviewed. Review of the Minutes does not reflect the members of the Resident Council invited, or were asked, if additional staff could attend the meeting although the record reflects as many of five additional staff attended. The documentation does not reflect a record of Nursing and Round Table issues concerning the residents that attended the meeting. The section titled Nursing reflected information on staff only. The sections of the minutes titled Round Table reflected only Resident and Employee of the month. The documentation of the Resident Council Minutes did not reflect views or concerns of the residents and did not include a facility response or rationale for facility resolutions. On 1/14/2020 at 10:00 AM, a confidential group interview was conducted with five alert and oriented residents. During the meeting the residents indicated they were not aware they had a right to meet without a staff facilitator or other staff. During the meeting residents reported food concerns are generally brought up every month. Five of five residents reported food concerns included individual issues, inconsistent food and drink temperatures, and timeliness of room tray deliveries. Five of five residents reported call light concerns. Five of five residents reported that the facility had ample staff but that this does not mean timely attention to the need that caused the request for nursing assistance. Five of five residents reported that staff often will come into the room, turn off the call light and say they will return later. The residents reported staff too frequently do not return timely or return at all without a repeat call light initiation. Two of five residents reported care problems because of the delay but declined to discuss this further. Four of five residents reported the call light care request issue comes up often at the Resident Council meetings. Four of five residents reported that, they are told by the facility that, We'll look into it, with any issue raised to include the call light issue. The group reported that if the facility was asked about an issue that they are told, it's taken care of without further explanation. Residents indicated the Resident Council meetings do not include any real discussion of issues raised, no probing questions or attempts to draw out the resident's concerns, and that concerns are answered quickly and move on to the next topic. Four of five residents indicated that they were unaware of Resident Rights and that it was not a topic brought up at Resident Council meetings. Only 1 resident reported knowledge that Resident Rights were posted in the hallway. four of five residents reported they do not know how to file a grievance and only 1 resident reported knowledge that this was posted by the office. The group reported they are informed during meetings that that if they have a complaint that they should just go to tell the desk (nurses' station) or you can complain to the state. The group reported they have not been informed of how to contact the state or advocacy agencies. Five of five residents reported staff treat them well, but three of five residents reported they are concerned about retribution from staff if they did complain and, consequently, may not be treated well. On 1/15/2020 at 9:03 AM, an interview was conducted with the NH[NAME] The NHA reported that a grievance can be filed by a resident or a family member and the forms are available by the public posting of the Survey Book. The NHA also reported that the form was part of the facility admission packet. The NHA reported that if a resident were to complain, a formal Grievance Form would be offered but, we don't get very many (complaints). The NHA reported that issues brought up in Resident Council are not addressed in the moment because issues are isolated, and that each department was usually present at the Resident Council meetings. The NHA indicated the pertinent department would follow up with that resident. Regarding group concerns, the NHA reported, we typically don't have any but if we did it would be addressed right away and follow up at the next meeting. The NHA was informed of the concerns raised by the residents during the Confidential Group interview. The NHA reported the residents, don't bring up those issues. The NHA reported that it has not been reported to him by the residents that they do not know how to file a grievance. The NHA reported Resident Rights have been discussed and that the abuse policy was reviewed at a recent meeting when informing the residents of the results of an abbreviated survey.

Based on interview and record review, the facility failed to ensure residents were verbally provided information regarding Resident Rights, filing a grievance and failed to ensure residents were aware of the availability of advocacy agencies resulting in residents unaware of methods to reveal and address concerns regarding resident care and to be informed their Resident Rights. Findings include: Review of the facility documentation of the Resident Council Meeting Minutes for (MONTH) through (MONTH) 2019 reflected the Nursing Home Administrator (NHA) was the designated staff person (facilitator) responsible for responding to requests from the Resident Council for five of the six Resident Council Meeting minute meetings reviewed. Review of the Minutes does not reflect documentation of discussion of Resident Rights, the facility grievance process, or that agencies were available to promote their care and well-being. The documentation of the Resident Council Minutes did not reflect views or concerns of the residents and did not include a facility response or rationale for facility resolutions. On 1/14/2020 a 10:00 AM, a Confidential Group interview was conducted with five alert and oriented residents. The Confidential Group reported food concerns are generally brought up every month in addition to call light and staffing issues. Four of five residents reported they are told by the facility that, We'll look into it, with any issue raised and if the facility is asked about the status of an issue that they are told, it's taken care of without further explanation. Residents indicated the Resident Council Meetings do not include any real discussion of issues raised, and that concerns are answered quickly and move on to the next topic. Four of five residents indicated that they were unaware of Resident Rights and that it was not a topic brought up at Resident Council meetings. Four of five residents reported they do not know how to file a grievance. The group reported they are informed during meetings that that if they have a complaint that they should just go to tell the desk (nurses' station) or you can complain to the state. The group reported they have not been informed of how to contact the state or advocacy agencies. Five of five residents reported staff treat them well, but three of five residents reported they are concerned about retribution from staff if they did complain and, consequently, may not be treated well. On 1/15/2020 an interview was conducted with the NH[NAME] The NHA reported that a grievance can be filed by a resident or a family member and the forms are available by the public posting of the Survey Book. The NHA also reported that the form is part of the facility admission packet. The NHA reported that if a resident were to complain a formal Grievance Form would be offered but, we don't get very many (complaints). The NHA reported that issues brought up in Resident Council are not addressed in the moment because issues are isolated, and that each department is usually present at the Resident Meetings. The NHA indicated the pertinent department would follow up with that resident. Regarding group concerns, the NHA reported, we typically don't have any but if we did it would be addressed right away and follow up at the next meeting. The NHA was informed of the concerns raised by the Residents during the Confidential Group Interview. The NHA reported the residents, don't bring up those issues. The NHA reported that it has not been reported to him by the residents that they do not know how to file a grievance. The NHA reported Resident Rights have been discussed and that the abuse policy was reviewed at a recent meeting when informing the residents of the results of an abbreviated survey. The NHA reported he knows the Ombudsman comes to the facility quarterly and that the contact information is posted.

Based on observation, interview, and record review, the facility failed to update and revise a care plan for 1 of 12 residents (Resident #35) reviewed for care plans. The deficient practice placed Resident #35 at risk for non-healing and worsening of a facility acquired pressure ulcer. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #35 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated moderate cognitive impairment and Resident #35 required extensive assistance for activities of daily life (ADLs). The Face Sheet reflected that Resident #35 had an appointed guardian. The facility provided a copy of the Inpatient Skin, Wound and Pressure Injury Prevention and Care policy dated 8/22/18 for review. The policy reflected, V. Plan of Care, A. The patient's plan of care and interventions will be individualized according to the patient's identified risk factors, skin assessment and clinical judgement .IX. A. All patients/family members are informed of the importance of repositioning, skin products used and methods for bathing. Based upon the risk assessment and the learner, the patient/family is educated on the importance of preventing pressure injuries during course of hospitalization , using approved patient education material as appropriate . The facility provided a copy of the most recent wound measurements and documentation for the 2 facility acquired pressure ulcers dated 1/31/19. The unstageable pressure ulcer to the left great toe (developed 12/20/18) measured 0.3 cm x 0.5 cm with the wound bed covered with eschar. The unstageable pressure ulcer to the right posterior ankle (developed 1/10/19) measured 1.0 cm x 3.0 cm with the wound bed covered with eschar. The skin care plan with a status of active reflected that Resident #35 has an unstageable pressure ulcer. Listed under the interventions it reflected, see the Resident Summary Template (RST). The RST with a print date of 2/1/19 at 1:06 PM reflected that staff should ensure that the Resident's feet do not touch the footboard, both feet should be elevated on a heels up device and there is a dressing to the right posterior ankle. An interview, record review, and a timeline review, of Resident #35's pressure ulcers was conducted on 2/2/19 at 9:45 AM with the Director of Nursing (DON). The DON stated that when a new pressure ulcer develops, she expects the nursing staff to measure and document the finding in the nurses note, notify the physician for treatment orders, notify the wound nurse, notify the dietitian, notify the resident/resident representative and initiate a care plan for the new wound. When asked if the facility investigates facility-acquired pressures ulcers, the DON stated that the staff complete an unusual occurrence form. The forms were requested for review, but the DON was unable to locate them and stated, It doesn't look like they were done for either of them. The DON stated that she spoke with the wound nurse and determined that the footboard on the bed may have caused the left toe pressure ulcer, so that bed was switched out. When asked about the right posterior ankle pressure ulcer the DON stated that they think the heels up wedge caused it and changed the care plan to have the feet elevated up on pillows instead. An interview, record review, and observation, were conducted with CNA L on 2/2/19 at 10:45 AM. When asked if Resident #35 had any special care needs for his pressure ulcers, CNA L reviewed the RST and stated he should have his heels up on a wedge. This surveyor, together with the CNA L observed Resident #35 in his bed with his feet elevated on a heel wedge (not pillows as the DON had stated). The wedge was a long triangle shape that caused direct pressure to the back the right posterior ankle dressing and wound. An additional interview and observation were conducted with the DON on 2/2/19 at 11:00 AM. The surveyor brought the DON to Resident #35's room to observe the heels up wedge that Resident #35 had in place causing pressure to the right posterior ankle. The DON stated that the wedge should be removed and pulled it out from under the Resident's feet and replaced it with pillows. The DON stated that she would also change it on the care plan and RST to elevate the lower legs on pillows instead of the heels up wedge. The facility failed to update and revise the care plan when the right posterior wound was first noted on 1/10/19.

Based on observation, interview and record review the facility failed to prevent and promote the healing of facility acquired pressure ulcers for 1 of 3 residents (Resident #35) reviewed for pressure ulcers. This deficient practice resulted in Resident #35 developing 2 unstageable pressure ulcers and the potential for infection and non-healing to occur. Findings include: The facility provided a copy of the Inpatient Skin, Wound and Pressure Injury Prevention and Care policy dated 8/22/18 for review. The policy reflected, Purpose: To outline the details of skin assessment, pressure injury prevention, management of pressure injuries and documentation of pressure injuries and other wounds .Unstageable pressure Injury: Full-thickness skin and tissue in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .The attending physician/designee will be notified regarding all new pressure injuries .Notify within 60 minutes from time of assessment for stage 3, 4, and unstageable pressure injuries. Obtain wound provider consult if not already ordered .High level wounds .unstageable pressure injuries .document in detail including relevant wound characteristics once daily, or with every dressing change whichever is less frequent .V. Plan of Care, A. The patient's plan of care and interventions will be individualized according to the patient's identified risk factors, skin assessment and clinical judgement .IX. A. All patients/family members are informed of the importance of repositioning, skin products used and methods for bathing. Based upon the risk assessment and the learner, the patient/family is educated on the importance of preventing pressure injuries during course of hospitalization , using approved patient education material as appropriate . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #35 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated moderate cognitive impairment and Resident #35 required extensive assistance for activities of daily life (ADLs). The Face Sheet reflected that Resident #35 had an appointed guardian. The facility provided a copy of the CMS-672 Census and Condition Report (signed and dated on 1/29/19) that reflected the facility had 3 residents with pressure ulcers and all pressure ulcers were present on admission. The facility was asked for a list of residents and pressure ulcers in the facility. An interview and record review was conducted with RN I on 2/1/19 at approximately 12:00 PM. RN I provided a hand-written list of the residents who had pressure ulcers and the dates that they were acquired. The list reflected 5 different residents who had pressure ulcers residing in the facility. It reflected 2 residents that were admitted with them and 3 residents who developed facility acquired pressure ulcers with the dates that they developed. The list reflected that Resident #35 had 2 facility acquired pressure ulcers that developed on 12/20/18 and 1/10/19. When asked why the facility completed the CMS-672 and the hand-written list did not match, RN I stated that she usually updates the CMS-672 daily but was behind in that. When asked why the facility acquired pressure ulcer that developed for Resident #35 on 12/20/18 and 1/10/19 were not included in the CMS-672 dated 1/29/19, RN I stated, I must have missed them. The facility provided a copy of the most recent wound measurements and documentation for the 2 facility acquired pressure ulcers dated 1/31/19. The unstageable pressure ulcer to the left great toe (developed 12/20/18) measured 0.3 cm x 0.5 cm with the wound bed covered with eschar. The unstageable pressure ulcer to the right posterior ankle (developed 1/10/19) measured 1.0 cm x 3.0 cm with the wound bed covered with eschar. The skin care plan with a status of active reflected that Resident #35 has an unstageable pressure ulcer. Listed under the interventions it reflected, see the Resident Summary Template (RST). The RST with a print date of 2/1/19 at 1:06 PM reflected that staff should ensure that the Resident's feet do not touch the foot board, both feet should be elevated on a heels up device and there is a dressing to the right posterior ankle. An observation of Resident #35 wound care was conducted with LPN F and RN E on 2/2/19 at approximately 8:30 AM. Both nurses washed their hands and doned gloves. RN E assisted LPN F by holding Resident #35's right leg elevated for wound care. A thick eschar was noted to the left great toe and a darkened covered pressure ulcer was noted to the right posterior ankle. Resident #35 was unable to answer specific questions regarding the wounds. LPN F cleansed the wound, removed her gloves and then returned to the bathroom to wash her hands for approximately 5 seconds (not 15 seconds as the policy directs). LPN F then doned gloves and applied the dressing to the right posterior ankle. When she completed the dressing, she returned to the bathroom and washed her hands for approximately 5 seconds (again not 15 seconds as the policy directs) and exited the room. An interview, record review and a time line review of Resident #35's pressure ulcers was conducted on 2/2/19 at 9:45 AM with the Director of Nursing (DON). The DON stated that when a new pressure ulcer develops, she expects the nursing staff to measure and document the finding in the nurses note, notify the physician for treatment orders, notify the wound nurse, notify the dietitian, notify the resident/resident representative and initiate a care plan for the new wound. The DON confirmed Resident #35 developed an unstageable pressure ulcer to the left great toe on 12/20/18 and another unstageable pressure ulcer to the right posterior ankle on 1/10/19. When asked if the guardian was notified of the new pressure ulcers, the DON stated that the staff would document that notification in the nursing notes but was unable to locate the notification documentation for the surveyor to review. When asked if the facility investigates facility acquired pressures ulcers the DON stated that the staff complete an unusual occurrence form. The forms were requested for review, but the DON was unable to locate them and stated, It doesn't look like they were done for either of them. The DON stated that she spoke with the wound nurse and determined that foot board on the bed may have caused the left toe pressure ulcer, so it was switched out. When asked about the right posterior ankle pressure ulcer the DON stated that they think the heels up wedge caused it and changed the care plan to have the feet elevated up on pillows instead. When asked if the pressure ulcer was avoidable or unavoidable the DON stated that she was unable to determine. An interview, record review and observation was conducted with CNA L on 2/2/19 at 10:45 AM. When asked if Resident #35 had any special care needs for his pressure ulcers, CNA L reviewed the RST and stated he should have his heels up on a wedge. Together with the CNA L observed Resident #35 in his bed with his feet elevated on a heel wedge (not pillows as the DON had stated). The wedge was a long triangle shape that caused direct pressure to the back the right posterior ankle dressing and wound. An additional interview, and observation was conducted with the DON on 2/2/19 at 11:00 AM. The surveyor brought the DON to Resident #35's room to observe the heels up wedge that Resident #35 had in place causing pressure to the right posterior ankle. The DON stated that the wedge should be removed and pulled it out from under the Resident's feet and replaced it with pillows. The DON stated that she would also change it on the care plan and RST to elevate the lower legs on pillows instead of the heels up wedge. A telephone interview was conducted with Resident #35's guardian on 2/2/19 at 11:09 AM. The guardian stated that she became aware that Resident #35 developed a pressure ulcer to the left great toe (on 12/20/18) when she visited on 12/25/18, noticed a dressing on the toe and asked about it. The guardian was unaware that Resident #35 had developed an additional pressure ulcer to the right posterior ankle and subsequently did not know how either of the pressure ulcers occurred.

This citation pertains to intake MI 285 Based on observation, interview, and record review, the facility failed to ensure alarm devices were in working order for one (Resident #1) and ensure safety precautions were implemented for two (Resident #5 and #6), for three residents out of four residents reviewed for falls. This deficient practice resulted in a fall with fracture leading to death for Resident #1 and potential for additional falls and injuries for Residents #5 and #6. Findings include: Resident #1 According to the Minimum Data Set (MDS), dated [DATE], Resident #1 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #1 was moderately cognitively intact and required the assistance of two staff members for transfers, bed mobility, and dressing. Resident #1 required limited assistance of one person when walking. Resident #1 no longer resided within the facility. Review of facility Incident Accident reports for the last three months revealed Resident #1 had fallen on 9/4/18, 9/18/18, 10/19/18, and 12/23/18. According to the Resident Summary Template's (RST) the following interventions were implemented after a fall on: 9/4/18 Alarms were placed on bed and chair, nonskid strips placed on the floor by the bed 9/18/18 No new interventions were implemented 10/19/18 Bedside mat on floor by bed and frequent checks. According to the facility investigation, dated 12/24/18, Resident #1 was found lying on the floor in her room on 12/23/18 at approximately 11:45 PM. Resident #1 was assessed as having a hematoma to the right side of her head and complained of discomfort in the right groin area. The call light was not activated by Resident #1 and the bed alarm was in place but not alarming, when tested , noted to be working intermittently. Resident #1 was transferred to the Emergency Department and admitted at approximately 12:32 AM on 12/24/18. Review of local hospital discharge records, dated 12/24/18, indicated Resident #1 was in obvious pain related to her hip and a hip x-ray revealed a right [MEDICAL CONDITION]. During this Emergency Department visit the patient (Resident #1) abruptly decompensated and rapidly progressing into asystole (no heart rate indicating death). Resident #1's Certificate of Death, dated 12/26/18, listed the cause of death was related to Complications of [MEDICAL CONDITION] following a fall occurring on 12/23/18. During an interview on 1/8/19 at 8:45 AM, the Administrator stated, .We (the facility staff) noticed a failure with (Resident #1's) fall. The battery had not been changed in the bed alarm but it was noted to be working that day by staff . During an interview on 1/8/19 at 3:30 PM, Registered Nurse (RN) D stated, I typically worked that hall and took care of (Resident #1) that evening (12/23/18). I had seen her a couple times prior to the fall and she was perfectly normal. Her pm (evening) medications required a pulse and blood pressure, there was nothing out of the ordinary. (At the time of the fall) one of the other nurses herd her saying she needed help, there was a mat on the floor by her bed. There was a hematoma (bleeding under the skin) on her right side of her head and pain in the right groin .one pupil was sluggish to respond, her vitals signs were stable, because of the [MEDICATION NAME] (a medication to thin the blood) we opted to send her to the emergency room as a precaution .(Resident #1) recognized a Certified Nursing Aide (CNA) in the emergency room that also works with us. I called the daughter and told her we were sending (Resident #1) as a precaution .(Resident #1) had a roommate that had been discharged four days prior (to the fall) and we realized the roommate would call us to let us know (Resident #1) was up (without assistance) . During an interview on 1/8/19 at 5:00 PM, CNA E stated, .(Resident #1) had dementia and would forget to use the call light about 95 percent of the time .she had a roommate that would use the call light for her .(Resident #1) had fallen before while trying to get out of bed, the falls were on the mat so she didn't get hurt .(Resident #1) had the floor mat, bed alarm, call light, and her bed was in low position .her alarm was working when I got her out of bed earlier, after the fall the alarm was tested by the nurse and it worked . During an interview on 1/9/19 at 8:55 AM, the Administrator and Director of Nursing (DON) stated that the alarm for Resident #1 was not checked per facility policy and the battery for the alarm was not changed per facility policy. It was also reported that the low battery indicator was not lit up indicating the alarm battery was low. The DON reported at this time that the alarm checks and battery changes are documented on the Treatment Administration Record. The Administrator and DON reported identifying the same concern with the one resident (Resident #6) in the facility that currently has an alarm. They reported staff education had been provided regarding alarm testing and battery change frequency. Resident #5 According to the MDS, dated [DATE], Resident #5 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #5's cognition was moderately impaired and required assistance of two staff members for transferring, dressing, bathing, hygiene needs, bed mobility, and using the bathroom. Resident #5 was not ambulatory. Review of facility Incident Accident reports for the last three months revealed Resident #5 had fallen on 10/12/18, 10/17/18, 11/20/18, 11/21/18, 12/7/18, 12/14/18, and 1/2/19. Review of Resident #5's RST revealed the following interventions were implemented after falling on: 10/12/18 no new interventions implemented, 10/18/18 keep height of bed adjustment locked, 11/22/18 assist me to bed after dinner as soon as possible, 12/13/18 no new interventions implemented, 12/14/18 I will unlock my bed to attempt to self transfer, 1/2/19 no new interventions implemented. An observation on 1/9/19 at 11:20 AM, revealed Resident #5 was resting in bed with eyes open. Resident #5 was lying with his head at the head of the bed and his feet were at the foot of the bed. The hand control was in reach of Resident #5 and the bed could be raised and lowered with the hand control. The bed was currently at waist level. It was noted the locks for the hand control were located on the lower edge of the footboard and was not lit up indicating the hand control was locked. That same day at 11:30 AM, CNA H stated she was assigned to Resident #5 and was asked to review safety precautions to prevent Resident #5 from falling. She entered Resident #5's room and stated that his bed should be in the low position, fall matt next to bed on floor, and his wheelchair should be out of reach. When CNA H was asked about locking his hand control to limit his ability to raise and lower the bed, CNA H stated that she did not know whether it should be locked. When CNA H was asked if the hand control was currently locked, CNA H stated it was not locked and demonstrated how to lock the hand control. When locked, the indicator light lit up. After locking the bed, CNA H stated, I think I will leave it that way. Upon leaving the room CNA H stated she was going to check and see if therapy had updated Resident #5's safety measures. Resident #6 According to the MDS, dated [DATE], Resident #6 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #6 was severely cognitively impaired and required extensive assistance of two people for transferring, dressing, hygiene, bathing, and toileting activities. Resident #6 was not ambulatory. During an observation on 1/9/19 at 1:05 PM, CNA F and CNA G transferred Resident #6 from the wheelchair to the bathroom using a sit to stand mechanical lift and a standing sling. The lower leg safety strap was not placed around Resident #6's lower legs. After Resident #6 was finished in the bathroom, CNA F and CNA G transferred Resident #6 from the bathroom to bed using the same lift and again did not secure the lower leg safety strap around Resident #6's lower legs. When asked when the lower leg safety strap should be used, CNA F stated, We should have used it. I noticed that .it (lower leg safety strap) is for safety . Review of mechanical lift manufacturers guidelines Instruction for Use, dated 11/2014, read, .Warning: An assessment must be made for each individual resident being raised by the (name of lift), by a medically qualified person, as to whether the resident requires the lower leg straps when using the standing sling. Use if necessary, e.g. with unruly residents, residents with spasms, etc. that were assessed as suitable to be raised with the . (This sentence was not completed in the manual.)

This requirement has two Deficient Practice Statements. A. Based on observation, interview and record review, the facility failed to prevent falls in 2 out of 2 residents reviewed for falls (#7 and 11) from 15 total sampled residents resulting in Resident #7 sustaining a fall with fractured pelvis on 9/8/13 and Resident #11 sustaining a fall with left hip fracture on 2/28/14. Findings include: Record review of facility 'Safety policy: Fall Prevention Safety' dated 2/21/13 revealed: The assessment of the environment and of patients for potential risks for falls is the responsibility of all employees ....Patient care considerations: Patients should be assessed on admission for risk of falling and reassessed frequently during their stay. Consider the following criteria which may increase risk of falling ...age over [AGE] years old, confusion, lethargy, agitation, poor judgment, incontinence, mobility deficit, sensory deficit and communication deficit. Record review of Resident #7 ' s Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with a Brief Interview of Mental Status (BIMS) of 13 out of 15; this means resident is cognitively intact. Medical [DIAGNOSES REDACTED]. Transfers and ambulation with assist of one person. Record review of Resident #7' s 'Fall Risk Assessment' dated 9/6/13 revealed that the resident had a history of [REDACTED]. It was noted that Resident #7 had a balance problem while walking. Total fall score was 13, a total score equal or greater than 10 represented a high risk for falls. Record review of Resident #7's 'Fall Event Summary' dated 9/19/13 described the following incident: On 9/8/13 at 3:55 PM, Certified Nurse Assistant (CNA) " I " reported that she was assisting Resident #7 to the bathroom using a walker and gait belt. When CNA "I" and the resident got to the bathroom door, CNA "I" let go of the resident to walk around the resident to open the bathroom door. Resident #7 lost her balance, fell backwards, hit her head on the bedside table, then fell on the back of her coccyx area. Resident #7 was noted to state that she hurt and indicated her hip/anterior thigh area and back of her head. Record review of the facility investigation file of Resident #7's fall on 9/8/13 revealed a typed investigation interview dated 9/10/13 at 10:30 AM with Certified Nurse Assistant "I". It confirmed CNA " I " was walking with Resident #7 to the bathroom on her left side, using a gait belt and a walker. CNA " I " stopped with the resident just before the resident ' s dresser, went around to the resident's right side and proceeded to open the bathroom door. While going to the residents other side to open the bathroom door, CNA "I" let go of Resident #7's gait belt. Resident #7 fell backwards at that time and CNA "I" was unable to reach the resident before the fall. CNA "I" was noted to state that she just did not know another way to get the bathroom door to open. An interview on 4/11/14 at 9:22 AM with Certified Nurse assistant "I" revealed that she got Resident #7 to the bathroom with a gait belt and walker with one person assist. CNA "I" stated that she let go of the gait belt to open the bathroom door and that she was in front of the resident and walker when Resident #7 stated that she felt unsteady. CNA "I" stated that she wanted to grab Resident #7 but was unable to since she was standing in front of the resident and the walker was in between them. CNA "I" added that she had walked Resident #7 to the bathroom several times prior to the fall with no problems. She walked her the same way that she did on the day of the fall. It was unclear why CNA "I" let go of the gait belt when reaching to open the door. CNA "I" stated that she was educated over the phone by management on different ways to transfer residents. Record review of Resident #7's physician progress notes [REDACTED]. The physician noted the x-ray results showed fracture to the inferior and superior ramus and left sacral alas and severe pain with pelvic fractures. Record review of Resident #11's Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with Brief Interview of Mental Status (BIMs) score of 2 out of 15, meaning severe cognitive impairment. Medical [DIAGNOSES REDACTED]. Record review of Resident #11's 'Fall Risk Assessment' dated 12/21/13 revealed a total score of 16. The form noted a total score equal or greater than 10 represented a high risk for falls. Record review of Resident #11's ' Resident Summary Template ' (undated) revealed under the safety heading: Alarm- sensor to be and wheelchair. Orientation: Unable to make needs known. Transfer: assist of one person. Eating: Cues needed. Record review of Resident #11's nursing notes dated 1/1/14 through 1/15/14 revealed that the resident ambulated and transferred with one person assist and had exhibited exit seeking behaviors. Nurse's notes dated 1/1/14 noted that the elder self-transfers and alarm sounds. Nurse's notes dated 1/15/14 noted that Resident #11's safety interventions were reviewed by the safety committee; Resident #11 has not had a fall while residing at the facility and the team agreed to discontinue the safety alarms at this time. It was unclear which safety interventions, wether the alarms, assist of one person, cuing contributed to resident #11 not having any falls. Record review of Resident #11's ' Resident Summary Template ' (undated) revealed under the safety heading: (nothing written-blank). Orientation: Unable to make needs known. Sensory/Communication: use yes/no questions. Transfer: assist of one person. Eating: Cues needed. Record review of Resident #11's nurse's notes dated 2/28/14 at 5:42 AM revealed: ' At 5:00 AM CNA charting at wallaroo outside of Resident #11's room when CNA heard a noise and Resident #11 stating, "OW". CNA into room and observed Resident #11 curled up on left side, her head resting against the bathroom door ... ....Resident #11 complained of hip and leg pain by facial grimacing and guarding to area unable to verbalize pain. The nurse transferred Resident #11 to ER (emergency room ) for evaluation and treatment. CNA staff in to assist resident at 3:00 AM she stated that resident had self-transferred to bathroom, urine observed in toilet. Resident #11 back into bed at that time ....." Record review of a physician consult dated 2/28/14 revealed: "The patient is an [AGE] year old female with past medical history of [REDACTED]. The patient experienced a fall on the morning of 2/28/14. The patient has been a resident at nursing center since 12/21/13.......Since she has been at the facility, the patient ambulates with 1 assist. Recently, the patient has had all alarms taken away. The patient got up twice during the night. At approximately 4:30 AM nursing staff was doing report and a Certified Nurse Assistant (CNA) was outside the patients room, a loud noise was heard as she fell and she immediately said, "OW". CNA and staff ran intro the room and the patient was on the floor in a C shape with her head against the door. Nursing staff tried to stand the patient up and she was not able to stand on her own. She is not able to express if she had pain". Record review of Resident #11's physician history and physical dated 3/6/14 revealed: "This elder is fairly well known to me. I have been her physician in a prior stay at nursing center. While here at a prior time she had gotten up and gone to the bathroom on her own though she was not stable and steady to do so. We knew she did it in the night because we saw urine in the toilet, and her roommate was bedridden. Staff apparently went in the room to get her up again around 5:00 AM and they found her on the floor. She had a fractured hip" . In an interview on 4/11/14 at 10:30 AM with resident #11's life partner and POA (Power of Attorney) revealed that he did received a phone call and was told that the resident was found on the floor by the bathroom with a broken hip. The POA stated that the resident used to get up and that the facility took all of her alarms off but did not tell him why they took them off. The POA stated that Resident #11 now has pneumonia since breaking her hip and needs oxygen. Resident #11's alarms were discontinued since she had not had any falls sometime in January. The resident Summary template (undated) under safety was blank. The resident was known to get up to use the bathroom on her own but she was assessed as 1 person assist with use of the gait belt and walker. It is unclear whether the facility had reassessed and specified interventions to meet the resident's desire to self- transfer and get up night to use the bathroom when she was unsteady. B. Based on observation, interview and record review, the facility failed to provide safe temperatures for 3 out of 3 resident room heat registers (#6, 9 and 12) and 5 residents sinks out of 12 bathroom sinks ( #1, 4, 6, 7 and 9) and the sink in the aviary had water temperatures at 120 degrees and above resulting in the potential for harm due to burns. Findings include: Record review of facility 'Domestic Hot Water Temperature' policy dated 5/2013 revealed that domestic hot water will be maintained within a range of 105 degrees to 120 degrees in all elder areas per state regulation. The maintenance department will be responsible for random testing of all elder areas on a weekly basis. The state surveyor requested facility water temperature logs, and was notified by the Quality/Safety coordinator staff "H" and the maintenance man "C" that there were no logs to review. It was unclear how the facility monitored implementation of their "Domestic Hot Water Temperature". Observation on 4/10/14 at 9:15 AM during the environmental tour with the Quality/Safety coordinator staff "H" and the maintenance man "C" for the long term care resident care area revealed that the water temperature sampling of the hand/eye wash sink in the aviary area of the long term care hall crossway revealed the water temperature to be 123.5 degrees. The area was accessible to residents, staff and visitors. Further observation of 12 resident rooms that were checked for water temperatures revealed that 5 of the residents bathroom sinks were over 120 degrees. These residents who were impacted with water temperatures exceeding 120 degrees Fahrenheit were: #1, 4, 6, 7 and 9.. The State surveyor requested to review the resident room The state surveyor requested to review the facility policy on resident room radiator temperatures when the state surveyor touched a very hot radiator and was temped at 128 degrees by the Quality/Safety coordinator "H". The surveyor was notified that there was no facility policy on radiator temperature settings. Observation and touch of Resident #9's in room radiator which had a stainless steel metal grate covering the heat outlet revealed that the temperature was 128 degrees. However, the resident's bed was pushed up against the wall and radiator. Observation and touch of Resident #6's in room radiator which had a stainless steel metal grate covering the heat outlet revealed that the temperature was 128.4 degrees. The resident's roommate's bed was pushed up against the wall and radiator. Observation and touch of Resident #12's in room radiator which had a stainless steel metal grate covering the heat outlet revealed that the temperature was 126 degrees. The resident's bed was pushed up against the wall and radiator. (# ) ( )

Based on observation, interview, and record review, the facility failed to prevent falls and ensure the safety in 2 of 9 sampled residents (#101 and #105) resulting in an Immediate Jeopardy (IJ) when: Resident #101, who was not provided an ordered sensor pad alarm for her wheelchair, was observed by facility staff on [DATE] around 4:50 p.m. on the floor in her room crying after a fall out of her wheelchair which caused a left hip fracture and the transfer of Resident #101 to a hospital for surgical repair of the hip where she continued to decline and subsequently died on [DATE], and Resident #105, who had a history of [REDACTED]. to ensure the functionality of alarms to ensure resident safety in 2 of 9 sampled residents (#102 and #103) resulting in the increased potential for a fall with injury. Findings include: Resident #101: Review of the Clinical Record revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 required extensive assistance with Activities of Daily Living. Review of the Facility's "Fall Risk Evaluation" dated [DATE] revealed Resident #101 scored a 22 (a score of 10 or above is higher risk for falls).The Evaluation dated [DATE] revealed Resident #101 was scored at 28. The Evaluation dated [DATE] revealed Resident #101 was scored at 22. The Evaluation dated [DATE] revealed Resident #101 was scored at 17. The Evaluation dated [DATE] revealed Resident #101 was scored at 16. The only interventions listed were sensor pad alarms to the bed, wheelchair, and recliner chair and for bed bolsters (foam rolls placed on the edge of the bed to prevent rolling out); however the Facility did not ensure that the alarms were placed in Resident #101's chairs or bed. Review of the Facility's incident report dated [DATE] at 5:15 PM revealed Resident #101 was found, in her room, sitting on the floor, in front of a recliner chair. There was no alarm sounding and the call light was not within reach. Resident #101's left foot was rotated outward and she complained of pain. Resident #101 was not able to move her leg without use of her arm to move it. Resident #101 was lifted off the floor and into a recliner chair. The Physician was notified. Resident #101 was transferred to the emergency room of an attached Hospital and then to a second Hospital for surgical repair of a fractured left hip. Review of the Hospital Discharge Documentation revealed Resident #101 had sustained a left displaced femoral neck fracture (hip fracture) as a result of a fall and underwent a left hip hemiarthroplasty (partial hip replacement). Review of the Discharge Documentation revealed postoperatively, Resident #101's health status declined, and on [DATE] Resident #101 had a respiratory arrest and expired. Review of the Administrative Report of Death revealed Resident #101 died on [DATE] at 6:35 PM. The cause of death listed were Congestive Heart Failure and a left hip fracture. In an interview, on [DATE] at 1:20 PM, Registered Nurse (RN) "N" said she worked on [DATE] and she had "just gotten out of report" (about 4:50 PM), when she heard Resident #101's roommate, crying. RN "N" said she prepared pain medication to administer to the roommate and as she went into the room RN "N" said she observed Resident #101 on the floor, with her left leg outwardly rotated (sign of a probable hip fracture), and Resident #101 was also crying. RN "N" said she stepped out into the hallway and asked Licensed Practical Nurse (LPN) "L" to help. RN "N" said we continued to assess Resident #101 but she "was begging for us to get her off the floor so we lifted her onto the recliner". RN "N" said she told LPN "L" to call the physician and the family because we have to get her to "ER" (emergency room ). RN "N" said the alarm was not sounding and there was no alarm on the wheelchair. RN "N" said there was an alarm on her recliner but it was not turned on and Resident #101 was in the wheelchair prior to her fall. RN "N" said she suspended Certified Nurse Aide (CNA) "H" for not placing her sensor pad alarm in her wheelchair. In a telephone interview on [DATE] at 2:30 PM, CNA "H", said she was assigned to care for Resident #101 on [DATE] starting at 2:00 PM and saw her in the Four Season Room, sitting in a wheelchair. When asked if she checked to ensure that Resident #101 had her wheelchair sensor pad alarm in place and functioning properly CNA "H" said, "I did not". When asked why she did not check Resident #101 to ensure her alarms were in place and functioning CNA "H" said because CNA "I" was assigned to care for her during the day shift and she had worked at the Facility a long time and had assumed she checked Resident #101's alarms. When asked if she had ever not checked alarms of Residents whose care plan interventions included to ensure placement of sensor pad alarms, CNA "H" said, "Yes. No one told me I was supposed to check alarms every hour". In a phone interview on [DATE] at 3:20 PM, CNA "I" said she took care of Resident #101 on [DATE] during the day until 2:00 PM. CNA "I" said before she left she checked Resident #101's wheelchair sensor pad alarm and the light was on. In a telephone interview on [DATE] at 9:40 AM, LPN "L" said she worked on [DATE] and about 5:00 PM she was asked to help with an emergency. LPN "L" said she saw Resident #101 sitting on the floor, crying in pain and Resident #101 said her legs hurt. LPN "L" reported Resident #101 stated she slid out of her chair. LPN "L" said a sensor pad was not in her wheelchair and was not sounding to alert staff. When asked what a Nurse's responsibility was for ensuring sensor pad alarms were in place and functioning properly for Residents whose care plan ordered the intervention LPN "L" said, "Nurses are suppose to manage the system to make sure CNA's are checking their Residents". When asked how, LPN "L" said, "they (the sensor alarms) have a flashing light and that tells us that there on and working". LPN "L" said she "does not" have Residents stand or have CNA's have Residents stand to check the pressure pad alarms. LPN "L" stated they just check the lights. Review of the care plan for Resident #101 dated [DATE], revealed the intervention to attempt to prevent a fall was for nursing staff to apply a sensor pad alarm to her bed and recliner. The care plan was updated on [DATE] and interventions written were "wheelchair and chair sensor pad alarm and motion detector". Review of the Facility's Bedside care plan under "special devices" revealed there was no intervention to have the alarms to the bed or wheelchair checked. Review of the Facility's incident report dated [DATE] at 1:30 AM revealed Resident #101 fell out of her bed and was observed sitting on the floor, soaked with urine and had no alarm in place. There was no injury noted on the incident report. The report stated Resident #101 was not independent for toileting. The Facility did not provide any additional fall interventions. Review of the Facility's incident report dated [DATE] at 3:50 PM revealed Resident #101 fell out of her wheelchair and was observed sitting on the floor and had no alarm. There was no injury noted on the incident report. The Facility, again, did not provide interventions, such as hip protectors or mattress on the floor to protect Resident #101 from injuries due to falls. Review of the Facility's incident report dated [DATE] at 3:58 AM revealed Resident #101 fell out of her wheelchair and was observed sitting on the floor and had no alarm. There was no injury noted on the incident report. The Facility, still, did not provide interventions, such as hip protectors or mattress on the floor to protect Resident #101 from injuries due to falls. Resident #105 Review of the Clinical Record revealed Resident #105 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the nurse's notes dated [DATE] at 4:45 PM revealed a housekeeper heard a loud noise by the bird aviary area and observed Resident #105 on the floor, face down with blood to his head and a 1 centimeter laceration to his right forehead area. Resident #105 was transferred to the hospital for evaluation and treatment of [REDACTED]. Resident #105 returned with sutures to his forehead. There were no new interventions noted for nursing to follow to attempt to prevent falls. Review of the Facility's "Fall Risk Evaluation" dated [DATE] revealed Resident #105 was scored at 16 (a score of 10 or above is higher risk for falls). The Evaluation dated [DATE] (a second evaluation), revealed Resident #105 was scored at 21. The Evaluation dated [DATE] revealed Resident #105 was scored at 21. The Evaluation dated [DATE] revealed Resident #101 was scored at 21. The Evaluation dated [DATE] revealed Resident #101 was scored at 20. Review of the Facility's incident report dated [DATE] at 3:15 AM revealed Resident #105 fell out of his wheelchair and was observed sitting on the floor and his alarm was sounding. He suffered head trauma (laceration to the forehead), was unresponsive, had a frothy mouth and was transferred to the hospital. Review of the nurse's notes dated [DATE] revealed Resident #105 returned to the facility with sutures on the top of his head. Review of the Facility's incident report dated [DATE] at 6:00 PM revealed Resident #105 fell out of his bed and was observed sitting on the floor and his alarm was "not sounding". He had no injuries noted. Review of the Facility's Care Conference meeting minutes dated [DATE] revealed Resident #105's family were told "no alarms will be used for prevention of falls". There were no new interventions ordered or implemented, such as a "lap buddy", to attempt to prevent falls out of the wheelchair. Review of the Facility's incident report dated [DATE] at 3:15 AM revealed Resident #105 fell out of his bed and was observed sitting on the floor and his alarm was "not placed". He had no injuries. Review of the Facility's incident report dated [DATE] at 5:05 PM revealed Resident #105 fell out of his wheelchair and was observed sitting on the floor and his alarm was "not placed". He had no injuries. During an interview, on [DATE] at 9:47 AM, when asked if the Facility had any Policy, Procedure, or Protocol for checking safety alarms or safety alarm maintenance, RN "A" said, "no, we don't". In an interview, on [DATE] at 3:30 PM, the Director of Nursing (DON), said they have not been checking to ensure that the sensor pad alarms sounded immediately when a Resident's weight was off of them. In second interview on [DATE] at 3:55 PM, the DON said the Facility's alarms are "supposed" to sound immediately. The DON said they changed Resident #102 and Resident #103's alarms on [DATE], immediately after this Surveyor had them tested and they failed to sound immediately. During a record review of the Facility's audit tool used to check sensor pad alarms, the DON said they were not checking the sensor pads for timing of alarms. The Administrator was notified on [DATE] at 3:10 PM of the Immediate Jeopardy that began on [DATE] as a result of the facility's failure to prevent falls and ensure the safety of: Resident #101, who was not provided an ordered sensor pad alarm for her wheelchair, was observed by facility staff on [DATE] around 4:50 p.m. on the floor in her room after a fall out of her wheelchair which caused a left hip fracture and the transfer of Resident #101 to a hospital for surgical repair of the hip where she continued to decline and subsequently died on [DATE], and Resident #105, who had a history of [REDACTED]. On [DATE] the surveyor confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. On [DATE], The Facility created a new Policy and Procedure titled, "Alarm/Sensor Pad Checks" 2. On [DATE], all 18 staff that worked in the afternoon and evening had been educated on implementing appropriate interventions on care plans and bedside care plans for any Resident who sustained a fall. 3. On [DATE], a Preventative Maintenance Tool was revised to include monitoring of safety alarms daily. 4. Beginning [DATE], all chair sensor pads currently in use will checked every day for a delay upon rising and documented on the revised Preventative Maintenance Tool by the CNA's and monitored by the Team Leader. 5. Beginning [DATE], all bed sensor pads will be checked prior to or during nightly care for delay upon rising and documented on the revised Preventative Maintenance Tool by the CNA's and monitored by the Team Leader (Licensed Nurses). 6. Beginning [DATE], random audits for chair sensors alarms for both types of alarms will be completed daily by the Director of Nursing or designee and will continue until substantial compliance is met and review by the Quality Assurance Team on the [DATE] meeting. 7. The Facility ordered "Attendant Timed Breakaway Voice Alarms and Pads" as evidenced by the purchase order to be delivered on [DATE]. 8. As of [DATE], 8 Residents were identified as requiring bed and/or chair sensor alarms. All eight Resident's care plans will re-evaluated by [DATE] to ensure appropriate safety interventions are in place. 9. On [DATE] all Residents with a score of 10 or above who are considered at risk for falls and may require safety interventions will be re-evaluated for any needed safety interventions. 10. On [DATE], the Facility Hourly Rounding Policy was revised to include more specific alarm monitoring. 11. Beginning [DATE], staff education began on the Alarm Monitoring and Preventative Maintenance Tool and will continue until all staff are trained. No staff will be allowed to work the floor until such training is received. 12. Beginning [DATE], staff education began on the revised Hourly Rounding Policy. Education will continue until all staff are trained. No staff will be allowed to work the floor until such training is received. 13. Beginning [DATE], staff will be educated on the implementation of appropriate interventions located on resident care plans and bedside care plans for any Resident who sustains a fall. Education will continuing until all staff is trained. No staff will be allowed to work the floor until such training is received. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staffs had not been in-serviced and sustained compliance had not been verified by the state agency. Resident #102 Review of the Clinical Record revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On [DATE] at 8:40 AM, Resident #102 was observed, sitting in a wheelchair with a sensor pad attached to an alarm box. The sensor pad alarm was hooked onto the back of Resident #102's wheelchair and a green light was flashing off and on. Registered Nurse (RN) "B" said that the green flashing light signified that the alarm was on and working. Upon request of the Surveyor, Certified Nurse Assistant (CNA) "C" raised Resident #102 completely off the sensor pad that was in her wheelchair, however the alarm did not sound immediately. There was a 7 second delay before the alarm sounded. CNA "C" took the sensor pad and tested it by sitting on the sensor pad herself and then she stood up and the alarm did not sound for 7 seconds again. The date on the sensor pad was written as applied on "start date [DATE]" and to expire as "end date [DATE]". Review of the care plan for Resident #102 dated [DATE], revealed an intervention for nursing staff to check the alarm every shift to ensure its functionality and that it is on. On [DATE] at 8:15 AM, a list of all Residents at the Facility who had sensor pad alarms was requested by this Surveyor. On [DATE] at 9:15 AM, RN "B" provided a list however, the list did not include Resident #102. RN "B " did not know why Resident #102 was not on the list of Residents with sensor pad alarms. The Director of Nursing (DON) stated during the exit conference on [DATE], that the reason Resident #102 was not on the list was because they had computer problems. Review of the Facility's incident report dated [DATE] at 10:30 AM revealed Resident #102 fell out of her wheelchair and was observed lying on the floor. There was no alarm sounding and Resident #102 had no alarm. Resident #102 sustained an eye injury. There were no new interventions provided. Review of the Facility's incident report dated [DATE] at 7:30 PM revealed Resident #102 fell out of her wheelchair, and again, had no alarm. There was no injury noted on the incident report. Resident #103 Review of the Clinical Record revealed Resident #103 was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On [DATE] at 8:55 AM, Resident #103 was observed, sitting in a wheelchair with a sensor pad attached to an alarm box. The sensor pad alarm was hooked onto the back of Resident #103's wheelchair and a green light was flashing off and on. Upon request of this Surveyor, RN "B" raised Resident #103 completely off the sensor pad that was in her wheelchair, however the alarm did not sound immediately. There was a 4 second delay before the alarm sounded. The procedure was repeated and the alarm did not sound for 4 seconds again. The date on the sensor pad was written as applied on "start date ,[DATE]" and to expire as "end date ,[DATE]". Review of the Facility's "Fall Risk Evaluation" dated [DATE] revealed Resident #103 was scored at 20. Review of her care plan dated [DATE] revealed an intervention that included a bed and chair sensor alarm. #