Every finding on record at Cottage Grove Place

Based on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Reviewed 1 of 3 dining areas. Facility reported a census of 56.Findings include:Observed on 06/22/2026 at 9:23 AM during the initial tour of the kitchen, the walk-in cooler revealed three containers of expired low-fat buttermilk stored on the top shelf on the right-hand side. The expiration date on the containers was 6/19/2026. Additionally, an empty cardboard box with water damage on the back edge was observed on the floor underneath the shelves. On 06/22/2026 at 12:14 PM prior to the lunch service, the floor of the main dining room was observed to be sticky when walked on.On 06/23/2026 at 9:02 AM a follow-up observation of the walk-in cooler was conducted. The three containers of expired buttermilk (dated 6/19/2026) remained on the shelf. Two loose apples and one loose orange were observed lying directly on the walk-in cooler floor. The water-damaged cardboard box had been removed.Observed on 06/22/2026 at 12:21 PM Staff A, cook, was preparing food plates for service in the main dining room while wearing gloves. With her left gloved hand, she held down sandwiches to cut them into halves or bite-sized pieces using a knife in her right gloved hand. Staff A then set the plates on the serving table and proceeded to touch the counter, paper menus, soup ladle handles, and the egg salad scoop with the same gloved hands. At 12:25 PM, Staff A placed bread directly onto the cutting table surface and then back on top of a sandwich. She touched every sandwich with the same pair of gloves during service, repeatedly cross-contaminating the food by touching the paper menus and ready-to-eat items consecutively. Staff A did not perform hand hygiene until 12:34 PM, after she completed meal service and removed her gloves.Observed on 06/23/2026 at 12:31PM during lunch Staff A was observed donning gloves without performing hand hygiene first, and immediately proceeded to cut a [NAME] sandwich into small squares which was then served to a resident.Observed on 06/25/2026 ,during breakfast, Staff A was observed plating breakfast food while wearing a glove on her left hand. After serving a plate, she touched the counter with her gloved hand, returned to the preparation area, and touched an egg bake directly with the same gloved hand to hold it while she cut it into pieces. When Staff A saw surveyor, the cook removed her glove and washed her hands. On 06/24/2026 at 9:25 AM during an interview with Staff G, registered dietician, stated that hands must be washed prior to serving meals, anytime they become visibly soiled, and both before and after donning gloves. Staff G explained that the facility's expectation when serving sandwiches was for staff to wear gloves or use utensils, such as tongs, to hold the sandwich down before cutting. Staff G further confirmed that gloves must be changed and hand hygiene performed between preparing individual sandwiches if staff members touched other surfaces. A review of a policy title Handwashing/Hand Hygiene, which was last reviewed/revised 02/2024, stated that all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used: before aseptic procedures; when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after eating or handling food; Before and after assisting a resident with meals.Applying and Removing Glovesa. Perform hand hygiene before applying non-sterile gloves.b. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff.c. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out.d. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. e. Perform hand hygiene.

Based on observation, interviews, and policy review, the facility failed to maintain an odor-free environment for 1 of 1 sampled resident. Resident #8's room reviewed for environment. Facility reported a census of 56.Findings include:During a review of resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.During an initial observation on 06/22/2026 at 2:54 PM, Resident #8 was observed lying in bed napping in his private room. There was a strong smell of urine in the room, and the resident's indwelling catheter tubing contained thick mucus. On 06/23/2026 at 11:00 AM, A follow-up observation was conducted. Resident #8 was not in the room; however, the room continued to have a strong scent of urine.On 06/24/2026 at 8:20 AM: A follow-up observation was conducted. Resident #8's room maintained a strong smell of urine. Housekeeping staff had not yet cleaned the room. At 9:35 AM another follow-up observation was conducted after housekeeping staff had completed cleaning the room. The room continued to have a strong smell of urine.During an interview on 06/24/2026 at 10:18 Staff B, Housekeeping associate, stated he had been working at the facility for almost 10 years. Staff B stated that all resident rooms received daily cleaning, which included vacuuming, dusting, and cleaning the bathroom floors and toilets. He indicated that carpet cleaning was completed as needed, and there were no recent carpet issues. He further stated that mattresses were cleaned on the resident's scheduled bath days, which involved spraying and wiping down the mattress. Staff B explained that if a mattress had an odor that would not dissipate, staff would contact Staff C, Environmental Supervisor or Staff I, Environmental Services Director, to submit a work order to have the mattress deodorized or replaced. He confirmed that there were currently no active work orders for unclean rooms.During an interview on 06/24/2026 at 11:00 Staff C, Housekeeping Supervisor, stated that housekeepers were expected to clean every resident's room daily, which included vacuuming, cleaning the toilet, removing garbage, dust-mopping the bathroom floor, and checking for spots on the floor. She noted that housekeepers did not perform carpet shampooing; instead, if they identified an issue, they were required to notify Staff C or Staff I so a carpet shampooer could be utilized. She added that staff would submit a maintenance work order for items they were unable to get clean, such as recliners and mattresses. On shower days, staff were expected to strip the bed and wash the entire bed frame, or submit a work order if it could not be cleaned. She confirmed that there were currently no active work orders for housekeeping issues. Staff C was informed of the odor in the resident's room and accompanied the surveyor to inspect it. Staff C confirmed that the room retained a strong urine odor even after housekeeping had completed their daily cleaning, and she stated that the room would require a deep clean and that she planned to replace the mattress.During an interview on 06/24/2026 at 4:07 PM, the Administrator confirmed that the housekeeping department did not have an official written cleaning schedule or check off list. He stated that housekeeping staff members were expected to clean every resident room daily. He further noted that mattresses were expected to be cleaned when the bed linens were stripped, which was scheduled to occur on each resident's designated shower days.An email was sent on 06/24/2026 requesting Housekeeping cleaning policy to the Administrator, but was never submitted to the survey team.

Based on observation, clinical record review, interviews, and policy review the facility failed to ensure a resident's leg brace was applied according to physician's orders for 1 of 1 residents reviewed (Resident #13). The facility did not have orders for the placement, timing, or care of the brace and the brace was not addressed in the resident's care plan. The facility reported a census of 56 residents. Findings include:The Minimum Data Set (MDS) for Resident #13 dated 06/10/2026 documented diagnoses of arthritis, polyneuropathy (damage or disease affecting nerves throughout the body), and weakness with repeat falls. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. Section GG recorded the resident used orthotics prior to this illness with impairments of the lower extremity on both sides of her body. She was dependent on staff for lower body dressing. The Care Plan dated 06/04/26 documented focus areas for pain risk, a decline in functional abilities, impaired skin integrity, and fall risk. Interventions did not include the placement, use, or care for a left leg brace. Review of the Electronic Health Record (EHR) Physician Orders for Resident #13 revealed there were no active orders for the placement, use, or care of a left leg brace. An order for an AFO (ankle-foot orthosis) cushion for right foot drop was revised 06/19/2026. On 06/22/2026 at 10:40 AM observed the resident was seated in her recliner. She wore tennis shoes and a hard white leg brace on her left leg.On 06/22/2026 at 2:04 PM Resident #13 reported she had the brace before she came to the facility. She stated she had drop foot (inability to lift the front part of the foot) on both feet and the brace helped her after she turned her ankle. She usually wore the brace from 6:30 AM when she woke up to about 8:00 PM when she went to bed. On 06/23/2026 at 2:49 PM observed Resident #13 had the brace on her left leg. The resident's spouse reported he made her doctor's appointments before she came to the facility and couldn't recall the name of the doctor who ordered the brace. He indicated the facility had the names of her doctors.On 06/24/2026 at 10:18 AM Staff N, Certified Nurses Aide (CNA) stated the CNAs were responsible for putting the resident's left leg brace on in the morning and that Resident #13 had the brace since she admitted . She was not aware of a brace for the right leg.On 06/24/2026 at 10:29 AM Staff K, Registered Nurse (RN) reported the resident had a left leg brace and needed a sleeve underneath it. She stated there should be doctor's orders, but putting it on in the morning and taking it off at night was something you just did when you are a nurse. Staff K said information about the brace should be in the care plan.On 06/24/2026 at 12:45 PM the Director of Nursing stated she would expect the brace to be addressed in the care plan. She stated she wasn't sure if the right AFO documented in the orders was a new order for the right foot or an entry error for the left leg brace.On 06/24/2026 at 3:13 PM Staff O, Medical Director stated the resident admitted with the left leg brace and the right AFO was a different order. He expected staff to get orders from the orthopedic doctor for the left brace.An undated policy titled Physician Order Transcription Policy and Procedure documented the following:All transcribed physician orders must be documented in the electronic medical records system, including the date, time, and identity of the healthcare professional involved. Any errors, clarifications, or amendments made to the transcribed orders should be clearly documented and linked to the original order.

Based on observation, staff and resident interview, clinical record review, and facility policy review the facility failed to appropriately transcribe, clarify and follow physician orders for wound care to open wounds for 2 of 2 residents (Resident #41 and Resident #65) reviewed for wound care. The facility reported a census of 65 residents. Findings include: 1. Review of the Minimum Data Set (MDS) Assessment, dated 4/07/26, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. The list of diagnoses included Cerebrovascular Accident (CVA or stroke), Diabetes Mellitus, and non-Alzheimer's dementia. Review of the Care Plan, dated 10/30/25, revealed a Focus area for Resident #41 being at risk for impaired skin integrity with the potential for resulting pressure ulcers related to limited mobility, age, incontinence, diabetes, and dementia with the goal to have intact skin, free of redness, blisters, or discoloration. Interventions included the following, in part: Administer treatments as ordered and monitor for effectiveness. Date initiated: 10/30/25. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound permeability, wound bed and healing progress. Report declines to my doctor. A nurse assess any skin impairment on a weekly basis and recommends any change in treatments. Date initiated: 10/30/25. Review of a Skin/Wound Note, dated 6/22/26 at 10:19 AM, revealed an entry: Weekly skin assessment complete. Skin area to left forearm and left lateral hand resolved. POA and Primary Care Provider (PCP) notified. Review of a Skin Issues Note, dated 6/22/26 at 10:26 AM, revealed the following, in part: Skin Issue #001: Location: Left outer forearm Issue type: Skin tear Progress: Improving, overall wound characteristics improved. Wound acquired in house, exact date: 6/14/26 Signs and symptoms of infection: None. Painful: No. Length (cm): 1.17. Width (cm): 1.9. Depth (cm): 0. Exudate amount: Light. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and artery. Other wound bed: pink or red. Periwound: Non-attached. Surrounding tissue: Dark reddish brown. Dressing appearance: Intact. Dressing saturation: None. Cleansing solution: Soap and Water Other primary dressing: Xeroform (non-adhering wound dressing made of fine mesh gauze impregnated with petrolatum and 3% bismuth tribromophenate)/Tegaderm (a transparent, waterproof, and breathable medical film dressing) Frequency of treatment: Every 3 days. Review of the Order Summary Report, dated 6/24/26, lacked orders for left forearm skin tear wound cares or dressing changes. Review of the Treatment Administration Record (TAR), dated June 2026, lacked orders for left forearm skin tear wound cares or dressing changes. During an observation on 6/23/26 at 10:48 AM, Resident #41 sat in a wheelchair at the nurse's station, an adhesive dressing, dated 6/22/26, in place on left forearm. During an interview on 6/23/26 at 1:21 PM, Resident #41 stated the wound on his left forearm did hurt but is now calmed down. During an observation on 6/23/26 1:21 PM, the dressing to Resident #41's left forearm, dated 6/22/26, had a moderate amount of light brown colored fluid that was contained within the transparent dressing. During an observation on 6/24/26 at 9:32 AM, the dressing to Resident #41's left forearm, dated 6/22/26, had a moderate amount of light brown colored fluid that was contained within the transparent dressing. During an observation on 6/25/26 at 3:37 PM, the dressing to Resident #41's left forearm, dated 6/22/26, had a copious amount of light brown drainage pooled on top of the gauze and contained within the transparent dressing. Staff L, also present in Resident #41's room, stated that Resident #41 had a skin tear on left forearm which occurred during a transfer the week prior. Staff L confirmed that the date 6/22 was written on top of Resident #41's left forearm dressing. Staff L stated that she called the nurse to change the dressing because it looked soiled. Review of a Health Status Note, dated 6/24/26 at 5:44PM, revealed an entry: Observed moderate amount of dark greenish/brown drainage from skin tear on right forearm, forming bubble underneath tegaderm dressing. Removed dressing and cleansed site, wound bed appears pink and moist with no additional drainage at time of dressing removal. Applied new Xeroform and Tegaderm per order. No noticeable erythema (redness) to periwound area, site is not warmer than other skin. Denies pain to the area. Review of a Health Status Note, dated 6/24/26 at 6:07 PM, revealed an entry: PCP updated, POA aware. During an interview on 6/25/26 at 10:36 AM, Staff H, Licensed Practical Nurse (LPN), confirmed working on 6/24/26 and changed the dressing on Resident #41's left forearm. Staff H stated there was a bubble of fluid that appeared murky, green/brown in color. Staff H stated the skin tear remained open with a moist skin flap but denied signs or symptoms of infection observed. Staff H reported that the facility had a protocol for skin tears to apply a certain type of dressing per standing order. Staff H stated the wound care orders should be found on the resident's TAR to reflect type and frequency of dressing changes. During an interview on 6/25/26 at 10:52 AM, Staff F, LPN, reported that when a resident gets a skin tear, the nurses are expected to apply Xeroform gauze and tegaderm film cover per standing orders, fax the provider to notify, and put wound care orders into TAR so other nurses are aware of wound cares and sign off on treatment completion. During an interview on 6/25/26 at 10:54 PM, the Director of Nursing (DON) revealed the expectation of nursing staff to follow skin tear protocol when a resident obtains a skin tear. The DON stated the current skin tear protocol included mepilex (padded adhesive dressing) to cover the wound but that the protocol was being revised to instead apply Xeroform gauze and Tegaderm film dressing. The DON reported that the revised skin tear dressing protocol had not yet been signed by the Medical Director. The DON revealed the expectation of nursing staff to enter wound care orders into resident medical records, so nurses are aware of treatment orders and can sign off wound cares when completed. 2. The MDS for Resident #65 dated 06/18/2026 was still in progress. The BIMS was completed with a score of 15/15 which indicated intact cognition. The resident's Care Plan, dated 06/12/2026 documented the resident was at risk for impaired skin integrity and interventions directed staff to administer medications as ordered, monitor/document for side effects and effectiveness, and to assess any skin impairment on a weekly basis. It did not include wound locations or treatments. A Progress Note titled Skin Issues dated 06/12/2026 (admission date) indicated the resident had a New Skin Issue #002, an abrasion on her right anterior (front) neck which measured 10 cm x 12 cm. Frequency of treatment was documented as antibiotic ointment with dry dressing. The note did not include the type of ointment or how often the dressing should be changed. There were no other documented wounds on the resident's right neck or right chest. A Progress Note titled Skin Issues dated 06/15/2026 documented Skin Issue #001 a laceration on the right anterior neck had not been evaluated and was present on admission. It did not include measurements. Skin Issue #007 an abrasion on the right anterior neck was documented as evaluated and improving. It was present on admission and measured 2.44 cm x 2.19 cm. Skin Issue #011 an abrasion on the right chest was documented as a new skin issue, present on admission, improving, and measured .93 cm x 1.13 cm. The assessments did not include current treatments. A Progress Note titled Skin Issues dated 06/22/2026 noted Skin Issue #001 a laceration on the right anterior neck was resolved. Skin Issue #006 an abrasion on the right anterior neck was present on admission and improved. It measured 1.81 cm x 2.42 cm. Exudate (fluid that leaks out of blood vessels) was light and serosanguineous (thin, watery, pale red). Skin Issue #008 an abrasion on the right chest was present on admission and improved. It measured .74 cm x 1.08 cm with serosanguineous fluid. A provider Facility Visit note dated 06/15/2026 included the following medications prior to visit: *bacitracin 500 units/gram ointment. Apply 1 application topically daily for 10 days. *mupirocin 2% ointment. Apply topically 2 times daily for 7 days. *wound dressings (triad hydrophilic topical past. Apply 1 application topically every other day. The medications listed did not include the locations of wounds to be treated. The Medication Administration Record (MAR) revealed Resident #65 had an order for bacitracin external ointment 500 unit/gm to be applied topically one time a day for skin irritation for 10 days beginning 06/13/2026. The MAR did not include a location for administration. A separate location of administration section of the MAR documented the bacitracin was administered to the resident's left leg, lower rear from 06/13/2026 through 06/19/2026. It did not include documentation of administration to the wounds on Resident #65's neck or chest. On 06/20/2026 the order for bacitracin was changed to apply the ointment to the right side of the resident's neck with dry gauze and to secure with paper tape. The location of administration section documented the bacitracin was administered to the resident's neck from 06/20/2026 through 06/22/2026. On 06/22/2026 at 10:27 AM Resident #65 stated her only concern was that when she transferred from the hospital the wounds on her neck and upper chest had almost healed, but opened back up because of a miscommunication about treatment. She reported that the wounds did not receive treatment for about 5 days. On 06/24/2026 at 9:19 AM observed the resident's neck wounds being treated. There was one open wound on the right side of her neck, below her ear and towards her jaw. There was a smaller second wound approximately 4 to 5 cm lower. Both were open with serosanguineous discharge on the gauze when patted dry. On 06/24/2026 at 9:29 AM the resident's spouse was in the room during the wound treatment and stated the treatments were not done for 5 days, and he thought the wounds got worse during that time. He said they now look the same as when she first arrived and getting better. He started taking pictures to monitor the care. On 06/24/2026 at 9:31 AM Staff K, Registered Nurse (RN) stated she thought there was a surgical treatment that could not be removed when the resident first admitted but she would have to look. During a follow up interview at 10:29 AM Staff K stated there was not a surgical wound there. Staff K said she was not putting the bacitracin on the resident's neck at first because the orders didn't say where to put it. She confirmed she put the bacitracin on the resident's leg and stated some of the days she used mupirocin on the resident's neck. She was unable to say what happened on the days where no neck treatments were documented. When asked if someone clarified the orders Staff K stated she didn't know but it was her fault too because she didn't look to see if there was clarification or ask questions. She stated she should have documented better. Staff K stated Staff P, Assistant Director of Nursing (ADON) and the DON were responsible for making sure orders were accurate and clarified. On 06/24/2026 at 9:32 AM Staff P said all of the information about the wound treatments should be in the MAR. On 06/24/2026 at 12:45 PM the DON reported the order was always to use bacitracin for Resident #65's neck according to the MAR. She stated the resident came with a 10 day order. When asked about the Administration Record date gaps and the orders missing administration locations the DON was unable to determine what happened. She stated they usually called the provider's office to get confirmation of the orders. On 06/24/2026 at 3:13 PM Staff O, Medical Director stated he was unable to tell from his notes when the resident's orders were clarified. He confirmed he saw her on 06/15/2026, and stated if he clarified them then they should have been active before the 20th when they were changed in the MAR. It should only take a day to get a common medication from the pharmacy, 2 at the most. Review of the facility provided document titled Skin Care Program, dated 9/11/23, instructed for new skin alteration noted by the nurse. The nurse would do the following: Notify the provider following the resident. Request treatment if necessary. Complete appropriate skin sheet/bruise sheet. Document findings in nurses' notes. Pass on new findings in report. If a change in a skin alteration is noted, then the nurse will follow the same steps listed above. The Skin Care Program revealed the following Skin Tear Protocol: If able to reapproximate skin flap edges: Cleanse wound with Normal Saline and gauze, pat dry. Re-approximate edges and cover with Mepitel One and change every 7 days and as needed if loose/soiled. If draining, cover with dry gauze and secure with Tubigrip. Change gauze daily and as needed until drainage stopped. 2. If Partial skin flap present and small amount of drainage: Cleanse wound with Normal Saline and gauze, pat dry. Cover with Optiflex Lite/Mepilex Lite Cover with Tubigrip, change dressing every 5 days and as needed if saturated with more than 50% drainage. 3. If partial skin flap with moderate to large amount of drainage or skin flap absent: Cleanse wound with Normal Saline and gauze, pat dry. Cover with Optiflex border/Mepilex border. Change dressing every 3 days and as needed if saturated with more than 50% drainage.

Based on observation, interview, policy review, and record review, the facility failed to ensure that a resident with an indwelling Foley catheter received the necessary care and services to manage catheter care and prevent urinary tract infections (UTIs) for one resident (Resident #8) reviewed for catheter care. Facility reported cencus of 54.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] , documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, indicating no to minimal cognitive impairment. Resident #8's diagnoses included urinary retention and an enlarged prostate (benign prostatic hyperplasia), which required the use of an indwelling Foley catheter. The assessment also noted that the resident was dependent on staff for personal cares, catheter care, and transfers.Review of Resident #8's admission Note stated that urine was clear yellow in color. No urinary complaints.Review of a Progress Note dated 06/09/2026 indicated the resident's catheter had been leaking, prompting a nurse to remove it and insert a new one. The note indicated urine return was established, sediment was present in the resident's urine, and the resident tolerated the procedure well.Observation on 06/22/2026 at 11:48 AM showed Resident #8 seated at a dining table. His catheter tubing was visible underneath his wheelchair and contained large chunks of mucus with some red-tinged areas.Follow up observation made on 06/22/2026 at 2:54 PM. Resident #8 was observed lying in bed in his room. A strong odor of urine was present throughout the room, and the indwelling catheter tubing continued to contain thick mucus. During an interview at this time, Resident #8 stated that no one had mentioned the room's odor or the mucus in his tubing to him. He noted that facility staff and hospice staff helped him with his catheter care. The resident then gave permission for the surveyor to watch his catheter care when it was performed.On 06/23/2026 at 2:00 PM observed Staff D (CNA) and Staff E (CNA) performing catheter and perineal care for Resident #8. The staff completed the cares but made no mention of the odor or the mucus in the tubing and catheter bag. When the surveyor pointed out the thick, red-tinged mucus in the catheter, Staff D responded that it was likely caused by the resident's thickened liquids diet, which was an incorrect clinical statement.During an interview on 06/24/2026 at 9:35AM Staff F (LPN) stated that CNAs were expected to perform catheter care every time they checked and changed a resident, and to empty the drainage bag every shift. She explained that if CNAs noticed any strong-smelling urine or mucus in the bag or tubing, they were required to report it to the nurse. The nurse was then expected to assess the resident, contact the medical provider or hospice with the concerns, and update the family. Staff F also noted that some residents had orders for catheter flushes, which would be utilized if mucus was found.A follow up interview on 06/24/2026 at 12:54 PM Staff F (LPN) stated that she had finally assessed the resident that morning and subsequently notified Hospice after speaking with the surveyor earlier. She confirmed that the resident was being started on an antibiotic for a urinary tract infection (UTI) and that a hospice nurse was scheduled to come out and change the catheter. Staff F also admitted that the CNAs from the previous day had told her about the mucus discharge, but she had forgotten to assess the resident at that time.During an interview on 06/24/2026 at 1:23PM the Director of Nursing (DON) stated that CNA staff were trained to identify UTI symptoms in residents with catheters and were required to notify the nurse on duty. The DON confirmed it was the nurse's responsibility to notify the provider or Hospice for further assessment. If large amounts of mucus were present, staff were expected to call the manager on call to help obtain an order to either flush or change the catheter. The DON also stated that the facility utilized the McGeer Criteria to identify UTIs.Resident #8's Care Plan indicated the resident had an indwelling catheter related to urinary retention and BPH, and that staff were actively providing care for it. The Care Plan noted the resident would not show signs of infection due to having an indwelling catheter. Specific interventions included cleansing the area around the Foley catheter site with soap and water and rinsing it twice daily, ensuring the tubing and dignity bag were kept off the floor, and changing the urinary drainage bag and dignity cover every 30 days. Additionally, the Care Plan directed staff to flush the catheter with 60 cc of Normal Saline 0.9% daily as needed if the Foley catheter became clogged.A review of the facility's McGeer Criteria policy for residents with indwelling catheters indicated that a resident must exhibit one or more of the following symptoms to meet criteria: fever, rigors (shaking chills), new-onset hypotension with no alternative cause, new-onset confusion or functional decline, new costovertebral (back/kidney) pain or tenderness, new or marked suprapubic (lower stomach) tenderness, acute pain, swelling or tenderness of the testes, epididymis, or prostate, or purulent (pus-like) discharge from around the catheter site.

Based on observations, clinical record review, staff and resident interviews the facility failed to use Enhanced Barrier Precaution (EBP) when handling a resident as directed for resident with wounds and catheters for 1 out of 3 residents reviewed (Resident#17). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident#17 dated 4/30/26 listed diagnoses of peripheral vascular disease (PVD), contracture of the right and left knee. The Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, intact cognition. The MDS listed Resident#17 dependent with lower body dressing and toileting. The MDS reflected Resident#17 held an indwelling urinary catheter. The MDS revealed 1 venous ulcer. The Care Plan for Resident#17 dated 4/18/24 directed special treatments/procedures: EBP due to suprapubic catheter (a flexible tube inserted directly into the bladder through a small incision in the lower abdomen). On 06/22/2026 at 9:59 AM Resident#17 sat in her chair on a cushion wore blue boots on both her feet, urinary catheter bag placed on her left side. The room failed to show a sign for EBP. A 3 drawer cart sat inside her room next to her chair. The cart held gowns, gloves. Resident#17 reported the staff wore gloves with her cares but they don't wear gowns. On 06/23/2026 at 12:25 PM door failed to hold an EBP sign, and failed to hold a cart outside the room to show the need for staff to use EBP. A 3-drawer cart sat inside her room next to her chair. On 06/24/2026 at 1:40 PM Resident#17's room failed to hold an EBP sign on the outside of the room. Staff J Registered Nurse (RN) sat directly on the floor in front of Resident#17 in her room. Staff J reported completing range of motion (ROM). Staff J sat on the floor and wore gloves on both hands as she put cream on Resident#17's legs. It smelled strongly of mentholated arthritis cream. Staff J failed to wear a gown as she pulled pant leg up that held catheter tubing to put cream on the left leg. The catheter drainage bag sat to the left side of the resident. At 1:49 PM Staff J left the room.On 06/25/2026 at 8:11 AM an EBP sign hung outside Resident#17 room on the wall. The sign directed EBP everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing, On 06/25/2026 at 9:23 AM Staff K RN walked to Resident#17's room asked Resident#17 if she could put the cream on her leg and complete ROM. Resident#17 said yes. At 9:27 AM the Administrator stood at the room door and offered to take the meal tray back to the kitchen, and tapped the EBP sign on the wall. Staff K pulled the privacy curtain applied gloves to her hands sat on the floor in front of Resident#17. Staff K reached her gloved hand up Residnet#17 right pant leg to put the cream on her leg. At 9:29 AM Staff K removed her gloves and threw them in the trash can. Staff K lifted the left leg 50 times. Staff K moved her hands to the right leg and lifted that leg 50 times. Staff K readjusted each blue foot boot Resident#17 wore.At 9:32 AM Staff K washed her hands, offered to wash Resident#17s face with a wipe from her bathroom. Staff K used the wipe and washed Resident#17s face and put her glasses back on.On 06/25/2026 at 9:34 AM Staff K reported she thought she just needed the EBP with the catheter contact.On 06/25/2026 at 9:38 AM the Director of Nursing (DON) Infection Preventionist (IP) reported she expected the staff to use the EBP when they go into her room and care for Resident#17. The DON said the staff needed to wear the EBP with hands on cares. The DON reported she's completed education to all the staff on the EBP. The facility provided a policy titled Enhanced Barrier Precautions undated that directed:Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following:Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO.Examples of indwelling medical devices include: central line, urinary catheter.Post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities.

Based on Minimum Data Set (MDS) review, observations, interviews, grievance logs and workorder reviews, the facility failed to ensure a resident's call system was operational and reliable to allow the resident to summon staff for assistance for 1 of 3 resident call lights reviewed (Resident #49). Facility reported a census of 56Findings include:A review of Resident #49's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.During an interview on 06/22/2026 at 1:45 PM Resident #49 stated that his call light was finicky at times and frequently failed to work. He explained that when it failed in the morning while he was still in bed, he had to jiggle the cord attached to the wall to make it function. The resident expressed anxiety about the call light malfunctioning while he was alone and seated in his recliner. He stated that on one occasion, he urgently needed to use the bathroom and self-transferred out of the recliner because the call light was unresponsive. He acknowledged that he knew he was supposed to wait for assistance but stated he had no alternative way to contact staff. The resident noted that he had reported the issue to staff previously, but they claimed it worked fine whenever they tested it. He confirmed he was never offered an alternative method to summon help. He added that the call light had been replaced twice since he occupied the room: first when he initially moved in, and a second time on the previous Friday.During an observation on 06/22/2026 at 1:46 PM the resident activated the call light, but it failed to register. A check of the wall module and the light outside the resident's room confirmed that neither light activated. The surveyor pressed the red call light button twice, and it remained non-functional. The resident reiterated that this was a frequent occurrence. He stated that staff had switched out the cord approximately 1 week prior, but it stopped working correctly shortly thereafter. He stated he had informed several people but did not know when it would be permanently fixed. The call light remained non-functional for the duration of the observation. On 06/24/2026 at 10:44 AM observed Resident #49 pressed the red call light button, and the system again failed to activate.A follow up interview was conducted on 06/24/2026 10:44. Resident #49's call light failed to function again. The resident asked the surveyor if an alternative communication device could be brought to his room because he was worried about his inability to contact staff for his needs. The surveyor informed Staff F, LPN, of the issue, who then provided a handheld bell for the resident to ring when the call light was non-functional.During an observation on 06/24/2026 at 12:12 PM the maintenance staff was in the resident's room testing the system and replacing the standard cord with a soft touch pad call light.During an observation on 06/24/2026 at 2:12 PM the surveyor entered the resident's room with the resident's spouse present. The resident was asked to test the new soft touch pad call light, but it failed to turn on. The resident attempted to activate the touch pad multiple times using different methods, but the system did not respond. The spouse and the surveyor also attempted to activate it without success. The surveyor requested assistance from Staff M, speech therapist, passing by the room to test the light, and it failed to work for her as well. Staff M unplugged the call light cord from the wall jack, plugged it back in, and the system began functioning. Staff M then reported the ongoing issue to Staff H, LPN, who stated they would notify the Administrator and the maintenance department of the continued malfunction.During an interview on 06/24/2026 at 11:30 AM Staff I, Environmental Services Director stated that call light failures were supposed to be reported immediately via the work order system, as well as through a direct phone call or text to maintenance staff. He explained that facility protocol required staff to provide the resident with a handheld bell as an interim safety measure until the call light could be repaired. He noted that nursing staff on the PM shift were required to test all room call lights monthly and sign off on a tracking sheet. This check required verifying that the room light, the corridor dome light, and the main console at the nurse's station all activated. If any component failed, a work order was to be submitted. Staff I stated that maintenance aimed to address call light concerns within 15 to 20 minutes of notification. However, he stated that no work orders had been received regarding this resident's call light. He added that the electronic call light system could print audit reports to notify them of internal system failures. Upon checking the report, it did not reflect any system errors during the times the call light had failed. He stated he was entirely unaware that the call light had been replaced or was experiencing ongoing issues.During an interview on 06/24/2026 at 2:10 PM Staff D stated that the resident's call light was replaced when he initially admitted to the facility, but it had not been replaced or serviced since that time that she was aware of.During a follow up interview on 06/25/2026 at 7:44 AM the Administrator reported the the call light technician had been out that morning and reported that the call light system was functioning without any mechanical problems following a complete diagnostic check. He stated that if a resident failed to press the button with enough pressure, it would not establish the connection required to signal the system. He explained that the new touch pad was highly sensitive around the edges but less responsive in the center. He further clarified that the seven-day printed audit report failed to show the call light was broken because the system's automated alerts only flag internal electronic component failures, not physical damage to the external cord. He confirmed that the facility had replaced the room's call light cord on the previous Friday because the physical cord showed signs of being broken.During an observation on 06/25/2026 at 11:37 AM while the resident was out of the room, the surveyor tested the soft touch pad call light, and it failed to turn on. The surveyor requested The Administrator to come to the room and test the device; the call light failed to function for the Administrator as well. The Administrator verbalized his understanding of the call light not working properly.A review was conducted of the facility-submitted work order list, titled Simple Work Order Listing, for May and June 2026, as well as the facility's Grievance Report 2026. The review revealed no documented work orders or grievances regarding call light failures. A review was conducted of the facility's policy for maintenance requests utilizing TheWorxHub system. The policy mandated that all maintenance requests be submitted through TheWorxHub and specified that no request was considered complete until the work order was documented and closed within the system.According to the policy's priority levels:Emergency Priority: Included failed resident safety equipment, which required an immediate response. b. Urgent Priority: Included nurse call light issues, which required a same-day response.The policy further outlined that all staff members maintained the ability to report maintenance issues and submit complete work requests. Maintenance staff were expected to respond to these requests based on priority level, complete the necessary repairs, and document all work performed. Additionally, the Maintenance Director was responsible for overseeing work order management, monitoring compliance, and ensuring the completion of preventative maintenance.

Based on clinical record review, staff interview, observation, fire department and police reports, ambulance reports, employee file review, and facility record review, the facility failed to utilize a lap and shoulder seatbelt restraint prior to transporting a resident in a facility van for 1 of 3 residents reviewed (Resident #1). On [DATE], during transport from a doctor's appointment, the facility van driver failed to secure a lap and shoulder seatbelt restraint for Resident #1, who was seated in a secured wheelchair in the back of a transport van. As a result, Resident #1 flew forward out of the wheelchair over a folded middle row seat when the driver swerved and braked to avoid another vehicle. Resident #1 landed face down on the folded second row seat, with her head near the floor between the second-row seating and back side of the driver's seat. Blood was present from Resident #1's nose. Resident #1 was unresponsive, did not appear to be breathing, was pulseless, and cyanotic (bluish or purplish discoloration of the skin) to the face from the neck up. This constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 49 residents.The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 11:00 AM. The IJ began on [DATE], the day Resident #1 was transported in a facility van without the use of a lap and shoulder restraint.Facility staff removed the Immediate Jeopardy on [DATE] through the following actions:-The facility halted van transportation services and utilized external transportation services. The scope lowered from J to D at the time of the survey after ensuring the facility utilized external transportation services. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of [DATE]. The MDS assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS revealed the resident used a wheelchair for mobility, the resident had no impairment for upper extremities (shoulder, elbow, wrist, hand), and had impairment on one side for lower extremity (hip, knee, ankle, foot). The MDS revealed Resident #1 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers are required for the resident to complete the activity) to move from sit to lying, lying to sitting on the side of the bed, and for chair/bed-to-chair transfers The MDS listed diagnoses of atrial fibrillation (rapid, irregular, and uncoordinated heart rhythm), heart failure (progressive condition where the heart cannot pump enough blood to meet the body's needs), Cerebrovascular Accident (when blood flow to part of the brain is blocked or a blood vessel ruptures, causing brain cells to die), and hemiplegia (paralysis on one side of the body). Per the MDS, the resident received anticoagulant medication (used for the prevention of blood clots from forming) and antiplatelet medication (used to prevent blood cells called platelets from sticking together) during the look back period.The Care Plan Report initiated on [DATE], for Resident #1 identified the following Focus areas:1. Resident #1 received antiplatelet medication. Interventions included, in part, to use extra caution with manually transferring or positioning (intervention initiated [DATE]). 2. Resident #1 received anticoagulant medication. Interventions directed staff to:-Report skin abnormalities to the nurse-Resident/family/caregiver teaching to include: avoid activities that could result in injury, and take precautions to avoid falls. -Use extra caution with manually transferring or positioning. 3. Resident #1 received skilled nursing facility level of care. Interventions dated [DATE] revealed the resident required transfer assist with 2 people using Hoyer (full body mechanical lift) lift using purple sling, the resident was non-ambulatory, and wheelchair mobility required assistance of one.4. Resident #1 was at risk for falls.5. Resident #1 desired to discharge home.6. Resident #1 had a deep vein thrombosis (DVT - a blood clot forms in deep veins) (initiated on [DATE]).The Medication Administration Record (MAR) recorded Resident #1 received the following: Aspirin 81 mg (milligram) delayed release (antiplatelet medication) one time per day, administered on [DATE]. The resident's anticoagulant medication, Warfarin, was on hold from [DATE] to [DATE].The facility CPR (cardiopulmonary resuscitation) Policy indicated Resident #1 requested do not resuscitate (DNR), which indicated she didn't want to be given cardiopulmonary resuscitation. Resident #1 signed the document on [DATE]. The physician signed on [DATE].A Nursing Advanced Skilled Evaluation note dated [DATE] at 8:21 AM documented Resident #1's vitals: temperature 97.7 degrees, blood pressure 101/64, pulse 61, respirations 18, O2 (oxygen saturation) 94% by continuous positive airway pressure (CPAP) and weight 294.4 pounds. Alert and orientated times 3 (indicating a patient is aware of three key areas: person (name), place (location), and time (date/time)). Resident #1 communicated verbally, speech was clear, able to understand and be understood when speaking. Resident was able to move all extremities with weakness noted to right and left leg, and to her feet.An Incident Note dated [DATE] at 5:00 PM documented the facility was notified regarding a motor vehicle incident between the medical appointment and transportation to return to the facility. [Redacted] Police Department informed [facility] of Resident #1's passing in route. Family and physician notified. Review of the Facility Summary of Alleged Incident Report for Resident #1's incident on [DATE] completed by the Administrator on [DATE] revealed, On [DATE] at approximately 1400 hours (2:00 pm), a resident [Resident #1] of [Facility Name Redacted] was involved in a motor vehicle-related incident while being transported from a cardiology appointment to the facility in a company-operated vehicle driven by a facility staff member [Staff A, Driver]. Per driver statement, the resident was secured in her wheelchair and the vehicle ramp was properly secured prior to departure. While traveling approximately 25 miles per hour in a 30 mile-per-hour zone near the intersection of [Street Redacted] and [Street Redacted] in [City Redacted], Iowa, another vehicle initiated a turn into the path of the transport van, creating an imminent risk of collision. The driver reported taking evasive action, including braking and swerving, to avoid a direct impact. Emergency Medical Services were immediately contacted. First responders, including [Police Department] and [Fire Department], arrived on scene. The resident was removed from the vehicle and emergency interventions were initiated. The resident was subsequently pronounced deceased at the scene.At this time. [Facility] cannot confirm that all required securement procedures were fully implemented at the time of transport, and the resident's cause of death remained under investigation.The Root Cause Analysis section of the Facility Summary of Alleged Incident Report revealed, in part, At this time, we are unable to confirm if an over-the -lap or cross-body seat belt was applied in addition to securing the wheelchair in the van. This may have contributed to the resident moving forward in the van compartment during the braking of the vehicle.A Calls for Service Report for the police department (PD) listed a received date of [DATE] at 2:10 PM. The report listed the nature of the incident as hemorrhage/lacerations. The report listed an officer was dispatched at 2:11 PM to [Street Redacted] and [Redacted Street, [City Redacted], Iowa. The report listed the officer arrived on scene at 2:11 PM.A Fire Department incident report listed the incident date of [DATE] at 2:08:50 with the primary reason listed as unconscious victim. The dispatch code listed hemorrhage/laceration. The Fire Department Patient Care Record dated [DATE] revealed at 2:14:00 the report documented Resident #1's mental status as unresponsive and skin as cold, cyanotic, lividity (discoloration due to settling/pooling of blood), mottled, and pale. The report revealed the patient had been wedged between the front driver seat and the middle row seats. Upon removal of the patient, it was noted she had a DNR bracelet. Ambulance services called to affirm the DNR and resuscitation efforts were not attempted. Patient was cyanotic (bluish or purplish discoloration of the skin) and pulseless with a few wounds from her fall. The report documented the driver stated she was conscious and alert prior to the fall but became unresponsive. The fall placed her in a face down upside down position in the vehicle. Patient was placed on a back board upon removal from the van, placed on the cot and moved to the ambulance.The Prehospital Care Report (PCR) Summary from the ambulance company for emergency response on [DATE] with call received at 2:11:06 PM revealed dispatch reason as serious hemorrhage, and chief complaint (primary) as cardiac arrest. The PCR summary detailed the resident was unresponsive, cyanotic, and apneic. The presumed cardiac arrest etiology section revealed suspected positional asphyxia (body in a position that obstructs or blocks breathing).The PCR summary further detailed a van which swerved to avoid a reckless driver causing a passenger to flip over the back seat and bleeding. While enroute to the scene, PD requests fire and emergency medical services (EMS) emergent and reports that the Patient (Pt) is upside down in the van.Upon arrival to the scene, [fire department] and [ambulance] are arriving at the same time. [PD] is on scene. Pt (patient) is found in the back seat (2nd row) of a small [Van Make/Model Redacted] run by [Facility]. Pt is in a prone (lying flat on the stomach) position lying on the driver's side 2nd row seat which is folded down. Pt's torso and head was found to be between the 2nd row seat and the back of the driver's seat with her head touching or nearly touching the floorboards. The position pt was found makes it impossible to assess her adequately, however, pt is unresponsive and does not appear to be breathing as her back cannot be seen moving.The PCR summary further revealed, Driver of the van reports that he was driving eastbound on [Street Redacted] from [Street Redacted] returning the pt to the facility from a doctor's appointment. Driver reports that while driving, a [Make/Model of Car Redacted] pulled out in front of him from his left on [Street Redacted]. Driver stated that he swerved and braked hard to prevent a collision, however, the pt then was thrown forward from her wheelchair in the far rear of the van and landed in the position described above. Pt was reportedly alert and talking prior to the incident but hasn't been responsive since.The PCR Summary further revealed, Pt is lifted by fire and EMS and dragged from the van through a sliding rear door on the driver's side. Pt is placed on the ground and rolled to a supine (lying flat on the back with the face and torso facing upward) position onto a scoop board. Pt is found to be pulseless, apneic (involuntary cessation of breathing), and is observed to be deeply cyanotic and purple to her face from the neck up with petechia (tiny, flat, non-itchy red, purple, or brown spots on the skin or mucous membranes caused by broken capillaries) noted to the face, neck, and clavicular areas. During the removal from the vehicle, pt is found to have a DNR bracelet on her right wrist. A packet of paperwork is provided to EMS from the [Facility Name Redacted] driver, however, paperwork does not include an Iowa Physician Orders for Scope of Treatment (IPOST) or DNR paperwork.The PCR Summary further revealed, Pt moved to the ambulance so she is not lying in the street. The Narrative History section further revealed the Emergency Department (ED) was contacted via phone and spoke to medical physician and provided a verbal report on the pt's condition, exam findings, and circumstances surrounding her arrest. [Medical physician] was advised of the presence of a DNR bracelet, without an or IPOST or DNR order. Medical Physician located the pt in [hospital system] and confirmed pt's DNR/ Do Not Intubate (DNI - medical directive to not insert a breathing tube) status. Cardiac monitor applied initially showing pt's pacemaker firing (the device delivered a small, controlled electrical impulse to the heart muscle to trigger a heartbeat). This quickly changes to v-fib (ventricular fibrillation, a life-threatening, chaotic heart rhythm where the lower heart chambers (ventricles) quiver).The PCR summary transfer report for mortuary services dated [DATE] included the following documentation:.It is believed Pt did not have a lap belt secured during the accident.On [DATE] at 1:30 PM, the Administrator reported the facility had a bus and two vans for transportation. The van involved in the incident had not been used since the incident. With the Administrator and the Director of Environmental Services (EVS Director) present, inspected [van used in the incident, make and model redacted, referred to as Van A]. The Administrator revealed that no one went to the incident site. A red tinged area which measured 2.5 inches by 1.75 inches was noted behind the driver's seat on the floor in front of the folded second row seating of [Van A]. The van was equipped with a ramp to the rear for wheelchairs. A shoulder belt was noted in the upper right side of the rear of the van. A red lap belt was noted rolled up on the floor on the passenger side in the rear of the van. The lap belt label revealed it was a [Brand and Part Number Redacted]. The Shoulder restraint belt was a [Brand and Part Number Redacted].On [DATE] at 9:15 AM during an interview with Staff E, Police Officer, Staff E verbalized injuries were consistent with being ejected from the wheelchair, and indicated lap/shoulder restraint had not been in place. Staff E reported no skid marks were noted at the scene. On [DATE] at 9:59 AM through email correspondence, Staff E explained the driver didn't receive a citation as he didn't have to stop or yield. The other driver would have been likely deemed at fault as they would have had a stop sign and would have needed to yield to the van.On [DATE] at 11:09 AM, Staff A, Driver stated that he had driven the bus and 2 vans for the facility. Staff A verbalized when he was trained, he was told to strap down the wheelchairs and use seat belts when residents were seated in the seats. Staff A verbalized he was trained in [second facility van, not used during time of Resident #1's incident, referred to as Van B] to use lap and shoulder restraints for residents in wheelchairs. Staff A reported his training was hands on and didn't involve any literature or videos for the restraints for the wheelchair or the lap/shoulder restraint seatbelts. Staff A verbalized he was not taught how to secure a resident in a wheelchair with lap and shoulder residents with the van involved in the incident. Staff A reported there was a lap/waist restraint and Staff A thought it was red. Staff A verbalized no one used it. Staff A reported he was only taught how to secure the wheelchair in the van involved in the incident. Staff A reported the wheelchair was locked firmly in place. Staff A reiterated he never used the lap/shoulder restraint when transporting residents in this particular van. Staff A verbalized he transported Resident #1 on 2 occasions. The first time he used [Van B] and the second time on [DATE] he used [Van A]. Staff A revealed he didn't secure a lap/shoulder restraint across the resident when he picked her up from her medical appointment. Staff A verbalized when he used [Van B], he used the lap/shoulder restraint belt for wheelchairs.Staff A reported he turned onto [Street Redacted] and when he was near [Street Redacted] a car came across and then another car pulled out and turned to the right. Staff A reported he swerved and put on the brakes and Resident #1 came out of the wheelchair. Staff A reported Resident #1 never asked about the lap/shoulder restraint. Staff A reported Resident #1 had been alert and orientated. Staff A believed he was going 25 mph (miles per hour) in the posted 30 mph zone when he swerved to avoid being hit by a car that turned on to [Street Redacted]. Staff A parked the van near the curb.Staff A exited the vehicle and opened the sliding passenger door for the second-row seating on the driver's side. Staff A verbalized he called 911. Staff A thought she (resident) was conscious at first. Staff A did not notice the resident had any injuries until the first Police Officer arrived, and then noticed blood coming out of her nose. Staff A verbalized Resident #1 did not say anything, and Staff A did not notice any other injuries. Staff A verbalized Resident #1 did not eat or drink anything while being transported. Staff A reported he did carry a cell phone and had not been on the phone prior to the incident.Staff A reported he returned to the facility at approximately 2:40 PM on [DATE]. Staff A explained he had reported to the Administrator's office when he returned. Present in the office were the Administrator, the Health Administrator, and the Executive Director. Staff A reported what occurred at the incident. Staff A revealed the Executive Director asked him about the lap/shoulder restraint the next morning when he came in to sign his statement.Staff A revealed he asked Staff B, Driver the week prior if he used the lap/shoulder restraint belts in [Van A] and was told no. On [DATE] at 2:13 PM, the EVS Director demonstrated how to secure a wheelchair in [Van A] with lap/shoulder restraint seatbelts. The van was parked and the rear door opened. He extended the folding ramp and pushed a wheelchair up the platform and locked the brakes. He attached the floor restraints to the rear of the wheelchair and then went to the driver's side passenger door. The second-row seat was folded down. He reached over the seat to attach the floor restraints to the front of the wheelchair. He unrolled and lengthened a red seatbelt [Brand and Model Redacted] and strung it through the arms of the wheelchair with one end of the red lap seatbelt buckled into the driver's side rear floor restraint near the floor behind the wheelchair. The other end of the red lap belt was brought across the back of the wheelchair and buckled into a buckle on the red lap belt. The shoulder restraint [Name and Model Redacted] was brought over the arm rest of the wheelchair on the passenger side. The shoulder restraint passed through the armrest on the driver's side and buckled behind the wheelchair into a buckle on the red lap belt. The EVS Director verbalized the facility didn't have instructions or manufacturer's guidelines for the lap/shoulder restraint seatbelts. The Administrator was present and reported facility transportation had ceased and was provided through external services.On [DATE] at 4:17 PM, the Administrator verbalized the facility was trying to obtain the manufacturer's guidelines for the lap/shoulder restraints. On [DATE] at 10:55 AM, the Administrator explained the facility hadn't received the manufacturer's guidelines for the lap/shoulder restraints yet.On [DATE] at 12:47 PM, Staff B, Driver verbalized he had driven for the facility for approximately 10 months. Staff B stated the training received was minimal. Per Staff B, he had 15 minutes of onboarding and then it was go time. Staff B reported the facility had a bus, a [Description of Van B] and [Van A]. Staff B revealed [Van A] didn't have as many safety features as [Van B]. Staff B revealed the wheelchairs were secured with 2 floor latches in the front and 1 sliding latch behind the wheelchair in [Van A] and Staff B verbalized no lap/shoulder restraint belt was provided in [Van A] . Staff B reiterated you put the ramp down for the wheelchair to be positioned. The second-row seat is folded down to secure the front of the wheelchair with 2 floor latches. Behind the wheelchair there is a sliding latch that is locked down. There was no lap/shoulder restraint belt available. Staff B verbalized when the proficiency test was completed, he hadn't been evaluated on all vehicles. Staff B revealed Staff A had asked him about the lap/shoulder restraints for [Van A]. Staff B reported he did transport residents in wheelchairs without lap/shoulder restraints when he used in [Van A], because they physically didn't exist.On [DATE] at 2:36 PM, Staff C, Driver reported she moved [Van A] after the van returned from the incident on [DATE]. Staff C reported she noticed the red tinged area between the driver's seat and second-row seating. Staff C reported she didn't notice if the lap/shoulder restraint belts were present. Staff C reported she had not been evaluated on proper technique for securing a wheelchair with lap/shoulder restraints in [Van A]. Staff C reported she did provide some training with Staff A and Staff B. Staff C revealed she utilized [Van B] when she trained others. Staff C verbalized training was hands on, and there were no paper instructions or videos to demonstrate proper securement of the wheelchair or lap/shoulder restraints. Staff C reported new drivers rode along for about a week prior to completing the Proficiency Test with the EVS Director.On [DATE] at 3:17 PM, the EVS Director revealed he received training from a previous driver when he had first been employed nearly 17 years prior. The EVS Director verbalized he supervised the drivers, and further reported the lap/shoulder restraints were different in [Van B] from [Van A]. He stated [Van B] had a 1 belt system for the lap/shoulder restraint belt versus a 2-belt system in [Van A]. The EVS Director reported new drivers rode along with another driver for about a week and then he completed the Proficiency Test with new drivers. The EVS Director explained the Proficiency Test was completed using [Van B] and not on all vehicles used for transporting residents. The EVS Director further revealed he was not aware of any drivers not using lap/shoulder restraint belts in [Van A]. The EVS Director explained the lap/shoulder restraints were kept in a pouch in the back of the van (Van A) when not in use.On [DATE] at 11:09 AM, the EVS Director verbalized he had no documentation to show specific training had been provided on [Van A] for any of the drivers.On [DATE] at 11:44 AM, the Administrator verbalized the expectation is laid out in the facility Fleet Management Program. The Administrator verbalized the facility expectation is seat belts are used.Staff A's employee file listed a start date of [DATE] for the position of Driver. The employee filed revealed the following: The Job Description for the position of Driver was signed by Staff A on [DATE]. The Environmental Services Director would supervise the driver position. The General Summary present on the Job Description revealed, in part, The Driver transports residents to and from appointments using facility vehicles. The Essential Job Duties and Responsibilities section revealed, in part, Resident Safety - First and foremost is the safe courteous transportation of our residents. Seatbelts - the driver and all passengers must wear their seatbelts at all times.Follow all procedures -Follows procedures for using the bus lift, assisting resident into the van, and securing residents with restraints. Performs all other duties in a safe manner. The Job Description further revealed, Know and abide by all policies and procedures as outlined in the Employee Handbook and in departmental policies and procedures.Review of Staff A's Driver Proficiency Test dated [DATE] documented the examiner was the EVS Director. The Driver Proficiency Test was signed on the Examiner Signature line. Topics or Subject Material per the Resident Assistance, Boarding, & Disembarking section of the Driver Proficiency Test included the following:1. Knowledge of the proper use of the wheelchair lift2. Proper use of the wheelchair tie-down procedure3. Knowledge of how to properly assist a resident on and off the vehicle4. Proper storage and securing of walkers, scooters, and other equipment5. Proper storage and securing of oxygen tanks/cylindersThe Driving Abilities section of the Driver Proficiency Test included the following: 1. Uses seatbelt2. Driving prominencea. Appropriate speedb. Proper passingc. Satisfactory distance from other vehiclesd. Slowing to stop (no abrupt stops)e. Appropriate speeds on turns (help eliminate fall dangers)f. Safe intersection navigationThe Driver Proficiency Test did not identify which facility vehicle had been used for the test. The Driver Proficiency Test also lacked proficiency in securing residents in wheelchairs with lap/shoulder restraint belts for each vehicle or type used. Review of the Job Description for the Director of Environmental Services position revealed the following per the Job Summary section: To manage, direct and coordinate the Department of Support Services which included the services of maintenance, housekeeping, laundry/linen, transportation and other duties as assigned. To maintain the highest possible standards and public relations. To follow accepted standards and administrative policies and procedures. To maintain the department within budget guidelines. This position reports to the Administrator. One of the Essential Job Functions included, ensures the on-the-job training program is followed and validates quality training.Review of the facility Fleet Management Program dated [DATE], revealed the following:It is the policy of [Facility Name Redacted] to promote the safety of our drivers and to protect residents and the public from vehicular harm or incident.The Responsibilities section of the Fleet Management Program included, in part: All facility employees (including managers and supervisors) who may drive vehicles or supervise those that drive vehicles for work-related purposes shall have the responsibility to. Conduct a safety check of [Facility Name Redacted] vehicles before operation. Any defects are to be immediately reported to the Plant Operations Depart. and direct supervisor.The Motor Vehicle Use section directed to conduct pre-use Inspection checklist sheet on the vehicle before use, located in each Vehicle. The Motor Vehicle Use section further revealed, While Vehicles are in motion driver and passengers must wear seat beltsThe Driver Training section of the Fleet Management Program revealed, Departments have the responsibility to train employee on the Fleet Management Program and department-specific procedures.The Motor Vehicle Operations section revealed, in part, the following per the Driver Safety Awareness section: Safety is the responsibility of the Driver. The Defensive Driving section of the Fleet Management Program revealed, Driving defensively means not only taking responsibility for yourself and your actions but also keeping an eye on other drivers around you. Make sure that all passengers are secured by a seat belt before starting a vehicle.Review of the Facility Vehicle Checklist for [Van A] dated [DATE] documented the following: A note on the checklist revealed, accident today with this car. Staff A driving. The Vehicle Checklist lacked information on the wheelchair restraint system and lap/shoulder restraint belts.Review of the Facility Assessment Tool reviewed on [DATE] reviewed revealed the following: The Staff training/education and competencies section revealed, All staff in-services occur at least annually, more often as needed. Each department has individual meetings and in-service that apply only to their department on an as needed basis, generally twice per year, often quarterly or monthly. The Facility Assessment Tool lacked facility transportation as a service and drivers as staff.

Based on observation, clinical record review, and staff interviews the facility failed to provide appropriate supervision to prevent a fall that resulted in fracture of the resident's right scapula (shoulder blade) and pain for one of three residents reviewed (Resident #1). The facility reported a census of 55 residents. Findings include:Resident #1 admitted to the facility on [DATE] from Assisted Living after she had a fall that resulted in a fracture of the left humerus (upper arm). The MDS (Minimum Data Set) dated 10/28/2025 revealed the resident had severely impaired cognitive skills for daily decision making, required substantial/maximum assistance to transfer from one surface to another, required supervision while eating, and had a history of falls with fracture in the prior 6 months. The resident had diagnoses including fractures, hypertension, diabetes, and dementia. The Care Plan initiated 10/22/2025 identified the resident had a risk for wandering related to dementia. It directed staff to be aware of the resident's tendency to wander and allow wandering in spaces where resident can be safely monitored and cannot harm self.The Care Plan initiated 10/23/25 reported the resident admitted to the facility related to a fracture of the upper end of the left humerus (bone of the upper arm), with a goal to get stronger with therapies. The Care Plan revealed the resident had a fall history including a fall within one month of admission, fall within 2-6 months prior to admission, and a fracture related to a fall withing the past 6 months. The resident required staff assistance to transfer with a mechanical lift, used a wheel chair for mobility and had an immobilizer to the left upper extremity at all times.The Care Plan initiated 10/23/25 identified the resident had a risk for falls related to limited mobility, assistance needed with functional abilities, unspecified fracture of the left humerus, personal history of TIA's (transient ischemic attack, a temporary blockage of blood flow to the brain), vascular dementia and Alzheimer's disease. The Care Plan instructed staff to assist the resident with ambulation and transfers per therapy recommendations, determine resident's ability to transfer, evaluate fall risk on admission and as needed. If fall occurs, alert provider, initiate frequent neuros (evaluates brain and nervous system functioning) and bleeding precautions. If resident is a fall risk, initiate fall precautions, keep door open when able, especially at night, keep call light near and personal items within reach. The Care Plan indicated the resident had a fall at the facility on 11/3/2025 when she slid out of bed with no injury noted.Fall risk evaluations dated 10/22/2025 and 11/28/2025 revealed the resident had a fall risk. The facility Self Report regarding Resident #1's accident with major injury on 11/28/2025 at 1:00 p.m. explained the resident had an unwitnessed fall in the dining room shortly after lunch. Staff found the resident on the floor seated upright with legs extended. The resident could not explain what happened. She could move all extremities, though she consistently guarded her right shoulder. The facility notified the physician and orders were obtained for cervical spine and right shoulder X-rays. [Portable X-ray company name redacted] confirmed they would arrive that same day. On 11/29/2025, during a follow up assessment, the resident had increased pain and [Portable X-ray company name redacted] confirmed they would not be able to come until 12/1/2025. The facility notified the physician and sent the resident to the Emergency Department for urgent evaluation. The imaging showed she had a fracture of the right scapula (shoulder blade) and returned with a right arm sling. The ED (Emergency Department) note dated 11/29/2025 reported Resident #1 had an unwitnessed fall yesterday at the nursing facility. The resident had a hematoma to the right forehead, right shoulder pain and arrived with a shoulder immobilizer on the left shoulder. Dementia at baseline, worse today per EMS (emergency medical services). She indicated she is having pain in her right shoulder. She also has a contusion to the right side of her face. Patient is unable to provide any significant history due to her dementia. Imaging resulted in acute fracture of the distal tip of the right acromion, superiorly displaced. (where the collar bone connects to the shoulder blade), and no acute abnormality of the chest, cervical spine, abdomen or pelvis. The CT of the head found no evidence of intracranial hemorrhage (bleeding inside the skull), fracture of other acute findings. The resident discharged back to the facility with a right arm sling. On 1/5/2026 at 4:10 P.M. Staff A, Administrator reported the following: Two aides were in the dining room and there was a brief moment where there was no supervision. When they returned they found Resident #1 on the floor. The facility had cameras downstairs but not angled so could see when staff entered and exited the dining room. The residents needed to be under supervision when they were in the dining room, eating. It appeared that Staff C, LPN ( Licensed Practical Nurse) went down, assessed another resident, told staff told staff to lay that resident down and then left. Staff A explained did a full education, a write up, a re-education with all staff. Per Staff A, did it immediately and all staff in person, and did some education electronically. Staff A explained staff knew not to leave residents unattended, and the facility was integrating the dining room supervision into new hire orientation. Staff A explained did not have a specific policy regarding dining room supervision. Staffing downstairs was two staff on days and evenings, one on the night shift with access to the float staff to come down and assist, and the ADON (Assistant Director of Nursing) had her office downstairs as well.On 1/6/2026 at 8:25 A.M, Staff A, Administrator added the x-ray delay was due to bad weather, had scheduled with [Portable X-ray company name redacted], they said they could come the same day, and when they did not come, they said they could not come until 12/1. So, the nurse called the physician and they sent her to the ED. The two aides received verbal education at the time of the incident, spoke about it at a nurse's meeting, and did postings in each mail box. Staff A explained the ADON's office was down there, but she did not work the day of the fall. On 1/5/2026 at 12:06 p.m., Staff B, ADON reported the resident had resided in the assisted living section prior to coming to the nursing home. At assisted living she had a fall and fractured her left shoulder. She moved over to long term care and had been working with therapy. Staff tried to keep her in the hallway with them for supervision. She had a previous fall on 11/3/2026 where she slid out of bed. She also had a low bed. On 11/28/2025, two aides, Staff E and Staff F left the dining room to lay another resident down. The Director of Nursing at the time of the incident, no longer worked at the facility, and the Administrator did the investigation. Staff B did not work on 11/28/2025, the day the resident fell in the dining room. On 1/5/2026 at 1:45 p.m., Staff F, CNA/Medication Aide reported on 11/28/2025 she worked downstairs as the Medication Aide from 10 A.M. - 2 P.M. Resident #1 fell in the dining room around 1 p.m. Staff E was the CNA and was assisting the residents with eating, and Staff F passed medications in the dining room. Lunch is served around noon. Staff C, Licensed Practical Nurse (LPN) came down and told Staff E and Staff F to lay another resident down so she could get a urine sample. Staff E and Staff F excused themselves and took the other resident to to her room and put her in bed. Staff C was in the dining room when they left with the other resident. When Staff E and Staff F returned to the dining room, about 8-10 minutes later, a male resident yelled he had seen Resident #1 fall but he could not do anything about it. Staff F observed Resident #1 laying on her right side with the wheelchair nearby. She had been at a table in her wheelchair when they left the room. Staff F asked her what she was doing and she said I don't know, and pointed to her right arm. She already had a sling on her left arm. Staff F called upstairs and asked Staff C to come downstairs. They assisted the resident up into her wheelchair and Staff C assessed her. Staff F indicated Staff C knew they had left the dining room to lay the other resident down. Per Staff F, had been told to have one person in the dining room at all times, and further explained communication was exchanged at monthly meetings and group texts. Staff F failed to recall if she received education immediately following the resident's incident.On 1/5/2026 at 3:15 p.m., Staff E, CNA reported she worked downstairs when Resident #1 fell on [DATE] along with Staff F. They were both in the dining room during lunch. Staff E fed residents while Staff F passed medication. Another resident had been refusing to eat and did not seem right so she called upstairs and informed Staff C. Staff C came down and told Staff E and Staff F to lay the resident down. They took that resident from the dining room in her wheelchair, and Staff C left the dining room and went back upstairs. Staff E and Staff F were gone about 15 minutes as they had to transfer the resident to bed using a stand up lift and provide cares. On the way to the dining room, a laundry aide reported someone was on the floor. When they returned to the dining room, no staff were present, and Resident #1 lay on the floor. Staff E called for Staff C to come downstairs. Staff C assessed the resident and they assisted the resident up off the floor and into her wheelchair. She did not initially complain of pain. They were educated about not leaving residents in the dining room without staff present. Residents were still eating when they left the dining room with the other resident. Staff E left around 2 p.m. at the end of the shift. Lunch is served around noon. Staff C asked them what transpired. Staff C came down and told them to lay a resident down; she did not mean later. Staff E explained two staff were scheduled in the downstairs unit. Staff E and Staff F were the only two staff in the dining room that day during lunch.On 1/6/2026 at 8:30 a.m., Staff C, LPN reported she worked on 11/28/2025 and got a call from staff downstairs. They asked her to come down and assess a female resident who was not acting right. She went down and saw two staff, Staff E and Staff F in the dining room assisting residents at the noon meal. Staff C told Staff E and Staff F to lay the resident down when they did lay downs. A little while later they called upstairs and said Resident #1 had fallen. Staff E and Staff F reported they had left the dining room to lay the other resident down. They should have pulled all of the residents from the dining room prior to laying her down. It was discussed at a monthly meeting that there should always be one person in the dining room. Staff C explained she called the physician, got an order for an x-ray and called [Portable X-ray company name redacted]. [Portable X-ray company name redacted] said they would get her that day. Resident #1 denied pain, however she grabbed her right shoulder. Staff C left at the end of the shift around 2 p.m. and did not work the following day. She learned that [Portable X-ray company name redacted] did not come that day and the resident went to the ED the next day.On 1/6/2026 at 2:30 p.m., Staff G, LPN reported working on 11/28/2025 from 6 p.m. until 6 a.m. on 11/29/2025. Staff G knew Resident #1 waited for an x-ray, and when Staff G she checked on Resident #1, the resident was sleeping. Staff G checked assessed her and had no concerns. Staff G would typically do treatments downstairs from approximately 7 - 9 p.m. Staff G informed the next staff that [Portable X-Ray company name redacted] did not come. She did not recall staff reported the resident complained of pain. On 1/5/2026 at 3:35 p.m., Staff H, RN (Registered Nurse) reported she worked on 11/28/2025 on the day shift, however her assignment did not include Resident #1. Staff H did a fall follow up assessment the following day and reported the resident had pain and high blood pressure. [Portable X-Ray company name redacted] said they could not come due to the snow. Staff H called the physician and got an order to send the resident to the ED. The resident denied pain, however Staff H could see she was in pain. The downstairs unit always scheduled two staff, and one person had to be in the dining room if there were residents present, staff knew there always had to be someone, and they waited to lay residents down until everyone was finished eating and they were taken from the dining room.On 1/6/2026 at 11:40 a.m., Staff I, LPN reported worked on 11/28/2025 from 2-6 p.m. Staff I could tell the resident had pain and she applied Voltaren gel (topical ointment for pain relief). She worked until 6 p.m., reported to Staff G and finished charting. During her shift she called [Portable X-Ray company name redacted] and told them the x-ray had to be done, and [Portable X-Ray company name redacted] said they would send a tech. On 1/5/2026 at 1:08 p.m., Staff J, CNA reported she did not work the day Resident #1 fell, and knew she was a fall risk. Staff would keep the resident at the nurse's station for supervision. Staff J explained she would not have left the resident out of sight for more than two minutes, the downstairs unit had two staff scheduled. Staff J explained Resident #1 already had a weak shoulder when she came to the facility, Staff J did not often work with the resident after she had the fall, and explained staff knew that one person must be in the dining room if residents were present.On 1/5/2026 at 1:15 p.m., Staff K, CNA reported she worked with Resident #1 before and after her fall and fracture. Staff knew to keep an eye on her. Staff attempted to keep the resident occupied to keep her from getting up on her own. Staff would keep her at the nurse's station. She also liked to watch the [Television channel name redacted] and hold stuffed animals. Staff K explained if the resident was tired, they put her into bed for a nap and checked on her frequently. Per Staff K, there was always supposed to be someone in the dining room until all residents were removed after they were done eating. Staff took turns, or one would stay with the residents while the other removed the residents. Staff K indicated she would not have left Resident #1. Staff K explained that staff were told to never leave residents alone in the dining room, and further explained the dining room is not within eye sight or hearing range and was out of the way. Per Staff K, Resident #1 already had one arm in a sling prior to that fall.

Based on observations, staff interviews, and policy review the facility failed to provide sufficient dietary staff with the appropriate skills and competencies to safely and effectively provide food service to the facility residents. The facility reported a census of 59 residents. Findings Include: During observation of the facility puree process with Staff A, [NAME] on 04/29/25 at 10:30 am revealed the staff member lacked training and knowledge of the puree process. Staff A lacked instruction on how to complete the puree process and ensure puree diet residents get the same portions as regular diets. Staff A was uncertain how to measure out the puree content, did not know portion sizes and advised they serve pudding or ice cream instead of the dessert of the day. Staff served dessert and advised it was a bit runny and made no attempts to thicken before serving. On 04/29/25 at 12:05 pm the facility Registered Dietician, (RD) was queried regarding the puree process. The RD advised Staff A did not follow the menu and served larger portions than the menu called for. The RD advised Staff A was not clear how to puree or substitute for the salads or desserts and all substitutions should be approved by her prior to serving. The RD advised additional training in the kitchen will be provided. During an interview on 05/01/25 at 08:55 am the facility Registered Dietician, (RD) advised the facility supervisor and manager have formal training but none of the other dietary staff members have had formal training or certification. On 05/01/25 at 09:33 am the Kitchen Supervisor was queried regarding the puree process. He advised the dietary staff need additional training with the puree process. The facility policy titled Cottage Grove Place Discover the Life Care Difference Policy and Procedures, Clinical Services-Puree Foods revised 01/2025 documented; Purpose: To ensure pureed foods meet optimal appearance, texture, flavor, temperature, and nutritional value. Procedure: 1. Regular menu items will be available as chosen by the dietitian or resident/loved one and pureed. 2. Food requiring pureeing will be processed according to the available pureeing technique guidelines. Pureed food should be smooth, lump free with a moist texture that requires no chewing. Consistency should be thick enough to hold shape on a plate, but not so thick as to be sticky. 3. Any food that is pureed must be pureed using a liquid of nutritional value such as juice, milk, broth, sauce, or gravy. 4. Fluids of nutritional value used to puree foods are not measured. Enough fluid is added to bring the puree to a proper consistency. 5. The pureed diet portion should be based on total food volume. 6. If a food product doesn't puree well to the proper consistency (tough foods, stringy foods, pits, hard shells, raw vegetables), a substitute from the same food group will used.

Based on observation, staff interviews, facility documentation, and policy review, facility staff failed to ensure the internal temperature of food provided to the residents was cooked to the proper internal temperature and failed to document internal temperatures in the log book. The facility reported a census of 59 residents. Findings Include: After observation of the facility meal process with Staff A, [NAME] on 04/29/25 at approximately 11:50 am Staff A failed to log food temperatures into the log book. Staff A advised all food temperatures where taken prior to meal service and all temperatures met required internal temperatures and it was an oversight not to log the temperatures. On 04/29/25 at 12:05 pm the facility Registered Dietician, (RD) was queried regarding food temperatures and logging. The RD advised Staff A did not follow proper guidelines for appropriate food handling processes. The RD advised all hot foods should be checked for safe internal temperatures and logged into the facility food temperature log book. The RD advised additional training in the kitchen will be provided. During an interview on 05/01/25 at 08:55 am the facility Registered Dietician, (RD) advised the facility supervisor and manager have formal training but none of the other dietary staff members have had formal training or certification. It is the expectation that all hot and cold food is checked for temperature and logged into the temperature log book at each meal. All dietary staff will be educated on Preventing Foodborne Illness, ensuring all food items are checked for proper temperature and logged into the temperature tracking log book. On 05/01/25 at 09:33 am the Kitchen Supervisor was queried regarding food temperatures and advised it is his expectation all food items are checked for proper temperature when prepared and documented in the food temperature log book. He advised the dietary staff needed additional training with internal cooking temperatures and proper holding temperatures. The Kitchen Supervisor advised there had been staff change over and he had been assigned new duties and did not realize he should have been monitoring the temperature log book. The facility policy titled Preventing Foodborne Illness-Food Handling dated 2001 documented the following; Policy statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Policy Interpretation and Implementation: 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. poor personal hygiene of food service employees; b. inadequate cooking and improper holding temperatures; c. contaminated equipment; and d. unsafe food sources. 2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. 4. This facility only accepts prepared foods from suppliers subject to federal, state or local food service inspections and who remain in good standing with such agencies. 5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees Fahrenheit, and that freezers keep frozen foods solid. 6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms.

Based on observation, policy review, resident and staff interview the facility failed to make reasonable accommodations for a resident to reach her clothes hanging in the closet for 1 of 1 residents reviewed (Resident #16). The facility reported a census of 59 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment with a reference date of 3/18/25 documented admission to the facility on 3/12/25. The Brief Interview for Mental Status (BIMS) for Resident #16 had recorded a score of 14/15, which identified intact cognition. The MDS documented it is very important to Resident #16 to take care of her personal belongings or things. The MDS documented a mobility device of a wheelchair. The MDS documented Resident #16's functional abilities at admission included: * Substantial maximal (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) assistance for toileting, bathing and lower body dressing. * Partial/moderate (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) assistance with upper body dressing. * For mobility - Resident #16 required substantial/maximal assistance for sit to lying, lying to sitting, and sit to stand. The MDS listed diagnoses of spinal stenosis of the lumbar region without neurogenic claudication, (a symptom characterized by pain in the legs or buttocks that worsens with walking or standing), diabetes mellitus, arthritis, anxiety, and depression. On 4/25/25 at 11:25 AM, Resident #16 had been observed sitting in her wheelchair in her room. Resident #16 revealed that she had been unable to reach clothing that had been hung in her wardrobe/closet as it failed to be at a level one could reach from a seated position. Resident #16 acknowledged she is scared to stand due to the risk of falling. Resident #16 revealed she relied on her family and facility staff to remove items from the wardrobe/closet. The clothing bar in the wardrobe/closet had been observed to be at a height approximately 6 foot from the floor. During an interview on 4/30/25 at 9:38 Staff B, Certified Nursing Assistant (CNA), acknowledged Resident #16 cannot reach her clothing hanging in her wardrobe/closet. Staff B revealed staff from a later shift assisted in laying clothing out for the next day. During an interview on 4/30/25 at 9:43 AM, Staff C, Laundry, recalled Resident #16 voiced concerns of being unable to reach her clothing while seated in her wheelchair on her day of admission. Staff C failed to pass this information on to other staff members to address Resident #16's concern. During an interview on 4/30/25 at 10:21 AM, Staff D, Assistant Director of Nursing (ADON)/RN, acknowledged she had heard Resident #16 request staff assistance to remove items from the wardrobe/closet on numerous occasions. Staff D revealed Resident #16 had not requested for the clothing bar in the wardrobe/closet to be lowered. Staff D acknowledged the clothing bar had been lowered for other residents when requested. During an interview on 4/30/25 at 10:39 AM, the Director of Nursing (DON) revealed a resident's needs are determined at the time of admission. The DON acknowledged she had been unaware of Resident #16's concern for reaching her clothing. The DON acknowledged staff should have reported Resident #16's concern to be addressed. A review of the undated facility policy for Activities of Daily Living (ADL) Care Policy and Procedure revealed nursing staff are required to report any significant changes in residents' ADL abilities or concerns to the appropriate interdisciplinary team members, primary care physician and resident representative.

Based on observation, a posted notice, record review, staff interview, and family interview the facility failed to ensure sufficient staffing to respond to door alarms that sounded in the facility. Two door alarms sounded 4 times in 14 minutes without a staff response. 34 of 58 residents in the facility scored 12/15 or lower on the Brief Interview for Mental Status (BIMS) assessment, which indicated they had moderate to severely impaired cognition. The facility reported a census of 58 residents. Findings include: On 9/28/24 beginning at 11:00 AM facility residents could participate in an activity outside. Residents, staff, and family members had access to at least 2 exits near the main entrance of the building, one leading to the wheelchair ramp and the other leading to the lobby. A plastic sign mounted on the wall to the left of the door with the ramp indicated a code was needed for the door and could be obtained by contacting the nurse at the number provided. At 11:21 AM on 9/28/24 the ramp door alarm sounded which indicated the door had been open for more than 15 seconds. At 11:24 AM, observed a resident's family member enter a code that silenced the alarm. He walked away from the door. No facility staff were observed in that area between 11:21 AM and 11:26 AM to ensure all residents were accounted for. The family member stated the alarm went off when the door was open too long and he had turned it off before. At 11:27 AM an alarm with the same tone sounded, this time at the lobby door. It was turned off at 11:28 AM. The lobby door alarm sounded again at 11:31 AM. Observed the same family member turn it off at 11:33 AM. Within a minute the alarm at the ramp door sounded. The family member cleared that alarm at 11:35 AM. No staff were present to turn off these alarms or ensure a resident had not gone outside unassisted. The family member stated he didn't see any staff so he cleared the lobby door alarm and then turned off the ramp door alarm. He explained he used the same code used to enter the building. On 9/28/24 at 11:53 AM the Director of Nursing and Administrator confirmed that the code used to enter the building is the same as the alarm shut off, this was the only way to deactivate the alarms, and that both alarms have the same tone. They did not think there was a way to run reports for the door alarms to determine how often they were going off. The Administrator stated family members should not deactivate the alarms. The Director of Nursing stated residents wearing wander guards who activated the alarm would be seen on the same TV screen where call lights were monitored. Electronic health record review revealed 34 of 58 residents scored 12 or lower on the BIMS, and 5 of them used a wander guard for safety. 14 residents lived between the dining room and the alarmed doors. 9 of them had a BIMS of 12 or lower. On 9/28/24 at 3:19 PM Staff B, CNA (Certified Nurses Aide) stated he didn't think they could hear the two door alarms by the lobby and the ramp from the dining room. He didn't know of anyone getting out recently and stated if staff heard the alarm and did not see a resident they were expected to check the grounds around the building. On 9/29/24 at 10:12 AM Staff A, LPN (Licensed Practical Nurse) stated she could not hear the door alarms from the nurse's desk or the dining room. She stated she had to be at least at the end of the hall where the lobby door was to start to hear it. Staff A said the number one priority was to check to see if any residents had left the building. She included two busy streets and around the building as part of the search area and a head count to ensure residents were all accounted for. On 9/29/24 at 12:42 PM the Administrator acknowledged the concerns with the door alarms, provided a copy of a new sign posted on the door to prevent future incidents, and stated training was started the day before. The Administrator stated they had been working with the communications company to try to improve their system.

Based on observation, record review, staff interview, resident interview, and policy review the facility failed to ensure psychotropic medications administered to a resident for anxiety and depression had matching diagnoses in the resident's electronic health record for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) for Resident #6 documented an admitted [DATE] and was in progress. Resident #6's Medication Administration Record (MAR) indicated the resident was taking the following: 1. Trazodone HCl oral tablet 50 MG, 25 mg by mouth at bedtime for depression/ insomnia (1/2 tab) 2. Duloxetine HCl oral capsule delayed release sprinkle 30 MG, 1 capsule by mouth two times a day for depression 3. Lorazepam Oral tablet 0.5 MG, 1 tablet by mouth three times a day for anxiety The resident's electronic health record diagnosis tab lacked diagnoses of depression and anxiety. The resident's Care Plan, with an admitted [DATE], included focus areas for anxiety and depression monitoring and medication management. During an interview on 9/27/24 at 2:43 PM Resident #6 stated he was anxious, wanted to go home, and felt depressed with all of the changes in his life after his stroke. Resident #6 thought he was on medication to help him and was happy the Administrator and Social Worker put in place to have 2 people come in together to care for him. It made him feel less anxious. During the interview observed the resident tapping on the arm of the chair, fidgeting with his call light, and his eyes repeatedly darting towards the door. On 9/29/24 at 10:12 AM Staff A, LPN (Licensed Practical Nurse) stated the resident was definitely confused and anxious. His anxiety, depression, and confusion had led to the resident calling out, making false reports to his wife and staff, and made it difficult at times to help him understand and adjust to his new environment. During a meeting on 9/29/24 at 12:42 PM the Director of Nursing reviewed the resident's diagnosis list in the electronic health record and confirmed it did not include anxiety or depression. She acknowledged further investigation was needed. An undated policy titled Medication Administration Policy Template Administration of Oral Medications did not include a procedure for ensuring diagnoses for medications aligned with resident diagnoses.

Based on observation, clinical record review, resident and staff interviews, the facility failed to implement interventions to prevent weight loss for 1 of 3 resident reviewed for weight loss (Resident #2). The facility identified a census of 50 residents. Findings include: The Minimum Data Set (MDS), dated [DATE] for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating no cognitive decision making abilities or impairment. Resident #2 required set up assistance with eating. No weight loss, or unknown, at the time of the assessment. Diagnoses included: anemia, hypertension, chronic pain, and malaise. The Care Plan, Nutritional Status with an initiated dated 5/7/24, I am at risk and interventions included: *has an allergy to strawberries and mushrooms. Also reports that she can't eat fungus such as bleu cheese or cruciferous vegetables. *Provide alternative foods to avoid allergens and intolerance's. *likes to snack in her room. Family brings in snacks of preference such as nuts and dried fruit. *participates in filling out her own menus. She frequently does not order enough food on her menu. Per her usual orders 2 glasses of milk for meals and reports that she mostly fills up on milk. *Dietitian assists with adding more items to her menu with known preferences and input from family. *Monitor weights per facility policy *Provide Regular Diet per physician orders *is a vegetarian, provide appropriate food choices to accommodate her food preferences. *Provide set up assistance at meals The Nursing Progress Notes revealed the following entries: 1. On 2/5/2024 Dietary-Nutrition Profile Nutrition Diagnosis: Limited food acceptance related to vegetarian. Interventions: Provide menu alternatives that meet vegetarian diet. Monitoring/Evaluation: Monitor for menu acceptance and if providing sufficient alternatives. Monitor weight trend. 2. On 3/21/2024, Weight Change, Note Text: Question accuracy of 139.6#; reweigh not obtained. Has been maintaining 146-148# Reassess weight at April monthly weights 3 On 5/7/2024, Nutrition Note Text: Quarterly Nutrition Evaluation. Diet: Regular; Vegetarian Has allergies to mushrooms and strawberries. Reports digestive discomfort with cruciferous vegetables. Intakes: 0-75% PO intakes with no notable pattern, prefers small portions, likes two glasses of milk at meals and typically fills up on that 10-500 milliliters, snacks in her room likes nuts and dried fruit. Supplements/Interventions: 2 handled cups, no straws, soup in a mug. Dining: Eats in room and in the dining room. Eats independently with set up assistance. Weights: 140# (4/1) no change/mo and down 6#/since 1/30 4. On 5/31/2024, Weight Change, Note Text: Weight is down 10# since 4/1; -10.7% wt loss x 3 month and -6.8% x 1 month. Weight loss related to decrease in meal intakes. Recently having issues with upset stomach and constipation. Nursing decreased Lortab and increased Senna. Change in meal intake also occurred around time Mirtazapine was discontinued. Question if this medication change affected her appetite. If continue to not see change after GI issues resolved may want to consider possibly starting antidepressant/appetite stimulant. At care plan conference family also brought up topic of hospice. Questions were invited and answered by Interdisciplinary Team. Recommendation/Plan: 1) Boost Plus BID. 2) Follow to see if med changes, decreased Lortab/increased Senna, help with GI issues. 3) Follow up with June monthly weight 5. On 5/31/2024, Health Status Note Text: Advanced Registered Nurse Practitioner (ARNP) approved 8 oz Boost plus BID for weight loss. Power of Attorney notified. 6. On 6/30/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident refused to drink. 7. On 7/2/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident refused. 8 On 7/2/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident refused. 9. On 7/6/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident declined boost 10. On 7/7/2024,Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident declined stated I don't do that 11. On 7/7/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident declined stated I don't drink that stuff 12. On 7/8/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss, resident and daughter stated that she does not like it. 13. On 7/21/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident declined boost stated I don't drink it. 14. On 7/21/2024. Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident daughter stated she was not going to drink it. 15. On 7/22/2024, Administration Note Text: Boost Plus 8 oz,two times a day for weight loss. Resident refused boost. 16. On 7/25/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident refused. 17 On 7/27/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident refused. 18 On 7/27/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident declined stated I don't drink that. 19. On 7/28/2024, Administration Note Text: Boost Plus 8 oz two times a day for weight loss. Resident refused. The Medication Administrator Record (MAR) dated June 2024, revealed an order for Boost Plus 8 ounces, two times a day for weight loss with a start date 5/31/24. The MAR documented the resident refused the Boost 5 times. The MAR dated July 2024, revealed the resident refused the Boost 28 times. The Electronic Health Record revealed the following weight for Resident #2: On 1/30/24, the resident weighed 146.4 pounds On 3/1/24, the resident weighed 139.6 pounds On 4/1/24, the resident weighed 140.2 pounds On 5/30/24, the resident weighed 130.6 pounds On 7/16/24, the resident weight 129.6 pounds Observation on 7/31/24, at 11:30 a.m., Resident #2 breakfast tray which had a burgundy bowl with oatmeal in it and a 1/2 banana that was not eaten, two burgundy mugs and two clear glasses of liquids and 3 packages of something on the tray and removed from the resident room. Resident stated that the food was not to her liking. Interview on 7/31/24 at 2:15 p.m., Resident #2 confirmed that she was a vegetarian and that she does not like meat and that the facility will give her cheese all the time, she wishes that she could have tofu, that is what she served her family when she was at home and does not understand why she cant have the foods she served at home. Resident also said that she does not like to drink the boost that she is offered, it usually comes in a berry flavor and she is allergic to strawberries and that she would like to try a different type of supplement, she knows that she is a vegetarian and that it is hard to eat meat, but the facility should be able to assist me with tofu or other forms of protein. Interview on 8/1/24 at 10:10 a.m., the facility Director of Nursing (DON) and the facility Dietician, both confirmed and verified that Resident #2 was a vegetarian and it is the facility responsibility to furnish foods appropriate for that diet and currently the facility only provides a general diet. The DON stated that the facility will speak with the resident and get a diet approved to serve the vegetarian diet to Resident #2. Interview on 8/1/24 at 11:30 a.m., The DON and facility administrator confirmed and verified that the facility has no weight loss policy and that the expectation of the dietician is to do assessments with the resident and provide the needed diet and document the dislikes/likes and to monitor the weight losses in the facility and put in place interventions to keep the resident from weight loss. The facility follows the Federal Rules and Regulations.

Based on observations, interviews, and chart review the facility failed to offer toileting on a timely basis and failed perform proper hand hygiene and proper personal protective equipment guidelines to prevent the spread of potential infection and germs during incontinence cares for 2 of 3 residents reviewed (Residents #21, #27). In an observation it was discovered that Resident #21 was left in her chair for over 4 hours before offered toileting. Also, the facility failed to provide baths to residents per the resident's desired frequency for 1 of 4 residents reviewed (Resident #48). Facility further failed to put interventions in place to prevent voiding in inappropriate locations for 1 of 2 residents reviewed for wandering behavior (Resident #34). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #21 was always incontinent of bowel and bladder. The MDS documents the resident was dependent with toileting, personal hygiene, transfers, and dressing. The MDS further documented the resident had diagnoses including dementia, hypertension, depression, and anxiety. The Care Plan for Resident #21 indicated that she had bladder incontinence due to diagnosis of dementia and needed staff to perform all her toileting cares. The following was an ongoing observation of Resident #21 on 07/02/24: 6:35 AM Resident observed sitting by the nurse's station in a wheelchair 9:25 AM Staff took resident from by the nurse's station to the dining room for breakfast 9:55 AM staff took resident back to sit by the nurse's station in the wheelchair 10:00 AM Staff took resident to the activity room. 10:45 AM Resident took from activity back to her room to be checked and changed. During an observation on 7/02/24 at 10:45 AM Staff B and Staff C, Certified Nursing Assistants (CNAs) performed incontinence cares on Resident #21. Staff C put a barrier under supplies. Staff C performed peri cares on the front wiping from front to back using only one area of the washcloth for each wipe. Staff B and Staff C rolled the resident onto her left side to proceed to do cares on the backside. The first wipe with the washcloth noted bowel movement on it and Staff C noted resident was having a bowel movement. Staff C placed the washcloth in the plastic bag. During this time Staff C touched the residents bedding and then went to her recliner and touched the recliner to grab a clean brief then place it under the resident still wearing the same dirty gloves. She then removed the gloves and did hand hygiene. At 10:55 AM resident was done having a bowel movement so Staff B and Staff C proceeded put on new gloves then roll the resident to her left side and proceed to clean the resident. Staff C wiped toward the front and not from front to back during peri care. Staff C then assisted the resident to her right side and Staff B proceeded to clean the right side. Staff B also wiped from back to front on the backside. Once the brief was on Staff B and Staff C removed their gloves and did hand hygiene. During an interview on 7/02/24 at 11:00 AM, the Director of Nursing (DON) reported Staff did not change their gloves from clean to dirty and should have. She further reported residents are to be toileted every two to three hours. During an interview on 7/02/24 at 2:20 PM, The DON verbalized the facility does not have a peri care or toileting policy. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #27 was always incontinent of bowel and bladder. The MDS documented the resident was dependent with toileting, personal hygiene, transfers, and dressing. The MDS further documented the resident had diagnoses including Alzheimer's disease, stage 3 pressure ulcer to left heel, depression, and anxiety. The Care Plan for Resident #27 indicated that she had bladder incontinence due to diagnosis of dementia and needed to be checked and changed by staff. During an observation on 7/2/24 at 10:15 AM, Staff D and Staff E, CNAs took Resident #27 from the dining room to lay down to be checked and changed. Staff D and Staff E did hand hygiene and applied gloves. Staff D began cleaning the resident from front to back using a new wipe each time she wiped. She put the wipes on the bed with no barrier underneath. Staff D wiped from front to back. Once the front was cleaned both Staff D and Staff E assisted resident to her left side. Staff D then pulled out the dirty brief and set it on the bed with no barrier underneath. Staff D then wiped the back-side wiping front to back with a new wipe each time and placing the dirty wipes on top of the dirty brief on the bed. Staff D without changing her dirty gloves then grabbed the clean brief and put it under the resident. While putting the brief under the resident Staff D touched the bedding with the dirty gloves. Staff D and Staff E secured the brief and pulled up the bedding and Staff D still was wearing the dirty glove. Staff D and Staff E removed the gloves and did hand hygiene. An interview on 7/02/24 at 10:25 AM, the DON reported the Staff D should have changed her gloves between dirty to clean and should not have put the dirty brief and wipes on the bed. 48888 3. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The MDS additionally indicated Resident #34 had continuous inattention and disorganized thinking, as well as frequent wandering behavior. Resident #34 was able to transfer and ambulate independently but required staff supervision for toileting hygiene. Diagnoses included non-Alzheimer's dementia, hypothyroidism, and depression. Resident #34 required antianxiety and antidepressant medications. The Care Plan, initiated 03/13/24, revealed Resident #34 had potential for wandering and had been at risk for falls due to dementia diagnosis and independent transfer status. The Care Plan instructed staff to allow wandering in spaces where Resident #34 can be safely monitored and cannot harm self. The Care Plan additionally instructed staff to assess the cause of wandering and attempt diversional activities. The Care Plan revealed that Resident #34 had been noted to sit onto the floor and get self up in a safe and gentle manner and informed that Resident #34 may suddenly squat down on the floor when needing to use restroom, staff instructed to intercede and offer toilet. In a Behavior Log, dated 06/10/24 through 07/09/24, staff documented Resident #34 had wandering type behavior on 23 of the 30 days recorded. Review of Nursing Progress Notes revealed the following entries: a. On 05/13/24 at 02:29 PM, a family member reported Resident #34 urinating on the floor of her mother's room. Director of Nursing (DON) and Primary Care Provider (PCP) notified. b. On 05/15/24 at 05:37 PM, during dinner Resident #34 pulled pants down in dining room and urinated in front of other residents, redirected to room. c. On 05/20/24 at 03:54 PM, Resident #34 observed removing pants in lounge area, redirected to room and redressed. d. On 05/30/24 at 12:27 PM, Facility attempted to call and left voicemail for family to report Resident #34 behaviors. e. On 06/05/24 at 03:00 PM, Resident #34 wandering, trying to pick up things off floor that aren't there, talking to people whom aren't there and wandering into rooms. f. On 06/11/24 at 12:41 PM, Resident #34 wandering and lying on floor at times with legs in the air, staff continued to monitor. g. On 06/17/24 at 02:40 PM, Resident #34 observed taking objects from Nurse's Station, would not comply with putting them back. Discouraged from entering other resident's rooms and wandered most of shift. h. On 06/28/24 at 03:54 PM, Resident #34 stood outside a room, talked to wall, and bent down as if to help someone at knee level. On 07/01/24 at 08:55 AM, Resident #34 wandered around the dining room, no staff or other residents present in area. No staff present within a viewing distance of resident due to L shaped layout of hallway. Resident #34 bent down below kitchenette island, looked into cabinets, and nearly missed bumping head on countertop when she stood back up. On 07/01/24 at 09:53 AM, Resident #34 had wandered into another resident's room, male resident began to yell, staff responded and redirected resident out of the room. On 07/01/24 at 10:00 AM, Resident #34 got onto hands and knees in hallway as staff had been in another resident's room. Resident #34 observed crawling on hands and knees attempting to pick up items from floor that had not been there, eventually she stood herself back up and continued to wander down the hallway unsupervised. On 07/01/24 at 10:11 AM, staff found Resident #34 behind nurse's station, able to redirect from area. On 07/01/24 at 01:34 PM, Resident #34 wandered around dining room following lunch, dirty dishes and used clothing protectors remained on tops of tables. No staff or other residents present in area or within visual distance of resident. Certified Nursing Assistants (CNAs) noted to both be in other resident's rooms. Resident #34 moved dining room chairs and touched dirty dishes on table tops. Resident #34 stood between a dining room table and chair, pulled pants down and urinated on the floor, she then grabbed used clothing protectors from the table and wiped self front and back with used clothing protector before she pulled pants back up. Noted urine soaked on left lower pant leg and large puddle of urine on the laminate flooring in dining room. On 07/02/24 at 08:23 AM, Staff G, Licensed Practical Nurse (LPN), stated the lower level, where Resident #34 resides, typically has 1 nurse to float between upper hallway and lower hallway and indicated this was enough supervision of residents in lower level with behaviors. On 07/03/24 at 10:30 AM, Staff I, CNA, reported 2 CNA staff are needed in lower level, that 1 CNA is not enough supervision or assistance with four residents who required 2 staff assistance to transfer. Staff I informed that if a resident wandered in hallway when both CNA staff were occupied, they would ask another staff in area to monitor the wandering behaviors while CNAs were in with other residents. Staff I informed that Resident #34 had not been on a toileting program but staff try to assist with toileting every two hours and watch for cues that resident may need to use restroom. On 07/08/24 at 02:29 PM, Staff K, CNA, reported staff would attempt to assist Resident #34 to the restroom every 2 hours and if resident wandered, staff would check on her and try a distraction activity before going into a room. On 07/08/24 at 04:41 PM, the Director of Nursing (DON), revealed the expectation of staff to ensure safety and attempt to redirect residents whom wander. The DON also expected staff to try and remain in common area when Resident #34 wanders in area or provide Resident #34 with an activity when occupied with other residents. 35434 4. The MDS (Minimum Data Set) assessment tool, dated 11/22/23, listed diagnoses for Resident #48 which included diabetes, non-Alzheimer's dementia, and Parkinson's. The MDS stated the resident required substantial assistance for rolling, partial/moderate assistance for showering, and was dependent on staff for transfers. The MDS listed the residents Brief Interview for Mental (BIMS) score as 4 out of 15, indicating severely impaired cognition. The Documentation Survey Report v2 reports for 11/1/23-12/31/23 documented the resident received baths/showers on 11/25/23, 11/29/23, 12/5/23, 12/7/23, 12/9/23, 12/23/23, and 12/28/23. The facility lacked documentation of additional baths provided during 11/1/23-12/31/23. A 2/9/24 Care Plan entry stated the resident required the assistance of 1 staff for showers. On 7/8/24 at 4:17 p.m., the Director of Nursing(DON) stated residents should receive a shower at at minimum of two times per week. The undated facility policy Activities of Daily Living(ADL) Care Policy and Procedure, stated residents would receive appropriate assistance with their ADLs including bathing, toileting, positioning, and transferring. On 7/9/24 at 1:24 p.m. via email correspondence, the Administrator stated she had no additional documentation related to baths provided during this time frame.

Based on observation, resident, family, and staff interviews the facility failed to respond to call lights in a timely manner for 5 of 5 residents reviewed (Residents #42, #44, #251, #39, #203, #48 ). Facility reported a census of 53 residents. Findings include: 1. Resident #44's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS documented Resident #44 required substantial/maximal (the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort) assistance for, toileting, bathing, and lower body dressing. The MDS listed diagnoses include hip fracture, hepatic encephalopathy, other cirrhosis of liver, and obesity. The Care Plan initiated on 5/30/2024 identified Resident #44 as alert and oriented. The Care Plan identified Resident #44 as needing assistance with transferring, toileting, bathing, and repositioning. On 07/01/24 at 1:27 PM, observed Resident #44 call light on. Staff answered the call light at 1:45 PM. 2. Resident #42's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating moderate cognitive impairment. The MDS documented Resident #42 as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity). The MDS listed diagnoses of osteomyelitis, cancer, heart failure, pneumonia, and septicemia. The Skilled Evaluation dated 07/02/24 documented mental status as alert & oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. The Care Plan initiated on 5/6/24 documented that Resident #42 needed help with activities of daily living and required assist of 1 with bed mobility, transfers, walking, and toileting. During an interview on 6/30/24 at 12:32 PM, Resident #42 reported he sometimes waits between 20-45 minutes for staff to respond to his call light. Observed on 7/2/24 at 6:42 AM, an active call light for Resident #42. Staff answered the call light at 7:00 AM. 3. The Clinical Admission assessment dated [DATE] for Resident #251 documented Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. The Resident #251 Admission Record listed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, morbid (severe) obesity due to excess calories, and body mass index (BMI) 45-49.9. The Care Plan initiated on 6/26/24 identified cognition as orientated and required assistance of 2 people for toileting, bed mobility, and repositioning. During an interview on 6/30/24 at 12:29 PM with Resident #251, resident reported the facility is short staffed and it takes too long to answer call lights. During an interview on 7/2/24 at 2:09 PM, Director of Nursing (DON) reported staff should answer call lights within 15 minutes. DON reported the facility has no call light audits and their system does not save data. During an interview on 7/03/24 at 9:31 AM, the Administrator reported the facility has not audited call lights in a while and the system does not have reports to show call light times. Administrator reported staff should answer call lights in 15 minutes or less. 35434 4. The Minimum Data Set (MDS) assessment tool, dated 11/22/23, listed diagnoses for Resident #48 which included skin changes, diabetes, and non-Alzheimer's dementia, and listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating severely impaired cognition. On 7/3/24 at 11:15 a.m., via phone, Resident #48's representative stated staff did not answer call lights in a timely manner when his father was in a room in the basement. He stated staff could not visualize the call light and at times they had to wait 35 minutes to 1 hour. 5. The MDS assessment tool, dated 12/12/23, listed diagnoses for Resident #203 which included diabetes, hip fracture, and pain. The MDS listed the Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 7/1/24 at 2:02 p.m., via phone, Resident #203 stated she had to wait 20 minutes for staff to respond to her call light when she had to go to the bathroom.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to notify a resident's representative of a fall, medication refusals, and a significant weight loss for for 1 of 4 residents reviewed for a change in condition (Resident #48). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 11/22/24, listed diagnoses for Resident #48 which included skin changes, diabetes, and non-Alzheimer's dementia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating severely impaired cognition. 12/18/23 eMAR Administration Notes stated the resident refused his Med Pass supplement. 12/28/23 eMAR Administration Notes stated the resident refused his donepezil (used to treat dementia), carbidopa-levodopa (used to treat Parkinson's disease, a neurological condition with affected movement), metformin (used to treat diabetes), and vinpocetine (used to treat degenerative diseases of the nervous system). The facility lacked documentation of family notification of the above refusals. 2. A 1/8/24 Health Status Note stated the resident remained on fall follow up. A 1/9/24 Health Status Note stated the resident was on fall follow ups from the previous day shift fall. Subsequent Health Status Notes/Nursing Progress Notes revealed fall follow-up assessments at the following times: 1/9/24 at 4:31 p.m., 1/10/24 at 7:35 a.m., 1/10/24 at 10:08 p.m., and 1/10/24 at 11:01 p.m. On 7/8/24, via email correspondence, the Administrator stated she could not locate a fall incident report around 1/8/24. The facility lacked documentation of family notification of the fall. 3. A 3/8/24 Physician Fax stated the resident had a significant weight loss from 172 lbs in February to 161 lbs. The facility lacked documentation of family notification of the weight loss. Care Plan entries, dated 2/9/24, stated the resident was at risk for falls and would not have any significant weight loss. On 7/8/24 at 4:17 p.m., the Director of Nursing (DON) stated the facility should notify the family of falls, medication refusals, and weight loss. The undated facility policy Reporting Resident Change in Condition, directed staff to report resident changes in condition to the physician and the family.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to administer medications in accordance with professional standards for 3 of 6 residents reviewed for medications (Residents #33, #203, and #204). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/12/23, listed diagnoses for Resident #203 which included diabetes, hip fracture, and pain. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 6/30/24 at 2:58 p.m., Resident #203 stated she received medications which were ordered twice daily 6 hours apart. The December Medication Administration Record (MAR) listed an order for sulfasalazine (used to treat ulcerative colitis, the inflammation of the colon) delayed release 500 milligrams, give 3 tablets by mouth two times per day. The hours for the MAR were listed as Day and Eve. The Medication Admin Audit Report listed an order for sulfasalazine delayed release 500 milligrams, give 3 tablets by mouth two times per day. The report revealed the following: a. On 12/15/23, the resident received her 7:00 a.m. dose at 10:41 a.m. and received her 4:00 p.m. dose at 7:17 p.m. a. On 12/16/23, the resident received her 7:00 a.m. dose at 10:20 a.m. and received her 4:00 p.m. dose at 5:48 p.m. b. On 12/17/23, the resident received her 7:00 a.m. dose at 12:08 p.m. and her 4:00 p.m. dose at 7:48 p.m. The facility Medication Administration schedule stated medications were scheduled at the following times: 5:00 a.m., 6:00 a.m., 8:00 a.m., 7:00 a.m.-10:00 a.m., 11:00 a.m., 12:00 a.m., 11:00 a.m.-1:00 p.m., 2:00 p.m.-4:00 p.m., 5:00 p.m., 6:00 p.m.-8:00 p.m., 7:00 p.m., and 10:00 p.m. The schedule did not have direction for staff on when to give medications if they were scheduled twice daily (bid) and did not give direction that staff could give Day medications anytime between 6:00 a.m. and 2:00 p.m. and Evening medications anytime between 2:00 p.m. and 10:00 p.m. The resident's Care Plan did not address the resident's medications. On 7/9/24 at 8:21 a.m. via email, the Director of Nursing(DON) stated if a medication was every day and evening shift, it would be given between 6:00 a.m. and 2:00 p.m. and 2:00 p.m. and 10:00 p.m. In a follow-up 7/9/24 8:32 a.m. email, she stated in theory, they could receive a morning dose at 1:00 p.m. and an evening dose at 2:00 p.m. On 7/9/24 at 9:32 a.m. via phone, the DON stated if a medication was ordered bid and on the MAR for day and evening then staff could give the day medication any time between 6:00 a.m. and 2:00 p.m. and the evening medication anytime between 2:00 p.m. and 10:00 p.m. She stated she did not know where this direction came from as it was in place prior to the start of her time at the facility. During an interview on 7/9/24 at 10:34 a.m. Staff F Advanced Registered Nurse Practitioner(ARNP) stated if a medication was ordered bid, she would assume it would be administered around morning and supper. She stated the practice of giving the day medications between 6-2 and the evening medications between 2-10 would not be a practice she would want carried out. The undated facility policy Physician Order Transcription Policy and Procedure, stated all orders must be accurately transcribed into the medical record. The undated facility policy Medication Administration Policy Template Administration Of Oral Medications, directed staff to provide medications safely and effectively. 48003 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) score of 09 indicating moderate cognitive impairment. The MDS further documented the resident had diagnoses including diabetes, hypertension, depression, and end-stage renal disease. The Care Plan for Resident #33 showed she had insulin dependent Diabetes. Staff were directed to follow orders for diabetes medications as ordered by the doctor. The electronic chart showed an order dated 6/21/24 at 4:44 PM was received by the facility. The order was noted on 6/22/24 at 5:42 AM. The order was to start Novolog 7 units (short acting insulin) with each meal and to notify the physician if the blood sugar was less than 70 or greater than 400. The Medication Administration Record documented the resident did not receive insulin on 6/21/24 for the supper meal. The resident's blood sugar at supper on 6/21/24 was 246 and at breakfast on 6/22/24 was 334. Further review documented the insulin was held the evening of 6/22/24 due to blood sugar of 69. The record lacked documentation of physician being notified. During an interview on 7/01/24 at 4:08 PM, Staff A, License Practical Nurse (LPN) reported she held the insulin for Resident #33 on 6/22/24 because she thought the order read to hold if the blood sugar was less than 70. She reported she should have called the physician for further directions with the low blood sugar During an interview on 7/01/24 at 4:15 PM, the Director of Nursing (DON) reported the nurse should have called to notify the physician of the low blood sugar and then received further instructions from the physician for insulin. The facility policy titled Physician Order Transcription Policy and Procedure undated directed staff that written orders should be transcribed into the electronic medical record system promptly upon receipt. 48888 3. The Minimum Data Set (MDS), dated [DATE], revealed Resident #204's diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, asthma, and pneumonia. Resident #204 had shortness of breath at rest and with exertion. Medications included antibiotic, diuretic, and Resident #204 required continuous oxygen therapy. The Care Plan, initiated 03/30/24, revealed Resident #204 required care at the facility due to a fall at home, recent hospitalization , and weakness that required skilled nursing facility cares. The Care Plan instructed nursing staff to administer all medications and treatments unless otherwise ordered by the doctor. The Post Acute Discharge Report, dated 04/18/24, informed that the reports included constitute orders and instructions for immediate care of the resident upon admission to the facility. This Report revealed an order for Prednisone 10 milligram (mg) tablet, to be given as follows: take 4 tablets for 1 day, then 3 tablets daily for 3 days, then 1 tablet daily for 3 days, then stop. The Discharge Report informed facility the next dose of Prednisone would be due on 04/19/24. The Medication Administration Record (MAR), dated April 2024, revealed an order for Prednisone 40 mg one time a day related to Chronic Obstructive Pulmonary Disease with start date of 04/19/24, coded 09 or other/see nurses notes. The MAR, dated April 2024, revealed additional order for Prednisone 30 mg one time a day for three days, with start day of 04/20/24, to be given through 04/22/24, coded 09 or other/see nurses notes. The MAR, dated April 2024, further revealed an order for Prednisone 20 mg one time a day for three days, with a start day of 04/23/24 , to be given through 04/25/24, coded 09 or other/see nurses notes on 4/23/24, a dose given on 04/24/24, and then coded 06 or hospitalized on [DATE]. Review of Nursing Progress Notes revealed the following entries: a. On 04/18/24 at 04:44 PM, Resident #204 returned to facility from Hospital. b. On 04/18/24 at 03:34 PM, Nurse Practitioner acknowledged resident's medication review without any new orders. c. On 04/19/24 at 05:56 PM, Resident #204 had loud wheezes, some relief after as needed medication given. d. On 04/21/24 at 03:40 PM, Resident #204 had scattered faint wheezes throughout the lungs with occasional non-productive cough. Nurse noted Resident #204 moving legs constantly and reported aches improved but unresolved after massage. Resident #204 mumbling. e. On 04/22/24 at 11:34 AM, Nurse called Pharmacy about missing Prednisone and told it would be sent out same day. f. On 04/23/24 at 11:26 AM, Nurse called Primary Care Provider office to report Resident #204 had not received Prednisone taper as Pharmacy had not delivered, order received to discontinue. g. On 04/23/24 at 11:17 PM, Resident #204 had scattered wheezes in the lungs, reported shortness of breath and had been anxious and talkative. h. On 04/25/24 at 06:47 AM, Resident #204 complained of shortness of breath and mid sternum chest pain. Oxygen saturation at 90% while on oxygen, nurse increased oxygen flow to 4 liters and noted Resident #204 had 24 respirations per minute with use of accessory muscles. Lung sounds had been diminished throughout with wheezes in the upper lungs and coarse crackles in the lung bases. Nurse administered an ordered inhaler and Aspirin. Resident #204 transferred to hospital via ambulance. i. On 04/25/24 at 11:18 AM, Nurse received update from hospital that Resident #204 would be admitted to hospital for pneumonia and fluid overload. The facility provided a list of medications kept on site in the emergency medication (E-kit) provided by the Pharmacy, document not dated. The list revealed Prednisone 10 mg tablet kept onsite in facility's E-kit. On 07/08/24 at 04:41 PM, Director of Nursing (DON) revealed that upon admission from Hospital, nursing staff were expected to transcribe and put resident orders into the MAR and fax the Pharmacy for medications to be delivered to facility on the next delivery. DON also revealed the facility kept an E-kit onsite at the nurses station that could be accessed if medication is not available. On 07/09/24 at 01:31 PM, the Facility Administrator revealed via Electronic mail (email), the facility had been unable to produce any evidence of physician notification of missing prednisone between 04/18/24 and 04/22/24. The facility policy titled, Physician Order Transcription Policy and Procedure, not dated, revealed that all transcribed Physician orders must be documented in the electronic medical records system, including the date, time, and identity of the healthcare professional involved and any errors, clarifications, or amendments made to the transcribed orders should be clearly documented and linked to the original order.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to obtain a treatment order for a new skin area in a timely manner for 1 of 3 residents observed with a non-pressure skin issue(Resident #203), failed to assess and carry out a treatment for a resident with moisture associated skin damage (MASD) for 1 of 3 residents observed with a non-pressure skin concern (Resident #48), failed to assess and intervene after a resident showed signs of altered mental status for 1 of 4 residents reviewed for a change in condition (Resident #48), and failed to assess and intervene when a surgical wound showed signs of infection for 1 of 3 residents revealed with a non-pressure skin concern (Resident #39). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 12/12/23, listed diagnoses for Resident #203 which included diabetes, hip fracture, and pain. The MDS stated the resident required partial to moderate assistance for rolling and transfers and listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The resident's Care Plan did not address any skin concerns. A 12/30/23 Health Status Note stated the resident complained of her coccyx (tailbone) being sore. A 1/1/24 1:43 p.m. Nursing Progress Note stated the resident had a new area to the coccyx. The area was 2 small 0.1 centimeters (cm) round blanchable partially open areas and the facility notified the physician to request a treatment order. A 1/4/24 Physician's Order Note listed an order for Medihoney (a type of wound treatment) plus Mepilex (a foam dressing) to opened area on the coccyx. The January 2024 Medication Administration Record (MAR) listed a 1/5/24 order for Medihoney Wound/Burn Dressing, apply to coccyx topically one time per day for opened area on the coccyx. The MAR documented the dressing started on 1/5/24. The facility lacked documentation of a treatment initiated earlier than 1/5/24. 2. The MDS assessment tool, dated 11/22/24, listed diagnoses for Resident #48 which included skin changes, diabetes, and non-Alzheimer's dementia. The MDS stated the resident had no pressure ulcers and had moisture associated skin damage. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating severely impaired cognition. a. A 12/26/23 Skilled Evaluation stated the resident had MASD on his buttocks A 12/30/23 Skilled Evaluation stated the resident had moisture associated skin damage (MASD). A 1/1/24 Resident Skin Report stated the resident had red open areas and displayed a diagram with an area on the left buttock circled. The December 2023 and January 2024 Treatment Administration Records (TARs) lacked documentation a skin treatment implemented for the resident's MASD. The facility lacked skin assessments from 12/30/23 to 1/16/24. A 1/16/24 Communication with Physician note stated the resident transferred to the hospital. A 2/5/24 hospital Progress Note stated the resident had a Stage 2 pressure injury (caused an open area to the top layer of the skin) to the left buttock present on admission. Care Plan entries, dated 2/9/24, stated the resident was at risk for pressure injuries and/or impairment to the skin, would be free from redness, blisters, or discoloration, and directed staff to administer treatments and monitor for effectiveness. The Care Plan did not address the resident's skin concerns prior to 2/9/24. b. A 2/9/24 Care Plan entry stated the resident had a Foley catheter (a tube which was inserted into the urinary tract to drain urine) and staff provided catheter cares. A 3/15/24 Health Status Note stated the family notified the facility that the resident had an altered mental status. The Temperature Summary report listed a 3/15/24 10:50 p.m. temperature of 99.1 degrees Fahrenheit. The facility lacked an assessment completed on 3/16/24. The facility obtained vital signs on 3/17/24 but lacked documentation of further assessments between 3/15/24 and 3/18/24 including assessments of the resident's mental status and appearance/quality of the urine in his catheter. On 3/18/24, the facility obtained an order for a urinalysis (a laboratory test of the urine). On 3/19/24, the resident's oxygen saturation was in the 80's (normal was 90 or above) and the facility transferred him to the ER. The hospital Discharge Summary Note, dated 3/21/24, stated the resident admitted from a care facility with a fever, confusion, and unresponsiveness. The resident had purulent (referring to pus) drainage from his Foley catheter. On 7/8/24 at 4:17 p.m. the Director of Nursing (DON) stated if a resident had MASD, they should carry out assessments every time there was a treatment. She stated if a resident had a skin issue, there should be a treatment in place and she would want full assessments carried out after a change in condition. In email correspondence on 7/9/24, the Administrator stated the facility did not have a specific policy for assessments and interventions. On 7/9/24 at 1:24 p.m. via email correspondence, the Administrator stated she had no additional documentation related to the Resident #48's skin assessments in January 2024 or assessments conducted between 3/15/24 and 3/18/24. The undated facility policy Wound Care stated the prevention, care, and treatment of wounds was carried out for all resident to prevent skin breakdown and stated the facility would utilize a protocol for the assessment and treatment of wounds. The facility would assess residents with compromised skin integrity no less than once per week. 48888 3. The Minimum Data Set (MDS), dated [DATE], revealed Resident #39 had been dependent upon staff for transfers and toilet hygiene and required substantial to maximal assistance with bed mobility. Resident #39 required both scheduled and as needed pain medication and utilized opioid medication. Diagnoses included aftercare following joint replacement surgery, presence of right artificial hip joint, and periprosthetic fracture around internal prosthetic right hip joint. The Care Plan, initiated 05/03/24, revealed Resident #39 had an infection of the right hip incision site with the goal to be free from complications related to infection through the review date. The Care Plan instructed staff to follow facility policy and procedures for line listing, summarizing, and reporting infections. The Care Plan revealed Resident #39 required the antibiotic Keflex for wound infection from 05/03/24 through 05/10/24, then required the antibiotic Levaquin from 05/14/24 through 05/21/24 for possible cellulitis to incision site. The Treatment Administration Record (TAR), dated April 2024, lacked orders for wound care for right hip surgical wound. The Treatment Administration Record (TAR), dated May 2024, revealed a wound care order, initiated 05/18/24, for Calcium Alginate applied to hip wound topically every day shift and cover with foam border. The Skin and Wound Assessment, dated 04/25/24, revealed a right hip surgical wound, incision approximated, measured 12.3 centimeters (cm) by 1.9 cm. Assessment noted a non-removable dressing had been in place. A picture of the wound revealed a foam type dressing, not dated, secured with transparent film in place, the film rolled around edges, and dressing had small amount of dark yellow drainage. The Skin and Wound Assessment, dated 05/01/24, revealed right hip surgical wound, measured 17.9 cm by 2.3 cm. Assessment noted a non-removable dressing remained in place. A picture of wound revealed foam type dressing remained, not dated, secured with transparent film. Film edges rolled and dressing had moderate amount of yellow, green colored drainage. The Skin and Wound Assessment, dated 05/06/24, revealed right hip surgical wound, measured 20.9 cm by 1 cm. Assessment revealed signs of infection included redness, inflammation, and warmth present as well as light amount of purulent drainage. Assessment noted Resident #39 went to the emergency room and had surgical bandage removed. A picture of wound revealed areas of redness on both sides of incision. Review of Nursing Progress Notes revealed the following entries: a. On 04/25/24 at 03:51 PM, Resident #39 admitted to facility with surgical wound to right hip, covered with a bandage and a small area of old drainage noted on dressing. Resident #39 rated right hip pain 10 on a scale of 1 to 10. b. On 04/29/24 at 11:14 PM, Right lower extremity is warm to touch, non-pitting edema to feet. c. On 05/01/24 at 02:03 PM, weekly skin assessment completed and surgical incision remained covered with a non-removable bandage. d. On 05/02/24 at 04:46 PM, Resident #39 requested to go to Hospital after several days without bowel movement. e. On 05/02/24 at 11:23 PM, Resident #39 returned to facility from emergency room (ER) with communication that resident had superficial infection around surgical site with an order for antibiotics and instruction to follow up with Orthopedic Surgeon, continue to monitor site, and if redness or drainage worsens to return to ER. Assessment of incision site revealed separation at upper incision line, yellow tinged drainage, redness noted at top to midline incision. Noted swelling and wound felt hardened to touch. On 07/08/24 at 03:03 PM, Staff L, Registered Nurse (RN), informed that signs of wound infection would include pink or redness around wound, warmth, more drainage, and pain. Staff L stated the Primary Care Provider or Orthopedic Surgeon would need to be notified the same day or shift for any signs of surgical wound infection. On 07/08/24 at 04:41 PM, Director of Nursing (DON), revealed the expectation of Nursing staff to complete weekly wound assessment and to notify Provider immediately for signs of wound infection. The facility policy, titled Wound Care, not dated, revealed the DON is responsible for implementation of policy. Policy revealed expectation that all residents be assessed for skin breakdown on admission, routinely thereafter, and as needed. The policy instructed staff that skin breakdown would be reported to the Physician and treatment orders to be requested.

Based on clinical record review and staff interview, the facility failed to ensure one (1) of four (4) residents received adequate supervision to prevent accidents (Resident #4). The residents sample included 4 residents with a census of 46 residents. Findings include: Resident #4's initial Minimum Data Set (MDS) assessment with the reference date of [DATE] identified with a BIMS (Brief Interview for Mental Status) of 7 which indicated severely impaired cognition. The MDS indicated the resident required extensive assistance of one staff for all activities of daily living. The resident utilized a walker for ambulation. The MDS indicated the resident had not been steady and could stabilize with staff assistance for ambulation but required staff assistance for stabilizing when transferring from one plane to another. The resident had no functional limitations on both sides of the body. Review of the resident's care plan with a goal date of [DATE] indicated the resident at risk for falls related to need for oxygen, weakness, and need for staff assistance for transfers and ambulation, poor safety awareness and needed reminders to use call light (to wait for assistance to arrive). The care plan instructed staff to attach call light to bed linens at night, ensure room is decluttered and oxygen tubing is not in walkway, keep frequently used items in reach and in same location. The care plan directed staff to check on resident frequently to identify and meet needs as well as note location and safety status, and keep in view as much as possible. After fall on ,[DATE] 17 the care plan instructed staff to offer the resident an evening snack. After fall on [DATE] the care plan instructed staff to place reminder signs in room and bathroom to use the call light and wait for assistance, make sure call light is near at all times, remind the resident frequently to use call light, and remain close to return from bathroom. After a fall on [DATE] the staff were instructed to utilize laser alarm at all times while in room, encourage or remind the resident to use assistance device (walker when ambulating, transfer bars in bathroom and handrails in hallway). The care plan instructed the resident at risk for bleeding related to atrial fibrillation, and recent cardiac surgery. The care plan noted the resident had been receiving an anti-coagulant (medication used to prevent blood clots) and instructed staff observe for unusual bleeding, such as hematuria (blood in urine), epitaxis (bloody vomit) or bleeding gums. The care plan instructed staff to reinforce risk of injury to the resident/family to bleeding potential and reinforce safety precautions. A fall risk assessment dated [DATE] indicated a score of 10 which placed the resident at high risk for falls. The care plan noted the resident had three previous falls on [DATE], [DATE] and [DATE]. On [DATE] the staff had notified the resident's physician of increased shortness of breath and resident stated had been due to his/her COPD and staff had been unable to get a good oxygen saturation reading related to the resident's cold hands. The staff noted the resident's nail beds slightly blue with sluggish capillarity refill. The staff asked for an order for [REDACTED]. The physician responded yes. An Event Report dated [DATE] at 3:35 a.m. Staff A, RN documented, a CNA found Resident #4 on abdomen with respirations and blood on back of head with bathroom door being close. A large laceration on occipital head with moderate amount of bleeding. Respirations had ceased and cardiopulmonary resuscitation (CPR) initiated and emergency services activated. The resident taken to the emergency room per ambulance with pulse and CPR. Staff A documented the CNA reported the resident had been asked if needed toileting around 2:30 a.m. and the resident denied. The resident did complain of some coughing. The CNA reported the resident in the bathroom with the door closed, no walker in the bathroom and laser alarm shut off. The CNA reported the laser alarm on at last check. The resident had nothing on his/her feet. On [DATE] at 6:08 a.m. Staff A, RN documented in the clinical record at 3:35 a.m. Resident #4 found on the floor in his/her bathroom face down with the door closed and nothing on feet. No walker found in the bathroom and bedroom dark. The laser alarm had been shut off but the CNA related the alarm on the last set of rounds. A laceration on back of head with moderate amount of blood. The CNA (Staff B) reported the resident had been breathing when found in the bathroom, but then became breathless. Emergency services called and CPR initiated. The police department and area ambulance took over and the resident eventually transferred to local emergency room . The director of nursing, physician and family notified. An emergency room nurse notified facility of resident's death at 4:56 a.m. The emergency room history stated patient presented following a head injury, the patient had seen by staff around 2:30 a.m. At 3:30 a.m. the resident had been found on the ground of the bathroom, unresponsive and no pulse. CPR initiated by police department and continued by area ambulance. The resident found PEA (pulseless electric activity) throughout transport with transport time of 36 minutes, time down just under an hour at this time. He/She and been given epinephrine times 4 and a King Laryngeal Tube placed due to blood in the airway. The resident had been a full code. The record revealed the resident had a large hematoma with active bleeding to the right frontal lobe, and King Laryngeal Tube in place with a significant amount of blood from the airway. The [DIAGNOSES REDACTED]. A Dopamine infusion started, unable to maintain a heart rate or blood pressure and continued to lose pulses, the bedside ultrasound showed no cardiac activity. Based on the length of time of the code approaching 1.5 hours, the resident had been pronounced deceased at 4:56 a.m. On [DATE] at 4:00 p.m. Staff I, CNA stated that Resident #4 had been alert/oriented most of the time but did have periods of confusion. She stated the resident had day that would want to be independent and would become upset when reminded to call for assistant. Staff I, CNA stated that the resident would turn off the laser alarm especially when the resident had been confused. Staff I stated the resident did not appear weaker but had been much quieter than normal. She stated the resident would become wobbly when short of breath and required more assistance from staff. On [DATE] at 11:05 a.m. Staff C, LPN stated on [DATE] on the day shift, Resident #4 had been demonstrating shortness of breath with exertion. She stated the resident had been walking back to his/her bedroom with a CNA when she noted the resident appeared short of breath. Staff C stated she notified the physician and received an order for [REDACTED]. She stated the resident oxygen saturation increased and the resident appeared more comfortable. Staff C stated the resident appeared as normal, alert/oriented, went to therapy and out to meals. On [DATE] at 11:30 a.m. Staff D, LPN stated she had worked [DATE] on the 2nd shift (2p-10p) and that Resident #4 had appeared more confused that evening. She stated she had been across the hall in another resident's room and as she came out she had peeked into Resident #4's bedroom, she stated the resident had been beating on the television remote and when asked what he/she were doing, the resident replied could not get the call light to work, that it had broken. Staff D stated she explained to the resident that he/she had the remote. Staff D stated the resident argued (confused and called it the call light). Staff D stated she could not get an oxygen saturation related to the resident's physical condition. Staff D stated the resident did have an oxygen order but she did not place the oxygen on the resident at that time. She stated other than inability to get oxygen saturation the resident had been symptomatic. Staff D stated the resident had frequent urination so she though the resident may have been working on a urinary tract infection. Staff D stated she did pain rounds at 5 p.m. and the resident had complained of any pain at that time. She stated the resident had been resting at her 9:00 p.m. rounds and did not appear to have any cardiac or respiratory distress at that time. On [DATE] at 12:01 p.m. Staff E, CNA stated that she had worked the day shift on [DATE] and other that needing to use the bathroom frequently the resident appeared normal as usual. She stated she did not recall the resident had complained of or appeared short of breath that day, but she had been at other times. She stated the resident had been alert and oriented that day, and that the resident normally became short of breath when ambulating. On [DATE] at 7:30 a.m. Staff A, RN stated on [DATE] he had been on lunch break when Staff F, CNA came down to the ground floor library, and told him that Resident #4 had been found on the floor and had been bleeding a lot. Staff A stated he stopped and checked the resident's code status, saw that the resident had been a full code and proceeded to the bedroom. Staff A stated he grabbed the crash cart and back board on the way to the resident's room. He stated the staff told him the resident had stopped breathing so he called 911 and then proceeded to initiate CPR. He stated when he got to the resident's room, he observed the resident lying face down on the bathroom floor, and there had been lot of blood. He stated that he assumed the resident had struck the back of the head. He stated the resident had not been breathing so tucked his/her arm and rolled the resident to the back and initiated CPR. He stated they worked on the resident ,[DATE] minutes until the emergency crew arrived. He stated the police arrived first and take over the CPR until the EMT's arrived. He stated at that time he left the room to gather paperwork and notify the director of nursing, doctor and family members. Staff A stated that Staff G, CNA told him that she had found the resident on the floor in the bathroom with the bathroom door closed. He stated she told him that the resident's bedroom light had been out, and they did not have anything on his/her feet, had a gown on and a brief pulled up. He stated Staff G stated she had seen the resident around 2:30 a.m., the resident had been in bed and offered toileting which the resident had refused. He stated the resident had used the call light several times earlier in the night. He stated the resident did not have his/her walker in the bathroom. On [DATE] at 1:52 p.m. Staff G, CNA stated she had been passing ice water around 3:00 a.m. on [DATE] when she got to Resident #4's bedroom she had noticed the resident had not been in bed. She stated the bathroom door had been opened and she noticed the resident on the floor and saw blood. She sated she walked over to see if the resident had been breathing. She stated she did note a faint breathing and called out to the other CNA for assistance. She stated Staff F, CNA came and checked the resident then went to get the nurse who was on break. She stated it had been about 5 minutes when she had found the resident and the time the nurse got into the room. She stated that by the time the other staff got in there, the resident took a last breath. She stated the nurse had brought the crash cart in and they began CPR. She stated the paramedics got there in about 15 minutes and took over caring for the resident. Staff G stated when she got into the resident's room, the lights were off, the laser alarm had not been sounding and the resident did not have anything on his/her feet. Staff G stated she had been in the room several times when the call light had sounded and assisted the resident. She stated she did not recall the last time prior to finding the resident on the floor. Staff G stated the resident had been confused and she had been told in report the resident appeared to be weaker. She stated the resident had not complained of any pain to her during the earlier part of the shift. Staff G stated the resident had been completely unresponsive when she first entered the room but she did have some faint breathing. She stated Staff A, RN had to roll the resident onto his/her back prior to starting the CPR. She stated that Staff F assisted the nurse as she had been to upset. On [DATE] at 2:52 p.m. Staff H, CNA stated the Resident #4 had been showing confusion at times. He stated the resident would put on the call light and not know what he/she wanted; or not recall they had pulled the call light. He stated when he ambulated the resident to the supper meal, the resident would be short of breath and would use oxygen as needed. He stated the resident had appeared weaker prior to the fall.

Based on record review, observation, review of policy and procedures and staff interviews, the facility failed to adequately supervise a resident to ensure against hazards from self (Resident #1). The resident had a history of [REDACTED]. The staff left the resident unattended on the toilet and the resident fell and fractured the pelvis. The facility reported a census of 46 residents and the sample consisted of 4 residents. Findings include: According to the MDS (Minimum Data Set) dated 10/20/2016, Resident #1 had severe impairment of cognitive skills for daily decision making and had [DIAGNOSES REDACTED]. The MDS identified the resident ambulated, transferred and used the toilet with limited assistance of one staff person and required staff assistance to balance while walking, turning and moving on and off the toilet. The MDS identified the resident had no pain. The resident used a walker for a mobility device. The significant change MDS dated [DATE] indicated Resident #1 required extensive assistance of two staff to transfer and failed to ambulate. The resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had occasional pain that limited the resident's activities over the prior five days. The resident used a wheelchair for a mobility device. The Care Plan dated 11/3/16, identified Resident #1 had a history of [REDACTED]. The Care Plan directed staff to assess and document cause and pattern of falls, provide diversion activities when restless, check on resident on rounds, keep in view as much as possible, encourage or remind to use assistive devices daily, ensure resident wears proper footwear, quarterly fall risk assessment, keep floors clean and free of clutter, fall committee to review falls per policy, keep frequently used personal items within reach, maintain call light within reach, medication reviews by pharmacy or physician, adequate lighting, PT/OT working with resident for strengthening and safety, trial laser motion detector alarm changed to floor mat alarm, and never leave unattended on toilet, keep within sight when using bathroom. The Care Plan verified on 9/20/2016, staff added the fall intervention: Never leave resident unattended on toilet, always keep resident in sight when using bathroom. The Fall Risk Assessments dated 7/11 and 10/31/2016 identified Resident #1 as a high fall risk. The Incident Reports indicated Resident #1 had the following falls at the facility: On 8/9/2016, at 3:40 p.m. the staff found the resident seated on the floor near the foot of the bed with no known injury. Staff checked the resident's urine and provided diversion activities. On 8/13/2016 at 7:00 p.m., the staff found the resident sitting on the floor, against the chair with legs outstretched in front with no known injury. The resident attempted to hang up the phone. The investigation indicated the resident would continue with physical therapy to increase safety and fit an AFO (splint). On 8/20/2016 at 1:00 p.m. the staff found the resident sitting on the floor with legs outstretched in front. The resident attempted to exit the bathroom with no known injury. Staff received education regarding providing toileting assistance before and after meals and frequent monitoring. Staff added a laser alarm when in chair or bed. On 9/18/2016 at 2:30 p.m., the staff found the resident laying on his/her back in the room with the walker nearby. Staff checked the resident's urine, replaced shoe strings and provided a picture book to occupy time. On 9/19/2016 at 3:30 p.m., the resident's laser alarm sounded and staff found the resident sitting on the floor mat. The resident had an occipital hematoma (bleeding under the skin at the lower back of head) that measured 3.3 by 3.0 cm (centimeters). Staff intervention included gripper socks and discuss dementia unit with family. On 10/31/2016 at 5:15 a.m., staff found the resident sitting on the floor between the bathroom and bed with the right shoe off. Staff instructed to keep the resident in sight when in the bathroom. The Emergency Department summary dated 10/31/2016 identified Resident #1 sustained a fracture of multiple pubic rami (part of pelvis), left, closed. Fall at Nursing Home. The hip and pelvis x-ray report dated 10/31/2016 indicated Resident #1 had a fall and left hip pain. Impression: The resident had a mildly displaced comminuted fracture of the left superior pubic ramus and linear fracture through the left inferior pubic ramus. The resident had mild degenerative changes in the hips bilaterally. The physician ordered Physical and Occupational Therapy evaluations with treatment, pain medication, weight bearing as tolerated and a follow up with physician in two weeks. The facility History and Physical dated 7/12/2016 indicated Resident #1 had a seizure disorder without recent seizures and two minor falls prior to admission. The hospital History and Physical dated 12/3/2016 identified Resident #1 had dementia, previously could walk a little bit, now bed bound due to recent pelvic fracture two weeks ago. Family reported the resident failed to eat well and lost weight. Labs indicated the resident had a urinary tract infection and required high oxygen. The Discharge Summary dated 12/4/2016 indicated Resident #1 transferred to hospice care and had [DIAGNOSES REDACTED]. Unfortunately the resident developed a lower GI (gastrointestinal) bleed. Observation on 11/30/2016 at 11:30 a.m. identified Resident #1 seated at the dining room table in the wheel chair with staff supervision. At 12:30 p.m., the resident requested to go to the bedroom after only eating a few bites of fruit. The resident transferred to the toilet with the assistance of two staff and a gait belt. Staff transferred the resident back to the wheel chair and bed with the floor mat alarm in place. During an interview on 11/30/2016 at 11:34 a.m. Staff C, DON stated the resident alarms are listed on CNA (Certified Nurse's Aide) worksheets and the Care Plans. The facility had no specific fall policy related to alarms. Staff need to stay near residents with alarms when on the toilet. Some residents become agitated, so staff need to remain outside the bathroom door. Staff access resident Care Plans on the computer. On 12/9/2016 at 12:15 p.m., Staff C revealed Resident #1 passed away on 12/8/2016. The resident went to the hospital on [DATE] after an unresponsive episode and admitted to the hospital hospice unit. During an interview on 12/20/2016 at 10:30 a.m., Staff A, LPN (Licensed Practical Nurse) reported working on 10/31/2016 when Resident #1 had a fall. Staff monitored the resident in the dining room from midnight until 5 o'clock a.m. when the resident had restless behaviors and indicated he/she needed to go to the bathroom. Staff A stated the resident often failed to sleep during night time hours and staff watched the resident in the dining room/nurses station area while he/she self-propelled the wheel chair. Staff A said they never left the resident out of sight. The resident had no alarm in the wheel chair but did have a floor mat alarm next to the bed. The resident attempted to exit the wheel chair and bed. Staff A pushed the resident in the wheel chair to the bathroom, assisted the resident without a gait belt to the toilet, parked the wheel chair in front of the resident and stepped out into the hall to speak to Staff B, CAN. Staff A stated she left the resident for no more than five minutes when they heard the resident call for help. Staff found the resident sitting on the floor near the bed. The resident never used the call light. Staff A assessed the resident, transferred the resident to the bed with the help of Staff B. The resident complained of hip pain and Staff A notified the family and physician and sent the resident to the emergency room . Staff A stated residents with alarms need supervision when on the toilet, something she learned after the resident fell . At the time, Staff A said she had no knowledge of how to open the Care Plans on the computer. The DON showed Staff A how to open the Care Plan and read it after the resident fell . Staff A saw the Care Plan directed staff not to leave the resident alone on the toilet and to keep the walker near. During an interview on 11/30/2016 at 12:00, noon, Staff B, CNA reported working when Resident #1 fell on [DATE]. Staff B went to do rounds and left Resident #1 with Staff A in the dining room area. While doing rounds, Staff A came around the corner and told Staff B that someone had called in for the next shift. Staff B asked about the resident and where Staff A left him/her. Staff A told Staff B she left the resident on the toilet. Staff B knew not to leave any resident with an alarm alone on the toilet. Approximately one minute later, they heard the resident fall. Staff B found the resident on the floor near the doorway in front of the wheelchair. The facility policy and procedures titled Fall Prevention and Management, effective date of January 2014 included: It is the policy of Cottage Grove Place to ensure a safe environment with least restrictive measures while promoting the highest possible level of independence and quality of life. Purpose: A Fall Prevention Program is used to provide a safe environment for residents of the Health care Center and Gardens area. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls, implement Quality Assurance measures to monitor progress; and provide ongoing education. All residents will be assessed for risk of falling using a standardized fall assessment on admission, quarterly and if a change in condition requiring completion of a new MDS occurs. Residents who are identified as high risk will be care planned and individualized precautions will be noted to avoid falls. Following a fall: Review and update causative factors, interventions, care plan and fall assessment will be completed. Nursing staff will make appropriate interventions upon the completion of the report to prevent reoccurrence of a fall or to minimize injury. All newly hired nursing staff will receive orientation to the Fall Prevention and Management program philosophy and forms.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and failed to ensure the written health Care Plan was followed in order to keep the resident safe (Resident #1). The sample consisted of 4 residents and the facility reported a census of 45 residents. The Care Plan directed staff to not leave the resident sitting up unattended on the side of the bed. This intervention was put in place due to the resident ' s history of a fall from the bed. The staff member left the resident unsupervised in bed while looking for a walker and returned later to find the resident on the floor. Findings include: 1. Documentation in the clinical record (resident Care Plan) reflected Resident #1 entered the facility on 08/07/2013 following a fall leading to a hip fracture on 08/04/2013. Review of the hospital past medical history report dated 01/06/2013 identified Resident #1 also had [DIAGNOSES REDACTED]. Resident #1 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of 11/4/13, which reflected the resident required extensive staff assistance with bed mobility, transferring, dressing, eating, toilet use, personal hygiene and bathing. Resident #1 did not ambulate. The assessment form also identified Resident #1 had balance problems and was not steady, and only able to stabilize him/herself with staff assistance when moving from seated to standing position, moving on and off the toilet, and surface to surface transferring. Resident #1 also scored a 5 (of 15) on the facility Brief Interview for Mental Status. A score of 5 revealed the resident had a severe impairment in his/her cognition and decision making skills. According to documentation in a facility Event Report dated 10/21/13, staff left Resident #1 alone on the side of his/her bed as they (staff) went to get additional assistance to transfer Resident #1. Upon returning to the room, staff found Resident #1 on the floor. Documentation revealed Resident #1 did not sustain any injuries from the fall. The facility educated staff to not leave Resident #1 alone, sitting on the bed and added this intervention to Resident #1's individualized plan of care. Additional interventions on the resident ' s Care Plan included: * Assist with activities as needed. * Ensure resident wears appropriate footwear, non- skid shoes, slippers, and socks. * Keep floors in room/hallways clean, dry, and free of clutter/obstacles that may impede safety while ambulating or in w/c. * Keep frequently used personal items within reach and in same familiar location. Documentation in the facility Event Report dated 01/03/2014,reflected the staff found Resident #1 on the floor, lying face down at the bedside with his/her head wedged between body and chest at the bedside. During an interview on 02/11/2014, the facility Administrator stated that on the morning of 01/03/14 the staff were rushed that morning and the certified nursing assistant had Resident #1 all dressed and ready for the day, when he/she noted Resident #1's walker wasn't in the room. The certified nursing assistant went to retrieve Resident #1's walker, got sidetracked with another resident while gone, and when he/she returned to the room, she found Resident #1 on the floor. The facility Administrator stated the certified nursing assistant laid Resident #1 on his/her bed, but the resident ' s feet were allowed to be off the mattress. The Administrator stated the amount of Resident #1's feet/body off the bed had changed over the course of interviews from being just feet and ankles to a portion of Resident #1's lower leg(s). Regardless of the exact amount of leg(s) off the bed, facility staff determined the certified nursing assistant left Resident #1 in a potentially dangerous situation/position. According to the hospital clinic report dated 01/10/2014, Resident #1 suffered a head trauma when he/she fell while getting out of bed. Resident #1 suffered a laceration to the eyebrow and the scalp. Resident #1 was doing poorly and returned to the hospital where a subdural hematoma (a collection of blood on the surface of the brain) was diagnosed . Resident #1 had been on Coumadin (used to prevent formation of blood clots) for a recent leg DVT (deep vein thrombosis) this Fall, and this has subsequently been stopped. Review of the facility Fall Questionnaire dated 1/3/14 at 7:17 a.m. revealed Staff F, certified nursing assistant, documented this fall could have been prevented if the resident had been laid back down before she left the room. Another certified nursing assistant, Staff E documented the fall could have been prevented by leaving the walker in the room and to not leave the resident on the side of the bed. On 2/12/14 at 8:51 a.m. Staff A, certified nursing assistant, was interviewed and stated she would never leave a resident alone on the side of the bed because it would be dangerous. On 2/12/14 at 10:00 a.m. Staff B, nursing assistant, stated she would never leave a resident alone and would have put the resident in bed, with feet in the bed, if she had to go somewhere else. On 2/12/14 at 10:05 a.m., Staff C, licensed practical nurse, was interviewed and stated it would be the expectation for the staff to follow the care plan. Staff C stated not all residents are unsafe at the edge of the bed and all residents have different needs. On 2/12/14 at 10:10 a.m., Staff D, certified nursing assistant, was interviewed and stated she would never leave a resident on the edge of the bed because the resident could fall.